Health Care Reform: Opportunities and Challenges for People Living with HIV and AIDS

Robert Greenwald Harvard Law School Center for Health Law & Policy Innovation

Treatment Access Expansion Project

April 2012

Presentation Outline

Part 1:

Why We Need Health Care Reform: The Current Access to Care Crisis

Part 2:

Major Health Care Reform Opportunities: The Changing Health Care Landscape

Part 3:

Key Health Care Reform Challenges: Turning Opportunities into Realities Part 4:

Next Steps

Presentation Outline

Part 1:

Why We Need Health Care Reform: The Current Access to Care Crisis

HIV/AIDS v. General Population: Health Care Coverage

SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006

General Population PWHIV/AIDS

SOURCE: Kaiser Family Foundation based on US Census Bureau, 2006; Kaiser State Health Facts Online; Cunningham WE et al. “Health Services Utilization for People with HIV Infection Comparison of a Population Targeted for Outreach with the U.S. Population in Care.” Medical Care, Vol. 44, No. 11, November 2006. NOTE: US income data from 2005, US unemployment data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal; HCSUS data from 1998.

8% 5%

45%

62%

Income <$10,000 Unemployed

US Population

People with HIV/AIDS

U.S. Population and PWHIV Income & Unemployment

Medicaid Is an Essential Source of HIV Care BUT Access is Limited in Most States…

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

South Northeast Midwest West U.S. Average

% of HIV Population Enrolled in Medicaid

Source: Susan Reif, et al., Duke Center for Health Policy and Inequalities Research, Southern AIDS Strategy Initiative, HIV/AIDS Epidemic in the South Reaches Crisis Proportions in Last Decade (2012).

Medicaid Is A Disability Program: (Not a Health Care Program) in Most States

~ 74% of people living

with HIV/AIDS on

Medicaid are eligible

because of disability

Spending per Medicaid user with and without HIV by type of service (2007)

Source: Jen Kates, Kaiser Family Foundation, Medicaid and HIV: A National Analysis

(October 2011)

2003 2004 2005 2006 2007 2008 2002 Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table12.htm; Ryan White Appropriations History, Heath Resources and Services Administration, ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Inflation calculated using http://www.usinflationcalculator.com; www.cdc.gov/hiv/surveillance/resources/reports/2009report/pdf/table16a.pdf; “Funding, FY2007-FY2010 Appropriations by Program, hab.hrsa.gov/reports/funding.html

Ryan White Program Funding is Not Keeping Pace with Increased Need

Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation)

Status Quo = Public Health and Access to Care Crisis

The Current

Crisis

29% of PWHIV

uninsured

Thousands on ADAP waitlists

Demand for Ryan White

care and services > funding

42-59% of low-income

PWHIV not in regular care

Impossible for PWHIV to

obtain individual insurance

policy

We Are Not Alone!

Number of Uninsured Americans

Sources: Center on Budget Policies and Priorities, The Number of Uninsured Americans is at an All-Time High (2006), http://www.cbpp.org/files/8-29-06health.pdf; Kaiser Family Foundation, The Uninsured: A Primer (2010), http://www.kff.org/uninsured/upload/7451-06.pdf.

0

10

20

30

40

50

60

2001 2005 2009

41.2 Million46.6 Million

50.9 Million

Part 2:

Major Health Care Reform Opportunities: The Changing Health Care Landscape

• Expands Eligibility in Most States – Starting in 2014, disability requirement is eliminated for

most up to 133% FPL ($14,484 indiv./$29,726 fam. of 4)

• Improves Services – Medicaid expansion includes Essential Health Benefits

(EHB) for the newly-eligible

• Improves Reimbursement – Enhances reimbursement for primary care providers in

2013-14

• Streamlines Application and Enrollment

1. Expands and Improves Medicaid

• Gives states the option to provide cost-effective, coordinated and enhanced care and services to people living with chronic medical conditions*

• States are eligible for planning grants and increased federal support – 90% FMAP for first two years of the program

• Reduces inpatient and emergency room costs while improving health outcomes through both enhanced care coordination and service integration – high intensity care/service management, integrated physical and

behavioral health services, health promotion, patient and family support, and prioritized housing

* Successful advocacy led to inclusion of people living with HIV/AIDS

2. Supports Enhanced & Coordinated Care Through Medicaid Health Home Program

• 50% discount on all brand-name prescription drugs

• AIDS Drug Assistance Program (ADAP) contributions now count toward copayment obligations

