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Health Care Reform Update
and Advocacy Priorities
Robert Greenwald
Clinical Professor of Law
Director, Center for Health Law and Policy Innovation of Harvard Law School
November 2012
PRESENTATION OUTLINE
Successful Health Reforms Could End the HIV Epidemic in the U.S.
• Part 1: The Affordable Care Act: Overview of
Where We Are and Where We are Going
• Part 2: Massachusetts as a Case Study of
Successful Health Reform Implementation
• Part 3: Key Advocacy Priorities &
Implementation Update
• Part 4: Steps for Ensuring Ongoing Success
Part 1:
The Affordable Care Act:
Overview of Where We Are & Were We Are Going
Where We Are:
Status Quo = Access to Care Crisis
Medicaid/ Medicare are
lifelines to care, but
disability standard means
they are very limited
Impossible to
obtain individual
insurance and few
insured through
employer system
Demand for Ryan
White care and
services > funding
The Current Crisis
42-59% of lowincome people
living with HIV
not in regular
care
29% of people
living with HIV
uninsured
Ryan White Program Not Keeping Pace with Increased Need
Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation)
2002
2003
2004
2005
2006
2007
2008
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
ACA Implementation Must Address
Engagement and Retention in Quality Health Care
Engagement in Selected Stages of
HIV Care
approx. 1.1.
National HIV/AIDS Strategy calls for:
• Increasing HIV screening and
improve linkages to care
• Increasing retention in care rates
• Closing the gap between those
who need antiretrovirals (ARVs)
and those who are on ARVs
• Providing needed care and
support services to increase
treatment adherence and
number of persons with
undetectable viral load rates
million
infected
100%
90%
80%
70%
82%
(902,000)
66%
(726,000)
60%
50%
40%
30%
20%
10%
0%
37%
(407,000)
33%
(363,000)
25%
(275,000)
WHERE WE ARE GOING
ACA Reforms Include New Responsibilities
Mandates
• Individual Mandate Penalty - $695 or 2.5% of income, with some
hardship exemptions
• Employer Mandate Penalty – Employers (ER) with more than 50
employees (EE) who don’t provide insurance and who have any
EE receiving an exchange subsidy subject to $2,000 penalty per
full-time EE beyond the first 30 EEs.
Taxes
• Tax credits for small businesses
• 0.9% increase for individuals with income above $200,000 and
couples above $250,000 (plus a 3.8% additional tax on unearned
income)
• Cadillac Tax of 40% of value of plan if plan costs more than
$10,200 for individual and $27,500 for families
ACA Expands and Improves Medicaid
• Expands Eligibility (Now optional, so state-by-state)
– Starting in 2014, disability requirement is eliminated for most
people with income up to 133% FPL
(~$14K for an individual/~$29K for family of four)
• Improves Reimbursement
– Enhances reimbursement for primary care providers in 20132014 (up to Medicare reimbursement rate)
• Streamlines Application and Enrollment (no wrong door
application process)
• Includes free preventive services (optional)
Includes 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
Prescription drugs
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services and
chronic disease management
Pediatric services
For All Newly Eligible
Medicaid
Beneficiaries
For Most New
Individual and
Small Group
Private Insurance
Beneficiaries
Supports Enhanced & Coordinated Care
Through Medicaid Health Home Program
• Gives states the option to provide cost-effective, coordinated
and enhanced care and services to people living with chronic
medical conditions*
• States are eligible for planning grants and increased federal
support – 90% FMAP for first two years of the program
• Reduces inpatient and emergency room costs while improving
health outcomes through both enhanced care coordination and
service integration
– high intensity care/service management, integrated physical and
behavioral health services, health promotion, patient and family support,
and prioritized housing
* Successful advocacy led to inclusion of people living with HIV/AIDS
Increases Access to Medicare Drug Coverage
• 50% discount on all brand-name prescription drugs
• Part D “donut hole” phased-out by 2020
• AIDS Drug Assistance Program (ADAP) contributions
now count toward copayment obligations
Reforms Private Insurance and Reduces
Discriminatory Insurance Practices
• Cannot be denied insurance because of
HIV or other health condition, even if you don’t
currently have coverage (2014)
• Health plans cannot drop people from coverage
when they get sick (in effect)
• No lifetime limits on coverage (in effect)
• No annual limits on coverage (2014)
