It's hard to imagine how the federal health reform law, known as the ACA, will work for people living with HIV/AIDS once it is fully implemented in 2014. Because the framework of the ACA is loosely based on health care reform in Massachusetts, a review of that state's system can help HIV/AIDS advocates understand how the national law might affect people with HIV nationwide.
Long before health reform dominated national headlines, officials in Massachusetts were working on strategies to reduce the number of uninsured in the state. Here's a quick recap.
2001: Massachusetts was the first state in the nation to implement a federal waiver allowing Medicaid expansion to non-disabled poor residents living with HIV. The state combined federal resources with state appropriations to offer a comprehensive benefit package to all uninsured state residents living with HIV at or below 200% of Federal Poverty Level (FPL).
With health insurance provided by Medicaid to most HIV-positive uninsured residents, the state used federal Ryan White Program grants to provide wrap-around support services to help connect and sustain people in care. The state's AIDS Drug Assistance Program (ADAP) shifted its focus from dispensing HIV medication to predominately providing premium and co-pay assistance for people living with HIV.
2006: Governor Romney signed reforms into law, including:
"Massachusetts serves as an excellent example of how properly implemented health reforms can substantially improve health outcomes for those living with HIV," said Robert Greenwald, Clinical Professor of Law and Director of the Center for Health Law and Policy Innovation at Harvard Law School.
In 2011, Dr. Edward Gardner and colleagues published a compelling analysis demonstrating severe gaps in care for people with HIV/AIDS in the U.S. The Centers for Disease Control and Prevention (CDC) published its own analysis in December 2011. Much like Gardner's original paper, CDC's "States of Engagement in HIV Care" reports sizeable gaps in linking and retaining people diagnosed with HIV to continuous clinical care and treatments.
The CDC found that only 28% of people living with HIV in the U.S. achieve the viral suppression needed to improve their longevity and reduce HIV transmission risk to others. Moreover, only 51% of people diagnosed with HIV are retained in continuous clinical care, which results in lower numbers of people gaining access to the HIV treatments they need.
The stages-of-engagement methodology is a useful performance metric to gauge how well or poorly systems achieve clinical engagement for HIV-positive populations. Given how similar the ACA is to RomneyCare, the Massachusetts analysis may forecast what outcomes might be possible under the ACA.
After a decade of reforms, health systems in Massachusetts are achieving remarkable results for HIV-positive residents that far exceed national outcomes.
According to recent Massachusetts state health department data on the state's HIV-positive population analyzed by Harvard Law School, by every metric, Massachusetts outperforms the national average by more than two to one.
"The Massachusetts data is clear evidence that if properly implemented, the ACA can greatly improve all outcome measures articulated in the CDC Engagement in Care Cascade for people living with HIV, as well as address the care and treatment needs of most other Americans living with chronic health conditions," Greenwald said.
According to Greenwald, Massachusetts reforms have also proved successful at reducing rates of new HIV infections, AIDS mortality, and overall cost of HIV-related care and treatment.
Between 2006 and 2009, HIV diagnoses fell by 25% in Massachusetts as compared to a 2% national increase, and between 2002 and 2008 Massachusetts AIDS mortality rates decreased by 44% compared to 33% nationally.
Massachusetts health reforms, while greatly expanding access to high-quality health care, have also resulted in significant cost savings. The amount spent post-reforms per HIV-positive Medicaid beneficiary has decreased significantly, especially the amount spent on inpatient hospital care, Greenwald said.
In addition, the Massachusetts Department of Health estimates that, because of health reforms and the resulting decline in HIV transmission rates, it has saved approximately $1.5 billion in HIV health care expenditures over the past 10 years.
Greenwald and others readily admit that reform efforts are not the only essential ingredients needed to bolster HIV-related outcomes. Health care infrastructure in a state, the number of medical providers with expertise in HIV care, other government assistance programs available to the poor, transportation options, and other socio-economic factors will weigh heavily on a state's performance in reaching people with HIV/AIDS.
These challenges notwithstanding, further efforts to implement the ACA nationwide could likely help areas across the country begin to replicate Massachusetts' successes and help lift the national performance across the "stages of engagement in HIV care."
That is, of course, if ACA implementation is not derailed by state actions, including opting out of expanding Medicaid to all low-income residents, or the repeal efforts pledged by many opponents of the law.
David Ernesto Munar is president/CEO of the AIDS Foundation of Chicago (AFC) and an HIV-positive advocate. Working with other AIDS advocacy organizations across the country, AFC hosts HIVhealthreform.org, an educational website on health reform policy geared toward people affected by HIV/AIDS, their organizations and advocates.