Health Care Reform W H A T D O E S I T M E A N F O R P E O P LE - PowerPoint PPT Presentation

Health Care Reform W H A T D O E S I T M E A N F O R P E O P LE W I TH H I V ? O v e r c o m i n g H e a l t h D i s p a r i t i e s i n t h e Ca l i f o r n i a B a y A r e a U s i n g H I V / A I D S a s a M o d e l S a n F r a n c i s c o M a y , 2 0 12 A N N E D O N N E L L Y P R O J E C T I N F O R M A D O N N E L L Y @ P R O J E C T I N F O R M . O R G 4 1 5 . 5 5 8 . 8 6 6 9 X 2 0 8

Presentation Outline  Part One: Considering Disparities  Part Two: The Supreme Court and Elections  Part Three: Turning Back?  Part Four: Health Care Reform and a Changing HIV/ AIDS Care Landscape  Part Five: California at the Crossroads  Part Six: Priorities for ACA Implementation

Health Care Reform and Disparities • How will Health PLWHA get Education information? and Prevention • Assistance? • What Diagnosis supports/ services and Linkage are necessary? to Care • Who pays? • Formularies? Treatment • Benefits and Retention Packages? in Care • Wrap Arounds?

The Supreme Court and Elections W H A T W I LL H A P P E N W I TH H E A LTH CA R E R E F O R M ?

The Supreme Court: What Could Happen? Opponents challenged constitutionality of the individual mandate and the Medicaid expansion and SCOTUS heard arguments in March. Decision is expected in June The entire The individual The entire law law survives mandate is struck is struck down down, but some parts of the law survive

2012 Elections = Watershed for Health Care Control of the Control of Senate the House Control of the White House Will the ACA be fully implemented? Will deficit reduction be achieved responsibly? Will our health care safety nets (Medicaid, Medicare, Ryan White Program) be preserved?

Can We Afford to Turn Back? T H E S Y S T E M I S B R O K E N

Broken Systems: Access to Care Crisis Demand for Ryan White 42 – 59% of Services is Thousands low income Growing on ADAP PLWH are Waiting List not in regular care The 30% of People with people living Current HIV can’t get with HIV insurance Crisis are uninsured coverage

Health Care Reform – A Changing Care Landscape

New Responsibilities  Creates an individual mandate that citizens must carry health insurance  Financial penalties apply to those who do not  Exemptions for hardship and some other reasons  Individual mandate under attack; many still think it will be upheld  Coverage expansions are – in effect – a mandate for people with HIV who want to stay in care  Ryan White payer of last resort rules

Coverage Expansions Medicaid: 16 million Income Under 138% FPL Estimated 3 32 Milli illion will g ill gain in cove verage b by 2019 Exchange: 26 million Income above 138% FPL

Medicaid: Improved and Expanded  Currently Medicaid is – for most with HIV – disability coverage  In 2014:  Expanded Eligibility  The disability requirement is eliminated  Most people with income up to 138%FPL will be eligible for Medicaid/ Medi-Cal (appr. $15K for an individual)  No asset test  Could Improve Services  Medicaid expansion includes Essential Health Benefits (EHB) for newly eligible people

Improves Access to Private Insurance State-Based Exchanges Insurance Reforms  Can’t be denied or dropped from insurance  Consumer friendly because of HIV (all plans) marketplace to purchase  Can’t be charged higher premiums because private insurance of HIV or gender (exchange plans)  Federal subsidies for  No more lifetime and annual limits (all people with income up to 400% FPL plans)  Plans must provide  Prevention services (including routine HIV essential health benefits testing for women) must be covered without cost sharing (all plans)  Caps amount spent out of pocket (exchange plans)

Increases Access to Medicare Part D  50% discount on all brand-name prescription drugs  AIDS Drug Assistance Program (ADAP) contributions now count toward copayment obligations, allowing people with HIV to move through the “donut hole”  Part D “donut hole” phased-out by 2020

