The ACA expanded access to Medicaid for low-income people with HIV. Prior to the ACA, low-income, childless adults with HIV (which is not considered a disability) had to progress to AIDS to become eligible for Medicaid. Now states are provided the option to expand their Medicaid program so that low-income individuals, no matter their health status, can receive health care. Today, Medicaid is the largest source of insurance coverage for people with HIV, covering 40 percent of people with HIV who are in care.
A reanalysis of the data in 2016, by the NEJM study author, Benjamin Sommers, found that “the introduction of highly-aggressive antiretroviral therapy for HIV in the late 1990s” coincided with the expansion of coverage in these three states in 2001 and 2002. But “the relative decline in HIV-related mortality was nearly twice as large in Medicaid-expanding states as in non-expanding states, suggesting that expanded insurance worked in tandem with new antiretrovirals to produce larger health impacts.” In other words, the insurance — not just the advent of effective medications — saved the lives of people with HIV.
The insurance rate for people living with HIV certainly increased under the ACA. The the Kaiser Family Foundation just put out the first national estimates of changes in insurance coverage, and found that Medicaid coverage increased among people with HIV from 36 percent in 2012 to 42 percent in 2014, while the uninsured rate in this group dropped from 22 percent to 15 percent.
The regional data on the ACA’s impact is also compelling. According to the AIDS Foundation of Chicago, as of 2016, at least 12,000 people living with HIV in Illinois newly gained health care through the ACA — or a third of the HIV-positive population in the state. Most have done so through the state’s ACA Medicaid expansion. “These are people who didn’t have insurance before,” said AIDS Foundation of Chicago CEO John Peller. “It’s huge.”
In Alabama, one of the states that didn’t expand Medicaid, about 1,200 people with HIV gained coverage through Ryan White funds, said Kathie M. Hiers, the CEO of AIDS Alabama.
The impact can be seen in clinics for HIV patients. Greg Huhn, an HIV doctor in the Cook County Health and Hospitals System, says the ACA decreased the number of patients who have no insurance by about 30 percent at his practice, and increased patients who have commercial insurance payers — including ACA marketplace plans — by more than 140 percent.
Getting more people with HIV into health care not only drives down mortality and help control the spread of the infection — it also improves the health status of HIV patients, he added.
“There are HIV patients that have heart conditions, that have liver problems, particularly hepatitis C. Oftentimes, they have mental health issues and depression,” Huhn said.
Before 2010, they couldn’t always access the services they needed to care for these conditions if they were uninsured in traditional health care networks. Ryan White programs provide health care to people who cannot get insurance. But they’re mainly focused on HIV care, not all the other health issues people may be dealing with, and most of the $2.3 billion that goes to Ryan White is spent on HIV-related treatment and medications.
That’s only a small slice of people’s health care needs. “As people with HIV live longer, we know they’re experiencing more co-occurring chronic conditions. And something as simple as asthma — if you’re uninsured, you can’t afford your asthma inhaler — can have an impact on your ability to manage HIV,” said Peller.
“The increase in coverage, the fact that a third of people living with HIV in the state got coverage, has been a game changer for efforts to end the epidemic in Illinois,” he added. “It’s just life-changing for people.”
HIV doctors and patients said they’re bracing for what might happen with Medicaid expansion, and any changes to the preexisting condition clauses and lifetime and annual caps on spending. Those who gained coverage through Ryan White in the states that didn’t expand Medicaid could lose it (since repealing the ACA, or even simply dismantling its components, might make HIV patients ineligible for affordable insurance again).
Ryan White funding may also be targeted by Congress. Unlike Medicaid, it’s not an entitlement program, so it’s subject to budget appropriations. Any cuts could help spur an uptick in the epidemic — which is already on the increase in gay and bisexual populations, particularly in the southern US.
“Since sexual contact continues — and unprotected sexual contact continues — the only reason we’ve seen [the HIV rate] go down is because [HIV-positive people] are on medications and their viral loads decrease, so they’re less infectious,” said HIV researcher Rick Elion. “The consequences of their behavior are mitigated by the efficacy of medication and prevention [because the medication makes them less likely to transmit the virus].” Creating barriers to patients accessing their medications and health care could be disastrous for the epidemic, he added.
President Trump hasn’t had much to say about HIV. But Vice President Mike Pence has. As governor of Indiana, he first resisted addressing an out-of-control HIV outbreak in his state for ideological reasons, and then changed his mind based on evidence that clean needle exchanges could slow infections among drug users. He advocated for abstinence-only education and, in 2000, suggested Ryan White only get funding after an audit, “to ensure that federal dollars were no longer being given to organizations that celebrate and encourage the types of behaviors that facilitate the spreading of the HIV virus.”