Blog Post for World AIDS Day, December 1, 2016
On world AIDS Day, following an election that called for a referendum on the elimination of The Patient Protection and Affordable Care Act (PPACA), it is important to consider the consequences of repealing the PPACA as it relates to the HIV/AIDS epidemic. It is estimated that the PPACA currently supports 20 million previously uninsured people with health insurance coverage. Under the PPACA, 32 states, as well as Washington D.C., expanded Medicaid, a significant source of coverage for people living with HIV/AIDS (PLWHA). Health equity has progressed under the PPACA, as well. Since 2013, the uninsured rate has declined by 9.2% among African Americans, 12.3% among Latinos and 7.7% among women. Insurers can no longer impose lifetime caps on insurance benefits and the Pre-existing Condition Insurance Plan was created for those precluded from care due to their health status. The PPACA has undoubtedly improved access to care for persons living with HIV/AIDS (PLWHA) and has been one of the most meaningful pieces of legislature in the history of the HIV/AIDS epidemic.
Equitable access to care unquestionably influences the state of the HIV/AIDS epidemic. Whatever dismantling or rebuilding of the PPACA may now occur, we must work to ensure that gains made in increasing access to HIV testing services and treatment are retained. The Kaiser Permanente HIV Access and Linkage to Care Initiative focuses on ensuring linkage to medical care for PLWHA via community based organizations (CBO) and outreach. Seven sites throughout the United States were funded to test this approach, and GEH researchers at UC San Diego have led the evaluation. While evaluation results are not yet available, information on engagement in care across these sites demonstrates clear findings:
1) Many PLWHA Are Socially Marginalized, Requiring Safety Net Health Care PLWHA participants, recruited through community-based organizations and outreach efforts, maintain a high social and health burden that can affect access to care. One-third (31%, relative to the 15% of US adults as a whole) did not complete high school. Over half (54%) were disabled, and 22% were living on the streets or in a shelter at recruitment. Most (81%) had an income of <$1000 per month. Medicaid expansion through the PPACA helps ensure health care coverage that might otherwise be denied can be guaranteed, facilitating access to HIV care for this population.
2) Insurance is Key to Support Health Care Utilization for PLWHA Even with the PPACA, more than 1 in 6 participants in our project (17.1%) reported no form of health insurance, with immigrants and rural residents being least likely to be insured. The importance of insurance for people living with HIV/AIDS cannot be understated. Consistent with prior research, the study thus far has found that participants with insurance were almost 3x as likely to have received HIV medical care in the past 6 months, which in turn increased their likelihood of being on anti-retroviral therapy and having known viral suppression.
3) Trauma and Substance Abuse Services Must Be Prioritized Victimization from violence is a disproportionate burden for PLWHA; more than one-third of participants reported victimization from physical and sexual violence, respectively (39.6% physical and 33.3% sexual). Such trauma increases risk for substance use across the lifespan. One in five participants (19%) used illicit drugs in the past 30 days, and most of these (69%) reported harms to self or others due to drug use in the same timeframe. Trauma support services and substances abuse treatment must be retained as part of health care coverage for PLWHA, and can support maintenance in HIV medical care.
Access to insurance undoubtedly falls under the "Patient Protections" component of the PPACA. It is clear that PLWHA need this access and dismantling it would have grave impact on HIV care utilization and consequent ART use and viral suppression. Not only will this compromise the health of PLWHA, it can potentially increase HIV infectioun rates, which has declined by 19% over the past decade. To address this possibility and to avoid a reversal in progress over the course of the HIV/AIDS epidemic, the US health care system must continue to prioritize PLWHA and ensure their access to insurance and comprehensive care inclusive of ART, mental health care, and substance abuse treatment.
- Finegold, K., Gee, E., Uberoi, N. (2016, March 3). Health Insurance Coverage and the Affordable Care Act, 2010-2016. U.S. Department of Health and Human Services. Retrieved from: http://garnerhelath.com/wp-content/uploads/2014/02/ACA2010-2016.pdf
- Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. Retrieved from: http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
- Center for Disease Control. 2015. The Affordable Care Act Helps People Living with HIV/AIDS. Retrieved form: https://www.cdc.gov/hiv/policie/aca.html
- United States Census Bureau. Quick Facts: United States. Retrieved from: https://census.gov/quickfacts/table/EDU635214/00
- AIDS.gov (2016, November 01). The Affordable Care Act and HIV/AIDS. Retrieved from: https://www.aids.gov/federal-resources/policies/halth-care-reform/
- Key Facts about the Uninsured Population. Kaiser Family Foundation. Retrieved from: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
- Center for Disease Control. 2016. Trends in U.S. HIV Diagnoses, 2005-2014. Retrieved from: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-data-trends-fact-sheet-508.pdf
Blog Prepared by the UCSD GEH Kaiser Permanente HIV Access and Linkage Care Team: Jennifer Yore, Emma Jackson, Lianne Urada, Laramie Smith, Daniel Triplett, and Anita Raj (Principal Investigator).
We would also like to acknowledge out partners in Kaiser Permanente Community Benefits (Alexandra Caraballo, John Edmiston, Pamela Schwartz, and Melissa Ramos) and our Site Coordinators: Sergio Avina & Christopher Hucks-Ortiz (JWCH, Los Angeles), Bradley Boekeloo & Abby Charles (iPH, Prince Georges Co, Maryland), Tooru Nemoto & Mariko Iwamoto (PHI, San Francisco), Nilda Ricard, Brandon O'Connell & Jahad Robinson (Fortune Society, New York City), Corey Rosmarin-DeStefano, Shariff Hall, & Liliane Windsor (NJCRI, Newark, NJ), Beth Stringfield & Sara LeGrand (Duke University, North Carolina), Cynthia Carey-Grant, Stephanie Cornwell, & Samantha Field (WORLD, Oakland, CA).