As policymakers consider expanding insurance coverage for individuals infec
ted with human immunodeficiency virus (HIV), it is useful to ask if insuran
ce has any affect on health outcomes and, if so, whether its magnitude has
changed with recent efficacious but expensive treatments. By using data fro
m a nationally representative cohort of HIV-infected (HIV+) persons receivi
ng regular medical care, we estimate the impact of insurance on mortality i
n this population. A naive single-equation model confirms the perverse resu
lt found by others in the literature-that insurance increases the probabili
ty of death for HIV+ patients. We attribute this finding to a correlation b
etween unobserved health status and insurance status in the mortality equat
ion for two reasons. First, the eligibility rules for Medicaid and Medicare
require HIV+ patients to demonstrate a disability, almost always defined a
s advanced disease, to qualify, Second, if unobserved health status is the
cause of the positive correlation, then including measures of HIV+ disease
as controls should mitigate the effect. Including measures of immune functi
on (CD4 lymphocyte counts) reduces the effect size by approximately 50%, al
though it does not change sign. To deal with this correlation, we develop a
two-equation parametric model of both insurance and mortality. The effect
of insurance on mortality is identified through the judicious use of state
policy variables as instruments (variables related to insurance status but
not mortality, except through insurance). The results from this model indic
ate that insurance does have a beneficial effect on outcomes, lowering the
probability of 6-month mortality by 71% at baseline and 85% at follow-up. T
he larger effect at followup can be attributed to the recent introduction o
f effective therapies for HIV infection, which have magnified the returns t
o insurance for HIV+ patients (as measured by mortality rates).