Keeping a Watchful Eye on ACA Implementation, and ADAPs

By Anna Meghan Nunn
Intern from the University of North Carolina at Wilmington, Department of Public and International Affairs

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as "Obamacare" – is in the early stages of implementation, but there are emerging uncertainties in the public health community about certain aspects of the law. Specifically, some advocacy groups, nonprofit organizations, advocacy coalitions, and policy institutes have voiced concern over the potential threat the ACA may pose to the HIV/AIDS community. While most in the public health community view the new healthcare law favorably with respect to HIV/AIDS care, there are some unintended consequences that have many worried. Specifically there are five areas of concern about the new law and its potential impact on HIV/AIDS supports and services:

• Gaps and barriers in access to comprehensive care and treatment
• Unintended consequences
• Uncertainties in treatment/coverage
• Future of the Ryan White CARE Act
• ADAP’s role in the distribution of allocated funds

Gaps and Barriers in Access to Comprehensive Care and Treatment
A recent Kaiser Health News article estimated that there are nearly 1 million patients living HIV/AIDS, and whereas the ACA will bring new opportunities for health care coverage to those patients, there will be some gaps in coverage. For example, the Henry J. Kaiser Family Foundation in its recent study, "Status of State Action on the Medicaid Expansion Decision, 2014," indicates that there are currently 19 states opting out of the Medicaid Eligibility expansion offered through the ACA, with 6 states still openly debating the decision. This includes, but are not limited to, the majority of the states in the Southeastern portion of the country. The Southeast also accounts for 8 of the top ten states with the highest HIV/AIDS rates. Patients in these states will see significant gaps in their healthcare coverage, as many of them will not qualify for Medicaid or tax exemptions for private insurance in the Marketplace Exchange. In total it is estimated that 4 million of the lowest income Americans will suffer gaps in coverage due to the states choosing to opt out of the expansion. Further, because the ACA will impact states differently there is concern that some states will suffer more than others. An article published by the Virginian-Pilot entitled, HIV Patients Wade Warily Into the Health Marketplace (2014), emphasizes a major concern in their state. They contend that, “… because of Ryan White funding rules, patients in the drug-assistance program can sign up only for plans that cover all HIV medications included on the program's formulary. Plans from Anthem Blue Cross and Blue Shield of Virginia don't include them all. That means none of the program's clients can sign up for an Anthem policy.” These state-by state cases are causing confusion for programs like the AIDS Drug Assistance Program (ADAP) that are ensured with helping clients find affordable health care coverage and medications.

An additional concern of some advocates is the fact that undocumented aliens will not be covered by ACA insurance and will therefore not benefit from the comprehensive care that would otherwise be available to them. This has considerable negative implications for public health, public clinics, and already over-burdened emergency rooms where these patients will likely be forced to receive their care.

Unintended Consequences 
The unintended consequences of the implementation of the ACA relates to the financial burden it will place on low-income patients living with HIV/AIDS. While many patients are enthusiastic about the potential of more comprehensive coverage, many are concerned about the out of pocket expenses that they may incur through co-pays, deductibles, and further costs associated with laboratory tests and associated costs related to HIV/AIDS care. Currently, ADAP assists with some of these costs including medications. The implementation of the ACA may force many patients to pay these costs until they reach an “out of pocket maximum,” which will potentially take months to reach and place a sizeable financial burden on patients, many of whom are living below the poverty level or on fixed incomes. A New York Times article entitled, On Health Exchanges, Premiums May Be Low, but Other Costs Can Be High (2013), states that, “For policies offered in the federal exchange, as in many states, the annual deductible often tops $5,000 for an individual and $10,000 for a couple.” It is still unknown how many HIV/AIDS patients will be impacted by these large deductibles and co-pays.

Uncertainties in Coverage/Treatment
With the rollout of the ACA still in the early stages there is a great deal of uncertainty in the future of coverage and care for patients living with HIV/AIDS. The ambiguity of the law and the reaction of the states has many worried that certain medications will not be covered. The previously mentioned Kaiser Health Network article also highlights these concerns saying that, “advocacy groups have criticized some health plans in the insurance exchanges for failing to cover key HIV medications, charging high amounts for necessary drugs or failing to tell consumers which doctors and medications are included.”  While this benefits these insurance companies, as they will not be covering the expenses related to patients living with HIV/AIDS, it puts the burden back on public clinics and leaves patients without access to crucial drugs that they need. Further still, many are concerned as to whether or not they will be able to continue seeing their current medical professionals and continue on their healthcare regimens. This is a notable concern due to the importance of the healthcare regimen and could have serious consequences to public health.

