The Patient Protection and Affordable Care Act

1. The Patient Protection and Affordable Care Act Update and Implications 2013 Annual Conference:AIDS Drug Assistance Programs: Renewing the Commitment Joseph Jefferson, MPH Director of Advocacy and Alliance Development

2. Presentation Preview • Assessing the Landscape • ACA Implementation Update • ACA Patient Protections and Access • ACA and Ryan White • ACA and Implications for ADAP • Informing the Advocacy Agenda

3. Assessing the Landscape

6. The Treatment Cascade

7. Landscape Changes Creating the Hybrid Provider

8. The PCP Profile

9. Providers and Growth in HIV Patient Care

11. Workforce Trends • Approximately 4,500 HIV providers (MD, DO, NP, PA) in US1 • Fewer than 1/3 of physicians are in private practice – migrating to larger health systems • The current HIV workforce is composed of first-generation providers who entered the field over 20 years ago • 50% of current HIV provider workforce retiring in next 5-10 years • Ryan White Part C-funded clinicsreport difficulty recruiting HIV clinicians 1 Physician Workforce Projections in an Era of Health Care Reform, Annual Review of Medicine, Vol. 63: 435-445, February 2012

12. Workforce Trends

13. PCP Role in Treating Co-occurring Conditions • Providers of HIV Care reported increasing numbers of HIV patients with co-occurring conditions like: • Cardiovascular disease (50%) • Renal disease (49%) • Mental health conditions (48%) • Substance abuse (38%) • Hepatitis C (36%) • 58% of HIV Providers are seeing increasing number of HIV patients with sexually transmitted infections

14. ACA Implementation Update

15. Implementation Benchmarks January 2013 January 2014 • State Notification Regarding Exchanges • Closing the Medicare Drug Coverage Gap • Medicaid Coverage of Preventive Services • Medicaid Payments for Primary Care • Medicaid Expansion • Individual Insurance Requirement • Health Insurance Exchanges • Guaranteed Availability of Insurance • No Annual Limits on Coverage • Essential Health Benefits

16. Medicaid Expansion Decision Map Kaiser Family Foundation, July 2013

17. Marketplace (Exchange) Decision Map Kaiser Family Foundation, July 2013

19. ACA Patient Protections and Access

20. Key ACA Patient Protections • Guaranteed availability of coverage, regardless of health status or pre-existing condition • Prohibitions on discriminatory premium rates, ie. gender and health status • Coverage of “specified” preventive health services without cost-sharing • Low-income PWLHs <64 may qualify for Medicaid in states that choose to expand

21. Key ACA Patient Protections • No lifetime or annual limits on coverage • Prohibitions on illness-related coverage discontinuation • Federal subsidies for people with incomes <400% FPL • Plans have to contract with “community providers”, including Ryan White programs • Plans must include EHB

22. PLWHs and Access

23. PLWHs and Access

24. PLWHs and Access http://policyinsights.kff.org/2012/september/how-the-aca-changes-pathways-to-insurance-coverage-for-people-with-hiv.aspx

25. ACA & the HCV Paradox • Increased Demand for Linkage and Retention • Increased HCV Screening • Increased Access to Coverage • Increased Demand on Service Delivery System • Increased Detection and Diagnosis • Stronger Case for National Surveillance System • Increased Emphasis on Prevention • Increased Treatment and Monitoring • Increased Urgency to Codify Prescription Drug Coverage Standards

26. ACA & Ryan White

27. Ryan White Reauthorization Update • Ryan White will likely not be reauthorized in 2013 – though 2009 reauthorization contains no sunset provision • Programs will likely continue in FY 14 and beyond • Final FY13 CR did not include Obama’s proposed emergency funding: $35M for ADAPs and $10M for PartC • Sequester likely to result in 5.2% HHS funding reduction • Obama FY14 budget provides $20M increase in RW • $10M ADAP; $10 for Part C clinics • As ACA is implemented FQHCs are likely to see an influx of HIV patients

28. Ryan White Reauthorization Update HRSA Justification Notes: “The Ryan White Program is authorized through September 30, 2013. However, the program will continue to operate. The 2009 reauthorization or the Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87, October 30, 2009) does not include an explicit sunset clause. In the absence of a sunset clause, the program will continue to operate without a Congressional reauthorization.”

