Alphabet Soup:
ACA, HIV, SUD, TB, and HCV on the Border
June 20, 2014
Tom Donohoe, MBA
Associate Professor of Family Medicine
Director, UCLA Pacific AIDS Education and Training Center
Associate Director, UCLA Center for Health Promotion and Disease Prevention
David Geffen School of Medicine at UCLA
1
I have already seen you present on the ACA
(in-person, webinar, etc)
16%
68%
16%
2
1. True
2. False
3. I don’t remember
How many ACA-related trainings have you
already attended (last 12 months)?
2%
5%
29%
64%
3
a.
b.
c.
d.
0
1-2
3-4
5 or more
Declaration of Disclosure
I do not have any financial arrangements
or affiliations with commercial sponsors
which have direct interest in the subject
matter
4
Educational Objectives 1
• State the importance of understanding ACA
implementation for California and Arizona and how
it will impact border communities & people living
with HIV, TB, HCV, and SUD
• Identify key dates for ACA roll-out and strategize to
effectively implement the ACA locally
5
Educational Objectives 2
• Explain how the ACA will extend new insurance
benefits and patients’ rights and responsibilities
• Improve HIV patients’ engagement (linkage &
retention) in high-quality HIV care as systems
change
• Obtain further information and referral resources
for ACA implementation in the border region as
more patients become enrolled
6
Which best describes WHERE you work?
17%
7%
5%
32%
5%
34%
7
a.
b.
c.
d.
e.
f.
Clinic
Community-based organization
Health department
University
Hospital
Other
Which best describes WHAT you do?
14%
8%
0%
8%
70%
8
a. Clinician (MD, PA, NP, nurse, dentist, etc)
b. Case manager
c. Health education (peer educator,
promotora)
d. Medical Assistant
e. Other
What type of clinician?
5%
3%
61%
8%
16%
8%
9
a.
b.
c.
d.
e.
f.
MD
NP
PA
Nurse
Dentist
Other
THE BORDER
10
The HRSA/Federal definition of the U.S. border
region is how many miles from Mexico?
13% a.
5 miles
12 miles
13% b.
62 miles
60% c.
75 miles
13% d.
100 miles
3% e.
11
The Border
12
U.S. Border Region Challenges
• Health Professional Shortage Area (HPSA)
• Higher incidence of infections diseases compared
with the U.S. average
• If made a state, the border region would rank:
–
–
–
–
–
1st in number of uninsured children
2nd in death rates due to hepatitis
3rd in deaths related to diabetes
Last in access to health care
Last in per capita income
Source: US/Mexico Border Health Commission
13
Where the Poor and Uninsured Americans Live
HIV Treatment Cascade
Gardner, E., et al. (2010). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 52(6):793-800.
15
AFFORDABLE CARE ACT (ACA)
16
Health Reform from the Beginning…
1965
Medicare &
Medicaid
established
17
2010
Affordable
Care Act (ACA)
signed into law
2011
Supreme Court
upholds ACA
Where We Are Now & Where We Are Going
2013
• Outreach/Education
• Assistors/Navigators
Marketplaces
Sign-up starting
October 1, 2013
18
2014
Health Insurance
(Marketplaces &
Medicaid expansion)
coverage begins
January 1, 2014
2019
ACA fully
implemented
I feel the ACA will make my job more secure
35%
40%
25%
19
1. True
2. False
3. I’m not sure/Don’t know
What About HepC and ACA?
Rachel McLean, MPH
*
Brian Risley, Danny Jenkins…..
*
MediCal expansion? Co-pays,
Payment assistance, budget busters, reinfection rates,
Costs costs costs costs sustainable? Undocumented?
Affordable Care Act (ACA) & HIV Services
• Elimination of pre-existing
condition exclusions
• Expansion of Medicaid to
non-disabled adults with
incomes of up to 133% of
FPL
• Subsidies to purchase
insurance through
exchanges for people with
income up to 400% FPL
• MORE PLWH ARE ELIGIBLE FOR
MEDICAID/MARKETPLACE
EXCHANGES
21
Ryan White Funds: Payer of Last Resort
Ryan White Program funds may not be used for any
item or service “for which payment has been made
or can reasonably be expected to be made by another
payment source.”