The Future of the Ryan White CARE Act
While the ACA will be beneficial for many patients in the country, there is unease among many as to how the law will affect the Ryan White CARE Act. The Ryan White program is funded through federal dollars and some are worried that increased access to healthcare may have inadvertent effects on funding. There may be a political pushback against funding programs like ADAP through federal grants like the Ryan White program. This was recently witnessed in the case of the Farm Bill with Republicans pushing to separate the legislation into two separate Bills in an effort to cut funding to food stamps and lower the price tag of the $939 billion proposal. Some worry that the same may occur with decreased funding for Ryan White or a loss of funding all together. We argue that these funds are still vital and necessary to providing access to medications, insurance plans, supplemental insurance, and associated costs of HIV/AIDS related treatment.

ADAP’s Role in the Distribution of Allocated Funds 
A final concern is the role ADAP will play in the distribution of the Ryan White program funds. It is ultimately going to be up to local programs and health departments receiving Ryan White funds as to how they will be allocated with regard to costs not associated with medications. These costs include co-pays, laboratory tests, and other cost sharing expenditures. There is a great deal of concern as to how ADAP will be able to administer these funds. A similar situation arose a few years ago when many ADAP programs in the southern states had to take drastic measures to reduce their extensive waiting lists. Many of these states were forced to cap enrollment, reduce formularies, discontinue reimbursements of laboratory expenses, and use emergency ADAP funds to reduce the number of patients living with HIV/AIDS on their waiting lists (NASTAD, 2012). It is the concern of ADAP that a parallel incidence will occur with the rollout of the ACA.

It is crucial that the public health community continue to monitor these glitches with the Affordable Care Act and collaborate on solutions to better assist the recipients of ADAP funds.

Improving Medication Adherence through Walgreens HIV-Specialized Pharmacies

By: Glen Pietrandoni, R.Ph., AAHIVP, senior manager, virology, Walgreens

What would it take for an HIV patient to achieve their best health and an improved quality of life? Could we…perhaps, realize an AIDS-free world? Walgreens studies show some of the ways in which better outcomes can be achieved.

Medication adherence is vital to maintaining optimal health for patients with the HIV virus and could contribute to suppressed viral loads which make the virus less likely to be transmittable. Walgreens HIV-specialized pharmacies are committed to keeping patients adherent and being a part of the solution to end AIDS.

A recent Walgreens study[1]  of more than 15,000 HIV patients showed that those who received care through one of its HIV-specialized pharmacies were significantly more adherent to their medication (74 percent) than those receiving care through a traditional, non-specialized Walgreens pharmacy (69 percent).

In examining the differences in medication adherence for HIV patients with a comorbid condition using Walgreens HIV-specialized pharmacies and those using other Walgreens retail pharmacies[2], researchers confirmed that HIV patients utilizing the specialized pharmacies were more adherent to their anti-retroviral and comorbid therapies.

This includes the nearly 30 percent of patients living with HIV and serious mental illness, a population which often experiences challenges associated with willingness and ability to take medication as prescribed such.  Of the HIV patients with serious mental illness who exclusively used HIV-specialized pharmacies, 33 percent were adherent to their anti-retroviral therapy versus 19 percent for HIV patients with serious mental illness using other Walgreens retail pharmacies.

Patients with other comorbid conditions, including hypertension and high cholesterol, also demonstrate increased adherence when using Walgreens HIV-specialized pharmacies.

So what’s our secret? It’s no secret at all. Since the beginning of the epidemic, more than 30 years ago, our pharmacists have been focused on education, counseling, testing and treatment. In the more than 700 U.S. communities impacted by HIV, our pharmacists have established deep relationships with local patients. Beyond dispensing medication, our HIV-specialized pharmacists are trained to provide confidential wellness consultations, coordinate care and benefits with physicians and insurance providers, and to help patients access financial support programs to reduce medication costs. Above all, medication adherence remains our primary objective because we know that taking the right medication at the right time is key to improving health outcomes.

Walgreens recently announced we’re leveraging the expertise of our pharmacists to collaborate with the Centers for Disease Control and Prevention (CDC) and University of North Texas (UNT) College of Pharmacy to develop and evaluate a model of HIV patient-centered care through a national project aimed at advancing clinical integration and medication therapy management.

