Transcript Powerpoint - UCLA School of Public Health
Federal & State HIV/AIDS Policy
UCLA School of Public Health Epidemiology 227 May 15, 2013 Prof. Arleen Leibowitz UCLA School of Public Affairs
Outline
Current Status and Affordable Care Act
Care and Treatment Now and Under Health Reform Medicaid
Medicare Ryan White CARE Act California issues Private Insurance and Health Reform Changes
Testing and Prevention Research Income Support and Housing Global Programs
Follow The Funding to Determine Priorities Federal HIV/AIDS Budget Request – FY2013
US $ Billions
Prevention 3% Research 10% Cash and Housing 10% Global 24% Care & Treatment 53%
Treatment as Prevention
New results show early treatment reduces transmission But many PLWH are not treated About 18% do not know their HIV status 33% on ARV therapy, 19-28% are virally suppressed Expanded guidelines HAART is costly--$12,000/year $20,000-30,000/year in total costs Highlights importance of insurance
Insurance Status PLWHA in Care: 2010
Affordable Care Act (ACA)
Individual mandate Employers (50+ workers) must offer insurance or pay penalty if employees get subsidy. Small business credits Expand Medicaid to all <65 with income <133% FPL States have option to expand Medicaid (per Supreme Court) 100% Federal funding for expansion, 90% in 2020 Preventive services Remove Medicare cost-sharing Pay Medicaid providers at Medicare rates
Affordable Care Act (2)
Health Insurance Exchanges with premium subsidies Cost sharing subsidies Out of pocket limits if income <400% FPL U.S. citizens and legal immigrants Requires guaranteed issue and renewability Outlaws medical underwriting Outlaws lifetime limits on coverage Essential benefits package Support for community health centers
Two Kinds of Federal Spending
Mandatory spending Congress must allocate funding to meet statutory obligation – e.g., Medicare, Medicaid, SSI “Entitlements” Defined benefit Discretionary spending Congress decides on spending level each year Defined contribution Block grants Examples: NIH, CDC, Ryan White, VA
Problems With Discretionary Spending
Block grant budget does not increase to accommodate increased enrollment Health care costs rise faster than CPI, so annual increases are “high” Annual budget process discourages long-term health investments Prevention may reduce costs in long run, but not in short Early treatment of HIV saves money in long run Share of discretionary spending is falling
Federal Support for Care and Treatment (FY2013)
Entitlement Medicaid (Federal share) Medicare FEHBP Discretionary Ryan White (ADAP) Veterans Affairs SAMHSA HOPWA $5.6 B $6.2 B $0.2 B 35% 39% 1% $2.5 B $1.0 B $0.2 B $0.3 B ($1.0 B) 16% 6 % 1% 2% Total $16.0 B
Medicaid
Federal/state health insurance program Created in 1965 States set eligibility criteria, subject to Federal minima States set benefits, subject to Federal mandated benefits Entitlement program that expands to meet demand of low income and disabled meeting state criteria Federal government pays a minimum of 50% of costs, more in low income states (average 55% of HIV $)
Medicaid Benefits
Covers most services; no or minimal cost-sharing Drugs, an optional service, are covered in all states Optional services include case management, hospice Some states limit services Number of Rx per month or year Number of MD visits In recessions, states try to cut Medicaid costs California instituted cost-sharing for Medicaid
Medicaid Eligibility
Current Law
Low income women and children Disabled who qualify for SSI States set income criteria for other eligibility; differs across states Medically Needy “spend down” to Medicaid level at state option Citizenship required Legal residents wait 5 years
Medicaid Eligibility
Current Law
Low income women and children Disabled who qualify for SSI States set income criteria for other eligibility; differs across states Medically Needy “spend down” to Medicaid level at state option Citizenship required Legal residents wait 5 years
Under Health Reform (2014)
Individuals w/o dependent children covered Disability not required Everyone under 133% of FPL [$14,404 } Uniform throughout U.S.
100% federal funding for eligibility expansions in 2014-16; after, 90% Citizenship required Legal residents wait 5 years
Medicaid Payment Issues
Low Medicaid provider payment levels make access difficult ACA raises Medicaid reimbursement rates to Medicare levels for primary care services, with 100% federal funding in 2013, 2014 ACA encourages primary care homes Medicaid discount on drugs of 15.1% less than what others get ACA increases drug 340b rebate to 23.1%, but some goes back to federal government
Rep. Paul Ryan’s Bill Would Convert Medicaid to Block Grant
Repeals ACA Caps Medicaid spending Uses formula, rather than costs, to allocate $ to states Cap grows with population growth and inflation Reduces federal Medicaid spending 2012-2021 UI estimate: $1.4 trillion By 34% relative to current law
Projected Result of Block Granting Medicaid
Federal budget savings and predictability Inflexibility in recession Reduction in federal payments to states Challenges states’ ability to provide care 36.4 million fewer people will be insured Hospitals lose 38% of revenue
Medicare
Federal entitlement program created in 1965 Covers persons 65+, persons with ESRD, and long term disabled Funded by payroll tax on earnings, general revenues, beneficiary premiums for Part B and co-payments (Medicaid can pay patient cost-sharing) Uniform throughout U.S.
