UCLA School of Public Health
Epidemiology 227
April 23, 2010
Prof. Arleen Leibowitz
UCLA School of Public Affairs

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Care and Treatment
Medicaid
Medicare
Ryan White CARE Act
Private Insurance and Health Reform Changes
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Testing and Prevention
California issues
Research
Income Support and Housing
Global Programs

Global, $6.46
Research,
$2.62
Housing/$,
$2.45
Prevention,
$0.79
Treatment,
$13.53

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But many PLWH are not in regular care
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About 21% do not know their HIV status
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Only 55% of those meeting clinical criteria for ARV therapy get it
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Expanded guidelines
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HAART is costly
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$12,000/year in ARV costs
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$20,000/year in total costs

Uninsured
20%
Medicaid
29%
Private
32%
Medicare
19%

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Medicaid (Federal share) $4.7 B
Medicare
Ryan White
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(ADAP
Veterans Affairs
SAMHSA
HOPWA
FEHBP
$5.1 B
$2.3 B
$0.8 B
$0.2 B
$0.3 B
$0.1 B
$0.8 B)
34.6%
37.5%
16.9%
5.9%
1.5%
2.2%
0.7%
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Total $13.5 B

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Mandatory spending
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Presumption that Congress must allocate funding to meet statutory obligation – e.g., Medicare, Medicaid, SSI
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“Entitlements”
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Defined benefit
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Discretionary spending
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Congress decides on spending level each year
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Defined contribution
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Block grants
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Examples: NIH, CDC, Ryan White, VA

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Block grant means that the budget does not increase to accommodate increased enrollment
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Health care costs rise faster than CPI, so annual increases are “high”
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Long-term health investments are discouraged by annual budget process
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Prevention may reduce costs in long run, but not in short
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Early treatment of HIV may save money in long run
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Share of discretionary spending is falling

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Created in 1965
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Federal/state health insurance program for low income and disabled
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Federal government pays a minimum of 50% of costs, more in low income states (average 55% of HIV $)
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Jointly administered
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States set eligibility criteria, subject to Federal minima
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States set benefits, subject to Federal mandated benefits

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States must cover
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Certain poor women and children
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Disabled who qualify for SSI (unable to engage in
“substantial gainful activity by reason of… (a medical condition) ….expected to result in death or that has lasted…up to 12 months”)
States set income criteria
State option to cover Medically Needy who “spend down” to income criteria

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Covers most services with no or minimal cost-sharing
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Drugs, an optional service, are covered in all states
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Optional services include case management, hospice
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Some states limit services
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Number of Rx per month or year
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Number of MD visits

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State variability in Medically Needy income eligibility criteria
Vermont
Louisiana
75% FPL
7% FPL
States can impose limits on discretionary services (drugs)
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Non-citizens can not qualify for Medicaid
Green-card holders must wait 5 years
Medicaid provider payment levels are low, making access difficult
Medicaid discount on drugs of 15.1% less than what others get

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Catch-22
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Medicaid eligibility depends on being disabled or having
AIDS
But early treatment of non-disabled could avert disability
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And reduce transmission
Some states have 1115-waivers to provide Medicaid to low income people with HIV prior to disability
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1115 waiver requires “budget neutrality” --Medicaid savings
>= additional Medicaid costs
But, given fractured system, inpatient savings of ARV treatment often go to Medicare, SSI or Ryan White

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Lose Medicaid if earnings exceed threshold, however, earnings may not cover the cost of costly ARV treatment
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Ticket to Work/Work Incentives Improvement Act of 1998 continues Medicaid coverage even if person returns to work
In recessions, states attempt to cut Medicaid benefits
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Gov. Schwarzenegger proposed premiums for Medicaid
Federal government raised its match rate during recession

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Persons <133% of FPL are eligible for Medicaid from 2014
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$14,404 for single individual; $29,327 for family of 4
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Does not depend on disability
Individuals w/o dependent children now will qualify
Removes eligibility variation by state, but undocumented still not eligible
100% federal funding for eligibility expansions in 2014-16, declining later to 90%
Increases drug 340b rebate to 23.1%, but some goes back to federal government
Provides 100% federal funding to raise Medicaid reimbursement rate to Medicare levels for primary care services in 2013, 2014
Encourages “medical home” for those with chronic conditions

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Created in 1965
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Covers persons 65+, persons with ESRD, and long term disabled
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Funded by payroll tax on earnings, general revenues, beneficiary premiums for Part B and co-payments
(Medicaid can pay patient cost-sharing)
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Uniform throughout U.S.

