Federal & State HIV/AIDS Policy

1. Federal & State HIV/AIDS Policy UCLA School of Public Health Epidemiology 227 April 23, 2010 Prof. Arleen Leibowitz UCLA School of Public Affairs

2. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Private Insurance and Health Reform Changes • Testing and Prevention • California issues • Research • Income Support and Housing • Global Programs

3. Follow The Funding to Determine PrioritiesFY 2010 Federal HIV/AIDS Budget Request ($ Billions)

4. National Treatment Guidelines Call for Early Access to Treatment and Care • But many PLWH are not in regular care • About 21% do not know their HIV status • Only 55% of those meeting clinical criteria for ARV therapy get it • Expanded guidelines • HAART is costly • $12,000/year in ARV costs • $20,000/year in total costs

5. Insurance Status of HIV Patients in Care, 1996 Uninsured 20%

6. Federal Support for Care and Treatment (FY2010) • Medicaid (Federal share) $4.7 B 34.6% • Medicare $5.1 B 37.5% • Ryan White $2.3 B 16.9% • (ADAP $0.8 B) • Veterans Affairs $0.8 B 5.9% • SAMHSA $0.2 B 1.5% • HOPWA $0.3 B 2.2% • FEHBP $0.1 B 0.7% • Total $13.5 B

7. Two Kinds of Federal Spending • Mandatory spending • Presumption that Congress must allocate funding to meet statutory obligation – e.g., Medicare, Medicaid, SSI • “Entitlements” • Defined benefit • Discretionary spending • Congress decides on spending level each year • Defined contribution • Block grants • Examples: NIH, CDC, Ryan White, VA

8. Problems With Discretionary Spending • Block grant means that the budget does not increase to accommodate increased enrollment • Health care costs rise faster than CPI, so annual increases are “high” • Long-term health investments are discouraged by annual budget process • Prevention may reduce costs in long run, but not in short • Early treatment of HIV may save money in long run • Share of discretionary spending is falling

9. Medicaid • Created in 1965 • Federal/state health insurance program for low income and disabled • Federal government pays a minimum of 50% of costs, more in low income states (average 55% of HIV $) • Jointly administered • States set eligibility criteria, subject to Federal minima • States set benefits, subject to Federal mandated benefits

10. Current Medicaid Eligibility • States must cover • Certain poor women and children • Disabled who qualify for SSI (unable to engage in “substantial gainful activity by reason of… (a medical condition) ….expected to result in death or that has lasted…up to 12 months”) • States set income criteria • State option to cover Medically Needy who “spend down” to income criteria

11. Medicaid Benefits • Covers most services with no or minimal cost-sharing • Drugs, an optional service, are covered in all states • Optional services include case management, hospice • Some states limit services • Number of Rx per month or year • Number of MD visits

12. Medicaid – Current Policy Issues • State variability in Medically Needy income eligibility criteria • Vermont 75% FPL • Louisiana 7% FPL • States can impose limits on discretionary services (drugs) • Non-citizens can not qualify for Medicaid • Green-card holders must wait 5 years • Medicaid provider payment levels are low, making access difficult • Medicaid discount on drugs of 15.1% less than what others get

13. Medicaid –Policy Issues (2) • Catch-22 • Medicaid eligibility depends on being disabled or having AIDS • But early treatment of non-disabled could avert disability • And reduce transmission • Some states have 1115-waivers to provide Medicaid to low income people with HIV prior to disability • 1115 waiver requires “budget neutrality” --Medicaid savings >= additional Medicaid costs • But, given fractured system, inpatient savings of ARV treatment often go to Medicare, SSI or Ryan White

14. Medicaid –Policy Issues (3) • Lose Medicaid if earnings exceed threshold, however, earnings may not cover the cost of costly ARV treatment • Ticket to Work/Work Incentives Improvement Act of 1998 continues Medicaid coverage even if person returns to work • In recessions, states attempt to cut Medicaid benefits • Gov. Schwarzenegger proposed premiums for Medicaid • Federal government raised its match rate during recession

15. Health Care Reform and Medicaid • Persons <133% of FPL are eligible for Medicaid from 2014 • $14,404 for single individual; $29,327 for family of 4 • Does not depend on disability • Individuals w/o dependent children now will qualify • Removes eligibility variation by state, but undocumented still not eligible • 100% federal funding for eligibility expansions in 2014-16, declining later to 90% • Increases drug 340b rebate to 23.1%, but some goes back to federal government • Provides 100% federal funding to raise Medicaid reimbursement rate to Medicare levels for primary care services in 2013, 2014 • Encourages “medical home” for those with chronic conditions

16. Medicare • Created in 1965 • Covers persons 65+, persons with ESRD, and long term disabled • Funded by payroll tax on earnings, general revenues, beneficiary premiums for Part B and co-payments (Medicaid can pay patient cost-sharing) • Uniform throughout U.S.

