Healthcare Reform and Patients with HIV

Ensuring that all individuals in the United States who are living with HIV have access to quality healthcare has been a challenge since the onset of the epidemic. The Patient Protection and Affordable Care Act (ACA) is designed to expand access to affordable health coverage and reduce the number of uninsured Americans. In 2014, when provisions of the law are fully implemented, it is expected that access to care will be significantly expanded for those with HIV who are currently uninsured or otherwise unable to gain access to affordable and stable healthcare.

The Henry J. Kaiser Family Foundation recently released a report titled The Affordable Care Act, the Supreme Court, and HIV: What Are the Implications? to address the implications of the ACA as they relate to individuals with HIV, taking into account the June 2012 US Supreme Court ruling.

There are significant benefits to early HIV treatment; 1 study found that early antiretroviral treatment (ART) reduced transmission of HIV from an HIV-positive partner to a negative partner by 96%. For patients with HIV, other findings from other studies suggest that early ART also significantly delays progression of the disease and reduces the occurrence of adverse health events and death.

There are more than 1 million people in the United States who are living with HIV and approximately 50,000 are newly infected each year. Of those, only an estimated 37% are retained in regular HIV care. Once retained in care, 89% receive ART. Of those, 76% are virally suppressed.

However, due to what the report termed “cliffs in the continuum of care,” only 25% of the total US HIV population is virally suppressed. This suggests that “while policy attention is needed at each stage of the cascade, increasing the share of people with HIV who are retained in regular care is a critical point of intervention for maximizing public health and clinical benefits,” the report stated.

There are several ACA provisions that are of particular relevance to people with HIV. The first is expansion of coverage or services, including the clause outlining insurance protections for consumers. The pre-existing condition insurance plan establishes a temporary program in every state to provide coverage for people with pre-existing medical conditions, including HIV, who have been uninsured for 6 months and denied medical coverage (effective July 2010; the program will be dissolved when other coverage expansion provisions take effect in 2014).

Among provisions aimed at disease prevention, a prevention and public health fund was established in July 2010. In fiscal year 2012, $30 million was allocated for new Centers for Disease Control and Prevention HIV Prevention Activities, including establishing the Enhanced Comprehensive HIV Prevention Plan, as well as increased investments in HIV surveillance and testing. Other prevention efforts include free annual HIV screenings for women (effective for plan years after August 2012).

HIV-related ACA provisions that will take effect in 2014 include expanded Medicaid coverage, the establishment of private health insurance exchanges, health insurance premium and cost-sharing subsidies, guaranteed availability of coverage, no annual limits on coverage, and the requirement that US citizens and legal residents have qualifying health coverage.

The report concluded with an overview of the US Supreme Court’s June 2012 ruling on the constitutionality of the ACA. The court ruling maintained the expansion of Medicaid coverage, but limited the Secretary’s enforcement authority of the expansion.

It is uncertain what the ultimate impact of the Court’s ruling will have on low-income people with HIV, although, according to the report, the ACA is still expected to greatly increase insurance coverage for that population.

In conclusion, the report’s authors stated, “The [ACA] has already led to improvements in access to and quality of care for people living with HIV and, when fully implemented in 2014, is expected to significantly expand access even further. At the same time, there are several outstanding questions regarding the implementation of the ACA, and decisions that have yet to be made by the federal government and the states that will affect its ultimate reach. There are also key opportunities for working to ensure that new systems of care will include high-quality HIV standards for realizing the potential of the ACA to be a ‘game changer’ in reducing the burden of the HIV epidemic in the United States.”