The Impact of the Affordable Care Act Medicaid Expansion on Racial/Ethnic and Sex Disparities in HIV Testing: National Findings from the Behavioral Risk Factor Surveillance System.

Abstract

Over half of Americans have not been tested for HIV in their lifetime, and over a third of all HIV diagnoses are made less than a year before progression to AIDS. The Affordable Care Act (ACA) Medicaid expansion of 2014 had potential to improve HIV and other health screenings. We assessed the differential impacts of Medicaid expansion on racial/ethnic and racial/ethnic-sex disparities in HIV testing. Using Behavioral Risk Factor Surveillance System data from all 50 states and D.C., we sampled low-income (≤ 138% of the federal poverty level) adults ages 19-64 who were non-pregnant and non-disabled. Using a difference-in-differences (DD) and triple difference-in-differences (DDD) study design, we assessed differential impacts by race/ethnicity (White, Black, Hispanic, and other) and race/ethnicity-sex between 2011 and 2013 and 2014-2018. Outcomes were (1) ever having received an HIV test and (2) having received an HIV test in the last year. Overall, Medicaid expansion was associated with a significant increase in HIV testing (p= 0.003). White females and Black males appeared most likely to benefit from this increase (DD 4.5 and 4.8 percentage points; p= 0.001 and 0.130 respectively). However, despite having baseline higher rates of HIV diagnosis, Black and Hispanic females did not have increased rates of ever having HIV testing following Medicaid expansion (DD - 1.9 and 0.9 percentage points; p= 0.391 and 0.703, respectively), including when compared to a White male reference subgroup and across other race/ethnicity-sex subgroups. Medicaid expansion was associated with an increased overall probability of HIV testing among low-income, nonelderly adults, but certain groups including Black females were not more likely to benefit from this increase, despite being disproportionately affected by HIV at baseline. Targeted and culturally informed interventions to increase Medicaid enrollment and access to primary care may be needed to expand HIV testing in vulnerable groups.