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McManus KA, Schurman E, An Z, Van Hook R, Keim-Malpass J, Flickinger TE. Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study. AIDS Res Hum Retroviruses 2021; 38:580-591. [PMID: 34538069 PMCID: PMC9297321 DOI: 10.1089/aid.2021.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll >33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 28) met our recruitment goal. Most participants had positive feelings about Medicaid before enrollment (general: 68%; good for general health: 75%, and good for HIV care: 67%) and after enrollment (general: 93% and good for HIV care: 93%). All participants expressed incomplete understanding about Medicaid before enrollment. Seventy-nine percent needed outside help to complete enrollment. Approximately 40% described overlaps of Medicaid with other insurance/payers or gaps in insurance coverage when transitioning from one insurance/payer (such as AIDS Drug Assistance Program [ADAP] medication provision and ADAP-subsidized insurance) to Medicaid. Participants suggested more access or easier access to information about Medicaid and more explanation of Medicaid benefits would be helpful. Our findings indicate participants had mostly positive perceptions of Medicaid before and after enrollment. Even with enrollment help, participants voiced that dealing with insurance is hard. Medicaid and other programs should prioritize more access to information, smoother processes, and less burdensome enrollment/re-enrollment.
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Affiliation(s)
- Kathleen A. McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
- Global Infectious Diseases Institute, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth Schurman
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Zixiao An
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Reed Van Hook
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Jessica Keim-Malpass
- Global Infectious Diseases Institute, University of Virginia, Charlottesville, Virginia, USA
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA
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McManus KA, Christensen B, Nagraj VP, Furl R, Yerkes L, Swindells S, Weissman S, Rhodes A, Targonski P, Rogawski McQuade E, Dillingham R. Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression. Clin Infect Dis 2021; 71:2572-2580. [PMID: 31734691 PMCID: PMC7744983 DOI: 10.1093/cid/ciz1123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States’ “Ending the HIV Epidemic” (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. Methods A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014–2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. Results Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06–3.53) and engagement in care in 2014 (aPR, 1.16; 1.04–1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs’ NNT for an additional person to achieve VS is 20 (14.1–34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28–1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99–1.14) was associated with VS. Conclusions Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.
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Affiliation(s)
- Kathleen A McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Center for Health Policy, University of Virginia, Charlottesville, Virginia, USA
| | | | - V Peter Nagraj
- School of Medicine Research Computing, University of Virginia, Charlottesville, Virginia, USA
| | - Renae Furl
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lauren Yerkes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Susan Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sharon Weissman
- Division of Infectious Diseases, University of South Carolina, Columbia, South Carolina, USA
| | - Anne Rhodes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Paul Targonski
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA.,Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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McManus KA, Srikanth K, Powers SD, Dillingham R, Rogawski McQuade ET. Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic. Open Forum Infect Dis 2020; 8:ofaa595. [PMID: 33598500 PMCID: PMC7875325 DOI: 10.1093/ofid/ofaa595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/02/2020] [Indexed: 01/01/2023] Open
Abstract
Background Although the Ryan White HIV/AIDS Program supports high-quality human immunodeficiency virus (HIV) care, Medicaid enrollment provides access to non-HIV care. People with HIV (PWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). Methods Participants were PWH ages 18–63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. Results Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% federal poverty level (adjusted prevalence ratio, 1.67; 95% confidence interval [CI], 1.00–1.86) compared with others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD], −8.5%; 95% CI, −16.9 to 0.1) and Medicare (aRD, −12.5%; 95% CI, −21.2 to −3.0) had lower 2019 engagement than others. For those with VS data (n = 548), after controlling for age and baseline VS, those with Medicaid (aRD, −4.0%; 95% CI, −10.3 to 0.3) and with Medicaid due to ME (aRD, −6.2%; 95% CI, −14.1 to −0.8) were less likely to achieve VS compared with others. Conclusions Given that PWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.
