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The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals

  • The Science of Prevention (JD Stekler and JM Baeten, Section Editors)
  • Published:
Current HIV/AIDS Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals.

Recent Findings

Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed.

Summary

While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.

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Abbreviations

ACA:

Affordable Care Act

ADAP:

AIDS Drug Assistance Program

ART:

antiretroviral therapy

BRFSS:

Behavioral Risk Factor Surveillance System

CDC:

Centers for Disease Control and Prevention

DID:

difference-in-differences analysis

FPL:

Federal Poverty Level

HIV:

human immunodeficiency virus

MSM:

men who have sex with men

PLWH:

people living with HIV

RWHAP:

Ryan White HIV/AIDS Program

UNAIDS:

Joint United Nations Program on HIV/AIDS

US:

United States

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Centers for Disease Control and Prevention (2017) Understanding the HIV Care Continuum National HIV Prevention Objectives on HIV Diagnosis and Care, 2014. 1–4.

  2. Skarbinski J, Rosenberg E, Paz-Bailey G, Hall HI, Rose CE, Viall AH, Fagan JL, Lansky A, Mermin JH (2015) Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Intern Med 175:588–588, 596.

  3. Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014) 90-90-90 an ambitious treatment target to help end the AIDS epidemic. Geneva.

  4. White House Office of National AIDS Policy National HIV/AIDS Strategy: Updated to 2020. 1–74.

  5. HIV.gov. How does the Affordable Care Act help people living with HIV/AIDS? In: 1–3; 2012.

    Google Scholar 

  6. • Wagner Z, Wu Y, Sood N. The Affordable Care Act may increase the number of people getting tested for HIV by nearly 500,000 by 2017. Health affairs (Project Hope). 2014;33:378–85 Modeling estimated a 22% reduction in the number of unware people living with HIV between 2013 and 2017.

    Article  Google Scholar 

  7. Bradley H, Viall AH, Wortley PM, Dempsey A, Hauck H, Skarbinski J. Ryan White HIV/AIDS program assistance and HIV treatment outcomes. Clin Infect Dis. 2016;62:90–8.

    Article  PubMed  Google Scholar 

  8. Centers for Disease Control and Prevention. NCHHSTP AtlasPlus; 2017.

  9. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2014. Atlanta. 2015.

  10. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data-United States and 6 dependent areas-2013. HIV Surveillance Supplemental Report. 2015;20:1–70.

    Google Scholar 

  11. Centers for Disease Control and Prevention. HIV surveillance report, 2016. 28:table 24; 2017.

  12. The Henry J. Kaiser Family Foundation (2018) Status of state action on the Medicaid expansion Decision.

  13. • Kates J, Garfield R, Young K, Quinn K, Frazier E, Skarbinski J. Assessing the impact of the Affordable Care Act on health insurance coverage of people with HIV | The Henry J. Kaiser Family Foundation. 2014. This report discusses how the ACA may increase or decrease access to care for people with HIV and how Medicaid expansion may interact with the resources from the Ryan White HIV/AIDS Program.

  14. Snider JT, Juday T, Romley JA, Seekins D, Rosenblatt L, Sanchez Y, et al. Nearly 60,000 uninsured and low-income people with HIV/AIDS live in states that are not expanding Medicaid. Health affairs (Project Hope). 2014;33:386–93.

    Article  Google Scholar 

  15. Goldman DP, Leibowitz AA, Joyce GF, Fleishman JA, Bozzette SA, Duan N, et al. Insurance status of HIV-infected adults in the post-HAART era: evidence from the United States. Appl Health Econ Health Policy. 2003;2:85–90.

    PubMed  Google Scholar 

  16. Yehia BR, Fleishman JA, Agwu AL, Metlay JP, Berry SA, Gebo KA. Health insurance coverage for persons in HIV care, 2006–2012. J Acquir Immune Defic Syndr. 2014;67:102–6.

