The Future of Health Care: Health Care Reform and Beyond

1
The Future of Health Care Health Care Reform
and Beyond

• Laura Hanen
• Director of Government Relations, National
  Alliance of State Territorial AIDS Directors
• Robert Greenwald
• Director, Health Law and Policy Clinic, Harvard
  Law School and Treatment Access Expansion Project

United States Conference on AIDS October 31,
2009
2
Part 1 Current Barriers to Care Why Our
Current Health Care System Fails to Meet the
Health Care Needs of PLWHIV Part 2 Our
Health Care Reform Agenda Priorities for
Addressing the Health Care Needs of PLWHIV Part
3 The Current Status of Health Care Reform and
Our Efforts to Reduce Barriers to Care
3
PART 1

• An introduction to why our health system is
  failing people living with HIV and AIDS

4
50 of people with HIV are NOT in regular care
in the U.S.

• Includes
• 29 who are uninsured
• 21 who dont 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 (no decrease
  2001-07)
• Disparate impact continues for, among others,
  MSM,
• Black and Hispanic men and women

Source Kaiser and CDC
5
How Americans Obtain Health Care Coverage
Population 293 Million
SOURCE Urban Institute and Kaiser Commission on
Medicaid and the Uninsured estimates based on
theCensus Bureau's March 2005 and 2006 Current
Population Survey (CPS Annual Social and
Economic Supplements).
6
US Population and Peoplewith HIV/AIDS

• Income Unemployment

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.
7
People with HIV/AIDS Health Care Coverage of
Those in Care
General Population
PWHIV/AIDS
Population 293 Million
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
8
Medicaid v. Medicare
MEDICAID MEDICARE
Needs Based Entitlement Program Entitlement Insurance Program
Eligibility for disabled w/ low-income, few assets, citizenship, state residency AND disability Eligibility for disabled basedon work history
Program varies by state . Mandated 24 month delay Prescription drug benefit comes with significant out of pocket co-payment requirements donut Hole
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. 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.
9
Medicaid Mandatory and Optional Benefits
Mandatory Optional
Physicians services Prescription drugs
Lab X-ray services Clinic services
Inpatient and outpatient hospital services Psychologist Services
Family planning services Substance Abuse Treatment
Federally-qualified health center and rural health clinic services Dental services and dentures
Nurse midwife and nurse practitioner services Case Management
Long-term nursing facilities and home health care for individuals 21 Prosthetic devices, eyeglasses
Kaiser Commission, Medicaid and the Uninsured,
p. 7 (2001). http//www.kff.org/medicaid/2256-inde
x.cfm
10
Medicaid Optional ServicesA Four State
Comparison
MA LA AR MS
Substance Abuse Treatment X X (lt21)
Dental Care X X (lt21) (gt21 dentures) X (lt21)
Pharmacy Services X X X X (5 per month)
Transportation X X X X
Case Management X X
Clinic Services X X
Psychologist Services X X (lt21)
Eyeglasses X X X
11
Medicare Benefits
Part A (no premium) Part B (96.40/mo)
36 of spending 29 of spending
Inpatient hospital services Physician and outpatient services
Skilled nursing facilities Preventive services
Home health and hospice Home health visits
Part C Part D
24 of spending 11 of spending
Medicare Advantage Choose a private health plan that receives govt funds Often higher benefits and lower copays than Medicare Prescription drug benefit (optional addition to coverage)
12
Medicare Standard Drug Plan Cost in 2009
Catastrophic Coverage
0- 275
275-2510
2,510 -5726
Total Spending
75 Plan Pays
80 Feds Pay Reinsurance
Donut Hole Coverage Gap

Deductible
95
25 out-of-pocket
15 Plan Pays
Consumer Out-Of-Pocket
5 out-of-pocket
601
3454
295
Total consumer out of pocket 4,350
Consumer Pays
Federal Government Pays
Private plan Pays
13
Public Funding HIV/AIDS CareIncluding Ryan
White (FY 2008)
14
Ryan White Program Overview

