the patient protection and affordable care act update and implications joseph jefferson, mph...

The Patient Protection and Affordable Care ActUpdate and Implications

Joseph Jefferson, MPHDirector of Advocacy and Alliance Development

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1) Assessing the Landscape

2) ACA Implementation Update

3) ACA Patient Protections and Access

4) ACA and Ryan White

5) ACA and Implications for ADAP

6) Informing the Advocacy Agenda

Assessing the Landscape

HIV/Hep C Surveillance Comparison

0%

10%

20%

30%

40%

50%

60%

70% 66%57%

40%

Workforce Trends

• Providers of HIV Care reported increasing numbers of HIV patients with co-occurring conditions like:– Cardiovascular disease (50%)– Renal disease (49%)– Mental health conditions (48%)– Substance abuse (38%)– Hepatitis C (36%)

• 58% of HIV Providers are seeing increasing number of HIV patients with sexually transmitted infections

Workforce Trends

• Approximately 4,500 HIV providers (MD, DO, NP, PA) in US

• Fewer than 1/3 of physicians are in private practice – Movement to larger health systems

• The current HIV workforce composed of first generation providers who entered the field over 20 years ago.—50% of current HIV provider workforce retiring in next 5 to 10

years—Ryan White Part C-funded clinics report difficulty recruiting

HIV clinicians

Workforce Trends

Federal HCV Initiatives

• Healthy People 2020 (Dec 2010)– Goal: Increase immunization rates and reduce preventable

infectious diseases

• National Viral Hepatitis Action Plan (May 2011)– Increase % of persons aware of HBV infection from 33% to

66%– Increase % of persons aware of HCV infection from 45% to

66%– Reduce number of new cases of HCV by 25%– Elimination of mother-to-child transmission of HBV

• CDC recommendations on HCV testing for baby boomers (August 2012)

• Patient Protection and Affordable Care Act (2014)– Focus on prevention

ACA ImplementationUpdate

Implementation Benchmarks

• State Notification Regarding Exchanges

• Closing the Medicare Drug Coverage Gap

• Medicaid Coverage of Preventive Services

• Medicaid Payments for Primary Care

• Medicaid Expansion • Individual Insurance

Requirement• Health Insurance

Exchanges • Guaranteed Availability of

Insurance • No Annual Limits on

Coverage• Essential Health Benefits

January 2013 January 2014

Medicaid Expansion Decision Map

Center for American Progress, March 2013

Marketplace (Exchange) Decision Map

ACA Patient Protections and Access

Key ACA Patient Protections

• Guaranteed availability of coverage, regardless of health status or pre-existing condition

• Prohibitions on discriminatory premium rates, ie. Gender and health status

• Prohibitions on pre-existing condition exclusions

• Coverage of “specified” preventive health services without cost-sharing

• Low-income PWLHs <64 may qualify for Medicaid in states that choose to expand

Key ACA Patient Protections

• No lifetime or annual limits on coverage

• Health plans cannot drop people from coverage when they get sick

• Federal subsidies for people with incomes <400% FPL

• Plans have to contract with “community providers”, including Ryan White programs

• Plans must include EHB

ACA & Implications for HCV

• Increased access to health insurance HCV testing and treatment– 24% of HCV+ individuals without insurance had any

knowledge of their chronic liver disease (compared with 50% among insured)1

– Studies have found that of HCV-infected individuals in the US who are candidates for treatment, only half have any form of health insurance coverage and can, therefore, access treatment2

• Coverage of preventive services– USPSTF draft recommendations

• “C” grade for HCV screening among baby boomers (birth cohort)

• “B” grade for HCV screening among adults at high risk

1Center for Liver Diseases at Inova Fairfax Hospital; John Cochran, VA Medical Center and Saint Louis University School of Medicine, St. Louis, MO; Michael E. DeBakey, Baylor College of Medicine; and Betty and Guy Beatty Center for Integrated Research2Brian Edlin, MD; Center for the Study of Hepatitis C, Weill Medical College of Cornell University

Very-low income individuals with income below $15,000 (133%

FPL)(22 million by 2014)

Eligible for Medicaid based on income alone,

(250,000 PLWH -- 2011)*(+175,000 PLWH – 2014)*

Ryan White Program will fill gaps not covered by

Medicaid(529,000 PLWH – 2011)*(Approx. 80,000 PLWH –

2014*)

Individuals earning between $15,000 and

$44,000 (134% to 400% FPL)

(61 million by 2014)

