Affordable Care Act (ACA) Celebrates Third Birthday: Many Successes, but Much Still To Do

By Amy Killelea, Senior Manager, Health Care Access, NASTAD

Signing of the ACAOn March 23, 2010 the Affordable Care Act (ACA) was signed into law. Three years later, many reforms are already helping people living with HIV and viral hepatitis access care and treatment:

  • AIDS Drug Assistance Program (ADAP) contributions now count toward Medicare Part D out-of-pocket spending, helping people living with HIV get through the coverage gap (“donut hole”) quicker.
  • Thousands of ADAP clients have been able to access insurance through Pre-existing Condition Insurance Plans (PCIPs).
  • Private insurance plans are now required to cover a range of preventive services (including services with a United States Preventive Services Task Force grade A or B as well as women’s preventive services) without cost sharing.
  • Several states have implemented the Medicaid Health Home program, which allows states to provide care coordination services – such as peer counseling, targeted social services referrals, and treatment management – for people with multiple chronic conditions, including HIV.

However, the most significant reforms for people living with HIV and viral hepatitis – namely, the Medicaid and private insurance expansions – will go into effect in January 2014. Over the coming weeks and months, federal agencies, state governments, and HIV/AIDS and viral hepatitis programs will be preparing for massive changes to the health care system. Ensuring that health reform implementation meets HIV and viral hepatitis prevention, care, and treatment needs turns on three questions:

1. Will the Medicaid Expansion Be Fully Implemented in Every State?

The Medicaid expansion – which allows states to expand Medicaid eligibility to most people with income up to 138 percent of the federal poverty level (FPL) in 2014 – is the most significant opportunity to increase access to care for people living with HIV and viral hepatitis. However, the Supreme Court’s decision taking away a major federal enforcement mechanism creates a question of when and if all states will comply with the expansion. As state advocacy efforts around the individual health, public health, and economic benefits of Medicaid expansion ramp up, there has been a growing trend of state acceptance of the expansion, even in states that had indicated initial political opposition to the ACA. This continued advocacy will be essential to ensure that every state eventually opts into the expansion.

2. Will the Benefits Available through Medicaid and Private Insurance Meet HIV and Viral Hepatitis Prevention, Care, and Treatment Needs?

Access to insurance, by itself, is not enough to ensure access to care or client utilization. The benefits available through Medicaid and private insurance must be able to meet HIV and viral hepatitis prevention, care, and treatment needs. The Essential Health Benefits (EHB) requirements for both the Medicaid expansion population and those purchasing private insurance in 2014 are largely being shaped and defined by the states. This means that state HIV/AIDS programs and providers must monitor benefits options and ensure that people living with HIV and viral hepatitis, particularly disproportionately impacted populations, have access to the care and treatment services they need to stay healthy as they transition to new coverage options.

3. Will We Be Able to Leverage the ACA and Preserve the Ryan White Program Expertise and Models of Care to Continue to Make Strides Along the Treatment Cascade?

As we move toward new coverage options through the ACA, HIV/AIDS and viral hepatitis programs are preparing for a vastly changing health care system. Programs are preparing to not only adapt to these changes, but to innovate along with a changing health care landscape to ensure engagement and retention in care even in an insured world. For instance, while ACA reforms provide a tremendous opportunity to improve access to care, even with increased access to Medicaid and private insurance there will be prevention, care, and treatment services not covered by insurance that HIV/AIDS and viral hepatitis programs will continue to provide. This is particularly true for vital enabling services (e.g., case management), affordability gaps (e.g., unmet cost-sharing and premium obligations even after federal subsidies), and populations left out of reform (e.g., undocumented immigrants). HIV/AIDS and viral hepatitis programs are preparing to transition clients to new coverage options and to operate in a post-health reform world to ensure continued access to the range of services that people need to engage in care and stay healthy.

As part of ongoing efforts to support health departments as they prepare for health reform implementation, NASTAD continues to develop presentations, issue briefs, and other health reform resources available on our Health Reform Resources Website. Check out our newest issue brief on Premium Tax Credits and Cost Sharing Subsidies and stay tuned for our forthcoming issue brief on viral hepatitis and health reform—“The Affordable Care Act and the Silent Epidemic: Increasing the Viral Hepatitis Response Through Health Reform.” To learn more about health reform and its impact of on health departments, please contact Amy Killelea.

We want to hear from you! What do you think about the anniversary of the ACA and what needs to happen between now and 2014? Tell us by leaving a comment below.

  • SSDHelp

    Thanks for the article! Quick Question, what exactly are the HIV and Viral Hepatitis Prevention, Care, and Treatment Needs?

    Social Security Disability Help

  • Matt Sharp

    Thanks Amy this is helpful. I’m also wondering however as the ACA is implemented, besides what you have mentioned in this article can you help me understand the processes and issues HIV+ are facing re: enrollment among the various sources of care coverage.


    Will HIV+ people have choices around which health plans to enroll in?
    If so, what are the issues for PLWH around choosing health plans?
    What should PLWH be taking into account in determining which plan to sign up for?
    Are there advocacy or education efforts to help PLWH understand the enrollment process



    Thanks for your question, Matt. As coverage through private insurance and Medicaid becomes available to people living with HIV, it will be important to make sure that people are able to access the plan that meets their care and treatment needs and that is affordable. This is particularly important given the fact that the “Essential Health Benefits” requirements have not been well-defined by the federal government, meaning that plans will continue to vary somewhat in scope of coverage and in benefit design. Exchanges/marketplaces will have a “plan finder” feature to help people compare scope of benefits, provider networks, and cost sharing obligations across plans. In addition, there will be outreach and enrollment programs, such as the Patient Navigator Program, that will fund organizations to assist people in applying for and enrolling in coverage (HIV/AIDS organizations are encouraged to apply for these programs). Stay tuned for a NASTAD Health Reform Issue Brief on this topic! -Amy

    • Matt Sharp

      Thanks Amy! I wonder if the “plan finder” will incorporate all the specific health care needs of HIV+ people and be specific enough to incorporate all the particular special care that HIV+ people require. Do you anticipate problems with the plans covering all HIV+ specific care needs?

      • NASTAD

        No problem, Matt! We’re expecting guidance in April and we plan to do an analysis that provides more information about client navigation for people living with HIV/AIDS at that point. – Amy