Health Care Reform

1. Health Care Reform WHAT DOES IT MEAN FOR PEOPLE WITH HIV? PAETC July, 2012 ANNE DONNELLY PROJECT INFORM ADONNELLY@PROJECTINFORM.ORG 415.558.8669X208

2. Presentation Outline • Part One: The Supreme Court Decision • Part Two: The Next Decision Point: Elections • Part Three: Changing HIV/AIDS Care Landscape • Part Four: Implementation Priorities • Part Five: Considerations for AETCs

3. The Supreme Court and Elections What will happen with Health care reform?

4. Supreme Court Decision – Largely a Win Opponents challenged constitutionality of the individual mandate and the Medicaid expansion and SCOTUS issued a decision Medicaid expansion remains – no federal penalty for states which don’t enact The law is largely upheld The individual mandate is upheld as a tax penalty

5. Serious Concern - Medicaid Expansion • Expansion is still in effect • Federal government pays 100% for 2014 – 2016 • Gradually reduces to 90% by 2020 • The federal government can’t take away traditional Medicaid funding if states refuse to participate • 26 states joined in the lawsuit claiming “coercion” by the federal government to take the expansion funding • Very bad if for low-income people if states don’t enact expansion • Lots of financial and political pressure to enact post election

6. 2012 Elections = Next Watershed for Health Care

7. Health Care Reform – A Changing Care Landscape

8. New Responsibilities • Creates a provision that citizens must carry health insurance • Tax penalties apply to those who do not • Exemptions for hardship and some other reasons • Coverage expansions are – in effect – a mandate for people with HIV who want to stay in care • Ryan White payer of last resort rules

9. Medicaid: Improved and Expanded • Currently Medicaid is – for most with HIV – disability coverage • In 2014: • Expanded Eligibility • The disability requirement is eliminated • Most people with income up to 138%FPL will be eligible for Medicaid/Medi-Cal (appr. $15K for an individual) • No asset test • Could Improve Services • Medicaid expansion includes Essential Health Benefits (EHB) for newly eligible people

10. Improves Access to Private Insurance State-Based Exchanges Insurance Reforms • Can’t be denied or dropped from insurance because of HIV (all plans) • Can’t be charged higher premiums because of HIV or gender (exchange plans) • No more lifetime and annual limits (all plans) • Prevention services (including routine HIV testing for women) must be covered without cost sharing (all plans) • Caps amount spent out of pocket (exchange plans) • Consumer friendly marketplace to purchase private insurance • Federal subsidies for people with income up to 400% FPL • Plans must provide essential health benefits

11. Increases Access to Medicare Part D • 50% discount on all brand-name prescription drugs • AIDS Drug Assistance Program (ADAP) contributions now count toward copayment obligations, allowing people with HIV to move through the “donut hole” • Part D “donut hole” phased-out by 2020

12. Other ACA Improvements • Essential Health Benefit provision establishes new floor for benefits • Mental health (MH) and substance use disorder (SUD) tx part of EHB • Mandatory coverage for MH and SUD at parity • New opportunities in primary care and integrated services • Invests in Prevention, Wellness, Access to Care and Innovation • Prevention and Public Health Fund • Community Health Center Expansion • Health Work Force Investments • Care Coordination Investments

13. Health Care Reform and Immigrants Certain immigrant populations are completely excluded from health care reform • Undocumented individuals are not eligible for: • Medicaid • Health Insurance Exchange • Subsidy • Legal immigrants continue to face a five year waiting period for Medicaid • Exceptions to five year waiting period include people seeking asylum, refugees and some others

14. Care Landscape in 2014

15. It’s All About State Implementation Priorities for people with HIV

16. 1. Ensuring Medicaid Expansion in All States • States could refuse • Some have said they will • Some states began to challenge current Maintenance of Effort requirements • Sec. Sebilius sent letter advising current requirements are in place and wants to work with States on expansion opportunities • Strong incentives in terms of funding • Strong allies to “convince” reluctant Governors • Hospital associations, pharmaceutical companies, health advocates