Purchase private insurance with premium tax credits and

cost-sharing subsidies

Ryan While Program will fill gaps not covered by private

insurance

People who can never enroll in health care

reform programs

Ryan White Program will be a safety net for legal

immigrants not eligible for Medicaid (5 year ban) or

undocumented immigrants(Approx. 80,000 PLWH --

2014

PLHWs and Access

http://policyinsights.kff.org/2012/september/how-the-aca-changes-pathways-to-insurance-coverage-for-people-with-hiv.aspx

PLHWs and Access

ACA & CHCs/FQHCs

• Contains $11B in new, dedicated funding for Health Centers

• Over 8,000 Health Centers currently serving 20 million people

• Health Centers will provide care and treatment of the vast majority of newly eligible Medicaid patients transferring from ADAP

ACA & Ryan White

Ryan White Reauthorization Update

• Ryan White will likely not be reauthorized in 2013 – though 2009 reauthorization contains no sunset provision

• Programs will likely continue in FY 14 and beyond• Final FY13 CR did not include $35M for ADAPs and

$10M for PartC• Sequester likely to result in 5.2% HHS funding

reduction• Obama FY14 budget provides $20M increase in RW

– $10M ADAP; $10 for Part C clinics

• As Health Care Reform is implemented FQHCs are likely to see an influx of HIV patients

HRSA Justification Notes:

“The Ryan White Program is authorized through

September 30, 2013. However, the program will

continue to operate. The 2009 reauthorization or

the Ryan White HIV/AIDS Treatment Extension Act

of 2009 (P.L. 111-87, October 30, 2009) does not

include an explicit sunset clause. In the absence of a

sunset clause, the program will continue to operate

without a Congressional reauthorization.”

Ryan White Reauthorization Update

HRSA/HAB Considerations: • Identify issues as RW beneficiaries transfer to private

insurance

• Reallocate RW dollars toward premium support

• Create flexible enrollment procedures/timelines

• Clarify effective coverage dates

• Network v. out-of-Network care

• Prior Authorization for both Medicaid and Marketplaces

Ryan White Reauthorization Update

Federal RW Funding (infl-adj) and HIV Prevalence, 1991-2012

Source: Andrea Weddle, HIV Medicine Association, HIV Medical Provider Experiences: Results of a Survey of Ryan White Part C Programs, Institute of Medicine Committee on HIV Screening and Access to Care, September

ACA & Implications for ADAP

HealthHIV HealthGram on Medicaid Expansion & HIV Incidence by State and Health Ranking

ADAP 2014 Population Estimates

http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Top Quartile

Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Bottom Quartile

http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

Estimated % of ADAP Clients NEWLY Eligible for Private Insurance Subsidies in 2014: Top Quartile

http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

Estimated % of ADAP Clients Eligible for Private Insurance Subsidies IN 2014: Bottom Quartile

http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

ACA & Payor Shifts

ACA & Payor Shift

Current Payor Current Service Venues

MedicaidPrivate Practice

Ryan White / ADAP

RW Clinics

CHCs

ACA & Payor Shift

Current Payor Post-ACA Payor Current Service Venues

Medicaid MedicaidPrivate Practice

Ryan White / ADAP Marketplaces

FQHCs

PCMHs

Informing the Advocacy Agenda

HHS/CMS must:

• Ensure “Alternative Benefit Plan” is similar to traditional Medicaid• Give states flexibility to design multiple ABPs targeting specific

populations• Extend EHB non-discrimination mandates to ABPs• Apply rules governing prescription drug coverage under Medicaid to

ABP • Apply non-disc protections to drug benefit• Include preventive services, including routing HIV and HCV screening • Mitigate burdensome cost-sharing proposals by adopting standard

established in Medicare Part D low- income subsidy program

2. Advocates must press for Medicaid expansion in states leaning against expansion

Medicaid

Essential Health Benefits

1. CMS must: • Evaluate and standardize “medical necessity” requirements • Develop mechanisms to monitor utilization management techniques,

exclusions, and service limits• Ensure meaningful stakeholder engagement involvement at Federal

and State level in the run-up to EHB framework reevaluation in 2016 – Goal: Higher and more clearly defined national standards

• Issue clarifying guidance to states to ensure reasonable, accessible, and expedited appeals process regarding benefit and service coverage decisions – including access to most appropriate and effective combination ARV therapy

2. Advocates need to work with CMS to overcome opposition by payers

1. Press for national data system and/or standards for hepatitis data collection

2. Press for increased funding for hepatitis prevention

3. Clarify EHB prescription drug coverage standards (given new HCV treatment opportunities in the pipeline)

4. Increase provider and consumer education

HCV

Washington, DC 20009202.232.6749

www.healthhiv.orgjoseph@healthhiv.org

202.507.4727