29. Ryan White Reauthorization Update HRSA/HAB Policy Considerations: • Identify issues as RW beneficiaries transfer to private insurance • Reallocate RW dollars toward premium support • Create flexible enrollment procedures & timelines • Clarify effective coverage dates • Recommend n=Network v. out-of-Network care policies • Assess impact of prior authorization for both Medicaid and Marketplaces

30. Federal RW Funding (infl-adj) and HIV Prevalence, 1991-2012 Source: Andrea Weddle, HIV Medicine Association, HIV Medical Provider Experiences: Results of a Survey of Ryan White Part C Programs, Institute of Medicine Committee on HIV Screening and Access to Care, September

31. ACA & Implications for ADAP

32. HealthHIV HealthGram on Medicaid Expansion & HIV Incidence by State and Health Ranking

33. Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Top Quartile Medicaid Eligibility ≠ Medicaid Access Only 2 of 12 top quartile states (Illinois and Michigan) are expanding Medicaid

34. Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Bottom Quartile 7 of 12 bottom quartile states are expanding Medicaid http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

35. Estimated % of ADAP Clients NEWLY Eligible for Private Insurance Subsidies in 2014: Top Quartile Federally Facilitated Exchange: 8 States Partnership Exchange: 2 States State-based Exchange: 2 States http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

36. Estimated % of ADAP Clients Eligible for Private Insurance Subsidies IN 2014: Bottom Quartile Federally Facilitated Exchange: 4 States Partnership Exchange: 3 States State-based Exchange: 5 States http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

37. Informing the Advocacy Agenda

38. Medicaid 1. HHS/CMS must: • Ensure “Alternative Benefit Plan” is similar to traditional Medicaid • Give states flexibility to design multiple ABPs targeting specific populations • Extend EHB non-discrimination mandates to ABPs • Apply rules governing prescription drug coverage under Medicaid to ABP • Apply non-disc protections to drug benefit • Include preventive services, including routing HIV and HCV screening • Mitigate burdensome cost-sharing proposals by adopting standard established in Medicare Part D low-income subsidy program 2. Advocates must press for Medicaid expansion in states leaning against expansion

39. Essential Health Benefits 1. CMS must: • Evaluate and standardize “medical necessity” requirements • Develop mechanisms to monitor utilization management techniques, exclusions, and service limits • Ensure meaningful stakeholder engagement involvement at Federal and State level in the run-up to EHB framework reevaluation in 2016 – Goal: Higher and more clearly defined national standards • Issue clarifying guidance to states to ensure reasonable, accessible, and expedited appeals process regarding benefit and service coverage decisions – including access to most appropriate and effective combination ARV therapy 2. Advocates need to work with CMS to overcome opposition by payers

40. Ryan White • Persuade Obama Administration to restore $35M for ADAP and $10M for Part C (lost in CR) – We’ve almost checked this one. • Preserve RW program funding through budget process (FY14 and beyond) – We feel pretty good about this one. • Engage Members and their staffs in ongoing education about how RW funding helps to reduce community viral load – and new infections • Work with HRSA/HAB to ensure transition issues remain a priority • Integrate HIV care into mainstream health system • Fortify collaborations between RW medical and support service providers • Strengthen focus on gay and bisexual men • Resource distributions that align with post-ACA coverage gaps - especially in states that are not expanding Medicaid • Conduct research to assess and identify scalable and effective interventions that link performance along the cascade

41. HCV • Press for national data system and/or standards for hepatitis data collection • Increase funding for hepatitis prevention • Institute national screening protocols • Clarify EHB prescription drug coverage standards (given new HCV treatment opportunities in the pipeline) • Address ADAP HCV drug formularies • Develop and resource education initiatives targeted at provider, consumers, and broader public

42. HIV/Hep C Surveillance Comparison

43. Federal HCV Initiatives • Healthy People 2020 (Dec 2010) • Goal: Increase immunization rates and reduce preventable infectious diseases • National Viral Hepatitis Action Plan (May 2011) • Increase % of persons aware of HBV infection from 33% to 66% • Increase % of persons aware of HCV infection from 45% to 66% • Reduce number of new cases of HCV by 25% • Elimination of mother-to-child transmission of HBV • CDC recommendations on HCV testing for baby boomers (August 2012) • Patient Protection and Affordable Care Act (2014) • Focus on prevention

44. Where Can I Obtain Additional Information? • HHS • www.healthcare.gov • CMS – Medicaid • Medicaid.gov • CMS – CCIIO • cciio.cms.gov • HRSA • hab.hrsa.gov/affordablecareact/index.html • For any questions related to RW and the ACA, please email: RWP-ACAQuestions@hrsa.gov

45. Washington, DC 20009202.232.6749 www.healthhiv.org joseph@healthhiv.org 202.507.4727