Health Care Reform WHAT DOES IT MEAN FOR PEOPLE WITH HIV? Overcoming Health Disparities in the California Bay Area Using HIV/AIDS as a Model San Francisco May, 2012 ANNE DONNELLY PROJECT INFORM ADONNELLY@PROJECTINFORM.ORG 415.558.8669X208
Presentation Outline Part One: Considering Disparities Part Two: The Supreme Court and Elections Part Three: Turning Back? Part Four: Health Care Reform and a Changing HIV/AIDS Care Landscape Part Five: California at the Crossroads Part Six: Priorities for ACA Implementation
Health Care Reform and Disparities Health Education and Prevention Diagnosis and Linkage to Care Treatment and Retention in Care How will PLWHA get information? Assistance? What supports/services are necessary? Who pays? Formularies? Benefits Packages? Wrap Arounds?
The Supreme Court and Elections WHAT WILL HAPPEN WITH HEALTH CARE REFORM?
The Supreme Court: What Could Happen? Opponents challenged constitutionality of the individual mandate and the Medicaid expansion and SCOTUS heard arguments in March. Decision is expected in June The entire law survives The individual mandate is struck down, but some parts of the law survive The entire law is struck down
2012 Elections = Watershed for Health Care Control of the House Control of the Senate 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?
Can We Afford to Turn Back? THE SYSTEM IS BROKEN
Broken Systems: Access to Care Crisis Thousands on ADAP Waiting List 30% of people living with HIV are uninsured Demand for Ryan White Services is Growing The Current Crisis 42 59% of low income PLWH are not in regular care People with HIV can t get insurance coverage
Health Care Reform A Changing Care Landscape
New Responsibilities Creates an individual mandate that citizens must carry health insurance Financial penalties apply to those who do not Exemptions for hardship and some other reasons Individual mandate under attack; many still think it will be upheld Coverage expansions are in effect a mandate for people with HIV who want to stay in care Ryan White payer of last resort rules
Coverage Expansions Estimated 32 Million will gain coverage by 2019 Medicaid: 16 million Income Under 138% FPL Exchange: 26 million Income above 138% FPL
Medicaid: Improved and Expanded Currently Medicaid is for most with HIV disability coverage In 2014: Expanded Eligibility The disability requirement is eliminated Most people with income up to 138%FPL will be eligible for Medicaid/Medi-Cal (appr. $15K for an individual) No asset test Could Improve Services Medicaid expansion includes Essential Health Benefits (EHB) for newly eligible people
Improves Access to Private Insurance State-Based Exchanges Insurance Reforms Consumer friendly marketplace to purchase private insurance Federal subsidies for people with income up to 400% FPL Plans must provide essential health benefits Can t be denied or dropped from insurance because of HIV (all plans) Can t be charged higher premiums because of HIV or gender (exchange plans) No more lifetime and annual limits (all plans) Prevention services (including routine HIV testing for women) must be covered without cost sharing (all plans) Caps amount spent out of pocket (exchange plans)
Increases Access to Medicare Part D 50% discount on all brand-name prescription drugs AIDS Drug Assistance Program (ADAP) contributions now count toward copayment obligations, allowing people with HIV to move through the donut hole Part D donut hole phased-out by 2020
Improvements in MH and SUD Services Mental health (MH) and substance use disorder (SUD) tx part of EHB Mandatory coverage for MH and SUD at parity New opportunities in primary care and integrated services Primary care, MH and SUD community health team grants; Centers of excellence for depression MH and SUD providers on team in Medicaid medical homes No cost preventative services include some mental health Projects at CMMI include mental health Provider non-discrimination provisions
New Mandatory Package of Benefits Essential Health Benefits Ambulatory services Emergency services Hospitalization Maternity/newborn care Mental health and substance use tx services to parity Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services
Invests in Prevention, Wellness, 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 Immigrants Certain immigrant populations are completely excluded from health care reform Undocumented individuals are not eligible for coverage Medicaid Health Insurance Exchange Subsidy Legal immigrants continue to face a five year waiting period for Medicaid Some states including CA -provide coverage to this population using state dollars but services threatened by budget cuts MA court case found that if states cover, comparable services must be offered Exceptions to five year waiting period include people seeking asylum, refugees and some others
Care Landscape in 2014 Individuals with income up to 138% FPL Eligible for Medicaid based on income alone (Ryan White Program still needed to fill in gaps not covered by Medicaid) Individuals between 138% and 400% FPL Eligible for premium tax credits and cost-sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps not covered by private insurance) Individuals with unmet care and treatment needs Ryan White Program still a safety net for: insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants
What Is Happening In California? MOVING TOWARD HEALTH CARE REFORM IN A DEFICIT REALITY
California at a Crossroads Opportunity: California is committed to HCR and moving ahead If health care reform is rescinded CA may be poised to implement some on its own Challenge: CA is moving too quickly and cost/savings is one of the top considerations in this economic climate Making decisions that are not fully vetted or understood Assuming immediate savings in programs that aren t realistic If federal health care reform is dismantled or defunded, particularly Medicaid expansion, CA at risk for having to rescind significant advances and actually push people out of care
