2. In 2004, the IOM identified numerous barriers to HIV care Current public financing strategies for HIV care have provided care and extended the lives of many low-income individuals. However, significant disparities remain in assuring access to the standard of care for HIV across geographic and demographic populations. The current federal–state partnership for financing HIV care is unresponsive to the fact that HIV/AIDS is a national epidemic with consequences that spill across state borders. State Medicaid programs that provide a significant proportion of coverage for HIV care are dependent upon widely varying resources and priorities that produce an uneven and therefore ineffective approach to managing the epidemic. Under the current patchwork of public programs that finance HIV care, many HIV- infected individuals have no access or limited access to the standard of care for HIV. Fragmentation of coverage, multiple funding sources with different eligibility requirements that cause many people to shift in and out of eligibility, and significant variations in the type of HIV services offered in each state prevent comprehensive and sustained access to quality HIV care. Low provider reimbursement in Medicaid and managed care delivery systems has the potential to discourage experienced physicians from treating patients with HIV infection and to undermine the quality of HIV care. Source: Institute of Medicine, Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White, Chapter 4, “Barriers to HIV Care”, Washington DC: National Academies, 2005.

3. HIV Care Today: “A Quilt with Many Holes”? Do the IOM’s 2004 conclusions still hold? What is the status of the “Quilt”? –What does the system of financing and care look like today? –What barriers exist? What will health reform mean?

4. What do we know?

5. Federal Funding for HIV/AIDS Care by Program, FY 2010 $ 13.2 billion (In billions) Source: Kaiser Family Foundation Analysis of Data from OMB, 2010.

6. Federal Funding for HIV/AIDS Care: Mandatory & Discretionary, FY 2010 $13.2 Billion Mandatory (75%) Discretionary (25%) Mandatory: Medicaid Medicare FEHB Discretionary: Ryan White VA SAMHSA Other Source: Kaiser Family Foundation Analysis of Data from OMB, 2010.

7. Insurance Coverage of People with HIV/AIDS? Robust, recent estimates are not readily available –HCSUS 1996 –HIVRN 2002 Ranges from HCSUS & HIVRN: –Medicaid: 38%-44% (including duals) –Medicare: 17%-19% (including duals) –Private:16%-31% –Uninsured: 20%-28% Sources: Bozzette, et al. “The Care of HIV-Infected Adults in the United States.” NEJM, Vol. 339, No. 26. December, 1998; Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication.

8. How Many People with HIV/AIDS are in Care? Robust, recent estimates are not readily available Glynn & Rhodes, 2003 –50% of people living with HIV/AIDS estimated to be in care Teshale et al, 2003 –55% of 15-49 year olds estimated to be eligible for HAART receiving HAART (15% in care, but not on HAART; 30% not in care) Sources: Teshale EH et al., “Estimated Number of HIV-infected Persons Eligible for and Receiving HIV Antiretroviral Therapy, 2003--United States”, Abstract #167, 12th Conference on Retroviruses and Opportunistic Infections, February 2005; Glynn MK and Rhodes P, “Estimated HIV Prevalence in the United States at the end of 2003.” Presentation at the 2005 National HIV Prevention Conference, June 14, 2005.

9. Multiple Sources of Care & Coverage for People with HIV/AIDS Medicaid Medicare Ryan White Private health insurance (individual, employer) Department of Veterans Affairs Community Health Centers High risk pools Pharmaceutical Access Programs (run by states and companies) Correctional system

10. Eligibility Pathways for People with HIV/AIDS, by Major Payer/Source MedicaidMedicare Private Ryan White EmployerIndividual Who Must be both low-income & categorically eligible Seniors or under 65 disabled Job-based Individual Market- Based Low-income & Uninsured or Underinsured Income/Asset Test YesNo N/A – but costs involved N/A – but costs involved Yes U.S. CitizenYesYes* Not necessarily No Pre-existing Condition limit No Some limits Yes, in most states No State VariationYesNoYes Capped funding No Yes HIV-Specific Program No*No Yes Source: Kaiser Family Foundation

11. Medicaid Today Nation’s principal safety-net health insurance program –Finances health & long-term care for 59 million low-income Americans –Pays for approximately 1 in 6 health care dollars Federal/state program; combined spending in FY 2010 of $412 billion Guaranteed entitlement to individuals & federal financing to states (funding matches need and cost of care) Largest source of health coverage for people with HIV/AIDS in U.S. –Covers an estimated 200,000-240,000 –Federal spending on HIV care in FY 2010 estimated at $4.7 billion, state spending close to $4 billion But must be both low income and “categorically” eligible Variation by state in eligibility, benefits, and other aspects of program Mandatory & optional eligibility categories and benefits –E.g., Rx and routine testing are optional – states must take them up Source: Kaiser Family Foundation; CMS.

