The ACA makes a measureable difference with HIV coverage

People with HIV experienced significant coverage gains under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) as a result of Medicaid expansion, the creation of the health insurance marketplaces, and the elimination of pre-existing condition exclusion. According to a Kaiser Family Foundation (KFF) Issue Brief, as long as the future of the ACA remains uncertain, those access and coverage gains are at risk.


To develop a baseline for understanding current access to care for people with HIV, KFF examined multiple variables across the three main pathways for HIV coverage and care: (1) Medicaid, (2) private insurance and the ACA marketplace, and (3) the Ryan White HIV/AIDS program. KFF considered factors like states’ Medicaid expansion status, the number of health insurance issuers per county, and AIDS Drug Assistance Program (ADAP) eligibility levels.


Prior to the ACA’s Medicaid expansion, most individuals with HIV obtained Medicaid coverage through the disability pathway, meaning that coverage was often not obtained prior to a beneficiary’s development of AIDS. Currently, 62 percent of people with HIV live in a Medicaid expansion state, where care is more likely to be accessible through the income pathway, regardless of disability level. Additionally, 24 states provide Medicaid coverage through the disability pathway above the federally mandated level of 73 percent of the federal poverty level (FPL).


In 33 states, where 83 percent of people with HIV live, there are three or more issuers in the ACA marketplace. While five states—Arkansas, Oklahoma, South Carolina and Wyoming—had only one issuer in 2017, some states had several. For example, Wisconsin had 15 insurers, New York had 14, and California had 11. KFF also looked at issuer representation in counties with high incidence of people with HIV. While 43 percent of people with HIV live in one of the eighteen (18) states with an average of three or more issuers per county, the majority of people with HIV—57 percent—live in one of the 33 states with less competition—one or two issuers per county.

Ryan White

The Ryan White HIV/AIDS Program provides outpatient HIV care and treatment to low and moderate income individuals. The program serves more than half of the people diagnosed with HIV in the country. The average eligibility level for the medication assistance program is 386 percent FPL. While 17 states use an eligibility level of 400 percent, 72 percent of people with HIV live in a state with eligibility levels at or above the national average. While the Ryan White program would continue to operate with an ACA repeal, many individuals currently covered by marketplace or Medicaid plans would likely turn to the program for coverage. Due to the program’s limited resources, KFF estimates that such an over-reliance could cause individuals to lose access to care.

$2.3B awarded to fund HIV/AIDS care, medications in 2016

Cities, states, and community organizations have received a total of almost $2.3 billion in Ryan White HIV/AIDS program grants. The program is overseen by the Health Resources and Services Administration (HRSA), and serves over 50 percent of people diagnosed with HIV in the United States. The program retained over 80 percent of those who received care in 2014, and over 81 percent of program clients were virally suppressed. All organizations receiving grants are working toward the goals found in the National HIV/AIDS Strategy.


To further these efforts, Part A of the program awarded about $627 million to 24 metropolitan areas and 28 transitional grant areas. These areas have the highest number of residents with HIV/AIDS or have an increased number of cases. Part B of the program awarded about $1.3 billion to allow states and territories to provide core medical and support services, and for the AIDS Drug Assistance Program (ADAP). Part B also issued Emerging Community and Minority AIDS initiative grants.

Part C Early Intervention Services (EIS) awarded about $186 million to local organizations that provide core services to HIV patients. Part C Capacity Development grants were also awarded to about 48 organizations. Part D awarded $66.6 million in grants to 115 organizations to fund family-centered care. Part F awarded several grants to fund dental care, as well as technical assistance and clinical training.