Last Friday’s unsuccessful repeal of the Affordable Care Act (ACA) leaves, at least for now, healthcare coverage for a notable proportion of HIV patients untouched. Had the GOP-led repeal of Obamacare been successful, a number of provisions afforded by the ACA that have helped increase insurance rates among people living with HIV (PLWHIV) could have been amended or eliminated. These provisions, which include the removal of exclusions due to pre-existing conditions and state Medicaid expansions, have helped increase the percentage of PLWHIV with health insurance by reducing the overall cost of health insurance. In particular, Medicaid expansions, which have rolled out in 32 states so far (including Washington DC), have been instrumental in offering Medicaid coverage for individuals ages 18 to 64 with incomes up to 138% above the federal poverty level. As the largest single payer for PLWHIV, the expansion of Medicaid was a key driver in reducing the percentage of uninsured HIV patients between 2012 and 2014, according to a CDC/Kaiser Family Foundation study. The study finds that over 90% of uninsured PLWHIV are effectively eligible for coverage under the Medicaid expansions. In fact, states implementing Medicaid expansions saw a decline in the percentage of uninsured PLWHIV from 13% in 2012 to 7% in 2014 (compared to a decline from 26% to 23% in non-expansion states). Further, early reports from Express Scripts, one of the nation’s largest pharmacy benefit management companies, claimed high utilization of HIV drugs among their ACA enrollees relative to their employer-based plans in 2014.

The United States stands out among other developed countries as the only nation with nearly half of its diagnosed HIV population untreated for their infection. Decision Resources Group estimates that in 2016, only about 55% of the diagnosed HIV population in the United States received antiretroviral therapy. In contrast, drug-treatment rates in the major European markets (e.g., France, Germany, United Kingdom) are well-above 80%. We know that in the U.S. linkage-to-care is the primary hurdle to receiving HIV treatment, which is where the ACA has played a central role in expanding care to previously uninsured patients. With an average yearly cost of $25,000 per HIV regimen, it is nearly impossible for uninsured patients to pay for these medications out-of-pocket or without government subsidies. Our analysis of the HIV market suggests that when prescribing of antiretroviral (ARV) therapies, managing physicians encounter few payer-imposed restrictions on the majority of HIV therapies, suggesting that once a patient is able to gain coverage, they are readily treated for HIV. HIV is a chronic disease requiring life-long, daily dosing of ARV agents, and although programs funded via the Ryan White Act can offer financial support to uninsured or underinsured individuals seeking HIV care, linkage-to-care is still critical for the adequate management of an HIV infection. We need only look to sub-Saharan Africa to see the devastation that not adequately treating HIV can cause. Africa is home to more than 90% of the world’s HIV-positive children, a result of inadequate treatment of HIV-positive pregnant mothers, and where 70% of global deaths due to HIV and AIDS occur. Linkage to care for PLWHIV is not just important for an individual, it can set the baseline for health and well-being of an entire continent.

Despite the House’s failure to pass a healthcare reform bill last week, Speaker Paul Ryan stresses that House Republicans will continue their efforts to reform healthcare in the United States. However, for now, one thing is clear: the ACA has helped PLWHIV get treatment for HIV. What remains to be determined is whether the same can be said for the next iteration of healthcare reform.

For more information on Decision Resources Group and our HIV coverage, please contact us here.

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