Federal & State HIV/AIDS Policy

1. Federal & State HIV/AIDS Policy UCLA School of Public Health Epidemiology 227 May 15, 2013 Prof. Arleen Leibowitz UCLA School of Public Affairs

2. Outline • Current Status and Affordable Care Act • Care and Treatment Now and Under Health Reform • Medicaid • Medicare • Ryan White CARE Act • California issues • Private Insurance and Health Reform Changes • Testing and Prevention • Research • Income Support and Housing • Global Programs

3. Follow The Funding to Determine Priorities Federal HIV/AIDS Budget Request – FY2013

4. Treatment as Prevention • 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 • Highlights importance of insurance

5. Insurance Status PLWHA in Care: 2010

6. Affordable Care Act (ACA) • 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 • Preventive services • Remove Medicare cost-sharing • Pay Medicaid providers at Medicare rates

7. Affordable Care Act (2) • Health Insurance Exchanges with premium subsidies • Cost sharing subsidies • Out of pocket limits if income <400% FPL • U.S. citizens and legal immigrants • Requires guaranteed issue and renewability • Outlaws medical underwriting • Outlaws lifetime limits on coverage • Essential benefits package • Support for community health centers

8. Two Kinds of Federal Spending • Mandatory spending • Congress must allocate funding to meet statutory obligation – e.g., Medicare, Medicaid, SSI • “Entitlements” • Defined benefit • Discretionary spending • Congress decides on spending level each year • Defined contribution • Block grants • Examples: NIH, CDC, Ryan White, VA

9. Problems With Discretionary Spending • 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 • Share of discretionary spending is falling

10. Federal Support for Care and Treatment (FY2013) Entitlement • Medicaid (Federal share) $5.6 B 35% • Medicare $6.2 B 39% • FEHBP $0.2 B 1% Discretionary • Ryan White $2.5 B 16% • (ADAP) ($1.0 B) • Veterans Affairs $1.0 B 6 % • SAMHSA $0.2 B 1% • HOPWA $0.3 B 2% • Total $16.0 B

11. Medicaid • Federal/state health insurance program • 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 $)

12. Medicaid Benefits • 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 • In recessions, states try to cut Medicaid costs • California instituted cost-sharing for Medicaid

13. Medicaid Eligibility

14. Medicaid Eligibility

15. Medicaid Payment Issues • Low Medicaid provider payment levels make access difficult • 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 • ACA increases drug 340b rebate to 23.1%, but some goes back to federal government

16. Rep. Paul Ryan’s Bill Would Convert Medicaid to Block Grant • Repeals ACA • Caps Medicaid spending • Uses formula, rather than costs, to allocate $ to states • Cap grows with population growth and inflation • Reduces federal Medicaid spending 2012-2021 • UI estimate: $1.4 trillion • By 34% relative to current law

17. Projected Result of Block Granting Medicaid • Federal budget savings and predictability • Inflexibility in recession • Reduction in federal payments to states • Challenges states’ ability to provide care • 36.4 million fewer people will be insured • Hospitals lose 38% of revenue

18. Medicare • 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.

19. Long-Term Disability Qualifies Many PLWH for Medicare • 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 • Medicaid coverage for low income persons during the 29 months

20. Medicare Benefits • 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”

21. Medicare – Current Policy Issues • 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 • Cost-sharing • High cost sharing if no supplemental coverage • No cap on out-of-pocket spending • Medicare “donut hole” • When ADAP pays, doesn’t count as “true out of pocket cost” (TROOP)

22. Health Reform and Medicare • 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 • 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)

23. Ryan White Care Act • 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

24. AIDS Drug Assistance Program (ADAP) • Funded by Part B of Ryan White Care Act • Congressional Earmark: $1B (approx 50%) • Plus state supplements (approx 25%) • And rebates from drug manufacturers (approx 25%) • States set eligibility • 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 • 3079 PLWH on ADAP waiting lists in April 2012

25. ADAP (2) • Drugs provided to 133,689 PLWH monthly in 2011 • Cost/enrollee c. $1000/month • Services • HIV Medications, drug monitoring and adherence services • Can purchase health insurance for eligible clients • Variation in state coverage • Louisiana had 28 drugs; New York had 460 • States set eligibility rules, resulting in variability • States with less generous Medicaid programs, need more Ryan White support

26. Ryan White – Current Policy Issues • Demand increases • Greater survival • Enhanced testing efforts • Loss of insurance due to recession • Medical costs increase faster than CPI • Block grant • But states have limited ability to supplement • Continued availability of prescription rebates?

