The Implications of the Affordable Care Act on the HIV Continuum of Care



Graphic created by Michelle Samplin-Salgado, JSI Senior Consultant

For people living with HIV, the Ryan White HIV/AIDS Program (RWHAP) has provided medical care and support services since its inception in 1990. However, people with HIV have medical needs beyond their HIV infection. With the aging of the HIV population in the United States, more are coping with diabetes, heart disease, arthritis and other conditions, not necessarily covered by the RWHAP. The ability for this community to access health insurance under the Affordable Care Act (ACA) marks yet another huge turning point in the HIV epidemic.

The Supreme Court of the United States in its recent ruling in King vs. Burwell found that tax subsidies in states with federally operated marketplaces were legal under the provisions of the ACA. The ruling has been hailed as a sign that the Affordable Care Act is “here to stay.” This optimism is based on the fact that the Supreme Court looked at the full intention of the law and not just a single phrase, taken out of context. As Chief Justice John Roberts said in his majority opinion, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

Much of our work in public health is focused on vulnerable populations. Historically, these individuals living with chronic diseases such as HIV, diabetes, cancer, substance use, and hepatitis, have often been excluded from health insurance coverage for having “pre-existing conditions.” These individuals have suffered financial collapse, untreated illness and, indeed, death as a result of the lack of health insurance. Now, our work is shifting, the ACA has been designed to bring EVERYONE under the umbrella of insurance coverage through financial subsidies and other supports that offset the costs of providing care to individuals with an illness with an expanded pool of healthy individuals. While some backlash has occurred among those who don’t think they need health insurance, it’s important to remember that virtually all human beings suffer some kind of illness in their lifetime and will need medical services.

Several of us at JSI have worked in the area of HIV/AIDS and health care reform for many years now. When we saw an opportunity to provide technical assistance to help enroll people living with HIV (PLWH) who are clients of the Ryan White HIV/AIDS Program into Affordable Care Act coverage options, it was an exciting opportunity to help move the HIV/AIDS community into the “modern era” of health care reform. The program was sponsored by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, and supported by the Secretary’s Minority AIDS Initiative Fund. This successful funding opportunity gave rise to the HRSA/JSI Affordable Care Enrollment (ACE) Technical Assistance (TA) Center.

The Center, now in its second year of operation, has developed 15 technical assistance and training tools and an online resource guide for provider staff including case managers and enrollment assisters. The ACE TA Center has also conducted nine skills-building webinars and provided targeted technical assistance in many settings across the country. At the same time, the nation’s efforts to end the HIV epidemic have increasingly focused on strengthening the HIV continuum of care, specifically by ensuring PLWH know their status, are linked to and retained in care, and receive and adhere to antiretroviral medication to achieve viral suppression.

As part of our work to support the efforts of RWHAP grantees across the country to enroll PLWH into new coverage options (both marketplace and Medicaid), we began to notice how various provisions of the ACA help support each of the steps along the HIV continuum of care, even as the Ryan White HIV/AIDS Program remains crucial to supporting engagement and retention in care.

It is clear that those implementing enrollment into the ACA and serving the HIV community that the ACA insurance coverage can improve results along each step of the continuum. By implementing health care reform among this population and enrolling them into health coverage, we can both improve the quality of their health care and help stem the tide of new HIV cases achieve the goal, ultimately, of no new infections.