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Affiliation(s)
- Kathleen A McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Center for Health Policy, University of Virginia, Charlottesville, Virginia, USA
| | - Karishma Srikanth
- Batten School of Leadership and Public Policy, University of Virginia, Charlottesville, Virginia, USA
| | - Samuel D Powers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Elizabeth T Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA.,Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
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A Cross-Sectional Study on the Affordable Care Act from the Perspective of People Living with HIV: The Interplay between Knowledge, Stigma, Trust, and Attitudes. AIDS Res Treat 2020; 2020:6081721. [PMID: 33376606 PMCID: PMC7744239 DOI: 10.1155/2020/6081721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/17/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022] Open
Abstract
Background Many AIDS Drug Assistance Programs (ADAPs) purchased Affordable Care Act (ACA) Qualified Health Plans (QHPs) for low-income people living with HIV (PLWH). To date, little has been published about PLWH's perspective on the ACA. We explored ACA knowledge, HIV stigma, trust in the healthcare system, and ACA attitudes among PLWH with ADAP-funded QHPs in Virginia. Methods Participants were surveyed about demographic characteristics, ACA knowledge, HIV stigma, trust in various healthcare and government entities, and attitudes toward the ACA. Descriptive statistics were used. We assessed for associations (1) between baseline characteristics and correct ACA knowledge, HIV-related stigma, trust, and ACA attitudes and (2) between correct ACA knowledge and the following data: sources of ACA knowledge, HIV stigma, and trust. Results Participants (n = 53) were a vulnerable population based on the assessment of social determinants of health, and 30% had correct ACA knowledge. Almost three-fourths of participants used HIV clinic case managers for ACA information. Participants who used websites for ACA information had correct ACA knowledge more often compared to those that did not (71% vs. 15%; p = 0.001). Those with correct ACA knowledge had lower stigma scores compared to those without correct ACA knowledge (93.8; SD: 15.4 vs. 108; SD: 20.3; p = 0.01). Participants trusted HIV clinicians more than general clinicians and insurance companies. No association was found between having correct ACA knowledge and endorsing having enough information about the ACA to understand how it will impact their HIV care. Conclusions Websites imparted accurate ACA information. HIV clinic case managers were the most used source, and HIV clinicians were a trusted source of information. HIV clinicians and case managers should consider disseminating information about the ACA and its impact on HIV care delivery via internet videos. Lack of internet and stigma are a threat to PLWH gaining actionable healthcare information.
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McManus KA, Killelea A, Honeycutt E, An Z, Keim-Malpass J. Assisters Succeed in Insurance Navigation for People Living with HIV and People at Increased Risk of HIV in a Complex Coverage Landscape. AIDS Res Hum Retroviruses 2020; 36:842-851. [PMID: 32631076 PMCID: PMC7548024 DOI: 10.1089/aid.2020.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Insurance enrollment is complex for people living with HIV (PLWH) and people at increased risk for HIV, in part, owing to needing to ensure access to adequate provider networks and appropriate formularies. Insurance for PLWH facilitates access to HIV care/treatment and, ultimately, viral suppression, which has the individual benefit of longevity and the public health benefit of decreased HIV transmission. For people at increased risk for HIV, access to insurance facilitates improved access to HIV biomedical prevention, which has the individual benefit of elimination of transmission risk and the public health benefit of decreased HIV transmission. The objective of this study was to explore perceptions of priorities related to plan navigation, barriers and facilitators for enrolling and maintaining insurance coverage, and questions related to regional, state, and federal policies impacting plans provided both on and off the Affordable Care Act (ACA) marketplace. We interviewed a national sample of assisters (n = 40), who specialize in insurance plan selection for these populations. We found that assisters tailor their approaches to HIV-specific and person-specific concerns by navigating challenges related to affordability, formularies, and provider networks. In a complex coverage landscape during a time of uncertainty about the long-term future of the ACA, assisters have mastered the ability to simplify the insurance selection process for a vulnerable population. Assisters have excelled at incorporating insurance literacy education and encouraging client engagement in the process. Assisters play an essential role in the current complicated and fragmented United States' health care delivery system for PLWH and people at increased risk for HIV and could be incorporated into the Ending the HIV Epidemic initiative.
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Affiliation(s)
- Kathleen A. McManus
- University of Virginia, School of Medicine, Division of Infectious Diseases and International Health, Charlottesville, Virginia, USA
| | - Amy Killelea
- NASTAD, Health Systems and Policy, Washington, District of Columbia, USA
| | - Ethan Honeycutt
- University of Virginia, College of Arts and Sciences, Charlottesville, Virginia, USA
| | - Zixiao An
- University of Virginia, College of Arts and Sciences, Charlottesville, Virginia, USA
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