• Single largest federal program specifically for
  PWHIVs (Provides services to people living with
  HIV - not just AIDS)
• First Authorized in1990. Reauthorized in 1996,
  2000, 2006 (Operating on continuing
  resolution since 9/31/09)
• Payer of last resort
• Original intent was to fill gaps in care/support
  (Increasingly primary funder of care and
  treatment)
• What you get depends upon where you live
• A discretionary program subject to annual
  appropriations

15
Ryan White Program Five Primary Parts

• Part A Grants to EMAs TGAs cities/ metro.
  areas most severely impacted by HIV (26.4)
• Part B Grants to states and territories
  including ADAP (52.2)
• Part C Grants to outpatient providers to support
  access to early intervention services and
  comprehensive primary health care (10)
• Part D Grants to outpatient/ambulatory care
  centers providing care and services tor women,
  infants and children living with HIV (3)
• Part F Grants to support Special Projects of
  National Significance (1), AIDS Education and
  Training Centers (1.3), Dental Programs (0.5)
  and the Minority AIDS Initiative (5.6)

16
ADAP Four State Comparison Chart
Massachusetts Louisiana Alabama N. Carolina
Drug Formulary Open 60 drugs 52 drugs 121 drugs
Hepatitis Coverage Yes for A,B C No No Yes for A,B C
Income Limit 50,000 (481 FPL) 20,800 (200 FLP) 26,000 (250 FPL) 26,000 (250 FPL)
Asset Limit No Asset Limit 4,000 No Asset Limit No Asset Limit
Part D Premiums Yes Yes Yes No
Part D Co-pays Yes Yes Yes No
Donut Hole Coverage Yes Yes Yes No
17
Number of People Living with AIDS in the US
v. Ryan White Funding ( No adjustment for
inflation)
Sources Estimated Number of Persons Living with
AIDS, Centers for Disease Control and
Prevention, http//www.cdc.gov/hiv/topics/surveill
ance/resources/reports/2007report/table12.htm
Ryan White Appropriations History, Health
Resources and Services Administration,
ftp//ftp.hrsa.gov/hab/fundinghis06.xls.
18
Number of People Living with AIDS in the US v.
Ryan White Funding (Adjustment for Inflation)
Sources Estimated Number of Persons Living with
AIDS, Centers for Disease Control and
Prevention, http//www.cdc.gov/hiv/topics/surveill
ance/resources/reports/2007report/table12.htm
Ryan White Appropriations History, Health
Resources and Services Administration,
ftp//ftp.hrsa.gov/hab/fundinghis06.xls.
Inflation calculated using http//www.usinflationc
alculator.com/.
19
Summary Private and Public Health Care Programs
Are Failing PWHIV

• Private Insurance
• Largely employer-based yet most people living
  with HIV are unemployed or low-wage workers
• Medicaid/Medicare
• We have a disability care system, not a health
  care system
• Medicaid Mandated benefits package insufficient
• Medicare Part D out-of-pocket co-pays too high
• ADAP/Ryan White Program
• Funding is not keeping pace with growing demand

20
PART 2 Our Health Care Reform Agenda
Priorities for Addressing the Health Care Needs
of PLWHIV
21
HIV Health Care Access Working Group

• Established in 2003
• Coalition of more than 100 national, local, and
  regional organizations representing HIV medical
  providers, public health, CBOs, advocates and
  people living with HIV/AIDS
• Part of the Federal AIDS Policy Partnership
• Mission to increase early and affordable access
  to quality, comprehensive care for people living
  with HIV/AIDS

22
HIV Health Care Access Working Group

• Calling for leadership
• Analyzing bills
• Weighing in on bills as they move
• Holding grassroots calls
• Developing simple messaging
• Conducting Hill visits
• Participating in other coalition activities

23
Priorities for Health Reform

• Medicaid
• Medicare
• Private Insurance
• Health Disparities
• Prevention and Public Health
• Medical Workforce Crisis
• Ryan White Program Extension and Integration