According to the CDC, only 25 percent of Americans with HIV have the virus under control. Our more than 2,000 HIV-specialized pharmacists can plan an important role in working with patients and providers to help improve the population’s health and help make an AIDS-free world a reality.

________________


1.  Murphy P, Cocohoba J, Tang M, et al. Impact of HIV-specialized pharmacies on adherence and persistence with antiretroviral therapy. AIDS PatientCare and STDs, Volume 26, Number 9, 2012.
 2. Dr Janeen DuChane PhD,Michael Taitel PhD,Leonard Fensterheim MPH,Bobby Clark PhD,John Hou PhD,Julia Zhu MPH,Jenny Jiang MS,Adam Cannon MPH,Glen Pietrandoni RPh
The Lancet - 3 November 2013 ( Vol. 382, Page S3 )
DOI: 10.1016/S0140-6736(13)62251-5

Is the RWCA dead?

By: 

Eddie Hamilton

Director

ADAP Educational Initiative

There has been a lot of chatter and disputes in the HIV/AIDS advocacy world regarding the Ryan White Program Care Act (RWCA) expiration on September 30, 2013. Granted, there are numerous valid arguments for and against Ryan White Program RWCA reauthorization and for reprioritization. There are inherent dangers by acting now and also waiting until 2015 until the numerous impacts of the ACA are known. With the ACA enrollment issues, it may be even longer than 2015 before all of the impacts are fully understood.

However, I truly believe that there are two bigger and dangerous elephants in the room that needs to be addressed by all nationwide advocacy groups.

The first is sequestration where organizations are already feeling tremendous negative impacts in service delivery and those impacts will only get worse. There is not much being said publically about Sequestration 2.0.

The second and more immediate issue is a much bigger problem. Upon further research from credible government sources, I have found that it is very possible that the Ryan White Program no longer legally exists due to sloppy appropriations writing and Washington gridlock.

Many HIV/ AIDS organizations are relying on the argument that “Even though there is not a 'sunset' provision, the RWCA program is just fine because there is money being appropriated for the program.”

I had to question that argument because it was too easy of an answer to such an important question.

Question: Is the RWCA dead? Short Answer: In other words, Maybe no but most likely so.

Long Answer: There are a few different sources of information regarding “Unauthorized Appropriations” primarily from the U. S. Government Accountability Office (GAO).  An “Unauthorized Appropriation” is where Congress has allocated money for a program whose primary authorization has since expired that could be subject to a point of order within either chamber that could possibly kill the bill.

In this toxic political atmosphere, anything can happen as it only takes one representative from either chamber to raise a point of order. In the case of the Ryan White program, the authorization had expired on 9/30/2013. The Program has already hit the list for Unauthorized Appropriations.

An authorization bill is known as an enabling statute or a program’s “organic’ authority that articulates a program parameters and an agencies’ mission within in a program. In usual course, no funds can be expended until an actual separate dedicated appropriation authority with specific language directing programs goals and requirements has been initiated.

However, when an appropriations authorization has expired, the language within a continuing resolution or appropriations bill is critical when making the determination of whether the appropriation has the force of a continuing reauthorization of its’ “organic “ authority.

In other words, unless an appropriations bill contains the explicit language reauthorizing the Ryan White Program, the “organic” authority laying out the priorities is still expired and therefore, dead. A catch-all sloppy appropriation to an agency (i.e. HRSA) on January 13th (the new appropriation date) is and will be insufficient without the adequate instructions for the Ryan White Program because there is no valid authorization on the books. The last CR that was passed to stop the shutdown does not explicitly lay out any new authority for the RWCA.

Therefore, in my opinion, the RWCA is legally dead!

Do we have a Plan B in the event the states cannot issue new operating rules (based on ACA or Medicaid expansion) based on the fact that the RWCA is dead?

I also argue at a bare minimum that the any state law and rules, Request for Proposals, bids and contracts constructed and awarded listing the RWCA 2009 as their source of authority, immediately become inoperative when the entity spends the last dollar authorized in their budgets (prior to 9/30/2013) for FY 2013 because they refer to RWCA 2009 as their source of authority. Rebate monies will not count towards this authority as this money comes from the pharmaceutical companies and not the Federal Government.

As a result, I would highly encourage that the entire HIV advocacy community do some appropriate research before coming out with blanket statements on such a vital program.

Various national HIV advocacy groups who are making assumptions that the status quo will be maintained are not viable options. It is imperative that both of these issues be addressed as our lives depend on it!   Hollow words of advocacy no longer cut it anymore.

