HIV Care in the Current Funding Environment

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2 HIV Care in the Current Funding Environment The ACA, Ryan White, and a Call for Advocacy Melanie Thompson, MD Principal Investigator AIDS Research Consortium of Atlanta Friday, April 29, 2016

3 Disclosures Research funding from Bristol Myers Squibb GlaxoSmithKline Gilead Sciences Merck Research Laboratories Pfizer Research Laboratories Taimed, Inc. ViiV Healthcare

4 Objectives Be able to Explain cost-sharing and other obstacles to ARV access under the ACA Address discriminatory practices under the ACA Discuss key advocacy issues for the Ryan White Program

5 What is the Current Funding Environment for HIV Care? Ryan White Medicaid, Medicare Veterans Administration Private insurance Affordable Care Act plans Federal marketplace State marketplace Non-ACA plans

6 The Patient Protection and Affordable Care Act (ACA) Focus on What is NOT Working for People with HIV But FIRST ACA 101

7 7 Insurance Terms: Cost-Sharing Structures Premium: monthly fee an insurance plan charges for plan membership Advance Premium Tax Credit (APTC): money that the government pays directly to a health plan (or to the consumer at the end of the tax year) in order to reduce a consumer s premium Co-pay: a set fee a consumer pays for each provider visit, prescription refill, lab test, or other healthcare service (e.g., $10, $20, or more) Co-insurance: a percentage of the cost of the healthcare service that the consumer must pay (e.g., 30% of the cost of a provider visit or of a procedure) Deductible: a set annual amount the consumer must pay before the insurance plan pays for any of the costs of care (e.g., $2,500) Cost-sharing Subsidy (Reductions): money that the government pays directly to a health plan in order to reduce a consumer s out-ofpocket costs (silver plans only) Center for Health Law and Policy Innovation

8 Marketplace Qualified Health Plans (QHPs) Premiums Cost-Sharing $$$$ $ $$$ $$ $$ $$$ $ $$$$ Center for Health Law and Policy Innovation 8

9 Who Bears the Cost? Higher medal plans may be cheaper for consumers with high cost-sharing for prescriptions

10 10 Awesome Things About the ACA No pre-existing conditions! Can t be dropped due to health! Young adults can stay on parents plans until age 26 No limits on lifetime benefits; annual out of pocket (OOP) caps No increase in premium due to health conditions (other than tobacco use) or gender Requirement to cover Essential Health Benefits, including much preventative care Premium and OOP cost-sharing subsidies and limits for % FPL Incorporates anti-discrimination provisions

11 Discrimination and the ACA: Sec The ACA prohibits Qualified Health Plans (QHPs) from imposing any pre-existing condition exclusions or other discrimination based on health status, race, sex, age, and disability. 1 Health plan cannot refuse to provide coverage for an illness or injury that you acquired before enrolling in the health plan, or provide you with fewer benefits than it provides others. 2 1.Insurers cannot charge an older person more than 3 times the premium for a younger person. Patient Protection and Affordable Care Act, Patient Protection and Affordable Care Act, 1201, ; 1557,

12 ENROLLMENT OF PEOPLE LIVING WITH HIV IN MEDICAID AND MARKETPLACE HEALTH INSURANCE PLANS SINCE ,000 people living with HIV in ADAP (38% of ADAP enrollees) are newly insured 48,000 enrolled in plans offered through the Marketplaces, almost all with subsidies 20,000 enrolled in Medicaid expansion 20,000 (primarily living in the Southeast US) did not gain coverage because their states rejected Medicaid expansion Center for Health Law and Policy Innovation 12

13 LACK OF MEDICAID EXPANSION UNDERCUTS ACA BENEFIT FOR PEOPLE WITH HIV CURRENT STATUS OF STATE MEDICAID EXPANSION DECISIONS WA OR NV CA AK ID AZ UT MT** WY CO NM HI ND SD NE KS OK TX MN WI* IA* IL MO AR* MS LA VT NY MI* PA* OH IN* WV VA KY NC TN SC AL GA FL ME NH* MA CT RI NJ DE MD DC Adopted (31 States including DC) Adoption Under Discussion Not Adopting At This Time SOURCE: Status of State Action on the Medicaid Expansion Decision, KFF State Health Facts, updated July 20,

14 Not-So-Awesome Things About the ACA (and Private Insurance!) Limited provider networks Low premiums = high deductibles High drug tiering unaffordable cost sharing Prior authorization delays access to drugs Step therapy never appropriate for HIV Quantity limits requires frequent prescriptions Specialty mail order pharmacies convenient for some, impossible for others

15 15 Lack of Transparency of Marketplace Inadequate drug coverage or essential provider information Failure to include adequate information as to cost of covered services and medications Lack of standardization of plan formulary information Inconsistencies between Marketplace and insurer websites Changing plan design and cost-sharing subsequent to enrollment Center for Health Law and Policy Innovation Hidden requirements such as mail order pharmacy only

16 16 Inadequate Coverage Within Plans In 2014, 28% of all HIV drugs and 19% of STRs not covered In 2015, only 46% included the ten most commonly prescribed HIV regimens on their formularies 12% covered six or fewer top ten regimens Recently approved treatments have lowest rates of coverage (i.e., dolutegravir/abacavir/lamivudine, approved in 2014, covered only 50%) Comparing 2014 and 15 data shows some plans moving in the wrong direction Avalere Health, Coverage of Top HIV Regimens in 2015 Exchange Plans, November 11, 2015; Avalere Health, Review of Formulary Coverage, Cost Sharing and Access in Top Exchange Plans, March 2014.

