1. Health Care Reform: Boon or Bust for TB Control? Kevin Cranston, MDiv Director Bureau of Infectious Disease Massachusetts Department of Public Health

2. A Time of Transition Current TB control system relies on specialized funding for dedicated public health and clinical services Federal, state, and local capacity for TB surveillance, laboratory services, medical management, and public education largely not tied to health insurance reimbursement Limited health insurance coverage have made alternative models unreliable or incomplete

3. A Time of Transition Massachusetts in 2006 expanded health insurance coverage statewide by: –Expanding Medicaid –Creating an individual mandate –Creating an employer mandate –Defining coverage –Offering subsidies –Establishing a state-managed authority to broker access to insurance (Connector Board)

4. Obvious Benefits Over 97% of MA legal residents have health insurance Pre-existing condition exclusions eliminated Insurers cannot drop coverage due to health conditions Annual and lifetime coverage caps eliminated Preventive care and screenings universally covered

5. Remaining Challenges Coverage Access Availability of primary care not keeping apace of coverage Undocumented residents not eligible for subsidies or Medicaid Penalties for not having insurance not high enough to compel some to purchase Cost of premiums remain high, growing Cost of care remains high Budget burden on state (coupled with budget crisis has strained available resources for public health)

6. National Health Reform Expands Medicaid (133% FPL); subsidies for up to 400% FPL Health insurance exchanges to be established to help individuals and small businesses buy in Continued coverage for children up to age 26 under family plans Individual mandate (lower penalty to start) Corporate mandate (50 of more employees) Moves toward elimination of pre-existing condition exclusions Eliminates co-insurance and deductibles for preventive services

7. National Health Reform Taxes on premium policies, pharma, medical devices Creates bonus payments for primary care doctors Establishes a long-term care voluntary insurance system (CLASS) Commits up to $7B/year for 2010-2015 ($2B/year thereafter) for public health, health education, preventive and wellness services; $11B for community health centers

8. Relevance for TB Control Health care public health Need to continue advocacy for core surveillance capacity at state and local health agencies Need to maintain specialized clinical capacity to diagnose, monitor, and fully treat TB Need to continue outreach to affected communities, sustain targeted screening, and public education on TB

9. Relevance for TB Control Expanded health insurance creates an incentive to bolster TB control programs through reimbursement Massachusetts is working with health centers, hospitals, and specialty clinics to expand billing for TB services Need to build TB awareness among primary care providers; offer supplementary clinical support

10. Relevance for TB Control Opportunity to demonstrate cost-effectiveness of more routine screening for TB Opportunity to link primary care (esp. through community health centers) and historic specialized TB clinical capacity Remaining challenge of reaching undocumented residents, newly arrived immigrants and refugees, hidden populations not addressed by the new system Continued role of state and local public health system

11. Thank you kevin.cranston@state.ma.us (send email with TB in subject line)