1. Health care
reform and people
with HIV/AIDS
Courtney Mulhern-Pearson
August 3, 2013

2. SAN FRANCISCO AIDS FOUNDATION 2
1
2
3
What does health care reform do?
What’s going on in California?
What can you do now?

3. SAN FRANCISCO AIDS FOUNDATION 3
Status quo = access to care crisis
The Current
Crisis
42-59% of low-
income people
living with HIV
not in regular
care
Impossible to
obtain individual
insurance and
few insured
through
employer
system
Medicaid/ Medicare
are lifelines to care,
but disability
standard means they
are very limited
Demand for Ryan
White care and
services > funding
29% of people
living with HIV
uninsured

4. SAN FRANCISCO AIDS FOUNDATION 4
Ryan White program not keeping pace with need
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

5. What does HCR actually do?
• Individual mandate: U.S. Citizens and Legal
Residents must maintain health insurance coverage.
• Addresses Affordability:
 Provides subsidies for lower income people;
 Exemptions for hardship;
 Out of pocket caps on coverage
• Expands Coverage and creates a standard package of
Benefits, including free preventive services
• Provides Consumer Protections
What does health care reform actually do?

6. New Insurance Options
Improves Medicaid (~ 60% of currently uninsured people
with HIV):
• Expands eligibility to everyone below 138% FPL regardless
of disability status
• provides essential health benefits (EHB); same package as
traditional Medi-Cal in CA
• allows for free preventive services
Creates Private Insurance Marketplaces (~ 30% of current
uninsured people with HIV):
• Federal subsidies up to 400% FPL
• Called Covered California
• eliminates premiums based on health/gender
• provides EHB
• supports outreach, navigation and enrollment
• Allows for Basic Health Plan – not this year
New insurance options

7. Who is left out?
Undocumented immigrants:
• Barred from state-based exchanges
• Not eligible for non-emergency Medicaid
• Eligible for restricted “emergency” Medicaid
• Eligible for services through community health centers and/or
safety-net providers, Ryan White, Healthy San Francisco
Legally present immigrants:
• Still face 5 year waiting period for Medicaid services
– California has chosen to move legally present immigrants into
the marketplace with full wrap-around
• Can purchase with subsidies in Marketplace
Medically Fragile and perpetually out-of-care
Who’s left out?

8. Ryan White – Challenges for PLWH and
their Providers
• Ryan White program (RW) – patient centered
comprehensive HIV care
• Payer of last resort : RW can’t pay for services that can
be provided under other coverage
• HCR expanded coverage means transitions
– Transitions to new plans, providers, pharmacies
– Once in new coverage, may need continued access
to some RW services:
• Those not offered by other coverage: specific
types of case management, adherence, linkage to
housing
• Help with costs: out of pocket and premium costs
for care and medications
Challenges for people with HIV and their providers

9. “A Bridge to Health Care Reform”
July 2011
• Low Income Health Program (LIHP) Partial and
temporary county – based Medicaid expansion: Health
PAC in Alameda
– Ends December 31, 2013
– State forgot to plan for people with HIV
• Alameda and LA finish PLWH transition 07/08, 2013
– Eligibility & delivery system varies by county
• Eligibility range from 25% FPL to 200% FPL
– Met goal: serves > 550,000 uninsured Californians
• Medi-Cal managed care expansion: moved most from
fee-for-service into Medi-Cal managed care plans
“A bridge to health care reform”

10. What Will Health Care Reform Bring in
2014?
• Medi-Cal (California’s Medicaid program) expansion
• A state run Marketplace - Covered California
• Transitions for people with HIV and providers:
– From LIHP and RW to Medi-Cal expansion and Covered
California
– Considerations: Continuity of care with providers and
pharmacy and integration (RW services working with
new forms of coverage) strategies
What will change in 2014?

11. Covered California
• Limited, standardized plan offerings
• Open enrollment October, 2013 - March 31, 2014
• Assistance with enrollment and trouble shooting
• Not clear how many HIV providers are in plan
networks
• Most people with HIV will need assistance with
costs
– Planning beginning for wrap around programs
• HIV - small population; “issues not on front
burner”
– Won’t get all we need/want in first year of development
Covered California

12. CA Assisters Program
• Assisters: entities and people who will be
compensated for enrolling individuals in
plans
– Applications should be out soon
– Training begins in August, 2013
• Navigators: entities that will outreach to
specific populations that are uninsured after
initial enrollment
The assisters program

13. Assisting with Cost in New Coverage
• State Office of AIDS beginning to plan for
assistance with out of pocket and premium
costs in Covered California
• Current programs OA Health Insurance
Premium Payment Program (OAHIPP)and
others pay only premiums
– Programs not working well now
– Need program development and
improvement
• ADAP pay co-pays for ADAP drugs only
• Need wrap around for primary care costs
Help with cost in new coverage

14. • Planning and funding services for new environment
• Individual transition planning and assistance
• Legal aid/benefits counseling for new systems
• Does RW funding support outreach, linkage, engagement and retention in
care?
• HIV Services sustainability
• Non-medical and prevention providers planning for sustainability
• Strategic partnerships
• Medical settings sustaining coordinated care model
• CHC alignment, Medi-Cal managed care, Managed/Accountable Care
structures, partnerships with community based organizations
• One planning model: SF Health Care Reform Task Force
• Helping clients and providers transition and integrate
• Recommendations, provider road map & client education templates
The role of local communities

15. Role of Individuals and Support
Groups
 Understand current health care coverage
 What services do you depend on and where do they come
from?
 Begin to consider your options in new environment
 What changes are coming in your area and how do they
affect you
 Begin conversation with your HIV providers including about
how they expect to offer services after 2014
 Read and save information you receive
 Ask if you don’t understand materials
 Each one, teach one
Role of individuals and support groups

16. Health Care Reform Planning
“If we wait for governments, it’ll be too little, too late.
If we act as individuals, it’ll be too little. But if we act
as communities, it might just be enough, just in time.”
Transition network
Health care reform planning

18. Resources
State HCR Information -
www.statereforum.org
Enroll America
www.enrollamerica.org
 Center for Budget and
Policy Priorities -
www.cbpp.org
Treatment Access
Expansion Project –
www.taepusa.org
Kaiser Family Foundation –
www.kff.org
Families USA –
www.familiesusa.org
NASTAD –
www.nastad.org
Health Resources and
Services Administration –
Resources

19. CA Resources
Covered California – www.coveredca.com
Health Access - www.health-access.org
Western Center on Law and Poverty –
www.wclp.org
National Senior Citizens Law Center –
www.nsclc.org
Health Consumer Alliance –
www.healthconsumer.org
California resources

20. Contact
Courtney Mulhern-Pearson, San Francisco AIDS
Foundation
415.487-8008 cpearson@sfaf.org
Contact

21. SAN FRANCISCO AIDS FOUNDATION 21
sfaf.org
1035 Market Street, Suite 400 | San Francisco, CA 94103