Promotes Access to Private Insurance
through State-Based Exchanges
• In 2014, consumer-friendly Exchanges to purchase private insurance
– Certify “qualified health plans” that will compete for consumers
– Educate consumers by establishing call center, website, navigators (at least one
non-profit), premium calculator
– Conduct or contract eligibility and enrollment through streamlined “no wrong
door” application process
– Sets standards for provider networks and is required to contract with
“sufficient number and geographic distribution of essential community
provides”
• Federal subsidies for people with income between 100-400% FPL
(200% FPL = ~$44K for an individual/~$89K for family of four)
• Plans cannot charge higher premiums based on gender or health
• Plans must include Essential Health Benefits
Allows States to Create a “Basic Health Plan”
for People with Income Between 133%-200% FLP
The optional Basic Health Plan is likely to be the same as a
state’s current Medicaid plan and could offer several
important advantages:
• Provides increased continuity of care as residents go in and
out of Medicaid due to income fluctuations
• Generally more affordable (lower premiums & cost sharing
than on the Exchange – state receives additional federal
payments – up to 95% of subsidies the consumer would’ve
received on exchange)
• Consumers are not responsible for paying back tax credits if
income fluctuates
• Includes legal immigrants with incomes below 133% FPL who
are barred from Medicaid because of 5 year ban
Invests in Prevention and 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)
Where We Are Going:
Great Potential But Successful Implementation Will Decide
Improves Medicaid:
Expands eligibility (state option); provides essential health benefits
(EHB) (federal and state regulations); improves reimbursement for
PCPs (only 2013-14); includes health home (state option); allows
for free preventive services (state option for Medicaid).
Creates Private Insurance Exchanges:
Provides subsidies up to 400% FPL (federal and state regulation);
eliminates premiums based on health/gender; provides EHB
(federal and state regulation); supports outreach, patient
navigation and enrollment (federal and state regulation); and
allows for Basic Health Plan (state option).
Only with Successful Medicaid Expansion and Exchange Development
Will We Dramatically Improve Health Outcomes and Meet Prevention Goals
Part 2:
Massachusetts as a Case Study of
Successful Health Reform Implementation
Massachusetts: A Post Health Care Reform
State in a Pre-Reform Country
• Expanded Medicaid coverage to pre-disabled people living with HIV
with an income up to 200% FPL (2001)
• Enacted private health insurance reform with a heavily subsidized
insurance plan for those with income up to 300% FPL (2006)
• Protected a strong Medicaid program for “already” & “newly” eligibles
• Re-tooled Ryan White Program
– ADAP funding largely spent on insurance not Rx (2006)
– Ryan White Program 75/25 rule waived to allow for increased
support of essential support services (2007)
– Maintaining unrestricted formulary and 500% FPL eligibility (2006 present)
The MA case study provides insight into how health reforms and
Ryan White Program work together to meet NHAS Goals
Massachusetts’ Successful Reform Implementation
Improves Health Outcomes and Meets NHAS Goals
MA Outcomes v. National Outcomes
100
80
Percent
60
40
20
0
In Medical Care
Taking HIV Medications
Virally Suppressed
Health Good to
Excellent
MA Outcomes
99
91
72
70
CDC MMWR (National Outcomes)
41
36
28
0
Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer
Study Final Report, December 2011, JSI Research and Training, Inc. Note: MA
Outcomes N = 1,004
Source: Cohen, Stacy M., et. al., Vital Signs: HIV Prevention Through Care
and Treatment — United States, CDC MMWR, 60(47);1618-1623
(December 2, 2011); Note: National Outcomes HIV-infected, N =
1,178,350; HIV-diagnosed, n=941,950
MA Reform Demonstrates Successful Implementation
Reduces New Infections and AIDS Mortality
• Between 2006 & 2009, Massachusetts new HIV diagnoses
rates fell by 25% compared to a 2% national increase
• Current MA new HIV diagnoses rates have fallen by 46%
• Between 2002 & 2008, Massachusetts AIDS mortality rates
decreased by 44% compared to 33% nationally
Sources: MA Dept of Public Health, Regional HIV/AIDS Epidemiologic Profile of Mass: 2011, Table 3; CDC, Diagnoses of HIV infection and AIDS in the United States
and Dependent Areas, 2010, HIV Surveillance Report, Vol. 22, Table 1A; CDC, Diagnoses of HIV infection and AIDS in the United States and Dependent Areas, 2008,
HIV Surveillance Report, Vol. 20, Table 1A.
