Alphabet Soup: ACA, HIV, SUD, TB, and HCV on the Border

1. Alphabet Soup: ACA, HIV, SUD, TB, and HCV on the Border June 20, 2014 Tom Donohoe, MBA Associate Professor of Family Medicine Director, UCLA Pacific AIDS Education and Training Center Associate Director, UCLA Center for Health Promotion and Disease Prevention David Geffen School of Medicine at UCLA

2. I have already seen you present on the ACA(in-person, webinar, etc) • True • False • I don’t remember

3. How many ACA-related trainings have you already attended (last 12 months)? • 0 • 1-2 • 3-4 • 5 or more

4. Declaration of Disclosure I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter

5. Educational Objectives 1 • State the importance of understanding ACA implementation for California and Arizona and how it will impact border communities &people living with HIV, TB, HCV, and SUD • Identify key dates for ACA roll-out and strategize to effectively implement the ACA locally

6. Educational Objectives 2 • Explain how the ACA will extend new insurance benefits and patients’ rights and responsibilities • Improve HIV patients’ engagement (linkage & retention) in high-quality HIV care as systems change • Obtain further information and referral resources for ACA implementation in the border region as more patients become enrolled

7. Which best describes WHERE you work? • Clinic • Community-based organization • Health department • University • Hospital • Other

8. Which best describes WHAT you do? • Clinician (MD, PA, NP, nurse, dentist, etc) • Case manager • Health education (peer educator, promotora) • Medical Assistant • Other

9. What type of clinician? • MD • NP • PA • Nurse • Dentist • Other

10. The Border

11. The HRSA/Federal definition of the U.S. border region is how many miles from Mexico? • 5 miles • 12 miles • 62 miles • 75 miles • 100 miles

12. The Border

13. U.S. Border Region Challenges • Health Professional Shortage Area (HPSA) • Higher incidence of infections diseases compared with the U.S. average • If made a state, the border region would rank: • 1st in number of uninsured children • 2nd in death rates due to hepatitis • 3rd in deaths related to diabetes • Last in access to health care • Last in per capita income Source: US/Mexico Border Health Commission

14. Where the Poor and Uninsured Americans Live

15. HIV Treatment Cascade Gardner, E., et al. (2010). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 52(6):793-800.

16. Affordable Care Act (ACA)

17. Health Reform from the Beginning… Medicare & Medicaid established Affordable Care Act (ACA) signed into law Supreme Court upholds ACA

18. Where We Are Now & Where We Are Going • Outreach/Education • Assistors/Navigators • Marketplaces • Sign-up starting October 1, 2013 Health Insurance (Marketplaces & Medicaid expansion) coverage begins January 1, 2014 ACA fully implemented

19. I feel the ACA will make my job more secure • True • False • I’m not sure/Don’t know

20. * What About HepC and ACA? Rachel McLean, MPH Brian Risley, Danny Jenkins….. * MediCal expansion? Co-pays, Payment assistance, budget busters, reinfection rates, Costs costs costs costs sustainable? Undocumented?

21. Affordable Care Act (ACA) & HIV Services • Elimination of pre-existing condition exclusions • Expansion of Medicaid to non-disabled adults with incomes of up to 133% of FPL • Subsidies to purchase insurance through exchanges for people with income up to 400% FPL • More PLWH are eligible for Medicaid/Marketplace exchanges

22. Ryan White Funds: Payer of Last Resort Ryan White Program funds may not be used for any item or service “for which payment has been made or can reasonably be expected to be made by another payment source.”

23. Income status of individuals who receiveRyan White-funded services FPL = Federal Poverty Level

24. What is 100% of the 2013 FPL for a single person • $5,025/year • $7,110/year • $11,490/year • $13,170/year • I have no idea

25. 2013 Federal Poverty Level 138% FPL=$15,856 CoverageforAll.org

26. Medicaid Expansion JAMA. 2013;309(12):1219. doi:10.1001/jama.2013.2481

27. Which border state has said it will NOT expand Medicaid as part of ACA implementation? • Arizona • California • New Mexico • Texas

28. Ryan White Core Services vs. Essential Health Benefits (EHB) Ryan White Core Services • Ambulatory & outpatient care • AIDS pharmaceutical assistance • Mental health services • Substance abuse outpatient care • Home health care • Medical nutrition therapy • Hospice services • Home and community-based health services • Medical case management, including treatment adherence services • Oral health care (not standard) ACA “Essential Health Benefits”* • Ambulatory patient services • Emergency services • Hospitalization • Maternity &newborn care • Mental health &substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative &habilitative services &devices • Laboratory services • Preventive and wellness services &chronic disease management • Pediatric services, including oral & vision care

