HIV and Health Care Reform

1
HIV and Health Care Reform

• Early Treatment for HIV Summit- July 20, 2009
• Laura Hanen, National Alliance of State and
  Territorial AIDS Directors
• Andrea Weddle, HIV Medicine Association

2
50 of people with HIV in the US Do Not Have
Reliable Access to HIV Care

• 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 (steady
  2001-07)
• - Disparities remain for MSM, Black and Hispanic
  men
• and women
• Source Kaiser and CDC

3
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.
  360181815-1826, 2009.
• 2Chen RY, et al. Clin Inf Dis 421003-1010, 2006.

4
U.S. Population and People with 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.

5
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
6
Federal Funding for HIV/AIDS Care by Program, FY
2008 (in billions)
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
FY1981FY2009,
7
Medicaid and Medicare
8
Ryan White Program

• Serves over 500,000 people
• Vital for uninsured and UNDERinsured
• Only federal health program for non-disabled
  people with HIV
• Annual, discretionary funded program does not
  grow based on need
• Benefits depend on where you live

9
HIV Health Care Access Group Key Steps to
Reform

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

10
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

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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

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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

13
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

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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

15

• Where Are We
• with
• Health Care Reform?

16
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

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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

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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 EC marking up
• Goal Bill to House floor before August recess

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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?

20
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

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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

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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)

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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

• Two Things You Can Do to Advance Health Care
  Reform
• Keep the Pressure OnWe must keep the pressure on
  Congress to ensure the needs of our HIV-positive
  community are met.
• 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!

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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

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Contact Information

• Laura Hanen
• Director of Government Relations
• National Alliance of State and Territorial AIDS
  Directors
• Co-chair HIV Health Care Access Working Group
• Ph 202.434.8091
• lhanen_at_nastad.org
• Andrea Weddle
• Executive Director
• HIV Medicine Association
• ph 703.299.0915
• aweddle_at_idsociety.org