Wednesday, December 18, 2013

HIV/AIDS Care and Treatment and Health Care Reform, Assumption 2

By Bob Bongiovanni

In Part 1, I talked about an assumption that we need to shake, an assumption that people living with HIV or AIDS(PLWH/A) are shut out of mainstream health care.  Under the Affordable Care Act (ACA) , we just can’t assume that is true any more.

Now let’s talk about that second assumption:

that most of the services needed by PLWH/A are not available from Medicaid, Medicare, or commercial health insurance.  

Before ACA, even those PLWH/A with health coverage had a lot to complain about.  Many things were not covered at all, or not covered well enough to benefit them.

Part of the ACA is to set minimum coverage standards for health insurance.  Specifically, plans are expected to cover the “ten essential health benefits,” which are:  ambulatory patient services;  emergency services; hospitalization; maternity and newborn care; mental health and substance use services; prescription drugs; rehabilitative and habilitative services; laboratory services; preventive and wellness services and chronic disease management; pediatric services, including oral and vision care. In addition, many preventive services will be provided free-of-cost to the patient, including many services often needed by PLWH/A, like mental health and basic health screenings.

The ACA also encourages providers to evolve into “medical homes” where a team of professionals meet the broad spectrum of needs of their patients, minimizing referrals to outsiders, and including nonclinical and behavioral services.

There is a lot more work to be done, but it does seem that PLWH/A will be able to get more services from Medicaid and private health insurance after ACA.  But how will case managers, clinicians, and other help them navigate systems to get what they really need?

Both in Colorado and nationally, there is a new way to look at the services being offered to PLWH/A, inspired by work done by Ed Gardner at Denver Health.  It is called the “care cascade,” and it breaks the client experience into four stages:  being diagnosed, accessing initial care, being retained in that care, and ultimately achieving viral suppression. The question then becomes:  what services do PLWH/A need to “move through” those stages, toward viral suppression.  And since we are talking about HIV as a chronic condition, we also need to factor in the inevitable lapses in care and re-engagement processes.

Combining the ACA services and the care cascade calls upon us to do a better job “triaging” the needs of clients.  It comes down to a few questions we must ask ourselves.  First, what services would help the client move through the care cascade toward viral suppression.  Second, who will pay for those services.  After ACA, more and more of those services will be paid for by Medicaid or commercial health insurance.  But not always.  If the client is ineligible for ACA coverage, or the service is not “reasonably accessible” through ACA coverage, Ryan White funding must continue as the “payer of last resort.”  PLWH/A need so many services to achieve viral suppression, no coverage will be 100 percent complete, but it is definitely getting better thanks to the ACA.

Just as with the first assumption, about PLWH/A being shut out of health care, so this second assumption is being shaken by the ACA.  We just can’t assume that all or even most PLWH/A have needs that only Ryan White funding can fulfill. Of course, there will still be barriers – financial, stigma, quality, and others.  But there will also be great new opportunities to be served.

Please visit our blog on Friday as I address the third assumption that must be challenged: The Ryan White system will continue to operate “as-is” after health care reform is implemented. Thank you for reading.

For questions or comments please email our Communications Specialist Ben Hammett at

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