    Article  PubMed  PubMed Central  Google Scholar 

  17. The Henry J. Kaiser Family Foundation. Medicaid enrollment and spending on HIV/AIDS (FY07-FY11). In: State Health Facts. 2016. http://kff.org/health-reform/state-indicator-enrollment-spending-on-hiv. Accessed 21 Mar 2018.

  18. •• Kates J, Dawson L. Insurance coverage changes for people with HIV under the ACA. The Henry J Kaiser Family Foundation; 2017, pp 1–11. This in-depth qualitative research communicates real people’s experiences and the trade-offs.

  19. del Rio C. The evolving HIV epidemic in the United States. Conference on Retroviruses and Opportunistic Infections.

  20. Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, et al. The Oregon experiment — effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368:1713–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. • Viall AH, McCray E, Mermin J, Wortley P. Current and (potential) future effects of the Affordable Care Act on HIV prevention. Curr HIV/AIDS Rep. 2016;13:95–106 This review provides the location reference for each section of the Affordable Care Act that creates a change impacting HIV prevention.

    Article  PubMed  Google Scholar 

  22. • Lipira L, Williams EC, Hutcheson R, Katz AB. Evaluating the Impact of the Affordable Care Act on HIV Care, Outcomes, Prevention, and Disparities: A Critical Research Agenda. J Health Care Poor Underserved. 2017;28:1254–75 This review focuses on disparities in HIV, expands on heterogeneity of risk, and discusses potential heterogeneity of ACA effect.

    Article  PubMed  Google Scholar 

  23. Massachusetts General Laws Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care.

  24. Massachusetts General Laws Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care. The 190th gGeneral Court of the Commonwealth of Massachusetts.

  25. Phillips AN, Staszewski S, Weber R, Kirk O, Francioli P, Miller V, et al. HIV viral load response to antiretroviral therapy according to the baseline CD4 cell count and viral load. JAMA. 2001;286:2560–7.

    Article  CAS  PubMed  Google Scholar 

  26. INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373:795–807.

    Article  CAS  Google Scholar 

  27. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375:830–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Bounthavong M, Adamson B, Basu A. Instrumental variables: a tool to reduce bias in non-randomized studies. Value and Outcomes Spotlight. 2016;2:25–5.

    Google Scholar 

  29. •• Cranston K, John B, Fukuda HD, Randall LM, Mermin J, Mayer KH, et al. Sustained reduction in HIV diagnoses in Massachusetts, 2000–2014. Am J Public Health. 2017;107:794–9 Massachusetts provides the first valid evidence that the percent of people unware of HIV infection is decreasing because of Medicaid expansion increasing the access to and frequency of HIV testing. At the same time, there were fewer new HIV diagnoses over time because effective prevention interventions lowered incidence rates.

    Article  PubMed  PubMed Central  Google Scholar 

  30. •• Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manage. 2017;36:390–417 Excellent example of a difference-in-differences regression analysis that can serve as a guide for future research on policy impact affect on 90-90-90 goals.

    Article  PubMed  Google Scholar 

  31. Sommers BD, Maylone B, Blendon RJ, Orav EJ, Epstein AM. Three-year impacts of the affordable care act: improved medical care and health among low-income adults. Health Aff. 2017;36:1119–28.

    Article  Google Scholar 

  32. •• Furl R, Watanabe-Galloway S, Lyden E, Swindells S. Determinants of facilitated health insurance enrollment for patients with HIV disease, and impact of insurance enrollment on targeted health outcomes. BMC Infect Dis. 2018;18:132 Among all people living with HIV that became eligible for Medicaid after expansion in Nebraska, those who enrolled had a significant improvement in viral suppression.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Erugo E. Impact of the Affordable Care Act on the HIV care continuum. Walden Dissertations and Doctoral Studies; 2017.

  34. Eaton EF, Mugavero MJ. Editorial commentary: affordable care act, Medicaid expansion … or not: Ryan White care act remains essential for access and equity. Clin Infect Dis. 2016;63:404–6.

