The Impact of Health Reform on Future Funding of HIV/AIDS Programs

Transcription

1 The Impact of Health Reform on Future Funding of HIV/AIDS Programs Lindsey Dawson

2 Outline The Domestic HIV Epidemic: Where we are today? The Impact of Health Reform: What can we expect? Impact of Health Care Reform: HIV Prevention Ryan White HIV/AIDS Program

3 Percentage Number And Percentage Of HIV-infected Persons Engaged and Unengaged In Selected Stages Of HIV Care United States % 206,676 34% 390,388 Engaged Unengaged % 63% 723,366 67% 769,294 75% 861, ,148,200 82% ,524 66% 757,812 37% 33% 424,834 Total HIV-infected HIV-diagnosis Linkage to HIV Care Retainment in HIV care Usage of ART Viral Suppression 25% 378, ,050 analysis. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data United States and 6 U.S. dependent areas HIV Surveillance Supplemental Report 2012;17(No. 3, part A).

4 Where are We Today? Domestic HIV Epidemic Making progress on the treatment cascade but significant gaps Especially linkage and retention in care RW + ACA + Continued funding can help Ongoing commitment from the administration: 2010: National HIV/AIDS Strategy (NHAS) Sets forth national roadmap and key goals to address domestic HIV epidemic 2013: HIV Care Continuum Initiative/orkgroup Builds on NHAS, recognizing scientific developments Coordinates federal efforts Workgroup made up of representatives from key agencies Will review data and make recommendations/reports

5 What can we expect from health reform?

6 Impact of Health Reform Health reform will have a dramatic impact on access to care and coverage Questions remain about how it will impact funding, who will gain coverage/how soon, and the breadth of new coverage Coverage expectations Estimated +34 million people will gain access to coverage 12m Medicaid Expansion 22m Health Insurance Markets/Exchanges

7 Impact of Health Reform New private market protections: Insurers required to cover people with preexisting conditions Cannot be dropped from coverage when sick Rates can vary based on location, smoking status, and age only (not gender, health status) Lifetime/yearly limits on coverage prohibited Guaranteed right to appeal

8 Impact of Health Reform More robust coverage Essential Health Benefits (EHBs) Medicaid expansion plans and plans sold in the individual and small group markets 10 categories of benefits, including: ambulatory and emergency services, maternity care, mental health services, and prescription drug coverage, among others Uses a benchmark methodology to define (state decision) Breadth of coverage to vary by state and plan but sets a floor The ACA contains many provisions that expand access to preventive care, including naming it as an EHB

9 Impact of Health Reform Assistance with private insurance costs Premium tax credits available to those 100%-400% FPL purchasing coverage on the exchange Expected premium contribution varies by income Paid in advance to the plan, reconciled at the end of tax year Cost-sharing subsidies available to those 100%-250% FPL purchasing cover on the exchange Paid in advance to the plan, varies by income Limits on out-of-pocket expenses, ranging by income from about $2,000 to about $6,000, for those with higher incomes Includes deductibles, co-pays, co-insurance, not premiums Yet, some expenses will remain

10 Impact of Health Reform Yet millions will remain uninsured: CBO estimates 31m will still be uninsured in 2016 Enrollment will take time, only 16m expected to enroll in Medicaid and exchanges in 2014 (of 34m expected by 2016) Some will be lost to care/churning Undocumented and recently legally present individuals ineligible for some forms of coverage Not all states are planning to expand Medicaid programs to childless adults under 138% FPL Not all states planning to expand their Medicaid programs will be ready Jan. 1

11 State Decisions on Medicaid Expansion Source: Center on Budget and Policy Priorities. Health Reform's Medicaid Expansion: A toolkit for State Advocates

12 Impact of Health Reform Impact on future funding: Even those with coverage will not get 100% of care needs met Funding for federal programs that address the HIV epidemic and care and treatment needs of PLWH will remain critical Especially important to protect safety net programs Funding also goes to activities not part of insurance packages (e.g. technical assistance and surveillance)

13 Prevention Funding Needs and ACA

14 Prevention under the ACA The ACA ensures prevention is a key component of health coverage Prevention included as an EHB The USPSTF is a body of independent experts that evaluate and assign grades to preventive services A and B grades are key to coverage Under the ACA major payers will be required or incentivized to cover these services, including HIV testing Annual HIV testing also covered through Women s Preventative Services and applies to private and Medicaid expansion plans (also includes other services specific to women s health) Important tool to ensure more people learn their status

