Health Care Reform and its Impact on People Living with HIV/AIDS - The Massachusetts Experience

In 2006, Massachusetts passed comprehensive health insurance reform in order to provide almost universal coverage for its residents. In doing so, the state introduced several health care reforms, which have become the foundation for the Affordable Care Act (ACA) and made MA the model for the Ryan White Program in a post-health care reform environment. Reforms included an individual mandate, Medicaid expansion, and increased access to subsidized private insurance and resulted in improved health outcomes and reduced health care costs for all residents. 

In 2001, Massachusetts became the first state in the nation to implement a federal waiver allowing Medicaid expansion to non-disabled people living with HIV (PLWH) with incomes up to 200% of the Federal Poverty Level (FPL). In 2006, Massachusetts became the first state to mandate that all residents carry health insurance coverage. These reforms allowed for subsidies for residents with incomes up to 300% of the FPL, and included the development of the first state health insurance exchange that certified plans with comprehensive benefits without preexisting condition exclusions. Additionally, the reforms preserved a comprehensive Medicaid benefits package for all residents, and the expansion of Medicaid to cover all uninsured residents with incomes up to 200% of the FPL. 

With local health care reform, Massachusetts has seen an impact on its Ryan White Program. Since 2006, funding to Massachusetts’s HIV Drug Assistance Program (HDAP) has been largely spent on health insurance plans and medication co-pays. The HDAP has maintained an unrestricted formulary and 500% FPL eligibility. The HDAP serves as a resource for ensuring Medicaid enrollment, as applicants must use the HDAP as the payer of last resort and show proof of having applied for Medicaid. In 2007, Massachusetts became the first state to receive a waiver to the 75/25 rule, which allows it to invest heavily in critical coverage completion services (such as medical case management and psychosocial support services) that are non-third-party reimbursable, but essential to ensure that PLWH are engaged, retained, and adherent to care. As a result of expanded insurance coverage, access to antiretroviral therapy, and a robust HIV provider network, including Ryan White-funded services, Massachusetts has seen a decline in new HIV diagnoses and has also achieved very high levels of viral suppression.

It is important to note that while the ACA will result in expanded access to health care for PLWH, as we have seen in Massachusetts, it will not address all needs PLWH face. Therefore, the Ryan White Program will continue to play a critical role in serving the needs of PLWH. Particularly, going forward with the ACA, the Ryan White Program will need to provide coverage completion services and continue to provide a full range of critical services for those who have no other source of coverage, including undocumented PLWH and legal residents living with HIV who are not yet eligible for public coverage. 

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