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The State(s) of Health: Federalism and the Implementation of Health Reform in the Context of HIV Care

Authors


  • Erika G. Martin is assistant professor of public administration and policy at the University at Albany and senior fellow in the Rockefeller Institute of Government, State University of New York. Her research interests include HIV, viral hepatitis, and drug policy; resource allocation; and examining the causes and population-level effects of variation in state health policies. She holds a doctorate from Yale University, a master of public health degree from the University of Michigan, and a bachelor's degree from Brown University. E-mail: emartin@albany.edu

  • Patricia Strach is associate professor of political science and public administration and policy at the University at Albany and senior fellow in the Rockefeller Institute of Government, State University of New York. Her research interests include social policy, health policy, and citizen participation in public programs. She holds master's and doctoral degrees from the University of Wisconsin–Madison and a bachelor's degree from the University of California, Davis. Previously, she was a Robert Wood Johnson Scholar in health policy research. E-mail: pstrach@albany.edu

  • Bruce R. Schackman is associate professor of public health and chief of the Division of Health Policy at Weill Cornell Medical College. His research interests include economic evaluation of health interventions conducted alongside clinical trials and cohort studies, cost-effectiveness simulation modeling, and implementation science research. His current research projects include economic evaluations of screening and treatment for HIV, hepatitis C, and opioid dependence. He holds bachelor's, master of business administration, and doctoral degrees from Harvard University. E-mail: brs2006@med.cornell.edu

Abstract

Although the federal government will finance most of the coverage expansions of the Patient Protection and Affordable Care Act (ACA), implementation is largely devolved to states. Drawing from interviews with HIV policy experts and program managers and a documents review, the authors enumerate actions that must occur at multiple levels of government in order for ACA implementation in the context of HIV care to improve access to health care and health outcomes and the conditions under which these may fall short. Positive outcomes are predicted for HIV patients in states with sufficient political support and resources to implement the ACA. However, outcomes may worsen in states that do not implement the Medicaid expansion or other ACA provisions, particularly if federal funding for discretionary safety net programs is reduced. Transitioning patients from HIV-specific programs to other coverage sources may also reduce HIV services in states that previously were at the forefront of HIV care.

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