HIV and Medicaid Expansion: Failure of Southern States to Expand Medicaid Makes Elimination of HIV Infection in the United States Much Harder to Achieve by Adam Searing, JD, MPH and Adaora A. Adimora, MD, MPH Key Findings zz Advances in public health programs and medical treatment mean HIV can be treated successfully in the long term, improving the health of individuals and significantly reducing the spread of the infection. Ending the HIV epidemic in the United States is achievable. However, lack of health coverage is a major barrier to success in the fight against HIV as without health coverage, individuals are unable to access medical treatment that can improve their health and minimize the spread of HIV. zz These medical treatments, combined with a robust public health campaign, have led to a decline in HIV infection and transmission in many states. The HIV epidemic is now concentrated in Southern states where progress against the disease has slowed. Approximately 45 percent of all people living with an HIV diagnosis in the U.S. live in the South despite the region containing only about one-third of the total U.S. population. In addition, more than half (52 percent) of all new HIV diagnoses in 2017 were in the South. zz Medicaid expansion is a key building block to ending the HIV epidemic. Unfortunately, 12 states—largely in the South—are still refusing the federal funding for Medicaid expansion and leaving many people and families who could benefit from HIV interventions still lacking access to comprehensive health coverage. Only 5 percent of people with HIV remain uninsured in states that have implemented the Medicaid expansion, compared to a 19 percent uninsured rate among people with HIV in non-expansion states. Expanding Medicaid would significantly improve health care and coverage for people with HIV and their families and move the United States forward in the public health fight to end the HIV epidemic. November 2020 CCF.GEORGETOWN.EDU hiv and medicaid expansion 1 Introduction Advances in public health programs and medical treatment HIV infections and higher mortality rates from the condition. mean HIV can be treated successfully in the long term, Failure to prioritize Medicaid expansion in dealing with HIV improving the health of individuals and reducing the spread ignores extensive research and the fact that the center of of the virus. While the federal government has multiple the epidemic in America—the South—is also the center of initiatives aimed at addressing and eventually eliminating HIV, resistance among states to expanding Medicaid. Federal 3 a fundamental base to ensure successful health outcomes for and state plans 4,5,6 to reduce and eliminate HIV infection must people with HIV and their families is access to comprehensive, acknowledge the important role of Medicaid expansion. affordable health care coverage. A proven way to increase Layered on top of the HIV epidemic is the current COVID-19 levels of coverage is for states to expand Medicaid1 under the pandemic. Striking parallels between the response to federal Affordable Care Act (ACA).2 HIV and COVID-19 were pointed out earlier this year in Unfortunately, the 12 states—largely in the South—still the course of the pandemic.7 The urgency of dealing with refusing the federal funding for Medicaid expansion leave many COVID-19 severely complicates the ongoing response to people and families who could benefit from HIV interventions the HIV epidemic, making response to HIV and multiple still lacking access to comprehensive health coverage. other public health challenges more difficult.8 However, Expanding Medicaid would significantly improve health care the basic fact remains that successful response to the HIV and coverage for people with HIV and their families. Medicaid epidemic requires more health coverage through Medicaid is the key building block to ending the epidemic. States that expansion. have not expanded Medicaid coverage experience more Overview of the current environment Years of research and innovation in HIV treatment means has been a fundamental change in the campaign to end HIV. virus levels in patients already infected with the virus can Taken by people who are not infected but are at high risk now be reduced to undetectable levels. This antiretroviral of developing an HIV infection, this daily pill is 99 percent therapy (ART)9 not only keeps people living with HIV healthier effective in preventing HIV transmission during sex.11 This but also effectively ends the ability of the infected patient to drug