health care reform and what it means for people living with hiv/aids duke aids policy project
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HEALTH CARE REFORMAND WHAT IT MEANS FOR PEOPLE LIVING WITH HIV/AIDS
Duke AIDS Policy Project
BARRIERS TO COVERAGE FOR PLWHA
1. Many can’t access employer based insurance
2. Pre-existing condition limitations
3. High cost
4. Can’t qualify for Medicaid because of income, assets, or inability to establish disability
5. Undocumented
Obamacare (the Affordable Care Act) solves everything but # 5
Americans want guaranteed coverage for pre-existing conditions
• Insurance market can’t add pre-existing conditions, getting most or all of the healthy people in the pool
• Getting most people in the pool means there has to be a requirement or very strong incentive
• If everyone has to be in the pool, there has to be financial aid to lower-income to pay premiums
• How the ACA does it:
• Elimination of medical discrimination• Mandated coverage• Premium Subsidies
COVERING THE SICK MEANS EVERYONE MUST BE IN THE POOL
THE LONG, TORTURED ROAD TO REFORM
1. ACA signed into law March 2010 – NO Republican voted for it
2. Immediate legal challenges – “individual mandate,” Medicaid
3. States and Federal Government engaged in frenzied implementation planning
4. March 2012 - Supreme Court upholds almost all of the law
5. Election 2012 & other threats to health care
OVERVIEW OF ACA CONSUMER PROTECTIONS
• Pre-existing conditions (effective 2014):
• Can’t be rejected• Health status can’t be considered in pricing
• Eliminates insurance caps
• Annual limits (effective 2014)• Lifetime limits (effective now)
• Can’t be dropped from insurance for getting sick
• Insurance can be terminated only for fraud
OVERVIEW OF INSURANCE EXPANSION
• Everyone who has adequate coverage already – employer, Medicaid, Medicare, etc -- stays the same
• People with inadequate or no coverage
• Over 133% of FPL State Insurance Exchange• State insurance exchanges with subsidies for
people 100 – 400% of poverty• Premiums, cost sharing, and maximum out of
• Under 133% of FPL Medicaid Expansion
• Temporary “Bridge” insurance: Federal Pre-existing Condition Insurance plan – available now through 2014
BENEFITS FOR NEWLY INSUREDBoth New Medicaid & Insurance Exchange require coverage of:
“Essential Health Benefits”• Specific benefits for
Medicaid and Insurance Exchange to be determined independently
• Specific benefits wont’ be the same between insurance plans or Medicaid
ESSENTIAL HEALTH BENEFIT CATEGORIES:
• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance
Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness
Services & Chronic Disease Management
• Pediatric services
SUPREME COURT DECISION• Upheld the
“individual mandate”
• ACA left standing, so consumer protections, etc remain in place, except….
• Limited the Medicaid Expansion• Feds can’t coerce
state to participate through withholding other Medicaid funds
• Left the public health fund intact.
IF MEDICAID IS NOT EXPANDEDOver 133% of FPL:
• Can buy insurance on Exchange
• Can get subsidies if under 400% of FPL
Under 133% of FPL
• No Medicaid Expansion unless State opts in
• Can buy insurance on exchange, BUT
• Subsidies not available to persons at or below 100% FPL
REFORM & HIV/AIDS: BREAKING IT DOWN
2014
Old Medicaid
New Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
2014
Old Medicaid
New Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
VA, Tricare
Medicare
PCIP
No change
2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
VA, Tricare
Medicare
PCIPNew Program
“NEW MEDICAID”
2014
New Medicaid
• Income up to 138% FPL (133% + 5% income disregard)
• No assets test• No disability requirement• Different benefits - based
on “benchmark” insurance plan
• Must cover “Essential Health Benefits”
(About 5000 PLWHA gain coverage)
NEW MEDICAID:ESSENTIAL HEALTH BENEFITS
2014
New Medicaid
• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance
Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness
Services & Chronic Disease Management
• Pediatric services
NEW MEDICAID:ESSENTIAL HEALTH BENEFITS
2014
New Medicaid
Potentially Missing:• Case Management• Oral Health• Vision• Long Term Care• Private Duty Nursing• Hospice• Personal Care
NEW MEDICAID:PRESCRIPTION DRUGS
2014
New Medicaid
• The ACA doesn’t specify how expansive (or not) the drug formulary will be.
