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An Update on Insurance Coverage Among People with HIV in the United States

Data Sources:

Coverage Data on General Population

Table 1 in this data note presents health insurance coverage data for the general nonelderly adult population (those 19-64). All general population coverage data comes from KFF analysis of the 2015 American Community Survey (limited to nonelderly adults) except for Marketplace enrollment. Marketplace enrollment is an estimate based off the number of nonelderly adults with effectuated marketplace enrollment at mid-year in 2015. Overall mid-year marketplace enrollment in 2015 was 9,949,079.1 The share estimated to be nonelderly adults was based off data on characteristics of individuals who selected a marketplace plan, whereby 8% of marketplace plan selectors were under 18.2 We assumed that age characteristics of those with effectuated marketplace enrollment were similar to those who had selected plans and subtracted 8% from the effectuated enrollment total to obtain an estimated adult marketplace enrollment of 9,153,153 or 5% of the ACS population (190,278,654).

Data on People with HIV

This analysis relies on data from the Medical Monitoring Project (MMP), a CDC surveillance system designed to produce nationally representative estimates of behavioral and clinical characteristics of adults (aged 18 and older) with diagnosed HIV in the United States. During 2015–2016, MMP employed a two-stage, complex sampling design in which US states and territories were sampled, followed by adults (aged 18 years and older) with diagnosed HIV sampled from the National HIV Surveillance System (NHSS), a census of US persons with diagnosed HIV.

Data used in this analysis were collected via telephone or face-to-face interviews and medical record abstractions between June 1, 2015 and May 31, 2016. All sampled states and territories participated in MMP.3

In 2015, of 9,700 sampled persons, 3,654 participated. The overall adjusted response rate was 40%.  Data were weighted based on known probabilities of selection at state or territory and patient levels. In addition, data were weighted to adjust for non-response using predictors of person-level response. Although characteristics associated with nonresponse varied among states and territories, the weighting classes for the national data were informed by sex at birth, HIV exposure category, and the person’s frequency of receipt of care (as indicated by NHSS records). This analysis includes information on 3,654 participants who represent all adults with diagnosed HIV in the United States and Puerto Rico.

Analysis:

For all respondents in MMP, we examined self-reported insurance coverage by using responses to the following question “I’d like to ask you about all of the types of insurance and other coverage you have to pay for healthcare, medicines, and supportive services like case management, transportation, or mental health services. During the past 12 months, have you had any of the following types of insurance or other coverage for any type of healthcare?” Response options included insurance programs (Medicaid, Medicare, private insurance – employer and marketplace -, Ryan White HIV/AIDS Program – Ryan White or the AIDS Drug Assistance Program-, Veteran’s Administration, Tricare or CHAMPUS coverage, other public insurance, and other unspecified insurance). “Other specify” responses were extensively recoded to reflect the most accurate coverage type when possible. It is important to note that patients may not be aware of all the services they receive that are paid for by the Ryan White HIV/AIDS Program (the program provides funding directly to service organizations in many cases) and therefore, the estimates of the number of individuals who receive Ryan White HIV/AIDS Program services is likely an underestimate.

We estimated weighted percentages of individuals with the following types of health care coverage: no coverage (uninsured), private insurance (with breakouts for employer coverage and marketplace coverage), Medicaid, Medicare, and other (specified). Because respondents in MMP may indicate more than one type of coverage, we relied on a hierarchy to group people into mutually exclusive coverage categories. Specifically, the hierarchy groups people into coverage types in the following order:

  • Private coverage (with breakouts for employer coverage and marketplace coverage)
  • Medicaid coverage, including those dually eligible for Medicare
  • Medicare coverage only
  • Other public coverage, including Tricare/CHAMPUS, Veteran’s Administration, or city/county coverage

In most cases, this hierarchy classifies individuals according to the coverage source that serves as their primary payer. People who do not report any of the sources of insurance coverage above are classified as uninsured.  We separately assess weighted percentages of persons receiving assistance through the Ryan White HIV/AIDS Program by health coverage type.

We assessed distributions of health coverage type in 2015, overall and by whether the participant lived in a Medicaid expansion or non-Medicaid expansion state. We also examined receipt of Ryan White assistance by coverage group and viral load suppression by coverage group. Statistical comparisons were made using Rao-Scott chi-square tests and prevalence ratios with predicted marginal means.

Limitations:

MMP only allows for extrapolation to the national level when using the full sample. Similar extrapolation is not possible when examining coverage changes in and contrasting Medicaid expansion states and non-expansion states. The Medicaid expansion and non-expansion coverage data presented here are representative only of the subset of states sampled that fell into each group.

FIndings