The Patient Protection and
Affordable Care Act
Update and Implications
Joseph Jefferson, MPH
Director of Advocacy and Alliance Development
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
AK
HI
HIV Prevalence
by State
33 - 68
69 - 116
117 - 228
229 - 338
339 - 488
489 - 810
CA
OR
WA
NV
ID
AZ
MT
WY
CO
ND
SD
NE
KS
OK
MN
IA
LA
AR
MO
WI
MS
IL
AL
TN
IN
MI
2011 State HIV Prevalence Rates
UT
NM
TX
Data was adapted from the Centers for Disease Control
and Prevention's 2011 HIV Surveillance Report.
Prevalence rates are calculated per 100,000 people.
April 19, 2013
KY
OH
GA
WV
SC
FL
PA
VA
NC
NY
CT
MA
RI
VT NH
NJ
MD DE
ME
PR
Puerto Rico
70%
60%
50%
40%
30%
20%
10%
0%
66%
57%
40%
HIV Caseload has increased More patients are using
Expect more hours
in the past 12 months
direct HIV care than in the providing HIV care over the
past
next 3 years
• 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
• 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
Increasing Caseloads and Decreasing Providers
Create a Fractured Delivery Landscape
Patients Accessing Care &
HIV Caseloads Increasing
HIV Care Provider
Workforce Decreasing
HIV Specialists
HIV Patients
500,000 - 600,000 will be newly insured in
2014*
0%
20%
40%
62%
60%
2012
1
73%
2010
65%
80%
* HealthHIV calculation based on 2009 CDC estimates of
45% of people living with HIV that are uninsured.
to reach
HIV PCPs “able to provide care to newly
diagnosed HIV positive patients.” 4
tti
ng
Se
60%
1
33% of physicians expected
retirement age by 2020.6
Sh
ift
to
CH
Cs
Consistent “increase in HIV
caseloads” among HIV PCPs
since 2010.3
2010
Primary Care Providers
Current shortage of 7,000 primary care
physicians in underserved areas.6
HIV Caseloads
2012
Roughly one-third of HIV Specialists are planning to
retire in the next 10 years.5
0%
20%
40%
60%
80%
• 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 Implementation
Update
Implementation Benchmarks
January 2013
January 2014
• 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
Center for American Progress, March 2013
Marketplace (Exchange) Decision Map
ACA Patient
Protections and Access
• 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
• 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
• 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 Research
2Brian 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)
Individuals earning
between $15,000 and
$44,000 (134% to 400% FPL)
(22 million by 2014)
(61 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*)
Purchase private insurance
with premium tax credits and
cost-sharing subsidies
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
Ryan While Program will fill
gaps not covered by private
insurance
http://policyinsights.kff.org/2012/september/how-the-aca-changes-pathways-to-insurance-coverage-forpeople-with-hiv.aspx
• 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 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.”
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
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
Estimated % of ADAP Clients Newly Eligible
for Medicaid in 2014: Top Quartile
http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf
http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf
http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf
http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf
ACA & Payor Shifts
Current Payor
Medicaid
Ryan White /
ADAP
Current Service
Venues
Private
Practice
RW
Clinics
CHCs
Current Payor
Medicaid
Ryan White /
ADAP
Post-ACA Payor
Medicaid
Current Service
Venues
Private
Practice
FQHCs
Marketplaces
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
against expansion
states leaning
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
HCV
1. Press for national data system and/or standards for
hepatitis data collection
1. Press for increased funding for hepatitis prevention
1. Clarify EHB prescription drug coverage standards
(given new HCV treatment opportunities in the
pipeline)
1. Increase provider and consumer education
Washington, DC 20009
202.232.6749
www.healthhiv.org
joseph@healthhiv.org
202.507.4727