title: 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.
abstract: OBJECTIVE
  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.
authors.affiliation: *Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA; †Division of Research, Kaiser Permanente, Oakland, CA; and ‡AIDS Research Institute, University of California San Francisco, San Francisco, CA.
authors.forename: Derek D
authors.initials: DD
authors.lastname: Satre
authors.forename: Andrea
authors.initials: A
authors.lastname: Altschuler
authors.forename: Sujaya
authors.initials: S
authors.lastname: Parthasarathy
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Silverberg
authors.forename: Paul
authors.initials: P
authors.lastname: Volberding
authors.forename: Cynthia I
authors.initials: CI
authors.lastname: Campbell
mesh_terms: D000328:Adult; D002140:California; D019033:Delivery of Health Care, Integrated; D019468:Disease Management; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000517:prevention & control; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D058991:Patient Protection and Affordable Care Act; D055815:Young Adult