The Affordable Care Act at work – increasing health care access for people living with HIV in California

Implementation and operational research: affordable care act implementation in a California health care system leads to growth in HIV-positive patient enrollment and changes in patient characteristics.

Satre DD, Altschuler A, Parthasarathy S, Silverberg MJ, Volberding P, Campbell CI. J Acquir Immune Defic Syndr. 2016 Dec 15;73(5):e76-e82.

Objectives: This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014.

Methods: This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization.

Results: Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort.

Conclusions: As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.

Abstract access   [1]

Editor’s notes: This paper provides a very useful assessment of the Affordable Care Act (ACA) (commonly called ‘Obama-Care’) coverage for people living with HIV in part of California. As the authors note, a goal of the Affordable Care Act was to increase health-care coverage for people with chronic conditions. They also note that before the implementation of the ACA, many people living with HIV lacked health-care insurance covering HIV-medications and HIV medical care. It has the potential to make a difference to people with chronic conditions. The ACA has removed exclusions for insurance access, like pre-existing conditions. It has also removed caps on costs and provides financial support for health care premiums. 

As anticipated by the authors, the passing of the ACA had provided greater access to care for people living with HIV. However, challenges exist in supporting people living with HIV who have co-morbidities. The authors note that people living with HIV in need of psychiatric care, or because of substance use, were not always reached. This is partly because people do not come forward for care.  The authors suggest that integrated care where HIV-care is provided with support for other chronic conditions can help reach more people to come forward.

At a time of change in the United States, this paper is timely in highlighting the value of the Affordable Care Act for people living with HIV.  

Northern America [6]
United States of America [7]
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