Where We Are: Status Quo = Access to Care Crisis The Current Crisis 42-59% of low-income people living with HIV not in regular care Impossible to obtain individual insurance and few insured through employer system Medicaid/ Medicare are lifelines to care, but disability standard means they are very limited Demand for Ryan White care and services > funding Thousands on ADAP waitlists 29% of people living with HIV uninsured To start I want to quickly level set – or, to the extent possible, maximize our common understanding of the current situation. As I see it, despite all the health systems in place in the US – including private insurance, Medicaid, Medicare and the Ryan White Program, the status quo is an increasing train wreck –increasingly more and more PLWHIV are being left behind along with approximately 49 million other Americans.

Ryan White Program Not Keeping Pace with Increased Need Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation) Looking at the RWP provides a significant example of the problem -- Despite our brilliance in creating and building the largest disease specific discretionary program in history, we must accept that despite our incredible success, it is a discretionary program subject to annual appropriations that is increasingly not keeping pace with increased demand for care, treatment and essential support services. 2002 2003 2004 2005 2006 2007 2008 Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/table12.htm; Ryan White Appropriations History, Heath Resources and Services Administration, ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Inflation calculated using http://www.usinflationcalculator.com; www.cdc.gov/hiv/surveillance/resources/reports/2009report/pdf/table16a.pdf; “Funding, FY2007-FY2010 Appropriations by Program, hab.hrsa.gov/reports/funding.html

Massachusetts as a Case Study of Successful Health Reform Implementation The good news is, if properly implemented, which will clearly not be an easy assignment, we can end this epidemic. And frankly, while I understand that MA is unique in many ways, MA as a case study demonstrates that we can end this epidemic.

Massachusetts: A Post Health Care Reform State in a Pre-Reform Country Expanded Medicaid coverage to pre-disabled people living with HIV with an income up to 200% FPL (2001) Enacted private health insurance reform (“RomneyCare”) with a heavily subsidized insurance plan for those with income up to 300% FPL (2006) More ADAP funding spent on insurance than on Rx, while maintaining unrestricted formulary and 500% FPL eligibility (2006) Waiver from Ryan White Program 75/25 rule supporting ability to provide necessary services (2007) Massachusetts’ provides a critical model for the nation’s progress on HIV. Just as in Massachusetts, the federal government grounded its reform effort in a few central policies: Medicaid expansion, mandated and subsidized insurance coverage, and subsidized private insurance reform. Massachusetts’ offers the nation a great deal to be hopeful for in a post-health reform world. The evidence is clear that Massachusetts has developed a system of care that contains the HIV epidemic more cost-effectively and more successfully than most, if not all other health systems in the nation. And let me say up front, this is the case not only because of health reform it is the result of strong ongoing support of long-standing existing programs including Medicaid and the Ryan White Program. (It also has to do with leadership at the state level that insisted 20 years ago that the ASO and CHCs work together and integrate….)

Massachusetts: A Post Reform State’s Utilization of ADAP YEAR Full Pay Co-Pay Premiums Total Cost (including rebates) FY02 $ 7,947,832 $ 648,030 $ 1,120,512 $ 9,716,375 FY03 $ 7,961,862 $ 963,205 $ 1,778,272 $ 10,703,342 FY04 $11,174,879 $ 1,553,758 $ 3,159,200 $ 15,887,838 FY05 $ 9,756,201 $ 1,839,807 $ 6,112,132 $ 17,708,142 FY06 $ 4,634,683 $ 1,893,206 $ 7,015,306 $ 13,543,197 FY07 $ 4,147,713 $ 2,071,118 $ 8,366,273 $ 14,585,106 FY08 $ 4,184,279 $ 2,083,431 $ 9,323,821 $ 15,591,533 FY09 $ 4,695,780 $ 2,567,789 $ 8,835,835 $ 16,099,405 As to Ryan White ADAP program, in particular, you can see that post–reform MA continues to use all of its ADAP funding, we just use it differently. Since 2006, it has served its initial purpose – filling gaps and helping people access comprehensive care – in this case tghrough assistance with private insurance premiums and copayments. Also, because of reforms ADAP eligibility is at 500%FPL and the program provides access to an unrestricted drug formulary. Basically the same funding as 2004 as in 2009 – but now primarily insurance support.

