The Evolution of the Ryan White Program Under Health Care

ReformIDWeek

October 18, 2012

Laura W. Cheever, MD,ScMDeputy Director, Chief Medical Officer

Department of Health and Human Services, Health Resources and Services Administration,

HIV/AIDS Bureau

Nothing to Disclose

Outline of Presentation

Overview of the Ryan White (RW) HIV/AIDS Program

Description of RW/Affordable Care Act (ACA) intersections

Future of Ryan White

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Ryan White HIV/AIDS Program - Intent

Increase access to care for people living with HIV disease domestically

Safety net for uninsured and low-income individuals living with HIV/AIDS

Funding for: Primary health care including medications

and support services Provider training, technical assistance,

demonstration projects (SPNS)

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Basic Tenets of Ryan White Local planning and prioritization of

funding based on needs assessment Involvement of people living with

HIV/AIDS in the planning process Funding of both primary care and

support services to improve access to care Support of a multidisciplinary team Building of a medical home

Quality of care4

Key Provisions of Ryan White Payer of last resort

Can “wrap around” other insurance 75% core services/ 25% support services

Core: outpt care, labs, meds, case management, mental health tx, substance abuse tx, oral health

Support: transportation, emergency housing, child care, food assistance

Can apply for Waiver if: no ADAP waiting list and core services available to all eligible patients

Funding based on living HIV/AIDS cases in the most recent year of data

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Ryan White HIV/AIDS Program Structure

Cities (Part A) States and Territories (Part B)

AIDS Drug Assistance Program (ADAP) Health Care Agencies

Early Intervention Services and Capacity Development (Part C)

Women, Infants, Children and Youth (Part D) Other programs (Part F)

Dental, Education/Training, Planning, Capacity Development and Demonstrations, Minority AIDS Initiative

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FY 2012 Ryan White HIV/AIDS Program Enacted Appropriation, $2.39* Billion

*“Includes $25 million for SPNS funding from Evaluation Set-Aside; $50 million announced on World AIDS Day 2011Source: HAB/HRSA Budget Office

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Ryan White HIV/AIDS Program - Clients Served Serves over 529,000 uninsured and underinsured

persons affected by HIV/AIDS annually Approximately 208,809 people received

medications through ADAP in 2010 About 46% of those on ARVs in U.S. use ADAP services

Reaches those most in need, with an estimated 72% racial minorities, 31% women, and 81.6% uninsured/underinsured or receiving public health benefits (Source: RW Data Report, 2010)

CDC reported AIDS cases- 66.5% minority, 23.5% women Reduced disparities in HIV care and treatment

outcomes attributed to RW program (Saag, CID, 2012)

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RW Clients’ Insurance Status

25.5

28.79.3

7.8

12.7

12.2

Insurance StatusNoInsuranceMedicaid

Medicare

Other Public

Private

MultipleInsurance

25.5% of RW clients are uninsured

Remainder are underinsured, with RW wrapping around to provide a full compliment of services

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Missing/unknown values (18%) excluded. Source: 2010 RW Services Report- Preliminary data

RW Clients’ Income

Most RW clients are below 100% FPL

Data is not available for clients <133% FPL

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Missing/unknown values (20%) excluded.Source: 2010 RW Services Report- Preliminary Data

HRSA working closely with CMS to examine roll out of state plans

HRSA supported CMS release of State Medicaid Director Waiver “Tool Kit”, including training and TA

Two studies to assess the gaps anticipated in care once ACA fully implemented

HAB qualitative study of 7 states DHHS/ASPE modeling (quantitative) study

HRSA examining states with expanded insurance to understand impact on RW

Understanding Impact of ACA Implementation on RW

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Lessons Learned from States with Expanded Coverage California

Continuity of care with expert, trusted providers

Gaps in care

Massachusetts Utilize RW funds to support services to

address gaps in treatment cascade Newly diagnosed and reported HIV rate fell

25% between 2006 & 2009 (increased 2% in U.S.); most recent rate fell by >50%

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Affordable Care Act Provisions with Immediate Impact on Ryan White

• Pre-Existing Conditions Insurance Plans (PCIPs) As of December 31, 2011, just under half of states were using

ADAP funds to enroll individuals in these new insurance plans - 2,393 clients total

• ADAP counting toward True Out of Pocket (TrOOP) Expenses for Medicare Part D ADAP costs can now cover eligible patients in the Medicare Part

D “donut hole” and then Part D assumes costs As of December 31, 2011, 35 ADAPs have data sharing

agreements in place with CMS

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Medicaid expansion to 133% of FPL Subsidies via health insurance

exchanges 133% - 400% FPL Private market reforms

Ban on health insurance rescissions Elimination of lifetime and annual caps

Support of the medical home

Affordable Care Act Provisions with Future Impact on Ryan White

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Ryan White and ACA: Areas of Interaction

Funding based on HIV/AIDS cases Aligns with the epidemic Not based on unmet need

Payer of last resort Little flexibility Continuity of care

75%/25% core/support services

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The Future of Ryan White• Full implementation of the ACA does not

eliminate the need for the Ryan White Program

• Gaps in coverage will remain – both Medicaid and private insurance

• Gaps in services: oral health care, medications, support services to link clients to care

• Some groups will remain uninsured• Training of providers (AETC)

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Reauthorization of Ryan White

Due for reauthorization in Fall, 2013 The Administration is working towards

reauthorization HHS and HRSA are working to determine

needed changes in the Program which may be driven by ACA.

HAB has solicited stakeholder input through virtual listening sessions, written comment period, national partner meetings

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RW Reauthorization: Major Themes Stakeholder Input

Support for reauthorization Concern about impact of variable ACA

implementation in jurisdictions Need for increased flexibility

75/25 core/support services, payer of last resort, administrative cap

Increased focus on continuity of care, retention in care, streamlining wrap-around and support services

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Conclusion

RW plays a key role in reducing health disparities and creating medical homes

RW will have a continued role with full implementation of ACA Role will vary by jurisdiction depending on

ACA implementation Fluid situation that requires continued

monitoring and response19

Applicability

Information from this session may assist participants in planning within their Ryan White funded programs for the transition to full implementation of the ACA.

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Contact InformationLaura Cheever, MD, ScM

Department of Health and Human ServicesHealth Resources and Services

AdministrationHIV/AIDS Bureau

5600 Fishers LaneRockville, MD 20857

Email: LCheever@hrsa.gov

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