• Part D “donut hole” phased-out by 2020

3. Increases Access to Medicare Prescription Drugs

• Cannot be denied insurance because of HIV (or other chronic condition) (2014)

• Health plans cannot drop people from coverage when they get sick (in effect)

• No lifetime limits on coverage (in effect)

• No annual limits on coverage (2014)

4. Reforms Private Insurance and Reduces Discriminatory Insurance Practices

• Starting in 2014, creation of consumer-friendly exchanges to purchase private insurance

• Federal subsidies for people with income up to 400% FPL ($43, 560 single/$89,400 for family of four)

• Plans cannot charge higher premiums based on gender or health status

• Plans must include Essential Health Benefits

• Plans have to contract with “community providers,” including Ryan White Programs

Promotes Access to Private Insurance Through State-Based Exchanges

• Prevention and Public Health Fund – $500 million in 2010 and increasing annually up to $2

billion in 2015 for community prevention initiatives

• Community Health Center Expansion – $11 billion in funding for the operation, expansion and

construction of health centers over the next five years

• Health Workforce Investments – Expands primary care workforce – Expands National Health Service Corps

• Care Coordination Investments – Center for Medicare and Medicaid Innovation (CMMI)

5. Health Care Reform Invests in Prevention, Access to Care, and Innovation

Individuals with income up to 133% FPL

Eligible for Medicaid based on income alone (Ryan White Program still needed to fill in gaps not covered by Medicaid)

Individuals between 133% and 400% FPL

Eligible for premium tax credits and cost-sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps not covered by private insurance)

Individuals with unmet care and treatment needs

Ryan White Program still a safety net for: insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants

Health Care Reform and HIV/AIDS Care: Looking Ahead to 2014

Massachusetts: A Case Study of a Post Health Care Reform State in a Pre-Reform Country

• Expanded Medicaid coverage to people living with HIV with an income up to 200% FPL (2001)

• Required every uninsured adult to purchase insurance or pay a fine (2006)

• Required all employers with 11 or more workers to “fair and reasonably “contribute to their employees health insurance or pay an assessment (2006)

• Enacted private health insurance reform with a heavily subsidized insurance plan for those with income up to 300% FPL (2006)

Part 3: Key Health Care Reform Challenges: Turning Opportunities into Realities

1. Ensuring a Smooth Transition for People Living With HIV/AIDS and Their Providers

• Ensuring effective integration of Ryan White Program models of care and providers into Medicaid and Exchange networks (federal and state)

• Creating simple, streamlined application (federal and state)

• Ensuring appropriate and effective outreach, patient navigation and coordination between health systems to minimize interruptions in care (state)

• Maximizing effectiveness by including HIV and AIDS community in state decisions on exchange and Medicaid expansion design (state)

2. Ensuring the EHB Package Provides the Level and Scope of Services Needed by People Living with HIV/AIDS

• Ensuring comprehensive coverage that meets care and treatment needs of people living with HIV (HHS and state)

• EHB must be the floor, not the ceiling to meet complex health care needs (state)

• Ambulatory

• Emergency

• Hospitalization

• Maternity/newborn care

• Mental health and substance use disorder

• Prescription drugs

• Rehabilitative and habilitative

• Laboratory

• Preventive and wellness and chronic disease management

• Pediatric services

Congressionally Mandated Essential Health Benefits

• States may pick from one of ten plans which will become the “benchmark” for purposes of EHB

– Any of the 3 largest small group insurance products by enrollment

– Any of the 3 largest state employee health benefit plans

– Any of the 3 largest national Federal Employee plans

– The largest commercial non-Medicaid HMO in the state

• Benchmark chosen must include the ten categories listed in the ACA (if not, wrap-around allowed)

HHS Essential Health Benefits (EHB): Benchmark Approach

• Flexibility for most states likely means bare bones plans

– Small group market has been limited and costly

• State variation & disparities continue

• Mandates may be included at state option (at least for 2014 & 2015)

What Does a Benchmark Approach Mean for Access to HIV/AIDS Care and Treatment?

What Are the Next Steps for EHB?