• One early statement from HHS – one drug per class
• Lots of advocacy on this nationally
2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
Improvements
NOW
Medicare
• Free Preventative care
• Free annual wellness visit
• Medicare Part D:
• “Donut Hole” discounts to help pay for prescriptions.
• Donut Hole phased out by 2020
• ADAP counts as client’s out-of-pocket for Medicare Part D
2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
Uninsured
PCIP
VA, Tricare
Medicare
No Disc
rimin
atio
n
• Lifetime limits to insurance coverage eliminated.
• Insurance companies can’t cancel coverage just because you get sick.
• Children can’t be denied coverage due to a pre-existing condition.
• Free coverage for preventative care, like mammograms and colonoscopies.
EMPLOYER/PRIVATE INSURANCE
NOW
Employer/Private Insurance
2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange with
Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
New Insurance Marketplace
• Limited to those without adequate or affordable insurance
• State-based consumer-friendly insurance “marketplace”
• Subsidies on premiums and cost sharing to make health care more affordable only for those eligible to purchase on the exchange
• If state doesn’t take the lead, the federal government will operate the exchange & choose a default plan
• NC legislature has not adopted an exchange, but work has been done on plan evaluation, provider networks, etc.2014
Insurance Exchange
with Subsidies
INSURANCE EXCHANGE
About 1000 PLWHA
Same as for Medicaid – but specific covered services can be different• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness Services &
Chronic Disease Management• Pediatric services
INSURANCE EXCHANGE – ESSENTIAL HEALTH BENEFITS
2014
Insurance Exchange
with Subsidies
• Like Medicaid – based on a “Benchmark Plan”
• Same issues around prescription drugs
• The likely NC benchmark plan has open formulary
INSURANCE EXCHANGE – ESSENTIAL HEALTH BENEFITS
2014
Insurance Exchange
with Subsidies
INSURANCE EXCHANGE PROVIDER NETWORKS• Network adequacy: State must assure enough providers
to permit adequate access
• Essential Community Providers:
• Plans offered in the Exchange must include “essential community providers” in networks
• ECPs = providers that serve predominantly low-income, medically underserved communities
• This includes FQHCs, Ryan White grantees, STD/TB clinics, family planning clinics disproportionate share hospitals, etc.
• Network Adequacy
• Insurance plans don’t need to contract with ALL ECPs
INSURANCE/MEDICAID ENROLLMENT
Diagram from NC Institute of Medicine, Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina: Draft Final Report Pending US Supreme Court Decision, p. 64, May 2012
HEALTH CARE NAVIGATORS
Becoming a navigator:
• Entities that have expertise working with low-income, or other at-risk groups.
• Must have existing, or easily established, relationships with employers, employees, consumers (including the un- or under-insured)
• Must give fair, accurate and impartial information
2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
Uninsured
PCIP
VA, Tricare
Medicare
Gaps remain
• Immigrants• Undocumented, or• In US less than 5 years
• Some will be exempt from mandate because insurance still not affordable
• Some will choose not to sign up for insurance
SOME STILL UNINSURED
2014
Uninsured
• There will still be gaps to fill• Oral Health• Support services • Case management• Transportation• Cost sharing help• Uninsured
• Reauthorization in 2013 –What will Ryan White look like after health reform?
RYAN WHITE & REFORM
THREE SCENARIOS
A LOOK AT WHAT HEALTH CARE REFORM WILL MEAN FOR LOW-INCOME CONSUMERS WHO DON’T QUALIFY FOR MEDICAID
• Jane Smith earns $16,433 a year. In 2012, she will be at 149% of the Federal Poverty Level.
