been implemented already, and others are slated for implementation in 2014.6
Among people with HIV in the United States, almost 30 percent have no health care coverage and only 17 percent have private insurance: the remaining 53 percent are covered by government programs such as Medicaid, Medicare, and the Ryan White HIV/AIDS Program (HHS, 2012a). As the ACA is implemented, most people with HIV in the United States will move into or shift between sources of care coverage. Figures 2-1, 2-2, and 2-3 depict the pathways to care coverage for people with HIV before, during, and following implementation of the ACA. As shown in Figure 2-2, as of 2010, the ACA gave states the option to expand Medicaid coverage to low-income adults up to 133 percent of the FPL regardless of disability or other status, which some states have done. In addition, individuals without access to employer-based coverage or who cannot purchase insurance in the individual market and are not eligible for Medicaid or Medicare can now purchase insurance through Preexisting Condition Insurance Plans (PCIPs) created under the ACA. PCIPs are high-risk pools operated by states or the federal government to provide insurance for individuals who are U.S. citizens or reside legally in the United States, have a preexisting condition, and have been without health coverage for at least 6 months.7 As depicted in Figure 2-3, beginning in 2014, low-income adults up to133 percent of the FPL become a new Medicaid-eligible group, although the Supreme Court has limited the authority of the federal government to enforce this provision, and therefore, eligibility for Medicaid coverage is likely to vary across states. Individuals without access to employer-based coverage who are not eligible for Medicaid or Medicare but are eligible for tax credits to purchase insurance and/or can afford to pay for health insurance may do so through state health insurance exchanges established to facilitate the purchasing of health insurance by qualified individuals and employers. As it did prior to the enactment of the ACA, the Ryan White HIV/AIDS Program continues to serve as a payer of last resort for people with HIV who are under- or uninsured. Federal funding is provided to states, cities, and providers but does not always match the number of people who need services or the cost of their care.
6Some provisions of the ACA apply to all health care plans, others (e.g., coverage for preventive care without cost sharing) do not apply or apply differently for grandfathered plans (i.e., those in which an individual was enrolled on March 23, 2010, the date the ACA was enacted).
7These criteria apply to people living in states served by the federally run PCIP (HHS, 2012b). State-run PCIPs have their own eligibility criteria.