15 CDC Funding Increased coverage + providers willingness to conduct tests should lead to increased HIV testing Will likely have some impact on future funding needs, will need further analysis Despite increased preventative coverage, CDC funding remains critical Reimbursement pays for the test itself, not outreach or surveillance Covers only billable clinical testing Not tests conducted in alternative settings or free sites that do not collect insurance information Does not help those without coverage

16 CDC Funding CDC funding will also remain necessary for: Encouraging providers to test Helping to develop and utilize billing systems Addressing barriers (e.g. bundled payments) Demonstrated support from the Administration with $10m in President's budget for these purposes

17 Ryan White Program and Future Funding Needs

18 Ryan White HIV/AIDS Program Last reauthorized by Ryan White HIV/AIDS Treatment Extension Act of 2009 Expires September 30, 2013 Does not sunset; program can continue to be funded Discussions taking place about how to proceed With support of the Administration and congress, the Ryan White Working Group of the Federal AIDS Policy Partnership (FAPP) is advocating to continue the program without reauthorization

19 Ryan White HIV/AIDS Program Why no reauthorization at this time? Effort to protect the program, partisan congress Not ready to make changes to program ahead of assessing health reform roll out/impact Hold harmless and the tiered loss of funding to TGAs that lose their status go away ACA will not supplant Ryan White, funding remains critical Studies underway to assess the relationship between the RWP and the ACA ASPE (delayed) & HRSA (Nov. 2012) Mathematica Studies CDC s Medical Monitoring Project will also be looking at this issue Community will continue to evaluate

20

21 Future Roles for the Ryan White Program (RWP) Despite increased coverage, gaps will exist RWP will play a critical role in filling these gaps and completing existing coverage Including for those with existing forms of coverage Anticipated gaps and variation in coverage across locations: Private insurance premiums will vary across regions State EHB benchmark decisions in private market State insurance mandates Decisions whether to expand state Medicaid programs Medicaid expansion benchmark decisions (ABPs) This will be particularly important for PLWH

22 80 Household Income of Ryan White Clients (by Federal Poverty Level) (2010) % % % 0 Equal to or below FPL % FPL >200% FPL * Missing/unknown values (20%) excluded. Source: 2010 RW Services Report- Preliminary Data from presentation: L. Cheever. IDWeek. The Evolution of the Ryan White Program Under Health Care Reform. October 18, 2012.

23

24 Future Roles for the RWP Additional gaps: Those without coverage Filling in less generous plans Service gaps: Transportation Legal Services Hospice Care Early intervention counseling Adult dental Case management Etc.

25 Case Study Source: Skarbinski, Jacek. Centers for Disease Control and Prevention. HIV Medical Monitoring Project (MMP): Follow up on Institute of Medicine Report and Other Patient Protection and Affordable Care ACA (ACA) Issues. CDC / HRSA Advisory Committee on HIV, Viral Hepatitis and STD Prevention and Treatment (CHACHSPT). June 18, Atlanta, Georgia.

26 Select Examples of Ryan White Services That Support Clients Along the HIV Treatment Cascade

27 Future Roles for the RWP Additional gaps: RWP can provide assistance with the cost of premiums and other out-of-pocket expenses such as copays and coinsurance While ACA and Medicaid provide some cost controls, expenses can remain unaffordable for those with low incomes Cost-sharing assistance will be particularly important for those living in non-expansion states States have started to reveal expected premium rates for coverage sold on the exchanges

28 Examples of 2014 approved monthly premium rates CA: Average across the state for 2 nd lowest cost silver plan for a 40yr old is $325; for the 2 nd lowest cost bronze plan is $235 NM: Silver plans for a 40yr old tend to be about $250-$350; bronze plans about $ FL: Statewide average for a silver plan is about $395 MD: Silver plan for a 50yr old averages about $350; about $200 for a bronze plan for a 25yr old These estimates do not take into account advance premium tax credits available to those between % FPL

29 The Massachusetts Example MA provides a case study for how Ryan White works in a post- health reform context MA went through a statewide health reform in 2006 Expanded Medicaid to PLWH/A up to 200% FPL in % of state residents now have some form of insurance The state continues to use Ryan White dollars Helping substantially with premiums and cost-sharing Since health reform, the proportion of ADAP funds used to cover the full cost of drugs has decreased while the share used towards premiums and cost-sharing has increased At the same time PLWH are experiencing better health outcomes compared to the nation at large

