title: Healthcare Coverage for HIV Provider Visits Before and After Implementation of the Affordable Care Act.
abstract: Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida).
  
  
  
  Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent.
  
  
  
  In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99).
  
  
  
  In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.
authors.affiliation: Department of Internal Medicine, Johns Hopkins University School of Medicine.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Berry
authors.affiliation: Department of Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality.
authors.forename: John A
authors.initials: JA
authors.lastname: Fleishman
authors.affiliation: Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Baligh R
authors.initials: BR
authors.lastname: Yehia
authors.affiliation: Department of HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland.
authors.forename: Laura W
authors.initials: LW
authors.lastname: Cheever
authors.affiliation: Department of HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland.
authors.forename: Heather
authors.initials: H
authors.lastname: Hauck
authors.affiliation: Department of Medicine, Oregon Health & Science University, Portland.
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
authors.affiliation: Department of Medicine, University of California San Diego School of Medicine.
authors.forename: W Christopher
authors.initials: WC
authors.lastname: Mathews
authors.affiliation: Department of Internal Medicine, Johns Hopkins University School of Medicine.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Keruly
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
authors.forename: Ank E
authors.initials: AE
authors.lastname: Nijhawan
authors.affiliation: Department of Pediatrics, Johns Hopkins University, Baltimore.
authors.forename: Allison L
authors.initials: AL
authors.lastname: Agwu
authors.affiliation: Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa.
authors.forename: Charurut
authors.initials: C
authors.lastname: Somboonwit
authors.affiliation: Department of Internal Medicine, Johns Hopkins University School of Medicine.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Moore
authors.affiliation: Department of Internal Medicine, Johns Hopkins University School of Medicine.
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Gebo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002140:California / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D008396:Maryland / Q000453:epidemiology; D008484:Medicaid; D008875:Middle Aged; D009518:New York / Q000453:epidemiology; D009922:Oregon / Q000453:epidemiology; D058991:Patient Protection and Affordable Care Act; D000072339:Sexual and Gender Minorities; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Affordable Care Act; HIV; Medicaid; Ryan White HIV/AIDS Program; insurance