Health Care Reform and Harm Reduction

8th National Harm Reduction Conference, Austin, TX November 18, 2010

Laura Hanen, Director, Government Relations, NASTADRachel McLean, Adult Viral Hepatitis Prevention Coordinator, STD

Control Branch, California Department of Public Health

• Major provisions of health reform

• Limitations of health reform

• Health Reform and Harm Reduction: Preparing for 2014 and Beyond

Overview

• 45-50 million Americans uninsured• 65% of all bankruptcies are health related

• 50% of people with HIV in the US do not have reliable access to HIV care– 29% who are uninsured– 21% who don’t know they are infected

• 75% of people with HCV in the US don’t know they are infected, many who do are not in care

How did we get here?

• Health insurance overhaul package was signed into law by President Obama on March 23, 2010

– “Patient Protection and Affordable Care Act”

• Most far reaching health legislation since the creation of the Medicare and Medicaid programs in the 1960s– Implications for every system of care

The Affordable Care Act

• Establishes a mandate that all U.S. Citizens and Legal Residents maintain health insurance coverage– Provides subsidies to help low income people maintain

insurance and exemptions for people for whom it would be a hardship

• Legislation makes significant changes/improvements to major components of our health care system:– Private health insurance– Medicaid– Medicare

• Elements phased in over the next ten years• Most significant changes are enacted in 2014

The Affordable Care Act

Coverage for < Age 65, in Millions

Estimated Coverage, 2019

162 159

35 5130 25

245423

0

50

100

150

200

250

300

Current Policy New Law

Uninsured

Exchange

Nongroup/other

Medicaid/SCHIP

Employer

Source: Congressional Budget Office, March 20, 2010

Plus 5 million employees in exchanges through employer plans

Overview of Key Health Coverage Expansion Components

Coverage Expansion Under Health Reform, by Income

> 400% Federal Poverty Level

• Able to purchase insurance through the exchanges if not already covered

133 – 400% Federal Poverty Level

• Offered subsidies, tax breaks to purchase insurance through the exchanges

< 133% Federal Poverty Level

• Covered by Medicaid Expansion

Key Improvements Through Reform: Medicaid

• Expanded to all under 65 with incomes up to 133% FPL ($14,400) in 2014– Uniform minimum eligibility across states

• State option to expand coverage now• Federal funding for Medicaid expansion: 2014• Newly eligible have benchmark benefits package

that includes MH, SA, Rx, and preventive services– Envisions drug treatment, mental health care

happening in primary care settings

Key Improvements Through Reform: Insurance Exchanges

• Centralized, state-based marketplaces to purchase insurance

• Goal is to create healthy market competition–Better benefits package/coverage–Lower costs passed on to consumer

• Established with federal funds and must meet national standards

Key Improvements Through Reform: Insurance Exchanges

• Open to individuals and small group employers with income over 133% FPL to purchase insurance

• More affordable and better coverage options for individuals without group coverage

• Federal premium and cost-sharing subsidies for individuals with incomes133% - 400% FPL – Around $19,000 to $57,616/per year for an

individual based on 2010 federal poverty level

Insurance Exchanges: Essential Benefits Package

• Preventive and wellness services and chronic disease management

• Mental health and substance use disorder services, including behavioral health treatment

• Prescription drugs

• Laboratory services

• Ambulatory, emergency, and hospitalization patient services

• Rehabilitative and habilitative services and devices

• Maternity and newborn care

• Pediatric services, including oral and vision care

Improvements to Group Insurance Coverage: 2010

• Eliminates discrimination based on health status for children (adults in 2014)

• Encourages employers to provide insurance coverage (small business tax credits)

• Extends dependant coverage to age 26

• Eliminates lifetime insurance caps on policies and plan rescissions

Improvements to Group Insurance Coverage: 2010

• Requires new plans to cover services that receive a Grade A or B from the U.S. Preventive Services Task Force with no cost sharing

• Establishes a temporary national high-risk insurance pool to cover the uninsured with pre-existing conditions (until 2014)

Key Improvements Through Reform:Temporary High Risk Pool Programs

• Purpose is to provide coverage between now and 2014• Eligible if have a pre-existing condition and have not

had creditable coverage during the previous 6 months• $5 billion available for program starting July 1, 2010 • 27 states opted for the feds to run the pool

– Requires a letter of denial of coverage• Premiums and out of pocket costs are limited but still

costly for low-income individuals (CA: $575/mo.)• Uptake has been limited; HHS reducing costs in 2011

Key Improvements Through Reform: Clinical Preventive Services

• Coverage of clinical preventive benefits under all forms of insurance– Eliminates co-pays for services with A or B under

U.S. Preventive Services Task Force• Does not include routine HIV testing or HBV/HCV

testing for IDUs, other at-risk adults– 1% increase in Medicaid federal matching funds

for providing these services in 2013– Medicare annual visit and personalized

prevention plan• Expanded access to immunizations for adults

– Includes hepatitis A and hepatitis B vaccination

USPSTF Recommendations: STI Screening

Nonpregnant Women Pregnant Women Men

STI Not at increased

risk

At increased

risk*

Not at increased

risk

At increased

risk*

Not at increased

risk

At increased

risk**

Chlamydia C A C B I I

Gonorrhea D B I B D I

Syphilis D A A A D A

HIV C A A A C A

Hepatitis B D D A A D D

Hepatitis C D I - - D I

HSV D D D D D D

* Increased risk for pregnant and nonpregnant women is defined as high-risk sexual behavior for all STIs; as age younger than 25 years for chlamydia and gonorrhea; and as high community prevalence for chlamydia, gonorrhea, and syphilis** Increased risk for men is defined as high-risk sexual behavior for all STIs and as high community prevalence for syphilis

