HIV and Health Care Reform

Early Treatment for HIV Summit- July 20, 2009

Laura Hanen, National Alliance of State and Territorial AIDS DirectorsAndrea Weddle, HIV Medicine Association

Includes:- 29% who are uninsured- 21% who don’t know they are infected

Also:- 29% simultaneously diagnosed with HIV & AIDS- 39% have an AIDS diagnosis within one year- New infection rate at 56K per year (steady 2001-07)- Disparities remain for MSM, Black and Hispanic men

and women

Source: Kaiser and CDC

50% of people with HIV in the US Do Not Have Reliable Access to HIV Care

Earlier Access to Treatment Makes a Difference

Risk of death reduced by 94% if initiate treatment earlier.1

Treatment costs are 2.6 times higher per year at later stages of HIV disease.2

1Kitahata M, et al. N Engl J Med. April 2009. 360;18:1815-1826, 2009.2Chen RY, et al. Clin Inf Dis 42:1003-1010, 2006.

U.S. Population and People with HIV/AIDS Income & Unemployment

8%5%

45%

62%

Income<$10,000

Unemployed

US Population

People withHIV/AIDS

SOURCE: Kaiser Family Foundation based on US Census Bureau, 2006; Kaiser State Health Facts Online; Cunningham WE et al. “Health Services Utilization for People with HIV Infection Comparison of a Population Targeted for Outreach with the U.S. Population in Care.” Medical Care, Vol. 44, No. 11, November 2006. NOTE: US income data from 2005, US unemployment data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal; HCSUS data from 1998.

SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006

General Population PWHIV/AIDS

Population: 293 Million

People with HIV/AIDS: Health Care Coverage of Those in Care

Federal Funding for HIV/AIDS Care by Program, FY 2008 (in billions)

Ryan White2.2 (19%)

Medicaid(federal share

only)4.1 (35%)

Other0.8 (7%)

Medicare4.5 (39%)

Total = $11.6 billion

Sources: April 2008; KFF. Fact Sheet: U.S. Federal Funding for HIV/AIDS: The FY 2009 Budget Request; April 2008. OMB, CMS Office of the Actuary, HHS Office of Budget, 2008; CRS. AIDS Funding for Federal Government Programs: FY1981–FY2009,

Medicaid and Medicare

MEDICAID:

Needs Based Entitlement Program

MEDICARE:

Entitlement Insurance Program

Eligibility for disabled w/ low-income, few assets, citizenship, state residency AND disability

Program varies by state

Eligibility for disabled based on work history

2 year waiting period post eligibility

Primary entry for PWHIVs is SSI Primary entry for PWHIVs is SSD

Both programs have the same cruel disability standard:

You have to get sick and disabled to get

access to the health care services that could have

prevented you from getting sick in the first place.

Ryan White Program

Serves over 500,000 peopleVital for uninsured and UNDERinsuredOnly federal health program for non-

disabled people with HIVAnnual, discretionary funded program

does not grow based on needBenefits depend on where you live

HIV HEALTH CARE ACCESS GROUP:

KEY STEPS TO REFORM

HIV Health Care Access Working Group: Key Steps to Improve Access to HIV Care

Improve Access to Private Insurance

ACCESS Ensure coverage regardless of health status Eliminate pre-existing conditions exclusions Ensure portability of coverage

AFFORDABILITY Limit the cost of premiums Cap total out-of-pocket spending

COVERAGE Comprehensive benefits package

Offer public insurance plan option

Why a National Public Plan?

Reliable, stable coverage option no matter where you live

Economies of scale will reduce prices for prescription drugs and other services

Private plans, even Part D, have discouraged people with HIV from enrolling, e.g., higher cost sharing, provider networks, etc.

Competition based on quality not profit

Make Medicare and Medicaid Work for People with HIV/AIDS

Medicaid Expand to all low-income

regardless of disability Increase eligibility up to

200% federal poverty level (around $22,000 per year)

Enact ETHA - allow states to ensure adequate eligibility and coverage for people with HIV

Address disparities in reimbursement

Mandate more benefits, e.g., prevention services, including routine HIV screening

Medicare End 2-year waiting period

for people with disabilities (or offer affordable, comprehensive alternatives)

Eliminate donut hole Allow ADAP to Count as

TrOOP Improve prevention

coverage, including routine HIV screening

Build On What Works: Ryan White HIV Clinics and Programs

Ryan White helped develop coordinated, comprehensive HIV care programs, i.e., medical homes for people with HIV/AIDS

Integrate Ryan White programs into the reformed system

Develop reimbursement systems to adequately support and improve access to these programs

Address the HIV Medical Workforce Crisis

Targeted loan forgiveness for working in Ryan White-funded clinics

Develop reimbursement systems that support specialized primary care

Conduct national study to assess regional variations in need and to identify barriers

Where Are We

with

Health Care Reform?

Obama Administration

Issued eight principles $634 billion reserve fund down payment Established Office of Health Reform at

White House and HHS Engaging in conversation with Hill leaders Hosting stakeholder meetings Rallying the grassroots – Cheerleader in

Chief

Key Congressional Players

U.S. Senate Finance Committee Health, Education, Labor and Pensions Committee

House of Representatives Energy and Commerce Committee Ways and Means Committee Education and Labor Committee

House and Senate Leadership Senate moderate Republicans and conservative

Democrats

Congressional Process

U.S. Senate HELP Committee passed bill July 15th Finance Committee negotiating (bill this week?) Goal = Merge bills before going to Senate floor prior

to August recess U.S. House of Representatives

Three committees worked together released Tri-Committee bill July 14th

Passed Ways & Means, Ed & Labor; E&C marking up Goal = Bill to House floor before August recess

Key Components of Reform Proposals

Insurance market reforms – no pre-existing exclusions; limit premium variability; limit plan profits; no lifetime caps

Create regulated marketplace for un/underinsured to purchase insurance with subsidies for low income

Expand Medicaid to Childless Adults Invest in Prevention and Workforce Choice of Public Plan?

