health care reform and what it means for people living with hiv/aids duke aids policy project
TRANSCRIPT
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HEALTH CARE REFORMAND WHAT IT MEANS FOR PEOPLE LIVING WITH HIV/AIDS
Duke AIDS Policy Project
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BARRIERS TO COVERAGE FOR PLWHA
1. Many can’t access employer based insurance
2. Pre-existing condition limitations
3. High cost
4. Can’t qualify for Medicaid because of income, assets, or inability to establish disability
5. Undocumented
Obamacare (the Affordable Care Act) solves everything but # 5
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Americans want guaranteed coverage for pre-existing conditions
• Insurance market can’t add pre-existing conditions, getting most or all of the healthy people in the pool
• Getting most people in the pool means there has to be a requirement or very strong incentive
• If everyone has to be in the pool, there has to be financial aid to lower-income to pay premiums
• How the ACA does it:
• Elimination of medical discrimination• Mandated coverage• Premium Subsidies
COVERING THE SICK MEANS EVERYONE MUST BE IN THE POOL
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THE LONG, TORTURED ROAD TO REFORM
1. ACA signed into law March 2010 – NO Republican voted for it
2. Immediate legal challenges – “individual mandate,” Medicaid
3. States and Federal Government engaged in frenzied implementation planning
4. March 2012 - Supreme Court upholds almost all of the law
5. Election 2012 & other threats to health care
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OVERVIEW OF ACA CONSUMER PROTECTIONS
• Pre-existing conditions (effective 2014):
• Can’t be rejected• Health status can’t be considered in pricing
• Eliminates insurance caps
• Annual limits (effective 2014)• Lifetime limits (effective now)
• Can’t be dropped from insurance for getting sick
• Insurance can be terminated only for fraud
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OVERVIEW OF INSURANCE EXPANSION
• Everyone who has adequate coverage already – employer, Medicaid, Medicare, etc -- stays the same
• People with inadequate or no coverage
• Over 133% of FPL State Insurance Exchange• State insurance exchanges with subsidies for
people 100 – 400% of poverty• Premiums, cost sharing, and maximum out of
• Under 133% of FPL Medicaid Expansion
• Temporary “Bridge” insurance: Federal Pre-existing Condition Insurance plan – available now through 2014
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BENEFITS FOR NEWLY INSUREDBoth New Medicaid & Insurance Exchange require coverage of:
“Essential Health Benefits”• Specific benefits for
Medicaid and Insurance Exchange to be determined independently
• Specific benefits wont’ be the same between insurance plans or Medicaid
ESSENTIAL HEALTH BENEFIT CATEGORIES:
• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance
Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness
Services & Chronic Disease Management
• Pediatric services
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SUPREME COURT DECISION• Upheld the
“individual mandate”
• ACA left standing, so consumer protections, etc remain in place, except….
• Limited the Medicaid Expansion• Feds can’t coerce
state to participate through withholding other Medicaid funds
• Left the public health fund intact.
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IF MEDICAID IS NOT EXPANDEDOver 133% of FPL:
• Can buy insurance on Exchange
• Can get subsidies if under 400% of FPL
Under 133% of FPL
• No Medicaid Expansion unless State opts in
• Can buy insurance on exchange, BUT
• Subsidies not available to persons at or below 100% FPL
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REFORM & HIV/AIDS: BREAKING IT DOWN
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2014
Old Medicaid
New Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
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2014
Old Medicaid
New Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
VA, Tricare
Medicare
PCIP
No change
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2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
VA, Tricare
Medicare
PCIPNew Program
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“NEW MEDICAID”
2014
New Medicaid
• Income up to 138% FPL (133% + 5% income disregard)
• No assets test• No disability requirement• Different benefits - based
on “benchmark” insurance plan
• Must cover “Essential Health Benefits”
(About 5000 PLWHA gain coverage)
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NEW MEDICAID:ESSENTIAL HEALTH BENEFITS
2014
New Medicaid
• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance
Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness
Services & Chronic Disease Management
• Pediatric services
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NEW MEDICAID:ESSENTIAL HEALTH BENEFITS
2014
New Medicaid
Potentially Missing:• Case Management• Oral Health• Vision• Long Term Care• Private Duty Nursing• Hospice• Personal Care
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NEW MEDICAID:PRESCRIPTION DRUGS
2014
New Medicaid
• The ACA doesn’t specify how expansive (or not) the drug formulary will be.