12. Medicaid Eligibility Pathways for People Living with HIV/AIDS CategoryCriteriaMandatory/Optional SSI beneficiariesSeverely disabled & low-income (standard 74% of FPL, varies by state) Mandatory (11 “209B” states can have more restrictive eligibility) Parents, children, pregnant women Low income; income & asset criteria vary by category & state Mandatory; states may offer higher income thresholds Medically NeedySeverely disabled & low income, after subtracting incurred medical expenses; income & asset criteria vary by state but generally well below SSI levels Optional (34 states use this option for people with disabilities) Workers with DisabilitiesSeverely disabled; low-income; for persons returning to workforce Optional Poverty-level expansionAllows for income above SSI levels up to FPL Optional State Supplementary Payment (SSP) Allows for coverage of those receiving SSP Optional Source: Kaiser Family Foundation

13. Medicare Today Federal health insurance program for elderly & disabled, covers 46 million –Medicare spending estimated at $515 billion in FY 2010 –Spending on HIV/AIDS estimated at $5.1 billion in FY 2010 –Covers an estimated one-fifth of people with HIV/AIDS Program has parts A,B,C, D –Part A: Hospital, skilled nursing care, facility stays, home health, hospice (automatically provided if eligible) –Part B: Physician, outpatient services, preventive services, home health Part A eligibles may enroll) –Part C: Medicare Advantage (voluntary enrollment in private health –plan, such as HMO) –Part D: Prescription drug benefit; low income subsidies (voluntary enrollment) HIV testing: New HIV screening policy as of December 8, 2009: annual volunteer routine screening for those at increased risk; voluntary screening for pregnant women during 3 rd trimester and at labor (CMS Decision Memo CAG-00409N) Sources: Kaiser Family Foundation; CMS.

14. Medicare Eligibility Pathways for People Living with HIV/AIDS CategoryCriteria Individuals age 65 and overSufficient number of work credits to qualify for Social Security payments Individuals under age 65 with permanent disability Sufficient number of work credits to qualify for SSDI payments due to disability; eligible for Medicare after receiving SSDI payments for 24 months Individuals with End-Stage Renal Disease (ESRD) or Lou Gehrig’s disease of any age Sufficient number of work credits to qualify for SSDI; eligible for Medicare as soon as they start receiving SSDI payments (no waiting period) Source: Kaiser Family Foundation

15. Ryan White Today Single largest federal program designed specifically for people with HIV in the United States Estimated to reach more than half a million people w/HIV each year Program has Parts A,B,C D (formerly, Titles I, II, III, IV) –Part A: Funding to cities (EMAs/TGAs) –Part B: Funding to states, including ADAP earmark –Part C: Funding to public/private organizations for provision of health services –Part F: Special Projects of National Significance (SPNS), AIDS Education & Training Centers (AETCs), Dental, Minority AIDS Initiative (MAI) Payer of last resort; Discretionary program dependent on annual federal, state, local appropriations, funding support HIV testing: Funds can be used to support diagnostic and laboratory tests “integral to the treatment of HIV infection and related complications” (HAB policy notice 07-02) Source: Kaiser Family Foundation; HRSA, HIV/AIDS Bureau

16. Department of Veterans Affairs Largest single provider of HIV care in the U.S. To date, nearly 64,000 Veterans with HIV have received care in VHA In 2008, over 23,000 Veterans with HIV served, about 1 in every 250 Veterans in care –Number of Veterans with HIV in care relatively stable over past several years Comprehensive care provided and management of population with high incidence of other health conditions and co-morbidities –Heart disease, diabetes, cancers, depression hypertension, –Hep C: one out of four Veterans with HIV HIV testing: As of August 17, 2009, VHA policy that HIV testing is part of routine medical care; verbal informed consent sufficient, pre- and post-test counseling no longer mandated (VHA Directive 2009-036) Source: Kaiser Family Foundation; Department of Veterans Affairs.

