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POSITIVELY AWARE November/December 2012

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comment The healthcare question - after the november election, what happens next? By David Ernesto Munar

The healthcare question - After the November election, what happens next? By David Ernesto Munar

The outcome of the November 6, 2012 presidential election will mean big changes for all health care consumers—including people living with HIV/AIDS—no matter who wins the White House. A comparison of the candidates’ positions on health care follows.

overnor Mitt Romney, the Republican nominee, has pledged to issue an executive order on his first day in office to halt any further implementation of the Patient Protection and Affordable Care Act’s (ACA) sweeping health care policy reforms and seek a full repeal of the law. Despite leading efforts as governor of Massachusetts to adopt a similar set of measures that inspired the ACA (see “RomneyCare and HIV/AIDS” on page 47), Romney says the prescription for the uninsured should be decided by each state and not the federal government.

Pre-existing conditions: Romney’s plan would ensure coverage for individuals with pre-existing conditions who maintain continuous coverage. His plan does not include routes to credible coverage for uninsured individuals with pre-existing conditions. In a CBS News’ 60 Minutes interview that aired on September 23, Romney pointed to emergency rooms as a form of health care for people without insurance.

Private insurance reform: Romney supports legislation to offer tax breaks to purchasers of individual health insurance coverage so they receive the same tax breaks as individuals with employer-based group insurance. Romney also advocates multi-state insurance products to help control the cost of insurance premiums. Other reforms, such as provisions to allow children to remain on their parents’ plans into early adulthood, would be left to the states to decide.

Medicaid: Romney supports block grants for states to implement Medicaid, the federal and state health insurance programs for the poor, disabled, and elderly. Growth in the federal Medicaid grants would be capped at the rate of inflation plus 1%. While the per capita growth in spending is 2.1% lower in Medicaid than in private plans, Medicaid growth has remained higher than inflation. With an aging Baby Boomer generation, long-term care and other care needs in Medicaid are likely to raise Medicaid spending even higher.

Medicare: Romney’s repeal of the ACA would restore the large “donut hole” in Medicare prescription drug coverage and his campaign has yet to announce how, or if, it would address this added cost to Medicare beneficiaries.
His Medicare plan would convert the program to a voucher system, providing beneficiaries with a fixed dollar amount to purchase private coverage. The proposal would not affect current retirees or those nearing retirement but be established for future retirees.

The ACA is a lightning rod issue for many voters, both for and against. How might the law help people with and at risk of HIV?

President Obama, the Democratic nominee seeking a second term, ushered passage of the federal health reform law in 2010. The law’s most significant provisions go into effect in January 2014. Sustaining implementation of the ACA is at the core of his second-term agenda.

In a twist of political irony, the ACA is loosely modeled on a health care plan in Massachusetts enacted by then-Governor Romney. This fact notwithstanding, candidate Romney supports the Massachusetts plan but disavows the ACA and pledges to repeal it if elected president (see above). How the Massachusetts plan impacts its HIV-positive residents is one way to assess the potential impact of the ACA on the nation’s ongoing AIDS fight (see following article, “Romneycare and HIV/AIDS”).

Pre-existing conditions: Under the ACA, the cost of private insurance premiums will be based solely on the individual’s age, geographic location, and tobacco use. Exclusions for pre-existing conditions will be outlawed beginning in 2014.
The Pre-Existing Condition Insurance Plan (PCIP) is a program created by the Affordable Care Act to help provide coverage for uninsured people with pre-existing conditions until new insurance market rules go into effect in 2014. The PCIP, which is administered by either individual states or the U.S. Department of Health and Human Services, will provide health insurance coverage for U.S. citizens or legal residents who have been uninsured for at least six months, have a pre-existing condition, or have been denied health coverage because of their health condition. There are no income thresholds required for pre-existing condition coverage and premium rates, as well as deductibles, vary in each state.

Private insurance reform: Also in 2014, every state will have a “health insurance exchange,” which is an online marketplace that allows individuals and small businesses to compare and purchase health insurance plans. Either the state government or the federal government will run the exchange in each state.

