1. Health Care Reform in Massachusetts: Opportunities and Obstacles in HIV Prevention Kevin Cranston, MDiv Director, Bureau of Infectious Disease Massachusetts Department of Public Health National HIV Prevention Conference August 16, 2011
2. Overview• Review of MA health reform law and coverage• Major HIV/STD/Hep C program changes in recent years• Challenges of maximizing benefits of universal health insurance coverage• New and ongoing opportunities inherent in universal coverage
3. MA Health Reform• Massachusetts in 2006 expanded health insurance coverage statewide by: – Expanding Medicaid to 150% FPL (200% for HIV due to 1115 Medicaid waiver) – Creating an individual mandate (income tax penalty) – Creating an employer mandate (11 employees or more) – Defining minimum creditable coverage – Offering subsidies for adults 150-300% FPL (Commonwealth Care) – Establishing a state-managed authority to broker access to insurance (Health Care Connector)
4. Clear Benefits of MA Health Reform• Over 98% of MA residents have health insurance• Pre-existing condition exclusions eliminated• Insurers cannot drop coverage due to emergent health conditions• Annual and lifetime coverage caps eliminated• Preventive care and screenings covered
5. Observed Challenges• Short-term pressure on state budget; savings are in the long term• Anecdotal reports of limited primary care providers and extended wait times for appointments• Transformation of health care seeking habits by the previously uninsured (replacing urgent care with care in the medical home)• Developing the skill of primary care clinicians in public health screening and priority treatment• Questions remain for the coverage of certain immigrant and refugee populations
6. Practical implications• Availability of coverage for most routine health screenings• Availability of expanded third-party reimbursement for many services previously billed to discretionary contracts• Reconsideration of value of discrete, walk-in public health services in clinical settings• New role of public health in supporting primary care providers
7. Recent evolution of MA HIV/STD/Hep C screening programs• Creation and expansion of integrated counseling, testing, and referral programs (ICTRs): comprehensive HIV, STD, and Hepatitis C screening at 14 sites• Loss of state funding for STD clinical services; closure of eight dedicated STD clinics• Transformation of role of STD Disease Intervention Specialist• Recent creation of PICTR-Ts (addition of behavioral prevention and priority treatment for STDs)• Through CDC Expanded Testing Initiative resources, expansion of clinic-based routine HIV screening• Creation of Hepatitis C medical management service
8. Monthly HIV Testing Volume in a Routine Screening Clinical Environments Supported by MDPH 600Number of HIV Tests per Month Routine screening at Routine screening at Routine screening at Codman begins 11/08 Dorchester begins 03/09 Baystate ED begins 02/09 500 400 300 200 100 0 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /0 /1 /1 /1 /1 /1 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 Time Period (Month/Year) Baystate Emergency Codman Square Dorchester House
9. Questions for discussion• Will CBOs delivering HIV services be able to adapt to a changing reimbursement structure?• How will health reform transform the HIV prevention work force? Will CHWs have a greater or lesser role?• To what degree does the new CDC funding for states and cities anticipate national health reform?
10. Questions for discussion• Will HIV screening ever become universally covered health care component?• If it does, what will be the role of discretionary funding for HIV testing and screening?• Will many states will seek Medicaid waivers to expand HIV treatment?• If they don’t how will treatment be provided for all the individuals identified through expanded screening?