Institute of Medicine Workshop to Explore
Facilitators and Barriers to HIV/AIDS Care
Entry Into and Sustained HIV/AIDS Care:
The Role of Federal and State and Private
Insurance Policies Panel
June 21, 2010
Heather Hauck, MSW, LICSW
Director
Maryland Department of Health and Mental Hygiene
Infectious Disease and Environmental Health
Administration
MD DHMH
Infectious Disease and Environmental Health (IDEHA)
MISSION

To improve the health of Marylanders by reducing the
transmission of infectious diseases, helping impacted
persons live longer, healthier lives, and protecting
individuals and communities from environmental health
hazards

We work in partnership with local health departments,
providers, community based organizations, and public
and private sector agencies to provide public health
leadership in the prevention, control, monitoring, and
treatment of infectious diseases and environmental
health hazards.
Infectious Disease and Environmental Health Administration
June 2010
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Governmental Public Health
System

State health departments are entrusted through U.S.
law as the “central authorities of the nation’s public
health system” and as such, bear the primary public
sector responsibility for health.
– Responsible for protecting and guaranteeing the health of
constituents within jurisdictions’ borders.
– Responsible for implementing a comprehensive HIV/AIDS, viral
hepatitis and STD response in every jurisdiction in the U.S.
*”The Future of Public Health.” Institute of Medicine, January 1, 1988
Infectious Disease and Environmental Health Administration
June 2010
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Components:
• Care and treatment access
• Prevention
• Surveillance & epidemiology
• STD, TB & viral hepatitis
State
HIV/AIDS
Programs
Partners with:
• Local/city/county health departments
• Community-based agencies
• Academic/research institutions
• Hospitals, public clinics, community
health centers
• Federal agencies
Linkages to:
• Adult Viral Hepatitis
Prevention Coordinators
• Hepatitis B Coordinators
• Substance abuse & mental
health
• Reproductive health
• Maternal & child health
• Adolescent & school health
• Correctional health
• Rural & migrant health
• Medicaid
• Housing
• State laboratories
Infectious Disease and Environmental Health Administration
June 2010
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Federal Level Inhibitors

Funding/Resource Related Policies
– Inadequate funding for AIDS Drug Assistance Programs
– Inadequate resources for Ryan White Part B and Part D
– Categorical funding streams that create barriers between
prevention and care and treatment services.

Include language in notice of grant awards that allows and encourages
flexibility.
– Restrictions on utilization of Ryan White funding (core vs.
supportive) reduces local flexibility to address client needs
– Federal guidance on criteria for states to receive supplemental
Ryan White funding.
Infectious Disease and Environmental Health Administration
June 2010
5
Federal Level Inhibitors
 Federal
Entitlement Programs’ Eligibility Policies and
Practices
– Medicare D Donut Hole and co-pays – anticipating ADAP
counting toward TrOOP
– Length of time to receive Medicare after SSDI determination
– Housing
– Immigration
Infectious Disease and Environmental Health Administration
June 2010
6
Federal Level Inhibitors

Coordination and Communication Policies and Practice
–
Lack of coordination at the federal level challenges coordination of
services at the state level.
•
•
•
–
CDC’s increased testing efforts have not been coordinated with
increased need for care and treatment services.
HRSA HAB and Bureau of Primary Health Care grantees within states
serve many of the same populations but there is little coordination other
than between Community Health Centers (CHCs) that are also Ryan
White Part C or Part B funded programs.
Provide comprehensive HIV and viral hepatitis testing and care in
CHCs, coordinated with state HIV/AIDS programs, in high HIV and viral
hepatitis incidence areas.
Include public health components and incentives (linking with health
departments to understand disease trends and surveillance, public
health programs, the importance of HIV/HCV testing) in Bureau of
Infectious Disease and Environmental Health Administration
Health Professions trainings.
June 2010
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Federal Level Inhibitors

Coordination and Communication Policies and Practice
– Enhance coordination among all relevant agencies: HRSA,
CDC, CMS, SAMHSA, Department of Education (DOE),
National Institutes of Health (NIH), Food and Drug
Administration (FDA), the Veterans Administration (VA) and
the Indian Health Service (IHS).
– Data collection and dissemination varies across grantees and
bureaus within HRSA.

