In 2010, the Centers for Disease Control and Prevention (CDC) estimated that more than 1.14 million people 13 years or older were living with the human immunodeficiency virus (HIV), which causes AIDS. About 18% (207,600) were unaware of their infection.1 The undiagnosed are responsible for about half of the HIV transmissions to the uninfected population (Figure 1).2 As alarming as that statistic is from a public health perspective, even those diagnosed with HIV infection do not necessarily receive good care (as defined by a suppressed viral load of ≤200 copies/mL) or have health insurance.
Strategies to Improve Care for Patients With HIV/AIDS
In 2010, President Obama identified a vision for a National HIV/AIDS Strategy (NHAS), which had 3 goals:
• Reduce new HIV infections
• Increase access to care and improve health outcomes for people living with HIV
• Reduce HIV-related health disparities3
When the Affordable Care Act (ACA) was signed into law that year, it was expected to expand insurance coverage for people without current health care coverage. The Institute of Medicine was directed by the White House Office of National AIDS Policy (ONAP) to identify core indicators that would be indicative of quality continuous clinical care as well as to monitor the effect of both the national HIV/AIDS strategy and ACA on improving HIV care.4
Insurance Coverage for Patients With HIV/AIDS Before ACA
Many people with HIV have not had the financial resources needed for adequate care, even if they have access to insurance or public assistance programs. Additionally, about 30% of patients have no insurance (Figure 2). The main sources of financial support for medical expenses before 2014 were group health or private insurance, public health care programs (eg, Medicaid, Medicare, a combination of Medicaid and Medicare, or the Ryan White HIV/AIDS program)5,6; additional options included participation in patient assistance programs or in clinical trials.
Impact of ACA for People With HIV The ACA, passed in March 2010, has the potential to improve the care and outcomes of people diagnosed with HIV and AIDS.5 The legislation insures that no person can be denied medical insurance coverage for a preexisting condition, and lifts lifetime caps on insurance benefits. Additionally, since more people will have access to care, HIV testing may increase. It is hoped that those testing positive (and newly insured) will begin treatment before the infection progresses to AIDS.
Two specific parts of the legislation are expected to have the greatest impact: (1) the expansion of Medicaid, and (2) the health insurance marketplaces where individuals can purchase affordable private insurance policies. Expansion of Medicaid In most states, adults were not eligible for Medicaid if they did not have any children (only 9 states provided benefits to adults without children)7 or if they were not considered to be disabled. A basic tenet of the ACA is the expansion of Medicaid coverage to adults with incomes of up to 138% of the federal poverty level.
This has significant implications for patients with HIV infection. Preliminary modeling data suggest that 2600 to 3300 additional patients with HIV infection could be diagnosed as a result of increased testing. Yet these figures are dependent upon the number of states that expand Medicaid2; the researchers based their study on the 18 states which had committed by July 2013 to expanding their Medicaid programs (resulting in the lower figure). The higher figure was calculated based on all 50 states expanding Medicaid.2 As of January 2014, 27 states had expanded their Medicaid programs or will do so in 2014.7
According to Snider and colleagues,8 an estimated 115,000 uninsured, low-income adults living with HIV/AIDS would be eligible for Medicaid as a result of the ACA, but that about 60,000 of these adults live in states that are not expanding Medicaid.7 Other estimates regarding the number of patients with HIV/AIDS who will gain medical coverage as a result of the expansion of Medicaid are less robust (~25,000).7
Development of Health Insurance Marketplaces
Within the health insurance marketplaces, patients may be eligible for subsidized coverage if their incomes are between 139% and 400% of the federal poverty level (FPL). Approximately 20,000 currently uninsured people with HIV are in this demographic group. About 2500 currently uninsured people with HIV have incomes greater than 400% of the FPL and would not qualify for federal assistance with purchasing health insurance.7 This number would increase if the people living in states that do not expand Medicaid sign up for health coverage in the health insurance marketplaces.
In states not expanding Medicaid, patients with incomes between 100% and 138% of the FPL may be eligible for subsidized coverage. Patients with incomes lower than 100% of the FPL and living in states not expanding Medicaid programs would potentially not be eligible for health insurance coverage in spite of the ACA. These people will need to try to find assistance through other means, such as the Ryan White HIV/AIDS program.7
In addition, the ACA will close the Medicare Part D prescription drug benefit coverage gap, or “donut hole,” by 2020, which will reduce the out-of-pocket costs for medication. Until then, if patients are receiving benefits through an AIDS Drug Assistance Program (ADAP), those benefits are considered to be contributions toward Medicare Part D’s True Out of Pocket Spending Limit (TrOOP),
which will decrease the amount of dollars a patient must spend before fulfilling the expenditure required of the coverage gap.The ACA has the potential to increase access to medical coverage for patients diagnosed with HIV/AIDS. This includes patients currently not diagnosed, those diagnosed and not seeking medical treatment, those not receiving continuous care, and those not receiving optimal antiretroviral therapy. Reducing the burden for patients with HIV and AIDS would be welcomed by patients, families, and society.