has been a game-changer, lowering rates of new transmit the virus through sex10 and likely reduces the ability infections dramatically. of the patient to transmit the virus through other activities Specific populations have also benefited from targeted like drug use. Coupled with better health care and long- interventions. For pregnant mothers, variations of these term treatments for people with the infection, HIV infection new treatment options have also almost eliminated the risk has become a disease that can be effectively treated as a that a woman who has HIV and gets pregnant passes the chronic condition. infection on to her child.12 To effectively prevent this perinatal The existence of an effective HIV treatment means access to HIV transmission however, pregnant women must be tested affordable, quality health care can and does drive a drastic for the infection and started quickly on ART. Most pregnant reduction or elimination of transmission and long-term, women are covered by Medicaid, and increasing numbers effective treatment of people living with HIV. of all women of childbearing age have gained coverage as a result of reforms under the ACA. More accessible Innovation in addressing the HIV epidemic also extends to and effective health care has made mother-to-child HIV prevention. A building block of this care is the development transmission increasingly rare in the United States, although and expanded acceptance of pre-exposure prophylaxis it has not eliminated the problem completely. Among (PrEP). The PrEP drug regimen (tenofovir/emtracitabine) women generally, the CDC estimates new HIV infections 2 hiv and medicaid expansion CCF.GEORGETOWN.EDU November 2020 are declining but still more than 7,000 women received a mystery. About 80 percent of new HIV infections in the U.S. diagnosis in 2018.13 are acquired from people who are not currently receiving health care treatment for their infection.14 Either people do These multiple advances in HIV prevention and treatment not know they are infected, or they are aware but are not mean drastic reduction and even elimination of the HIV getting the effective treatment options now available. In epidemic is a realistic goal in the United States, but only if all addition, people who are not accessing health care on a avenues to improve prevention and treatment are used. regular basis are usually not able to start and maintain the Unfortunately, despite the fact that elimination of HIV daily PrEP drug regimen. infection nationwide is a goal within our reach, progress in HIV prevention has largely stalled. The reason is no States in the South are the center of the U.S. HIV epidemic. Even as HIV infection and transmission has declined in many U.S. population. In addition, more than half (52 percent) of all states, the epidemic has been concentrated in Southern new HIV diagnoses in 2017 were in the South. states where progress against the disease has been less Looking specifically at women and youth, 56 percent of robust. Approximately 45 percent of all people living with an women newly diagnosed with HIV in 2018 lived in the South HIV diagnosis in the U.S. live in the South even though the (see Figure 1). region contains only about one-third (38 percent) of the total Figure 1. Number of New HIV Diagnoses for Women, 2018 56% of women newly diagnosed with HIV in 2018 lived in the South. 800+ 250-499 500-799 0-249 Source: Centers for Disease Control and Prevention November 2020 CCF.GEORGETOWN.EDU hiv and medicaid expansion 3 And in 2018, nine of the top 10 states with the highest rates of new HIV diagnoses among youth were in the South. Table 1. Top 10 States with Highest Rates of New HIV Diagnoses Among Youths, 2018 New HIV Diagnoses Rates State per 100,000 District of Columbia 57.8 Georgia 35.1 9 of the 10 Louisiana 31.1 states Florida 26.8 with the highest rates of Mississippi 25.5 new HIV diagnoses Alabama 24.3 for youth were in Nevada 22.0 the South. Maryland 21.2 South Carolina 20.7 Texas 20.5 Source: Centers for Disease Control and Prevention. Finally and most discouragingly, in 2018, nearly 48 percent of deaths among people with HIV were in the South.15 Figure 2. Number of Deaths by Region, 2018 Midwest 12.5% In 2018, almost Northeast South 22.3% 48% of all 47.7% deaths among people with HIV were in the South. West 17.6% Source: Centers for Disease Control and Prevention. Rates of PrEP use are lower in the South, which makes the epidemic harder to contain. In addition, people with HIV in the South are less likely to be aware they have the condition,16 so they are less likely to get timely care and are more likely to transmit the virus. 