Health Care Reform:Opportunities and Challenges forPeople Living with HIV and AIDS Robert Greenwald Harvard Law School Center for Health Law & Policy Innovation Treatment Access Expansion Project April 2012
PresentationOutline Presentation OutlinePart 1:Why We Need Health Care Reform: The Current Access to Care CrisisPart 2:Major Health Care Reform Opportunities: The Changing Health Care LandscapePart 3:Key Health Care Reform Challenges: Turning Opportunities into RealitiesPart 4:Next Steps
Part 1:Why We Need Health Care Reform: The Current Access to Care Crisis
HIV/AIDS v. General Population: Health Care Coverage General Population PWHIV/AIDSSOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, MedicalCare, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006
U.S. Population and PWHIV Income & Unemployment 62% 45% US Population People with HIV/AIDS 8% 5% Income <$10,000 UnemployedSOURCE: 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 datafrom 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal; HCSUS data from 1998.
Medicaid Is an Essential Source of HIV Care BUT Access is Limited in Most States… % of HIV Population Enrolled in Medicaid 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% South Northeast Midwest West U.S. AverageSource: Susan Reif, et al., Duke Center for Health Policy and Inequalities Research, Southern AIDS Strategy Initiative, HIV/AIDS Epidemic in theSouth Reaches Crisis Proportions in Last Decade (2012).
Medicaid Is A Disability Program: (Not a Health Care Program) in Most StatesSpending per Medicaid user with and without HIV by type of service (2007) ~ 74% of people living with HIV/AIDS on Medicaid are eligible because of disabilitySource: Jen Kates, Kaiser Family Foundation, Medicaid and HIV: A National Analysis(October 2011)
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) 2002 2003 2004 2005 2006 2007 2008Sources: “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
Status Quo = Public Health and Access to Care Crisis Demand for Ryan White care and services > 42-59% of Thousands funding low-income on ADAP PWHIV not in waitlists regular care Impossible 29% of The for PWHIV to obtain PWHIV Current individualuninsured Crisis insurance policy
We Are Not Alone! Number of Uninsured Americans 60 50.9 Million 46.6 Million 50 41.2 Million 40 30 20 10 0 2001 2005 2009Sources: 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.
Part 2:Major Health Care Reform Opportunities: The Changing Health Care Landscape
1. Expands and Improves Medicaid• 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
2. Supports Enhanced & Coordinated Care Through Medicaid Health Home Program• 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
3. Increases Access to Medicare Prescription Drugs• 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
4. Reforms Private Insurance andReduces Discriminatory Insurance Practices • 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)
Promotes Access to Private Insurance Through State-Based Exchanges• 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
5. Health Care Reform Invests inPrevention, Access to Care, and Innovation• 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)
Health Care Reform and HIV/AIDS Care: Looking Ahead to 2014Individuals with income up Eligible for Medicaid based on income aloneto 133% FPL (Ryan White Program still needed to fill in gaps not covered by Medicaid)Individuals between 133% Eligible for premium tax credits and cost-and 400% FPL sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps not covered by private insurance)Individuals with unmet Ryan White Program still a safety net for:care and treatment needs insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants
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 andScope of Services Needed by People Living with HIV/AIDS Congressionally Mandated Essential Health Benefits • Ambulatory • Prescription drugs • Emergency • Rehabilitative and habilitative • Hospitalization • Laboratory • Maternity/newborn care • Preventive and wellness and • Mental health and chronic disease management substance use disorder • Pediatric services• 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)
HHS Essential Health Benefits (EHB): Benchmark Approach• 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)
What Does a Benchmark Approach Mean for Access to HIV/AIDS Care and Treatment?• 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)
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 EstimatesState 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 inPrevention & 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? Ryan White HIV/AIDS Program – Peer support services – Premium co-pay assistance• Medicaid will NOT be available for: – Undocumented immigrants – Legal immigrants within the 5 year ban
Know the Facts: Health Care Reform Will Reduce the Federal DeficitFederal v. State Share of From the Congressional Medicaid Expansion 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 Control of Supreme House and Court ACA Senate Decision Control of the White House 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?
5. Get involved… At the Federal At the State Stay Informed Level Level• Take every • Talk to state officials • Keep your finger on opportunity to about the needs of the pulse of federal influence Congress people living with HIV and state legislative and other federal and AIDS as states and regulatory HCR officials expand Medicaid and initiatives create Exchanges • WE CAN HELP! • Encourage state officials to take advantage of Medicaid Health Homes and other opportunities
Available ResourcesHRSA Resources, www.hrsa.gov • Planning grants • Technical assistanceTreatment Access Expansion Project, www.taepusa.orgAIDS United, www.aidsunited.orgDose of Change, www.doseofchange.orgHIV Medicine Association, www.hivma.orgHealth Care Reform Resources • Kaiser Family Foundation, www.kff.org • FamiliesUSA, www.familiesusa.org • Community Catalyst, www.communitycatalyst.org • Healthcare.gov, www.healthcare.gov