References:

• GAO-04-2618P Principles of Appropriations Law, U.S. Government Accountability Office (2004), p.69-71, http://www.gao.gov/assets/210/202437.pdf
• CBO Testimony (Douglas Holtz Eakin) , Unauthorized Resolutions and Senate Resolution 173, Congressional Budget Office, http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/44xx/doc4400/07-09-uaea.pdf
• GAO-06-382SP Principles of Appropriations Law, U.S. Government Accountability Office (2006), p.32-36, http://www.gao.gov/assets/210/202819.pdf
• Unauthorized Appropriations and Expiring Resolutions, Congressional Budget Office (Jan. 15, 2013) Page 24.
• Analysis H. R. 2775 Continuing Resolution for 2014, http://www.gop.gov/bill/113/1/hr2775-senateamendment

Survey Reveals Sequestration Impacting AIDS Care while Number of Patients Increase

By: 
Carl Schmid
Deputy Executive Director
The AIDS Institute

A survey conducted by The AIDS Institute found that HIV care in the United States is suffering as a result of sequestration and cuts in the Budget Control Act, while the number of AIDS patients is increasing. One hundred and thirty-one AIDS organizations in 29 states and the District of Columbia took the survey on the impact of these cuts, and the findings were troublesome.

In the last year, domestic HIV/AIDS programs have been cut nearly $380 million. As a result of these and other cuts 85% of the organizations surveyed experienced funding reductions. At the same time, 79% experienced an increase in clients.

As a result of cuts, 52% of survey respondents who detailed the impact of their lost funding indicated they have had to reduce staff, while 38% had to cut prevention education programs, and 22% cut back on HIV testing.  At least one organization had to close down completely.

Staff reductions impacted case management, administrative and clinical staff the hardest, and researchers, educators, and peer advocates were also cut from organizations. The majority of responding organizations had to lay off three to five staff members due to these cuts.

According to survey respondents, the funding reductions have resulted in cuts to patient services, including longer times between appointments and increased wait times at the clinic.  Some have even stopped seeing certain patients.

During the same period , the number of clients was increasing. The average increase in clients since January 1, 2012 was 18% according to surveyed organizations, compared to the average reported reduction in funding of 17%.

This survey demonstrates that the severe cuts enacted by the Budget Control Act are having real, negative consequences on HIV/AIDS organizations and their patients across the nation.  These budget cuts, coupled with an increasing number of HIV patients, have impacted their ability to provide timely, quality care and prevent future HIV infections.  If these cuts continue, they will certainly lead to increased infections, more deaths, and higher healthcare costs.

At a time when we know how to reduce an infectious disease such as HIV through prevention and treatment, and we have a National HIV/AIDS Strategy grounded in science, now is not the time to reverse the substantial progress that has been made.

There are nearly 50,000 new infections each year in the U.S. and only one third of the nearly 1.2 million people with HIV in the US have been prescribed antiretroviral treatment.

We have a long way to go before we can realize the dream of an AIDS-free generation.  We urge the Congress and the President to reverse the cuts caused by sequestration and adequately fund critical public health programs, including those that prevent HIV and provide for care and treatment for people living with HIV.

Negotiations going on right now in the Congress on the budget will directly impact if these cuts continue in the future.  The AIDS Institute hopes that these survey results, which have been forwarded to all members of congress, will help convince budget conferees that these cuts to domestic HIV programs must end.

The full survey results can be found at: http://bit.ly/1hwV52p.

The Affordable Care Act Crystal Ball

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as "Obamacare" – is supposed to see most of the law’s major provisions phased in by January 2014, with other provisions phased in by 2020. The ACA will have numerous implications generally on the United State’s health care delivery system, but more specifically on the supports and services afforded to people living with HIV-infection, or viral Hepatitis. What’s more, ongoing Medicaid expansion and the implementation of insurance exchanges will also impact nearly all healthcare providers, as well as their patients.

President Obama signs the Affordable Care Act into law on March 23, 2010.

As the full implementation of the law fast approaches, it seems to be raising more questions than providing answers. The roll-out hasn't been without its share of bumps, either. Nonetheless, many public health advocates see a lot of "positive" (no pun intended) changes coming with respect to the delivery of health care supports and services for individuals living with HIV/AIDS, as well as Viral Hepatitis.