The hotly contested “individual mandate” requiring Americans to carry health insurance coverage was recently upheld by the U.S. Supreme Court. People and small businesses who fail to comply with the requirement will be assessed a federal tax penalty.

The exchange will help U.S. citizens and some legal residents with annual incomes above $11,170 (or $23,050 for a family of four)* to shop for and purchase private health insurance. Eligible individuals with incomes up to $44,680 (or $92,200 for a family of four) will be provided a federal subsidy to help offset the cost of mandated insurance coverage.

Out-of-pocket health care costs are capped by the ACA to prevent health care-related bankruptcies that all too often occur after an injury or catastrophic illness. Other ACA reforms include guaranteed coverage without co-pays for preventative health care, including HIV testing and contraception for women, a provision that went into effect recently.

Medicaid: The Supreme Court affirmed the constitutionality of the ACA and kept virtually all its provisions intact. While upholding the Medicaid expansion, a central provision to cover low-income citizens, the Supreme Court ruled that the federal government could not withhold all of a state’s Medicaid funding in order to enforce the expansion provision, as was previously stated in the law. The Court ruled that only new funding available for the expansion can be withheld as a penalty for failure to expand Medicaid eligibility. Facing a less severe penalty, 15 states have already announced intentions to not expand Medicaid as required by the ACA and 22 more are undecided.
States that elect the expansion will receive federal funds to offset 100% of their new costs in 2014-2016, dropping to 90% by 2020. The law will make Medicaid an insurance program for low-income Americans with incomes up to $15,420 ($31,812 for a family of four), regardless of health status. Medicaid provider payment rates will also rise to match Medicare rates for a two-year period beginning in 2013, which should expand the number of medical providers willing to accept Medicaid coverage.

Medicare: Under the ACA, the so-called “donut hole” in Medicare prescription drug coverage shrinks over time. As a source of revenue to pay for its many new provisions, the ACA reduces incentives to health insurance companies to offer Medicare Advantage plans. The reduced incentives are not expected to affect Medicare benefits.

The ACA is a lightning rod issue for many voters, both for and against. How might the law help people with and at risk of HIV, if fully implemented? Are we better off halting implementation and starting over with Romney’s plans for the nation? The answers to these questions are critical for everyone committed to the fight against HIV/AIDS as we head to the polls in November.

* Income eligibility amounts cited reflect current threshold amounts published in the 2012 HHS Poverty Guidelines. The Census Bureau updates poverty threshold amounts annually.

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Romneycare and HIV/AIDS - A look at Massachusetts offers insight on national healthcare reform

Romneycare and HIV/AIDS - A look at Massechusetts offers insight on national health care reform by David Munar

t’s hard to imagine how the federal health reform law, known as the ACA, will work for people living with HIV/AIDS once it is fully implemented in 2014. Because the framework of the ACA is loosely based on health care reform in Massachusetts, a review of that state’s system can help HIV/AIDS advocates understand how the national law might affect people with HIV nationwide.

Massachusetts reforms
Long before health reform dominated national headlines, officials in Massachusetts were working on strategies to reduce the number of uninsured in the state. Here’s a quick recap.

2001: Massachusetts was the first state in the nation to implement a federal waiver allowing Medicaid expansion to non-disabled poor residents living with HIV. The state combined federal resources with state appropriations to offer a comprehensive benefit package to all uninsured state residents living with HIV at or below 200% of Federal Poverty Level (FPL).

With health insurance provided by Medicaid to most HIV-positive uninsured residents, the state used federal Ryan White Program grants to provide wrap-around support services to help connect and sustain people in care. The state’s AIDS Drug Assistance Program (ADAP) shifted its focus from dispensing HIV medication to predominately providing premium and co-pay assistance for people living with HIV.

