The document discusses challenges and opportunities around HIV in the Southern United States. It notes that the South has a large population that faces health disparities like higher rates of poverty and being uninsured. While the Affordable Care Act expands protections and coverage nationwide, 11 Southern states have not expanded Medicaid eligibility. As a result, many low-income people with HIV in these states may fall into a "coverage gap" without insurance options. Ongoing monitoring of new health plans and provider networks will also be important, as the Ryan White program continues playing a critical role across the region.

1. 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
jkates@kff.org
http://kff.org/hivaids

2. Figure 1
SOURCE: United States Census Bureau. http://www.census.gov/geo/maps-data/maps/pdfs/reference/us_regdiv.pdf
Census Regions and Divisions of the United States

3. 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.

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

5. Figure 4
Most Southern States (11 of 17) are Not Implementing
Medicaid Expansion in 2014
WV VA
TX
TN
SCOK
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, 2014..
SOURCES: States implementing in 2014 and not moving forward at this time are based on data from CMS 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

6. Figure 5
27%
25%
22%
22%
21%
20% 20% 19%
18%
17% 17%
16% 16%
15% 15%
12%
9%
TX FL LA GA AR OK NC SC MS WV KY AL TN VA MD DE DC
NOTE: Uninsured rates among nonelderly southerners, 2011-2012.
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%

7. Figure 6
27%
25%
22%
22%
21%
20% 20% 19%
18%
17% 17%
16% 16%
15% 15%
12%
9%
TX FL LA GA AR OK NC SC MS WV KY AL TN VA MD DE DC
Expanding
Not Expanding
NOTE: Uninsured rates among nonelderly southerners, 2011-2012.
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.
And, Most Southern States Not Expanding Medicaid Have
Higher than Average Uninsured Rates

8. Figure 7
<100% FPL
51%
100-138% FPL
16%
139-399% FPL
29%
400% FPL+
4%
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, 2009. 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 2014.
Most Uninsured Individuals with HIV are Low Income; Half
Have Incomes < 100% FPL

9. Figure 8
<100% FPL
51%
100-138% FPL
16%
139-399% FPL
29%
400% FPL+
4%
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, 2009. 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 2014.
Most Uninsured Individuals with HIV are Low Income; Half
Have Incomes < 100% FPL
“Coverage
Gap”
in Non-
Expansion
States

10. 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