The Affordable Care Act's impact on insurance coverage and treatment in patients with HIV and cancer
A recent study reveals that, for people living with both HIV and cancer (PLWHC), implementation of the Patient Protection and Affordable Care Act (ACA) improved insurance coverage, both in states that expanded Medicaid coverage and those that did not. Lack of insurance is still common in non-expansion states, however, and patients who are minorities or have low income are most likely to live in these states. The findings are published early online in CANCER, a peer-reviewed journal of the American Cancer Society.
The study is the first to measure the benefits of the ACA on insurance coverage and cancer treatment in PLWHC. The ACA created several new options for states regarding Medicaid. States that exercised the option to expand Medicaid eligibility to adults with incomes up to 138 percent of the federal poverty level, or developed new state plans under the ACA, were defined as expansion states. All states that did not fully expand Medicaid by 2015 were defined as non-expansion states. In this study, which was conducted by a team led by Gita Suneja, MD, MSHP, at the Duke University School of Medicine (currently at Huntsman Cancer Institute at the University of Utah), the pre-ACA era was defined as 2011-2013 and the post-ACA era was defined as 2014-2015.
In the analysis, of 4,794 U.S. adults with HIV who were diagnosed with cancer from 2011-2015, 49 percent resided in non-expansion states and were more often uninsured (16.7 percent versus 4.2 percent), non-white (65.2 percent versus 60.2 percent), and low income (36.3 percent versus 26.9 percent) than those in expansion states. After 2014, the percentage of PLWHC who were uninsured decreased in expansion states from 4.9 percent to 3 percent and in non-expansion states from 17.6 percent to 14.6 percent, possibly due to increased Medicaid coverage in expansion states (36.9 percent to 39.2 percent) and increased private insurance coverage in non-expansion states (29.5 percent to 34.7 percent). There was no significant difference in the likelihood that PLWHC would receive cancer treatment between expansion and non-expansion states.
"A concerning finding is that people with HIV most at risk for not receiving cancer treatment—for example those of Black/African-American race or with low income—were more likely to live in states that did not expand Medicaid. In these non-expansion states, the percentage of uninsured people living with HIV and cancer was five times higher compared with expansion states," said Dr. Suneja. "We didn't see differences in insurance coverage translate to differences in cancer treatment; however, longer follow-up time is needed to fully evaluate this and the impact of insurance on cancer survival for people with HIV. Regardless, further insurance coverage options are urgently needed to ensure access to the full spectrum of cancer services—including prevention, screening, diagnosis, management, and surveillance—and ultimately improve cancer outcomes for this population."