The Affordable Care Act and Ryan White

2013 United Conference on AIDS (USCA)New OrleansSeptember 10, 2013

Jen Kates, Kaiser Family Foundation

What Will the ACA Mean for Addressing the HIV Epidemic?

Private Insurance

Expansions & Consumer Protections

Benefit Standards

Medicare Fixes Prevention Medicaid

Expansion

Key ACA Provisions for People with HIV

Expansion of Private

Coverage & Consumer

Protections

Medicaid Expansion

Medicaid Expansion

Medicare Fixes

Medicare Fixes

Benefit Standards

Benefit Standards

Private Market

• End to lifetime and annual coverage limits

• Elimination of pre-existing conditions exclusions

• Dependent coverage to age 26• Non-discrimination protections• State-based health insurance

marketplaces, with subsidies based on income

• To Follow: State decisions on exchanges, network adequacy and inclusion of “essential community providers”

Benefit Standards

Medicaid Expansion

Medicaid Expansion

Medicare Fixes

Medicare Fixes

Benefit Standards

Benefit Standards

Benefits

• Essential Health Benefits (EHB) - must provide comprehensive set of services across 10 categories, including Rx

• EHB required for plans in individual and small group markets in and outside of marketplaces, Medicaid benchmark and benchmark-equivalent, Basic Health Plan, Alternate benefit Plan

• To Follow: State flexibility means benefits will vary by state; service limits could still be used

Medicare Fixes

Medicaid Expansion

Medicaid Expansion

Medicare Fixes

Medicare Fixes

Benefit Standards

Benefit Standards

Medicare

• As of 2011, ADAP prescription expenses count towards True out of pocket costs (TrOOP), to reach catastrophic coverage level for drug coverage

• Closing the Part D coverage gap for all, starting in 2010 and fully by 2020

Prevention

Medicaid Expansion

Medicaid Expansion

Medicare Fixes

Medicare Fixes

Benefit Standards

Benefit Standards

Prevention

• Prevention & Public Health Fund• Free preventive services: USPSTF “A”

and “B” rated services, including routine HIV screening, must be provided for free in new health plans, Medicaid expansion benefits; financial incentive to provide in traditional Medicaid

• Additional preventive services for free for women

• To Follow: State decisions on coverage of routine HIV screening in traditional Medicaid; Will Medicare cover routine HIV screening

Medicaid Expansion

Medicaid Expansion

Medicaid Expansion

Medicare Fixes

Medicare Fixes

Benefit Standards

Benefit Standards

Medicaid

• In 2014, Medicaid eligibility expanded to nearly all low-income individuals (state option as of 2010): Eliminates “Catch-22” for people with HIV, sets floor of eligibility

• Supreme Court decision effectively makes this a state option

• Today, Medicaid coverage of childless, non-disabled adults very limited; without mandatory expansion, will lead to new “coverage gap”, uneven access

• Note: other Medicaid provisions include Medicaid health home option

• To Follow: State decisions on expansion; benefits package for expansion population; Use of Medicaid for premium assistance in marketplace in non-expansion states?

NOTE: MN /VT also offer waiver coverage more limited than Medicaid. OR/UT also offer “premium assistance” with open enrollment. IL/ LA/MO offer coverage for adults residing in a single county/area. SOURCES: KCMU/Georgetown University, survey of states, as of January 2013. KFF Analysis of data from the CDC Atlas

Current Medicaid Coverage of Low-Income Adults is Limited

More Limited than Medicaid (16 states) – 30% PLWH

Medicaid Benefits (9 states, including DC) – 22% PLWH

No Coverage (26 states) – 48% PLWH

“Closed” = enrollment closed to new applicants

WY

WI(closed)

WV

WA(closed)

VA

VT*

UT*(closed)

TX

TN

SD

SC

RI

PA

OR*(closed)

OK

OH

ND

NC

NY

NM(closed)

NJ

NH

NV NE

MT

MO*

MS

MN

MI(closed)

MA

MD

ME (closed)

LA

KY KS

IA IN

(closed) IL

ID

HI(closed)

GA

FL

DC

DE

CT

CO(closed)

CA

AR AZ (closed)

AK

AL

NJ

Just Over Half of People with HIV are in States that Plan to Expand Medicaid; Almost 4 in 10 are not

NOTE: As of September 3, 2013SOURCES: KCMU analysis of recent news reports, executive activity and legislative activity in states. KFF analysis of data from the CDC Atlas.

