At an individual patient level, the Affordable Care Act (ACA) provides a number of straightforward benefits for people living with HIV/AIDS (PLWH). Many previously uninsured Americans now have access to coverage under the law’s Medicaid expansion and new health insurance Marketplaces, where all qualified health plans must cover preventative services like cancer screening. The ACA also prohibits insurers from excluding people from coverage based on pre-existing conditions (including HIV). However, the law’s broader, system-wide impact on the delivery of HIV care is less certain.
For more than 25 years, access to high quality medical care and antiretroviral therapy (ART), was provided to PLWH through the Ryan White HIV/AIDS Program and AIDS Drug Assistance Programs (ADAPs), important safety nets for the uninsured and underinsured. In the coming years, however, the role of these longstanding programs may evolve.
Until recently, state based ADAPs have been the primary means for low-income PLWH to access lifesaving ART. Through direct ADAP, individual states pay for low-income patients’ HIV medications, which they receive along with HIV-related medical care and related support services (such as social work and nutrition counseling) at Ryan White-funded clinics. However, the advent of the ACA has created another possible route for ADAPs to improve access to care and medications for PLWH.
In some states, such as Virginia, the ADAP has begun to use some of its funds to purchase for patients, not just HIV drugs, but full insurance coverage through the ACA’s insurance marketplaces. As a result, Virginia’s low-income PLWH now have two options: traditional or “direct” ADAP in which the state pays for medications that patients receive care through Ryan White clinics; or enrollment in an ACA health plan using funds provided by Virginia’s ADAP to cover insurance premiums, deductibles, and medication copays.
Comparing Outcomes
At October’s annual, infectious disease-focused IDWeek Conference, researchers from the University of Virginia described their experience enrolling patients in ACA plans between January 2013 and December 2014 using ADAP dollars to pay these costs. The two year study included 3,933 ACA-eligible ADAP patients in Virginia. Researchers compared treatment outcomes among individuals enrolled in ACA plans (n=1,849) to those who continued to get medications through the state’s ADAP (n=2,084). The primary clinical outcome of interest was viral suppression (having an undetectable level of HIV virus circulating in the blood): 85.5 percent of patients enrolled in ACA plans achieved this benchmark versus 78.7 percent of those receiving medication through direct ADAP.
“We found patients fared better under ACA health plans, possibly due to broader access to medical care and medications beyond those that target HIV,” said physician Kathleen McManus, lead study author. By comparison, a recent study of Ryan White-supported clinics reported viral suppression rates of 65 percent among Medicaid recipients.
McManus explains that it has been especially important for Virginia to use ADAP dollars in this manner because the state is one of 20 that did not elect to expand Medicaid. As a result, many low-income PLWH remain ineligible for Medicaid and would otherwise be, perversely, too poor to receive subsidies to purchase coverage through the insurance marketplaces. It is the ADAP funds that have kept many from falling through the cracks. “Moving patients to ACA insurance helps the Virginia ADAP use federal and state funds to cover a larger number of patients and help avoid waitlists for medications and services,” said McManus.
On a practical level, this shift is about getting more bang for the state’s buck. That is because ACA coverage offers more “comprehensive” care compared to Ryan White for the same or less money. According to McManus, Virginia ADAP pays an annual average of $6,234 per patient to keep patients insured under an ACA plan — which also provides services like primary care, diabetes management, and cancer screenings. That cost is just over half of the $11,500 the state typically spends merely to cover a patient’s medications through a traditional ADAP.
McManus noted that factors such as age, race, gender, and the disease’s progression affected patients’ decision whether or not to use ADAP funds to enroll through the insurance marketplace. She adds that the percentage of eligible patients who pursued that option varied from 14 percent to 74 percent depending on the location of the clinic where they typically received care. Currently, McManus and her colleagues are exploring why some sites saw lower enrollment rates than others. She notes that some clinic sites hired specially trained “certified application counselors” to assist patients with ACA enrollment.
Carlos del Rio, professor of medicine at Emory University and Chair of the HIV Medicine Association (HIVMA) praised the Virginia experience as a way to achieve better health outcomes despite the political climate. “We need better use of resources, not more resources,” said del Rio. He added that ACA enrollment provides the convenience of annual enrollment, in contrast to ADAP which requires renewal every six months. According to del Rio, ACA coverage may also expand access to more combinations of ART, compared to an individual ADAP’s set formulary.
Looking Ahead
While questions remain about how the ACA will ultimately impact ADAP and Ryan White funding, there is no uncertainty that PLWH who are engaged in care and treated with ART are more likely to achieve viral suppression and in turn, better health outcomes. From a public health standpoint, virologic suppression means less transmission of HIV and fewer new infections. Since the cost of HIV care in the U.S. is primarily covered by tax payers, good health outcomes are meaningful to everyone.
“We believe enrolling patients in ACA health plans would help ADAP clients in states without Medicaid expansion and those in states with Medicaid expansion who still do not qualify for Medicaid, but are struggling to afford care,” McManus summarizes. She notes that the nationwide landscape of HIV care “still is a patchwork,” but the experience in Virginia suggests the ACA may provide a cost-effective option to improve care.
“The ACA offers the opportunity to greatly expand access to HIV prevention, care, and treatment,” says del Rio. “Effective implementation [of the ACA] is critical to meeting the goals of the National HIV/AIDS Strategy and improving the lives of people with HIV/AIDS.”
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