22
Income status of individuals who receive
Ryan White-funded services
201-300% FPL,
6%
>300% FPL,
3%
101-200%
FPL, 21%
100% FPL
100% FPL,
70%
101-200% FPL
201-300% FPL
>300% FPL
HIV/AIDS Bureau. 2009 RDR. Household Income Data.
23
FPL = Federal Poverty Level
What is 100% of the 2013 FPL
for a single person
0%
18%
82%
0%
0%
24
a.
b.
c.
d.
e.
$5,025/year
$7,110/year
$11,490/year
$13,170/year
I have no idea
2013 Federal Poverty Level
138% FPL=$15,856
CoverageforAll.org
Medicaid Expansion
JAMA. 2013;309(12):1219. doi:10.1001/jama.2013.2481
26
Which border state has said it will NOT expand
Medicaid as part of ACA implementation?
100% a.
0%
0%
0%
27
Arizona
b. California
c. New Mexico
d. Texas
Ryan White Core Services vs.
Essential Health Benefits (EHB)
Ryan White Core Services
ACA “Essential Health Benefits”*




•
•
•
•
•
•
•
•
•
•
•
Ambulatory & outpatient care
AIDS pharmaceutical assistance
Mental health services
Substance abuse outpatient care
Home health care
Medical nutrition therapy
Hospice services
Home and community-based health
services
Medical case management, including
treatment adherence services
Oral health care (not standard)
•
•
•
•
•
28
Ambulatory patient services
Emergency services
Hospitalization
Maternity & newborn care
Mental health & substance use disorder
services, including behavioral health
treatment
Prescription drugs
Rehabilitative & habilitative services &
devices
Laboratory services
Preventive and wellness services &
chronic disease management
Pediatric services, including oral & vision
care
Health Insurance (Marketplace) Exchanges
Kaiser Family Foundation. State Decisions for Creating Health Insurance Marketplaces. http://www.kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insuranceexchanges-and-expanding-medicaid/
29
State-Based Marketplace Exchanges:
California & New Mexico
30
Federally Facilitated Marketplace Exchanges:
Arizona & Texas
31
ACA IMPLEMENTATION ON THE BORDER
32
ACA Implementation on the Border
• Expanding health insurance coverage in every state
• Increasing access to Medicaid
• Establishing Health Insurance Marketplaces
• Covering preventive services with no deductible or
co-pay
33
ACA Implementation in Arizona
 Expanded Meidicad
 Implemented federally-run health insurance
marketplace
34
Case Study: Arizona
Pedro is a 28 year old resident of
Nogales, Arizona making ($12,065 or
105% FPL) who commutes to Tucson for
HIV care at a Ryan White clinic. He has
been in the U.S. legally for 7 years. He
also receives HIV dental care and case
management services through the Ryan
White program in Tucson. He wants to
stay at his HIV clinic.
35
Under the ACA, will Pedro be required to
purchase health insurance?
0%
62%
38%
36
1. Yes
2. No
3. I’m not sure.
Will Pedro be able to continue to receive HIV
dental care through the Ryan White program?
21%
26%
54%
37
1. Yes
2. No
3. I don’t know.
ACA Implementation in California
 Increasing access to Medicaid
 Transition to Medicaid expansion: Low Income
Health Programs (LIHPs)
 Implementing state-run health
insurance marketplace
38
Border Rating Regions/Plans
San Diego
Imperial
HealthNet (HMO)/$269
Kaiser Perm (HMO)
Anthem (EPO)
Blue Shield (PPO)
Kaiser Permanente (HMO)
Anthem (PPO)
Molina Healthcare (HMO)
SHARP Health Plan (HMO co-pay)
Blue Shield (PPO)
SHARP Health Plan (HMO co-insurance)
Anthem (HMO)/$336
40
ACA, FPL, HIV, and OAHIPP
Medicaid Expansion
(MediCal) 138% of Federal Poverty Level (FPL)
$15,856 (Individual)
$32,500 (Household of 4)
100%
138%
Immediate (or deferred) Premium Tax Credits
400%
500%
HIV-------OAHIPP<$50,000
$11,490 (Individual)
$23,550 (4)
100 % 138%
$45,960 (Individual)
$94,200 (4)
Subsidies
250%
Silver Plan
$11,490 (Individual)
$23,550 (4)
$28,725 (Individual)
$58,875 (4)
Case Study: California
Antonio is a 28 year old single
construction worker with no children
living with HIV. He was born in Los
Angeles and now lives in San Diego. He
earns $19,000/year (165% FPL). He does
not have health insurance and goes
regularly to a Ryan White clinic for his
HIV care. He has bonded with his HIV
treatment team who he says “saved my
life.” He says he wants health insurance
so he can take care of his chronic back
problems, which he thinks may require
surgery .
