Current HIV/AIDS Reports

, Volume 16, Issue 1, pp 105–112 | Cite as

The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals

  • Blythe AdamsonEmail author
  • Lauren Lipira
  • Aaron B. Katz
The Science of Prevention (JD Stekler and JM Baeten, Section Editors)
Part of the following topical collections:
  1. Topical Collection on The Science of Prevention


Purpose of Review

Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals.

Recent Findings

Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed.


While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.


Affordable Care Act Medicaid expansion HIV 90-90-90 Viral suppression Policy analysis 



Affordable Care Act


AIDS Drug Assistance Program


antiretroviral therapy


Behavioral Risk Factor Surveillance System


Centers for Disease Control and Prevention


difference-in-differences analysis


Federal Poverty Level


human immunodeficiency virus


men who have sex with men


people living with HIV


Ryan White HIV/AIDS Program


Joint United Nations Program on HIV/AIDS


United States



We would like to thank Anirban Basu for the input on policy analysis methods for causal inference using observational data. Lisa McLoughlin provided technical editing.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Supplementary material

11904_2019_429_MOESM1_ESM.pdf (1.3 mb)
ESM 1 (1.28 mb)


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Centers for Disease Control and Prevention (2017) Understanding the HIV Care Continuum National HIV Prevention Objectives on HIV Diagnosis and Care, 2014. 1–4.Google Scholar
  2. 2.
    Skarbinski J, Rosenberg E, Paz-Bailey G, Hall HI, Rose CE, Viall AH, Fagan JL, Lansky A, Mermin JH (2015) Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Intern Med 175:588–588, 596.Google Scholar
  3. 3.
    Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014) 90-90-90 an ambitious treatment target to help end the AIDS epidemic. Geneva.Google Scholar
  4. 4.
    White House Office of National AIDS Policy National HIV/AIDS Strategy: Updated to 2020. 1–74.Google Scholar
  5. 5. How does the Affordable Care Act help people living with HIV/AIDS? In: 1–3; 2012.Google Scholar
  6. 6.
    • Wagner Z, Wu Y, Sood N. The Affordable Care Act may increase the number of people getting tested for HIV by nearly 500,000 by 2017. Health affairs (Project Hope). 2014;33:378–85 Modeling estimated a 22% reduction in the number of unware people living with HIV between 2013 and 2017.CrossRefGoogle Scholar
  7. 7.
    Bradley H, Viall AH, Wortley PM, Dempsey A, Hauck H, Skarbinski J. Ryan White HIV/AIDS program assistance and HIV treatment outcomes. Clin Infect Dis. 2016;62:90–8.CrossRefGoogle Scholar
  8. 8.
    Centers for Disease Control and Prevention. NCHHSTP AtlasPlus; 2017.Google Scholar
  9. 9.
    Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2014. Atlanta. 2015.Google Scholar
  10. 10.
    Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data-United States and 6 dependent areas-2013. HIV Surveillance Supplemental Report. 2015;20:1–70.Google Scholar
  11. 11.
    Centers for Disease Control and Prevention. HIV surveillance report, 2016. 28:table 24; 2017.Google Scholar
  12. 12.
    The Henry J. Kaiser Family Foundation (2018) Status of state action on the Medicaid expansion Decision.Google Scholar
  13. 13.
    • Kates J, Garfield R, Young K, Quinn K, Frazier E, Skarbinski J. Assessing the impact of the Affordable Care Act on health insurance coverage of people with HIV | The Henry J. Kaiser Family Foundation. 2014. This report discusses how the ACA may increase or decrease access to care for people with HIV and how Medicaid expansion may interact with the resources from the Ryan White HIV/AIDS Program.Google Scholar
  14. 14.
    Snider JT, Juday T, Romley JA, Seekins D, Rosenblatt L, Sanchez Y, et al. Nearly 60,000 uninsured and low-income people with HIV/AIDS live in states that are not expanding Medicaid. Health affairs (Project Hope). 2014;33:386–93.CrossRefGoogle Scholar
  15. 15.