24
Medicaid

• Eliminate the disability requirement and expand
  access to all who are low-income
• Include ETHA for increased access
• Create a new national benefits package
• Limit the amount low-income people pay
• Cover voluntary, routine HIV testing
• Adequately reimburse and create incentives to
  strengthen the HIV provider workforce

25
Medicare

• Eliminate the 2-year waiting period for disabled
• Eliminate the donut hole and other cost sharing
  barriers
• Include ADAP as TrOOP
• Continue to protect access to HIV meds
• Offer buy-in to younger populations
• Cover voluntary, routine HIV testing

26
Private Insurance

• Access
• Ensure coverage regardless of health status
• Eliminate pre-existing condition preclusions and
  lifetime caps on benefits
• Ensure portability of coverage
• Affordability
• Limit the cost of premiums
• Cap total out-of-pocket spending
• Sufficient subsidies
• Coverage
• Mandate comprehensive benefits package
• Voluntary, routine HIV testing
• National Public Insurance Option

27
Health Disparities

• Data collection
• Incentives for providers to work in underserved
  communities
• Address linguistic and cultural concerns such as
  credentialing and adequate reimbursement for
  medical translators
• Include racial and ethnic minorities in clinical
  trials
• Elevate the National Center on Minority Health
  and Health Disparities at NIH
• Strengthen the Office of Minority Health at DHHS

28
Prevention and Public Health

• Prevention and Wellness Trust with dedicated
  mandatory funding
• Grants for community, population based prevention
  programs
• Grants to strengthen public health
  infrastructure/core capacity
• Including disease surveillance and monitoring
  systems
• Address public health workforce shortages
• National electronic health information exchange
  system that integrates public health and clinical
  data
• Support coverage for comprehensive clinical
  preventive services
• Comprehensive sexuality education

29
Addressing the Medical Workforce Crisis

• Develop reimbursement systems that reflect true
  cost of care and support specialized primary care
• Integrate HIV workforce issues into primary care
  workforce initiatives
• Offer loan forgiveness
• Conduct national study to assess regional
  variations in need and to identify barriers
• Specifically focus on workforce development
  addressing health disparities

30
Ryan White Program

• Extend and fully fund Ryan White Program
• Access expansion under health reform are off in
  the future
• Program still essential to fill gaps and provide
  support services
• Integrate the network of RW-funded providers into
  the broader health system
• Provide adequate cost-based reimbursement
• Ensure that Medicaid/ private insurers build RW
  providers into disease management or medical home
  networks

31

• PART 3
• The Current Status of Health Care Reform and Our
  Efforts to Reduce Barriers to Care

32
Obama
So let there be no doubt health care reform
cannot wait, it must not wait, and it will not
wait another year. President Barack Obama,
Feb. 24, 2009 Joint Session of Congress
33
Key Congressional Players

• House Energy and Commerce, Ways and Means,
  Education and Labor
• Senate Finance and HELP
• House and Senate Leadership
• Olympia Snowe (and other Senate moderate
  Republicans?) and conservative Democrats

34
Private Insurance Reform

• Overview
• Access
• Coverage mandated benefits
• Affordability cost-sharing
• Individual and Employer Mandates

35
Overview Overall Approach to Expanding Access to
Health Insurance
Finance HELP House
Require most citizens / residents to have health insurance Require individuals to have health insurance Require individuals to have health insurance
State-based exchanges for individual market Small business exchanges (SHOPs) for small group market State-based American Health Benefit Gateways for individuals and small employers National Health Insurance Exchange for individuals and employers
No public option co-ops State-based public option National public option
By 2019, 25M non-elderly uninsured. By 2019, 20M non-elderly uninsured. (Doesnt address 14M Medicaid.) By 2019, 12M non-elderly uninsured