MA Reform Demonstrates Successful
Health Reform Implementation Reduces Costs
• Massachusetts cost per Medicaid beneficiary living with HIV has
decreased, particularly the amount spent on inpatient hospital care
• Massachusetts DPH estimates reforms reduced HIV health care
expenditures by ~$1.5 billion in past 10 years
Source: MA Office of Medicaid, data request
A Post-Reform State Needs the
Ryan White Program (RWP) to Meet NHAS Goals
YEAR
Full Pay
Co-Pay
Premiums
Total Cost
Enrolled
FY05
$ 9,756,201
$ 1,839,807
$ 6,112,132
$ 17,708,142 4738
FY11
$ 4,467,727
$ 3,175,917
$ 10,990,818
$ 18,634,462 7009
The RWP is essential to reducing gaps in care and affordability
to meet NHAS retention in care and viral suppression goals
• ADAP reduces barriers to HIV medications
- Individuals with income of $16,000 (150% FPL) cannot afford $3,333
- Families with income of $33,000 (150% FPL) cannot afford $6,666
• RWP provides essential care - dental, vision and behavioral health…
• RWP provides essential services - case management, transportation,
food and nutrition…
California’s Ineffective Implementation Undermines NHAS Goals
Lack of Proper Planning and Oversight Results in
Disruptions in Care (Moving Us in the Wrong Direction)
Both federal and state officials largely failed to account for people
living with HIV who became newly eligible through reform
• Failed to ensure that the health benefits package met HIV
standard of care
• Failed to integrate HIV providers and models of care delivery
• Failed to consider Ryan White Program coordination and
“payer of last resort” provisions
Part 3:
Key Advocacy Priorities
&
Implementation Update
Action Needed to Ensure Success:
Step 1. Federal and State Regulations to Promote
Retention in Care and HIV Standard of Care
Success will depend upon strong federal regulations & state
regulations to the extent the federal government falls short
• Exchange Development
• Comprehensive Essential Health Benefits (EHB) for Medicaid
and Exchanges
• Limits on / Regulation of Utilization Management
• Outreach, navigation and enrollment systems
• Anti-discrimination protections and enforceable appeals
processes
Exchange Update: Where the States Are
Three choices: State-based, Partnership or Federally Facilitated Exchange
and states must submit their exchange blueprint to HHS by 11/16/12
Essential Health Benefits Implementation Update
Federal guidance suggests (at least for private plans):
• Insurers may have flexibility to substitute scope and level of
benefits as long as “actuarially” equivalent to benchmark plan
• Coverage of “one drug per class” could meet EHB Rx
requirement
• Plans may have discretion over utilization management
Flexibility for most states likely means bare bones plans
No current mandate that EHB must meet standards of care for HIV
State variation and disparities continue
EHB will depend upon final federal regulations &
state regulations to the extent the federal government falls short
ACA is the Law of the Land:
Requires Comprehensive EHB Despite Resistance in Some States
ACA’s Essential
Health Benefits
Mandates
=
+
§1937
Benchmark
Mandates
(applies to Medicaid)
+
ACA NonDiscrimination
Mandates
Regulations that Ensure Medicaid and Exchanges
Successfully Provide HIV Standard of Care
Access to care, treatment and services that reflect national standards =
• Outreach & patient navigation services successfully integrating people with HIV
• Sufficient provider networks and unlimited access to specialists
• Unlimited access to necessary medications
• Case management, care coordination, treatment adherence, & counseling
• Comprehensive mental health & substance abuse services
• Preventive & wellness services
Action Needed to Ensure Success:
Step 2: Success Requires High Level Officials at
HHS/CMS and in States Collaborating on Reforms
with HIV Consumers and Providers
Guidance/Support to states to promote optional programs:
• Expansion of Medicaid, Health Home, Preventive services, Basic Plan
Guidance/Support to states to maximize potential of mandatory programs:
• Medicaid, Exchanges, and RWP coordination
• Inclusion of AIDS service providers as navigators for outreach,
enrollment, and retention efforts
Technical Assistance:
• Workforce development
• Integration of people living with HIV and their providers
Oversight:
• Streamlined HIV measures and reporting requirements (to monitor &
manage the epidemic)
ACA Medicaid Expansion Update
SCOTUS decisions turns the Medicaid expansion
into a state-by-state advocacy issue
• CMS has said there is no deadline for states to opt in
– But 100% federal match only applies 2014 to 2016
• States can opt out after expanding at any time
• States required to maintain eligibility & benefit levels until
exchange is fully operational in 2014 (“MOE requirement”)
• States are pushing for partial expansion (e.g., up to 100% FPL)
– CMS has said it will not entertain such requests
• Now that the elections are over…..
