How should we evaluate ACA impact on HIV?

Lipira and colleagues recently published this comprehensive review article framing a research agenda to evaluate the impact of the Affordable Care Act (commonly called the “ACA” or “Obamacare”) on HIV care, outcomes, prevention, and disparities. Lipira and colleagues identified several challenges to comprehensive HIV care that could be remedied with informed programming and policy. First, the ACA does not increase access to drugs or care for people living with HIV due to a change in the source of coverage for these patients and a shift in the distribution of costs among the healthcare payers. Second, some wrap-around care services that provide food, housing, and transportation could be lost to people with HIV who go from uninsured to insured, which can place them in a vulnerable position without healthcare coverage.

The researchers pose several important but challenging questions for us to answer, including:

Do changes in access to and/or quality of care after the ACA lead to improvements in health for patients with HIV?
What are the drivers of total costs and cost growth reduction in HIV care and prevention?
How is the incidence of HIV changing afer the ACA and to what extent are changes in HIV incidence attributable to the ACA?
Which subpopulations are benefiting the most/least from changes in access/quality/spending?

How can we move from association to causal inference?

Crude statistical methods can lead to bias conclusions and misinform policy decision makers. Rigorous study design with appropriate statistical analysis is necessary to provide unbiased empirical evidence of a policy’s effectiveness. Several quasi-experimental approaches are available (e.g., regression discontinuity design, interrupted times series analysis, and propensity score matching); however, they are limited by the type of scenario and data that are available. Certain assumptions are necessary to generate causal interpretation from these methods, without which, biased conclusions can still emerge from a lack of internal validity. Stata 15 has new features for extended estimating equations that we could try. What methods do you think are needed for causal inference?

What data do we need?

I am intrigued by these policy questions; however, a lack of a single dataset (that I know about) from commercial claims or the government that has all the necessary variables prevent me from designing a study that would result in causal interpretation. We need to pull information from lots of credible sources to assemble a dataset to support that study design. I want the usual cascade of care numbers (i.e., cases diagnosed, linked to care, on antiretroviral therapy, and virally suppressed), sexually transmitted infections, costs by payer type (including Ryan White HIV/AIDS Program, Centers for Medicare/Medicaid Services, private insurance, patient out-of-pocket) and all by state and over time (at least years but preferably a smaller increment). Do we need patient-level data or would aggregates by state be sufficient? It is possible that models based on one set of sources (Medicaid and CDC Surveillance) could be validated with comparison to the observations from another source (Truven Marketscan)?

Next Step

I leave you with Lipira’s conclusion:

In order to make a meaningful impact on relevant health care policy, swift and judicious contribution to this body of literature is imperative.

Let’s get to work.

Source: Lipira L, Williams E, Hutcheson R, Katz A. Evaluating the Impact of the Affordable Care Act on HIV Care, Outcomes, Prevention, and Disparities: A Critical Research Agenda. Journal of Health Care for the Poor and Underserved, Volume 28, Number 4, November 2017, pp. 1254-1275.

Acknowledgments: Drs. Mark Bounthavong and Nathaniel Hendrix contributed to this post.

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Allow me to refer you to the Kaiser Family Foundation website that has conducted some research on the topic.
https://www.kff.org/hivaids/fact-sheet/the-ryan-white-hivaids-program-the-basics/

Ryan White HIV/AIDS Program & Affordable Care Act

Research has demonstrated that the Ryan White Program remains a critical component of the nation’s response to HIV in the ACA era.16 The program continues to fill gaps for those with traditional insurance – such as private coverage, Medicare and Medicaid – by providing support services like case management, transportation, and nutritional support, which are critical to engaging people with HIV in care. In fact, recent Ryan White program data shows that client insurance coverage through Medicaid and private insurance increased in the ACA era while the rate of uninsurance declined.17 Additionally, its role in insurance purchasing assistance has become increasingly important under the ACA as thousands of clients gained insurance through the private market. The number of ADAP clients that received insurance purchasing assistance to help defray the cost of coverage increased by 1162% between 2002 and 2015.18 Finally, while thousands of people with HIV gained coverage under the ACA, many are still without coverage and, for them, the Ryan White HIV/AIDS Program will remain a critical safety net, providing life-saving care and treatment.
Key Issues

The Ryan White HIV/AIDS Program, first enacted as an emergency measure, has grown to become a central component of HIV care in the U.S., playing a critical role in the lives of low and moderate-income people with HIV who have little or no access through other sources. Looking ahead, there are several key issues facing the program:

As a federal grant program, its funding depends on annual appropriations by Congress, and funding levels do not necessarily correspond to actual need including the number of people who need services or the costs of services. As a result, historically, not all states and communities have been able to meet the needs of their jurisdictions. For these reasons, monitoring appropriations allocations and any cuts enacted by Congress will be important going forward.
It will be critical to assess how future reauthorization impact structure and financing of the program.
If the ACA is repealed, or repealed and replaced – a policy option currently on the table – it will have significant implications for the health coverage of people with HIV, many of whom have gained coverage through the Medicaid expansion and the marketplaces, and for the Ryan White Program. In particular, it will be important to assess whether the program is able to meet the HIV care and treatment needs of those losing coverage in such an environment.

1 thought on “How should we evaluate ACA impact on HIV?”

Gerald Cheves says:

January 10, 2018 at 1:52 am

Allow me to refer you to the Kaiser Family Foundation website that has conducted some research on the topic.
https://www.kff.org/hivaids/fact-sheet/the-ryan-white-hivaids-program-the-basics/

Ryan White HIV/AIDS Program & Affordable Care Act

Research has demonstrated that the Ryan White Program remains a critical component of the nation’s response to HIV in the ACA era.16 The program continues to fill gaps for those with traditional insurance – such as private coverage, Medicare and Medicaid – by providing support services like case management, transportation, and nutritional support, which are critical to engaging people with HIV in care. In fact, recent Ryan White program data shows that client insurance coverage through Medicaid and private insurance increased in the ACA era while the rate of uninsurance declined.17 Additionally, its role in insurance purchasing assistance has become increasingly important under the ACA as thousands of clients gained insurance through the private market. The number of ADAP clients that received insurance purchasing assistance to help defray the cost of coverage increased by 1162% between 2002 and 2015.18 Finally, while thousands of people with HIV gained coverage under the ACA, many are still without coverage and, for them, the Ryan White HIV/AIDS Program will remain a critical safety net, providing life-saving care and treatment.
Key Issues

The Ryan White HIV/AIDS Program, first enacted as an emergency measure, has grown to become a central component of HIV care in the U.S., playing a critical role in the lives of low and moderate-income people with HIV who have little or no access through other sources. Looking ahead, there are several key issues facing the program:

As a federal grant program, its funding depends on annual appropriations by Congress, and funding levels do not necessarily correspond to actual need including the number of people who need services or the costs of services. As a result, historically, not all states and communities have been able to meet the needs of their jurisdictions. For these reasons, monitoring appropriations allocations and any cuts enacted by Congress will be important going forward.
It will be critical to assess how future reauthorization impact structure and financing of the program.
If the ACA is repealed, or repealed and replaced – a policy option currently on the table – it will have significant implications for the health coverage of people with HIV, many of whom have gained coverage through the Medicaid expansion and the marketplaces, and for the Ryan White Program. In particular, it will be important to assess whether the program is able to meet the HIV care and treatment needs of those losing coverage in such an environment.