Health Care Reform Update and Advocacy Priorities

1
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

2
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

3
Part 1 The Affordable Care ActOverview of
Where We Are Were We Are Going
4
Where We AreStatus Quo Access to Care Crisis
5
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)
2003
2004
2005
2006
2007
2008
2002
Sources Estimated Number of Persons Living with
AIDS, Centers for Disease Control and
Prevention, http//www.cdc.gov/hiv/topics/surveill
ance/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.usinflationc
alculator.com www.cdc.gov/hiv/surveillance/resour
ces/reports/2009report/pdf/table16a.pdf
Funding, FY2007-FY2010 Appropriations by
Program, hab.hrsa.gov/reports/funding.html
6
ACA Implementation Must Address Engagement and
Retention in Quality Health Care

• 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

7
WHERE WE ARE GOINGACA 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 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

8
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 2013-2014 (up to Medicare reimbursement rate)
• Streamlines Application and Enrollment (no wrong
  door application process)
• Includes free preventive services (optional)

9
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
10
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

11
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

12
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)

13
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

14
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
  fluctuations
• 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
  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

15
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)

16
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
17

• Part 2
• Massachusetts as a Case Study of
• Successful Health Reform Implementation

18
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

19
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,
n941,950
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
20
MA Reform Demonstrates Successful
ImplementationReduces 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.
21
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
22
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

23
Californias 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

24
Part 3 Key Advocacy Priorities
Implementation Update
25

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

26
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
27
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
28
ACA is the Law of the Land Requires
Comprehensive EHB Despite Resistance in Some
States
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
  services
• Preventive wellness services

29
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
  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)

30
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..

31
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
  dollars
• supporting access to care in NY, CA and MA?

32
Step 3 Protect Medicaid Shifting Costs to
States Threatens NHAS Access to Care Goals
Action Needed to Ensure Success
33
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
  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

34
Part 4 Steps for Ensuring Ongoing Success
35
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!

36
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
  communityclinical and non-clinical
• Develop response plan for populations that will
  remain ineligible for coverage under health
  reforms

37
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

38
2012 Elections Watershed for Health
Reform but everything is not won or lost
39
Available Resources