The Affordable Care Act and Ryan White
2013 United Conference on AIDS (USCA)
New Orleans
September 10, 2013
Jen Kates, Kaiser Family Foundation
What Will the ACA Mean for Addressing the HIV Epidemic?
Key ACA Provisions for People with HIV
Private
Insurance
Expansions
&
Consumer
Protections
Benefit
Standards
Medicare
Fixes
Prevention
Medicaid
Expansion
Private Market
Expansion of
Private
Coverage &
Consumer
Protections
• End to lifetime and annual coverage
limits
• Elimination of pre-existing
conditions exclusions
• Dependent coverage
to age 26 Benefit
Medicaid
Medicare
• Non-discrimination
Expansion
FixesprotectionsStandards
• State-based health insurance
marketplaces, with subsidies based
on income
• To Follow: State decisions on
exchanges, network adequacy and
inclusion of “essential community
providers”
Benefits
Benefit
Standards
• Essential Health Benefits (EHB) must provide comprehensive set of
services across 10 categories,
including Rx
• EHB requiredMedicare
for plans in individual
Medicaid
Benefit
and small groupFixes
markets in andStandards
Expansion
outside of marketplaces, Medicaid
benchmark and benchmarkequivalent, Basic Health Plan,
Alternate benefit Plan
• To Follow: State flexibility means
benefits will vary by state; service
limits could still be used
Medicare
Medicare
Fixes
• As of 2011, ADAP prescription
expenses count towards True out
of pocket costs (TrOOP), to reach
catastrophic coverage level for
drug coverageMedicare
Medicaid
Benefit
• Closing the PartFixes
D coverage gapStandards
Expansion
for all, starting in 2010 and fully
by 2020
Prevention
Prevention
• Prevention & Public Health Fund
• Free preventive services: USPSTF “A”
and “B” rated services, including
routine HIV screening, must be
provided for free in new health
plans, Medicaid
expansion benefits;
Medicaid
Medicare
Benefit
financial incentive
to provide inStandards
Expansion
Fixes
traditional Medicaid
• Additional preventive services for
free for women
• To Follow: State decisions on
coverage of routine HIV screening in
traditional Medicaid; Will Medicare
cover routine HIV screening
Medicaid
Medicaid
Expansion
• In 2014, Medicaid eligibility expanded to
nearly all low-income individuals (state
option as of 2010): Eliminates “Catch-22”
for people with HIV, sets floor of eligibility
• Supreme Court decision effectively makes
this a state option
• Today, Medicaid
coverage of childless,
nonMedicaid
Medicare
Benefit
disabled adults Fixes
very limited; without
Expansion
Standards
mandatory expansion, will lead to new
“coverage gap”, uneven access
• Note: other Medicaid provisions include
Medicaid health home option
• To Follow: State decisions on expansion;
benefits package for expansion population;
Use of Medicaid for premium assistance in
marketplace in non-expansion states?
Current Medicaid Coverage of Low-Income Adults is
Limited
WA
(closed)
VT*
MT
ND
NH
MN
OR*
ID
(closed)
WI
(closed)
SD
NE
CA
UT*
CO
(closed)
(closed)
AZ
(closed)
MI
IA
IL
KS
OK
NM
PA
OH
(closed)
MO*
WV
KY
AL
RI
DC
SC
AR
MS
VA
CT
NJNJ
DE
MD
NC
TN
(closed)
TX
IN
MA
NY
(closed)
WY
NV
ME
(closed)
GA
LA
AK
FL
HI
(closed)
Medicaid Benefits (9 states, including DC) – 22% PLWH
More Limited than Medicaid (16 states) – 30% PLWH
No Coverage (26 states) – 48% PLWH
“Closed” = enrollment closed to new applicants
NOTE: MN /VT also offer waiver coverage more limited than Medicaid. OR/UT also offer “premium assistance” with open enrollment. IL/ LA/MO offer coverage for adults
residing in a single county/area. SOURCES: KCMU/Georgetown University, survey of states, as of January 2013. KFF Analysis of data from the CDC Atlas
Just Over Half of People with HIV are in States that Plan to
Expand Medicaid; Almost 4 in 10 are not
VT
WA
MT
ME
ND
NH
MN
OR
ID
MI
WY
NV
UT
CA
PA
IA
NE
IL
CO
IN
OH
WV
KS
MO
KY
OK
NM
TX
AK
AL
DC
SC
AR1
MS
VA
CT RI
NJ
DE
MD
NC
TN
AZ
MA
NY
WI
SD
GA
LA
FL
HI
Moving Forward at this Time (25 States including DC) – 55% PLWH
Debate Ongoing (4 States) – 8% PLWH
Not Moving Forward at this Time (22 States) – 38% PLWH
NOTE: As of September 3, 2013
SOURCES: KCMU analysis of recent news reports, executive activity and legislative activity in states. KFF analysis of data from the CDC Atlas.
