Medicaid Expansion’s Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic

Abstract

Background While the Ryan White HIV/AIDS Program (RWHAP) supports high-quality HIV care, Medicaid enrollment provides access to non-HIV care. People living with HIV (PLWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PLWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). Methods Participants were PLWH ages 18-63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. Results Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% Federal Poverty Level (adjusted prevalence ratio [aPR] 1.67; 95% confidence interval [CI] 1.00-1.86) compared to others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD] -8.5%, 95% CI -16.9-0.1) and Medicare (aRD -12.5%, 95% CI -21.2- -3.0) had lower 2019 engagement than others. For those with VS data (n=548), after controlling for age and baseline VS, those with Medicaid (aRD -4.0%, 95% CI -10.3-0.3) and with Medicaid due to ME (aRD -6.2%, 95% CI -14.1- -0.8) were less likely to achieve VS compared with others. Conclusions Given that PLWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.

Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study

“… 16 We hypothesize that these overlap and gap issues described by this cohort may be the reason for the lower viral suppression among PWH who transitioned to Medicaid in 2019, which was observed in our clinic's quantitative study. 7 Overlaps/gaps may have only been an issue during the transition year (2019). Future studies will need to see if the overlap/gap issue and lower viral suppression persist for this population.…”

“…"*Getting HIV medications+ started getting easier once they worked all the kinks out because they still had me active with the Marketplace and then I had to call and get inactive and then I still had to wait some, like a 2 (7)…”

“…[1] Additionally, employment changes brought on by the COVID-19 pandemic [6] may result in more PWH transitioning from individual and/or employer-based private insurance to Medicaid. Our recent quantitative analysis demonstrated lower rates of viral suppression in 2019 for PWH who transitioned to Medicaid [7]. Given this observation, it is critical to understand the patient experience of PWH who transition to Medicaid Expansion.…”

“…Of those eligible, 77 (51%) enrolled. [7] This prospective study's goal for recruitment was to enroll at least one-third (> 26) of the RWHAP clients who newly enrolled in Medicaid in 2019 due to Medicaid expansion. The UVA Institutional Review Board approved this study.…”

“…Our recent quantitative analysis demonstrated lower rates of viral suppression in 2019 for PWH who transitioned to Medicaid. 7 Given this observation, it is critical to understand the patient experience of PWH who transition to Medicaid Expansion. Our goal was to understand the patient perspective and health care experience of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion.…”