    Article  PubMed  Google Scholar 

  35. Satre DD, Parthasarathy S, Altschuler A, Silverberg MJ, Storholm E, Campbell CI. Demographic, insurance, and health characteristics of newly enrolled HIV-positive patients after implementation of the Affordable Care Act in California. Am J Public Health. 2016;106:1211–3.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Diepstra KL, Rhodes AG, Bono RS, Patel S, Yerkes LE, Kimmel AD. Comprehensive Ryan White assistance and human immunodeficiency virus clinical outcomes: retention in care and viral suppression in a Medicaid nonexpansion state. Clin Infect Dis. 2017;65:619–25.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Emory University Rollins School of Public Health AIDSVu. www.aidsvu.org.

  38. Reif S, Safley D, McAllaster C, Wilson E, Whetten K. State of HIV in the US deep south. J Community Health. 2017;42:844–53.

    Article  PubMed  Google Scholar 

  39. Garfield R, Damico A. The coverage gap: uninsured poor adults in states that do not expand Medicaid. The Henry J. Kaiser Family Foundation; 2017.

  40. Del Rio C. The evolving HIV epidemic in the United States. Boston; 2018, p. 1.

  41. Rosenberg ES, Millett GA, Sullivan PS, del Rio C, Curran JW. Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: a modelling study. Lancet HIV. 2014;1:e112–8.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Comulada WS, Desmond KA, Gildner JL, Leibowitz AA. Transitioning from Medicaid disability coverage to long-term Medicare coverage: the case of people living with HIV/AIDS in California. AIDS Educ Prev. 2017;29:49–61.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Winkelman TNA, Chang VW. Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. J Gen Intern Med. 2018;33:376–83.

    Article  PubMed  Google Scholar 

  44. Geter A, Sutton MY, Hubbard McCree D. Social and structural determinants of HIV treatment and care among black women living with HIV infection: a systematic review: 2005–2016. AIDS Care. 2018;30:409–16.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Gilman B, Bouchery E, Hogan P, Degrusa S, Trent-Adams S, Cheever L. The HIV clinician workforce in the United States: supply and demand projections from 2010–2015. HIV Specialist. 2016;8:1–32.

    Google Scholar 

  46. Paterson C. Mind the gap: the impact of the ACA Medicaid expansion on health outcomes in the United States. 2017.

  47. Newhouse JP, McClellan M. Econometrics in outcomes research: the use of instrumental variables. Annu Rev Public Health. 1998;19:17–34.

    Article  CAS  PubMed  Google Scholar 

  48. Johnston KM, Gustafson P, Levy AR, Grootendorst P. Use of instrumental variables in the analysis of generalized linear models in the presence of unmeasured confounding with applications to epidemiological research. Stat Med. 2008;27:1539–56.

    Article  CAS  PubMed  Google Scholar 

  49. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41–55.

    Article  Google Scholar 

  50. Strand L, Adamson B, Basu B. The good, the bad, and the ugly: reminders about propensity scores. Value and Outcomes Spotlight. 2017;3:21–2.

    Google Scholar 

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Acknowledgments

We would like to thank Anirban Basu for the input on policy analysis methods for causal inference using observational data. Lisa McLoughlin provided technical editing.

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Authors and Affiliations

  1. The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, 1959 NE Pacific Street, HSB H-375, Box 357630, Seattle, WA, 98195-7630, USA

    Blythe Adamson

  2. Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, USA

    Blythe Adamson

  3. Department of Health Services, University of Washington, Seattle, USA

    Lauren Lipira & Aaron B. Katz

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  1. Blythe Adamson
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Correspondence to Blythe Adamson.

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Adamson, B., Lipira, L. & Katz, A.B. The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals. Curr HIV/AIDS Rep 16, 105–112 (2019). https://doi.org/10.1007/s11904-019-00429-6

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