Transcript Powerpoint - UCLA Fielding School of Public Health

Federal & State
HIV/AIDS Policy
UCLA School of Public Health
Epidemiology 227
April 23, 2010
Prof. Arleen Leibowitz
UCLA School of Public Affairs
Outline

Care and Treatment
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Testing and Prevention
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Medicaid
Medicare
Ryan White CARE Act
Private Insurance and Health Reform Changes
California issues
Research
Income Support and Housing
Global Programs
Follow The Funding to Determine Priorities
FY 2010 Federal HIV/AIDS Budget Request
($ Billions)
Global, $6.46
Treatment,
$13.53
Research,
$2.62
Housing/$,
$2.45
Prevention,
$0.79
National Treatment Guidelines Call for
Early Access to Treatment and Care

But many PLWH are not in regular care
About 21% do not know their HIV status
 Only 55% of those meeting clinical criteria for ARV therapy
get it
 Expanded guidelines


HAART is costly
$12,000/year in ARV costs
 $20,000/year in total costs

Insurance Status of HIV Patients in Care,
1996
Uninsured
20%
Private
32%
Medicaid
29%
Medicare
19%
Federal Support for Care and Treatment
(FY2010)
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Medicaid (Federal share)
Medicare
Ryan White

$4.7 B
$5.1 B
$2.3 B
(ADAP
34.6%
37.5%
16.9%
$0.8 B)

Veterans Affairs
SAMHSA
HOPWA
FEHBP
$0.8 B
$0.2 B
$0.3 B
$0.1 B

Total
$13.5 B

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
5.9%
1.5%
2.2%
0.7%
Two Kinds of Federal Spending

Mandatory spending
Presumption that 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 means that the budget does not increase to
accommodate increased enrollment
Health care costs rise faster than CPI, so annual
increases are “high”
Long-term health investments are discouraged by
annual budget process
Prevention may reduce costs in long run, but not in short
 Early treatment of HIV may save money in long run

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Share of discretionary spending is falling
Medicaid
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Created in 1965
Federal/state health insurance program for low income
and disabled
Federal government pays a minimum of 50% of costs,
more in low income states (average 55% of HIV $)
Jointly administered
States set eligibility criteria, subject to Federal minima
 States set benefits, subject to Federal mandated benefits

Current Medicaid Eligibility

States must cover
Certain poor women and children
 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”)
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States set income criteria
State option to cover Medically Needy who “spend
down” to income criteria
Medicaid Benefits

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Covers most services with 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

Medicaid – Current Policy Issues
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State variability in Medically Needy income eligibility criteria
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75% FPL
7% FPL
States can impose limits on discretionary services (drugs)
Non-citizens can not qualify for Medicaid
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Vermont
Louisiana
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
Medicaid –Policy Issues (2)

Catch-22
Medicaid eligibility depends on being disabled or having
AIDS
 But early treatment of non-disabled could avert disability
 And reduce transmission

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Some states have 1115-waivers to provide Medicaid to
low income people with HIV prior to disability
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

Medicaid –Policy Issues (3)
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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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In recessions, states attempt to cut Medicaid benefits


Ticket to Work/Work Incentives Improvement Act of 1998
continues Medicaid coverage even if person returns to work
Gov. Schwarzenegger proposed premiums for Medicaid
Federal government raised its match rate during
recession
Health Care Reform and Medicaid
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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
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
Medicare
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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.
Medicare: Eligibility for Disabled

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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
 Low income subsidy needed for “the donut hole”

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
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
Ryan White Funds Systems of Care
Originally designed to provide relief to cities with
disproportionate burden of caring for HIV/AIDS
Part A:
Part B:
Part C:
Part D:
Part F
Emergency Relief (EMA, TGA)
HIV Care (including ADAP)
Early Intervention
Women, Infants, Children, Youth
AIDS Education and Training,
Dental, SPNS
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: $835 M (approx 50%)
Plus state supplements (approx 25%)
And rebates from drug manufacturers (approx 25%)
Other Federal funding
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

States have used waiting lists to ration
ADAP (2)
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Drugs provided to 110,000 PLWH monthly in 2008
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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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Drug Formularies
Must include at least one medication w/I each ARV class
 Louisiana had 28 drugs; New York had 460
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Ryan White – Current Policy Issues
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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
Ryan White – Policy Issues (2)