What Will the ACA Mean for Ryan White?
Ryan White is the Third Largest Source of Federal Funding
for HIV Care in the U.S.
FY 2012
In Billions
Medicare
$5.8
39%
Ryan White, $2.4,
16%
Medicaid (federal
only)
$5.3
36%
$14.8 billion
SOURCE: Kaiser Family Foundation analysis of data from OMB, CBJs, and appropriations bills.
VA
SAMSHA $0.9
Other $0.1 6%
$0.3 1%
2%
Federal Ryan White Funding (adjusted for inflation) and
HIV Prevalence, 1991-2012
Funding
Prevalence
$3,000
$2,500
1,400,000
Ryan White Funding, Current $
Ryan White Funding, Constant 1991 $
HIV/AIDS Prevalence
1,200,000
1,000,000
$2,000
800,000
$1,500
600,000
$1,000
400,000
$500
200,000
$-
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
NOTES: The Consumer Price Index (CPI) from the Bureau of Labor Statistics (BLS) was used to adjust for inflation. HIV prevalence data are
estimates based on analysis of data from CDC. SOURCES: Funding amounts based on Kaiser Family Foundation analysis of data from OMB, CBJs,
appropriations bills, and CRS; Prevalence based on data from CDC; U.S. Department of Labor, Bureau of Labor Statistics.
Most Ryan White Clients Are Insured, And Rely on the
Program Because They Face Limits in Their Coverage
Other
Insurance
3%
Other
Public
Medicare, 14% 9%
Medicaid
32%
Uninsured
30%
Private
13%
NOTES: Based on those with reported insurance status (duplicated number of clients, N=764,163) in 2010.
SOURCE: HRSA, HAB, http://hab.hrsa.gov/stateprofiles/index.htm.
Select Examples of Ryan White Services That Support
Clients Along The HIV Treatment Cascade
HIV Counseling & Testing
Outreach
to Engage in Care
82%
Health Insurance Premium Assistance & CostSharing
Non- Medical Case
Management
Treatment Adherence
37%
Medical
Transportation
33%
Medical Case Management
25%
Referrals to Health &
Support Services
HIV-Infected
Diagnosed
Linked to
HIV Care
Retained in
HIV Care
On ART
Suppressed
Viral Load
SOURCES: Adapted from CDC "HIV in the United States–The Stages of Care" July 2012; Service Definitions from HRSA, HAB, 2012
Annual Ryan White HIV/AIDS Program Services Report (Rsr) Instruction Manual.
Key Messages on Ryan White & the ACA
• State-level decisions, particularly on Medicaid, will have significant
implications for Ryan White
• More Ryan White clients will gain insurance coverage through Medicaid
and private insurance coverage through the marketplace
• Greater share of Ryan White funding can shift to cover services not
covered in private sector or by Medicaid, or those with limits
• Ryan White providers can join Medicaid and Marketplace provider
networks
– Marketplaces required to include “essential community providers”
– Ryan White providers will need to proactively engage with marketplaces and Medicaid
managed care networks
• Ryan White providers can assist clients with enrollment in new coverage
options (including as Navigators & Assistors)
Key Messages, continued
• Ryan White will continue to be important source of care and
services for many people with HIV:
– Most Ryan White clients already have coverage but still need the
program to complete their care, fill in gaps, help with costs. Even as
more gain coverage, they may still need help
– Ryan White provides important HIV-related services that are not
always provided by insurance plans
– Current Medicaid coverage of low income adults (who are not
disabled) is very limited
– Not all states will expand Medicaid, at least not in 2014
– Those who are undocumented are not eligible for Medicaid or
marketplaces; Legal residents have 5 year waiting period for Medicaid