Transcript Powerpoint - UCLA School of Public Health

Federal & State
HIV/AIDS Policy
UCLA School of Public Health
Epidemiology 227
May 15, 2013
Prof. Arleen Leibowitz
UCLA School of Public Affairs
Outline
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Current Status and Affordable Care Act
Care and Treatment Now and Under Health Reform
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Medicaid
Medicare
Ryan White CARE Act
California issues
Private Insurance and Health Reform Changes
Testing and Prevention
Research
Income Support and Housing
Global Programs
Follow The Funding to Determine Priorities
Federal HIV/AIDS Budget Request – FY2013
US $ Billions
Global
24%
Research
10%
Prevention
3%
Cash and
Housing
10%
Care &
Treatment
53%
Treatment as Prevention
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New results show early treatment reduces transmission
But many PLWH are not treated
About 18% do not know their HIV status
 33% on ARV therapy, 19-28% are virally suppressed
 Expanded guidelines
 HAART is costly--$12,000/year
 $20,000-30,000/year in total costs
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Highlights importance of insurance
Insurance Status PLWHA in Care:
2010
Affordable Care Act (ACA)
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Individual mandate
Employers (50+ workers) must offer insurance or pay
penalty if employees get subsidy. Small business credits
Expand Medicaid to all <65 with income <133% FPL
States have option to expand Medicaid (per Supreme Court)
 100% Federal funding for expansion, 90% in 2020
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Preventive services
Remove Medicare cost-sharing
 Pay Medicaid providers at Medicare rates
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Affordable Care Act (2)
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Health Insurance Exchanges with premium subsidies
Cost sharing subsidies
 Out of pocket limits if income <400% FPL
 U.S. citizens and legal immigrants
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Requires guaranteed issue and renewability
Outlaws medical underwriting
Outlaws lifetime limits on coverage
Essential benefits package
Support for community health centers
Two Kinds of Federal Spending
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Mandatory spending
Congress must allocate funding to meet statutory obligation –
e.g., Medicare, Medicaid, SSI
 “Entitlements”
 Defined benefit
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Discretionary spending
Congress decides on spending level each year
 Defined contribution
 Block grants
 Examples: NIH, CDC, Ryan White, VA
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Problems With Discretionary Spending
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Block grant budget does not increase to accommodate
increased enrollment
Health care costs rise faster than CPI, so annual
increases are “high”
Annual budget process discourages long-term health
investments
Prevention may reduce costs in long run, but not in short
 Early treatment of HIV saves money in long run
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Share of discretionary spending is falling
Federal Support for Care and Treatment
(FY2013)
Entitlement
 Medicaid (Federal share)
 Medicare
 FEHBP
Discretionary
 Ryan White
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$5.6 B
$6.2 B
$0.2 B
35%
39%
1%
$2.5 B
16%
(ADAP)
($1.0 B)
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Veterans Affairs
SAMHSA
HOPWA
$1.0 B
$0.2 B
$0.3 B
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Total
$16.0 B
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6%
1%
2%
Medicaid
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Federal/state health insurance program
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Created in 1965
States set eligibility criteria, subject to Federal minima
States set benefits, subject to Federal mandated benefits
Entitlement program that expands to meet demand of
low income and disabled meeting state criteria
Federal government pays a minimum of 50% of costs,
more in low income states (average 55% of HIV $)
Medicaid Benefits
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Covers most services; no or minimal cost-sharing
Drugs, an optional service, are covered in all states
Optional services include case management, hospice
Some states limit services
Number of Rx per month or year
 Number of MD visits
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In recessions, states try to cut Medicaid costs
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California instituted cost-sharing for Medicaid
Medicaid Eligibility
Current Law
Low income women and children
Disabled who qualify for SSI
States set income criteria for other
eligibility; differs across states
Medically Needy “spend down” to
Medicaid level at state option
Citizenship required
Legal residents wait 5 years
Medicaid Eligibility
Current Law
Under Health Reform (2014)
Low income women and children
Individuals w/o dependent children
covered
Disabled who qualify for SSI
Disability not required
States set income criteria for other
eligibility; differs across states
Medically Needy “spend down” to
Medicaid level at state option
Everyone under 133% of FPL
[$14,404 } Uniform throughout U.S.
100% federal funding for eligibility
expansions in 2014-16; after, 90%
Citizenship required
Legal residents wait 5 years
Citizenship required
Legal residents wait 5 years
Medicaid Payment Issues
Low Medicaid provider payment levels make access
difficult
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ACA raises Medicaid reimbursement rates to Medicare
levels for primary care services, with 100% federal funding
in 2013, 2014
ACA encourages primary care homes
Medicaid discount on drugs of 15.1% less than what
others get
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ACA increases drug 340b rebate to 23.1%, but some goes
back to federal government
Rep. Paul Ryan’s Bill Would Convert
Medicaid to Block Grant
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Repeals ACA
Caps Medicaid spending
Uses formula, rather than costs, to allocate $ to states
 Cap grows with population growth and inflation
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Reduces federal Medicaid spending 2012-2021
UI estimate: $1.4 trillion
 By 34% relative to current law
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Projected Result of Block Granting
Medicaid
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Federal budget savings and predictability
Inflexibility in recession
Reduction in federal payments to states
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Challenges states’ ability to provide care
36.4 million fewer people will be insured
Hospitals lose 38% of revenue
Medicare
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Federal entitlement program created in 1965
Covers persons 65+, persons with ESRD, and long
term disabled
Funded by payroll tax on earnings, general revenues,
beneficiary premiums for Part B and co-payments
(Medicaid can pay patient cost-sharing)
Uniform throughout U.S.