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Disabled must have sufficient covered work history to quality for SSDI
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29 Month Waiting period
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Federal law requires 5 month wait after disability determination before receiving SSDI payments
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24-month waiting period for Medicare, following SSDI
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Medicaid coverage for low income persons during the
29 months

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Hospital
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Outpatient (20% cost-sharing)
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Drugs have been covered since January 1, 2006 under
Part D, private drug insurance plans
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Plans required to cover all ARVs
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Low income subsidy needed for “the donut hole”

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Eligibility
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Must have sufficient work history to qualify for SSDI, a problem for young, poor persons with HIV
29 month wait for Medicare eligibility
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Catch-22 of disability requirement
Cost-sharing
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High cost sharing if no supplemental coverage
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No cap on out-of-pocket spending
Medicare “donut hole”
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When ADAP pays, doesn’t count as “true out of pocket cost” (TROOP)

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Medicare “donut” hole will be closed
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2010--$350 towards cost
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Phase-down coinsurance rate in donut hole from 100% to
25%, starting 2011 by requiring 50% rebate from manufacturers plus federal 25% subsidy
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ADAP payments will count as TROOP in Part D
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No cost-sharing for covered preventive services (rated
A or B by U.S. Preventive Services Task Force)

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CARE= Comprehensive AIDS Relief Emergency
Enacted 1990
Administered by Health Resources and Services
Administration (HRSA)
Payer of last resort for 553,000 uninsured and underinsured
PLWA
Outpatient care, including medical, dental, case management, home health, hospice, housing, transportation, drugs (through
ADAP), insurance continuation

Originally designed to provide relief to cities with disproportionate burden of caring for HIV/AIDS
Part A: Emergency Relief (EMA, TGA)
Part B: HIV Care (including ADAP)
Part C: Early Intervention
Part D: Women, Infants, Children, Youth
Part F AIDS Education and Training,
Dental, SPNS

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Funded by Part B of Ryan White Care Act
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Congressional Earmark: $835 M (approx 50%)
Plus state supplements (approx 25%)
And rebates from drug manufacturers (approx 25%)
Other Federal funding
States set eligibility
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5 x FPL in NJ; 4 x FPL in CA; 2 x FPL Texas
Disability not required
Residency, not citizenship required
ADAP is a block grant
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States have used waiting lists to ration

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Drugs provided to 110,000 PLWH monthly in 2008
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Cost/enrollee c. $1000/month
Services
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HIV Medications
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Drug monitoring and adherence services
Can purchase health insurance for eligible clients
Drug Formularies
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Must include at least one medication w/I each ARV class
Louisiana had 28 drugs; New York had 460

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Discretionary grant program provides a block grant
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Growth in PLWHA increases demand for CARE Act services
Medical costs increase faster than CPI
States have limited ability to supplement
Resulted in waiting lists for ADAP
States set eligibility rules, resulting in variability
States with less generous Medicaid programs, need more Ryan White support
Provides support for non-citizens

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2006 Reauthorization of Ryan White Act revised funding formulas for Parts A and B
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Funding now based on reported HIV cases, not only AIDS cases
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Directs funding to reflect emerging epidemic
California just began names reporting of HIV cases
Required 75% of funding to be used for core medical services

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Coordination with Medicare Part D
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Payment for Part D co-pays, deductibles, premiums
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ADAPs can pay for drugs in “donut hole”
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Increasing demand for ADAP as more PLWHA are not disabled, but require medication
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Longer bridge to Medicaid
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New, more costly drugs

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Continued availability of prescription rebates?
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State fiscal environments challenge states’ ability to supplement ADAP
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States seek to reduce formularies to cut costs
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Need to explore cost containment strategies that maintain client access (i.e. purchasing options)

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Insurance exchanges should reduce number of uninsured, and reliance on ADAP
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Would provide for medical care, not just drugs
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CARE/HIPP could help purchase insurance
ADAP will count as TROOP
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ADAP costs after donut hole should decrease
Cost of drugs while in donut hole is reduced by 50%
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Effect on rebates?
Effect of health reform on Ryan White funding?
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Undocumented

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Eliminates “medical underwriting” and rescissions
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Provides subsidies for purchase from exchanges (32 million people by 2019) with mandated benefits
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Legal immigrants eligible for subsidies
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Bronze plan—covers 60% of cost
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Caps out of pocket expenditures for persons<4xFPL
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Sets up high risk pool—June 2010 to Jan 2014
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Allows children to stay on parents’ policy until age 26
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May reduce pressure on COBRA for unemployed

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Care and Treatment
Medicaid
Medicare
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Ryan White CARE Act
Health Reform and private insurance
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California Issues
Research
Income Support and Housing
Global Programs

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21% of PLWH do not know they are HIV+
1.
2.
3.
4.
CDC “Advancing HIV Prevention” (2004)
Make voluntary HIV testing a part of routine medical care
Test for HIV outside of medical care settings
Prevent new infections by focusing on HIV+ individuals and their partners
Further decrease perinatal HIV transmission

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CDC goal to “normalize” HIV testing
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Destigmatize
Opt-out vs. opt-in testing recommended by CDC in
Sept. 2006
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Default is testing; patient must specifically decline test
Covered by general consent to treat
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CA state law since Jan. 1, 2008 removes requirement for specific written informed consent for testing
Need prevention counseling accompany testing?

