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

Figure 1 SOURCE: United States Census Bureau. Census Regions and Divisions of the United States WI SD OH ND NE MO MN MI KS IA IN IL WY WA UT OR NM NV MT ID HI CO CA AZ AK VT RI PA NY NJ NH MA ME CT WV VA TX TN SC OK NC MS MD LA KY GA FL DC DE AR AL South (17 states, including DC) West (13 states) Midwest (12 states) Northeast (9 states)

Figure 2 Leading role The Southern Region of the United States: Broader Considerations & Context Beyond HIV Major role, but not leading 100% 82% 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 SOURCE: Stephens J, Artiga S, Paradise J, Health Coverage and Care in the South in 2014 and Beyond, Kaiser Family Foundation, April 2014.

Figure 3 CONSUMER PROTECTIONS HEALTH CARE MARKETPLACES IN EVERY STATE BENEFITS STANDARDS, INCLUDING PREVENTION Key ACA Provisions for People with HIV MEDICAID EXPANSION

Figure 4 Most Southern States (11 of 17) are Not Implementing Medicaid Expansion in 2014 WV VA TX TN SC OK NC MS MD LA KY GA FL DC DE AR AL Implementing Expansion (6 states, including DC) Not Expanding (11 States) NOTES: Eligibility as of January 2014 and Medicaid expansion data as of March 26, SOURCES: States implementing in 2014 and not moving forward at this time are based on data from CMS here.here 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

Figure 5 NOTE: Uninsured rates among nonelderly southerners, SOURCE: KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS. 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%

Figure 6 Expanding Not Expanding NOTE: Uninsured rates among nonelderly southerners, 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.here And, Most Southern States Not Expanding Medicaid Have Higher than Average Uninsured Rates

Figure 7 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, 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 Most Uninsured Individuals with HIV are Low Income; Half Have Incomes < 100% FPL

Figure 8 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, 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 Most Uninsured Individuals with HIV are Low Income; Half Have Incomes < 100% FPL “Coverage Gap” in Non- Expansion States

Figure 9 Leading role Looking Ahead: Challenges & Opportunities Major role, but not leading 100% 82% 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