HIV/AIDS Housing and the Affordable Care Act Presented by the National AIDS Housing Coalition

1. HIV/AIDS Housing and the Affordable Care Act Presented by the National AIDS Housing Coalition 2012 United States Conference on AIDS Caesar’s Palace Hotel Las Vegas, Nevada September 29, 2012 2:30-5:30 PM

2. Seminar Faculty Chair Shawn Lang, CT AIDS Resource Coalition, Hartford, CT • Seminar Faculty Cassandra Ackerman, Columbus, OH Jeff Allen, Ormond Beach, FL Art Bendixen, AIDS Foundation Chicago, Chicago, IL Nancy Bernstine, National AIDS Housing Coalition, Washington, DC Christine Campbell, Housing Works, Inc., Washington, DC Michael Kaplan, Cascade AIDS Project, Portland, OR Kathie Hiers, AIDS Alabama, Birmingham, Alabama Gina Quattrochi, Bailey House, New York, New York Ginny Shubert, Shubert Botein Policy Associates, New York, New York

3. Housing is HIV Prevention and Health Care: An Overview Shawn Lang Connecticut AIDS Resource Coalition

4. Homelessness—a major risk factor for HIV infection • Rates of HIV infection are 3 times to 16 times higher among persons who are homeless or unstably housed, compared to similar persons with stable housing. • 3% to 14% of all homeless persons are HIV positive (10 times the rate in the general population). • Over time studies show that among persons at high risk for HIV infection due to injection drug use or risky sex, those without a stable home are more likely than others to become infected.

5. HIV—a major risk factor for homelessness • Up to 70% of all PLWHA report a lifetime experience of homelessness or housing instability. • 10% to 16% of all PLWHA in some communities are literally homeless at any time —sleeping in shelters, on the street, in a car or other place not meant for human habitation. • Many more PLWHA are unstably housed, faced with housing problems or the threat of housing loss. • Rates of housing need remain high - as some persons get their housing needs met others develop housing problems.

6. Housing instability = poor health outcomes for PLWHA • Homeless/unstably housed PLWHA are less likely to receive appropriate health care & experience higher rates of opportunistic infections, HCV and other co-morbidities. • The all-cause death rate among homeless PLWHA is five times the death rate for housed PLWHA. • The death rate due to HIV/AIDS is among homeless PLWHA is seven to nine times the death rate due to HIV/AIDS among the general population. • Poverty is the most significant factor contributing to HIV health inequities.

7. Housing status predicts HIV risk behaviors • Research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues. • Homeless or unstably housed persons were 2 to 6 times more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal and service use characteristics. • Homeless women were 2 to 4 times as likely to have multiple sex partners as housed indigent women - in part due to the effects of physical violence. • Harm reduction and other behavioral prevention interventions are much less effective for participants who lack stable housing.

8. Housing is HIV Medical Care • Receipt of housing assistance is among the strongest predictors of accessing • HIV care. • Homeless/unstably housed PLWHA whose housing status improves over time are: • More likely to report HIV primary care visits, continuous care & care that meets clinical practice standards • More likely to return to care after drop out • More likely to be receiving HAART • Increased housing stability is positively associated with: • Effective HAART (viral suppression) • Better HIV related health status ( as indicated by viral load, CD4 count, lack of co-infection with HCV or TB) • Significantly decreased mortality (a SF study shows that access to supportive housing reduced mortality among homeless PLWA 80% over a 5-year period)

9. Housing is HIV Prevention • Over time, studies show a strong association between change in housing status and risk behavior change. • Over time, persons who improved housing status reduced risk behaviors by half; while persons whose housing status worsened over time were 4 times as likely to exchange sex. • Access to housing also increases access to appropriate care and antiretroviral medications which lower viral load, reducing the risk of transmission.

10. Housing Saves Costs • People coping with homelessness are frequent users of expensive crisis • services including shelters, jails, and available emergency and hospital • care. • The CHHP cost analysis documented that improved housing stability • reduces these costs my amounts that more than offset the costs of • housing intervention. Generating an average annual savings of $6,000. • Each new HIV infection prevented through housing stability saves over • $300,000 in lifetime medical costs. • An ongoing study of PWHIV enrolled in a SF housing program showed • that median healthcare costs for high users (>$50,000/year) dropped from • $100,000/year prior to housing to $1,819 after placement.

11. How Supportive Housing Links with the Affordable Care Act Christine Campbell Housing Works

12. Overview of the Affordable Care Act • Signed into law March 2010 • Goal is to decrease the number of uninsured Americans, improve overall health outcomes and reduce the overall cost of healthcare • Despite several state challenges, the Supreme Court upheld the individual mandate provision and found the Medicaid Expansion provision coercive thereby allowing states to opt out without risking federal funding.