17. Medicare: Eligibility for Disabled • Disabled must have sufficient covered work history to quality for SSDI • 29 Month Waiting period • Federal law requires 5 month wait after disability determination before receiving SSDI payments • 24-month waiting period for Medicare, following SSDI • Medicaid coverage for low income persons during the 29 months

18. Medicare Benefits • Hospital • Outpatient (20% cost-sharing) • Drugs have been covered since January 1, 2006 under Part D, private drug insurance plans • Plans required to cover all ARVs • Low income subsidy needed for “the donut hole”

19. Medicare – Current Policy Issues • Eligibility • Must have sufficient work history to qualify for SSDI, a problem for young, poor persons with HIV • 29 month wait for Medicare eligibility • Catch-22 of disability requirement • Cost-sharing • High cost sharing if no supplemental coverage • No cap on out-of-pocket spending • Medicare “donut hole” • When ADAP pays, doesn’t count as “true out of pocket cost” (TROOP)

20. Health Reform and Medicare • Medicare “donut” hole will be closed • 2010--$350 towards cost • Phase-down coinsurance rate in donut hole from 100% to 25%, starting 2011 by requiring 50% rebate from manufacturers plus federal 25% subsidy • ADAP payments will count as TROOP in Part D • No cost-sharing for covered preventive services (rated A or B by U.S. Preventive Services Task Force)

21. Ryan White Care Act • CARE= Comprehensive AIDS Relief Emergency • Enacted 1990 • Administered by Health Resources and Services Administration (HRSA) • Payer of last resort for 553,000 uninsured and underinsured PLWA • Outpatient care, including medical, dental, case management, home health, hospice, housing, transportation, drugs (through ADAP), insurance continuation

22. Ryan White Funds Systems of Care Originally designed to provide relief to cities with disproportionate burden of caring for HIV/AIDS Part A: Emergency Relief (EMA, TGA) Part B: HIV Care (including ADAP) Part C: Early Intervention Part D: Women, Infants, Children, Youth Part F AIDS Education and Training, Dental, SPNS

23. AIDS Drug Assistance Program (ADAP) • Funded by Part B of Ryan White Care Act • Congressional Earmark: $835 M (approx 50%) • Plus state supplements (approx 25%) • And rebates from drug manufacturers (approx 25%) • Other Federal funding • States set eligibility • 5 x FPL in NJ; 4 x FPL in CA; 2 x FPL Texas • Disability not required • Residency, not citizenship required • ADAP is a block grant • States have used waiting lists to ration

24. ADAP (2) • Drugs provided to 110,000 PLWH monthly in 2008 • Cost/enrollee c. $1000/month • Services • HIV Medications • Drug monitoring and adherence services • Can purchase health insurance for eligible clients • Drug Formularies • Must include at least one medication w/I each ARV class • Louisiana had 28 drugs; New York had 460

25. Ryan White – Current Policy Issues • Discretionary grant program provides a block grant • Growth in PLWHA increases demand for CARE Act services • Medical costs increase faster than CPI • States have limited ability to supplement • Resulted in waiting lists for ADAP • States set eligibility rules, resulting in variability • States with less generous Medicaid programs, need more Ryan White support • Provides support for non-citizens

26. Ryan White – Policy Issues (2) • 2006 Reauthorization of Ryan White Act revised funding formulas for Parts A and B • Funding now based on reported HIV cases, not only AIDS cases • Directs funding to reflect emerging epidemic • California just began names reporting of HIV cases • Required 75% of funding to be used for core medical services

27. ADAP - Policy Issues • Coordination with Medicare Part D • Payment for Part D co-pays, deductibles, premiums • ADAPs can pay for drugs in “donut hole” • Increasing demand for ADAP as more PLWHA are not disabled, but require medication • Longer bridge to Medicaid • New, more costly drugs

28. ADAP - Policy Issues (2) • Continued availability of prescription rebates? • State fiscal environments challenge states’ ability to supplement ADAP • States seek to reduce formularies to cut costs • Need to explore cost containment strategies that maintain client access (i.e. purchasing options)

29. Health Reform and ADAP • Insurance exchanges should reduce number of uninsured, and reliance on ADAP • Would provide for medical care, not just drugs • CARE/HIPP could help purchase insurance • ADAP will count as TROOP • ADAP costs after donut hole should decrease • Cost of drugs while in donut hole is reduced by 50% • Effect on rebates? • Effect of health reform on Ryan White funding? • Undocumented

30. Health Reform and Private Insurance • Eliminates “medical underwriting” and rescissions • Provides subsidies for purchase from exchanges (32 million people by 2019) with mandated benefits • Legal immigrants eligible for subsidies • Bronze plan—covers 60% of cost • Caps out of pocket expenditures for persons<4xFPL • Sets up high risk pool—June 2010 to Jan 2014 • Allows children to stay on parents’ policy until age 26 • May reduce pressure on COBRA for unemployed

31. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Health Reform and private insurance • Testing and Prevention • California Issues • Research • Income Support and Housing • Global Programs

32. HIV Testing • 21% of PLWH do not know they are HIV+ • CDC “Advancing HIV Prevention” (2004) • Make voluntary HIV testing a part of routine medical care • Test for HIV outside of medical care settings • Prevent new infections by focusing on HIV+ individuals and their partners • Further decrease perinatal HIV transmission

33. HIV Testing – Policy Issues • CDC goal to “normalize” HIV testing • Destigmatize • Opt-out vs. opt-in testing recommended by CDC in Sept. 2006 • Default is testing; patient must specifically decline test • Covered by general consent to treat • CA state law since Jan. 1, 2008 removes requirement for specific written informed consent for testing • Need prevention counseling accompany testing?

34. Testing—Policy Issues (2) • Rapid test could increase knowledge of HIV status • Results ready in 20 minutes, no need to return for results • But needs to be confirmed if “preliminarily positive” • CA state law relating to who can perform finger prick test limited use of rapid tests • Just changed

35. Prevention • Centers for Disease Control and Prevention administers most federal prevention efforts (FY 10 budget: $785.1 B) • National budget share for prevention (4%) is decreasing over time • California share for prevention <6%

36. California Cut 09/10 HIV/AIDS Budget by $59M

37. Prevention: Policy Issues • Balance efforts targeting HIV- and HIV+ individuals • Target increased risk behavior among MSM • Methamphetamine epidemic in CA • Internet—prevention challenge or opportunity? • Reach populations who may not realize their risk and may not receive routine medical care • Young men are not in routine medical care • STI clinics, EDs, jails? • Separation between federal treatment and prevention efforts

38. Prevention – Policy Issues • Federal government promotion of abstinence only • The Task Force on Community Preventive Services concludes that there is insufficient evidence to determine the effectiveness of group-based abstinence education delivered to adolescents to prevent pregnancy, HIV and other sexually transmitted infections (STIs). • HIV Federal Materials Review Process • Congressionally mandated review of HIV prevention education materials supported by CDC funds • Messages must emphasize ways to fully protect against acquiring or transmitting the virus • Materials can not directly encourage sexual activities or drug use

39. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Testing and Prevention • Research • Income Support and Housing • Global Programs

40. Research • NIH Budget for HIV research is $2.62B in FY10 • Largest investments are biomedical • California HIV Research Program • FY07 $12M

41. Income Support and Housing • Cash Assistance (11% of Domestic HIV funding) • SSI - $500 M in FY10 • SSDI - $1,636 M in FY10 • Entitlement programs for the disabled • Housing Opportunities for Persons with AIDS (HOPWA) $310 M in FY10 • AIDS exceptionalism?

42. Conclusions—Domestic Issues • Health Reform has addressed many HIV/AIDS policy issues • But, the fragmented system still presents challenges

43. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Testing and Prevention • Research • Income Support and Housing • Global Programs

44. Global Programs • President’s Emergency Plan for AIDS Relief (PEPFAR) • President Bush proposed $15B commitment over 5 years in 2003 • Upped to $48 B over 5 years • Most US funding is bilateral, circumvents Global Fund • But US is still largest single contributor to GF • Obama administration changes in May 2009 • Funding at $63B over 6 years Global Health Initiative (GHI) • Shift from emergency response to sustainable mode • Recipient country ownership of planning process • Rebalance Global Health portfolio from HIV to MCH

45. HIV Is Largest Share of GHI

46. 2003 55% of funding for treatment; 20% for prevention 33% prevention funding had to be targeted to abstinence In 2005, 2/3 on abstinence, 1/3 condoms + Condoms only for “high-risk” (prostitutes, discordant couples, substance abusers) 2010 Over half of funding for treatment Target 50% of prevention funds on abstinence. If less, report to Congress AB-C still in place Global Policy Issues

47. 2003 ARVs must be approved by FDA (WHO approval not sufficient) HIV exempted from “gag rule” on abortions, but many misunderstood Funded organizations need “policy explicitly opposing prostitution and sex trafficking.” (PL108-25) No funding for needle exchange 2010 By 2007, 73% of drugs distributed were generic. Accelerated FDA approval. Pres. Obama rescinded “gag rule” on abortion Focus on MTCT, MC and services for IDUs Global Policy Issues (2)

48. Overarching Policy Questions • Will care and treatment crowd out prevention because we adopt a short term planning horizon? • Why do we spend so little on prevention? • Fragmented funding makes it difficult to • Know what resources are available • Coordinate care

49. Policy Resources HRSA http://www.hrsa.gov CDC http://www.cdc.gov/hiv NIH http://www.nih.gov CHRP http://chrp.ucop.edu CHIPTS http://chipts.ucla.edu Kaiser Family Foundation http://www.kff.org/hivaids CAPS http://www.caps.ucsf.edu