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Figure 1 Getting Ready for Health Reform: An Overview of Health Coverage for People with HIV/AIDS Jeffrey S. Crowley, M.P.H. Senior Research Scholar Health.

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Presentation on theme: "Figure 1 Getting Ready for Health Reform: An Overview of Health Coverage for People with HIV/AIDS Jeffrey S. Crowley, M.P.H. Senior Research Scholar Health."— Presentation transcript:

1 Figure 1 Getting Ready for Health Reform: An Overview of Health Coverage for People with HIV/AIDS Jeffrey S. Crowley, M.P.H. Senior Research Scholar Health Policy Institute, Georgetown University jsc26@georgetown.edu / (202) 687-0652 ADAP Advocacy Association December 4, 2008

2 Figure 2 Goals for this session Provide a background on how people with HIV/AIDS obtain health insurance coverage Describe the role of private insurance--and key issues as we approach a national debate on health care reform Describe the role of Medicaid and Medicare and discuss current policy issues Discuss the role of the Ryan White programs in filling in gaps left by private insurance, Medicaid, and Medicare

3 Figure 3 How Americans Obtain Health Insurance Coverage, 2007 SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of March 2008 Current Population Survey. Population = 298 Million

4 Figure 4 People with HIV/AIDS: Insurance Coverage (HIVRN), 2002 SOURCE: Kaiser Family Foundation based on 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, July 2006 Of those in care

5 Figure 5 Health Insurance Coverage of the Low-Income Nonelderly Population by Race/Ethnicity, 2005 42.8 million23.7 million17.8 million3.8 million0.9 million 1.7 million Notes: Low-income is defined as family income less than 200% of the federal poverty level, or $39,942 for a family of four in 2005. Nonelderly includes individuals up to age 65. “Other Public” includes Medicare and military-related coverage. Data source is the March 2005 Current Population Survey. Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates.

6 Figure 6 Poor Near-Poor (<100% Poverty) (100-199% Poverty) Poor Near-Poor (<100% Poverty) (100-199% Poverty) Poor Near-Poor (<100% Poverty) (100-199% Poverty) Children Parents Adults without children Notes: Medicaid also includes SCHIP and other state programs, Medicare and military-related coverage. The federal poverty level was $19,971 for a family of four in 2005. Data may not total 100% due to rounding. Source: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of March 2006 Current Population Survey. Health Insurance Coverage of Low-Income Adults and Children, 2005

7 Figure 7 Non-Elderly Uninsured, by Age and Employment Status, 2005 SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2005 and 2006 Current Population Survey (CPS: Annual Social and Economic Supplements). 46.1 Million Uninsured AgeEmployment Status

8 Figure 8 U.S. Population and People with HIV/AIDS: Income & Unemployment SOURCE: Kaiser Family Foundation based on US Census Bureau, 2006; Kaiser State Health Facts Online; Cunningham WE et al. “Health Services Utilization for People with HIV Infection Comparison of a Population Targeted for Outreach with the U.S. Population in Care.” Medical Care, Vol. 44, No. 11, November 2006. NOTE: US income data from 2005, US unemployment data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal; HCSUS data from 1998.

9 Figure 9 In & Not in Care: Receipt of HAART by Those Eligible for HAART, 2003 SOURCE: 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. Of those aged 15-49 estimated to be eligible for HAART

10 Figure 10 Dynamics of Health Coverage Health insurance coverage is not static 45 million uninsured in 2004, vs. 80 million uninsured over two-year period Approximately 2 million Americans lose health insurance every month – often for a short period Coverage options can change with… –Loss or change of job –Change in family status (e.g. divorce, death of spouse) –Birthday (e.g. 19 th ) –Move –Change in health status SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from www.KaiserEDU.org.

11 Figure 11 Many Policy Makers Seek to Expand Access to Private Coverage …but not all health insurance is created equal Employer-sponsored coverage: –Often comprehensive, but not always –Variation in benefits covered as well as premium and deductible costs Individually-purchased policies: –Typically less comprehensive Less coverage of maternity, mental health and prescription drugs Can have high deductibles as well –Generally unavailable or unaffordable to people with HIV/AIDS SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from www.KaiserEDU.org.

12 Figure 12 Health Conditions Denied by Individual Market Insurers Always denied o Cancero Multiple Sclerosis o HIV/AIDSo Pregnancy o Diabeteso Stroke Often denied o Overweighto High blood pressure o Cancer historyo Asthma Sometimes denied o Acneo Hay fever Pollitz, K., Sorian, R., and Thomas, K. How Accessible is Individual Health Insurance for Consumers in Less Than Perfect Health?, Kaiser Family Foundation, June 2001.