• One early statement from HHS – one drug per class
• Lots of advocacy on this nationally
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2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
with Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
Improvements
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NOW
Medicare
• Free Preventative care
• Free annual wellness visit
• Medicare Part D:
• “Donut Hole” discounts to help pay for prescriptions.
• Donut Hole phased out by 2020
• ADAP counts as client’s out-of-pocket for Medicare Part D
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2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
Uninsured
PCIP
VA, Tricare
Medicare
No Disc
rimin
atio
n
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• Lifetime limits to insurance coverage eliminated.
• Insurance companies can’t cancel coverage just because you get sick.
• Children can’t be denied coverage due to a pre-existing condition.
• Free coverage for preventative care, like mammograms and colonoscopies.
EMPLOYER/PRIVATE INSURANCE
NOW
Employer/Private Insurance
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2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange with
Subsidies
Uninsured
PCIP
VA, Tricare
Medicare
New Insurance Marketplace
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• Limited to those without adequate or affordable insurance
• State-based consumer-friendly insurance “marketplace”
• Subsidies on premiums and cost sharing to make health care more affordable only for those eligible to purchase on the exchange
• If state doesn’t take the lead, the federal government will operate the exchange & choose a default plan
• NC legislature has not adopted an exchange, but work has been done on plan evaluation, provider networks, etc.2014
Insurance Exchange
with Subsidies
INSURANCE EXCHANGE
About 1000 PLWHA
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Same as for Medicaid – but specific covered services can be different• Ambulatory Services• Hospitalization• Maternity & Newborn Care• Mental Health/Substance Abuse• Prescription Drugs• Emergency Services• Rehabilitative/Habilitative • Lab Services• Preventative & Wellness Services &
Chronic Disease Management• Pediatric services
INSURANCE EXCHANGE – ESSENTIAL HEALTH BENEFITS
2014
Insurance Exchange
with Subsidies
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• Like Medicaid – based on a “Benchmark Plan”
• Same issues around prescription drugs
• The likely NC benchmark plan has open formulary
INSURANCE EXCHANGE – ESSENTIAL HEALTH BENEFITS
2014
Insurance Exchange
with Subsidies
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INSURANCE EXCHANGE PROVIDER NETWORKS• Network adequacy: State must assure enough providers
to permit adequate access
• Essential Community Providers:
• Plans offered in the Exchange must include “essential community providers” in networks
• ECPs = providers that serve predominantly low-income, medically underserved communities
• This includes FQHCs, Ryan White grantees, STD/TB clinics, family planning clinics disproportionate share hospitals, etc.
• Network Adequacy
• Insurance plans don’t need to contract with ALL ECPs
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INSURANCE/MEDICAID ENROLLMENT
Diagram from NC Institute of Medicine, Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina: Draft Final Report Pending US Supreme Court Decision, p. 64, May 2012
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HEALTH CARE NAVIGATORS
Becoming a navigator:
• Entities that have expertise working with low-income, or other at-risk groups.
• Must have existing, or easily established, relationships with employers, employees, consumers (including the un- or under-insured)
• Must give fair, accurate and impartial information
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2014
Old Medicaid New
Medicaid
Employer Insurance
Insurance Exchange
Uninsured
PCIP
VA, Tricare
Medicare
Gaps remain
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• Immigrants• Undocumented, or• In US less than 5 years
• Some will be exempt from mandate because insurance still not affordable
• Some will choose not to sign up for insurance
SOME STILL UNINSURED
2014
Uninsured
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• There will still be gaps to fill• Oral Health• Support services • Case management• Transportation• Cost sharing help• Uninsured
• Reauthorization in 2013 –What will Ryan White look like after health reform?
