Health Care Reform and Harm Reduction
8th
National Harm Reduction Conference, Austin, TX
November 18, 2010
Laura Hanen, Di...
• Major provisions of health reform
• Limitations of health reform
• Health Reform and Harm Reduction:
Preparing for 2014 ...
• 45-50 million Americans uninsured
• 65% of all bankruptcies are health related
• 50% of people with HIV in the US
do not...
• Health insurance overhaul package was signed
into law by President Obama on March 23, 2010
– “Patient Protection and Aff...
• Establishes a mandate that all U.S. Citizens and Legal
Residents maintain health insurance coverage
– Provides subsidies...
Coverage for < Age 65, in Millions
Estimated Coverage, 2019
162 159
35 51
30
25
2454
23
0
50
100
150
200
250
300
Current P...
Overview of Key Health Coverage
Expansion Components
Coverage Expansion Under Health Reform, by Income
> 400% Federal Poverty Level
• Able to purchase insurance through the ex...
Key Improvements Through Reform: Medicaid
• Expanded to all under 65 with incomes up to 133%
FPL ($14,400) in 2014
– Unifo...
Key Improvements Through Reform:
Insurance Exchanges
• Centralized, state-based marketplaces to
purchase insurance
• Goal ...
Key Improvements Through Reform:
Insurance Exchanges
• Open to individuals and small group employers with
income over 133%...
Insurance Exchanges:
Essential Benefits Package
• Preventive and wellness services and chronic disease
management
• Mental...
Improvements to Group Insurance Coverage:
2010
• Eliminates discrimination based on health status for
children (adults in ...
Improvements to Group Insurance Coverage:
2010
• Requires new plans to cover services that receive a
Grade A or B from the...
Key Improvements Through Reform:
Temporary High Risk Pool Programs
• Purpose is to provide coverage between now and 2014
•...
Key Improvements Through Reform:
Clinical Preventive Services
• Coverage of clinical preventive benefits under all
forms o...
USPSTF Recommendations:
STI Screening
Nonpregnant Women Pregnant Women Men
STI Not at
increased
risk
At
increased
risk*
No...
Opportunities for Harm Reduction
Programs: Patient-Centered Medical Homes
• Option for Medicaid beneficiaries with 2+ chro...
Opportunities for Harm Reduction
Programs: Investment in Prevention
• Community Health Centers
– Receiving $11 billion ove...
Limitations of Health Reform
• Specifically excludes undocumented immigrants
• Does not apply to people who are incarcerat...
Health Care Reform and Harm Reduction:
Preparing for 2014 and Beyond
What does health reform mean for
harm reduction organizations?
• Financial impact
– Potential for clients to eligible for ...
What does health reform mean for
harm reduction organizations?
• Systems Impact
– Need to build relationships with primary...
What does health reform mean for
harm reduction organizations?
• Systems Impact
– Case management intake process will need...
National HIV/AIDS Strategy:
Ryan White Will Still be Needed
“Gaps in essential care and services for people living
with HV...
Future of Health Reform
Future of Health Reform
• Educate policymakers on what is good about the
law and why you want to keep it
– Investments in ...
Priorities for Implementation
• Increasing Community Health Center’s role in harm
reduction service delivery
• Weighing in...
Priorities for Implementation
• Seek health workforce development opportunities
to address workforce shortage, cultural co...
Resources
• Trust for America’s Health
• Kaiser Family Foundation
• www.healthcare.gov
• The Commonwealth Fund
• National ...
Questions for Clarification
• What stands out as the most significant aspect of
health reform for your community/organizat...
Questions for Discussion
• How have you been tracking reform
implementation in your state?
• How do you envision your role...
Contact Information
Laura Hanen
Director, Government Relations
National Alliance of State and Territorial AIDS Directors
P...
