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Health Care Reform Update and Advocacy Priorities


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 – PowerPoint PPT presentation

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Title: Health Care Reform Update and Advocacy Priorities

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

  • 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
  • Part 4 Steps for Ensuring Ongoing Success

Part 1 The Affordable Care ActOverview of
Where We Are Were We Are Going
Where We AreStatus Quo Access to Care Crisis
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)
Sources Estimated Number of Persons Living with
AIDS, Centers for Disease Control and
Prevention, http//
Ryan White Appropriations History, Heath
Resources and Services Administration,
Inflation calculated using http//www.usinflationc
Funding, FY2007-FY2010 Appropriations by
ACA Implementation Must Address Engagement and
Retention in Quality Health Care
  • National HIV/AIDS Strategy calls for
  • Increasing HIV screening and improve linkages to
  • 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

  • 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 dont 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
  • Starting in 2014, disability requirement is
    eliminated for most people with income up to 133
  • (14K for an individual/29K for family of
  • Improves Reimbursement
  • Enhances reimbursement for primary care providers
    in 2013-2014 (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
For All Newly Eligible Medicaid Beneficiaries
  • 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 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
  • 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 dont
    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
  • Sets standards for provider networks and is
    required to contract with sufficient number and
    geographic distribution of essential community
  • 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 states 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
  • Generally more affordable (lower premiums cost
    sharing than on the Exchange state receives
    additional federal payments up to 95 of
    subsidies the consumer wouldve received on
  • 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
  • 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

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
  • 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
  • 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
  • Ryan White Program 75/25 rule waived to allow for
    increased support of essential support services
  • 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
ImplementationImproves Health Outcomes and Meets
NHAS Goals
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,
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
MA Reform Demonstrates Successful
ImplementationReduces New Infections and AIDS
  • 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
  • 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

Californias Ineffective Implementation
Undermines NHAS Goals
Lack of Proper Planning and Oversight Results
in Disruptions in Care (Moving Us in the Wrong
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

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
Essential Health Benefits Implementation Update
  • Federal guidance suggests (at least for private
  • 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
  • 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
ACAs Essential Health Benefits Mandates
1937 Benchmark Mandates (applies to Medicaid)
ACA Non-Discrimination 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
  • Preventive wellness services

Step 2 Success Requires High Level Officials at
HHS/CMS and in States Collaborating on Reforms
with HIV Consumers and Providers
Action Needed to Ensure Success
  • Guidance/Support to states to promote optional
  • 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
  • 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 2014-2016 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
  • supporting access to care in NY, CA and MA?

Step 3 Protect Medicaid Shifting Costs to
States Threatens NHAS Access to Care Goals
Action Needed to Ensure Success
Step 4. Address the Ryan White Program Challenge
Ongoing Funding Required to Meet NHAS Goals
Action Needed to Ensure Success
  • It is too soon to discuss Ryan White Program
  • 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
  • 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
  • Identify expertise to support health insurance
    navigation for HIV residents
  • Ensure readiness of the provider
    communityclinical and non-clinical
  • Develop response plan for populations that will
    remain ineligible for coverage under health

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
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