Improvements in MH and SUD Services  Mental health (MH) and substance use disorder (SUD) tx part of EHB  Mandatory coverage for MH and SUD at parity  New opportunities in primary care and integrated services  Primary care, MH and SUD community health team grants;  Centers of excellence for depression  MH and SUD providers on team in Medicaid medical homes  No cost preventative services include some mental health  Projects at CMMI include mental health  Provider non-discrimination provisions

New Mandatory Package of Benefits Essential Health Benefits  Ambulatory services  Emergency services  Hospitalization  Maternity/ newborn care  Mental health and substance use tx services – to parity  Prescription drugs  Rehabilitative and habilitative services  Laboratory services  Preventive and wellness services and chronic disease management  Pediatric services

Invests in Prevention, Wellness, Access to Care and Innovation • Prevention and Public Health Fund $500 million in 2010 and increasing annually up to $2 – billion in 2015 for community prevention initiatives • Community Health Center Expansion $11 billion in funding for the operation, expansion and – construction of health centers over the next five years • Health Workforce Investments Expands primary care workforce – Expands National Health Service Corps – • Care Coordination Investments Center for Medicare and Medicaid Innovation (CMMI) –

Health Care Reform and Immigrants Certain immigrant populations are completely excluded from health care reform  Undocumented individuals are not eligible for coverage  Medicaid  Health Insurance Exchange  Subsidy  Legal immigrants continue to face a five year waiting period for Medicaid  Some states – including CA -provide coverage to this population using state dollars but services threatened by budget cuts  MA court case found that if states cover, comparable services must be offered  Exceptions to five year waiting period include people seeking asylum, refugees and some others

Care Landscape in 2014 Individuals with income up to 138% FPL Eligible for Medicaid based on income alone (Ryan White Program still needed to fill in gaps not covered by Medicaid) Individuals between 138% and 400% Eligible for premium tax credits and FPL cost-sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps not covered by private insurance) Individuals with unmet care and Ryan White Program still a safety net treatment needs for: insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants

What Is Happening In California? M O V I N G TO W A R D H E A LTH CA R E R E F O R M I N A D E F I CI T R E A LI TY

California at a Crossroads  Opportunity: California is committed to HCR and moving ahead  If health care reform is rescinded CA may be poised to implement some on its own  Challenge: CA is moving too quickly and cost/ savings is one of the top considerations in this economic climate  Making decisions that are not fully vetted or understood  Assuming immediate savings in programs that aren’t realistic  If federal health care reform is dismantled or defunded, particularly Medicaid expansion, CA at risk for having to rescind significant advances and actually push people out of care

HIV Care Transitioning to New Systems  Ryan White programs and support systems created a relatively seamless system of care  Both people with HIV and HIV providers will need to transition to new forms of coverage  California’s preparation for health care reform  Low Income Health Programs  Movement into Medi-Cal managed care  Pre-existing Condition Insurance Program  There is no one agency/ individual “in charge” of this massive transition  It involves multiple agencies (previously siloed) working together in new ways  No effective communications system for providers or clients  No clarity on new systems, and no assistance for individuals, technical assistance for providers  Inadequate provider rates, including pharmacy

Low Income Health Programs (LIHPs)  Medicaid-like expansion established by the Medi-Cal 1115 waiver  Temporary program will end January 1, 2014  “Bridge to health care reform” - each individual will have a transition plan to full Medi-Cal expansion  Developed, implemented and financed by the county  Benefits can vary  Eligibility for the program is established by county  Ranges from 25% of Federal Poverty Level (FPL) – 200%FPL*  Counties are at different stages of LIHP development

Movement to Medi-Cal Managed Care  All state Medicaids are moving toward managed care  Two thirds of beneficiaries currently in managed care  California began moving Seniors and People with Disabilities in to mandatory managed care in May 2011; complete by July 2012  Protections for those whose doctors were not contracted with managed care broke down  Medical Exemption Request – out of managed care for one year  Continuity of Care request – in managed care; continue to see fee-for-service doctor for up to one year  Out of county contracting remains unclear