HIV in the Southern United States: Regional Challenges & Opportunities

1. HIV in the Southern United States: Regional Challenges & Opportunities Jen Kates, PhD June 18, 2014 Vice President; Director, Global Health & HIV Policy Kaiser Family Foundation jkates@kff.org http://kff.org/hivaids

2. Census Regions and Divisions of the United States ME Northeast (9 states) VT ND Midwest (12 states) MN NH WA MT WI MA SD OR NY MI RI CT ID IA PA NE NJ OH WY IN IL West (13 states) NV KS MO CO UT DE CA MD WV VA DC KY AZ NC NM TN SC OK AR GA AL MS AK LA TX HI FL South (17 states, including DC) SOURCE: United States Census Bureau. http://www.census.gov/geo/maps-data/maps/pdfs/reference/us_regdiv.pdf

3. SOURCE: Stephens J, Artiga S, Paradise J, Health Coverage and Care in the South in 2014 and Beyond, Kaiser Family Foundation, April 2014. The Southern Region of the United States: Broader Considerations & Context Beyond HIV • The southern region represents more than a third (37%) of the U.S. population: • Largest share of any census region • Its population is growing rapidly • Its population is racially/ethnically diverse • The South has faced longstanding disparities in health coverage, health status, and health care. Relative to the rest of the United States, Southerners are: • More likely to be poor • More likely to be uninsured • Less likely to have access to needed health services (e.g., no usual source of care, postponing care due to cost) • More likely to report poor health and experience a number of chronic health conditions • More likely to live in areas with a shortage of primary care providers 100% 82% Leading role Major role, but not leading

4. Key ACA Provisions for People with HIV CONSUMER PROTECTIONS HEALTH CARE MARKETPLACES IN EVERY STATE MEDICAID EXPANSION BENEFITS STANDARDS, INCLUDING PREVENTION

5. Most Southern States (11 of 17) are Not Implementing Medicaid Expansion in 2014 36% PLWHA Live in the 11 Southern States Not Expanding In These 11 States, There is no Medicaid Coverage of Childless Adults, Regardless of Income DE MD WV VA DC KY NC TN SC OK AR GA AL MS LA TX FL Implementing Expansion(6 states, including DC) Not Expanding (11 States) NOTES: Eligibility as of January 2014 and Medicaid expansion data as of March 26, 2014.. SOURCES: States implementing in 2014 and not moving forward at this time are based on data from CMS here.

6. Uninsured Rates in the South Vary by State; Half Had Rates at or Above the U.S. Average (Pre-2014) United States: 18% The South: 21% NOTE: Uninsured rates among nonelderly southerners, 2011-2012. SOURCE: KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS.

7. And, Most Southern States Not Expanding Medicaid Have Higher than Average Uninsured Rates Expanding Not Expanding NOTE: Uninsured rates among nonelderly southerners, 2011-2012. SOURCE: KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS; States implementing in 2014 and not moving forward at this time are based on data from CMS here.

8. Most Uninsured Individuals with HIV are Low Income; Half Have Incomes < 100% FPL FPL=Federal Poverty Level. The FPL in 2009 was $10,830 for an individual. NOTES: May not total 100% due to rounding. Non-elderly people with HIV in care, 2009. N = 69,720. SOURCE: 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, Kaiser Family Foundation, January 2014.

9. Most Uninsured Individuals with HIV are Low Income; Half Have Incomes < 100% FPL “Coverage Gap” in Non-Expansion States FPL=Federal Poverty Level. The FPL in 2009 was $10,830 for an individual. NOTES: May not total 100% due to rounding. Non-elderly people with HIV in care, 2009. N = 69,720. SOURCE: 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, Kaiser Family Foundation, January 2014.

10. Looking Ahead: Challenges & Opportunities • The South is a populous, diverse region, but one that has faced historical barriers to access, including for people with HIV • ACA offers new opportunities for insurance coverage and access • New consumer protections and benefit standards nationwide • Health care marketplaces in all 17 southern states • Medicaid expansion in 6 southern states • Yet, in the 11 southern states not expanding Medicaid, uninsured, low income, people with HIV likely to be in the “coverage gap” • In all health care marketplaces, it will be important to monitor qualified health plans for: • Benefit packages and costs, including drug tiering • Provider networks • Ryan White will continue to be critical in all 17 southern states, particularly in those not expanding Medicaid • ACA implementation is still a work in progress 100% 82% Leading role Major role, but not leading