13 Figure 13 Take Aways on Private Insurance Private insurance is mainstay of health coverage for most Americans, but… –Access, affordability, adequacy of coverage not guaranteed –Complex, with high administrative costs Difficulty of getting/keeping private coverage increases with health problems, especially during coverage transitions Regulation to limit risk selection involves tradeoffs: access vs. adequacy vs. affordability Additional public policy responses needed to subsidize and expand coverage SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from www.KaiserEDU.org.

14 Figure 14 Public Coverage is Often More Efficient and Targeted than Private Coverage Kaiser Commission on Medicaid and the Uninsured (KCMU) conducted an extensive review of research literature on health coverage for low-income Americans. Key findings include: Role of Public Coverage: Expanding publicly sponsored health insurance offers the most targeted and efficient strategy for expanding health coverage among low-income populations Eligibility: Basing eligibility for publicly sponsored health coverage on having a low income, without categorical restrictions, could substantially reduce the number of uninsured Americans SOURCE: Health Coverage for Low-Income Americans: An Evidence-Based Approach to Public Policy, Kaiser Commission on Medicaid and the Uninsured, January 2007.

15 Figure 15 Role of Public Coverage (continued) Use of Premiums: Premiums can be expected to depress participating among people living at or near poverty Use of Cost-Sharing: Even at low levels, cost-sharing can adversely affect access to care for low-income people Scope of Benefits: The relatively poor health status of low- income Americans, combined with their limited ability to pay for care out-of-pocket mean that comprehensive benefits are important to meet the diverse needs of this population Financing: A federal-state financing partnership that takes into account national trends, countercyclical pressures at the state level, and the federal government’s greater fiscal capacity could provide a strong and sustainable source of support for a health coverage program for low-income Americans SOURCE: Health Coverage for Low-Income Americans: An Evidence-Based Approach to Public Policy, Kaiser Commission on Medicaid and the Uninsured, January 2007.

16 Figure 16 The Institute of Medicine Endorsed Expanded Public Coverage for HIV/AIDS Many individuals with HIV/AIDS experience delays in treatment access … there are missed opportunities to reduce mortality, morbidity, and disability among individuals with HIV infection The Committee’s principal recommendation to address system deficiencies is the establishment of a new federal program for financing HIV care … the program would entitle individuals based on HIV infection rather than AIDS, and by specifying a set of benefits that meet the standard of care for HIV. SOURCE: Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White, Institute of Medicine, 2004.

17 Figure 17 Key Messages The HIV/AIDS community must be part of the campaign to achieve universal coverage Recent state efforts to achieve universal coverage are encouraging—but likely insufficient –Federal leadership and new resources are needed –Close attention to low-income populations is needed Access to coverage alone, however, is not a solution –Coverage also must be adequate and affordable –Many current state efforts appear to fudge the affordability issue and do not fully address the adequacy issue Protecting public coverage–as the anchor of the health system must be a key goal

18 Figure 18 Medicaid Anchors the Rest of the Health System Nation’s largest health care program in terms of enrollment: In FY 2005, covered 59 million low-income Americans 29.4 million non-disabled children, 15.2 million non-disabled adults, 6.1 million seniors, and 8.3 million children and adults with disabilities Largest source of health coverage for people with HIV/AIDS (≈195,000 Medicaid beneficiaries with HIV/AIDS, at a federal cost of $5.4 billion in 2004) Provides health and long-term services coverage to 15% of the U.S. population SOURCE: Urban Institute analysis of CMS MSIS data for the Kaiser Commission on Medicaid and the uninsured.

19 Figure 19 Medicaid Eligibility Pathways for People Living with HIV/AIDS CategoryCriteriaMandatory/Optional SSI beneficiaries Severely disabled AND low-income (74% of FPL) Mandatory Parents, children, pregnant women Low income; income & asset criteria vary by category & state Mandatory; states may offer higher income thresholds Medically Needy Severely disabled and low income (median = 56% of FPL) after subtracting incurred medical expenses Optional (35 states use this option for people with disabilities) Workers with Disabilities Severely disabled; low-income; for persons returning to workforce Optional Poverty-level expansion Allows for income above SSI levels up to FPL Optional (19 states use this option) State Supplementary Payment (SSP) Allows for coverage of those receiving SSP Optional (21 states use this option) SOURCE: Kaiser Family Foundation.

20 Figure 20 Medicaid is a Major Source of Financing for Health Services Second largest health care program (after Medicare) in terms of spending: –Federal government matches states spending under a formula based on state per capita income. Federal share can vary from 50-83% of total costs. In FY 2008, 13 states have a federal share of only 50%, and MS has the highest match, with the federal government paying 76.29% of total costs. –In FY 2006, the program spent $303.9 billion, with the federal government paying 57% of the cost and the states paying the remainder. Responsible for 15% of national health expenditures in 2006. SOURCES: Urban Institute analysis for the Kaiser Commission on Medicaid and the Uninsured of CMS- 64 Reports, July 2007 and National Health Expenditure Accounts, 2008, CMS Office of the Actuary.