Long-Term Disability Qualifies Many PLWH for Medicare
Disabled must have sufficient covered work history to quality for SSDI 29 Month Waiting period Federal law requires 5 month wait after disability determination before receiving SSDI payments 24-month waiting period for Medicare, following SSDI Medicaid coverage for low income persons during the 29 months
Medicare Benefits
Hospital Outpatient (20% cost-sharing) Drugs have been covered since January 1, 2006 under Part D, private drug insurance plans Plans required to cover all ARVs ACA will gradually close “donut hole” 100% 75% 50% 25% 5% $0-310 Drug $310-2830 Spending $2830-6640 $6640+
Medicare – Current Policy Issues
Eligibility Must have sufficient work history to qualify for SSDI, a problem for young, poor persons with HIV 29 month wait for Medicare eligibility Catch-22 of disability requirement Cost-sharing High cost sharing if no supplemental coverage No cap on out-of-pocket spending Medicare “donut hole” When ADAP pays, doesn’t count as “true out of pocket cost” (TROOP)
Health Reform and Medicare
Medicare “donut” hole will be closed 2010--$350 towards cost Phase-down coinsurance rate in donut hole from 100% to 25%, starting 2011 by requiring 50% rebate from manufacturers plus federal 25% subsidy ADAP payments will count as TROOP in Part D No cost-sharing for covered preventive services (rated A or B by U.S. Preventive Services Task Force)
Ryan White Care Act
CARE= Comprehensive AIDS Relief Emergency Discretionary program enacted 1990, Originally designed to help cities heavily impacted by HIV/AIDS (EMA; TGA) Payer of last resort for uninsured and underinsured PLWA Patient Centered Medical Home --Outpatient care, including medical, dental, case management, home health, hospice, housing, transportation, drugs (through ADAP and insurance continuation) Current authorization will expire in September If eligible under ACA, will have to leave Ryan White
AIDS Drug Assistance Program (ADAP)
Funded by Part B of Ryan White Care Act Congressional Earmark: $1B (approx 50%) Plus state supplements (approx 25%) And rebates from drug manufacturers (approx 25%) States set eligibility 5 x FPL in NJ; 4 x FPL in CA; 2 x FPL Texas Disability not required Residency, not citizenship required ADAP is a block grant 3079 PLWH on ADAP waiting lists in April 2012
ADAP (2)
Drugs provided to 133,689 PLWH monthly in 2011 Cost/enrollee c. $1000/month Services HIV Medications, drug monitoring and adherence services Can purchase health insurance for eligible clients Variation in state coverage Louisiana had 28 drugs; New York had 460 States set eligibility rules, resulting in variability States with less generous Medicaid programs, need more Ryan White support
Ryan White – Current Policy Issues
Demand increases Greater survival Enhanced testing efforts Loss of insurance due to recession Medical costs increase faster than CPI Block grant But states have limited ability to supplement Continued availability of prescription rebates?
Health Reform and Ryan White
RWCA is funder of “last resort”; what will its role be under health reform?
ACA increases insurance -- Medicaid and Exchanges Especially for non-disabled, reducing need for “bridge” to pay for drugs CARE/HIPP could help purchase insurance Effect of ACA on Ryan White funding?
Congress is looking for “offsets” Undocumented How will RW sites interact with Medicaid or CHCs?
Health Reform and ADAP
ADAP and Medicare Part D drug coverage Donut hole costs will fall, reducing need for ADAP Cost of drugs while in donut hole is reduced by 50% Donut hole coinsurance drops to 25% ADAP payments count as TROOP Effect on rebates?
Drug rebate for ADAP is better than rebate for Medicaid Where will undocumented get ART?
Health Reform and Private Insurance
Mandates employer offer and individual coverage Eliminates “medical underwriting” and rescissions Provides subsidies for purchase from exchanges (32 million people by 2019) with mandated benefits Legal immigrants eligible for subsidies Bronze plan—covers 60% of cost Caps out of pocket expenditures for persons<4xFPL Sets up high risk pool—June 2010 to Jan 2014 Allows children to stay on parents’ policy until age 26
Outline
Care and Treatment Medicaid Medicare Ryan White CARE Act California Issues Health Reform and private insurance
Testing and Prevention
Research Income Support and Housing Global Programs
HIV Testing
18% of PLWH do not know they are HIV+ CDC “Advancing HIV Prevention” (2004) Make voluntary HIV testing a part of routine medical care Test for HIV outside of medical care settings Prevent new infections by focusing on HIV+ individuals and their partners Further decrease perinatal HIV transmission National AIDS Strategy (2010) Focus on communities where HIV most concentrated
HIV Testing – Policy Issues
CDC goal to “normalize” HIV testing Destigmatize Opt-out vs. opt-in testing recommended by CDC in Sept. 2006 Default is testing; patient must specifically decline test Covered by general consent to treat CA state law since Jan. 1, 2008 removes requirement for specific written informed consent for testing Question: need prevention counseling accompany testing?