13. Caveats There is no panacea. Covering the costs of support services in housing programs continues to be a challenge. The Affordable Care Act will be implemented differently from state to state – what your state implements will be dependent on strong advocacy and involvement on all our parts.

14. Overview of the Affordable Care Act • Requires insurers to issue policies regardless of medical condition and the same policies and coverage to people of the same age and geographical locations regardless of gender or pre-existing condition • Health Insurance Exchanges: Individuals and families above 100% and 400% poverty can purchase insurance with federal subsidies on a sliding scale • Medicaid Expansion to all individuals at or below 133% of poverty Most homeless HIV+ adults will be Medicaid eligible in 2014

15. Possibilities: Affordable Care Act and Supportive Housing Care Management - Health Homes (ACA Section 2703) and Managed Care Organizations Home and Community Based Waivers [1915(i) of Social Security Act – amended by ACA] • Rehabilitation Option • Targeted Case Management

16. Health Home Eligibility To the extent elected by the State in its approved State plan, those eligible for Medicaid with: • two or more chronic conditions;  • One chronic condition and are at risk for a second; or   • a serious and persistent mental health condition.

17. Chronic conditions identified in statute include mental health, substance use disorder, asthma, diabetes, heart disease, and being overweight (as evidenced by a BMI of >25).   States may request that CMS identify other chronic conditions for purposes of eligibility. States may request to base eligibility on additional or different chronic conditions in a SPA.  While CMS approval is discretionary, this flexibility provides States the option to request to expand the chronic conditions list to include more beneficiaries or use more specific chronic conditions to target the population.  

18. Health Home Services • Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care/follow-up • Patient and family support • Referral to community and social support services

19. Policy and Advocacy Priorities and Considerations • States will need to participate in Medicaid Expansion to maximize funding opportunities • States and housing providers need to ensure supportive housing is targeting high need/high cost HIV+ homeless individuals as those whose health care utilization will be positively impacted through this approach while achieving future cost savings. • States will need to determine Medicaid payment option that will best serve their clients to reimburse supportive housing services and then advocate for them to be inclusive of the needs of PLWHA’ – such as getting HIV/AIDS included as a chronic condition.

20. Policy and Advocacy Priorities and Considerations • New organizational configurations with appropriate policies, regulations and technical assistance, are needed to transition current supportive housing capacity to Medicaid eligible environments • Systems with appropriate funds and training are needed for tracking and managing costs for HIV+ homeless individuals and families.

21. State Health Home Models

22. New York State’s Health Home Model Gina Quattrochi Bailey House

23. New York State’s Health Home Model • Medicaid funded Targeted Case Management transitioned to Health Home Care Management • Goal is to provide comprehensive medical care management to frequent users of high end Medicaid funded services • Components of Care Management (formerly TCM) include “locate and engage” and shared medical records • Reimbursement based on acuity rates – homelessness as “acuity factor” being negotiated in NYS Health Information Technology HIT is strongly encouraged in the SMD letter, but is not required.  If HIT is neither feasible nor appropriate the State will need to respond accordingly in the State Plan Amendment (SPA) submission.  In the absence of HIT, the State will need to demonstrate how they achieve the care coordination activities between multiple settings of a health home through other methods.  

24. New York State’s Health Home Model • Care Management (formerly TCM) is not limited to HIV+ Medicaid users • Not currently designed to fund services in supportive housing; it’s not a funding stream , it’s a system for medical case management using Medicaid • Organizations that become Care Management providers (formerly TCM providers) must have or develop EMR (electronic medical record) capacity • TCM is not limited to HIV+ Medicaid users • Not designed to fund services in supportive housing • Organizations that become TCMs must have or develop EMR capacity

25. Oregon’s Health Home Model Michael Kaplan Cascade AIDS Project

26. Triple Aim: Vision for Oregon • Better health. • Better care. • Lower costs.

27. Accountable Care Organizations • Providers and suppliers work together to coordinate care for patients under Medicare; • Goal: Deliver seamless, high quality care; Improving health outcomes with lower cost. • Patient-centered organizations with providers, suppliers and beneficiaries on governing board; • Must take responsibilities for 5,000 beneficiaries

28. Difference Between Medicare and Medicaid Medicare • A federal program attached to social security • Available to all U.S. citizens 65 and older as well as people with certain disabilities. • Available regardless of income Medicaid • A joint federal and state program • Helps low-income individuals and families • Often targeted – families, pregnant women, children and disable. • Eligibility rules vary by state