WY

WI

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV NE

MT

MO

MS

MN

MIMA

MD

ME

LA

KY KS

IA

IN IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR1AZ

AK

AL

Debate Ongoing (4 States) – 8% PLWH

Moving Forward at this Time (25 States including DC) – 55% PLWH

Not Moving Forward at this Time (22 States) – 38% PLWH

What Will the ACA Mean for Ryan White?

Medicaid (federal only)5.3

36%

Medicare5.8

39%

Ryan White2.39216%

VA0.881

6%SAMSHA0.136315

1%Other

0.2563682%

FY 2012In Billions

$14.8 billion

Ryan White is the Third Largest Source of Federal Funding for HIV Care in the U.S.

SOURCE: Kaiser Family Foundation analysis of data from OMB, CBJs, and appropriations bills.

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 $-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Ryan White Funding, Current $Ryan White Funding, Constant 1991 $HIV/AIDS Prevalence

Funding Prevalence

NOTES: The Consumer Price Index (CPI) from the Bureau of Labor Statistics (BLS) was used to adjust for inflation. HIV prevalence data are estimates based on analysis of data from CDC. SOURCES: Funding amounts based on Kaiser Family Foundation analysis of data from OMB, CBJs, appropriations bills, and CRS; Prevalence based on data from CDC; U.S. Department of Labor, Bureau of Labor Statistics.

Federal Ryan White Funding (adjusted for inflation) and HIV Prevalence, 1991-2012

Private13%

Medicaid32%

Medicare14%

Other Public9% Other

Insurance3%

Uninsured30%

NOTES: Based on those with reported insurance status (duplicated number of clients, N=764,163) in 2010.SOURCE: HRSA, HAB, http://hab.hrsa.gov/stateprofiles/index.htm.

Most Ryan White Clients Are Insured, And Rely on the Program Because They Face Limits in Their Coverage

HIV-Infected Diagnosed Linked to HIV Care

Retained in HIV Care

On ART Suppressed Viral Load

82%

37%33%

25%

HIV Counseling & Testing

Medical Case Management

Outreach to Engage in Care

Medical Transportation

Non- Medical Case Management

Referrals to Health & Support Services

SOURCES: Adapted from CDC "HIV in the United States–The Stages of Care" July 2012; Service Definitions from HRSA, HAB, 2012 Annual Ryan White HIV/AIDS Program Services Report (Rsr) Instruction Manual.

Select Examples of Ryan White Services That Support Clients Along The HIV Treatment Cascade

Treatment Adherence

Health Insurance Premium Assistance & Cost-Sharing

Key Messages on Ryan White & the ACA

• State-level decisions, particularly on Medicaid, will have significant implications for Ryan White

• More Ryan White clients will gain insurance coverage through Medicaid and private insurance coverage through the marketplace

• Greater share of Ryan White funding can shift to cover services not covered in private sector or by Medicaid, or those with limits

• Ryan White providers can join Medicaid and Marketplace provider networks– Marketplaces required to include “essential community providers”– Ryan White providers will need to proactively engage with marketplaces and Medicaid

managed care networks

• Ryan White providers can assist clients with enrollment in new coverage options (including as Navigators & Assistors)

Key Messages, continued

• Ryan White will continue to be important source of care and services for many people with HIV:

– Most Ryan White clients already have coverage but still need the program to complete their care, fill in gaps, help with costs. Even as more gain coverage, they may still need help

– Ryan White provides important HIV-related services that are not always provided by insurance plans

– Current Medicaid coverage of low income adults (who are not disabled) is very limited

– Not all states will expand Medicaid, at least not in 2014– Those who are undocumented are not eligible for Medicaid or

marketplaces; Legal residents have 5 year waiting period for Medicaid