36
Private Insurance - Access
Finance HELP House
Guaranteed issue and renewability Guaranteed issue and renewability Guaranteed issue and renewability
Prohibits pre-existing condition exclusions rescissions (except in case of fraud) Prohibits pre-existing condition exclusions rescissions (except in case of fraud) Prohibits pre-existing condition exclusions rescissions (except in case of fraud)
Prohibits lifetime caps on coverage for individual and small group plans Allows reasonable cap on large group plans Prohibits lifetime caps on coverage Prohibits lifetime caps on coverage

37
Private Insurance Access, contd.
Finance HELP House
No premium adjustment for health or gender No premium adjustment for health or gender No premium adjustment for health or gender
Premium adjustment only for tobacco (1.51 ratio), family size (31 ratio), age (41 ratio) Premium adjustment only for geography, tobacco (1.51 ratio), family size, age (21 ratio) Premium adjustment only for geography, family size, age (21 ratio)
Applies to exchange and small groups Applies to all plans Applies to all plans
Requires plans to allow dependent coverage for up to age 26

38
Private Insurance Coverage Mandated Benefits
for Exchange Plans
Finance HELP House
Hospitalization Emergency services Prescription drugs Physician services Outpatient care Preventive, primary care Maternity and newborn Pediatric care (inc. dental and vision) Mental health and substance abuse services that meet min. legal standards Diagnostic imaging / screenings (X-rays) Medical/surgical care Radiation chemo Hospitalization Emergency services Prescription drugs Outpatient care Preventive and wellness Maternity and newborn Pediatric care Mental health and substance abuse care Rehabilitative and habilitative services and devices Laboratory services Hospitalization Emergency services Prescription drugs Physician professionals Outpatient care Preventive care Maternity, well baby Pediatric (inc. oral, vision, and hearing) Mental health and substance abuse care Rehabilitative and habilitative services Equipment and supplies
39
Affordability Federal Poverty Level
Family Size
1 2 3 4
100 10,830 14,570 18,310 22,050
200 21,660 29,140 36,620 44,100
300 32,490 43,710 54,930 66,150
400 43,320 58,280 73,240 88,200
40
Affordability Premiums

• Premium Subsidies Individual consumer share is
  a percentage of income.
• For example, a single individual at 200FPL pays
• 7 of income under Senate Finance
• 3.3 of income under Senate HELP
• 5.5 of income under House bill
• Government provides a subsidy to cover the
  remainder

41
Affordability Consumer Share after Premium
Subsidy

• Premium Credits (as of annual income)

Finance HELP House
100 FPL 2 (in 2014)
133 FPL 2 (in 2013) 1.5
150 FPL 4.5 1 3
200 FPL 7 3.3 5.5
300 FPL 12 7.9 10
400 FPL 12 12.5 12
42
Affordability Consumer Share of Insurance
Premiums
43
Affordability Cost-Sharing Subsidies and Caps

• Cost-Sharing Subsidies
• Individual consumer share is percentage of cost
  of care or treatment provided based on income.
• Government provides a subsidy to cover the
  remainder
• Cost-Sharing Caps
• Each bill establishes an out-of-pocket limit or
  cap on consumer spending on the cost of care or
  treatment

44
Affordability Consumer Share after Cost-Sharing
Subsidies
Finance HELP House
100 FPL 10 3
133 FPL 10 3
150 FPL 20 7 7
gt200 FPL 35 15
gt250 FPL 35 22
gt300 FPL 35 28
gt350 FPL 35 30
gt400 FPL 35 24 30
45
Affordability - Cost-Sharing Spending Caps
Finance HELP House
lt150 FPL 1,964 individual 3,937 family 1,190 individual 2,380 family 500 individual 1,000 family
150-200 FPL 1,964 individual 3,937 family 1,190 individual 2,380 family 1,000 individual 2,000 family
200-250 FPL 2,975 individual 5,950 family 2,975 individual 5,950 family 2,000 individual 4,000 family
250-300 FPL 2,975 individual 5,950 family 2,975 individual 5,950 family 4,000 individual 8,000 family
300-350 FPL 3,966 individual 7,933 family 5,950 individual 11,900 family 4,500 individual 9,000 family
350-400 FPL 3,966 individual 7,933 family 5,950 individual 11,900 family 5,000 individual 10,000 family
gt 400 FPL 5,950 individual 11,900 family 5,950 individual 11,900 family 5,000 individual 10,000 family
46
Affordability - Cost-Sharing at 150 FPL
Finance
HELP
House
7,143 9,820
17,000
For an individual with income at 150 FPL (16,
245 per year).
47
Affordability Cost-Sharing at 300 FPL
House
HELP/Finance
Finance
HELP
8,500 13,523
18,182 18,594

