The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States

The Ryan White Program, enacted in 1990, is the nation’s safety net program for HIV care and treatment and serves about half a million people with the disease in the United States. The federal government has authorized the use of Ryan White funds for purchasing health insurance on behalf of clients since the enactment of the program and using funds this way has increased over time. While insurance purchasing has always been a permissible use of Ryan White funds, its role has become both more important and more complex with the implementation of the Affordable Care Act (ACA), as many more people with HIV have become newly eligible for insurance coverage. How Ryan White grantees at the state and local levels elect to move forward with insurance purchasing in the ACA era has key implications for the program and for the clients it serves.

This brief discusses the historic role the Ryan White Program has played in helping clients purchase insurance coverage and provides an early look how grantees have elected to use Ryan White funds and ready systems for insurance purchasing in the ACA era, in five states – California, Florida, Georgia, New York, and Texas. The focus of this brief is on the first open enrollment period (lasting from October 2013 through April 2014) and on insurance purchasing activities conducted through the health insurance marketplaces for qualified health plans (QHPs). The findings of this brief are based on stakeholder interviews, focus groups with HIV positive individuals, and reviews of federal, state, and local documents.

Key findings from the state studies include:

• Most insurance purchasing in the Ryan White Program occurs through AIDS Drug Assistance Programs (ADAPs), a component of the state (Part B) program. ADAPs approached the first open enrollment period with different degrees of insurance purchasing experience and this often paralleled the degree to which they were prepared to offer insurance purchasing through the marketplaces. Among the states in this analysis, two ADAPs moved ahead with larger scale insurance purchasing programs (California and New York), two (Florida and Georgia) operated small-scale or pilot programs, and one (Texas) did not pursue an insurance purchasing program that could support QHP coverage.
• All ADAPs examined here, including those more proactively pursuing QHP premium assistance, faced challenges. For those embracing QHP premium support, stakeholders described technical and/or process issues related to leveraging existing systems – which in some cases needed to be updated – for larger scale enrollment and challenges in orchestrating third party payments.
• In the states that less aggressively pursued QHP insurance purchasing, stakeholders explained that challenges ran deeper and were often related to operating programs in states that were, overall, resistant to ACA implementation. As a result, stakeholders in these states reported that ADAPs were unable to sufficiently prepare for client enrollment through the marketplaces, were only able to conduct limited insurance purchasing, or, in the case of one state, were not able to start a QHP insurance purchasing program altogether.
• States also varied in their ability to assist with cost-sharing assistance beyond premiums. While one state was able to provide complete cost-sharing assistance, other states provided only limited support beyond paying premiums. Stakeholders worried that without full cost-sharing assistance, clients would find insurance expenses unaffordable and may not be able to maintain their coverage, jeopardizing their care and treatment.
• Part As, often by funding AIDS Service Organizations (ASOs), frequently stepped in to fill gaps in coverage and assist with costs not met through ADAP program insurance purchasing. This included covering premiums in states whose ADAPs had no or limited QHP insurance purchasing programs, helping with cost-sharing not supported by ADAPs, and preventing gaps in care and treatment during bumpy enrollment processes or coverage transitions. In some cases additional support was obtained through private foundations and pharmaceutical assistance programs.
• The ADAPs that had the most limited QHP insurance purchasing programs in this study operated in states that did not expand Medicaid. Conversely, the states that embraced premium support for QHPs through their ADAP programs early on also expanded Medicaid, offering clients more robust coverage options.
• The federal government encouraged Ryan White Program grantees to “vigorously pursue” client enrollment into available coverage, including QHPs. While this directive was clear to some grantees and helped to underpin efforts to enroll clients in QHPs with insurance purchasing assistance, others found the directive difficult to interpret. Some stakeholders trying to operate programs in states that were more resistant to ACA implementation overall reported a conflict between what was being asked of them by the federal government with regard to enrollment under the Ryan White Program and state-level decisions opposing to ACA implementation which lead to limited insurance purchasing opportunities.