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The Future of Health Care: Health Care Reform and Beyond

The Future of Health Care: Health Care Reform and Beyond. Laura Hanen Director of Government Relations, National Alliance of State & Territorial AIDS Directors Robert Greenwald Director, Health Law and Policy Clinic, Harvard Law School and Treatment Access Expansion Project.

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The Future of Health Care: Health Care Reform and Beyond

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  1. The Future of Health Care: Health Care Reform and Beyond Laura Hanen Director of Government Relations, National Alliance of State & Territorial AIDS Directors Robert Greenwald Director, Health Law and Policy Clinic, Harvard Law School and Treatment Access Expansion Project United States Conference on AIDS October 31, 2009

  2. Part 1: • Current Barriers to Care: Why Our Current Health Care System Fails to Meet the Health Care Needs of PLWHIV • Part 2: • Our Health Care Reform Agenda: Priorities for Addressing the Health Care Needs of PLWHIV • Part 3: • The Current Status of Health Care Reform and Our Efforts to Reduce Barriers to Care

  3. PART 1 An introduction to why our health system is failing people living with HIV and AIDS

  4. 50% of people with HIV are NOT in regular care in the U.S. • 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 (no decrease 2001-07) • Disparate impact continues for, among others, MSM, Black and Hispanic men and women Source: Kaiser and CDC

  5. How Americans Obtain Health Care Coverage Population = 293 Million SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on theCensus Bureau's March 2005 and 2006 Current Population Survey (CPS: Annual Social and Economic Supplements).

  6. US Population and Peoplewith 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.

  7. 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

  8. Medicaid v. Medicare

  9. Medicaid: Mandatory and Optional Benefits Kaiser Commission, “Medicaid and the Uninsured,” p. 7 (2001). http://www.kff.org/medicaid/2256-index.cfm

  10. Medicaid Optional Services:A Four State Comparison

  11. Medicare Benefits

  12. Medicare: Standard Drug Plan Cost in 2009 Catastrophic Coverage Total Spending $0- $275 $275-$2510 $2,510 -$5726 75% Plan Pays 80% Feds Pay Reinsurance “Donut Hole” Coverage Gap $ + Deductible ≈ 95% 25% out-of-pocket Consumer Out-Of-Pocket 15% Plan Pays 5% out-of-pocket $295 $601 $3454 Total consumer out of pocket = $4,350 Consumer Pays Private plan Pays Federal Government Pays

  13. Public Funding HIV/AIDS Care:Including Ryan White (FY 2008)

  14. Ryan White Program Overview • Single largest federal program specifically for PWHIVs (Provides services to people living with HIV - not just AIDS) • First Authorized in1990. Reauthorized in 1996, 2000, 2006 (Operating on continuing resolution since 9/31/09) • Payer of last resort • Original intent was to fill gaps in care/support (Increasingly primary funder of care and treatment) • What you get depends upon where you live • A discretionary program subject to annual appropriations

  15. Ryan White Program: Five Primary Parts • Part A: Grants to EMAs & TGAs – cities/ metro. areas most severely impacted by HIV (26.4%) • Part B: Grants to states and territories including ADAP (52.2%) • Part C: Grants to outpatient providers to support access to early intervention services and comprehensive primary health care (10%) • Part D: Grants to outpatient/ambulatory care centers providing care and services tor women, infants and children living with HIV (3%) • Part F: Grants to support Special Projects of National Significance (1%), AIDS Education and Training Centers (1.3%), Dental Programs (0.5%) and the Minority AIDS Initiative (5.6%)

  16. ADAP: Four State Comparison Chart

  17. Number of People Living with AIDS in the US v. Ryan White Funding ( No adjustment for inflation) Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table12.htm; Ryan White Appropriations History, Health Resources and Services Administration, ftp://ftp.hrsa.gov/hab/fundinghis06.xls.

  18. Number of People Living with AIDS in the US v. Ryan White Funding (Adjustment for Inflation) Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table12.htm; Ryan White Appropriations History, Health Resources and Services Administration, ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Inflation calculated using http://www.usinflationcalculator.com/.

  19. Summary: Private and Public Health Care Programs Are Failing PWHIV Private Insurance: • Largely employer-based – yet most people living with HIV are unemployed or low-wage workers Medicaid/Medicare: • We have a disability care system, not a health care system • Medicaid – Mandated benefits package insufficient • Medicare – Part D out-of-pocket co-pays too high ADAP/Ryan White Program: • Funding is not keeping pace with growing demand

  20. PART 2Our Health Care Reform Agenda: Priorities for Addressing the Health Care Needs of PLWHIV

  21. Established in 2003 Coalition of more than 100 national, local, and regional organizations representing HIV medical providers, public health, CBOs, advocates and people living with HIV/AIDS Part of the Federal AIDS Policy Partnership Mission to increase early and affordable access to quality, comprehensive care for people living with HIV/AIDS HIV Health Care Access Working Group