For an individual with income at 430 FPL
(32,490 per year).
48
Total Out-Of Pocket Cost to Consumer Premium and
Cost-Sharing
49
Private Insurance Individual Mandate
Finance HELP House
Enforced through a tax penalty of 750 per adult per year, phased in through 2016 Enforced through a minimum tax penalty of 750 per individual per year Those without coverage pay a penalty of 2.5 of MAGI up to the cost of the average national premium under a basic Exchange plan
Exemptions Financial hardship Religious objections American Indians The lowest cost plan option exceeds 8 of an individuals income Incomes below 133 FPL Exemptions Individuals in a state without a Gateway Members of Indian tribes Those with no available affordable coverage Those without coverage for fewer than 90 days Incomes below 150 FPL Exemptions Financial hardship Religious objections Dependents Non-Resident aliens Those residing outside of the U.S. Those residing in possessions of the U.S.

50
Private Insurance Employer Mandate
Finance HELP House
Employers must provide coverage Employers must provide coverage and 60 of premium Employers must provide coverage and 72.5 of individual premium or 65 of family premium
Employer penalty ONLY for employees who receive subsidies cost of subsidy or 400 per employee 750 employer penalty for each uninsured employee (375 for part time) Employer penalty pay 8 of payroll into Health Insurance Exchange Trust Fund
Small employer exception Exemption 25 or fewer employees Small employer exception sliding scale ranging from 0-6
Employers with 200 employees must automatically enroll employees Employers that provide coverage must automatically enroll employees
51
Public Insurance Overview

• Public Option
• Medicaid
• Medicare Part D

52
The Public Option
Finance HELP House
No public option State-based public option National public option
Consumer Operated and Oriented Plan (CO-OP) - non-profits Community health insurance offered through state Gateways Offered through Health Insurance Exchanges
State Advisory Council to advise on policies and procedure Must offer basic, enhanced, and premium plans, and may offer premium plus plans
Provider payment rates negotiated by the HHS Secretary, cannot exceed local average private rates Provider rates must not be lower than Medicare, not higher than average rates of other plans
Voluntary provider participation Providers may opt-out of participation
53
Expansion of Medicaid
Finance House
All individuals up to 133 of FPL (2014) All individuals up to 150 of FPL (2013)
State option to expand to 133 FPL as of 2011 (w/o federal support) ETHA state option to expand to low-income people with HIV before 2013
No Medicaid payment rate enhancement Medicaid payment rates for PCPs enhanced to 100 of Medicare rate by 2012
Federal for expansion varies by state, up to 95 Federal for expansion fully financed through 2014, 91 as of 2015
Between 100-133 FPL can choose subsidy or Medicaid (as of 2014)
New beneficiaries have reduced benefits benchmark package
Medicaid is outside HELPs jurisdiction, but
HELP assumes expansion to 150 FPL.
54
Finance Bill Medicaid vs. Benchmark
Medicaid Benchmark
Physicians services Lab X-ray services Inpatient and outpatient hospital services Family planning services Federally-qualified health center and rural health clinic services Early and periodic screening, diagnostic, and treatment for lt21 Nurse midwife and nurse practitioner services Long-term nursing facilities and home health care for individuals 21 Physicians' surgical and medical services Lab and x-ray services Inpatient and outpatient hospital services Well-baby and well-child care, including immunizations Preventive services, as designated by the Secretary
55
Medicare Part D Coverage The Donut Hole
Issue
Catastrophic Coverage
0- 275
275-2510
2,510 -5726
Total Spending
75 Plan Pays
80 Feds Pay Reinsurance
Donut Hole Coverage Gap