2006: Governor Romney signed reforms into law, including:

  • A mandate for all state residents to carry health insurance coverage
  • Development of the first state insurance exchange that certifies plans with comprehensive benefits without pre-existing condition exclusions
  • Medicaid expansion to cover all uninsured residents with incomes up to $22,340 (200% of FPL)
  • Development of a comprehensive Medicaid benefits package
  • State subsidies to help people with income between 200% and 300% of FPL purchase private insurance

“Massachusetts serves as an excellent example of how properly implemented health reforms can substantially improve health outcomes for those living with HIV,” said Robert Greenwald, Clinical Professor of Law and Director of the Center for Health Law and Policy Innovation at Harvard Law School.

The Case for national reform: stages of engagement in HIV care

n 2011, Dr. Edward Gardner and colleagues published a compelling analysis demonstrating severe gaps in care for people with HIV/AIDS in the U.S. The Centers for Disease Control and Prevention (CDC) published its own analysis in December 2011. Much like Gardner’s original paper, CDC’s “States of Engagement in HIV Care” reports sizeable gaps in linking and retaining people diagnosed with HIV to continuous clinical care and treatments.
The CDC found that only 28% of people living with HIV in the U.S. achieve the viral suppression needed to improve their longevity and reduce HIV transmission risk to others. Moreover, only 51% of people diagnosed with HIV are retained in continuous clinical care, which results in lower numbers of people gaining access to the HIV treatments they need.

The stages-of-engagement methodology is a useful performance metric to gauge how well or poorly systems achieve clinical engagement for HIV-positive populations. Given how similar the ACA is to RomneyCare, the Massachusetts analysis may forecast what outcomes might be possible under the ACA.

Ahead of the curve

fter a decade of reforms, health systems in Massachusetts are achieving remarkable results for HIV-positive residents that far exceed national outcomes.

According to recent Massachusetts state health department data on the state’s HIV-positive population analyzed by Harvard Law School, by every metric, Massachusetts outperforms the national average by more than two to one.

  • 99% of the state’s HIV-positive population is retained in clinical care (41% nationally).
  • 90% of HIV-positive state residents receive HIV medication regimens (36% nationally)
  • 72% of state residents with HIV have a suppressed viral load (vs. 28% nationally).

“The Massachusetts data is clear evidence that if properly implemented, the ACA can greatly improve all 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,” Greenwald said.

According to Greenwald, Massachusetts reforms have also proved successful at reducing rates of new HIV infections, AIDS mortality, and overall cost of HIV-related care and treatment.

Between 2006 and 2009, HIV diagnoses fell by 25% in Massachusetts as compared to a 2% national increase, and between 2002 and 2008 Massachusetts AIDS mortality rates decreased by 44% compared to 33% nationally.

Massachusetts health reforms, while greatly expanding access to high-quality health care, have also resulted in significant cost savings. The amount spent post-reforms per HIV-positive Medicaid beneficiary has decreased significantly, especially the amount spent on inpatient hospital care, Greenwald said.

In addition, the Massachusetts Department of Health estimates that, because of health reforms and the resulting decline in HIV transmission rates, it has saved approximately $1.5 billion in HIV health care expenditures over the past 10 years.

Greenwald and others readily admit that reform efforts are not the only essential ingredients needed to bolster HIV-related outcomes. Health care infrastructure in a state, the number of medical providers with expertise in HIV care, other government assistance programs available to the poor, transportation options, and other socio-economic factors will weigh heavily on a state’s performance in reaching people with HIV/AIDS.

These challenges notwithstanding, further efforts to implement the ACA nationwide could likely help areas across the country begin to replicate Massachusetts’ successes and help lift the national performance across the “stages of engagement in HIV care.”
That is, of course, if ACA implementation is not derailed by state actions, including opting out of expanding Medicaid to all low-income residents, or the repeal efforts pledged by many opponents of the law.


David Ernesto Munar is president/CEO of the AIDS Foundation of Chicago (AFC) and an HIV-positive advocate. Working with other AIDS advocacy organizations across the country, AFC hosts HIVhealthreform.org, an educational website on health reform policy geared toward people affected by HIV/AIDS, their organizations and advocates.

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