Health Care Reform and Harm Reduction: Laura Hanen, Rachel McLean - HRC 2010
Health Care Reform and Harm Reduction: Laura Hanen, Rachel McLean - HRC 2010
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Health Care Reform and Harm Reduction: Laura Hanen, Rachel McLean - HRC 2010

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A presentation by Laura Hanen (NASTAD) and Rachel McLean (California Department of Public Health) on what health care reform means for harm reduction and drug user health. Presented at the Harm Reduction Coalition's 8th National Conference, November 18-21, 2010 in Austin, Texas.

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  • Julie
  • Six month anniversary
    Not ideal but provides a significant opportunity to expand access to care to people with chronic infectious diseases
  • Benchmark package includes MH, SA, Rx, preventive and wellness services and chronic disease management
    Limitations:
    Two-tiers of benefits for existing clients and newly eligible
    Continues 5-year exclusion on legal immigrants
    Increase in provider reimbursement rates limited and temporary (2013 &amp; 2014)
    Having Medicaid doesn’t ensure access to care
    Medicaid reimbursement rates a challenge for HIV providers
  • Small group + 100 or fewer employees.
  • Small group + 100 or fewer employees.
    Insurance reforms do not apply to existing large group and self-insured plans
    Undocumented immigrants are not assisted with subsidies
    Essential benefits package doesn’t include vision and dental
    Subsidies stop at 400% FPL. Affordability could still be a barrier for PLWHA and others with chronic conditions.
  • HHS is going to determine definitions of prevention, wellness, chronic conditions…
    Will it cover testing both for HIV and Hepatitis to identify new cases
  • The $5 billion will pay claims in excess of the premiums collected from members in the pool.
     
    Benefits are determined by the Secretary. Coverage may not limit benefits for preexisting conditions and must have an actuarial value of at least 65 percent of the total costs of the benefits provided. The out-of-pocket limits can be no greater than those linked to amounts for high-deductible health plans with linked health savings accounts or $5,950 for individuals and $11,900 for families, excluding premiums. Premiums charged to enrollees may vary on the basis of age, by a factor not greater than 4 to 1.
    Annual out-of-pocket limit -$5,950/individual or $11,900 for a family
    Premiums based on average rates and may only be adjusted for age
  • Medicare personalized prevention service include comprehensive health risk assessment, medical history, 5-10 year screening schedule for services recommended by the USPSTF and ACIP, review or referral for testing and treatment of chronic conditions
  • Nonpregnant Women
    - The USPSTF recommends chlamydia, gonorrhea, HIV, and syphilis screening for women who engage in high-risk sexual behavior (e.g., having multiple current partners, having a new partner, using condoms inconsistently, having sex while under the influence of alcohol or drugs, having sex in exchange for money or drugs)
    - The USPSTF further recommends chlamydia and gonorrhea screening for all sexually active women younger than 25 years (including adolescents), even if they are not engaging in high-risk sexual behaviors.
    - The USPSTF does not recommend STI screening for women 25 years and older who do not engage in high-risk sexual behavior.
    - After reviewing the evidence, the USPSTF noted that some women who do not engage in high-risk sexual behavior may benefit from screening for chlamydia and HIV. It was concluded, however, that because of the low prevalence of infection in the overall population, the net benefits of chlamydia and HIV screening do not justify routine screening in all women.
    - The USPSTF explicitly recommends against screening asymptomatic women for hepatitis B and herpes simplex virus (HSV). Although screening can identify women with these infections, there is no evidence that treating an asymptomatic patient improves long-term health outcomes.
    Pregnant Women
    - Because of the implications of treatment for the newborn, the USPSTF recommends that all pregnant women be screened for hepatitis B, HIV, and syphilis. Also, the USPSTF recommends that pregnant women younger than 25 years and those engaging in high-risk sexual behaviors also be screened for chlamydia and gonorrhea.
    - Although the USPSTF does not recommend routine screening for chlamydia in pregnant women not at increased risk, it notes that individual circumstances may support screening. The USPSTF has made no recommendation about screening for gonorrhea in pregnant women who are not at increased risk, noting there is insufficient evidence to recommend for or against it.