4 hiv and medicaid expansion CCF.GEORGETOWN.EDU November 2020 As more states have expanded Medicaid, the core of resistance to Medicaid expansion has, like the HIV epidemic, centered in the South. As of October 2020, 39 states (including the District of year and implementation efforts proceeding in Nebraska Columbia) have expanded Medicaid. The 12 states still after a successful ballot measure passed in 2018. refusing the federal funding available for Medicaid expansion In addition to lack of Medicaid expansion, many other are largely in the South (see Figure 3). characteristics of the South work in concert to challenge Four Southern states account for nearly 70 percent of HIV-related health care in the region. Rates of poverty people who would gain affordable health coverage if the and prevalence of uninsured individuals exceed those of final 12 holdout states expanded Medicaid: Texas, Florida, other regions. Medicaid eligibility criteria tend to be more Georgia and North Carolina. And 92 percent of people in this restrictive. Health care infrastructure in some areas is Medicaid “coverage gap” now live in the South.17 inadequate. The large swaths of rural areas require people living in those areas to travel long distances for care. The current movement toward Medicaid expansion is Homophobia, HIV-related stigma, and HIV criminalization happening mainly outside the South, with voters approving laws also thwart prevention and care efforts and tend to be expansion ballot measures in Missouri and Oklahoma this more pervasive in the South.18 Figure 3. Medicaid Expansion Status The 12 states still refusing funding to expand Medicaid are mostly in the South. Adopted and implemented Adopted but not implemented Not adopted Source: Kaiser Family Foundation November 2020 CCF.GEORGETOWN.EDU hiv and medicaid expansion 5 Racial inequities and HIV Black Americans are disproportionately affected by the HIV access to quality health care, and resultant mistrust of the epidemic. As the Kaiser Family Foundation documents, 43 health care system.21 Medicaid expansion enables access percent of HIV diagnoses, 42 percent of people living with to care, and Black and Hispanic residents experience the HIV, and 44 percent of deaths are among Black Americans. greatest decreases in uninsured rates in states that have This is a much higher rate than any other racial or ethnic expanded Medicaid.22 Recent research overviews show that group in the United States.19 The racial inequities in HIV Medicaid expansion has narrowed racial disparities in health infection observed in the nation overall are also apparent coverage and in some instances has also narrowed racial in the South. New infection rates are higher among Black disparities in certain measures of health outcomes.23 women and heterosexual men than among Whites, but Black Racial inequities in health care coupled with poor and Latino men who have sex with men bear the highest infrastructure in many rural areas of the South present burden of infection.20 challenges to HIV prevention and care. Lack of Medicaid Chief among the myriad factors that contribute to racial expansion exacerbates these inequities in the South. disparities in HIV infection are poverty, racial discrimination that restricts economic and social opportunities as well as Recent research highlights how Medicaid expansion has positive affects for people with HIV. zzStates that expanded Medicaid saw a 5% zzMedicaid expansion decreased HIV reduction in new HIV cases. mortality rates in states with pre-ACA States that expanded Medicaid saw significant increases Medicaid expansions. in the use of the drug PrEP, one of the most effective Similar to recent research that has confirmed health ways to prevent HIV transmission. Research presented measures like maternal mortality have decreased in in late 2019 found that in Medicaid expansion states Medicaid expansion states26, expansion has also been the use of PrEP soared among people most at risk of shown to reduce mortality from infection with HIV in a HIV infection. This translated into a significant drop in 2017 overview paper by Benjamin Sommers. According new HIV infections in expansion states compared to to Sommers: non-expansion states.24 For example, Louisiana, which “[I]n this differences-in-differences analysis of state expanded Medicaid in 2016, saw in 2018 the lowest Medicaid expansions to low-income adults, I find that number of HIV cases diagnosed