With so many changes forthcoming under the ACA, there is no crystal ball that will show what is in store for the nation's health care system. For starters, at least pre-existing conditions will no longer prevent people from gaining access to insurance, and thus access to care. Of particular interest to stakeholders advocating for a robust AIDS Drug Assistance Program (ADAP), an ACA provision allows ADAP to count toward the true-out-of-pocket expenses (TrOOP) under the Medicare Part D program is also welcome news.

Antonio J. Carrion, PharmD, MPH, who is an Assistant Professor of Pharmacy Practice at Florida A&M University's College of Pharmacy and Pharmaceutical Services (COPPS), has outlined some of these changes in his recent blog. In fact, Carrion's analysis dispels the myth that the Ryan White CARE Act -- including ADAP -- is going away under the ACA.

The blog reads, in part: "Because of the new health care law, ADAP benefits will be considered as contributions toward Medicare Part D’s True Out of Pocket Spending Limit (TrOOP). What does that mean? ADAP clients who are Medicare Part D enrollees will be able to move more quickly through the “donut hole.” Before the ACA, this transition was very difficult for ADAP enrollees to complete" (Florida/Caribbean AETC, 10/30/13).

Another excellent resource on this topic was made available by the National Alliance of State & Territorial AIDS Directors (NASTAD), which can be downloaded here.

TheBodyPro also recently published an excellent interview with Dr. Michael Saag and Dr. Michael Wong, whereby they each shared their perspective about the upcoming ACA implementation. The article can be viewed online, here.

In the interview when asked if the law was a good or bad thing for HIV patient care, Dr. Saag pretty much summed-up the advocacy community's sentiment: "I think, overall, it's a good thing. Number one, it will put, generally speaking, more people into insurance plans, be it Medicaid or some other kind of plan. And it creates more options. In essence, there's more money flowing to clinics and flowing to cover the costs of medications, so it will give some relief to the Ryan White CARE Plan -- and we'll get back to that, I'm sure, later. But the bottom line is, it's a good thing" (TheBodyPro, 08/22/13).

Unfortunately, one other area that also tends to draw a common theme is the concern over the ACA's uneven implementation nationwide. Whereas some states, like California, Massachusetts, and New York will accept the Medicaid expansion provisions included under the law, other states, such as Alabama -- which has the largest ADAP waiting list creeping up on nearly 200 patients statewide -- plans to decline the Medicaid expansion. The South appears to be disproportionately impacted, again.

Patients, advocates, providers and healthcare professionals alike would be well-advised to obtain the latest information about the ACA, its implementation, and how it might affect the healthcare delivery for individuals living with HIV/AIDS, and/or Viral Hepatitis. One thing is for certain, it remains very fluid.

To that end, the ADAP Advocacy Association (aaa+) -- in partnership with the Community Access National Network (CANN) Great Lakes ADA Center, and HealthHIV -- is hosting an educational webinar on Wednesday, November 6th, 2013. The webinar, themed "Impact of the Affordable Care Act, Medicaid Expansion & Insurance Exchanges on HIV/AIDS and Viral Hepatitis Services," will be open to all HIV/AIDS and Virtal Hepatitis stakeholders nationwide. It is free, so there is no excuse not to participate and learn more about what changes are coming...

Learn More about the Impact of the Affordable Care Act, Medicaid Expansion & Insurance Exchanges on HIV/AIDS and Viral Hepatitis Services

SANDBOX STANDOFF: Day 11

It has now been 11 DAYS since the government closed its doors on the American people because the politicians in Washington, DC are more concerned with scoring political points and posturing on the cable news programs rather than collectively doing their job; in the meantime, people living with HIV/AIDS -- and many other underserved populations -- scramble to make ends meet, including how the shutdown is impacting their daily lives. Some political pundits have described the current partisan rancor on Capitol Hill as nothing less than a bunch of cranky children fighting over a sandbox. The ADAP Advocacy Association (aaa+) agrees.

The negative consequences of the current political stalemate between the President, House Republicans (especially the Tea Party element of the GOP) and Senate Democrats cannot be under-estimated, or maybe even truly comprehended without digging deeper. But recent new reports provide ample evidence that the budget debacle is already raging havoc on the nation's public health system.

The Washington Blade reported that the shutdown will prevent the Health Resources & Services Administration (HRSA) from properly monitoring grants administered under the Ryan White CARE Act -- including the AIDS Drug Assistance Programs. And after the debacle with the Florida ADAP several years ago, there is plenty of reason for advocates to be concerned over the loss of federal oversight. The impasse also will halt the seasonal influenza program. It even means potential delays in Food and Drug Administration (FDA) approvals of new drugs, as well as delays in clinical trials at the National Institutes of Health.

