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HIV and Health Care Reform

HIV and Health Care Reform. Early Treatment for HIV Summit- July 20, 2009 Laura Hanen, National Alliance of State and Territorial AIDS Directors Andrea Weddle, HIV Medicine Association. 50% of people with HIV in the US Do Not Have Reliable Access to HIV Care. Includes:

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HIV and Health Care Reform

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  1. HIV and Health Care Reform Early Treatment for HIV Summit- July 20, 2009 Laura Hanen, National Alliance of State and Territorial AIDS Directors Andrea Weddle, HIV Medicine Association

  2. 50% of people with HIV in the US Do Not Have Reliable Access to HIV Care Includes: - 29% who are uninsured - 21% who don’t know they are infected Also: - 29% simultaneously diagnosed with HIV & AIDS - 39% have an AIDS diagnosis within one year - New infection rate at 56K per year (steady 2001-07) - Disparities remain for MSM, Black and Hispanic men and women Source: Kaiser and CDC

  3. Earlier Access to Treatment Makes a Difference • Risk of death reduced by 94% if initiate treatment earlier.1 • Treatment costs are 2.6 times higher per year at later stages of HIV disease.2 1Kitahata M, et al. N Engl J Med. April 2009. 360;18:1815-1826, 2009. 2Chen RY, et al. Clin Inf Dis 42:1003-1010, 2006.

  4. U.S. Population and People with HIV/AIDS Income & Unemployment SOURCE: Kaiser Family Foundation based on US Census Bureau, 2006; Kaiser State Health Facts Online; Cunningham WE et al. “Health Services Utilization for People with HIV Infection Comparison of a Population Targeted for Outreach with the U.S. Population in Care.” Medical Care, Vol. 44, No. 11, November 2006. NOTE: US income data from 2005, US unemployment data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal; HCSUS data from 1998.

  5. People with HIV/AIDS: Health Care Coverage of Those in Care General Population PWHIV/AIDS Population: 293 Million SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006

  6. Federal Funding for HIV/AIDS Care by Program, FY 2008 (in billions) Total = $11.6 billion Sources: April 2008; KFF. Fact Sheet: U.S. Federal Funding for HIV/AIDS: The FY 2009 Budget Request; April 2008. OMB, CMS Office of the Actuary, HHS Office of Budget, 2008; CRS. AIDS Funding for Federal Government Programs: FY1981–FY2009,

  7. Medicaid and Medicare

  8. Ryan White Program • Serves over 500,000 people • Vital for uninsured and UNDERinsured • Only federal health program for non-disabled people with HIV • Annual, discretionary funded program does not grow based on need • Benefits depend on where you live

  9. HIV Health Care Access Working Group: Key Steps to Improve Access to HIV Care HIV Health Care Access Group: Key Steps to Reform

  10. Improve Access to Private Insurance • ACCESS • Ensure coverage regardless of health status • Eliminate pre-existing conditions exclusions • Ensure portability of coverage • AFFORDABILITY • Limit the cost of premiums • Cap total out-of-pocket spending • COVERAGE • Comprehensive benefits package • Offer public insurance plan option

  11. Why a National Public Plan? • Reliable, stable coverage option no matter where you live • Economies of scale will reduce prices for prescription drugs and other services • Private plans, even Part D, have discouraged people with HIV from enrolling, e.g., higher cost sharing, provider networks, etc. • Competition based on quality not profit

  12. Make Medicare and Medicaid Work for People with HIV/AIDS Medicaid • Expand to all low-income regardless of disability • Increase eligibility up to 200% federal poverty level (around $22,000 per year) • Enact ETHA - allow states to ensure adequate eligibility and coverage for people with HIV • Address disparities in reimbursement • Mandate more benefits, e.g., prevention services, including routine HIV screening Medicare • End 2-year waiting period for people with disabilities (or offer affordable, comprehensive alternatives) • Eliminate donut hole • Allow ADAP to Count as TrOOP • Improve prevention coverage, including routine HIV screening

  13. Build On What Works: Ryan White HIV Clinics and Programs • Ryan White helped develop coordinated, comprehensive HIV care programs, i.e., medical homes for people with HIV/AIDS • Integrate Ryan White programs into the reformed system • Develop reimbursement systems to adequately support and improve access to these programs

  14. Address the HIV Medical Workforce Crisis • Targeted loan forgiveness for working in Ryan White-funded clinics • Develop reimbursement systems that support specialized primary care • Conduct national study to assess regional variations in need and to identify barriers

  15. Where Are We with Health Care Reform?

  16. Obama Administration Issued eight principles $634 billion reserve fund down payment Established Office of Health Reform at White House and HHS Engaging in conversation with Hill leaders Hosting stakeholder meetings Rallying the grassroots – Cheerleader in Chief

  17. Key Congressional Players U.S. Senate Finance Committee Health, Education, Labor and Pensions Committee House of Representatives Energy and Commerce Committee Ways and Means Committee Education and Labor Committee House and Senate Leadership Senate moderate Republicans and conservative Democrats

  18. Congressional Process U.S. Senate HELP Committee passed bill July 15th Finance Committee negotiating (bill this week?) Goal = Merge bills before going to Senate floor prior to August recess U.S. House of Representatives Three committees worked together released Tri-Committee bill July 14th Passed Ways & Means, Ed & Labor; E&C marking up Goal = Bill to House floor before August recess

  19. Key Components of Reform Proposals • Insurance market reforms – no pre-existing exclusions; limit premium variability; limit plan profits; no lifetime caps • Create regulated marketplace for un/underinsured to purchase insurance with subsidies for low income • Expand Medicaid to Childless Adults • Invest in Prevention and Workforce • Choice of Public Plan?