for the past decade— expansions led to a 6 percent relative decline in mortality an improvement that officials are linking directly to over five years of follow-up, compared with a control expansion and wider PrEP use: group of counties with similar pre-expansion mortality “New transmissions have dropped by 12 percent over the trends and demographic features.”27 past three years, according to the Louisiana Department of Health. State officials chalk up the decrease in new cases to the state’s Medicaid expansion, which gave people more access to HIV medication that makes the virus undetectable and PrEP, a once-daily pill that prevents HIV, as well as increases in screening.”25 6 hiv and medicaid expansion CCF.GEORGETOWN.EDU November 2020 zzThe initial expansion of Medicaid resulted zzMedicaid expansion and IV drug use. in half of people with HIV moving from Although HIV infection rates have decreased safety net providers for their care to substantially since the 1980s among people who inject comprehensive Medicaid coverage. drugs in the U.S., the current epidemic of injection One of the initial studies to look at the effect of Medicaid drug use threatens this progress. Recent outbreaks of expansion on health coverage for people with HIV found HIV infection in rural areas with a high prevalence of significant movement to Medicaid coverage even in the such drug use demonstrate the potential speed of HIV early stages of state expansions. States that expanded transmission through a population linked by networks Medicaid in 2014 saw half of people with HIV move into connected by injecting drugs.31 CDC identified 220 U.S. Medicaid. Previously a patchwork of safety net providers counties at highest risk for rapid dissemination of HIV and programs had been providing care.28 among people who inject drugs; more than two-thirds (69 percent) of these counties were in the South.32 zzMedicaid is the single largest source of Medicaid coverage has been shown to result in higher coverage for people with HIV. rates of treatment for people with opioid use disorder Nationally, 40 percent of people with HIV have Medicaid, in general than among patients either uninsured or with while only 13 percent of the population overall is covered private insurance.33 And a recent study found that a by Medicaid. The status of a state’s Medicaid expansion significantly higher proportion of people who inject drugs decision under the ACA has a significant effect on HIV have Medicaid coverage—and all the substance use and Medicaid coverage. Only 5 percent of people with disorder treatment options available under Medicaid—in HIV remain uninsured in states that have implemented the expansion states.34 Medicaid expansion compared to a 19 percent uninsured rate among people in HIV in non-expansion states. And 48 percent of people with HIV are covered by Medicaid in expansion states, compared to 29 percent of people with highlights HIV covered by Medicaid in non-expansion states.29 Medicaid Expansion Key zzExpanding Medicaid means expanding to Ending HIV Epidemic HIV testing. zz Expands HIV testing A key measure of progress in addressing the HIV epidemic has been the rate of HIV testing in states. zz Improves access to preventative Testing leads to identification of HIV infection and the drugs that reduce infection rate opportunity to provide treatment and education. Recent zz Provides comprehensive coverage research has shown states that have expanded Medicaid for life-saving treatments are able to increase the use of HIV tests. Wider diagnosis and opportunity for treatment has been the result: zz Leads to reduction in new cases and mortality rate “Medicaid expansion has been effective by increasing HIV tests without increasing HIV risk behavior. The zz Offers help and treatment for IV majority of non-expansion states are in the South, drug use where HIV infection rates and AIDS cases are higher than in any of the other 3 US regions. Their decisions not to expand Medicaid could carry heavy financial and wellness costs in the long run because undiagnosed HIV cases could lead to contagion and more serious AIDS symptoms.”30 November 2020 CCF.GEORGETOWN.EDU hiv and medicaid expansion 7 Conclusion The HIV epidemic affects men, women, children and Research has shown that Medicaid expansions bring families, especially in Southern states. However, there people with HIV or at risk of HIV infection into the health is hope. Several trends have accelerated in the past few care system where they can receive new treatment options years to point to