17. ACA Essential Health Benefits • Ambulatory services • Emergency services • Hospitalization • Maternity/newborn care • Mental health and substance use disorder services – to parity • Prescription drugs • Rehabilitative and habilitative services • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services 2. Ensuring a Comprehensive Essential Health Benefits Package Federal Guidance/Regulations State Implementation Decisions

18. What Does a Benchmark Approach Mean? • Flexibility for most states likely means bare bones plans • State variation and disparities will continue • Continued federal advocacy needed to enforce anti-discrimination protections • California: • Decisions are being made now • Legislature and Exchange Board are working together • Benchmark plan: Kaiser small group plan for Exchange • Medicaid benchmark guidance not complete • Choices of FEHBP, State Employees, Largest commercial HMO, Secretary determined equivalent • Advocates say Medi-Cal plus - administrative burden much lower

19. 3. Ensuring Access to Ryan White: Filling the Gaps • Essential services needed by people living with HIV/AIDS NOT fully covered by EHB: • Dental services • Case management • Medical case management? • Nutrition services • Transportation • Mental health and substance use services • Peer support services • Insurance assistance • Medicaid will NOT be available for: • Undocumented immigrants • Legal immigrants within the 5 year ban Ryan White HIV/AIDS Program

20. MA: Post HCR ADAP Costs

21. 4. And 5. Transitioning to New Systems • Ryan White programs and support systems created a relatively seamless system of care • Both people with HIV and HIV providers will need to transition to new forms of coverage • There is no one agency/individual “in charge” of this massive transition • It involves multiple agencies (previously siloed) working together in new ways

22. 4. And 5. Transitioning to New Systems • -No effective communications system for providers and/or clients • -Little to no information materials • -Details of new systems in development /changing • -Little clear guidance from agencies • -No clear assistance for clients • -No comprehensive technical assistance for providers (medical and non-medical) • -Inadequate provider rates, including pharmacy

23. 5. Preparing for Change in HIV Care -Become a Federally Qualified Health Center (FQHC) Affiliate or integrate w/a FQHC Successful integration in Sonoma County -Diversify Funding Need as many different types of coverage/insurance as possible -Prepare for an insured client base -Look at data systems -Strategize about when and where Ryan White must fill gaps

24. 6. Making Medicaid Managed Care Work • -Ensure HIV providers are part of the managed care network and can be identified • -Consider state – specific enhanced reimbursement strategies • -Consider pharmacy networks as well as medical providers • -Transition from fee-for-service to managed care critical • Clear and effect continuity of care protections are essential • -Medicaid Health Home Program Opportunities

25. Consideration for AETCs Ways that AETCs could support providers during health care reform

26. Health Care Reform and Disparities:Long term – positive; short term - challenges

27. AETCs Supporting Providers Through HCR • Information • No communication or education plan • HIV providers will need to understand changes; how it affects them and their clients; more about broader systems of care • Planning • Clinics will have to realistically plan how they and their clients will transition to new systems • Best done in dialogue internally and with other clinic systems

28. AETCs Supporting Providers Through HCR • Identifying and providing technical assistance where needed • Can providers contract with, bill, and interact with Medicaid, private and public managed care organizations, private insurance? • How could warm lines support providers with information/TA? • Supporting engagement in advocacy • Providers are needed in policy development • Adequate formularies with new coverage • Supporting Testing, Linkage, Engagement and Retention in Care • Identification and dissemination of best practices • Identification and dissemination of best transition practices • Work with providers to create “best practices”

29. AETC Support • AETCs - change facilitators? • Planning for the unknown is hard • Details, details, details: state and local level • Collaboration and partnership are essential • Adaptive versus technical change; Cross sector participation important • If partnerships are developed in advance, trust makes planning easier • Easy to waste time and get frustrated by blaming others • Fear of change is part of the process • Openly addressing fears and seeking opportunities are important steps in the process

30. Health Care Reform Planning “The causes of today’s problems are complex and interconnected. There are no simple answers, and no one individual can possibly know what to do - it is time to stop waiting for someone to save us. We’re all in this together, we all have a voice in how we go forward.” Meg Wheatley

31. Resources