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Alphabet Soup: ACA, HIV, SUD, TB, and HCV on the Border

June 20, 2014

Tom Donohoe, MBAAssociate Professor of Family Medicine

Director, UCLA Pacific AIDS Education and Training CenterAssociate Director, UCLA Center for Health Promotion and Disease Prevention

David Geffen School of Medicine at UCLA

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I have already seen you present on the ACA(in-person, webinar, etc)

16%

68%

16% 1. True2. False3. I don’t remember

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How many ACA-related trainings have you already attended (last 12 months)?

64%

29%

5%

2% a. 0b. 1-2c. 3-4d. 5 or more

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Declaration of Disclosure

I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter

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Educational Objectives 1• State the importance of understanding ACA

implementation for California and Arizona and how it will impact border communities & people living with HIV, TB, HCV, and SUD

• Identify key dates for ACA roll-out and strategize to effectively implement the ACA locally

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Educational Objectives 2• Explain how the ACA will extend new insurance

benefits and patients’ rights and responsibilities

• Improve HIV patients’ engagement (linkage & retention) in high-quality HIV care as systems change

• Obtain further information and referral resources for ACA implementation in the border region as more patients become enrolled

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Which best describes WHERE you work?

34%

5%

32%

5%

7%

17% a. Clinicb. Community-based organizationc. Health departmentd. Universitye. Hospitalf. Other

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Which best describes WHAT you do?

70%

8%

0%

8%

14% a. Clinician (MD, PA, NP, nurse, dentist, etc)b. Case managerc. Health education (peer educator, promotora)d. Medical Assistante. Other

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What type of clinician?

8%

16%

8%

61%

3%

5% a. MDb. NPc. PAd. Nursee. Dentistf. Other

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THE BORDER

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The HRSA/Federal definition of the U.S. border region is how many miles from Mexico?

3%

13%

60%

13%

13% a. 5 milesb. 12 milesc. 62 milesd. 75 milese. 100 miles

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The Border

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U.S. Border Region Challenges

• Health Professional Shortage Area (HPSA)• Higher incidence of infections diseases compared

with the U.S. average• If made a state, the border region would rank:

– 1st in number of uninsured children– 2nd in death rates due to hepatitis– 3rd in deaths related to diabetes– Last in access to health care– Last in per capita income

Source: US/Mexico Border Health Commission

Where the Poor and Uninsured Americans Live

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HIV Treatment Cascade

Gardner, E., et al. (2010). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 52(6):793-800.

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AFFORDABLE CARE ACT (ACA)

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Health Reform from the Beginning…

1965 2010 2011Medicare &

Medicaid established

Affordable Care Act (ACA) signed into law

Supreme Court upholds ACA

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Where We Are Now & Where We Are Going

2013 2014 2019• Outreach/Education• Assistors/Navigators

MarketplacesSign-up starting October 1, 2013

Health Insurance (Marketplaces &

Medicaid expansion) coverage begins January 1, 2014

ACA fully implemented

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I feel the ACA will make my job more secure

25%

40%

35% 1. True2. False3. I’m not sure/Don’t know

What About HepC and ACA?Rachel McLean, MPHBrian Risley, Danny Jenkins…..

*MediCal expansion? Co-pays, Payment assistance, budget busters, reinfection rates, Costs costs costs costs sustainable? Undocumented?*

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Affordable Care Act (ACA) & HIV Services

• Elimination of pre-existing condition exclusions

• Expansion of Medicaid to non-disabled adults with incomes of up to 133% of FPL

• Subsidies to purchase insurance through exchanges for people with income up to 400% FPL

• MORE PLWH ARE ELIGIBLE FOR MEDICAID/MARKETPLACE EXCHANGES

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Ryan White Funds: Payer of Last Resort

Ryan White Program funds may not be used for any item or service “for which payment has been made

or can reasonably be expected to be made by another payment source.”