17. Federally-Qualified Community Health Centers Located in or serve a high need community (designated Medically Underserved Area or Population) Provide comprehensive primary health care services as well as supportive services (education, translation and transportation, etc.) that promote access to health care Provide services available to all with fees adjusted based on ability to pay. FQHCs include: Community Health Centers, Migrant Health Centers, Healthcare for the Homeless, Public Housing Primary Care Programs, also FQHC look-alikes People with HIV/AIDS served by CHCs in 2008 –394,983 encounters –87,509 patients –653,466 HIV tests Source: Kaiser Family Foundation; HRSA, Health Center Uniform Data System.

18. What is the Current State of the Quilt?

19. Issue 1: Eligibility depends on who you are & where you live ? Age Income & Assets Marital Status Parental Status Health Status Insurance Status Where you Live Employment Status & Work History Source: Kaiser Family Foundation

20. Issue 2: Even if eligible, access depends on capacity of system ? Provider Capacity Provider Payments Medicaid Benefits Package State Funding Federal Funding Ryan White Capacity/ Waiting Lists Source: Kaiser Family Foundation

21. Issue 3: Even if eligible & system has capacity, other barriers exist ? Transportation Ability to Leave Work Child Care Stigma Knowledge of Where to Go Translation Coordination Of Services Source: Kaiser Family Foundation

22. Variation Across the Country: Select Examples Medicaid –SSI: 25 states ≤ 75% FPL for disabled –Low income parents: 34 states < 100% FPL (17 <50% FPL) –Childless adults: state needs waiver to cover; only 5 cover comparable to Medicaid (15 more limited) –Medically needy program: 34 states –Rx limits: 19 states Private insurance protections –Rating limits: 18 states –Guaranteed Issue: 6 states (an additional 7 for some products) –High risk pools: 32 states Ryan White –EMAs: 14 states (22 EMAs) –TGAs: 19 states (34 TGAs) –ADAP waiting lists (10 states) Source: Kaiser Family Foundation analysis; National Alliance of State and Territorial AIDS Directors.

23. The “Swiss Cheese Model” of Healthcare Financing & Delivery

24. The Size of the Gap That Needs to be Filled Varies by State Medicaid Program Medicaid Program STATE A STATE B

25. What should we expect from health reform?

26. Health Reform & Expansion of Access Medicaid be expanded to all under age 65 with incomes up to 133% FPL as of 2014 (state option as of April 1, 2010) –Uniform minimum Medicaid eligibility threshold across states –Eliminates limitation that prohibits most adults without dependent children from enrolling in the program today, the HIV/AIDS “Catch-22” (though as under current law, undocumented immigrants not eligible) Uninsured individuals with incomes above 133% FPL will obtain coverage through newly created state health insurance Exchanges Medicare (elderly & under-65 disabled) –End to Medicare Part D drug benefit coverage gap (“doughnut hole” by 2019 –Allows ADAP payments to count toward true out-of-pocket (TrOOP) threshold used to determine eligibility for catastrophic coverage under Part D –Improves coverage of prevention benefits - beginning in 2011, no coinsurance or deductibles will be charged in traditional Medicare for preventive services that are rated A or B by the U.S. Preventive Services Task Force Source: Kaiser Family Foundation

27. Health Reform & Expansion of Access, continued Private health Insurance –Requires guaranteed issue & renewability as of 2014 (health insurers prohibited from denying coverage for any reason, including health status, and prohibited from charging more based on health status and gender) –Establishes temporary national high-risk pool for those with pre-existing conditions prior to 2014 –Ends annual and lifetime limits on coverage –Young adults to remain on parent’s health insurance up to age 26, as of 2010 –Minimum coverage of prevention services, without cost-sharing, if rated A or B by USPSTF Emphasis on Prevention –New Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs (Initial appropriation in 2010) –Includes support for federal, state, community initiatives to use evidence-based interventions to address HIV-related health disparities Source: Kaiser Family Foundation

28. Looking Ahead Access will improve for millions of Americans, including people with HIV/AIDS –New KFF study finds that Medicaid expansion will significantly increase number covered by the program and markedly reduce the uninsured in states across the country, with the federal government picking up majority of cost (May 26, 2010) –States with large uninsured populations today expected to see the biggest increases in Medicaid coverage But implementation challenges & Not all will gain access Coordination with existing programs in interim will be critical Coverage of routine HIV screening uncertain Role of Ryan White post-health reform will change