3. Medicaid Health Home:

Ensuring the Needs of Medicaid Beneficiaries Living with Serious Chronic Illnesses are Addressed

• Provides state with the opportunity to manage the whole patient successfully and control care costs

• Ideas on patient engagement include offering PCPs stipends, waiving copayments for evidence-based treatment’ giving patients monetary incentives for achieving medical milestones

• Ideas for improving care coordination include innovative payment models, shared saving arrangements, care management fees, enhanced capitation, enhanced support of PCPs, co-location of services, telemedicine, extended hours

• Provides an opportunity for integration of essential Ryan White Program support services in Medicaid

New York’s Health Home Savings Estimates

State Fiscal Year

2011-12

2012-13

2013-14

2014-15

State Savings

$-33.20

$-112.40

$-119.20

$-95.10

Total Savings

$-46.30

$-162.90

$-186.40

$-165.90

(Dollars in Millions)

4. Leveraging New Investments in Prevention & Wellness, Health Centers and Workforce

• Educating state officials and community –based organizations on potential funding opportunities

– Securing funding to support HIV prevention and wellness

– Ensuring health center investments include support for comprehensive care for people with HIV

– Securing funding for training and retention of HIV/AIDS primary care physicians and specialists

5. Ensuring Access to Essential Services: Covering the Gaps

• Essential services needed by people living with HIV/AIDS NOT fully covered by Medicaid: – Dental services

– Nonmedical case management

– Nutrition services

– Transportation

– Mental health services?

– Peer support services

– Premium co-pay assistance

• Medicaid will NOT be available for: – Undocumented immigrants

– Legal immigrants within the 5 year ban

Ryan White HIV/AIDS Program

Massachusetts: Utilization of ADAP

YEAR Full Pay Co-Pay Premiums Total Cost (including rebates)

FY02 $ 7,947,832 $ 648,030 $ 1,120,512 $ 9,716,375

FY03 $ 7,961,862 $ 963,205 $ 1,778,272 $ 10,703,342

FY04 $11,174,879 $ 1,553,758 $ 3,159,200 $ 15,887,838

FY05 $ 9,756,201 $ 1,839,807 $ 6,112,132 $ 17,708,142

FY06 $ 4,634,683 $ 1,893,206 $ 7,015,306 $ 13,543,197

FY07 $ 4,147,713 $ 2,071,118 $ 8,366,273 $ 14,585,106

FY08 $ 4,184,279 $ 2,083,431 $ 9,323,821 $ 15,591,533

FY09 $ 4,695,780 $ 2,567,789 $ 8,835,835 $ 16,099,405

Part 4: Next Steps

Know the Facts: Health Care Reform Will

Reduce the Federal Deficit Federal v. State Share of

Medicaid Expansion From the Congressional

Budget Office and the Joint Committee on Taxation:

“The effects . . . [of health care reform] on direct spending and revenues related to health care will reduce federal deficits by $210 billion over the 2012-2021 period.”

Sources: Center on Budget Policies and Priorities, Hatch-Upton Report on Costs to States of Expanding Medicaid Relies on Seriously Flawed Estimates (2011), http://www.cbpp.org/files/3-16-11health.pdf. Congressional Budget Office , CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010, (March 2011), http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf

2012 Supreme Court Decision & Elections

= Watershed for Health Care

Will the ACA be fully implemented?

Will deficit reduction be achieved responsibly?

Will our health care safety nets (Medicaid, Medicare, Ryan White Program) be preserved?

Control of the White

House

Supreme Court ACA Decision

Control of House and

Senate

5. Get involved…

At the Federal Level

• Take every opportunity to influence Congress and other federal officials

At the State Level

• Talk to state officials about the needs of people living with HIV and AIDS as states expand Medicaid and create Exchanges

• Encourage state officials to take advantage of Medicaid Health Homes and other opportunities

Stay Informed

• Keep your finger on the pulse of federal and state legislative and regulatory HCR initiatives

• WE CAN HELP!

Available Resources

HRSA Resources, www.hrsa.gov

• Planning grants

• Technical assistance

Treatment Access Expansion Project, www.taepusa.org

AIDS United, www.aidsunited.org

Dose of Change, www.doseofchange.org

HIV Medicine Association, www.hivma.org

Health Care Reform Resources

• Kaiser Family Foundation, www.kff.org

• FamiliesUSA, www.familiesusa.org

• Community Catalyst, www.communitycatalyst.org

• Healthcare.gov, www.healthcare.gov