Opportunities for Harm Reduction Programs: Patient-Centered Medical Homes

• Option for Medicaid beneficiaries with 2+ chronic conditions to designate a medical home

• Supports pilot projects that have the potential to reduce costs while preserving or enhancing quality– HRSA and CMS could develop a pilot to evaluate cost

effectiveness of coordinated drug user health services (HIV/HCV testing & care, syringe access, buprenorphine, overdose prevention, soft tissue infection treatment, etc.)

• Workforce training targeted to patient-centered medical home and to physicians working with vulnerable populations (e.g., IDUs)

Opportunities for Harm Reduction Programs: Investment in Prevention

• Community Health Centers– Receiving $11 billion over next 5 years – Presents an opportunity to ensure that CHCs can

expand access to prevention and care services

• Prevention and Public Health Fund– $500 million in FY10 growing up to $2 billion in FY15– FY10: $30M for HIV prevention– Public health infrastructure, lab and epi capacity,

workforce training, community transformation grants– Primary care physician capacity

• National Prevention Strategy

Limitations of Health Reform

• Specifically excludes undocumented immigrants

• Does not apply to people who are incarcerated

• Insurance coverage ≠ access or quality

• Not enough primary care physicians for everyone

• Will not suddenly make health professionals culturally competent with the people we serve

• Requires continued funding / support from Congress

Health Care Reform and Harm Reduction: Preparing for 2014 and Beyond

What does health reform mean for harm reduction organizations?

• Financial impact– Potential for clients to eligible for high risk pool

programs/Pre-Existing Condition Insurance Plans

– Many clients (single, uninsured, “non-disabled” adults) to be covered by Medicaid or private insurance as of 2014

– Siloed funding streams may diminish as preventive services, drug treatment, move into primary care settings

– Need for services will remain for uninsured individuals

– Monitor Public Health Prevention Fund for opportunities

What does health reform mean for harm reduction organizations?

• Systems Impact– Need to build relationships with primary care providers

• FQHCs, homeless / rural health centers

• State and regional primary care associations

– Advocate for drug user health services in primary care:

• HIV, HCV, HBV testing, clinical management

• Hepatitis A and B vaccination

• Syringe access

• Overdose prevention (naloxone prescription)

• Opiate replacement therapy (buprenorphine, methadone)

– Market skills in serving “hard to reach populations”?

What does health reform mean for harm reduction organizations?

• Systems Impact– Case management intake process will need to be altered

to include screening for additional benefits– Health care, drug treatment providers will need to ensure

that they’re included in Medicaid managed care, Medicare, and private insurance provider networks

– Providers will need to ensure infrastructure in place for billing of various payers

National HIV/AIDS Strategy: Ryan White Will Still be Needed

“Gaps in essential care and services for people living with HV will continue to need to be addressed along with the unique biological, psychological and social effects of living with HIV. Therefore, the Ryan White HIV/AIDS Program and other Federal and State HIV-focused programs will continue to be necessary after the law is implemented.”

National HIV/AIDS Strategy for the United States: July 2010 (page ix).

Future of Health Reform

Future of Health Reform

• Educate policymakers on what is good about the law and why you want to keep it– Investments in prevention– Expansion of coverage to low-income, middle-

income people• Participate in implementation

– Federal and state• Educate clients, providers

Priorities for Implementation

• Increasing Community Health Center’s role in harm reduction service delivery

• Weighing in on the Essential Benefits Package for the exchanges and Medicaid

• Medical Home pilots in Medicaid and the Center for Medicare and Medicaid Innovation

• Tracking implementation of National HIV/AIDS Strategy and National Viral Hepatitis Action Plan

Priorities for Implementation

• Seek health workforce development opportunities to address workforce shortage, cultural competency

• Modify U.S. Preventive Svs. Task Force recommendations for HIV and hepatitis testing

• Ask for HIV, HCV dollars in Prevention and Public Health Fund for FY2011 and FY2012

• Leverage Community Transformation Grants• Meet with HHS health reform implementers• Client organizing; provider, policymaker education

Resources

• Trust for America’s Health• Kaiser Family Foundation • www.healthcare.gov• The Commonwealth Fund• National Alliance of State and Territorial AIDS

Directors www.nastad.org

Questions for Clarification

• What stands out as the most significant aspect of health reform for your community/organization?

• What is still unclear about health reform?• What challenges and opportunities does health

reform present for your organization?

Questions for Discussion

• How have you been tracking reform implementation in your state?

• How do you envision your role in ensuring that the implementation of health reform benefits drug users and other communities we serve?

• What other considerations should we keep in mind between now and 2014?

Contact Information

Laura Hanen

Director, Government Relations

National Alliance of State and Territorial AIDS Directors

P: 202.434.8091

lhanen@nastad.org

Rachel McLean, MPH

Adult Viral Hepatitis Prevention Coordinator

STD Control Branch

California Department of Public Health

P: (510) 620-3403

Rachel.McLean@cdph.ca.gov

www.cdph.ca.gov/programs/pages/ovhp.aspx