Studying the impact of Section 1115 Medicaid waivers on the Ryan White HIV/AIDS program

Dates: 2012-2014

Geographic Scope: Nationwide

Client(s): HRSA - HAB

Services: Health Care & Public Health Planning, Applied Research & Evaluation, Health Systems Transformation

Technical Expertise: Health Care Reform, HIV & Infectious Diseases, Primary Care


Section 1115 of the Social Security Act allows states to try approaches to providing Medicaid coverage that differ from federal program rules. Some states have used Section 1115 demonstration waivers to expand eligibility to individuals who would otherwise be ineligible (e.g., adults without dependent children), to provide services not typically covered by Medicaid, and to implement innovative service delivery models.

In September 2012, the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA) contracted with JSI to conduct a study on states that have implemented 1115 waivers in ways that have expanded Medicaid eligibility for people living with HIV (PLWH) who would otherwise have been ineligible. The purpose of the study was to understand the nature of the waiver and its effects on the Ryan White HIV/AIDS Program (RWHAP), including on clients and service providers, as well as the implications for RWHAP after the implementation of the Patient Protection and Affordable Care Act (ACA) in 2014.

The study evaluated six states (AZ, CA, CO, MA, MN, and OR) and the District of Columbia. Because California implemented its 1115 waiver at the county level, the researchers included two major counties (Alameda and Los Angeles). JSI developed a case study of each site based on interviews with Medicaid and RWHAP grantees, a review and analysis of secondary sources (e.g., websites and journal or news articles), and a review of data provided by participants. JSI presented the case studies and final report to HRSA/HAB in May 2014.

Key findings include:

• Under Medicaid expansion, RWHAP funding is still critical for filling gaps for PLWH in clinical care and supplementing care completion services.

• The RWHAP AIDS Drug Assistance Program has been pivotal in supporting insurance continuation, as well as coverage of deductibles and co-payments for PLWH.

• Expanded Medicaid coverage decreases the demand for RWHAP core medical services.

• Some HIV safety net clinics may be challenged to maintain a strong medical home model of care as PLWH clients shift to Medicaid coverage.