The Patient Protection and Affordable Care ActUpdate and Implications

2013 Annual Conference:AIDS Drug Assistance Programs:

Renewing the Commitment

Joseph Jefferson, MPHDirector of Advocacy and Alliance Development

Presentation Preview

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

The Treatment Cascade

Landscape Changes Creating the Hybrid Provider

The PCP Profile

0%

10%

20%

30%

40%

50%

60%

70% 66%57%

40%

Providers and Growth in HIV Patient Care

• Approximately 4,500 HIV providers (MD, DO, NP, PA) in US1

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

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

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

clinicians

Workforce Trends

1 Physician Workforce Projections in an Era of Health Care Reform, Annual Review of Medicine, Vol. 63: 435-445, February 2012

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

PCP Role in Treating Co-occurring Conditions

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

Kaiser Family Foundation, July 2013

Marketplace (Exchange) Decision Map

Kaiser Family Foundation, July 2013

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

• 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

• Prohibitions on illness-related coverage discontinuation

• Federal subsidies for people with incomes <400% FPL

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

• Plans must include EHB

PLWHs and Access

PLWHs and Access

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

PLWHs and Access

ACA & the HCV Paradox

Increased Access to Coverage

Increased Emphasis

on Prevention

Increased HCV Screening

Increased Detection and

Diagnosis

Increased Treatment and

Monitoring

Increased Demand for Linkage and

Retention

Increased Demand on Service Delivery

System

Stronger Case for National Surveillance

System

Increased Urgency to Codify Prescription

Drug Coverage Standards

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 Obama’s proposed

emergency funding: $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 ACA 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 Policy 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

• Recommend n=Network v. out-of-Network care policies

• Assess impact of 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

Medicaid Eligibility ≠ Medicaid Access

Only 2 of 12 top quartile states (Illinois and Michigan) are expanding Medicaid

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

7 of 12 bottom quartile states are expanding Medicaid

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

Federally Facilitated Exchange: 8 States Partnership Exchange: 2 States State-based Exchange: 2 States

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

Federally Facilitated Exchange: 4 States Partnership Exchange: 3 States State-based Exchange: 5 States

Informing the Advocacy Agenda

1. 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

Ryan White• Persuade Obama Administration to restore $35M for ADAP and $10M

for Part C (lost in CR) – We’ve almost checked this one.• Preserve RW program funding through budget process (FY14 and

beyond) – We feel pretty good about this one.• Engage Members and their staffs in ongoing education about how

RW funding helps to reduce community viral load – and new infections

• Work with HRSA/HAB to ensure transition issues remain a priority• Integrate HIV care into mainstream health system• Fortify collaborations between RW medical and support service

providers• Strengthen focus on gay and bisexual men • Resource distributions that align with post-ACA coverage gaps -

especially in states that are not expanding Medicaid• Conduct research to assess and identify scalable and effective

interventions that link performance along the cascade

• Press for national data system and/or standards for hepatitis data collection

• Increase funding for hepatitis prevention

• Institute national screening protocols

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

• Address ADAP HCV drug formularies

• Develop and resource education initiatives targeted at provider, consumers, and broader public

HCV

HIV/Hep C Surveillance Comparison

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

Where Can I Obtain Additional Information?

Where Can I Obtain Additional Information?

• HHS – www.healthcare.gov

• CMS – Medicaid– Medicaid.gov

• CMS – CCIIO– cciio.cms.gov

• HRSA – hab.hrsa.gov/affordablecareact/index.html

• For any questions related to RW and the ACA, please email: RWP-ACAQuestions@hrsa.gov

Washington, DC 20009202.232.6749

www.healthhiv.orgjoseph@healthhiv.org

202.507.4727