  20. HELP Bill “Affordable Health Choices Act” - Coverage Based on Version that was Marked Up by Committee Creates “Gateway” – state-based exchanges Establishes a government run “public plan” Defines Essential Benefits – ambulatory and ER, hospitalization, maternity and newborn, medical & surgical, mental health & substance abuse, prescription drugs, rehabilitative, habilitative, laboratory services, preventive and wellness, pediatric services Creates Commission to advise Secretary on benefits Weak provider network provisions

  21. HELP Bill - Affordability • Three tiers of plans vary by cost sharing • Provides subsidies up to 400% of FPL • Annual out of pocket cap - $5,800 for individual; $11,600 family • Limits out of pocket expenses • 1 to 12.5% for individuals up to 400% FPL • Premiums no greater than 12.5% generally

  22. HELP Bill - Medicaid and Medicare • Expands Medicaid to 150% of FPL • Federally financed initially – cost transitions back to states • No changes Medicaid reimbursement, benefits (Finance jurisdiction) • Does not address Medicare, Part D (Finance jurisdiction)

  23. HELP Bill – Primary Care Workforce • Creates National Workforce Commission • Expands primary care workforce loan forgiveness and training programs • Creates new primary care and dental training grant program that prioritizes programs addressing HIV among other vulnerable groups

  24. HELP Bill - Prevention and Public Health National Prevention, Health Promotion and Public Health Council to develop and carry out a national strategy Prevention and Public Health Investment Fund that grows from $2 to $10 billion for activities authorized by the Public Health Service Act Research on public health services and systems Data collection to better identify and address racial, ethnic, regional health disparities

  25. Senate Finance Committee – Policy Options Tax credits for mandated individual coverage up to 300% FPL, fine for non-compliance Looking for public plan alternatives, e.g., non-profit consumer owned and oriented plan Consumer protections regardless of health status

  26. Senate Finance Committee Options Medicare eligibility at 55 and no 2-year wait Phased-in Medicaid for all citizens below 100% of FPL, children and pregnant women up to 133% Market reforms in small and non-group markets Four benefit categories – Bronze, Silver, Gold, and Platinum Prevention in the context of Medicare, Medicaid and workplace wellness

  27. House Tri-Committee Bill - Coverage National “exchange” for purchasing insurance National public health insurance option Establishes essential benefits similar to HELP bill except also specifies coverage for medical equipment and supplies Stronger provider network provisions - requires plans contract 340B programs, i.e., Ryan White programs

  28. House Tri-Committee Bill - Affordability • Four benefit levels- three vary by cost sharing – premium plus can offer extra services, e.g., vision, dental • Subsidies for premiums and cost sharing available up to 400% FPL • Caps on out-of-pocket spending • Annual - $5,000 for an individual; $10,000 for a family • Premium/cost sharing cap ranges 1.5% (133%) to 11% (400%) of income (sliding scale)

  29. House Tri-Committee Bill - Medicaid and Medicare Expands Medicaid to 133% FPL and adds childless adults – 2013 (federally financed) ETHA available to states until 2013 Raises Medicaid reimbursement to Medicare levels (federally financed) Requires coverage preventive services according to USPHTF Improves Medicare Part D – ADAP as TrOOP, coverage gap phased out 2011 to 2023

  30. House Tri-Committee Bill – Public Health Public Health Investment Fund which grows from $4.7 billion in FY2010 to $8.8 billion in FY2014 Expansion of Community Health Centers Data collection to better identify and address racial, ethnic, regional health disparities Health and public health workforce Prevention and Wellness Trust starting at $2.4 billion in FY2010 and rising to $3.5 billion in FY2014

  31. Tri-Committee Bill - Workforce • Similar to HELP bill expands primary care loan forgiveness and training program, including targeted grants prioritized to “vulnerable populations” • Also creates new loan forgiveness and training programs to shore up public health workforce

  32. Make It Happen – Visit AIDS Foundation of Chicago - www. AFC.org • Two Things You Can Do to Advance Health Care Reform • Keep the Pressure OnWe must keep the pressure on Congress to ensure the needs of our HIV-positive community are met. • Tell Us Your StoryAFC is working to collect individual health care stories from people living with HIV/AIDS. Personal anecdotes, like your own, will help us advocate for the strongest health care provisions possible. Tell us your story today!

  33. Resources Bill Analysis: • HIV Health Care Access Working Group www.taepusa.org • Kaiser Family Foundation healthreform.kff.org Bills, Summaries and Mark Ups: • edlabor.house.gov • waysandmeans.house.gov • energycommerce.house.gov • finance.senate.gov • help.senate.gov

  34. Contact Information Laura Hanen Director of Government Relations National Alliance of State and Territorial AIDS Directors Co-chair HIV Health Care Access Working Group Ph 202.434.8091 lhanen@nastad.org Andrea Weddle Executive Director HIV Medicine Association ph 703.299.0915 aweddle@idsociety.org

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