    Men
    - The USPSTF does not recommend STI screening for men who are not at increased risk. The USPSTF recommends HIV and syphilis screening for men engaging in high-risk sexual behavior.
    - In men, as in women, it is important that physicians take a thorough sexual history to assess if the patient engages in high-risk sexual behavior. In men who have sex with men, it is important to focus on high-risk sexual behavior and not on sexual orientation.
    http://www.uspreventiveservicestaskforce.org/uspstf08/methods/stinfections.htm#ref5
  • As described before, doesn’t kick in until 2014, essential benefits don’t include routine HIV testing; HCV screening for at-risk adults…
  • Health Care Reform and Harm Reduction: Laura Hanen, Rachel McLean - HRC 2010

    1. 1. Health Care Reform and Harm Reduction 8th National Harm Reduction Conference, Austin, TX November 18, 2010 Laura Hanen, Director, Government Relations, NASTAD Rachel McLean, Adult Viral Hepatitis Prevention Coordinator, STD Control Branch, California Department of Public Health
    2. 2. • Major provisions of health reform • Limitations of health reform • Health Reform and Harm Reduction: Preparing for 2014 and Beyond Overview
    3. 3. • 45-50 million Americans uninsured • 65% of all bankruptcies are health related • 50% of people with HIV in the US do not have reliable access to HIV care – 29% who are uninsured – 21% who don’t know they are infected • 75% of people with HCV in the US don’t know they are infected, many who do are not in care How did we get here?
    4. 4. • Health insurance overhaul package was signed into law by President Obama on March 23, 2010 – “Patient Protection and Affordable Care Act” • Most far reaching health legislation since the creation of the Medicare and Medicaid programs in the 1960s – Implications for every system of care The Affordable Care Act
    5. 5. • Establishes a mandate that all U.S. Citizens and Legal Residents maintain health insurance coverage – Provides subsidies to help low income people maintain insurance and exemptions for people for whom it would be a hardship • Legislation makes significant changes/improvements to major components of our health care system: – Private health insurance – Medicaid – Medicare • Elements phased in over the next ten years • Most significant changes are enacted in 2014 The Affordable Care Act
    6. 6. Coverage for < Age 65, in Millions Estimated Coverage, 2019 162 159 35 51 30 25 2454 23 0 50 100 150 200 250 300 Current Policy New Law Uninsured Exchange Nongroup/other Medicaid/SCHIP Employer Source: Congressional Budget Office, March 20, 2010 Plus 5 million employees in exchanges through employer plans
    7. 7. Overview of Key Health Coverage Expansion Components
    8. 8. Coverage Expansion Under Health Reform, by Income > 400% Federal Poverty Level • Able to purchase insurance through the exchanges if not already covered 133 – 400% Federal Poverty Level • Offered subsidies, tax breaks to purchase insurance through the exchanges < 133% Federal Poverty Level • Covered by Medicaid Expansion
    9. 9. Key Improvements Through Reform: Medicaid • Expanded to all under 65 with incomes up to 133% FPL ($14,400) in 2014 – Uniform minimum eligibility across states • State option to expand coverage now • Federal funding for Medicaid expansion: 2014 • Newly eligible have benchmark benefits package that includes MH, SA, Rx, and preventive services – Envisions drug treatment, mental health care happening in primary care settings
    10. 10. Key Improvements Through Reform: Insurance Exchanges • Centralized, state-based marketplaces to purchase insurance • Goal is to create healthy market competition –Better benefits package/coverage –Lower costs passed on to consumer • Established with federal funds and must meet national standards
    11. 11. Key Improvements Through Reform: Insurance Exchanges • Open to individuals and small group employers with income over 133% FPL to purchase insurance • More affordable and better coverage options for individuals without group coverage • Federal premium and cost-sharing subsidies for individuals with incomes133% - 400% FPL – Around $19,000 to $57,616/per year for an individual based on 2010 federal poverty level
    12. 12. Insurance Exchanges: Essential Benefits Package • Preventive and wellness services and chronic disease management • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Laboratory services • Ambulatory, emergency, and hospitalization patient services • Rehabilitative and habilitative services and devices • Maternity and newborn care • Pediatric services, including oral and vision care
    13. 13. Improvements to Group Insurance Coverage: 2010 • Eliminates discrimination based on health status for children (adults in 2014) • Encourages employers to provide insurance coverage (small business tax credits) • Extends dependant coverage to age 26 • Eliminates lifetime insurance caps on policies and plan rescissions