HELP Bill “Affordable Health Choices Act” - Coverage

Based on Version that was Marked Up by Committee Creates “Gateway” – state-based exchanges Establishes a government run “public plan” Defines Essential Benefits – ambulatory and ER,

hospitalization, maternity and newborn, medical & surgical, mental health & substance abuse, prescription drugs, rehabilitative, habilitative, laboratory services, preventive and wellness, pediatric services

Creates Commission to advise Secretary on benefits Weak provider network provisions

HELP Bill - Affordability

Three tiers of plans vary by cost sharing Provides subsidies up to 400% of FPL Annual out of pocket cap - $5,800 for

individual; $11,600 family Limits out of pocket expenses

1 to 12.5% for individuals up to 400% FPL Premiums no greater than 12.5% generally

HELP Bill - Medicaid and Medicare

Expands Medicaid to 150% of FPL Federally financed initially – cost

transitions back to states No changes Medicaid reimbursement,

benefits (Finance jurisdiction) Does not address Medicare, Part D

(Finance jurisdiction)

HELP Bill – Primary Care Workforce

Creates National Workforce Commission Expands primary care workforce loan

forgiveness and training programs Creates new primary care and dental

training grant program that prioritizes programs addressing HIV among other vulnerable groups

HELP Bill - Prevention and Public Health

National Prevention, Health Promotion and Public Health Council to develop and carry out a national strategy

Prevention and Public Health Investment Fund that grows from $2 to $10 billion for activities authorized by the Public Health Service Act

Research on public health services and systems

Data collection to better identify and address racial, ethnic, regional health disparities

Senate Finance Committee – Policy Options

Tax credits for mandated individual coverage up to 300% FPL, fine for non-compliance

Looking for public plan alternatives, e.g., non-profit consumer owned and oriented plan

Consumer protections regardless of health status

Senate Finance Committee Options

Medicare eligibility at 55 and no 2-year wait

Phased-in Medicaid for all citizens below 100% of FPL, children and pregnant women up to 133%

Market reforms in small and non-group markets

Four benefit categories – Bronze, Silver, Gold, and Platinum

Prevention in the context of Medicare, Medicaid and workplace wellness

House Tri-Committee Bill - Coverage

National “exchange” for purchasing insurance

National public health insurance option

Establishes essential benefits similar to HELP bill except also specifies coverage for medical equipment and supplies

Stronger provider network provisions - requires plans contract 340B programs, i.e., Ryan White programs

House Tri-Committee Bill - Affordability

Four benefit levels- three vary by cost sharing – premium plus can offer extra services, e.g., vision, dental

Subsidies for premiums and cost sharing available up to 400% FPL

Caps on out-of-pocket spending Annual - $5,000 for an individual; $10,000 for a

family Premium/cost sharing cap ranges 1.5% (133%)

to 11% (400%) of income (sliding scale)

House Tri-Committee Bill - Medicaid and Medicare

Expands Medicaid to 133% FPL and adds childless adults – 2013 (federally financed)

ETHA available to states until 2013 Raises Medicaid reimbursement to Medicare

levels (federally financed) Requires coverage preventive services

according to USPHTF Improves Medicare Part D – ADAP as TrOOP,

coverage gap phased out 2011 to 2023

House Tri-Committee Bill – Public Health

Public Health Investment Fund which grows from $4.7 billion in FY2010 to $8.8 billion in FY2014 Expansion of Community Health Centers Data collection to better identify and address racial,

ethnic, regional health disparities Health and public health workforce Prevention and Wellness Trust starting at $2.4

billion in FY2010 and rising to $3.5 billion in FY2014

Tri-Committee Bill - Workforce

Similar to HELP bill expands primary care loan forgiveness and training program, including targeted grants prioritized to “vulnerable populations”

Also creates new loan forgiveness and training programs to shore up public health workforce

Two Things You Can Do to Advance Health Care Reform

1.Keep the Pressure OnWe must keep the pressure on Congress to ensure the needs of our HIV-positive community are met.

2.Tell Us Your StoryAFC is working to collect individual health care stories from people living with HIV/AIDS. Personal anecdotes, like your own, will help us advocate for the strongest health care provisions possible. Tell us your story today!

Make It Happen – Visit AIDS Foundation of Chicago - www. AFC.org

Resources

Bill Analysis: HIV Health Care

Access Working Group www.taepusa.org

Kaiser Family Foundation healthreform.kff.org

Bills, Summaries and Mark Ups: edlabor.house.gov waysandmeans.house.gov energycommerce.house.gov finance.senate.gov help.senate.gov

Contact Information

Laura HanenDirector of Government RelationsNational Alliance of State and Territorial AIDS

DirectorsCo-chair HIV Health Care Access Working GroupPh 202.434.8091lhanen@nastad.org

Andrea WeddleExecutive DirectorHIV Medicine Associationph 703.299.0915aweddle@idsociety.org