29. Health Insurance (Marketplace) Exchanges Kaiser Family Foundation. State Decisions for Creating Health Insurance Marketplaces. http://www.kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/

30. State-Based Marketplace Exchanges:California & New Mexico

31. Federally Facilitated Marketplace Exchanges: Arizona & Texas

32. ACA Implementation on the Border

33. ACA Implementation on the Border • Expanding health insurance coverage in every state • Increasing access to Medicaid • Establishing Health Insurance Marketplaces • Covering preventive services with no deductible or co-pay

34. ACA Implementation in Arizona • Expanded Meidicad • Implemented federally-run health insurance marketplace

35. Case Study: Arizona Pedro is a 28 year old resident of Nogales, Arizona making ($12,065 or 105% FPL) who commutes to Tucson for HIV care at a Ryan White clinic. He has been in the U.S. legally for 7 years. He also receives HIV dental care and case management services through the Ryan White program in Tucson. He wants to stay at his HIV clinic.

36. Under the ACA, will Pedro be required to purchase health insurance? • Yes • No • I’m not sure.

37. Will Pedro be able to continue to receive HIV dental care through the Ryan White program? • Yes • No • I don’t know.

38. ACA Implementation in California • Increasing access to Medicaid • Transition to Medicaid expansion: Low Income Health Programs (LIHPs) • Implementing state-run health insurance marketplace

40. Border Rating Regions/Plans San Diego Imperial HealthNet (HMO)/$269 Kaiser Perm (HMO) Anthem (EPO) Blue Shield (PPO) Kaiser Permanente (HMO) Anthem (PPO) Molina Healthcare (HMO) SHARP Health Plan (HMO co-pay) Blue Shield (PPO) SHARP Health Plan (HMO co-insurance) Anthem (HMO)/$336

41. ACA, FPL, HIV, and OAHIPP Medicaid Expansion (MediCal) 138% of Federal Poverty Level (FPL) $15,856 (Individual) $32,500 (Household of 4) 100% 138% Immediate (or deferred) Premium Tax Credits 400% 500% HIV-------OAHIPP<$50,000 $11,490 (Individual) $23,550 (4) $45,960 (Individual) $94,200 (4) 100 % 138% Subsidies 250% Silver Plan $28,725 (Individual) $58,875 (4) $11,490 (Individual) $23,550 (4)

42. Case Study: California Antonio is a 28 year old single construction worker with no children living with HIV. He was born in Los Angeles and now lives in San Diego. He earns $19,000/year (165% FPL). He does not have health insurance and goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says “saved my life.” He says he wants health insurance so he can take care of his chronic back problems, which he thinks may require surgery .

43. Border Rating Regions/Least expensive plan San Diego

44. Case Study: Antonio Silver(eligible for Federal Subsidy) Premium:$41/month (of a $231/month premium--per Covered CA calculator) Copays: Primary Care Visit: $15   Generic Drugs: $5 Lab Test $15 X-Ray: $20 Deductible: $500  Out of pocket maximum: $2250

45. Case Study: California Juan is a single construction worker with no children living with HIV. He lives in Imperial county and earns $15,512/year (135% FPL). He does not have health insurance and goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says “saved my life.” Juan has been in the United States legally for 5 ½ years.

46. Will Juan need to go to the Marketplace to purchase health insurance? • No, he will go to the Market Place and enroll in Medicaid (Medi-Cal) • Yes, and he will could get his entire premium paid by OAHIPP • Yes, he will need to purchase health insurance in the Market Place, but he will get no subsidy • I have no idea

47. Juan is in an auto accident and receives care in the emergency room. Does he have health insurance? • Yes • No • I don’t know.

48. Case Study: Maria Maria is a single 51 year old house/hotel cleaner living in Calexico who estimates she will make $21,027 in 2014 (183% FPL), but has no health insurance. She says she could never afford the rates for “someone my age.” She has not seen a doctor for years, but sometimes goes across the border for antibiotics, dental care, and “back pain medicine.” She wants health insurance as she has chronic back problems and owns a small house worth $200,000. She is afraid an ER trip could bankrupt her or cause her to lose the house.

49. Maria (con’t) Maria is a little worried that she is taking too much ‘back pain medicine’ as she has to take more and more to get relief from “pain …and sometimes stress” as she heard these pills could be addictive. Otherwise, she believes she is in good health and feels great. However, she does not know that she is living with HIV and hepatitis C. She would not report any risks for either if asked.

50. Under the Affordable Care Act, Maria will be required to purchase health insurance or face a tax penalty. • a. True • b. False • c. I’m not sure