The Patient Protection and Affordable Care Act

1. The Patient Protection and Affordable Care Act Update and Implications Joseph Jefferson, MPH Director of Advocacy and Alliance Development

2. Presentation Preview • Assessing the Landscape • ACA Implementation Update • ACA Patient Protections and Access • ACA and Ryan White • ACA and Implications for ADAP • Informing the Advocacy Agenda

3. Assessing the Landscape

6. HIV/Hep C Surveillance Comparison

8. Workforce Trends

9. Workforce Trends • Providers of HIV Care reported increasing numbers of HIV patients with co-occurring conditions like: • Cardiovascular disease (50%) • Renal disease (49%) • Mental health conditions (48%) • Substance abuse (38%) • Hepatitis C (36%) • 58% of HIV Providers are seeing increasing number of HIV patients with sexually transmitted infections

10. Workforce Trends • Approximately 4,500 HIV providers (MD, DO, NP, PA) in US • Fewer than 1/3 of physicians are in private practice – Movement to larger health systems • The current HIV workforce composed of first generation providers who entered the field over 20 years ago. • 50% of current HIV provider workforce retiring in next 5 to 10 years • Ryan White Part C-funded clinicsreport difficulty recruiting HIV clinicians

13. Federal HCV Initiatives • Healthy People 2020 (Dec 2010) • Goal: Increase immunization rates and reduce preventable infectious diseases • National Viral Hepatitis Action Plan (May 2011) • Increase % of persons aware of HBV infection from 33% to 66% • Increase % of persons aware of HCV infection from 45% to 66% • Reduce number of new cases of HCV by 25% • Elimination of mother-to-child transmission of HBV • CDC recommendations on HCV testing for baby boomers (August 2012) • Patient Protection and Affordable Care Act (2014) • Focus on prevention

14. ACA Implementation Update

15. Implementation Benchmarks January 2013 January 2014 • State Notification Regarding Exchanges • Closing the Medicare Drug Coverage Gap • Medicaid Coverage of Preventive Services • Medicaid Payments for Primary Care • Medicaid Expansion • Individual Insurance Requirement • Health Insurance Exchanges • Guaranteed Availability of Insurance • No Annual Limits on Coverage • Essential Health Benefits

16. Medicaid Expansion Decision Map Center for American Progress, March 2013

17. Marketplace (Exchange) Decision Map

18. ACA Patient Protections and Access

19. Key ACA Patient Protections • Guaranteed availability of coverage, regardless of health status or pre-existing condition • Prohibitions on discriminatory premium rates, ie. Gender and health status • Prohibitions on pre-existing condition exclusions • Coverage of “specified” preventive health services without cost-sharing • Low-income PWLHs <64 may qualify for Medicaid in states that choose to expand

20. Key ACA Patient Protections • No lifetime or annual limits on coverage • Health plans cannot drop people from coverage when they get sick • Federal subsidies for people with incomes <400% FPL • Plans have to contract with “community providers”, including Ryan White programs • Plans must include EHB

21. ACA & Implications for HCV • Increased access to health insurance HCV testing and treatment • 24% of HCV+ individuals without insurance had any knowledge of their chronic liver disease (compared with 50% among insured)1 • Studies have found that of HCV-infected individuals in the US who are candidates for treatment, only half have any form of health insurance coverage and can, therefore, access treatment2 • Coverage of preventive services • USPSTF draft recommendations • “C” grade for HCV screening among baby boomers (birth cohort) • “B” grade for HCV screening among adults at high risk • 1Center for Liver Diseases at Inova Fairfax Hospital; John Cochran, VA Medical Center and Saint Louis University School of Medicine, St. Louis, MO; Michael E. DeBakey, BaylorCollege of Medicine; and Betty and Guy Beatty Center for Integrated Research • 2Brian Edlin, MD; Center for the Study of Hepatitis C, Weill Medical College of Cornell University

23. PLHWs and Access

24. PLHWs and Access http://policyinsights.kff.org/2012/september/how-the-aca-changes-pathways-to-insurance-coverage-for-people-with-hiv.aspx