    Goldman DP, Leibowitz AA, Joyce GF, Fleishman JA, Bozzette SA, Duan N, et al. Insurance status of HIV-infected adults in the post-HAART era: evidence from the United States. Appl Health Econ Health Policy. 2003;2:85–90.Google Scholar
  16. 16.
    Yehia BR, Fleishman JA, Agwu AL, Metlay JP, Berry SA, Gebo KA. Health insurance coverage for persons in HIV care, 2006–2012. J Acquir Immune Defic Syndr. 2014;67:102–6.CrossRefGoogle Scholar
  17. 17.
    The Henry J. Kaiser Family Foundation. Medicaid enrollment and spending on HIV/AIDS (FY07-FY11). In: State Health Facts. 2016. Accessed 21 Mar 2018.
  18. 18.
    •• Kates J, Dawson L. Insurance coverage changes for people with HIV under the ACA. The Henry J Kaiser Family Foundation; 2017, pp 1–11. This in-depth qualitative research communicates real people’s experiences and the trade-offs.Google Scholar
  19. 19.
    del Rio C. The evolving HIV epidemic in the United States. Conference on Retroviruses and Opportunistic Infections.Google Scholar
  20. 20.
    Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, et al. The Oregon experiment — effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368:1713–22.CrossRefGoogle Scholar
  21. 21.
    • Viall AH, McCray E, Mermin J, Wortley P. Current and (potential) future effects of the Affordable Care Act on HIV prevention. Curr HIV/AIDS Rep. 2016;13:95–106 This review provides the location reference for each section of the Affordable Care Act that creates a change impacting HIV prevention.CrossRefGoogle Scholar
  22. 22.
    • Lipira L, Williams EC, Hutcheson R, Katz AB. Evaluating the Impact of the Affordable Care Act on HIV Care, Outcomes, Prevention, and Disparities: A Critical Research Agenda. J Health Care Poor Underserved. 2017;28:1254–75 This review focuses on disparities in HIV, expands on heterogeneity of risk, and discusses potential heterogeneity of ACA effect.CrossRefGoogle Scholar
  23. 23.
    Massachusetts General Laws Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care.Google Scholar
  24. 24.
    Massachusetts General Laws Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care. The 190th gGeneral Court of the Commonwealth of Massachusetts.Google Scholar
  25. 25.
    Phillips AN, Staszewski S, Weber R, Kirk O, Francioli P, Miller V, et al. HIV viral load response to antiretroviral therapy according to the baseline CD4 cell count and viral load. JAMA. 2001;286:2560–7.CrossRefGoogle Scholar
  26. 26.
    INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373:795–807.CrossRefGoogle Scholar
  27. 27.
    Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375:830–9.CrossRefGoogle Scholar
  28. 28.
    Bounthavong M, Adamson B, Basu A. Instrumental variables: a tool to reduce bias in non-randomized studies. Value and Outcomes Spotlight. 2016;2:25–5.Google Scholar
  29. 29.
    •• Cranston K, John B, Fukuda HD, Randall LM, Mermin J, Mayer KH, et al. Sustained reduction in HIV diagnoses in Massachusetts, 2000–2014. Am J Public Health. 2017;107:794–9 Massachusetts provides the first valid evidence that the percent of people unware of HIV infection is decreasing because of Medicaid expansion increasing the access to and frequency of HIV testing. At the same time, there were fewer new HIV diagnoses over time because effective prevention interventions lowered incidence rates.CrossRefGoogle Scholar
  30. 30.
    •• Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manage. 2017;36:390–417 Excellent example of a difference-in-differences regression analysis that can serve as a guide for future research on policy impact affect on 90-90-90 goals.CrossRefGoogle Scholar
  31. 31.
    Sommers BD, Maylone B, Blendon RJ, Orav EJ, Epstein AM. Three-year impacts of the affordable care act: improved medical care and health among low-income adults. Health Aff. 2017;36:1119–28.CrossRefGoogle Scholar
  32. 32.