    14. 14. Improvements to Group Insurance Coverage: 2010 • Requires new plans to cover services that receive a Grade A or B from the U.S. Preventive Services Task Force with no cost sharing • Establishes a temporary national high-risk insurance pool to cover the uninsured with pre- existing conditions (until 2014)
    15. 15. Key Improvements Through Reform: Temporary High Risk Pool Programs • Purpose is to provide coverage between now and 2014 • Eligible if have a pre-existing condition and have not had creditable coverage during the previous 6 months • $5 billion available for program starting July 1, 2010 • 27 states opted for the feds to run the pool – Requires a letter of denial of coverage • Premiums and out of pocket costs are limited but still costly for low-income individuals (CA: $575/mo.) • Uptake has been limited; HHS reducing costs in 2011
    16. 16. Key Improvements Through Reform: Clinical Preventive Services • Coverage of clinical preventive benefits under all forms of insurance – Eliminates co-pays for services with A or B under U.S. Preventive Services Task Force • Does not include routine HIV testing or HBV/HCV testing for IDUs, other at-risk adults – 1% increase in Medicaid federal matching funds for providing these services in 2013 – Medicare annual visit and personalized prevention plan • Expanded access to immunizations for adults – Includes hepatitis A and hepatitis B vaccination
    17. 17. USPSTF Recommendations: STI Screening Nonpregnant Women Pregnant Women Men STI Not at increased risk At increased risk* Not at increased risk At increased risk* Not at increased risk At increased risk** Chlamydia C A C B I I Gonorrhea D B I B D I Syphilis D A A A D A HIV C A A A C A Hepatitis B D D A A D D Hepatitis C D I - - D I HSV D D D D D D * Increased risk for pregnant and nonpregnant women is defined as high-risk sexual behavior for all STIs; as age younger than 25 years for chlamydia and gonorrhea; and as high community prevalence for chlamydia, gonorrhea, and syphilis ** Increased risk for men is defined as high-risk sexual behavior for all STIs and as high community prevalence for syphilis
    18. 18. Opportunities for Harm Reduction Programs: Patient-Centered Medical Homes • Option for Medicaid beneficiaries with 2+ chronic conditions to designate a medical home • Supports pilot projects that have the potential to reduce costs while preserving or enhancing quality – HRSA and CMS could develop a pilot to evaluate cost effectiveness of coordinated drug user health services (HIV/HCV testing & care, syringe access, buprenorphine, overdose prevention, soft tissue infection treatment, etc.) • Workforce training targeted to patient-centered medical home and to physicians working with vulnerable populations (e.g., IDUs)
    19. 19. Opportunities for Harm Reduction Programs: Investment in Prevention • Community Health Centers – Receiving $11 billion over next 5 years – Presents an opportunity to ensure that CHCs can expand access to prevention and care services • Prevention and Public Health Fund – $500 million in FY10 growing up to $2 billion in FY15 – FY10: $30M for HIV prevention – Public health infrastructure, lab and epi capacity, workforce training, community transformation grants – Primary care physician capacity • National Prevention Strategy
    20. 20. Limitations of Health Reform • Specifically excludes undocumented immigrants • Does not apply to people who are incarcerated • Insurance coverage ≠ access or quality • Not enough primary care physicians for everyone • Will not suddenly make health professionals culturally competent with the people we serve • Requires continued funding / support from Congress
    21. 21. Health Care Reform and Harm Reduction: Preparing for 2014 and Beyond
    22. 22. What does health reform mean for harm reduction organizations? • Financial impact – Potential for clients to eligible for high risk pool programs/Pre-Existing Condition Insurance Plans – Many clients (single, uninsured, “non-disabled” adults) to be covered by Medicaid or private insurance as of 2014 – Siloed funding streams may diminish as preventive services, drug treatment, move into primary care settings – Need for services will remain for uninsured individuals – Monitor Public Health Prevention Fund for opportunities
    23. 23. What does health reform mean for harm reduction organizations? • Systems Impact – Need to build relationships with primary care providers • FQHCs, homeless / rural health centers • State and regional primary care associations – Advocate for drug user health services in primary care: • HIV, HCV, HBV testing, clinical management • Hepatitis A and B vaccination • Syringe access • Overdose prevention (naloxone prescription) • Opiate replacement therapy (buprenorphine, methadone) – Market skills in serving “hard to reach populations”?