2006 Reauthorization of Ryan White Act revised
funding formulas for Parts A and B
Funding now based on reported HIV cases, not only AIDS
cases
 Directs funding to reflect emerging epidemic
 California just began names reporting of HIV cases
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Required 75% of funding to be used for core medical
services
ADAP - Policy Issues
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Coordination with Medicare Part D
Payment for Part D co-pays, deductibles, premiums
 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
Longer bridge to Medicaid
 New, more costly drugs
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ADAP - Policy Issues (2)
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Continued availability of prescription rebates?
State fiscal environments challenge states’ ability to
supplement ADAP
States seek to reduce formularies to cut costs
Need to explore cost containment strategies that
maintain client access (i.e. purchasing options)
Health Reform and ADAP

Insurance exchanges should reduce number of
uninsured, and reliance on ADAP
Would provide for medical care, not just drugs
 CARE/HIPP could help purchase insurance
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ADAP will count as TROOP
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Cost of drugs while in donut hole is reduced by 50%
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ADAP costs after donut hole should decrease
Effect on rebates?
Effect of health reform on Ryan White funding?

Undocumented
Health Reform and Private Insurance
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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
May reduce pressure on COBRA for unemployed
Outline

Care and Treatment
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
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

Testing and Prevention
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


Medicaid
Medicare
Ryan White CARE Act
Health Reform and private insurance
California Issues
Research
Income Support and Housing
Global Programs
HIV Testing


21% of PLWH do not know they are HIV+
CDC “Advancing HIV Prevention” (2004)
1.
2.
3.
4.
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
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
 Need prevention counseling accompany testing?

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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CA state law relating to who can perform finger prick
test limited use of rapid tests
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Just changed
Prevention

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Centers for Disease Control and Prevention
administers most federal prevention efforts (FY 10
budget: $785.1 B)
National budget share for prevention (4%) is
decreasing over time
California share for prevention <6%
California Cut 09/10 HIV/AIDS Budget
by $59M
State Cut State Cut State Share (09/10)/
(08/09)
($ million) (%)
(%)
C&T, HERR
32.9
100
78.6
0.266
Care & Support 22.8
100
40.0
0.607
SOA
3.0
44.8
31.1
0.728
ADAP
25.0
0-funded Increased
by rebates for FY11
1.00
Prevention: Policy Issues
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
Balance efforts targeting HIV- and HIV+ individuals
Target increased risk behavior among MSM
Methamphetamine epidemic in CA
 Internet—prevention challenge or opportunity?

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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
Prevention – Policy Issues

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
Outline

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 $2.62B in FY10
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Largest investments are biomedical
California HIV Research Program
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FY07 $12M
Income Support and Housing
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Cash Assistance (11% of Domestic HIV funding)
SSI - $500 M in FY10
 SSDI - $1,636 M in FY10
 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?
Conclusions—Domestic Issues


Health Reform has addressed many HIV/AIDS policy
issues
But, the fragmented system still presents challenges
Outline

Care and Treatment



Medicaid
Medicare
Ryan White CARE Act

Testing and Prevention
Research
Income Support and Housing
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Global Programs
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Global Programs
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President’s Emergency Plan for AIDS Relief (PEPFAR)
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Most US funding is bilateral, circumvents Global Fund

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President Bush proposed $15B commitment over 5 years in 2003
Upped to $48 B over 5 years
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
HIV Is 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
Global Policy Issues
2003
 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 +
 Condoms only for “high-risk”
(prostitutes, discordant couples,
substance abusers)
2010
 Over half of funding for
treatment
 Target 50% of prevention funds
on abstinence. If less, report to
Congress
 AB-C still in place
Global Policy Issues (2)
2003
 ARVs must be approved by FDA
(WHO approval not sufficient)
 HIV exempted from “gag rule”
on abortions, but many
misunderstood
 Funded organizations need
“policy explicitly opposing
prostitution and sex trafficking.”
(PL108-25)
 No funding for needle exchange
2010
 By 2007, 73% of drugs
distributed were generic.
Accelerated FDA approval.
 Pres. Obama rescinded “gag rule”
on abortion
 Focus on MTCT, MC and
services for IDUs
Overarching Policy Questions

Will care and treatment crowd out prevention because
we adopt a short term planning horizon?


Why do we spend so little on prevention?
Fragmented funding makes it difficult to
Know what resources are available
 Coordinate care

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