Testing—Policy Issues (2)
Rapid test could increase knowledge of HIV status Results ready in 20 minutes, no need to return for results But needs to be confirmed if “preliminarily positive” New “60 second” test Home testing?
New York mandated HIV testing offer in medical settings Increase in tests No increase in number of new positives
Prevention
Centers for Disease Control and Prevention administers most federal prevention efforts (FY 12 budget: $786 M) National budget share for prevention (3%) is decreasing over time California cut General Fund support for prevention by $59M in 2009/10
New Prevention Strategies
Treatment as Prevention Early treatment reduced transmission by 96% Heterosexual couples in Africa Pre-Exposure Prophylaxis (PrEP) Reduced transmission by 44% (more if 90% adherent) MSM in US and Latin America Post-Exposure Prophylaxis
Prevention: Policy Issues
Target increased risk behavior among MSM Methamphetamine epidemic in CA Internet—prevention challenge or opportunity?
Social networks?
Reach populations who may not realize their risk and may not receive routine medical care Young men are not in routine medical care STI clinics, EDs, jails?
Separation between federal treatment and prevention efforts
Outline
Care and Treatment Medicaid Medicare Ryan White CARE Act Testing and Prevention
Research Income Support and Housing
Global Programs
Research
NIH Budget for HIV research is $2.7B in FY12 Largest investments are biomedical California HIV Research Program
Income Support and Housing
Cash Assistance (11% of Domestic HIV funding) SSI - $520 M in FY12 SSDI - $1.9 B in FY12 Entitlement programs for the disabled Housing Opportunities for Persons with AIDS (HOPWA) $332 M in FY12 AIDS exceptionalism?
Conclusions—Domestic Issues
HIV care is being mainstreamed Both clinically And in finance Is there still a need for special programs like Ryan White?
Health Reform has addressed many HIV/AIDS policy issues Issue of immigrants unresolved But, the fragmented system still presents challenges Difficult to know what resources are available Coordinate care
Outline
Care and Treatment Medicaid Medicare Ryan White CARE Act Testing and Prevention Research Income Support and Housing
Global Programs
Global Programs
Most US AIDS funding is bilateral, circumvents Global Fund US is still largest single contributor to GF (58%) Obama’s Global Health Initiative (GHI) Funding at $63B over 6 years (FY2009-2014) Rebalances GHI portfolio from HIV to MCH HIV/AIDS funding of $5.6B (+0.5% over FY11) MNCH $846M (+78% over FY11) Nutrition $150M (+100% over FY11)
HIV Is Still Largest Share of GHI
Slide 10 U.S. Global Health Initiative (GHI), FY 2011 Budget Request In Millions HIV $5,739.1 Global Fund $1,000 Nutrition $200 Other $108 MCH $700 FP/RH $590 NTDs $155 TB $251 Malaria $829.2
Total = $9.6 billion
*FY 2011 is President ’s Budget Request to Congress. SOURCES: Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and White House Statement by the President on Global Health Initiative, May 5, 2009.
Return to Tutorials
Also see: Kates J.,
The U.S. Global Health Initiative: Overview & Budget Analysis
, Menlo Park: Kaiser Family Foundation, December 2009.
Focus on Health Outcomes
Rather than on dollars spent Cost-effectiveness approach: Save the most lives within a given budget HIV 1.9 M deaths Respiratory infections Diarrheal diseases Malaria and TB 2.9 M deaths 2.2 M deaths 2.3 M deaths
Cost/DALY
Condom promotion and distribution $1-99 Prevent MTCT VCT $1-34 $18-22 First Line ART $350-2010 Management of neonatal pneumonia $1 Oral rehydration Bed nets $24-139 $11-41
Global Policy Issues
2003
33% prevention funding had to target abstinence In 2005, 2/3 on abstinence, 1/3 condoms Condoms only for “high-risk” (prostitutes, discordant couples, substance abusers) Funded organizations need “policy explicitly opposing prostitution and sex trafficking.” (PL108-25) ARVs must be approved by FDA (WHO approval not sufficient)
2010
Abstinence rules lapsed Pres. Obama rescinded “gag rule” on abortion By 2007, 73% of drugs distributed were generic. Accelerated FDA approval.
Focus on MTCT, MC and services for IDUs
Overarching Policy Questions
Is treatment as prevention feasible in developing world?
How to balance domestic and global needs Can we provide PrEP for uninfected in U.S. while many are not treated in developing world?
Is the movement toward other diseases in GHI ethical?
Policy Resources
HRSA CDC NIH CHRP CHIPTS Kaiser Family Foundation CAPS http://www.hrsa.gov
http://www.cdc.gov/hiv http://www.nih.gov
http://chrp.ucop.edu
http://chipts.ucla.edu
http://www.kff.org/hivaids http://www.caps.ucsf.edu