    •• Furl R, Watanabe-Galloway S, Lyden E, Swindells S. Determinants of facilitated health insurance enrollment for patients with HIV disease, and impact of insurance enrollment on targeted health outcomes. BMC Infect Dis. 2018;18:132 Among all people living with HIV that became eligible for Medicaid after expansion in Nebraska, those who enrolled had a significant improvement in viral suppression.CrossRefGoogle Scholar
  33. 33.
    Erugo E. Impact of the Affordable Care Act on the HIV care continuum. Walden Dissertations and Doctoral Studies; 2017.Google Scholar
  34. 34.
    Eaton EF, Mugavero MJ. Editorial commentary: affordable care act, Medicaid expansion … or not: Ryan White care act remains essential for access and equity. Clin Infect Dis. 2016;63:404–6.CrossRefGoogle Scholar
  35. 35.
    Satre DD, Parthasarathy S, Altschuler A, Silverberg MJ, Storholm E, Campbell CI. Demographic, insurance, and health characteristics of newly enrolled HIV-positive patients after implementation of the Affordable Care Act in California. Am J Public Health. 2016;106:1211–3.CrossRefGoogle Scholar
  36. 36.
    Diepstra KL, Rhodes AG, Bono RS, Patel S, Yerkes LE, Kimmel AD. Comprehensive Ryan White assistance and human immunodeficiency virus clinical outcomes: retention in care and viral suppression in a Medicaid nonexpansion state. Clin Infect Dis. 2017;65:619–25.CrossRefGoogle Scholar
  37. 37.
    Emory University Rollins School of Public Health AIDSVu.
  38. 38.
    Reif S, Safley D, McAllaster C, Wilson E, Whetten K. State of HIV in the US deep south. J Community Health. 2017;42:844–53.CrossRefGoogle Scholar
  39. 39.
    Garfield R, Damico A. The coverage gap: uninsured poor adults in states that do not expand Medicaid. The Henry J. Kaiser Family Foundation; 2017.Google Scholar
  40. 40.
    Del Rio C. The evolving HIV epidemic in the United States. Boston; 2018, p. 1.Google Scholar
  41. 41.
    Rosenberg ES, Millett GA, Sullivan PS, del Rio C, Curran JW. Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: a modelling study. Lancet HIV. 2014;1:e112–8.CrossRefGoogle Scholar
  42. 42.
    Comulada WS, Desmond KA, Gildner JL, Leibowitz AA. Transitioning from Medicaid disability coverage to long-term Medicare coverage: the case of people living with HIV/AIDS in California. AIDS Educ Prev. 2017;29:49–61.CrossRefGoogle Scholar
  43. 43.
    Winkelman TNA, Chang VW. Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. J Gen Intern Med. 2018;33:376–83.CrossRefGoogle Scholar
  44. 44.
    Geter A, Sutton MY, Hubbard McCree D. Social and structural determinants of HIV treatment and care among black women living with HIV infection: a systematic review: 2005–2016. AIDS Care. 2018;30:409–16.CrossRefGoogle Scholar
  45. 45.
    Gilman B, Bouchery E, Hogan P, Degrusa S, Trent-Adams S, Cheever L. The HIV clinician workforce in the United States: supply and demand projections from 2010–2015. HIV Specialist. 2016;8:1–32.Google Scholar
  46. 46.
    Paterson C. Mind the gap: the impact of the ACA Medicaid expansion on health outcomes in the United States. 2017.Google Scholar
  47. 47.
    Newhouse JP, McClellan M. Econometrics in outcomes research: the use of instrumental variables. Annu Rev Public Health. 1998;19:17–34.CrossRefGoogle Scholar
  48. 48.
    Johnston KM, Gustafson P, Levy AR, Grootendorst P. Use of instrumental variables in the analysis of generalized linear models in the presence of unmeasured confounding with applications to epidemiological research. Stat Med. 2008;27:1539–56.CrossRefGoogle Scholar
  49. 49.
    Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41–55.CrossRefGoogle Scholar
  50. 50.
    Strand L, Adamson B, Basu B. The good, the bad, and the ugly: reminders about propensity scores. Value and Outcomes Spotlight. 2017;3:21–2.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Blythe Adamson
    • 1
    • 2
    Email author
  • Lauren Lipira
    • 3
  • Aaron B. Katz
    • 3
  1. 1.The Comparative Health Outcomes, Policy, and Economics (CHOICE) InstituteUniversity of WashingtonSeattleUSA
  2. 2.Vaccine and Infectious Diseases DivisionFred Hutchinson Cancer Research CenterSeattleUSA
  3. 3.Department of Health ServicesUniversity of WashingtonSeattleUSA

Personalised recommendations