Transcript Health Care Reform: Update on Federal Efforts to Improve Access to Care for People Living with HIV/AIDS Robert Greenwald Director, Health Law and Policy Clinic, Harvard.

Health Care Reform:
Update on Federal Efforts to
Improve Access to Care for
People Living with HIV/AIDS
Robert Greenwald
Director, Health Law and Policy Clinic,
Harvard Law School &
Treatment Access Expansion Project
This slide presentation is available with comprehensive
background notes at www.taepusa.org.
Last updated 4/12/2010
Part 1:
Why our current health care system
fails to meet the health care needs of
people living with HIV and AIDS
Part 2:
Federal efforts to increase access to
care through health care reform
PART 1
An introduction to why our
current health system is failing
people living with HIV and AIDS
HIV/AIDS v. General Population:
Health Care Coverage
General Population
PWHIV/AIDS
Population: 293 Million
SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical
Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006
US Population and People
with HIV/AIDS
Income & Unemployment
62%
45%
US Population
People with
HIV/AIDS
8%
Income <$10,000
5%
Unemployed
SOURCE: 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 data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest
decimal; HCSUS data from 1998.
Medicaid
and
Medicare
Entitlement Programs.
Both programs have the same
cruel disability standard !!!
You have to get sick and disabled to get
access to the health care services that
could have prevented you from getting
sick in the first place.
Public Funding HIV/AIDS Care:
Including Ryan White (FY 2008)
Ryan White
18%
$2.6B
Medicaid
50%
$7.2B
Medicare
32%
$4.5B
Total= $14.3 Billion
Number of People Living with AIDS in the US
vs. Ryan White Funding (adjusted for inflation)
35
30
% change in
the number
of people
living with
AIDS
25
20
15
10
5
0
% change in
Ryan White
funding
-5
-10
2002 2003 2004 2005 2006 2007
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, Health Resources and Services Administration,
ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Inflation calculated using http://www.usinflationcalculator.com/.
Private and Public Health Care Programs
Are Failing People Living with HIV/AIDS
Private Insurance:
• Employer-based system doesn’t work well for low-income
or unemployed
Medicaid/Medicare:
• Disability care systems, not health care systems
• Medicaid – Benefits are insufficient & vary by state
• Medicare – Part D out-of-pocket co-pays too high
ADAP/Ryan White Program:
• You can’t fund the health care needs of an epidemic
through a discretionary program
We are not alone!
The health care system is failing
more and more Americans each year.
Number of Uninsured Americans
47
48.4
44.7
39.8
2000
2003
2006
Uninsured in Millions
2009
PART 2
Update on health care reform:
Efforts to improve access to care
for people living with HIV and AIDS
Medicaid Reform
Improvements:
• Medicaid expansion—eliminates the disability requirement
and provides access to all below 133% FPL in 2014
• Increases Medicaid provider reimbursement rates
• FMAP—provides federal support for Medicaid expansion
• Increases FMAP and spending caps for territories
Limitations:
• Medicaid’s 5-year exclusion on legal immigrants continues
• Increase in provider reimbursement rates limited and
temporary (2013-14)
• Full federal support for Medicaid expansion is temporary
• No new mandatory minimum benefits package for Medicaid
• No Early Treatment for HIV Act (ETHA)
Medicare Reform
Improvements:
• Eliminates cost sharing for some preventive services
• Part D donut hole closed by 2020
–
–
–
–
–
$250 rebate in donut hole (only in 2010)
ADAP as TrOOP (beginning 2011)
50% brand-name discount (beginning 2011)
Phase-down of consumer co-pay for generics (2011-2020)
Phase-down of consumer co-pays for brand names (20132020)
Limitations:
• Closing donut hole over 10 years is too slow
• Actual out-of-pocket maximum not decreased for
consumers’ generic medications
Private Health Insurance Reform:
Creation of Exchanges
• Exchanges are portals for consumers
(individuals and small businesses) to
compare and buy health plans
• Exchanges certify plans that are compliant
with all health care reform requirements
• States must set up and begin administration
of exchanges by 2014
• States have option to include large group
market (101+ employees) starting in 2017
• Exchanges include new OPM-certified multistate plans and non-profit coop plans but no
public option
Additional Private Health Insurance Reforms
Exchange Reforms
• Increased Coverage – creates a new mandatory benefits package
(2014)
• Increased Affordability – premium subsidies and cost-sharing
assistance for people up to 400% FPL (2014)
• Increased Access – limits variation in premium ratings (2014)
Additional Reforms
• Increased Access – largely eliminates discrimination based on health
status (2010-2014)
• Requires individuals to purchase health insurance (2014)
• Establishes a temporary high-risk insurance pool to cover those with
pre-existing conditions (starting within 90 days)
Private Health Insurance Reform: Limitations
• No national plan, so state variation continues
• Insurance reforms do not apply to existing,
large group and self-insured plans
• Vision and dental coverage are not included
in mandated benefits package
• Subsidies don’t fully solve the affordability
gap
Total Out-Of Pocket Cost to Consumer:
Premium and Cost-Sharing
Maximum Consumer Spending
10000
$40,000
Maximum Total Annual Consumer Share
9000
$7,133 (18%)
$35,000
8000
$6,658 (19%)
7000
$30,000
$5,150 (17%)
6000
$25,000
$4,340 (17%)
5000
$20,000
4000
$2,791 (14%)
$15,000
3000
$2,160 (14%)
2000
1000
0
100
150
200
250
Income (% FPL)
300
350
400
Other Key Provisions: New Investments
• Invests in prevention, wellness, and public
health activities
• Invests in efforts to reduce health disparities
• Supports clinical workforce development with
an emphasis on serving vulnerable populations
NEXT STEPS:
Health Care Reform Implementation
• Securing bridge to 2014 Medicaid expansion through
emergency ADAP funding, ETHA and state option to
start expansion early
• Ensuring HIV inclusion in prevention, wellness, health
disparities and workforce investments
• Defining essential health benefits package for private
insurance
• Facilitating eligibility and enrollment in temporary highrisk insurance pool
• Securing community representation on Community
Preventive Services Task Force and other task forces