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How The Affordable Care Act Opens The Door For Two Vulnerable Populations


One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges and disparities facing people who make up two groups of Americans, most of whom are impoverished and uninsured. This issue of Health Affairs addresses the needs of these two groups: the 1.1 million Americans who are living with HIV/AIDS and the 11.6 million people who cycle through the nation’s 3,300 local and county jails every year.

The following discussion provides an overview of the research in this month’s special issue of Health Affairs:


101392310-141709174.530x298More than three decades after the first cases of HIV/AIDS were diagnosed, the benefits of early diagnosis and treatment have been well documented. Dr. Dana Goldman and his coauthors estimate that such treatments prevented about 13,500 infections per year during 1996–2009. Dr. John Romley and his colleagues calculate that early HIV treatment led to life expectancy gains valued at $80 billion for people infected over the same time period.

In the context of the ACA, an important aspect of HIV/AIDS treatment has come to the fore: the role of the Ryan White Program in providing comprehensive health and other support services to people living with HIV/AIDS. Some have argued that the ACA renders the Ryan White Program redundant, while others, including Dr. Neeraj Sood and colleagues, urge continuation of the program because of the proven benefit of its wraparound approach to care for people living with HIV/AIDS. Reauthorization of the Ryan White Program has been stalled in Congress since the latest funding measure expired in September 2013.

The Affordable Care Act will expand insurance coverage for nearly 200,000 Americans with HIV — but nearly 60,000 of these individuals live in states refusing the law’s optional Medicaid expansion. 

Of the 1.1 million HIV-positive Americans above the age of 13, approximately 407,000 are actively receiving care. Over 40 percent of them are covered by Medicaid, the single largest provider for people with the virus, while another 30 percent have private health insurance. Around 17 percent of the HIV-positive Americans getting treatment remain uninsured, and could benefit greatly from the law’s coverage expansion. But many of them won’t. Over four in ten uninsured HIV-positive Americans won’t be eligible for Medicaid in the 24 GOP-led states opposed to the health law’s optional expansion of the program.

The staggering cost of HIV treatment presents a major barrier for many Americans living with the virus.  Monthly HIV treatment regimens range from $2,000 to $5,000 — much of it for drugs. With the life expectancy for HIV patients increasing, the lifetime cost of treatment in today’s terms is estimated at more than half-million dollars. In total, the cost of HIV-related medical care for all HIV-positive Americans is estimated to be over $12 billion per year.

Through the ACA’s statewide marketplaces, some of those left uninsured in GOP-led states refusing the Medicaid expansion may find relief from subsidized private insurance programs designed specifically to provide coverage for individuals with HIV. But the fact remains that 96 percent of uninsured Americans with HIV would be able to get either subsidized Obamacare plans or Medicaid coverage if all states expanded the program.

Jail-Involved Populations

aclu03_pr_healthCompared with the general public, people who populate jails—disproportionately male, minority, and poor—have higher rates of communicable diseases such as HIV/AIDS; tuberculosis; mental illnesses and substance abuse disorders; and chronic conditions, including asthma, diabetes, and hepatitis B and C. Regardless of where these people reside, it is important that their conditions be treated, particularly because 95 percent of them return to the community without coverage—at least before enactment of the ACA.

Appropriate treatment has been lacking because, in general, health professionals have not viewed the criminal justice system as part of community health; most care is provided through large correctional corporations that hold contracts with hundreds of jails. When fully implemented, the ACA will offer coverage to people released from jails by reducing the financial barriers through Medicaid expansion (in twenty-six states thus far) and subsidized insurance through exchanges.

The ACA does not change Medicaid’s prohibition on paying for eligible services while people are incarcerated; once jailed individuals are released, benefits could accrue to those who are eligible and enroll. Researchers Marsha Regenstein and Sara Rosenbaum estimate that 25–30 percent of people released from jails could enroll in Medicaid in expansion states and that about 20 percent could enroll in an exchange, depending upon their reported income. But as Drs. Kavita Patel and colleagues note, this will occur only if correctional facilities and community providers work more closely together. Dr. Matthew Bechelli and his coauthors examine three case studies for evidence that closer coordination helped bend the cost curve. Dr. Josiah Rich and colleagues offer recommendations for improving both correctional care and access to community-based care.  Drs. Amy Boutwell and Jonathan Freedman underscore the critical role that health plans will play in enrolling former inmates, and Dr. Stephen Somers and colleagues emphasize the importance of new partnerships between Medicaid and corrections agencies.

James Marks of the Robert Wood Johnson Foundation, working through Community Oriented Correctional Health Services, and Nicholas Turner, president and director of the Vera Institute of Justice, emphasize that strong linkages among correctional health care, community providers, and inmate reentry are critical to improving treatment for a largely “hidden” population. But, at the same time, the country has a vested stake in improving this population’s care because if its members’ health problems remain unresolved, they could jeopardize the public health and safety of the communities to which they return.

HIV/AIDS and jail-involved populations overlap in important ways. In 2009, because of the proven benefits of early HIV diagnosis and treatment, the Centers for Disease Control and Prevention encouraged correctional facilities to adopt more effective HIV testing and treatment programs. Also, based on a survey of jail and prison medical directors, HIV/AIDS expert Dr. Liza Solomon and coauthors found that opportunities to link HIV-positive inmates with community care once they are released are being missed.


Affordable-Care-ActThe Affordable Care Act represents a groundbreaking opportunity to reduce health disparities and promote equity in health outcomes among a wide range of vulnerable populations, including HIV-positive individuals, current and former jail inmates, low-income Americans, and minorities. For many traditionally underserved populations, the Medicaid expansion will offer unprecedented access to affordable, high quality health care and preventive services. Unfortunately, in many GOP-led states, the misguided decision to refuse the Medicaid expansion will disproportionately harm vulnerable populations. While approximately 11 million Americans are now eligible for Medicaid in states that expanded the program, another 6 million will be left uninsured because of the actions of Republican governors who chose to prioritize partisanship over the health and wellbeing of Americans.

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