State Health Departments Navigate ACA Enrollment Challenges While Strengthening Insurance Purchasing Infrastructure and Addressing Unmet Need
Washington, DC – This week, the National Alliance of State and Territorial AIDS Directors (NASTAD) released new data [PDF 150 KB] emphasizing the essential role the Ryan White Program, specifically the AIDS Drug Assistance Program (ADAP), plays for people living with HIV (PLWH), including those who have insurance and those who are uninsured. During the inaugural open enrollment period of the Affordable Care Act (ACA), ADAPs transitioned over 25,000 clients to new coverage options. This represents a significant portion of the estimated 56,000 previously uninsured Ryan White clients.
As state health departments continue to analyze their enrollment data, preliminary figures indicate that approximately 12,000 ADAP clients enrolled in Medicaid expansion with the rest enrolling in Qualified Health Plans (QHPs). For the over 13,000 clients newly insured in QHPs, ADAPs are providing assistance with premium payments and out-of-pocket costs, without which access to QHPs would be unaffordable, even with federal subsidies. This assistance has been particularly critical in states not expanding Medicaid where ADAPs are paying for unsubsidized coverage for those under 100% of the federal poverty level who would otherwise fall into the “Medicaid gap.” As PLWH transition to insurance coverage, the Ryan White Program also continues to provide the vital care completion services that are not covered by public and private insurance (for example, case management and transportation). These services are essential in keeping people retained in care. At the same time, ADAPs are increasing their response to unmet need and are expanding outreach efforts to enroll people who were previously not in or who have fallen out of care.
“Even with this unprecedented expansion of access to public and private insurance, ADAP and the Ryan White Program continue to meet a critical need by filling coverage and affordability gaps, ramping up efforts to address unmet need and engage and reengage people living with HIV in care, and providing a vital public health safety net for the remaining uninsured,” stated NASTAD Executive Director, Julie Scofield. “States overcame significant challenges during the first open enrollment period to transition thousands of ADAP clients to new coverage options, doing so in many cases with limited resources, particularly in states that have not yet chosen to fully expand Medicaid,” Scofield added.
ADAPs, outreach and enrollment workers, and clients encountered many challenges during the ACA’s first open enrollment period. Technical glitches in the online Marketplace portals combined with limited availability of plan formulary, cost, and provider network information slowed enrollment efforts in many states. In addition, high cost sharing/co-insurance associated with HIV medications provided through QHPs as well as lack of coverage for commonly prescribed single-tablet regimens have presented formidable barriers to accessing care, resulting in unanticipated costs to ADAPs, and a continued need for state and federal advocacy and funding for ADAP.
Although ADAPs were successful in transitioning nearly 25,000 clients to Medicaid expansion and QHPs during open enrollment, it will take additional time to transition all eligible ADAP clients to the new ACA coverage options. Client transition varied by state depending on Medicaid expansion decisions, the ability of state employees to participate in ACA outreach and enrollment efforts, and the availability of Ryan White/ADAP insurance purchasing programs to assist with QHP costs. ADAP client enrollment efforts as well as work to increase insurance purchasing infrastructure and capacity will continue over the coming months.
AIDS Drug Assistance Programs (ADAPs) provide life-saving HIV treatments to low income, uninsured, and underinsured individuals living with HIV/AIDS in all 50 states and the territories. In addition, 45 ADAPs provide insurance purchasing assistance to eligible individuals. ADAPs are a component of the federal Ryan White Part B Program.
The National Alliance of State & Territorial AIDS Directors (NASTAD), founded in 1992, is a nonprofit national association of state and territorial health department HIV/AIDS program directors who have programmatic responsibility for administering HIV/AIDS, viral hepatitis and associated public health programs. NASTAD works to strengthen the role and promote the success of state and territorial public health programs in the U.S. and internationally. For more information, visit www.NASTAD.org .
 Some ADAP clients were previously insured through Pre-Existing Condition Insurance Plans (PCIPs), high-risk pools, and other private insurance prior to transitioning to new ACA coverage. This estimated number of previously uninsured Ryan White clients is based on projections provided by Kaiser Family Foundation, Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People With HIV (January 2014), available at http://kaiserfamilyfoundation.files.wordpress.com/2013/12/8535-assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage.pdf .