29. Coordinated Care Organizations (CCO) • A local network of all types of health care providers working together to deliver care for Oregon Health Plan clients • Care is coordinated at every point-from where services are delivered to how the bills are paid • CCOs shall serve Medicaid population and “dual eligible (Medicaid and Medicare)” enrollees

30. Elements of Coordinated Care Organizations (CCO) • Benefits and services are integrated and coordinated, • One global budget that grows at a fixed rate, • Local flexibility • Local accountability for health and budget • Metrics: standards for safe and effective care

31. Benefits & Services Integrated • Physical health, behavioral health, dental health • Focus on chronic disease prevention and management • Focus on primary care • Get better outcomes: • Health equity • Prevention • Community health workers/non-traditional health workers • Electronic health records

32. Oregon’s 1115 Medicaid Waiver • Allows CCO’s as delivery system for Medicaid • No reduction in benefits • Allows use of Medicaid dollars for flexible services (e.g. - non-traditional health care workers). • Provides $1.9 Billion over 5 years from feds tied to state showing reduction in per capita medical trend. • Quality metrics to ensure savings not through service reduction, but improved health outcomes

33. CCO Timeline • August 1, 2012 – First CCO’s come on line with waves to follow. Currently – 13 approved as of Sept. 1, 2012 • Not before 2013, but eventually – HIV/AIDS targeted case management to be included in CCO Global Budgets • By 2017 – CCO’s replace Oregon’s Medicaid Managed Care system • CCOs include Medicare, State Public Employees & Private Business Sector – no target date set.

34. Understanding Oregon’s Epidemic • 70% of state epidemic in three counties 15% estimated to be homeless or unstably housed • 4256 PLWHA in Portland TGA • In 2007 – ~20% of HIV-positive population in Oregon enrolled on Medicaid

35. CAP’s & Housing Program • CAP – Incorporated in 1985; $5.2 Million budget • Mission – To prevent HIV infections, support and empower people affected and infected by HIV/AIDS and eliminate HIV/AIDS related stigma. • Housing approx. $2 million of budget – provides emergency, short-term and long-term housing support (in 2011 - $871k in direct assistance, 574 individuals supported in housing services)

36. CAP Housing Clients - Insurers • OMIP/FMIP – 36% • Medicaid – 31% • Medicare – 16% • Private – 13% • VA – 3%

37. CCO’s Serving Portland TGA • Two CCO’s Serving the Tri-County Area (36% of total Medicaid population – ~ $1.44 Billion) • Family Care and Oregon Health Share(David & Goliath) • Oregon Health Share (includes OHSU, 3 counties, 5 Health Systems, one insurer (Care Oregon) and one Housing/Health Agency (CCC) • The systems engaged in OHS account for all HIV-positive patients in care in the tri-county area (Multnomah County FQHC, Kaiser IDC (50% of all positives)

38. How to link to Goliath - Challenges • While CCO’s will include medical, dental and behavioral health, no discussion or plan of how housing funds link • Housing funds have greatest opportunity to impact frequent fliers • HOPWA at CAP comes through city & state, while Ryan White & most of prevention through counties and CCO includes counties, but not city or state

39. Current Effort / Strategies • Be at the table, inclusion in discussions as CCOs form. • Linking our work to CCO’s • Every Housing Case Manager linked to a Medical Case Manager • HRSA/SPNS – allow staff to input into EPIQ • Starting to look at ability to bill under sub-contract to Medicaid • Create/expand our own non-traditional health care workers (mental health peer specialists)

40. The Marriage (or engagement or hook-up) of AIDS Housing with the ACA’s Health Homes, ACOs, or Other Health Plans“A Chicago Model” Arturo V. Bendixen AIDS Foundation of Chicago

41. Increase access to care Increase quality / outcomes Decrease costs HHS Mantra for the ACA

42. 32,000,000 uninsured will become insured…. Up to 16,000,000 of them through Medicaid

43. Changed Landscape - $$$ • No more “fee for service” • Required coordinated care – NO MORE SILOS • Increase health outcome • DECREASE COSTS

45. Hospital Days Intervention Group: 2.7 fewer days than the Usual Care Group

46. Emergency Room Visits Intervention Group: 1.2 fewer visits than the Usual Care Group

47. Nursing Home Days Intervention Group: 37% Usual Care Group: 63%

48. Survival with Intact Immunity P = 0.04

49. For every 100 chronically homeless HIV positive individuals housed, there is a savings of a $1 million in public funds

50. The new world of USA health care NEEDS AIDS Housing to save $$$$$$$$$$$$$$$