Institute of Medicine Workshop to Explore Facilitators and Barriers to HIV/AIDS Care

1. Institute of Medicine Workshop to Explore Facilitators and Barriers to HIV/AIDS Care Entry Into and Sustained HIV/AIDS Care: The Role of Federal and State and Private Insurance Policies Panel June 21, 2010 Heather Hauck, MSW, LICSW Director Maryland Department of Health and Mental Hygiene Infectious Disease and Environmental Health Administration

2. MD DHMHInfectious Disease and Environmental Health (IDEHA)MISSION • To improve the health of Marylanders by reducing the transmission of infectious diseases, helping impacted persons live longer, healthier lives, and protecting individuals and communities from environmental health hazards • We work in partnership with local health departments, providers, community based organizations, and public and private sector agencies to provide public health leadership in the prevention, control, monitoring, and treatment of infectious diseases and environmental health hazards.

3. Governmental Public Health System • State health departments are entrusted through U.S. law as the “central authorities of the nation’s public health system” and as such, bear the primary public sector responsibility for health. • Responsible for protecting and guaranteeing the health of constituents within jurisdictions’ borders. • Responsible for implementing a comprehensive HIV/AIDS, viral hepatitis and STD response in every jurisdiction in the U.S. *”The Future of Public Health.” Institute of Medicine, January 1, 1988

4. Partners with: • Local/city/county health departments • Community-based agencies • Academic/research institutions • Hospitals, public clinics, community • health centers • Federal agencies • Linkages to: • Adult Viral Hepatitis Prevention Coordinators • Hepatitis B Coordinators • Substance abuse & mental health • Reproductive health • Maternal & child health • Adolescent & school health • Correctional health • Rural & migrant health • Medicaid • Housing • State laboratories • Components: • Care and treatment access • Prevention • Surveillance & epidemiology • STD, TB & viral hepatitis State HIV/AIDS Programs

5. Federal Level Inhibitors • Funding/Resource Related Policies • Inadequate funding for AIDS Drug Assistance Programs • Inadequate resources for Ryan White Part B and Part D • Categorical funding streams that create barriers between prevention and care and treatment services. • Include language in notice of grant awards that allows and encourages flexibility. • Restrictions on utilization of Ryan White funding (core vs. supportive) reduces local flexibility to address client needs • Federal guidance on criteria for states to receive supplemental Ryan White funding.

6. Federal Level Inhibitors • Federal Entitlement Programs’ Eligibility Policies and Practices • Medicare D Donut Hole and co-pays – anticipating ADAP counting toward TrOOP • Length of time to receive Medicare after SSDI determination • Housing • Immigration

7. Federal Level Inhibitors • Coordination and Communication Policies and Practice • Lack of coordination at the federal level challenges coordination of services at the state level. • CDC’s increased testing efforts have not been coordinated with increased need for care and treatment services. • HRSA HAB and Bureau of Primary Health Care grantees within states serve many of the same populations but there is little coordination other than between Community Health Centers (CHCs) that are also Ryan White Part C or Part B funded programs. • Provide comprehensive HIV and viral hepatitis testing and care in CHCs, coordinated with state HIV/AIDS programs, in high HIV and viral hepatitis incidence areas. • Include public health components and incentives (linking with health departments to understand disease trends and surveillance, public health programs, the importance of HIV/HCV testing) in Bureau of Health Professions trainings.

8. Federal Level Inhibitors • Coordination and Communication Policies and Practice • Enhance coordination among all relevant agencies: HRSA, CDC, CMS, SAMHSA, Department of Education (DOE), National Institutes of Health (NIH), Food and Drug Administration (FDA), the Veterans Administration (VA) and the Indian Health Service (IHS). • Data collection and dissemination varies across grantees and bureaus within HRSA. • Harmonize reporting requirements with other federal agencies (primarily CDC) to reduce administrative burden and improve data coordination

9. State Level Inhibitors • HIV Testing Policies and Practices • Not enough outreach and testing to ensure that individuals know their status and are linked to range of care services  • Requirement that confirmatory Western Blot received prior to initiation of care – depends on state and clinical practice • Lack of integrated services due to categorical funding and/or resource constraints (missed opportunities and/or system too complicated for clients to navigate)

10. State Level Inhibitors • State High Risk Insurance Pool Policies and Practices • Lack of SHIP in some states • Varying ability to work with Ryan White Part B/ADAP • Pre-existing conditions clauses • Prohibitively expensive monthly premiums

11. State Level Inhibitors • Resource Related Policies and Practices • ADAP Waitlists • Federal Poverty Level eligibility limitations • Limited ADAP formularies – missing critical classes of drugs for mental health, cardiovascular, gastrointestinal issues. • Various distribution methodologies for ADAP medications (direct order; clinic pick up; pharmacy based – ADAP pharmacy only or any pharmacy) • Individuals unable to pay co-pays or insurance dropped by employers • Limited ID doctors/clinic capacity - effectively limiting access to care

12. State Level Inhibitors • Medicaid Related Policies and Practices • Income eligibility - Federal Poverty Levels vary and are mostly very low • Disability requirement - Only some states have Medicaid expansion programs which allow coverage for non-disabled individuals • Limited coverage for non-medical services • Data system limitations impact assessment of quality/outcomes of care provided

13. State Level Inhibitors • Coordination and Access Policies and Practices • Different eligibility criteria between and across jurisdictions (State and EMA) line – even within an EMA boundary • Eligibility to access services across jurisdictional boundaries • Utilization of Ryan White funding formulas differs across jurisdictional boundaries • Coordination between entitlement programs, Ryan White, other health care initiatives • Data collection systems and requirements – repetitive and onerous for clients

14. State Level Inhibitors • Structural • Limitations or non-existence of domestic partner benefits • Lack of protective State laws and policies addressing sexual and gender minorities • Immigration status • Housing

15. State Level Inhibitors • Special Populations: Incarcerated in State Prison Systems • Testing not routinely offered in State Prisons/Local Detention • Inability to provide continuity of care to incarcerated due to institutional and jurisdictional policies • Medication dispensing/clinical care policies and practices • Application processes for Supplemental Security Income (SSI), Medicaid and/or ADAP – may not be started until close to release • Notification of benefit determination and linkage to medical care post release • CBO Access to inmates limited for discharge planning/linkages to care

16. Private Insurance Inhibitors • Eligibility and Coverage Related Policies and Practice • Lack of coverage for routine HIV screening – Health Care Reform and USPHTF recommendation requirements a concern • Prohibitive out-of-pocket co-pay and/or deductible costs to clients - flat, tiered, or percentage • Medication limitations or caps – formulary, financial and/or dispensing amount • Annual or life time caps • Prohibitively expensive premiums • Employer knowledge of HIV status - Fear of being dropped from insurance • Pre-existing condition exclusions • Medical/dental providers not accepting insurance carrier • Limitations to comprehensive care (e.g. substance abuse treatment, mental health treatment, case management, specialty care)

17. Questions? Heather Hauck, MSW, LICSW Director Infectious Disease and Environmental Health AdministrationDepartment of Health and Mental Hygiene Baltimore, MD http://eh.dhmh.md.gov/ideah/

18. Maryland Infectious Disease and Environmental Health Administration