Transcript Health Care Reform WHAT DOES IT MEAN FOR PEOPLE WITH HIV? PAETC July, 2012 ANNE DONNELLY PROJECT INFORM [email protected] 415.558.8669X208

Health Care Reform
WHAT DOES IT MEAN FOR
PEOPLE WITH HIV?
PAETC
July, 2012
ANNE DONNELLY
PROJECT INFORM
[email protected]
415.558.8669X208
Presentation Outline
 Part One: The Supreme Court Decision
 Part Two: The Next Decision Point: Elections
 Part Three: Changing HIV/AIDS Care Landscape
 Part Four: Implementation Priorities
 Part Five: Considerations for AETCs
The Supreme Court and
Elections
WHAT WILL HAPPEN WITH HEALTH
CARE REFORM?
Supreme Court Decision – Largely a Win
Opponents challenged constitutionality of the individual mandate
and the Medicaid expansion and SCOTUS issued a decision
The
law is largely
upheld
The individual
mandate is upheld as
a tax penalty
Medicaid expansion
remains – no federal
penalty for states
which don’t enact
Serious Concern - Medicaid Expansion
 Expansion is still in effect
 Federal government pays 100% for 2014 – 2016
 Gradually reduces to 90% by 2020
 The federal government can’t take away traditional
Medicaid funding if states refuse to participate
 26 states joined in the lawsuit claiming “coercion” by
the federal government to take the expansion
funding


Very bad if for low-income people if states don’t enact
expansion
Lots of financial and political pressure to enact post election
2012 Elections = Next 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?
Health Care Reform – A
Changing Care Landscape
New Responsibilities
 Creates a provision that citizens must carry health
insurance


Tax penalties apply to those who do not
Exemptions for hardship and some other reasons
 Coverage expansions are – in effect – a mandate for
people with HIV who want to stay in care

Ryan White payer of last resort rules
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
 Consumer friendly
marketplace to purchase
private insurance
 Federal subsidies for
people with income up to
400% FPL
 Plans must provide
essential health benefits
Insurance Reforms
 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
Other ACA Improvements
 Essential Health Benefit provision establishes new floor
for benefits
 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
 Invests in Prevention, Wellness, Access to Care and
Innovation




Prevention and Public Health Fund
Community Health Center Expansion
Health Work Force Investments
Care Coordination Investments
Health Care Reform and Immigrants
Certain immigrant populations are completely
excluded from health care reform
 Undocumented individuals are not eligible for:
 Medicaid
 Health
Insurance Exchange
 Subsidy
 Legal immigrants continue to face a five year
waiting period for Medicaid
 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 in coverage and
affordabilitye)
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
It’s All About State Implementation
PRIORITIES FOR PEOPLE WITH HIV
1. Ensuring Medicaid Expansion in All States
 States could refuse
 Some have said they will
 Some states began to challenge current Maintenance
of Effort requirements

Sec. Sebilius sent letter advising current requirements are in
place and wants to work with States on expansion
opportunities
 Strong incentives in terms of funding
 Strong allies to “convince” reluctant Governors
 Hospital associations, pharmaceutical companies, health
advocates
2. 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 anti-
discrimination 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
3. 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
4. And 5. 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
 There is no one agency/individual “in charge” of this
massive transition

It involves multiple agencies (previously siloed) working together in
new ways
4. And 5. Transitioning to New Systems
 -No effective communications system for providers






and/or clients
-Little to no information materials
-Details of new systems in development /changing
-Little clear guidance from agencies
-No clear assistance for clients
-No comprehensive technical assistance for
providers (medical and non-medical)
-Inadequate provider rates, including pharmacy
5. Preparing for Change in HIV Care
-Become a Federally Qualified Health Center (FQHC)
Affiliate or integrate w/a FQHC
Successful integration in Sonoma County
-Diversify Funding
Need as many different types of coverage/insurance as
possible
-Prepare for an insured client base
-Look at data systems
-Strategize about when and where Ryan White must
fill gaps
6. 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
Consideration for AETCs
WAYS THAT AETCS COULD SUPPORT
PROVIDERS DURING HEALTH CARE
REFORM
Health Care Reform and Disparities:
Long term – positive; short term - challenges
• How will
Health
PLWHA get
Education information?
and
Prevention• Assistance?
• Testing?
Diagnosis• What
and Linkage supports/services
to Care are necessary?
• Who pays?
• Formularies?
Treatment
• Benefits
and
Retention Packages?
in Care
• Wrap Arounds?
AETCs Supporting Providers Through HCR
• Information
• No communication or education plan
• HIV providers will need to understand changes; how it
affects them and their clients; more about broader systems
of care
• Planning
• Clinics will have to realistically plan how they and their
clients will transition to new systems
• Best done in dialogue internally and with other clinic
systems
AETCs Supporting Providers Through HCR
• Identifying and providing technical assistance where
needed
•
•
Can providers contract with, bill, and interact with Medicaid, private
and public managed care organizations, private insurance?
How could warm lines support providers with information/TA?
• Supporting engagement in advocacy
•
Providers are needed in policy development
•
Adequate formularies with new coverage
 Supporting Testing, Linkage, Engagement and Retention
in Care


Identification and dissemination of best practices
Identification and dissemination of best transition practices

Work with providers to create “best practices”
AETC Support
• AETCs - change facilitators?
• Planning for the unknown is hard
– Details, details, details: state and local level
• Collaboration and partnership are essential
– Adaptive versus technical change; Cross sector
participation important
– If partnerships are developed in advance, trust makes
planning easier
– Easy to waste time and get frustrated by blaming others
• Fear of change is part of the process
– Openly addressing fears and seeking opportunities are
important steps in the process
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
Community based website with California subsite
FamiliesUSA
http://www.familiesusa.org/health-reformcentral/
Summaries, fact sheets, issue briefs; Join
listserv for information updates, including
periodic national conference calls on health
reform topics
Kaiser Family Foundation
http://healthreform.kff.org/
Summaries and implementation timeline;
Fact sheets on Part D, exchanges and
subsidies
Treatment Access Expansion Project
http://www.taepusa.org/
Analysis of HIV-related provisions,
including presentations
HealthReform.gov
http://www.healthreform.gov/
Administration website with information on
the new law, including an ongoing Q&A
forum and state-specific information
Center for Medicare Advocacy
http://www.medicareadvocacy.org/
Policy analysis and beneficiary information
on the new law’s impact on Medicare,
including Part D