While Medicaid expansion led to more healthcare access for millions of Americans, it had a more complicated impact on people living with HIV, according to a study from Health Affairs
that took a look at how people living with HIV in California navigated the changes.
Before Medicaid expansion, low-income people living with HIV relied heavily on the Ryan White HIV/AIDS Program, which has served as a “payer of last resort” for the patient population. However, the program can only pay for services not covered by any other source.
With the expansion of Medicaid, eligible, low-income people living with HIV were transferred from the Ryan White Program to Medicaid, causing concern for interrupted access to care and treatment.
While Medi-Cal—California’s Medicaid program—is required to cover outpatient behavioral health diagnosis and treatment, as well as intensive inpatient and residential services, the coverage is not as comprehensive as that provided by the Ryan White Program, which offers ongoing mental health and substance use counseling delivered in culturally tailored, integrated care settings.
“Overall, the transition to Medi-Cal coverage means that newly eligible people living with HIV now need to navigate a complicated array of services and payers,” wrote the researchers. “This transition to a system of multiple funding streams necessitates additional assessments not needed under a single-payer system.”
The researchers conducted 47 interviews with 53 public health officials, state and local policy makers, and clinical or service providers, between April 2015 and June 2016.
According to those interviewed, Medicaid expansion did produce improved access to behavioral services. Before the expansion, low-income people could typically access services through the county only for severe mental health needs. Medicaid expansion led to mental health services being more accessible for those with low-to-moderate mental health needs. However, the Ryan White Program remained necessary as it continued to cover people who were deemed ineligible for Medi-Cal or who experienced a coverage gap, as well as those who required more care.
Those interviewed also expressed that many patients who moved from the Ryan White Program to Medi-Cal or county-run behavioral health services struggled finding culturally tailored providers that they were used to. Additionally, as a result of the fragmentation across multiple payers and providers, there was a need for greater care coordination and integration. Medi-Cal patients often accessed separate providers and clinics for each of their needs, and their providers lacked a standardized way of sharing information.
Based on the interviews, the researchers also found that the Ryan White Program provided wraparound services that Medi-Cal did not. These services included support for transportation, housing, child care, and case management.
“Our findings across counties support expanding integration and collaboration among providers across the Medi-Cal managed care plan and county and Ryan White Program care systems to share culturally competent practices for serving people with HIV, as well as increasing the use of care setting equipped to address a range of needs,” wrote the researchers.
The study comes soon after a 3-part series from the National Academy for State Health Policy
that argued that states can improve HIV care through Medicaid and Ryan White Program collaboration. The series explored how states can use policy levers to more efficiently utilize limited resources and provide better care, improve care coordination services, and ensure consistent access to care for people living with HIV.
Arnold E, Fuller S, Kirby V, et al. The impact of Medicaid expansion on people living with HIV and seeking behavioral health services [published online September, 2018]. Health Aff
. doi: https://doi.org/10.1377/hlthaff.2018.0414.