Many Reasons to Opt In
• Federal government pays 100% of expansion costs for 20142016 and gradually reduced to 90% in 2020 and beyond
• Other reforms (e.g., DSH payment reductions) make it
difficult not to expand because of the increased pressure on
hospitals without increased revenue from insured patients
• Uptake may be slow, but states have generally come around
to Medicaid and CHIP expansions
Will Texas want its residents’ federal tax dollars
supporting access to care in NY, CA and MA?
Action Needed to Ensure Success:
Step 3: Protect Medicaid: Shifting Costs to States
Threatens NHAS Access to Care Goals
Currently, Medicaid is an entitlement program jointly
funded by federal and state governments
(if you’re eligible, you’re in)
Capping federal spending for Medicaid will shift costs to
already cash-strapped states
States will be unable to respond to increased need
for services given current economic downturn
and will likely cut services and eligibility
Action Needed to Ensure Success:
Step 4. Address the Ryan White Program Challenge:
Ongoing Funding Required to Meet NHAS Goals
It is too soon to discuss Ryan White Program cost-offsets
• Premature to discuss cost-offsets or destabilization of HIV
care, treatment, and disease management services
• Success in addressing HIV epidemic requires ongoing support
of HIV-specific expertise and experience
• Post 2014, we need to evaluate ongoing ACA integration of
HIV care, treatment and services and re-tool the Ryan White
Program to address gaps in care and affordability
Part 4:
Steps for Ensuring Ongoing Success
#1 Build Connections with State Medicaid Agency,
Insurance Regulators, and Exchange Leadership
• Identify allies and formalize connections – get them to
understand the needs of people living with HIV
• Review Medicaid expansion and Exchange application and all
regulations and guidance and prepare comments
• Understand plan types and coverage scopes to assist clients
• Train all providers about Medicaid and Exchange eligibility and
enrollment processes, co-payment obligations, and
recertification requirements
• Integrate ADAP into “no wrong door” component of health
reform
Stretch yourself or we will be left behind!
#2 Educate Consumers and Providers
• Develop fact sheets/literature about changing health care
landscape
• Engage consumer advisory boards and planning bodies
• Identify expertise to support health insurance navigation for
HIV+ residents
• Ensure readiness of the provider community—clinical and
non-clinical
• Develop response plan for populations that will remain
ineligible for coverage under health reforms
#3 Assess Your Role Post Health Care Reform
• Integrate with larger providers that have diverse portfolios of
services and funding
•
Grow to expand capacity/mission and decrease reliance on Ryan
White Program that will likely not be able to provide sufficient
ongoing support
• Go forward as is, but understand that overtime you may not be
able to exist as a free-standing disease-specific organization
without diversified services and funding
2012 Elections = Watershed for Health Reform…
but everything is not won or lost
Control of
Senate
Control of
House
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?
Available Resources
Treatment Access Expansion Project, www.taepusa.org
www.HIVHealthreform.org
AIDS United, www.aidsunited.org
30 for 30 Campaign, www.facebook.com/30for30
Health Care Reform Resources
•
•
•
•
Kaiser Family Foundation, www.kff.org
Families USA, www.familiesusa.org
Community Catalyst, www.communitycatalyst.org
Healthcare.gov, www.healthcare.gov