30 Massachusetts ADAP Expenditures by Category & Enrollment Fiscal Year Full Pay Co-Pay Premiums Enrollment FY04 $11.2 m $1.6 m $3.2 m 4,399 FY12 $4.6 m $3.5 m $10.9 m 8,022 Massachusetts Department of Public Health

31 100% Linkage to Care CDC vs. MA 95% 80% 80% 60% 45% 40% 20% 0% Of those aware of status, linked to Care (CDC) Of those aware of status, retained in Care (CDC) Seen provider in Last 6 months (MA) Source: JSI Research and Training, Inc. Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report. December 2011.

32 100% ART Use CDC vs. MA 91% 80% 60% 40% 40% 20% 0% Of those aware of status, prescribed ART (CDC) Taking Medication (MA) Source: JSI Research and Training, Inc. Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report. December 2011.

33 80% Viral Supression CDC vs. MA 72% 60% 40% 30% 20% 0% (1) CDC defines suppression as 200 copies/ml) (2) Self-reported Of those aware of status, virally supressed (CDC) (1) Undetectable viral load or less than 400 Copies/mL (MA) (2) Source: JSI Research and Training, Inc. Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report. December 2011.

34 Concluding Thoughts MA makes a strong case for continued funding Demonstrates that continued Ryan White services and financial assistance along with health reform can positively impact HIV health outcomes Help to meet the care and treatment goals of the National HIV AIDS Strategy Health Reform is unlikely to meet the care and treatment needs of people living with HIV on its own: Ryan White will remain critical Don t want to jeopardize the good job Ryan White is doing

35 Percentage HIV+ Ryan White Program Clients Who Received RW-Funded Medical Care 100% 90% 80% 70% 76% 80% 70% 60% 50% 40% 30% 20% 10% 0% Retained in HIV Care 1 Prescribed ART 2 Viral Suppression 3 1 Includes only those with visit date available 2 Includes only those with ART data and visit date available 3 Includes only those with viral load data available Doshi R, Matthews T, Isenberg D, Matosky M, Milberg J, Malitz F, Cheever, L. (2013). Continuum of HIV care among Ryan White HIV/AIDS Program clients, United States, 2010.

36 Concluding Thoughts Not yet possible to determine future funding needs We do know caring for people with HIV early on is costeffective Payer of last resort will ensure that Ryan White works alongside health reform Full and seamless implementation will take time All systems will not be up and ready Jan. 1, 2014 There are bound to be unexpected problems Current systems must remain until people can be carefully transitioned

37 Concluding Thoughts Health reform will change the landscape regarding access to healthcare, yet: Many new people will enter healthcare systems and will need additional services and cost-sharing assistance to help complete their coverage Those currently in care can continue to benefit from this support There will be variability among payers, plans and regions It remains critical to preserve the expertise of the Ryan White system of care and CDC prevention efforts We cannot threaten the wellbeing of those in proven systems of care by uprooting them until we truly understand how implementation plays out and assess gaps, both in services and among people

38 Concluding Thoughts Alternate futures and funding for HIV/AIDS programs can only be responsibly assessed after full implementation of health reform We will need to evaluate how ACA and RW work together in the future President s budget proposed two studies: Examination of Coverage Completion Services by Other Payer Sources Assess Impact of Full ACA Implementation on Ryan White Program In the meantime we must be vigilant in protecting Ryan White and other HIV/AIDS program funding, especially given the challenging budgetary and highly partisan climate

39 CBO. May 2013 Estimates of the effects of the Affordable Care Act on Health Insurance Coverage: hinsurancecoverage_2.pdf Kaiser Health News is collecting state documents as premium rates are release: HRSA Ryan White State Profiles: Resources Health Resources and Services Administration. Going the Distance: The Ryan White HIV/AIDS Program20 Years of Leadership, a Legacy of Care. August JSI Research and Training, Inc. Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report. December pdf Massachusetts Department of Public Health: The Commonwealth Fund. S. R. Collins, R. et. al. The Income Divide in Health Care: How the Affordable Care Act Will Help Restore Fairness to the U.S. Health System. February

40 Resources Federal Gov t: HRSA/HAB ACA: TARGET Center: HIV Community: Kaiser Family Foundation: Families USA:

41 THANK YOU Lindsey Dawson - ldawson@theaidsinstitute.org