Editorial Commentary: Affordable Care Act, Medicaid Expansion … or Not: Ryan White Care Act Remains Essential for Access and Equity

(See the HIV/AIDS Major Articles by Berry et al on pages 387–95and McManus et al on pages 396–403.) The Patient Protection and Affordable Care Act (ACA) has the potential to improve healthcare for hundreds of thousands of persons living with human immunodeficiency virus (HIV) (PLWH) in the United States. The ACA offers many benefits including consumer protections, Medicaid expansion, and private insurance reform, but there are significant, regional differences in healthcare coverage based on state Medicaid expansion status and variations in qualified health plans (QHPs). Most changes were implemented in 2014, including the elimination of private insurance exclusions for preexisting conditions, the law expanding Medicaid eligibility, and requirements that insurance plans provide essential health benefits and restrict cost sharing (deductibles, copayments, and out-of-pocket costs) [ 1 ]. The goal for eligible individuals is an increase in insurance coverage and a reduction in reliance on federal “safety net” funds, such as the Ryan White HIV/AIDS Program (RWHAP) for PLWH. For 2 decades, the Ryan White Part B program has allowed funding for medications through the AIDS Drug Assistance Program (ADAP) as a “payer of last resort” for uninsured and underinsured PLWH. Now, in an effort to improve enrollment in QHPs, the HIV/AIDS bureau allows ADAP funds to be used to cover copayments, deductibles, and premiums associated with QHP coverage [ 2 ]. Owing to differences in Medicaid expansion by state, experts anticipate potential coverage gaps that will probably require additional resources, namely, funding through RWHAP [ 3 ]. Initially, the national political climate and slow adoption of Medicaid expansion made it challenging to predict the impact of the ACA [ 4 ]. Now, more than 2 years since many ACA provisions went into effect in 2014, it is critical that providers and policy makers evaluate changes in healthcare coverage and clinical outcomes for PLWH to ensure optimal health benefits in the ACA era.