• Currently, she is uninsured and gets her care through Ryan White & ADAP.
• In 2014, she will be required to purchase health insurance for herself.
• What does Health Reform mean for Jane?
JANE SMITH
JANE SMITH & INSURANCE SUBSIDIESJane will be eligible for cost-sharing subsidies, premium credits, and reduced out-of-pocket limit
Without Subsidies With Subsidies
Premium $5700 $670/year (4% of income)$56/month
Cost sharing (deductible, copay, co-insurance)
Plan pay 70% of costs
Reduced so plan pays 96% of costs
Out of pocket $5950 $1984
• Mr. and Mrs. Diaz are undocumented immigrants. Their daughter, Maria, was born in the United States.
• Mr. Diaz has HIV, and currently gets care through Ryan White.
• Mr. and Mrs. Diaz pay taxes, and earn $25,390 a year, putting them at 133% of the Federal Poverty Limit.
• What happens to the Diaz family in 2014?
THE DIAZ FAMILY
THE DIAZ FAMILY & REFORM
• Because Mr. and Mrs. Diaz are undocumented, they will not qualify for Medicaid, or for any other protections under the ACA.
• The Diaz’ family can apply for Health Choice on behalf of Maria. (They will not have to provide any information on their immigration status).
• Mr. Diaz still needs Ryan White and ADAP to cover his care.
• Richard Doe is 30 years old and lives with his partner.
• Richard makes $46,021 a year, so he is at 400% of the estimated 2014 Federal Poverty Level.
• Richard’s employer – a small, local company, does not currently offer insurance. But, in 2014, they will begin providing insurance to their employees.
• Richard does not want his company to find out about his HIV status.
• What does reform mean for Richard?
RICHARD DOE
RICHARD, REFORM & CONFIDENTIALITY• Richard may not have to purchase his employer’s
insurance, if it costs more than 9.5% of his income ($4372/year or $364/month).
• Because insurers can no longer deny coverage based on pre-existing conditions, there is no reason for Richard’s employer to ask him about his health status.
• If the employer doesn’t offer insurance, Richard can buy on the Exchange. Richard will qualify a reduced premium: about $3440/year or $287/month
IS NC ON TRACK TO IMPLEMENTATION?• State leadership taking a “wait and see” approach (governor candidates,
legislative leaders)
• Looking to see what elections hold, chances of repeal• Federal government is moving forward at full speed – but that could
change with election outcome
• Health Benefit Exchange:
• State has not passed a bill to create its own Exchange & time is running short
• Feds may run exchange in 2014• Department of Insurance doing some planning• Because NC has not picked a benchmark plan, default plan will be the
largest insurance plan among the small-market plans, i.e. Blue Options.• Medicaid Expansion:
• Will require legislative action• Governor, candidates, and legislative leaders taking a “wait and see”
attitude• DMA (Medicaid) is planning, running numbers
THREATS TO REFORM ON NATIONAL LEVEL
• Depending on election outcome:
• “Obamacare waivers”?• Repeal
• Senate requires 3/5 majority if filibustered
• Repeal & Replace• Budget Reconciliation
• Takes time• Limited subject matter permitted
• Refusal of new administration to enforce ACA?• More litigation likely to compel
THREATS ON NATIONAL LEVEL BEYOND THE ACA
Sequestration
• Would cut 8.2% of non-exempt non-defense discretionary budget
• $659 million from domestic HIV/AIDS & viral hep
Medicare – Romney/Ryan plan for vouchers
• fixed dollar amount to buy coverage
Medicaid –
• Romney/Ryan: Block grant with growth limited to rate of inflation plus 1% annually (way less than current growth)
• 1.2 trillion drop in federal funding from 2014 to 2022• 14-27 million beneficiaries could lose coverage
• Per Capita funding – being discussed by both parties
GOP PLAN FOR MEDICAID