Massachusetts’ Successful Reform Implementation Improves Health Outcomes and Meets NHAS Goals SO WHAT ARE THE OUTCOMES I HAVE ALLUDED TO: Massachusetts serves as an example of how properly implemented health reforms can substantially improve health outcomes for those living with HIV. - MA has 99% of its HIV population retained in care (as opposed to 41% nationally) - 91% taking medications (as opposed to 36% nationally), and - 72% with suppressed viral loads (as opposed to about 28% nationally). Earlier this week, Paul posted a model for ending the epidemic based on a Holtgrave report – and as you can see, we are very close to achieving the outcomes articulated in that report. In short, the reformed Massachusetts health system has greatly improved health outcomes for people living with HIV and AIDS, with almost 70% of the HIV/AIDS population experiencing good to excellent health. The Massachusetts data is clear evidence that if properly implemented the ACA can greatly improve all of the outcome measures articulated in the CDC Engagement in Care Cascade for people living with HIV as well as address the care and treatment needs of most other Americans living with chronic health conditions. Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc. Note: MA Outcomes N = 1,004 Source: Cohen, Stacy M., et. al., Vital Signs: HIV Prevention Through Care and Treatment — United States, CDC MMWR, 60(47);1618-1623 (December 2, 2011); Note: National Outcomes HIV-infected, N = 1,178,350; HIV-diagnosed, n=941,950

MA Reform Demonstrates Successful Implementation Reduces New Infections and AIDS Mortality Massachusetts has also demonstrated that through successful health reform implementation we can greatly reduce new HIV infection and AIDS mortality rates. The Massachusetts data compared to national data is compelling: Between 2006 & 2009, HIV diagnoses fell by 25% in Massachusetts as compared to a 2% national increase. (Current rates have fallen more than 50%.) And between 2002 and 2008 Massachusetts AIDS mortality rates decreased by 44% compared to 33% nationally. Between 2006 & 2009, Massachusetts new HIV diagnoses rates fell by 25% compared to a 2% national increase Current MA new HIV diagnosis rates fell by more than 50% Between 2002 & 2008, Massachusetts AIDS mortality rates decreased by 44% compared to 33% nationally Sources: MA Dept of Public Health, Regional HIV/AIDS Epidemiologic Profile of Mass: 2011, Table 3; CDC, Diagnoses of HIV infection and AIDS in the United States and Dependent Areas, 2010, HIV Surveillance Report, Vol. 22, Table 1A; CDC, Diagnoses of HIV infection and AIDS in the United States and Dependent Areas, 2008, HIV Surveillance Report, Vol. 20, Table 1A.

MA Reform Demonstrates Successful Implementation Reduces Costs Health reforms, while greatly expanding access to high-quality health care, have also resulted in significant cost savings. In terms of cost, the amount spent per HIV-positive Medicaid beneficiary post-reforms has decreased, especially the amount of money spent on inpatient hospital care. In addition, the Massachusetts Department of Health estimates that as a result of health reforms and the resulting decline in HIV transmission rates it has saved approximately $1.5 billion dollars in HIV health care expenditures over the past ten years. WE CAN END THIS EPIDEMIC!!! Massachusetts cost per Medicaid beneficiary living with HIV has decreased, particularly the amount spent on inpatient hospital care Massachusetts DPH estimates reforms reduced HIV health care expenditures by ~$1.5 billion Source: MA Office of Medicaid, data request

State Healthcare Reform Implementation Modeling Project Designed to objectively assess how the healthcare needs of low-income people living with HIV will be met as states implement the ACA. Assesses the impact that healthcare reform will have on people living with HIV using RWP and ADAP data to predict the shift of uninsured people living with HIV from these discretionary programs to Medicaid or private insurance in all 50 states. For 21 states and D.C., used detailed budgets and benefits guidelines to assess the services provided by the RWP, ADAP, Medicaid, and plans sold on an exchange, in to estimate the impact that a transition into Medicaid will have on low-income people living with HIV.

State Healthcare Reform Implementation Modeling Project These detailed assessments focus on four state specific inquiries: What demographic information is available about Ryan White Program and ADAP clients? How many of these clients will be newly eligible for Medicaid or private insurance subsidies in 2014? What services are currently available to people living with HIV under the Ryan White Program versus Medicaid or plans to be sold on an exchange, and what gaps in services currently exist? Given the current Ryan White and Medicaid programs, what are the likely outcomes of a transition from one program to another in 2014? For more information: chlpi@law.harvard.edu