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Income status of individuals who receiveRyan White-funded services

100% FPL, 70%

101-200% FPL, 21%

201-300% FPL, 6%

>300% FPL, 3%

100% FPL

101-200% FPL

201-300% FPL

>300% FPL

HIV/AIDS Bureau. 2009 RDR. Household Income Data.

FPL = Federal Poverty Level

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What is 100% of the 2013 FPL for a single person

0%

0%

82%

18%

0% a. $5,025/yearb. $7,110/yearc. $11,490/yeard. $13,170/yeare. I have no idea

2013 Federal Poverty Level

CoverageforAll.org

138% FPL=$15,856

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Medicaid Expansion

JAMA. 2013;309(12):1219. doi:10.1001/jama.2013.2481

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Which border state has said it will NOT expand Medicaid as part of ACA implementation?

0%

0%

0%

100% a. Arizonab. Californiac. New Mexicod. Texas

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Ryan White Core Services vs. Essential Health Benefits (EHB)

Ryan White Core Services Ambulatory & outpatient care AIDS pharmaceutical assistance Mental health services Substance abuse outpatient care• Home health care• Medical nutrition therapy• Hospice services• Home and community-based health

services• Medical case management, including

treatment adherence services• Oral health care (not standard)

ACA “Essential Health Benefits”*• Ambulatory patient services• Emergency services• Hospitalization• Maternity & newborn care• Mental health & substance use disorder

services, including behavioral health treatment

• Prescription drugs• Rehabilitative & habilitative services &

devices• Laboratory services• Preventive and wellness services & chronic

disease management• Pediatric services, including oral & vision

care

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Health Insurance (Marketplace) Exchanges

Kaiser Family Foundation. State Decisions for Creating Health Insurance Marketplaces. http://www.kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/

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State-Based Marketplace Exchanges:California & New Mexico

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Federally Facilitated Marketplace Exchanges: Arizona & Texas

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ACA IMPLEMENTATION ON THE BORDER

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ACA Implementation on the Border

• Expanding health insurance coverage in every state

• Increasing access to Medicaid

• Establishing Health Insurance Marketplaces

• Covering preventive services with no deductible or co-pay

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ACA Implementation in Arizona

Expanded Meidicad Implemented federally-run health insurance

marketplace

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Case Study: Arizona

Pedro is a 28 year old resident of Nogales, Arizona making ($12,065 or 105% FPL) who commutes to Tucson for HIV care at a Ryan White clinic. He has been in the U.S. legally for 7 years. He also receives HIV dental care and case management services through the Ryan White program in Tucson. He wants to stay at his HIV clinic.

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Under the ACA, will Pedro be required to purchase health insurance?

38%

62%

0% 1. Yes2. No3. I’m not sure.

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Will Pedro be able to continue to receive HIV dental care through the Ryan White program?

54%

26%

21% 1. Yes2. No3. I don’t know.

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ACA Implementation in California

Increasing access to MedicaidTransition to Medicaid expansion: Low Income

Health Programs (LIHPs) Implementing state-run health

insurance marketplace

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Border Rating Regions/PlansSan Diego Imperial

HealthNet (HMO)/$269 Kaiser Perm (HMO)Anthem (EPO) Blue Shield (PPO)Kaiser Permanente (HMO) Anthem (PPO)Molina Healthcare (HMO)SHARP Health Plan (HMO co-pay)Blue Shield (PPO)SHARP Health Plan (HMO co-insurance)Anthem (HMO)/$336

ACA, FPL, HIV, and OAHIPP

Medicaid Expansion (MediCal) 138% of Federal Poverty Level (FPL)

100% 138% Immediate (or deferred) Premium Tax Credits 400% 500%

100 % 138% Subsidies 250%

$15,856 (Individual)$32,500 (Household of 4)

$11,490 (Individual)$23,550 (4) $45,960 (Individual)

$94,200 (4)

$11,490 (Individual)$23,550 (4)

$28,725 (Individual)$58,875 (4)

Silver Plan

HIV-------OAHIPP<$50,000

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Case Study: CaliforniaAntonio is a 28 year old single construction worker with no children living with HIV. He was born in Los Angeles and now lives in San Diego. He earns $19,000/year (165% FPL). He does not have health insurance and goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says “saved my life.” He says he wants health insurance so he can take care of his chronic back problems, which he thinks may require surgery .

