July 26, 2016
2 min read
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Guest Commentary: Limited Medicaid expansion leaves many blacks, women with HIV uninsured

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In this guest commentary, Adaora Adimora, MD, MPH, FIDSA, professor of medicine and epidemiology at the University of North Carolina, Chapel Hill, and immediate past president of the HIV Medicine Association, discusses the role of the Affordable Care Act in increasing health insurance coverage among people with HIV and the gaps in coverage that remain, particularly among individuals of low socioeconomic status and blacks.

The Affordable Care Act has been hugely important for people with HIV. We don’t yet have definitive numbers about how many patients with HIV gained health care insurance coverage with the ACA, but, as of about a year ago, the AIDS Drug Assistance Program had enrolled more than 45,000 people in an ACA plan and approximately 20,000 people in Medicaid, which is pretty remarkable.

Adaora Adimora

Adaora Adimora

People with HIV tend to be disproportionately poor. Before the health coverage expansion under the ACA, the Medicaid program covered approximately 50% of people living with HIV. Only about 20% of people had commercial insurance and at least 30% were uninsured.

The estimated number of uninsured people living with HIV who could get access to Medicaid coverage due to the expansion ranged from approximately 47,000, when you consider only people living with HIV who aren’t already in care, to more than 110,000 when you consider all people with HIV and not just those who are already in care.

There are some states that decided not to expand Medicaid coverage, which has left an estimated 20,000 to 60,000 people living with HIV without Medicaid coverage, which affects significant numbers of women and blacks. Many of the states that did not expand Medicaid are in the South, where there tends to be more women living with HIV infection. Blacks are disproportionately poor in the United States and they’re also disproportionately affected by HIV. Expanding Medicaid in every state is important to improving access to health care coverage for uninsured black men and, certainly, black women.

There’s a coverage gap in the non-Medicaid expansion states because the premium subsidies to help purchase insurance through the marketplace really are only available to people between 100% and 400% of the federal poverty level. When the ACA was being crafted, it was assumed that those people whose income was less than 100% of the federal poverty level would receive Medicaid – and, therefore, they weren’t made eligible for these premium subsidies. Unfortunately, in states that didn’t expand Medicaid, the poorest people – many of whom are African American and many of whom are women, but this also includes men – have been left behind. Uninsured black adults are more than twice as likely as uninsured white and Hispanic adults to fall into the coverage gap in those states that didn’t expand Medicaid.

The ACA really has been a tremendous boon for all Americans. But to the working poor, it’s extremely important. Expansion of Medicaid in all states really would be the best thing for people’s personal – as well as public – health.

Disclosure: Adimora reports no relevant financial disclosures.