42
Border Rating Regions/Least expensive plan
San Diego
Age
Plan
Income
Least $ Option (per mo)
40
Silver
No Tax Credit
(>400% FPL)
40
Silver
With Tax Credit HealthNet (HMO): $81
(200% FPL)
(plus subsidies)
40
Silver
With Tax Credit HealthNet (HMO): $18
(150% FPL)
(plus subsidies)
43
HealthNet (HMO): $269
Case Study: Antonio
Silver (eligible for Federal Subsidy)
Premium: $41/month
(of a $231/month premium--per Covered CA
calculator)
Copays:
Primary Care Visit:
$15
Generic Drugs:
$5
Lab Test
$15
X-Ray:
$20
Deductible:
$500
Out of pocket maximum: $2250
44
Case Study: California
Juan is a single construction worker with
no children living with HIV. He lives in
Imperial county and earns $15,512/year
(135% FPL). He does not have health
insurance and goes regularly to a Ryan
White clinic for his HIV care. He has
bonded with his HIV treatment team
who he says “saved my life.” Juan has
been in the United States legally for 5 ½
years.
45
Will Juan need to go to the Marketplace to
purchase health insurance?
3%
9%
36%
52%
46
1. No, he will go to the Market Place and enroll in
Medicaid (Medi-Cal)
2. Yes, and he will could get his entire premium paid
by OAHIPP
3. Yes, he will need to purchase health insurance in
the Market Place, but he will get no subsidy
4. I have no idea
Juan is in an auto accident and receives care in the
emergency room. Does he have health insurance?
0%
0%
100%
47
1. Yes
2. No
3. I don’t know.
Case Study: Maria
Maria is a single 51 year old house/hotel cleaner living in
Calexico who estimates she will make $21,027 in 2014
(183% FPL), but has no health insurance. She says she
could never afford the rates for “someone my age.” She
has not seen a doctor for years, but sometimes goes
across the border for antibiotics, dental care, and “back
pain medicine.” She wants health insurance as she has
chronic back problems and owns a small house worth
$200,000. She is afraid an ER trip could bankrupt her or
cause her to lose the house.
Maria (con’t)
Maria is a little worried that she is taking too much ‘back
pain medicine’ as she has to take more and more to get
relief from “pain …and sometimes stress” as she heard
these pills could be addictive. Otherwise, she believes she
is in good health and feels great.
However, she does not know that she is living
with HIV and hepatitis C. She would not report
any risks for either if asked.
Under the Affordable Care Act, Maria will be
required to purchase health insurance or face a tax
penalty.
33%
33%
33%
1. a. True
2. b. False
3. c. I’m not sure
3%
3%
3%
I think Maria will sign up for health
insurance (NOT pay the penalty)
1. a. True
2. b. False
3. c. I’m not sure
Maria signs up & chooses a qualified health plan primary
care provider. Do you think she will be tested for HIV as
part of her routine care with her provider in 2014?
33%
33%
33%
1. a. Yes
2. b. No
3. c. I’m not sure
5%
5%
5%
5%
Were YOU offered an HIV test the last time YOU saw
your primary care provider?
1. a. Yes—I remember
2. b. No
3. c. No—we already knew my HIV status
4. d. I’m not sure I don’t remember
Do you think Maria will be tested for HCV as part of
her routine care with her provider in 2014?
0%
100%
0%
1. a. Yes
2. b. No
3. c. I’m not sure
Remaining Uninsured
Millions of individuals will remain uninsured after
January 1, 2014, including:
• Individuals subject to the mandate who do not enroll
• Individuals who are eligible for Medicaid, but do not
enroll
• Individuals who are not lawfully present
55
Resources
DONOHOE@UCLA.EDU
56
57