The US health-care delivery system differs markedly from that of other high-income countries,1, 2, 3 as does its HIV response.4, 5 The USA has a different approach to social welfare, contributing to how the US health-care system is structured and financed, and, uniquely among its peers, does not have universal health coverage. Despite spending more per person on health care than other high-income countries, the USA has worse health outcomes and poorer access to coverage and care.1 To understand the US health-care system, it is important to understand how financing and coverage are structured and organised, and how this structure affects individual access and outcomes, including those for HIV.
Financing and insurance coverage in the USA generally, and for HIV specifically, have been highly fragmented, characterised by a complex patchwork of payers and financing mechanisms. This patchwork varies substantially by state, creating uneven access across the country and leaving some people outside the system altogether.6 The Ryan White HIV/AIDS Program (RWHAP), the largest disease-specific US federal grant programme, was enacted in 1990 to address some of these challenges by creating a national safety-net system for HIV care. The RWHAP operates as the payer of last resort and provides outpatient services and other support to people with HIV who are uninsured and underinsured.7
With the passage of the Patient Protection and Affordable Care Act (ACA) in March, 2010, the US health insurance system underwent one of its most substantial transformations, which has helped to expand access to coverage and services for millions of people in the USA, including people with and at risk of HIV.8 Studies of the ACA's Medicaid expansion have shown how health-care coverage correlates with clinical outcomes and found that expansion has not only improved the timeliness of and access to treatment, but has also attenuated disparities in care.9, 10 Although uninsurance has declined sharply under the law, some people still remain uninsured or underinsured, costs are high for many, and access is still variable. In addition, despite spending more per person on health care, the USA continues to lag behind other high-income countries on numerous key overall health and HIV-specific metrics, including HIV incidence and rates of viral suppression.1, 2, 3, 11, 12 In response to these epidemiological challenges, in February, 2019, the Trump Administration announced the Ending the HIV Epidemic: A Plan for America (EHE) initiative, which aims to cut HIV incidence in the USA by 90% by 2030.13, 14
Key messages
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Before the Affordable Care Act (ACA), people with and at risk of HIV faced substantial barriers to health-care access and coverage; the ACA sought to address these and many other access barriers and has thus far improved both clinical outcomes and disparities in care
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Despite a historic transformation under the ACA and increases in insurance coverage, the US health-care system remains a complex and often opaque network of payers, providers, and financing mechanisms; coverage opportunities still vary substantially across the country, providing some people with access to care and leaving others outside the syste; state-based decisions around Medicaid expansion are a notable example
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Important scientific advancements, including new evidence for the role of antiretroviral treatment in HIV prevention and the approval of pre-exposure prophylaxis, fundamentally change the equation for addressing HIV but at the same time reveal challenges within the system
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Although a new initiative, Ending the HIV Epidemic: A Plan for America, promises to offer new funding, focus, and political will, an uneven playing field in treatment and prevention coverage threatens its progress
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The ability to curb the national HIV epidemic depends on an uncertain future of health-care financing, care and prevention coverage, and safety-net programmes, and on curtailing high HIV drug costs in the USA, as well as on responses to a range of complex inequalities and experiences of stigma and discrimination
Meanwhile, the past decade has seen enormous scientific breakthroughs in HIV treatment and biomedical prevention. Data now conclusively show that suppressive antiretroviral therapy (ART) also serves as HIV prevention; people with HIV who have an undetectable viral load cannot transmit the virus to others.15 Clinical trials and demonstration projects have also provided evidence for the efficacy and effectiveness of short-acting and long-acting pre-exposure prophylaxis (PrEP), leading to its approval in the USA for HIV prevention in 2012.16, 17 Both interventions have fundamentally changed the equation for addressing the HIV epidemic. Even in the post-ACA era, ART and PrEP have brought to the fore the challenges caused by a patchwork payer system with varying levels of access and health-system capacity, complicated by few mechanisms to control health-care spending and drug pricing. List prices of first-line ART regimens for most people with HIV range from US$23 000 to $39 000 annually (wholesale acquisition cost [WAC]) and have nearly doubled in price over the past decade.18, 19 As consolidated two-drug regimens (eg, dolutegravir–lamivudine), medications with unique administration routes (eg, injectables or implants), and generics become more widely available, policy makers, providers, and advocates will continue to grapple with what financing and delivery mechanisms best ensure suppressive, sustainable, and ethical access to recommended medications.
In this paper in the Series, we provide an overview of the insurance coverage and financing landscape for HIV treatment and prevention in the USA. We discuss changes brought about because of the ACA, examine the major programmes and payers that provide coverage and services to people with and at risk of HIV, and identify several remaining challenges. Although not addressed here, these challenges have been further strained by the ongoing COVID-19 pandemic, which is likely to have repercussions for the US health-care system for some time to come.