17 Assessing a Health Plan Step 1: Assess Overall Cost-Sharing Step 2: Assess Services and Providers Step 3: Assess the Formulary Center for Health Law and Policy Innovation

18 Assessment Tool: Marketplace Health Plans Template Assessment Worksheet Center for Health Law and Policy Innovation: Available at CHLPI.org

19 CHLPI QHP State Analyses Alabama, Georgia, Illinois, Louisiana, Minnesota, Mississippi, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and Wisconsin: Download your state QHP analysis

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22 Aetna/Coventry Silver $10 Copay 2750 HMO

23 Aetna/Coventry Silver $10 Copay 2750 HMO

24 BCBS Silver Pathway X HMO 10

25 Cigna Health Flex 2000

26 DISCRIMINATION ALERT! Pre-existing conditions or discrimination based on health status, race, sex, age, or disability Higher cost-sharing for antiretroviral medications Limits on mental health or substance abuse services Center for Health Law and Policy Innovation

27 27 Discriminatory Practices Against PLWH Placing ARV on high tiers dissuades PLWH from enrolling and shifts costs onto those who do PLWH enrolled in plans with high cost sharing for ARV (adverse tiering) spend $3,000 more per year Of Marketplace QHPs analyzed in 5 Southern states over the past two years of open enrollment: 54% require co-insurance of 30% for ARV 63% placed more than 50% of ARV in the highest cost sharing tier 93% charge 30% of median yearly annual discretionary income for efavirenz/tenofovir DF/emtricitabine Center for Health Law and Policy Innovation; unpublished data

28 28 Advocacy Approaches Grievance letters to insurers Grievance letters to state Insurance Commissioners and Departments of Insurance (DOI) Appropriate topics for complaints to state regulators in private health insurance plans include: Changing coverage after the open enrollment period ends Refusing to cover the care and treatment people living with HIV need Requiring unreasonably high cost-sharing for HIV treatment Template grievance letters available: CHLPI.org Litigation or filing of complaints with Office of Civil Rights

29 Patient Assistance with Meds The Patient Advocate Foundation (PAF) accepts applications for co-pay assistance The PAN Foundation has run out of money for the year, but will probably open again Industry patient assistance programs Don t forget co-pay cards!

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31 The Ryan White HIV/AIDS Program HRSA 2014 RSR Overview

32 10 Top Used Ryan White Services (2014) HRSA 2014 RSR Overview

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37 What About Reauthorization? Ryan White Program was created by Congress in 1990 and last reauthorized in 2009 The program can be and has been funded annually without reauthorization Although it has always enjoyed bipartisan support, there is concern that reauthorization might be hazardous in the current partisan political environment

38 Advocacy is Needed to Maintain and Increase Ryan White Funding While numbers of patients increase, the budget has remained relatively flat Medicaid expansion has relieved some burden on expansion states, allowing them to use their funds for much needed services In Medicaid non-expansion states, there has been little change because of the ACA, and patient numbers continue to rise. Many of these states are located in the Southern epicenter of the epidemic.

39 Issues for Ryan White Advocacy ACA supplements but does not replace Ryan White Unequal application across nation with lack of uniform Medicaid expansion High out of pocket costs for patients ACA does not provide comprehensive services Case management Transportation Childcare Integrated substance use and mental health care Premium and cost-sharing assistance ARV without cost to patients Highly trained HIV expert providers

40 Issues for Ryan White Advocacy Ryan White is a public health intervention, not an insurance program HIV is not hypertension or Alzheimer s Disease Yes, AIDS is Exceptional Lethal infectious disease with epidemic spread Viral resistance develops if not treated properly Treatment is prevention: adequate treatment decreases the public health burden Increasing concentration of HIV in areas of poverty and health disparities requires federal intervention Decreased funding risks epidemic resurgence, similar to the story of TB and MDR-TB

41 Issues for Ryan White Advocacy Increasing numbers of persons living with HIV Effective antiretroviral therapy can prolong life to a normal life span or beyond New infections continue at the unabated pace of nearly 50,000 per year in the US Funding is not keeping pace with growing numbers of patients Ryan White is one of our most effective and efficient public health interventions

42 Issues for Ryan White Advocacy Maintain and increase Ryan White funding Avoid combination of Parts C and D without appropriate accommodations to preserve coverage, especially in underserved areas Expand services needed to treat HCV-HIV coinfection Expand access to substance use and mental health services, including ability to provide opioid substitution treatment Explore how Ryan White can support PrEP

43 43 Become an Advocate Meet your elected representatives at all levels of government Visit your US Senators and Representatives when they are in the state to introduce yourself as a resource on HIV information Invite them to visit your clinic Learn more about advocacy by joining HIVMA and the Ryan White Medical Provider Coalition

44 You Might Get a Nice Souvenir Picture! 44

45 45 Acknowledgments Harvard Center for Health Law and Policy Innovation (CHLPI) Carmel Shachar for sharing slides HIV Medicine Association; Ryan White Medical Provider Coalition

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