Deductible
95
25 out-of-pocket
15 Plan Pays
Consumer Out-Of-Pocket
5 out-of-pocket
601
3454
295
Total consumer out of pocket 4,350
Consumer Pays
Federal Government Pays
Private plan Pays
56
Medicare Part D Legislation
Finance House
Does not close the donut hole Will close the donut hole by 2019.
50 discount for enrollees in the coverage gap total drug cost count toward TrOOP
ADAP contributions count as TrOOP (2011) ADAP contributions count as TrOOP (2011)
Medicare is outside HELPs jurisdiction.
57
New Investments and HIV Specific Issues

• Prevention and Wellness
• Clinical Workforce
• Health Disparities and Immigrant Issues
• ETHA, ADAP as TrOOP, Ryan White and Voluntary,
  Routine HIV Screening

58
Prevention and Wellness
Finance HELP House
1 increase in funding for preventive services in Medicaid and prevention plans under Medicare Develops national prevention/health promotion strategy. And, creates a prevention and public health fund with 10B per year Develops national prevention/health promotion strategy. And, creates a prevention and public health fund with 2.4-3.6B per year
75M for pregnancy, HIV STI prevention 50M for abstinence-only programs. Grants to small businesses Competitive grants to implement/evaluate preventive health activities (specifically to reduce chronic disease rates and address health disparities. 50M Healthy Teen Initiative for teen pregnancy, HIV, STI prevention programs. Grants to support employer wellness programs.
Allows 30 discount for employees in wellness programs. Allows 30 discount for employees in wellness programs.
Minimizes cost-sharing Minimizes cost-sharing Minimizes cost-sharing
Expands USPHS Expands USPHS Expands USPHS
59
Addressing Health Disparities
Finance HELP House
Collects data on Race, Ethnicity, Gender, Primary language, and Disability Collects data on Race, Ethnicity, Gender, Primary language, Disability, Geographic location, and Socioeconomic status Collects data on Race, Ethnicity, Gender, Primary language, and Sexual orientation
Requires HHS to share data with other agencies Reducing disparities quality improvement measure Reducing disparities National Strategy for Quality Improvement
Establishes HHS Office of Womens Health 50 of prevention and wellness must be aimed at reducing a specific disparity
Workforce grants for medically underserved areas funding for training to work with vulnerable populations, including people with HIV and Increased support for nursing education, training and loan repayment programs Scholarships and loans for workers in shortage areas and expands training for PCPs to work with vulnerable populations
60
Investing in the Clinical Workforce
Finance HELP House
Develop national workforce strategy Creates National Workforce commission Expands national health service corps
Grants for low income individuals to pursue health care careers Centers of excellence for minority health care workers, diversity training and grants Increased support for workforce diversity
Medicare graduate medical education in outpatient services (July 2010) Primary care and dental training program loan forgiveness and funding for FQHCs Medicare graduate medical education in outpatient services
Redistribute unused residency slots to primary care and surgery Redistribute unused residency slots to primary care
61
Immigrant Issues
Finance HELP House
Continues 5-year wait for Medicaid for legal immigrants Continues 5-year wait for Medicaid for legal immigrants Continues 5-year wait for Medicaid for legal immigrants
Legal immigrants eligible for insurance subsidies Legal immigrants eligible for insurance subsidies Legal immigrants eligible for insurance subsidies
Verification of legal status required for exchange and tax credits Eligibility verification left to Secretary Eligibility verification left to Secretary
Undocumented cannot participate in exchange Undocumented can purchase in gateway (without subsidies) Undocumented can purchase in exchange (without subsidies)
Undocumented subject to tax penalty for failure to be insured
62
HIV-Specific Issues
Finance HELP House
Voluntary, routine HIV testing not addressed Voluntary HIV testing for at-risk populations only Voluntary HIV testing for at-risk populations only
ETHA
ADAP as TrOOP ADAP as TrOOP
No integration of Ryan White programs Integration of Ryan White providers required of all exchange plans Integration of Ryan White providers required of all exchange plans
63
Summary Key Reform Improvements