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Rapid test could increase knowledge of HIV status
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Results ready in 20 minutes, no need to return for results
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But needs to be confirmed if “preliminarily positive”
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CA state law relating to who can perform finger prick test limited use of rapid tests
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Just changed

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Centers for Disease Control and Prevention administers most federal prevention efforts (FY 10 budget: $785.1 B)
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National budget share for prevention (4%) is decreasing over time
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California share for prevention <6%

State Cut
($ million)
State Cut
(%)
State Share
(%)
(09/10)/
(08/09)
C&T, HERR 32.9
100 78.6
0.266
Care & Support 22.8
SOA
ADAP
3.0
25.0
100 40.0
44.8
31.1
0-funded by rebates
Increased for FY11
0.607
0.728
1.00

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Balance efforts targeting HIV- and HIV+ individuals
Target increased risk behavior among MSM
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Methamphetamine epidemic in CA
Internet—prevention challenge or opportunity?
Reach populations who may not realize their risk and may not receive routine medical care
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Young men are not in routine medical care
STI clinics, EDs, jails?
Separation between federal treatment and prevention efforts

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Federal government promotion of abstinence only
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The Task Force on Community Preventive Services concludes that there is insufficient evidence to determine the effectiveness of groupbased abstinence education delivered to adolescents to prevent pregnancy, HIV and other sexually transmitted infections (STIs).
HIV Federal Materials Review Process
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Congressionally mandated review of HIV prevention education materials supported by CDC funds
Messages must emphasize ways to fully protect against acquiring or transmitting the virus
Materials can not directly encourage sexual activities or drug use

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Care and Treatment
Medicaid
Medicare
Ryan White CARE Act
Testing and Prevention
Global Programs

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NIH Budget for HIV research is $2.62B in FY10
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Largest investments are biomedical
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California HIV Research Program
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FY07 $12M

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Cash Assistance (11% of Domestic HIV funding)
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SSI - $500 M in FY10
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SSDI - $1,636 M in FY10
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Entitlement programs for the disabled
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Housing Opportunities for Persons with AIDS
(HOPWA) $310 M in FY10
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AIDS exceptionalism?

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Health Reform has addressed many HIV/AIDS policy issues
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But, the fragmented system still presents challenges

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Care and Treatment
Medicaid
Medicare
Ryan White CARE Act
Testing and Prevention
Research
Income Support and Housing

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President’s Emergency Plan for AIDS Relief (PEPFAR)
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President Bush proposed $15B commitment over 5 years in 2003
Upped to $48 B over 5 years
Most US funding is bilateral, circumvents Global Fund
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But US is still largest single contributor to GF
Obama administration changes in May 2009
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Funding at $63B over 6 years Global Health Initiative (GHI)
Shift from emergency response to sustainable mode
Recipient country ownership of planning process
Rebalance Global Health portfolio from HIV to MCH

Slide 10
U.S. Global Health Initiative (GHI), FY 2011 Budget Request
In Millions
HIV
$5,739.1
Global Fund
$1,000
Nutrition
$200
Other
$108
MCH
FP/RH NTDs
$700 $590 $155
Malaria
$829.2
TB
$251
Total = $9.6 billion
*FY 2011 is President
’s Budget Request to Congress.
SOURCES: Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget
Justifications, Congressional Appropriations Bills, and White House Statement by the President on Global Health Initiative, May 5, 2009.
Return to Tutorials
Also see: Kates J., The U.S. Global Health Initiative: Overview & Budget Analysis , Menlo Park: Kaiser Family Foundation, December 2009.

2003
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55% of funding for treatment;
20% for prevention
33% prevention funding had to be targeted to abstinence
In 2005, 2/3 on abstinence, 1/3 condoms +
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Condoms only for “high-risk”
(prostitutes, discordant couples, substance abusers)
2010
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Over half of funding for treatment
Target 50% of prevention funds on abstinence. If less, report to
Congress
AB-C still in place

2003
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ARVs must be approved by FDA
(WHO approval not sufficient)
HIV exempted from “gag rule” on abortions, but many misunderstood
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Funded organizations need
“policy explicitly opposing prostitution and sex trafficking.”
(PL108-25)
No funding for needle exchange
2010
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By 2007, 73% of drugs distributed were generic.
Accelerated FDA approval.
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Pres. Obama rescinded “gag rule” on abortion
Focus on MTCT, MC and services for IDUs

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Will care and treatment crowd out prevention because we adopt a short term planning horizon?
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Why do we spend so little on prevention?
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Fragmented funding makes it difficult to
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Know what resources are available
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Coordinate care

HRSA
CDC
NIH
CHRP
CHIPTS
Kaiser Family Foundation
CAPS http://www.hrsa.gov
http://www.cdc.gov/hiv http://www.nih.gov
http://chrp.ucop.edu
http://chipts.ucla.edu
http://www.kff.org/hivaids http://www.caps.ucsf.edu