The Patient Protection and Affordable Care Act (ACA), more commonly known as health reform, is designed to expand health coverage to 32 million uninsured Americans by 2019 and makes significant changes to public and private health insurance systems that will affect providers of HIV care. We review the major features of the legislation and when they will be implemented, discuss the ways in which it will affect HIV care for different patient populations, and outline implementation challenges that are relevant for HIV care. We conclude with ways in which HIV providers can get involved to learn more about the law and help their patients take advantage of the new opportunities for health coverage.
With the Affordable Care Act set to expand insurance coverage to millions more Americans next year, existing discretionary health programs that receive federal support might find themselves competing for funds as the health reform law is fully implemented. To assess the implications the Affordable Care Act might have on discretionary health programs, we focused on state AIDS Drug Assistance Programs, which provide free medications to low-income HIV patients. We conducted semistructured interviews with program managers from twenty-one states. Many of the managers predicted that their programs will change focus to provide "wrap-around services," such as helping newly insured clients finance out-of-pocket expenses, including copays, deductibles, and premiums. Although program managers acknowledged that they must adapt to a changing environment, many said that they were overwhelmed by the complexity of the Affordable Care Act and some expressed fear that state AIDS Drug Assistance Programs would be eliminated entirely. To remain viable, such programs must identify and justify the need for services in the context of the Affordable Care Act and receive sufficient political support and funding.
Although the federal government will finance most of the coverage expansions of the Patient Protection and Affordable Care Act (ACA), implementation is largely devolved to states. Drawing from interviews with HIV policy experts and program managers and a documents review, the authors enumerate actions that must occur at multiple levels of government in order for ACA implementation in the context of HIV care to improve access to health care and health outcomes and the conditions under which these may fall short. Positive outcomes are predicted for HIV patients in states with sufficient political support and resources to implement the ACA. However, outcomes may worsen in states that do not implement the Medicaid expansion or other ACA provisions, particularly if federal funding for discretionary safety net programs is reduced. Transitioning patients from HIV‐specific programs to other coverage sources may also reduce HIV services in states that previously were at the forefront of HIV care.
A state-transition model of HIV disease was used to project the costs to Medicaid, Medicare, and AIDS Drug Assistance Programs of proposed Section 1115 Medicaid demonstration projects for the early treatment of HIV-infected patients in Georgia and Massachusetts. Neither demonstration project was projected to meet 5-year tests of no increase in Federal spending and in both States average patient costs to all payers were highest in the first year after enrollment. In assessing expanded health care access for patients with chronic diseases, government payers should consider overall budgetary effects and separately analyze costs for each year's enrollees to avoid creating incentives to cap enrollments.
CONTEXT: Curative treatments for hepatitis C virus (HCV) can alter the course of a devastating epidemic, but high drug prices have contributed to restrictions on HCV treatment access. OBJECTIVE: We aimed to learn how state health agencies have responded to the challenges of treatment access for HCV. DESIGN: Qualitative study using semi-structured key informant interviews, focused on aspects of HCV treatment access, between June 2016 and March 2017. Content analysis was used to identify dominant themes. SETTING: United States PARTICIPANTS: Eighteen health officials and treatment advocates across six states, selected using purposive sampling. RESULTS: Drug pricing is the most important barrier to access, encouraging restrictive authorization criteria from payers that in turn discourage providers from offering treatment. However, payers have not experienced the budget impact that was initially feared. Although authorization criteria are being lifted for fee-for-service Medicaid programs, ensuring that managed care organizations follow suit remains a challenge. The effect of stigma, a shortage of treating providers, and lack of political motivation are additional challenges to expanding treatment. The response to the HIV epidemic can augment or inform strategies for HCV treatment delivery, but this is limited by the absence of dedicated funding. CONCLUSIONS: While treatment eligibility criteria for HCV treatment are improving, many other barriers remain to achieving the scale-up needed to end the epidemic. Political disinterest, stigma, and a lack of specialty providers are continued barriers in some jurisdictions. States may need to invest in strategies to overcome these barriers, such as engaging in public and provider education and ensuring treatment by primary care providers is reimbursed. Despite uncertainty about how federal policy changes to Medicaid may affect states' ability to respond, states can identify opportunities to improve access.
Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to office staff, and state participation in interstate data sharing. Our analysis of information from a large commercial insurance database indicated that comprehensive use mandates implemented during 2011–15 were associated with a 6–9 percent reduction in opioid prescriptions with high risk for misuse and overdose. We also found delegate laws to be associated with reductions of a similar magnitude for selected outcomes. In general, the effects of all three policies strengthened over time, especially beginning in the second year after implementation. Our findings support comprehensive use mandates and delegate laws to optimize prescribers' use of drug monitoring programs, but the results will need updates in the context of evolving state opioid policies—including the increasing integration of drug monitoring data with electronic health records.
Objectives. This study was designed to examine the societal cost-effectiveness and the impact on government payers of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults.
Background: HIV prevalence in Puerto Rico is nearly twice that of the mainland United States, a level that was substantially fueled by injection drug use. Puerto Rico has a longstanding history of health provision by the public sector that directly affects how HIV and substance use disorder (SUD) treatment services are provided and funded. As part of pre-implementation research for a randomized trial of a community-level intervention to enhance HIV care access for substance users in San Juan, Puerto Rico, we sought to understand the structural and health policy environment for providing HIV and SUD treatments. Methods: We conducted semi-structured qualitative interviews (n = 8) with government and program administrators in English and Spanish. Data were analyzed to identify dominant and recurrent themes. Results: Participants discussed how lack of integration among medical and mental health service providers, lack of public transportation, and turnover in appointed government officials were barriers to integrated HIV and SUD treatment. Federal funding for support services for HIV patients was a facilitator. The Affordable Care Act has limited impact in Puerto Rico because provisions related to health insurance reform do not apply to U.S. territories. Discussion and Conclusions: Implications for intervention design include the need to provide care coordination for services from multiple providers, who are often physically separated and working in different reimbursement systems, and the potential for mobile and patient transportation services to bridge these gaps. Continuous interaction with political leaders is needed to maintain current facilitators. These findings are relevant as the current economic crisis in Puerto Rico affects funding, and may be relevant for other settings with substance use-driven epidemics.
IntroductionRetention in HIV care prior to ART initiation is generally felt to be suboptimal, but has not been well‐characterized.MethodsWe examined data on 37,352 adult pre‐ART patients (ART ineligible or unknown eligibility) who enrolled in care during 2005–2008 with >1 clinical visit at 23 clinics in Mozambique. We defined loss to clinic (LTC) as >12 months since the last visit among those not known to have died/transferred. Cox proportional‐hazards models were used to examine factors associated with LTC, accounting for clustering within sites.ResultsOf 37,352 pre‐ART patients, 61% had a CD4 count within three months of enrolment (median CD4: 452, IQR: 345–611). 17,598 (47.1%) were ART ineligible and 19,754 (52.9%) were of unknown eligibility status at enrolment because of missing information on CD4 count and/or WHO stage. Kaplan‐Meier estimates for LTC at 12 months were 41% (95% CI: 40.2–41.8) and 48% (95% CI: 47.2–48.8), respectively. Factors associated with LTC among ART ineligible patients included male sex (AHRmen_vs_non‐pregnant women: 1.5; 95% CI: 1.4–1.6) and being pregnant at enrolment (AHRpregnant_vs_non‐pregnant women: 1.3; 95% CI: 1.1–1.5). Older age, more education, higher weight and more advanced WHO stage at enrolment were independently associated with lower risks of LTC. Similar findings were observed among patients whose ART eligibility status was unknown at enrolment.ConclusionsSubstantial LTC occurred prior to ART initiation among patients not yet known to be eligible for ART, including nearly half of patients without documented ART eligibility assessment. Interventions are needed to target pre‐ART patients who may be at higher risk for LTC, including pregnant women and patients with less advanced HIV disease.