27. Health Reform and Ryan White • 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 • Effect of ACA on Ryan White funding? • Congress is looking for “offsets” • Undocumented • How will RW sites interact with Medicaid or CHCs?

28. Health Reform and ADAP • ADAP and Medicare Part D drug coverage • 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 • Effect on rebates? • Drug rebate for ADAP is better than rebate for Medicaid • Where will undocumented get ART?

29. Health Reform and Private Insurance • 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 • 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

30. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • California Issues • Health Reform and private insurance • Testing and Prevention • Research • Income Support and Housing • Global Programs

31. HIV Testing • 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 • National AIDS Strategy (2010) • Focus on communities where HIV most concentrated

32. HIV Testing – Policy Issues • CDC goal to “normalize” HIV testing • 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?

33. Testing—Policy Issues (2) • 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” • 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

34. Prevention • 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

35. New Prevention Strategies • Treatment as Prevention • Early treatment reduced transmission by 96% • Heterosexual couples in Africa • Pre-Exposure Prophylaxis (PrEP) • Reduced transmission by 44% (more if 90% adherent) • MSM in US and Latin America • Post-Exposure Prophylaxis

36. Prevention: Policy Issues • Target increased risk behavior among MSM • Methamphetamine epidemic in CA • Internet—prevention challenge or opportunity? • Social networks? • 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? • Separation between federal treatment and prevention efforts

37. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Testing and Prevention • Research • Income Support and Housing • Global Programs

38. Research • NIH Budget for HIV research is $2.7B in FY12 • Largest investments are biomedical • California HIV Research Program

39. Income Support and Housing • Cash Assistance (11% of Domestic HIV funding) • SSI - $520 M in FY12 • SSDI - $1.9 B in FY12 • Entitlement programs for the disabled • Housing Opportunities for Persons with AIDS (HOPWA) $332 M in FY12 • AIDS exceptionalism?

40. Conclusions—Domestic Issues • HIV care is being mainstreamed • Both clinically • And in finance • Is there still a need for special programs like Ryan White? • Health Reform has addressed many HIV/AIDS policy issues • Issue of immigrants unresolved • But, the fragmented system still presents challenges • Difficult to know what resources are available • Coordinate care

41. Outline • Care and Treatment • Medicaid • Medicare • Ryan White CARE Act • Testing and Prevention • Research • Income Support and Housing • Global Programs

42. Global Programs • 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)

43. HIV Is Still Largest Share of GHI

44. Focus on Health Outcomes • Rather than on dollars spent • Cost-effectiveness approach: Save the most lives within a given budget • HIV 1.9 M deaths • Respiratory infections 2.9 M deaths • Diarrheal diseases 2.2 M deaths • Malaria and TB 2.3 M deaths

45. Cost/DALY Condom promotion and distribution $1-99 Prevent MTCT $1-34 VCT $18-22 First Line ART $350-2010 Management of neonatal pneumonia $1 Oral rehydration $24-139 Bed nets $11-41

46. 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 Global Policy Issues

47. Overarching Policy Questions • Is treatment as prevention feasible in developing world? • How to balance domestic and global needs • 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?

48. Policy Resources HRSA http://www.hrsa.gov CDC http://www.cdc.gov/hiv NIH http://www.nih.gov CHRP http://chrp.ucop.edu CHIPTS http://chipts.ucla.edu Kaiser Family Foundation http://www.kff.org/hivaids CAPS http://www.caps.ucsf.edu