Harmonize reporting requirements with other federal agencies
(primarily CDC) to reduce administrative burden and improve data
coordination
Infectious Disease and Environmental Health Administration
June 2010
8
State Level Inhibitors

HIV Testing Policies and Practices
– Not enough outreach and testing to ensure that individuals
know their status and are linked to range of care services
– Requirement that confirmatory Western Blot received prior to
initiation of care – depends on state and clinical practice
– Lack of integrated services due to categorical funding and/or
resource constraints (missed opportunities and/or system
too complicated for clients to navigate)
Infectious Disease and Environmental Health Administration
June 2010
9
State Level Inhibitors

State High Risk Insurance Pool Policies and
Practices
– Lack of SHIP in some states
– Varying ability to work with Ryan White Part B/ADAP
– Pre-existing conditions clauses
– Prohibitively expensive monthly premiums
Infectious Disease and Environmental Health Administration
June 2010
10
State Level Inhibitors

Resource Related Policies and Practices
– ADAP Waitlists
– Federal Poverty Level eligibility limitations
– Limited ADAP formularies – missing critical classes of drugs for
mental health, cardiovascular, gastrointestinal issues.
– Various distribution methodologies for ADAP medications (direct
order; clinic pick up; pharmacy based – ADAP pharmacy only or any
pharmacy)
– Individuals unable to pay co-pays or insurance dropped by employers
– Limited ID doctors/clinic capacity - effectively limiting access to care
Infectious Disease and Environmental Health Administration
June 2010
11
State Level Inhibitors

Medicaid Related Policies and Practices
– Income eligibility - Federal Poverty Levels vary and are
mostly very low
– Disability requirement - Only some states have Medicaid
expansion programs which allow coverage for non-disabled
individuals
– Limited coverage for non-medical services
– Data system limitations impact assessment of
quality/outcomes of care provided
Infectious Disease and Environmental Health Administration
June 2010
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State Level Inhibitors

Coordination and Access Policies and Practices
– Different eligibility criteria between and across jurisdictions
(State and EMA) line – even within an EMA boundary
– Eligibility to access services across jurisdictional boundaries
– Utilization of Ryan White funding formulas differs across
jurisdictional boundaries
– Coordination between entitlement programs, Ryan White,
other health care initiatives
– Data collection systems and requirements – repetitive and
onerous for clients
Infectious Disease and Environmental Health Administration
June 2010
13
State Level Inhibitors

Structural
– Limitations or non-existence of domestic partner benefits
– Lack of protective State laws and policies addressing sexual
and gender minorities
– Immigration status
– Housing
Infectious Disease and Environmental Health Administration
June 2010
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State Level Inhibitors

Special Populations: Incarcerated in State Prison
Systems
– Testing not routinely offered in State Prisons/Local Detention
– Inability to provide continuity of care to incarcerated due to
–
–
–
–
institutional and jurisdictional policies
Medication dispensing/clinical care policies and practices
Application processes for Supplemental Security Income (SSI),
Medicaid and/or ADAP – may not be started until close to
release
Notification of benefit determination and linkage to medical care
post release
CBO Access to inmates limited for discharge planning/linkages
to care
Infectious Disease and Environmental Health Administration
June 2010
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Private Insurance Inhibitors

Eligibility and Coverage Related Policies and Practice
– Lack of coverage for routine HIV screening – Health Care Reform and
–
–
–
–
–
–
–
–
USPHTF recommendation requirements a concern
Prohibitive out-of-pocket co-pay and/or deductible costs to clients - flat,
tiered, or percentage
Medication limitations or caps – formulary, financial and/or dispensing
amount
Annual or life time caps
Prohibitively expensive premiums
Employer knowledge of HIV status - Fear of being dropped from insurance
Pre-existing condition exclusions
Medical/dental providers not accepting insurance carrier
Limitations to comprehensive care (e.g. substance abuse treatment,
mental health treatment, case management, specialty care)
Infectious Disease and Environmental Health Administration
June 2010
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Questions?
Heather Hauck, MSW, LICSW
Director
Infectious Disease and Environmental
Health Administration
Department of Health and Mental Hygiene
Baltimore, MD
http://eh.dhmh.md.gov/ideah/
Infectious Disease and Environmental Health Administration
June 2010
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Maryland
Infectious Disease
and
Environmental
Health
Administration
Infectious Disease and Environmental Health Administration
June, 2010
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