HIV Care Transitioning to New Systems Ryan White programs and support systems created a relatively seamless system of care Both people with HIV and HIV providers will need to transition to new forms of coverage California s preparation for health care reform Low Income Health Programs Movement into Medi-Cal managed care Pre-existing Condition Insurance Program There is no one agency/individual in charge of this massive transition It involves multiple agencies (previously siloed) working together in new ways No effective communications system for providers or clients No clarity on new systems, and no assistance for individuals, technical assistance for providers Inadequate provider rates, including pharmacy
Low Income Health Programs (LIHPs) Medicaid-like expansion established by the Medi-Cal 1115 waiver Temporary program will end January 1, 2014 Bridge to health care reform - each individual will have a transition plan to full Medi-Cal expansion Developed, implemented and financed by the county Benefits can vary Eligibility for the program is established by county Ranges from 25% of Federal Poverty Level (FPL) 200%FPL* Counties are at different stages of LIHP development
Movement to Medi-Cal Managed Care All state Medicaids are moving toward managed care Two thirds of beneficiaries currently in managed care California began moving Seniors and People with Disabilities in to mandatory managed care in May 2011; complete by July 2012 Protections for those whose doctors were not contracted with managed care broke down Medical Exemption Request out of managed care for one year Continuity of Care request in managed care; continue to see fee-for-service doctor for up to one year Out of county contracting remains unclear
Dual Eligible Coordinated Care Demonstration California one of 15 states approved for demonstration project Between 4 and 10 counties, including LA scheduled for inclusion Originally scheduled for January 2013, moved to March Passive enrollment, exception AIDS Health Care Foundation Opt out option for Medicare Managed Care; NOT Medi-Cal services Effectively ends AIDS Home and Community Based Waiver
California Pre-Existing Condition Insurance Pool (PCIP) Temporary program ends January, 2014 Eligibility: Must be a California resident; Have no health insurance coverage for the past 6 months Ryan White is not considered coverage; Be lawfully present in the United States; Office of AIDS will pay the premium, drug deductible ($500), drug co-pay on ADAP drugs Will not pay primary care deductible ($1500) or co-pays Establishes a cap on out of pocket costs ($2400 annually)
Implementation PRIORITIES FOR PEOPLE WITH HIV
1. Ensuring a Comprehensive Essential Health Benefits Package ACA Essential Health Benefits Ambulatory services Emergency services Hospitalization Maternity/newborn care Mental health and substance use disorder services to parity Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services Federal Guidance/Regulations State Implementation Decisions
What Does a Benchmark Approach Mean? Flexibility for most states likely means bare bones plans State variation and disparities will continue Continued federal advocacy needed to enforce antidiscrimination protections California: Decisions are being made now Legislature and Exchange Board are working together Benchmark plan: Kaiser small group plan for Exchange Medicaid benchmark guidance not complete Choices of FEHBP, State Employees, Largest commercial HMO, Secretary determined equivalent Advocates say Medi-Cal plus - administrative burden much lower
2. Ensuring Access to Ryan White: Filling the Gaps Essential services needed by people living with HIV/AIDS NOT fully covered by EHB: Dental services Case management Medical case management? Nutrition services Transportation Mental health and substance use services Peer support services Insurance assistance Medicaid will NOT be available for: Undocumented immigrants Legal immigrants within the 5 year ban Ryan White HIV/AIDS Program
MA: Post HCR ADAP Costs
3. Ensuring a Safe Transition for Vulnerable Populations There is no one agency in charge State Office of AIDS must work in new ways with Medicaids and Exchange Boards New level of both leadership and collaboration Joint stakeholders committee Data sharing Communication/Education/Outreach/Enrollment o Although there are funds under ACA for navigators/assistance will be essential for RW to cover for people with HIV o Strategies for screening for movement will need to be in place
4. Preparing for Change in HIV Care Become a Federally Qualified Health Center (FQHC) Affiliate or integrate w/a FQHC Successful integration in Sonoma County Careful planning; hired a change specialist and individual transition coordinator 98% retention in care rate Diversify Funding Need as many different types of coverage/insurance as possible Prepare for an insured client base Begin to strategize about when and where Ryan White must fill gaps
5. Making Medicaid Managed Care Work Ensure HIV providers are part of the managed care network and can be identified Consider state specific enhanced reimbursement strategies Consider pharmacy networks as well as medical providers Transition from fee-for-service to managed care critical Clear and effect continuity of care protections are essential Medicaid Health Home Program Opportunities
Health Care Reform Planning The causes of today s problems are complex and interconnected. There are no simple answers, and no one individual can possibly know what to do - It is time to stop waiting for someone to save us. We re all in this together, we all have a voice in how we go forward. Meg Wheatley
Resources www.hivhealthreform.org FamiliesUSA http://www.familiesusa.org/health-reformcentral/ Kaiser Family Foundation http://healthreform.kff.org/ Treatment Access Expansion Project http://www.taepusa.org/ HealthReform.gov http://www.healthreform.gov/ Center for Medicare Advocacy http://www.medicareadvocacy.org/ Community based website with California subsite Summaries, fact sheets, issue briefs; Join listserv for information updates, including periodic national conference calls on health reform topics Summaries and implementation timeline; Fact sheets on Part D, exchanges and subsidies Analysis of HIV-related provisions, including presentations Administration website with information on the new law, including an ongoing Q&A forum and state-specific information Policy analysis and beneficiary information on the new law s impact on Medicare, including Part D