    24. 24. What does health reform mean for harm reduction organizations? • Systems Impact – Case management intake process will need to be altered to include screening for additional benefits – Health care, drug treatment providers will need to ensure that they’re included in Medicaid managed care, Medicare, and private insurance provider networks – Providers will need to ensure infrastructure in place for billing of various payers
    25. 25. National HIV/AIDS Strategy: Ryan White Will Still be Needed “Gaps in essential care and services for people living with HV will continue to need to be addressed along with the unique biological, psychological and social effects of living with HIV. Therefore, the Ryan White HIV/AIDS Program and other Federal and State HIV- focused programs will continue to be necessary after the law is implemented.” National HIV/AIDS Strategy for the United States: July 2010 (page ix).
    26. 26. Future of Health Reform
    27. 27. Future of Health Reform • Educate policymakers on what is good about the law and why you want to keep it – Investments in prevention – Expansion of coverage to low-income, middle- income people • Participate in implementation – Federal and state • Educate clients, providers
    28. 28. Priorities for Implementation • Increasing Community Health Center’s role in harm reduction service delivery • Weighing in on the Essential Benefits Package for the exchanges and Medicaid • Medical Home pilots in Medicaid and the Center for Medicare and Medicaid Innovation • Tracking implementation of National HIV/AIDS Strategy and National Viral Hepatitis Action Plan
    29. 29. Priorities for Implementation • Seek health workforce development opportunities to address workforce shortage, cultural competency • Modify U.S. Preventive Svs. Task Force recommendations for HIV and hepatitis testing • Ask for HIV, HCV dollars in Prevention and Public Health Fund for FY2011 and FY2012 • Leverage Community Transformation Grants • Meet with HHS health reform implementers • Client organizing; provider, policymaker education
    30. 30. Resources • Trust for America’s Health • Kaiser Family Foundation • www.healthcare.gov • The Commonwealth Fund • National Alliance of State and Territorial AIDS Directors www.nastad.org
    31. 31. Questions for Clarification • What stands out as the most significant aspect of health reform for your community/organization? • What is still unclear about health reform? • What challenges and opportunities does health reform present for your organization?
    32. 32. Questions for Discussion • How have you been tracking reform implementation in your state? • How do you envision your role in ensuring that the implementation of health reform benefits drug users and other communities we serve? • What other considerations should we keep in mind between now and 2014?
    33. 33. Contact Information Laura Hanen Director, Government Relations National Alliance of State and Territorial AIDS Directors P: 202.434.8091 lhanen@nastad.org Rachel McLean, MPH Adult Viral Hepatitis Prevention Coordinator STD Control Branch California Department of Public Health P: (510) 620-3403 Rachel.McLean@cdph.ca.gov www.cdph.ca.gov/programs/pages/ovhp.aspx
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