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Border Rating Regions/Least expensive planSan Diego

Age Plan Income Least $ Option (per mo)

40 Silver No Tax Credit (>400% FPL)

HealthNet (HMO): $269

40 Silver With Tax Credit

(200% FPL)

HealthNet (HMO): $81 (plus subsidies)

40 Silver With Tax Credit

(150% FPL)

HealthNet (HMO): $18 (plus subsidies)

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Case Study: AntonioSilver (eligible for Federal Subsidy) Premium: $41/month(of a $231/month premium--per Covered CA calculator)

Copays: Primary Care Visit: $15 Generic Drugs: $5Lab Test $15X-Ray: $20Deductible: $500 Out of pocket maximum: $2250

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Case Study: CaliforniaJuan is a single construction worker with no children living with HIV. He lives in Imperial county and earns $15,512/year (135% FPL). He does not have health insurance and goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says “saved my life.” Juan has been in the United States legally for 5 ½ years.

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Will Juan need to go to the Marketplace to purchase health insurance?

52%

36%

9%

3% 1. No, he will go to the Market Place and enroll in Medicaid (Medi-Cal)

2. Yes, and he will could get his entire premium paid by OAHIPP

3. Yes, he will need to purchase health insurance in the Market Place, but he will get no subsidy

4. I have no idea

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Juan is in an auto accident and receives care in the emergency room. Does he have health insurance?

100%

0%

0% 1. Yes2. No3. I don’t know.

Case Study: Maria

Maria is a single 51 year old house/hotel cleaner living in Calexico who estimates she will make $21,027 in 2014 (183% FPL), but has no health insurance. She says she could never afford the rates for “someone my age.” She has not seen a doctor for years, but sometimes goes across the border for antibiotics, dental care, and “back pain medicine.” She wants health insurance as she has chronic back problems and owns a small house worth $200,000. She is afraid an ER trip could bankrupt her or cause her to lose the house.

Maria (con’t)

Maria is a little worried that she is taking too much ‘back pain medicine’ as she has to take more and more to get relief from “pain …and sometimes stress” as she heard these pills could be addictive. Otherwise, she believes she is in good health and feels great.

However, she does not know that she is living with HIV and hepatitis C. She would not report any risks for either if asked.

Under the Affordable Care Act, Maria will be required to purchase health insurance or face a tax

penalty.

33%

33%

33% 1. a. True2. b. False3. c. I’m not sure

I think Maria will sign up for health insurance (NOT pay the penalty)

33%

33%

33% 1. a. True2. b. False3. c. I’m not sure

Maria signs up & chooses a qualified health plan primary care provider. Do you think she will be tested for HIV as

part of her routine care with her provider in 2014?

33%

33%

33% 1. a. Yes2. b. No3. c. I’m not sure

Were YOU offered an HIV test the last time YOU saw your primary care provider?

25%

25%

25%

25% 1. a. Yes—I remember2. b. No3. c. No—we already knew my HIV status4. d. I’m not sure I don’t remember

Do you think Maria will be tested for HCV as part of her routine care with her provider in 2014?

0%

100%

0% 1. a. Yes2. b. No3. c. I’m not sure

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Remaining Uninsured

Millions of individuals will remain uninsured after January 1, 2014, including:• Individuals subject to the mandate who do not enroll • Individuals who are eligible for Medicaid, but do not

enroll• Individuals who are not lawfully present

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Resources

DONOHOE@UCLA.EDU

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