ACA Coverage Has a Positive Impact on Adults With HIV, Viral Suppression

Following implementation of several major provisions of the Affordable Care Act (ACA) in 2014, health insurance coverage for HIV-positive individuals increased, leading to sustained viral suppression in some instances and improving their ability to increase access to often life-saving services. These are among the many findings discussed in an electronic poster presentation at AIDS 2020, this year’s virtual presentation of the International AIDS Conference.

“Insurance Coverage and Viral Suppression Among People With HIV in the United States, 2015-2017,” was presented by Lindsey Dawson, MPP, associate director of HIV policy, and Jennifer Kates, PhD, MPA, senior vice president and director of global health & HIV policy, both at the Kaiser Family Foundation.

Dawson and Kates provided an update on ACA coverage effects based on 2015 through 2018 data from the CDC’s Medical Monitoring Project on behavioral and clinical characteristics of adults living with HIV in the United States, as well as trends since 2015. They estimated insurance coverage rates for private, Medicaid, Medicare, and other coverage (eg, Tricare/CHAMPUS, Veteran’s Administration), as well as provided results in the context of those individuals who received HIV care and support services through the Ryan White HIV/AIDS Program.

Their results show that in 2018, most adults with HIV received their insurance coverage through Medicaid (40%), followed by private insurers (35%), Medicare (8%), and other (7%). Just 11% remained uninsured. These rates actually represent that coverage rates for this vulnerable population have remained stable since 2015. In comparison, the overall general population of the United States was most often covered by private insurance (56%).

Additional results show that in states that expanded their coverage with the ACA, Medicaid continues to represents the largest insurer for people with HIV (46%), followed by private insurance (34%) and Medicare plus other coverage (15%). However, most HIV-positive adults in nonexpansion states continued to receive their coverage privately (36%), followed by Medicaid (30%) and Medicare plus other coverage (14%). People with HIV also are much less likely to be uninsured in Medicaid expansion states compared with states that did not expand coverage (6% vs 20%).

These coverage difference persist among the races and sexes:

• HIV-positive men (39%) and white adults (45%) are more likely to have private insurance and Medicare compared with women (23%) and blacks (31%) or Hispanics (28%)
• HIV-positive women vs men are more likely to have Medicaid: 54% vs 36%
• HIV-positive blacks (14%) and Hispanics (15%) have a 3-fold greater chance of remaining uninsured compared with whites (4%)

The Ryan White HIV/AIDS Program was, and continues to be, a significant resource for the HIV-positive population in the years of this analysis. So much so, that 46% of adult patients received some form of outpatient care or services through the program no matter what insurance coverage they had.

Broken down, however, more HIV-positive uninsured patients (82%) partook of these services than did those with Medicare (62%) or private insurance (38%). And among those with private insurance, 56% with marketplace coverage utilized care and support services from Ryan White vs 32% with employer-provided coverage.

Care and support through the Ryan White HIV/AIDS Program was also associated with higher rates of viral suppression compared with the general population:

• Private insurance: 75% vs 69%
• Medicaid: 64% vs 59%
• Medicare: 73% vs 67%
• Uninsured: 60% vs 54%

Overall, at their last test, viral suppression was evident in 68% of those with HIV and 62% had evidence of sustained viral suppression, leading to the authors’ conclusion that “Ryan White support appears to make a significant difference in achieving sustained viral suppression.”

“The findings from this study will provide the latest nationally representative data on insurance coverage of people with HIV in the US, as well as the relationship between coverage and viral suppression,” Dawson noted. “Such data are critical for monitoring and assessing changes in the US health financing landscape, and their impact on the coverage and health of those with HIV.”