The US 2020 HIV/AIDS Strategy and the Limits of ACA

Aug 04, 2015 | Labs Blog

By Leslie Francis for, originally posted on Harvard Law “Bill of Health” blog.

Leslie_Francis_kmphsaOn July 30, the White House announced the updated 2020 HIV/AIDS strategy. The admirable vision of the strategy is that “The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

This said, the strategy reflects continuing concerns about the numbers of people who do not know their HIV status, who do not have access to effective treatment, and who do not take advantage of preventive strategies. Demographic groups especially at risk include men having sex with men, African American men and women, Latino men and women, people who inject drugs, youth age 13-24, people in the Southern United States, and transgender women. The strategy emphasizes care coordination, coordination between health care and other social services such as housing, treatment as prevention, and pre-exposure prophylaxis. Notable initiatives since the 2010 HIV/AIDS strategy include interagency efforts to address the intersection of HIV and violence against women, a DOJ and CDC collaboration to publish a comprehensive examination and best practices guide on the intersection between HIV and criminal laws, and demonstration projects funded through the HHS Minority AIDS Initiative Fund.

Another major improvement since the 2010 strategy is implementation of the Affordable Care Act. The 2020 strategy takes due note of the coverage expansions the ACA has brought: the end to pre-existing condition exclusions for people seeking coverage, Medicaid expansion, and access to marketplace plans. Yet given the demographic groups at greatest risk, there is a far darker side: what ACA has not yet achieved and possibly will not achieve.

In 2014, the Kaiser Family Foundation published a report estimating the impact of ACA on health insurance coverage for people with HIV. The 2020 strategy relies on the estimates in this report: that of 70,000 persons with HIV who were uninsured, about 47,000 would become eligible for Medicaid if that program were expanded in all states and that another 23,000 would qualify for subsidized private coverage in the marketplaces. These estimates, however, refer only to people with HIV who are uninsured and are already in care. The KFF report (relying on CDC estimates) also guesses that about 700,000 people with HIV are not yet in care and that an additional 124,000 people in this group could gain new coverage were the ACA Medicaid expansion and marketplace subsidies to be in effect in all states.

By my calculation, this leaves out over 500,000 people who are not yet in care and who still would not gain coverage even with the full deployment of ACA. Half a million—not a trivial figure in view of the importance of encouraging testing, treatment as prevention, and pre-exposure prophylaxis. To be sure, Ryan White funds pay pick up some of the slack—but only for those who know their HIV status.

Leslie Francis holds joint appointments as Alfred C. Emery professor of law and professor of philosophy, and adjunct appointments in Family and Preventive Medicine (in the Division of Public Health), Internal Medicine (in the Division of Medical Ethics), and Political Science.