Long-Term Disability Qualifies Many
PLWH for Medicare
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Disabled must have sufficient covered work history to
quality for SSDI
29 Month Waiting period
Federal law requires 5 month wait after disability
determination before receiving SSDI payments
 24-month waiting period for Medicare, following SSDI
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Medicaid coverage for low income persons during the
29 months
Medicare Benefits
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Hospital
Outpatient (20% cost-sharing)
Drugs have been covered since January 1, 2006 under
Part D, private drug insurance plans
Plans required to cover all ARVs
 ACA will gradually close “donut hole”
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100%
75%
50%
25%
5%
$0-310
$310-2830
Drug
Spending
$2830-6640
$6640+
Medicare – Current Policy Issues
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Eligibility
Must have sufficient work history to qualify for SSDI, a
problem for young, poor persons with HIV
 29 month wait for Medicare eligibility
 Catch-22 of disability requirement
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Cost-sharing
High cost sharing if no supplemental coverage
 No cap on out-of-pocket spending
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Medicare “donut hole”
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When ADAP pays, doesn’t count as “true out of pocket
cost” (TROOP)
Health Reform and Medicare
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Medicare “donut” hole will be closed
2010--$350 towards cost
 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
No cost-sharing for covered preventive services (rated
A or B by U.S. Preventive Services Task Force)
Ryan White Care Act
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CARE= Comprehensive AIDS Relief Emergency
Discretionary program enacted 1990, Originally designed to
help cities heavily impacted by HIV/AIDS (EMA; TGA)
Payer of last resort for uninsured and underinsured PLWA
Patient Centered Medical Home --Outpatient care, including
medical, dental, case management, home health, hospice,
housing, transportation, drugs (through ADAP and insurance
continuation)
Current authorization will expire in September
If eligible under ACA, will have to leave Ryan White
AIDS Drug Assistance Program (ADAP)
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Funded by Part B of Ryan White Care Act
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States set eligibility
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Congressional Earmark: $1B (approx 50%)
Plus state supplements (approx 25%)
And rebates from drug manufacturers (approx 25%)
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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3079 PLWH on ADAP waiting lists in April 2012
ADAP (2)
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Drugs provided to 133,689 PLWH monthly in 2011
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Cost/enrollee c. $1000/month
Services
HIV Medications, drug monitoring and adherence services
 Can purchase health insurance for eligible clients
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Variation in state coverage
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Louisiana had 28 drugs; New York had 460
States set eligibility rules, resulting in variability
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States with less generous Medicaid programs, need more Ryan White
support
Ryan White – Current Policy Issues
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Demand increases
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Block grant
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Greater survival
Enhanced testing efforts
Loss of insurance due to recession
Medical costs increase faster than CPI
But states have limited ability to supplement
Continued availability of prescription rebates?
Health Reform and Ryan White
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RWCA is funder of “last resort”; what will its role be
under health reform?
ACA increases insurance -- Medicaid and Exchanges
Especially for non-disabled, reducing need for “bridge” to pay for
drugs
 CARE/HIPP could help purchase insurance
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Effect of ACA on Ryan White funding?
Congress is looking for “offsets”
 Undocumented
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How will RW sites interact with Medicaid or CHCs?
Health Reform and ADAP
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ADAP and Medicare Part D drug coverage
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Donut hole costs will fall, reducing need for ADAP
Cost of drugs while in donut hole is reduced by 50%
 Donut hole coinsurance drops to 25%
 ADAP payments count as TROOP
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Effect on rebates?
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Drug rebate for ADAP is better than rebate for Medicaid
Where will undocumented get ART?
Health Reform and Private Insurance
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Mandates employer offer and individual coverage
Eliminates “medical underwriting” and rescissions
Provides subsidies for purchase from exchanges (32
million people by 2019) with mandated benefits
Legal immigrants eligible for subsidies
 Bronze plan—covers 60% of cost
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Caps out of pocket expenditures for persons<4xFPL
Sets up high risk pool—June 2010 to Jan 2014
Allows children to stay on parents’ policy until age 26
Outline
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Care and Treatment
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Medicaid
Medicare
Ryan White CARE Act
California Issues
Health Reform and private insurance
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Testing and Prevention
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Research
Income Support and Housing
Global Programs
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HIV Testing
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18% of PLWH do not know they are HIV+
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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National AIDS Strategy (2010)
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Focus on communities where HIV most concentrated
HIV Testing – Policy Issues
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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
Default is testing; patient must specifically decline test
 Covered by general consent to treat
 CA state law since Jan. 1, 2008 removes requirement for
specific written informed consent for testing
 Question: need prevention counseling accompany testing?