RYAN WHITE & REFORM
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THREE SCENARIOS
A LOOK AT WHAT HEALTH CARE REFORM WILL MEAN FOR LOW-INCOME CONSUMERS WHO DON’T QUALIFY FOR MEDICAID
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• Jane Smith earns $16,433 a year. In 2012, she will be at 149% of the Federal Poverty Level.
• Currently, she is uninsured and gets her care through Ryan White & ADAP.
• In 2014, she will be required to purchase health insurance for herself.
• What does Health Reform mean for Jane?
JANE SMITH
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JANE SMITH & INSURANCE SUBSIDIESJane will be eligible for cost-sharing subsidies, premium credits, and reduced out-of-pocket limit
Without Subsidies With Subsidies
Premium $5700 $670/year (4% of income)$56/month
Cost sharing (deductible, copay, co-insurance)
Plan pay 70% of costs
Reduced so plan pays 96% of costs
Out of pocket $5950 $1984
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• Mr. and Mrs. Diaz are undocumented immigrants. Their daughter, Maria, was born in the United States.
• Mr. Diaz has HIV, and currently gets care through Ryan White.
• Mr. and Mrs. Diaz pay taxes, and earn $25,390 a year, putting them at 133% of the Federal Poverty Limit.
• What happens to the Diaz family in 2014?
THE DIAZ FAMILY
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THE DIAZ FAMILY & REFORM
• Because Mr. and Mrs. Diaz are undocumented, they will not qualify for Medicaid, or for any other protections under the ACA.
• The Diaz’ family can apply for Health Choice on behalf of Maria. (They will not have to provide any information on their immigration status).
• Mr. Diaz still needs Ryan White and ADAP to cover his care.
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• Richard Doe is 30 years old and lives with his partner.
• Richard makes $46,021 a year, so he is at 400% of the estimated 2014 Federal Poverty Level.
• Richard’s employer – a small, local company, does not currently offer insurance. But, in 2014, they will begin providing insurance to their employees.
• Richard does not want his company to find out about his HIV status.
• What does reform mean for Richard?
RICHARD DOE
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RICHARD, REFORM & CONFIDENTIALITY• Richard may not have to purchase his employer’s
insurance, if it costs more than 9.5% of his income ($4372/year or $364/month).
• Because insurers can no longer deny coverage based on pre-existing conditions, there is no reason for Richard’s employer to ask him about his health status.
• If the employer doesn’t offer insurance, Richard can buy on the Exchange. Richard will qualify a reduced premium: about $3440/year or $287/month
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IS NC ON TRACK TO IMPLEMENTATION?• State leadership taking a “wait and see” approach (governor candidates,
legislative leaders)
• Looking to see what elections hold, chances of repeal• Federal government is moving forward at full speed – but that could
change with election outcome
• Health Benefit Exchange:
• State has not passed a bill to create its own Exchange & time is running short
• Feds may run exchange in 2014• Department of Insurance doing some planning• Because NC has not picked a benchmark plan, default plan will be the
largest insurance plan among the small-market plans, i.e. Blue Options.• Medicaid Expansion:
• Will require legislative action• Governor, candidates, and legislative leaders taking a “wait and see”
attitude• DMA (Medicaid) is planning, running numbers
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THREATS TO REFORM ON NATIONAL LEVEL
• Depending on election outcome:
• “Obamacare waivers”?• Repeal
• Senate requires 3/5 majority if filibustered
• Repeal & Replace• Budget Reconciliation
• Takes time• Limited subject matter permitted
• Refusal of new administration to enforce ACA?• More litigation likely to compel
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THREATS ON NATIONAL LEVEL BEYOND THE ACA
Sequestration
• Would cut 8.2% of non-exempt non-defense discretionary budget
• $659 million from domestic HIV/AIDS & viral hep
Medicare – Romney/Ryan plan for vouchers
• fixed dollar amount to buy coverage
Medicaid –
• Romney/Ryan: Block grant with growth limited to rate of inflation plus 1% annually (way less than current growth)
• 1.2 trillion drop in federal funding from 2014 to 2022• 14-27 million beneficiaries could lose coverage
• Per Capita funding – being discussed by both parties
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GOP PLAN FOR MEDICAID