were underinsured in 2010 (Schoen et al., 2011).2 Although the number and percent of uninsured decreased between 2010 and 2011, millions of people in the United States, including approximately one-third of those with HIV, still lack health insurance (HHS, 2012a). It is against this background that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), was signed into law on March 23, 2010. This chapter is not designed to provide a comprehensive and detailed review of all aspects of the ACA that have implications for people living with HIV but rather to highlight the aspects of the ACA that the committee anticipated would be most pertinent to its task, such as those that are likely to effect changes in sources of health coverage for that population and to establish the basis for the selection of data systems that would be most relevant to tracking the impact of the ACA on health coverage and care for people with HIV (e.g., Medicaid, Medicare, Ryan White HIV/AIDS Program, private insurers).

AFFORDABLE CARE ACT

The ACA has the potential to significantly improve access to and quality of health care for the majority of people living with HIV in the United States. The law sets out numerous provisions that will be implemented over time, with major changes occurring in 2014. Most notably, the law includes both a provision that most citizens and legal residents of the United States must have qualifying health insurance coverage by 2014 or pay a tax penalty and a provision for the expansion of Medicaid coverage to most non–Medicare eligible individuals under age 65 with incomes less that 133 percent of the federal poverty level (FPL) (KFF, 2011a).3 The ACA includes additional provisions of particular importance to people with HIV, such as increased access to private health insurance and consumer protections, establishment of state or regional health insurance exchanges (the legislation uses the term “health benefit exchange”), gradual elimination of the Medicare Part D prescription drug coverage gap, and development of an “essential health benefits package” and improved coverage for preventive care services.4

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2Individuals were identified as underinsured if they had health insurance for the full year but also had very high medical expenses relative to their income (Schoen et al., 2011). In this study, “health insurance” referred to private health insurance, Medicaid or some other type of state medical assistance for low-income people, Medicare, and “health insurance through any other source, including military or veteran’s coverage” (Commonwealth Fund, 2010, Questionnaire).

3A “mandatory income disregard” equal to 5 percent of the FPL will make the “effective income limit 138 percent of the FPL” (Natoli et al., 2011).

4Other major provisions of the ACA are not discussed here, including the development of accountable care organizations, increased payments for primary care providers, and expanded



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