The ACA and People with HIV: Profiles from the Field
When taken regularly, antiretroviral therapy not only improves the health and longevity of people with HIV, it has also been shown to significantly reduce the risk of HIV transmission.1 For these reasons, current federal HIV treatment guidelines recommend initiation of ART as soon as one is diagnosed alongside regular care and monitoring.2 However, less than one third of people with HIV in the U.S. have an undetectable viral load and many more are not yet engaged or retained in care and treatment.3 Therefore, improving access to insurance coverage under the ACA could play an important role in bringing more HIV positive individuals into care and treatment and is one key component to further addressing the domestic epidemic.
While many provisions of the ACA have implications for people with HIV, two are expected to have the most far reaching effects on coverage – the expansion of Medicaid, in states that choose to expand, and the creation of health insurance marketplaces in each state where individuals can purchase private coverage, subsidized for those with low and moderate incomes. In addition, key insurance reforms in the private market, including the prohibition on rate setting tied to health status, elimination of preexisting condition exclusions, and end to life time and annual caps means that those with HIV and other chronic conditions have more equitable access to coverage.
While these reforms could have a profound impact on those who enroll in new coverage opportunities, not all people with HIV will gain insurance. Many with HIV live on both limited incomes and in states that have not elected to expand their Medicaid programs. Individuals in non-expansion states below the threshold to gain subsidies on the exchanges (100% of the federal poverty level) will find themselves in the coverage gap- ineligible for Medicaid as well as subsidies to help to purchase coverage in the marketplace. There are many other reasons why individuals may not have engaged with new coverage opportunities as well. For one, having public or private coverage may be new to some and enrollment and ability to navigate insurance may take time. Others, such as undocumented immigrants, are not eligible for coverage at all. In addition, even those who gain new coverage may still face barriers to paying for that coverage or may find that some HIV-related services they need are not covered.
It is for these reasons that the Ryan White HIV/AIDS Program has played and will continue to play a critical role in the lives of many with HIV. In addition to providing HIV care and treatment to those ineligible or unenrolled in coverage, including those in the coverage gap, the Ryan White Program, along with other- often industry lead- programs, is helping some clients with affordability by assisting with the cost of health insurance premiums and other out-of-pocket costs.4 In addition, the Ryan White Program may support those who have gained insurance access with certain types of services that are important for HIV care but remain unreimbursed under traditional coverage (e.g. Medicaid or private insurance), such as transportation and case management. The program can also provide consistency for those experiencing gaps in coverage and will continue to be the primary payer of care and treatment for those who have been left out of new coverage opportunities.