the importance of Medicaid expansion as and prevention drugs. Previous and ongoing studies show a key strategy to eliminate the HIV epidemic in the U.S., a that both HIV diagnoses and mortality from HIV decline decades-long goal finally within our grasp. The development when states expand Medicaid. There are many strategies to of effective treatment options and prevention strategies has combat the HIV epidemic from the HRSA Ryan White HIV/ made treatment of HIV infection and stopping transmission AIDS Program to the new multi-pronged prevention and possible. But an epidemic can only be stopped if the tools of rapid-treatment initiative announced by the Department of attack are available to everyone. Health and Human Services last year.35 But leaving Medicaid expansion out of these efforts is an omission that creates a As the U.S. HIV epidemic has concentrated in the South, the large roadblock to success. Medicaid should be front and last states still refusing to expand Medicaid to two million center of HIV elimination efforts, especially in the South, the Americans are also largely in the South. And the four states center of the current epidemic. with the largest number of people who would gain affordable health coverage under Medicaid expansion are Texas, Florida, Georgia and North Carolina. Acknowledgments About the authors: Adam Searing is Research Professor, Georgetown University McCourt School of Public Policy, Center for Children and Families, Georgetown University; Adaora A. Adimora is Professor of Medicine, Department of Medicine, Division of Infectious Diseases, UNC-Chapel Hill and Professor of Epidemiology, Department of Epidemiology, UNC-Chapel Hill. The authors would like to thank Catherine Hope and Phyllis Jordan for their editorial assistance. Design and layout was provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. 8 hiv and medicaid expansion CCF.GEORGETOWN.EDU November 2020 Endnotes 1 L. Antonines, R. Garfield, and M. Guth, “The Effects of Medicaid Centers for Disease Control and Prevention, Issue Brief, “HIV in the 16 Expansion under the ACA: Updated Findings from a Literature Review,” Southern States United States, September 2019,” available at https:// Kaiser Family Foundation, Aug 15, 2019, available at https://www.kff. www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf. org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca- 17 R. Garfield, K. Orgera, A. Damico, “The Coverage Gap: Uninsured updated-findings-from-a-literature-review/. Poor Adults in States that Do Not Expand Medicaid,” Kaiser Family 2 Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010). Foundation, Jan 14, 2020, available at https://www.kff.org/medicaid/ 3 A. Fauci, R. Redfield, G. Sigounas, M. Weahkee, and B. Giroir, “Ending issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do- the HIV Epidemic: A Plan for the United States,” February 7, 2019, not-expand-medicaid/. JAMA, 2019;321(9):844-845, available at https://jamanetwork.com/ 18 Southern AIDS Coalition, “Southern states manifesto update 2012 journals/jama/fullarticle/2724455. Note: This plan does not mention Policy Brief and Recommendations, available at https://www.rwhp.org/ Medicaid expansion. extra/Southern-States-Manifesto-Update-2012.pdf. 4 S. Karlin-Smith and B. Ehley, “How killing Obamacare could backfire 19 “Black Americans and HIV/AIDS: The Basics,” Kaiser Family for Trump: President Donald Trump’s renewed push to gut Obamacare Foundation, February 2020, available at https://www.kff.org/hivaids/ could sabotage the rest of his health agenda,” Politico, April 1, 2019, fact-sheet/black-americans-and-hivaids-the-basics/. available at https://www.politico.com/story/2019/04/01/obamacare- 20 Centers for Disease Control and Prevention, HIV Surveillance Report, trump-hiv-health-agenda-1244370. 2018 (Preliminary); vol. 30., November 2019, available at http://www. 5 P. 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Van Handel et al., “County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs, United States,” Journal of Acquired Immune Deficiency Syndromes 2016;73:323, available at https://journals.lww.com/jaids/ Fulltext/2016/11010/County_Level_Vulnerability_Assessment_for_ Rapid.13.aspx. Georgetown University Center for Children and Families McCourt School of Public Policy 600 New Jersey Avenue, NW Washington, DC 20001 Phone: (202) 687-0880 Email: childhealth@georgetown.edu ccf.georgetown.edu/blog/ facebook.com/georgetownccf twitter.com/georgetownccf 10 hiv and medicaid expansion CCF.GEORGETOWN.EDU November 2020