• Private Health Insurance
• Increased Access largely eliminates
  discrimination on health status
• Increased Coverage establishes new mandatory
  benefits packages
• Affordability subsidies up to 400
• Public Health Insurance
• Creation of public health insurance option (House
  and Senate HELP)
• Increased Medicaid Eligibility Senate below
  133, House below 150
• Increased Medicaid reimbursement rates to
  providers (House only)
• Phase out of Medicare Part D donut hole over by
  2019 (House only)
• HIV Specific
• HIV testing of at-risk (House and HELP), ADAP as
  TrOOP (Finance and House) and ETHA (House only)
• Other Key Improvements

64
Summary What Isnt Addressed

• Private Health Insurance
• Affordability still too expensive
• Public Health Insurance
• Senate fails to include a public plan option
• No new mandated Medicaid benefits state
  variation continues
• Senate fails to increase Medicaid reimbursement
  rates to providers
• Senate fails to phase out Medicare Part D donut
  hole and House15 year donut hole phase out too
  long
• HIV Specific
• Senate fails to include ETHA no broad HIV
  Screening Senate Finance fails to address Ryan
  White integration
• Other Insufficient Key Improvements
• Insufficient investment in prevention, wellness
  and disparities
• House and Senate fail to address legal immigrant
  5 year exclusion

65
Whats Coming Next Schedule for Bills to Expand
Health Care Coverage

• Senate leadership merging Senate Finance and HELP
  Committee bills (Oct/Nov)
• House leadership merging tri-committee bills
  (Oct/Nov)
• Bill on Senate Floor (Nov)
• Bill on House Floor (Nov)
• Conference in Mid to Late November
• Bill signed into law by late December

66
HCR Legislative Alert Five Top Priorities

• Establish a Public Health Insurance Plan Option
• Ensure that private insurance is affordable
• Establish New Minimum Medicaid Benefit Package
• Increase Medicaid Provider Reimbursement Rates
• HIV/AIDS-Specific Requests

67
Where Do We Go From Here

• Ensure passage of legislation
• Ongoing work to ensure strong appropriations and
  integration of Ryan White Programs in HCR
• Ensure proper implementation of HCR on national
  and state levels (including possible legislative
  fixes)
• Ensure that states do not reduce support of
  existing programs (i.e., Medicaid, Ryan White
  Programs) to address fiscal crises

68
Resources

• Bill Analysis
• HIV Health Care Access Working Group/Treatment
  Access Expansion Project (TAEP) www.taepusa.org
• Kaiser Family Foundation http//healthreform.kff.o
  rg
• TFAH http//healthyamericans.org/health-reform/
• Commonwealth Fund www.commonwealthfund.org
• AFC HCR Toolkit www.aidschicago.org

• Bills, Summaries, and Mark-Ups
• www.edlabor.house.gov
• www.waysandmeans.house.gov
• www.energycommerce.house.gov
• www.finance.senate.gov
• www.help.senate.gov

69
Sources

• This presentation was prepared using the
  following sources
• Kaiser Family Foundation. Focus on Health Reform
  Health Care Reform Proposals Modified
  October 8, 2009. Online www.kff.org
• National Immigrant Law Center. Selected Features
  of Health Reform Proposals Working Draft,
  October 5, 2009.
• US Senate Finance Committee. Americas Healthy
  Future Act Full Text as amended October 2nd.
  http//finance.senate.gov/.
• US Senate Health, Education, Labor and Pensions
  Committee. S. 1679, the Affordable Health
  Choices. http//help.senate.gov/.
• US House of Representatives Energy and Commerce
  Committee. HR 3200 America's Affordable Health
  Choices Act of 2009. http//energycommerce.house.g
  ov/