The online publication, Medical Economics, has made available a listing of healthcare agencies being affected by the shutdown.

With so much of the blame being placed at the feet of the Tea Party, it is rather ironic that one of the nation's leading coffee retailers has entered the fray. On October 10th, Starbucks launched its "Come Together" campaign designed "to harness the sentiment many of us are feeling — a growing concern about the lack of progress from our Congressional leadership to work together to resolve the business of the American people." The company is encouraging people to sign an online petition at www.ComeTogetherPetition.com.

All ADAP stakeholders -- especially people living with HIV-infection -- are encouraged to contact their elected federal lawmakers in Washington and urge them to end the government shutdown. Lives are at stake!

• Find Your Senators & Representative: CLICK HERE

Medicaid Reform and a (New) New York State of Mind: Housing Is Healthcare!

By:

Christine Rodriguez, Program Associate

National Advocacy & Organizing

Housing Works

A few short days from the October 1 marketplace openings, and uncertainty and confusion linger in discussions around healthcare and implementation of the Affordable Care Act (ACA). Policy experts, providers, and consumers alike speculate, and it seems there will be more questions than answers until we at last see how reforms play out across the country.

The HIV/AIDS community knows that health reform, both affectionately and derisively referred to as “Obamacare,” certainly benefits people living with HIV/AIDS (PLWHA) and those at risk; we absolutely need to spread the word far and wide. But let us also be sure to remember the existing tools in our arsenal that can maximize those benefits. One such tool, often detrimentally omitted from conversations about health care, is unequivocally an effective, cost-saving intervention – HOUSING.

Housing is Healthcare!, Housing is Prevention!, or Housing Saves Lives!, aren’t rallying cries that Housing Works advocates causally toss into articles and testimony or banners and protest signs simply out of habit after nearly 25 years of advocacy and activism. The health and cost-related benefits conferred by access to safe, affordable housing are well demonstrated by research, both for PLWHA and to prevent transmission among HIV-negative homeless populations.

Housing Works' Housing is Healthcare Rally

For marginalized communities – whether HIV-positive, living with mental illness or substance abuse issues, or others unstably housed – having housing means better holistic health. Even without the research this is common sense, right? Housing means having a place to store medications and healthy food, get a full night’s sleep, and often relief from the fear of violence. It means an address for job applications, avoiding hypothermia in the winter, and a safe space to engage with family, friends, and lovers. It means treatment adherence, safer sex, and everything taken for granted by many of us every day.

New York State, leading by example, is not taking housing for granted in its current efforts to improve the healthcare system. Governor Cuomo is proving to be a national leader in the effort to effectively utilize the Medicaid program and underscore that housing IS healthcare. New York’s Medicaid Redesign Team (MRT) was initiated in 2011, and early on an Affordable Housing work group was deemed critical and included in the process. Gov. Cuomo, thanks to MRT’s efforts, recently announced a $4.6 billion savings over the past year alone. From those savings, the Supportive Housing Initiative will be allocated $36.4 million in capital funds, $30.6 million in rental/service subsidies, and $24 million for critical new pilot programs – a total of $91 million.

New opportunities require new ways of thinking; innovation is necessary to address the complex and diverse health concerns of PLWHA, especially as the population ages. The MRT allocation for pilot housing programs begins to address this – one of several critical projects being the “Health Home HIV+ Rental Assistance Project.” Much to our collective chagrin, it is not uncommon for official policy to be somewhat disconnected from lived reality. Under current HIV/AIDS Services Administration regulations in New York City, instead of providing housing to prevent exacerbating illness, one must already have an AIDS diagnosis or advanced HIV-illness to even qualify for such services. This pilot project creates access to housing for HIV-positive individuals otherwise medically ineligible for existing programs, finally prioritizing true preventive care PLWHA.

Jason Helgerson, New York’s Medicaid Director, explained it plain and simple – that finally “[t]here is a growing national recognition that addressing the social determinants of health is critical for improving health while reducing health care costs. This is most evident in the matter of housing.” This recognition, coupled with financial commitment, is essential for homeless communities and PLWHA. States seeking to maximize Medicaid dollars – whether or not they opt for expansion – should consider adopting or (dare I say) expanding upon this model of redesign, reinvestment, and innovation. The historic opportunities created by ACA reforms present a crucial time to take full advantage of evidence-based interventions, like housing, to truly commit to realizing the end of AIDS.