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Testing—Policy Issues (2)
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Rapid test could increase knowledge of HIV status
Results ready in 20 minutes, no need to return for results
 But needs to be confirmed if “preliminarily positive”
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New “60 second” test
Home testing?
New York mandated HIV testing offer in medical
settings
Increase in tests
 No increase in number of new positives
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Prevention
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Centers for Disease Control and Prevention
administers most federal prevention efforts (FY 12
budget: $786 M)
National budget share for prevention (3%) is
decreasing over time
California cut General Fund support for prevention by
$59M in 2009/10
New Prevention Strategies
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Treatment as Prevention
Early treatment reduced transmission by 96%
 Heterosexual couples in Africa
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Pre-Exposure Prophylaxis (PrEP)
Reduced transmission by 44% (more if 90% adherent)
 MSM in US and Latin America
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Post-Exposure Prophylaxis
Prevention: Policy Issues
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Target increased risk behavior among MSM
Methamphetamine epidemic in CA
 Internet—prevention challenge or opportunity?
 Social networks?
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Reach populations who may not realize their risk and
may not receive routine medical care
Young men are not in routine medical care
 STI clinics, EDs, jails?
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Separation between federal treatment and prevention
efforts
Outline
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Care and Treatment
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Medicaid
Medicare
Ryan White CARE Act
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Testing and Prevention
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Research
Income Support and Housing
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Global Programs
Research
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NIH Budget for HIV research is $2.7B in FY12
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Largest investments are biomedical
California HIV Research Program
Income Support and Housing
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Cash Assistance (11% of Domestic HIV funding)
SSI - $520 M in FY12
 SSDI - $1.9 B in FY12
 Entitlement programs for the disabled
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Housing Opportunities for Persons with AIDS
(HOPWA) $332 M in FY12
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AIDS exceptionalism?
Conclusions—Domestic Issues
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HIV care is being mainstreamed
Both clinically
 And in finance
 Is there still a need for special programs like Ryan White?
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Health Reform has addressed many HIV/AIDS policy
issues
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Issue of immigrants unresolved
But, the fragmented system still presents challenges
Difficult to know what resources are available
 Coordinate care
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Outline
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Care and Treatment
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Medicaid
Medicare
Ryan White CARE Act
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Testing and Prevention
Research
Income Support and Housing
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Global Programs
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Global Programs
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Most US AIDS funding is bilateral, circumvents
Global Fund
 US is still largest single contributor to GF (58%)
Obama’s Global Health Initiative (GHI)
 Funding at $63B over 6 years (FY2009-2014)
Rebalances GHI portfolio from HIV to MCH
 HIV/AIDS funding of $5.6B (+0.5% over FY11)
 MNCH $846M (+78% over FY11)
 Nutrition $150M (+100% over FY11)
HIV Is Still Largest Share of GHI
Slide 10
U.S. Global Health Initiative (GHI), FY 2011 Budget Request
In Millions
HIV
$5,739.1
Global Fund
$1,000
Nutrition
TB
$200
$251
Other
$108
Malaria
MCH
$700
FP/RH
NTDs
$590
$155
$829.2
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
Also see: Kates J., The U.S. Global Health Initiative: Overview & Budget Analysis, Menlo Park: Kaiser Family Foundation, December 2009.
to Tutorials
Focus on Health Outcomes
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Rather than on dollars spent
Cost-effectiveness approach: Save the most lives
within a given budget
HIV
 Respiratory infections
 Diarrheal diseases
 Malaria and TB
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1.9 M deaths
2.9 M deaths
2.2 M deaths
2.3 M deaths
Cost/DALY
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Condom promotion and distribution
Prevent MTCT
VCT
First Line ART
Management of neonatal pneumonia
Oral rehydration
Bed nets
$1-99
$1-34
$18-22
$350-2010
$1
$24-139
$11-41
Global Policy Issues
2003
 33% prevention funding had to target
abstinence
 In 2005, 2/3 on abstinence, 1/3 condoms
 Condoms only for “high-risk” (prostitutes,
discordant couples, substance abusers)
 Funded organizations need “policy
explicitly opposing prostitution and sex
trafficking.” (PL108-25)
 ARVs must be approved by FDA (WHO
approval not sufficient)
2010
 Abstinence rules lapsed
 Pres. Obama rescinded
“gag rule” on abortion
 By 2007, 73% of drugs
distributed were generic.
Accelerated FDA
approval.
 Focus on MTCT, MC
and services for IDUs
Overarching Policy Questions
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Is treatment as prevention feasible in developing
world?
How to balance domestic and global needs
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Can we provide PrEP for uninfected in U.S. while many are
not treated in developing world?
Is the movement toward other diseases in GHI ethical?
Policy Resources
HRSA
CDC
NIH
http://www.hrsa.gov
http://www.cdc.gov/hiv
http://www.nih.gov
CHRP
http://chrp.ucop.edu
CHIPTS
Kaiser Family Foundation
CAPS
http://chipts.ucla.edu
http://www.kff.org/hivaids
http://www.caps.ucsf.edu