25. ACA & CHCs/FQHCs • Contains $11B in new, dedicated funding for Health Centers • Over 8,000 Health Centers currently serving 20 million people • Health Centers will provide care and treatment of the vast majority of newly eligible Medicaid patients transferring from ADAP

26. ACA & Ryan White

27. Ryan White Reauthorization Update • Ryan White will likely not be reauthorized in 2013 – though 2009 reauthorization contains no sunset provision • Programs will likely continue in FY 14 and beyond • Final FY13 CR did not include $35M for ADAPs and $10M for PartC • Sequester likely to result in 5.2% HHS funding reduction • Obama FY14 budget provides $20M increase in RW • $10M ADAP; $10 for Part C clinics • As Health Care Reform is implemented FQHCs are likely to see an influx of HIV patients

28. Ryan White Reauthorization Update HRSA Justification Notes: “The Ryan White Program is authorized through September 30, 2013. However, the program will continue to operate. The 2009 reauthorization or the Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87, October 30, 2009) does not include an explicit sunset clause. In the absence of a sunset clause, the program will continue to operate without a Congressional reauthorization.”

29. Ryan White Reauthorization Update HRSA/HAB Considerations: • Identify issues as RW beneficiaries transfer to private insurance • Reallocate RW dollars toward premium support • Create flexible enrollment procedures/timelines • Clarify effective coverage dates • Network v. out-of-Network care • Prior Authorization for both Medicaid and Marketplaces

30. Federal RW Funding (infl-adj) and HIV Prevalence, 1991-2012 Source: Andrea Weddle, HIV Medicine Association, HIV Medical Provider Experiences: Results of a Survey of Ryan White Part C Programs, Institute of Medicine Committee on HIV Screening and Access to Care, September

31. ACA & Implications for ADAP

32. HealthHIV HealthGram on Medicaid Expansion & HIV Incidence by State and Health Ranking

34. ADAP 2014 Population Estimates

35. Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Top Quartile http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

36. Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Bottom Quartile http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

37. Estimated % of ADAP Clients NEWLY Eligible for Private Insurance Subsidies in 2014: Top Quartile http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

38. Estimated % of ADAP Clients Eligible for Private Insurance Subsidies IN 2014: Bottom Quartile http://www.hivhealthreform.org/wp-content/uploads/2013/03/50-states-Modeling-Final.pdf

39. ACA & Payor Shifts

40. ACA & Payor Shift Current Payor Current Service Venues Private Practice Medicaid RW Clinics Ryan White / ADAP CHCs

41. ACA & Payor Shift Current Payor Post-ACA Payor Current Service Venues Private Practice Medicaid Medicaid FQHCs Ryan White / ADAP Marketplaces PCMHs

42. Informing the Advocacy Agenda

43. Medicaid HHS/CMS must: • Ensure “Alternative Benefit Plan” is similar to traditional Medicaid • Give states flexibility to design multiple ABPs targeting specific populations • Extend EHB non-discrimination mandates to ABPs • Apply rules governing prescription drug coverage under Medicaid to ABP • Apply non-disc protections to drug benefit • Include preventive services, including routing HIV and HCV screening • Mitigate burdensome cost-sharing proposals by adopting standard established in Medicare Part D low-income subsidy program 2. Advocates must press for Medicaid expansion in states leaning against expansion

44. Essential Health Benefits 1. CMS must: • Evaluate and standardize “medical necessity” requirements • Develop mechanisms to monitor utilization management techniques, exclusions, and service limits • Ensure meaningful stakeholder engagement involvement at Federal and State level in the run-up to EHB framework reevaluation in 2016 – Goal: Higher and more clearly defined national standards • Issue clarifying guidance to states to ensure reasonable, accessible, and expedited appeals process regarding benefit and service coverage decisions – including access to most appropriate and effective combination ARV therapy 2. Advocates need to work with CMS to overcome opposition by payers

45. HCV • Press for national data system and/or standards for hepatitis data collection • Press for increasedfunding for hepatitis prevention • ClarifyEHB prescription drug coverage standards (given new HCV treatment opportunities in the pipeline) • Increase provider and consumer education

46. Washington, DC 20009202.232.6749 www.healthhiv.org joseph@healthhiv.org 202.507.4727