  22. Calling for leadership Analyzing bills Weighing in on bills as they move Holding grassroots calls Developing simple messaging Conducting Hill visits Participating in other coalition activities HIV Health Care Access Working Group

  23. Priorities for Health Reform Medicaid Medicare Private Insurance Health Disparities Prevention and Public Health Medical Workforce Crisis Ryan White Program Extension and Integration

  24. Medicaid Eliminate the disability requirement and expand access to all who are low-income Include ETHA for increased access Create a new national benefits package Limit the amount low-income people pay Cover voluntary, routine HIV testing Adequately reimburse and create incentives to strengthen the HIV provider workforce

  25. Medicare Eliminate the 2-year waiting period for disabled Eliminate the “donut hole” and other cost sharing barriers Include ADAP as TrOOP Continue to protect access to HIV meds Offer buy-in to younger populations Cover voluntary, routine HIV testing

  26. Private Insurance Access Ensure coverage regardless of health status Eliminate pre-existing condition preclusions and lifetime caps on benefits Ensure portability of coverage Affordability Limit the cost of premiums Cap total out-of-pocket spending Sufficient subsidies Coverage Mandate comprehensive benefits package Voluntary, routine HIV testing National Public Insurance Option

  27. Health Disparities Data collection Incentives for providers to work in underserved communities Address linguistic and cultural concerns such as credentialing and adequate reimbursement for medical translators Include racial and ethnic minorities in clinical trials Elevate the National Center on Minority Health and Health Disparities at NIH Strengthen the Office of Minority Health at DHHS

  28. Prevention and Public Health Prevention and Wellness Trust with dedicated mandatory funding Grants for community, population based prevention programs Grants to strengthen public health infrastructure/core capacity Including disease surveillance and monitoring systems Address public health workforce shortages National electronic health information exchange system that integrates public health and clinical data Support coverage for comprehensive clinical preventive services Comprehensive sexuality education

  29. Addressing the Medical Workforce Crisis Develop reimbursement systems that reflect true cost of care and support specialized primary care Integrate HIV workforce issues into primary care workforce initiatives Offer loan forgiveness Conduct national study to assess regional variations in need and to identify barriers Specifically focus on workforce development addressing health disparities

  30. Ryan White Program Extend and fully fund Ryan White Program Access expansion under health reform are off in the future Program still essential to fill gaps and provide support services Integrate the network of RW-funded providers into the broader health system Provide adequate cost-based reimbursement Ensure that Medicaid/ private insurers build RW providers into disease management or medical home networks

  31. PART 3 The Current Status of Health Care Reform and Our Efforts to Reduce Barriers to Care

  32. Obama “So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.” President Barack Obama, Feb. 24, 2009 Joint Session of Congress

  33. Key Congressional Players House – Energy and Commerce, Ways and Means, Education and Labor Senate – Finance and HELP House and Senate Leadership Olympia Snowe (and other Senate moderate Republicans?) and conservative Democrats

  34. Private Insurance Reform • Overview • Access • Coverage – mandated benefits • Affordability – cost-sharing • Individual and Employer Mandates

  35. Overview: Overall Approach to Expanding Access to Health Insurance

  36. Private Insurance - Access

  37. Private Insurance – Access, cont’d.

  38. Private Insurance Coverage Mandated Benefits for Exchange Plans

  39. Affordability – Federal Poverty Level Family Size

  40. Affordability – Premiums • Premium Subsidies – Individual consumer share is a percentage of income. • For example, a single individual at 200%FPL pays: • 7% of income under Senate Finance • 3.3% of income under Senate HELP • 5.5% of income under House bill • Government provides a subsidy to cover the remainder

  41. Affordability – Consumer Share after Premium Subsidy • Premium Credits (as % of annual income)

  42. Affordability:Consumer Share of Insurance Premiums

  43. Affordability – Cost-Sharing Subsidies and Caps Cost-Sharing Subsidies • Individual consumer share is percentage of cost of care or treatment provided based on income. • Government provides a subsidy to cover the remainder Cost-Sharing Caps • Each bill establishes an out-of-pocket limit or cap on consumer spending on the cost of care or treatment

  44. Affordability – Consumer Share after Cost-Sharing Subsidies

  45. Affordability - Cost-Sharing Spending Caps

  46. Affordability - Cost-Sharing at 150% FPL Finance HELP House $7,143 $9,820 $17,000 For an individual with income at 150% FPL ($16, 245 per year).

  47. Affordability – Cost-Sharing at 300% FPL House Finance HELP/Finance HELP $8,500 $13,523 $18,182 $18,594 *For an individual with income at 430% FPL ($32,490 per year).

  48. Total Out-Of Pocket Cost to Consumer: Premium and Cost-Sharing

  49. Private Insurance – Individual Mandate

  50. Private Insurance – Employer Mandate

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