Increased healthcare access for marginalized communities through Medicaid expansion greatly improves the effectiveness of EtE efforts.[i][ii] With TasP, PrEP, and PEP—our most effective evidence-based tools for preventing new infections—comprehensive healthcare coverage is required; pills cannot be accessed without healthcare provider visits, labs, and medication coverage. Taking full advantage of federal funding for state Medicaid programs is likely essential for all communities to see drastic declines in new infections. State Medicaid accounted for nearly 68% of the estimated HIV financial resources in 2015 and 2016 in New York, making it the single most important financial pillar of the state EtE blueprint.[iii]
However, this should not discourage advocates living in states without Medicaid expansion from moving forward. While Medicaid expansion may ultimately be necessary for sustainable declines in incidence, it is not a prerequisite for launching an EtE initiative. Plans are moving forward in both Democrat- and Republican-dominated states and cities, with or without Medicaid expansion.
Mobilizing community members and key stakeholders behind a plan may help political allies push for the socially progressive advances that are necessary for ending HIV/AIDS in marginalized communities, including Medicaid expansion. EtE may serve as a pillar of broader statewide efforts to expand Medicaid or to engage with state Medicaid staff and political leaders to ensure that expansion, where it has occurred, is maximized to benefit people living with and vulnerable to HIV infection.
Although we would hope that the health and well-being of their constituents would be enough for politicians to advocate for EtE and, by extension, Medicaid expansion, there are compelling financial reasons for stopping new infections that may be more palatable arguments for more conservative jurisdictions. According to a recent analysis by Bruce Schackman of Weill Cornell Medical College and his colleagues, every new HIV infection costs $443,904 in health spending alone.[iv] A 2015 analysis by Housing Works and Treatment Action Group found that the New York State plan, if successfully implemented, would generate over $6.8 billion in total Medicaid savings thanks to averted infections.
Numbers like this make EtE plans politically enticing.
[i] Kates J, Dawson L. Insurance Coverage Changes for People with HIV Under the ACA. KFF. 14 February 2017. https://www.kff.org/health-reform/issue-brief/insurance-coverage-changes-for-people-with-hiv-under-the-aca/.
[ii] Bradley H, Prejean J, Dawson L, et al. Health Care Coverage and Viral Suppression Pre- and Post- ACA Implementation (Abstract 1012). Poster session presented at: 24th Conference on Retroviruses and Opportunistic Infections; 2017 February 13-16; Seattle, WA. http://www.croiconference.org/sessions/health-care-coverage-and-viral-suppression-pre-and-post-aca-implementation.
[iii] New York State Department of Health. Integrated HIV Prevention and Care Plan 2017 –2021. Albany, NY: New York State Department of Health.
[iv] Schackman BR, Fleishman JA, Su AE, Berkowitz BK, Moore RD, Walensky RP, et al. The lifetime medical cost savings from preventing HIV in the United States. Med Care. 2015 Apr;53(4):293-301. doi: 10.1097/MLR.0000000000000308.