21 Figure 21 Medicaid has a unique role in relation to private coverage and Medicare Catastrophic needs: Assists people with extensive needs at all stages of life Essential public role: Shoulders uniquely public responsibilities, such as covering children in foster care Integrates acute and long-term services: By contrast, private insurance and Medicare mostly cover acute care or short-term rehabilitation Critical safety net: Private insurance and Medicare not designed to meet the needs of some populations with extensive needs

22 Figure 22 Medicaid Serves a Diverse Population Note: “Poor” defined as <100% of federal poverty level, which was $19,971 for a family of four in 2005. Source: Estimates by Kaiser Commission on Medicaid and the Uninsured and Urban Institute; birth data from MCH Update, National Governors Association. Percent with Medicaid: Families Seniors and People with Disabilities

23 Figure 23 A large share of Medicaid spending is for dual eligibles SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on CMS data and Urban Institute analysis of data from MSIS. Total = 51 Million Medicaid Enrollment 10% Medicaid Spending Total = $232.8 Billion (42% on Duals) Spending on Other Groups Prescription Drugs Long-Term Care Medicare Premiums 27% 58% 6% 2% Other Acute Care 6% (2003)

24 Figure 24 Small Share of Population Accounts for Large Share of Expenditures SOURCE: Sommers and Cohen, Medicaid’s High Cost Enrollees: How Much Do They Drive Program Spending? Kaiser Commission on Medicaid and the Uninsured, March 2006. Based on MSIS 2001 data. Adults 1% Disabled 25% Total = 46.9 millionTotal = $180.0 billion Elderly 20% <$25,000 in Costs 96% Children 3% <$25,000 in Costs 52% >$25,000 in Costs Adults 0.1% Disabled 2% Elderly 2% Children 0.2% >$25,000 in Costs 3.6% 49%

25 Figure 25 Medicare Today Covers 44 million people –~37.4 million seniors –~6.6 million non-elderly people with disabilities –Second largest source of HIV/AIDS coverage (≈85,000 Medicare beneficiaries with HIV/AIDS, includes ≈ 55,000 dual eligibles; at a cost of ≈ $2.5 billion in 2004) Net Federal cost of $459.4 billion in 2008 Program now has 4 parts A,B,C, and D –Part A – Hospital and skilled nursing care –Part B – Physician and outpatient hospital care –Part C – Medicare Advantage (voluntary managed care alternative to Parts A and B) –Part D – Outpatient prescription drug covera ge Source: CBO Medicare Baseline, March 2008.

26 Figure 26 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; also includes spouses and adults disabled since childhood Have been receiving SSDI payments for at least 24 months Individuals with End-Stage Renal Disease, any age Sufficient number of work credits to qualify for Social Security payments SOURCE: Kaiser Family Foundation.

27 Figure 27 Qualifying for Medicare Individuals under age 65 can qualify for Medicare on the basis of disability if they have a sufficient work history and after a waiting period 1. SSA determines that an individual has a disability; 2.To ensure that disability is permanent or long-lasting, individuals must then wait 5 months before they start receiving SSDI; 3.Starting when they first receive SSDI, individuals must wait an additional 24 months to start receiving Medicare Individuals with disabilities since childhood can receive Medicare based on the work history of a parent. These individuals are called disabled adult children (DACs), and are subject to the 24 month waiting period when they turn 18 (or develop a disability before age 22)

28 Figure 28 Percent of Total Medicare Population: SOURCE: Medicare Current Beneficiary Surveys 2003 and 2002. Low-Income <150% FPL ($14,700 in 2006) Enrolled in Medicaid (“Dual Eligibles”) Cognitive/Mental Impairment Nursing Home Resident 3+ Chronic Conditions Under-65 Disabled Medicare Covers a Population with Diverse Needs and Significant Vulnerabilities Fair/Poor Health Age 85+ 39% 35% 31% 27%

29 Figure 29 MMA Out-of-Pocket Drug Spending in 2008 + ~$304 in annual premiums Deductible $275 No Coverage Catastrophic Coverage Partial Coverage up to Limit $2,510 $5,726 (equivalent to $4,050 in out-of-pocket spending) 25% $3,216 Gap Out-of-Pocket Spending Medicare Part D Benefit SOURCE: Kaiser Family Foundation. Individual Pays 5% Plan Pays 15% Medicare Pays 80% Plan Pays 75%

30 Figure 30 Limitations of Medicare In addition to prescription drug affordability issues, gaps in Medicare coverage that shift costs and responsibilities onto Medicaid and Ryan White include: –Long-term services and supports –Dental care and dentures –Hearing aids –Routine eye care and eyeglasses –Routine foot care –Limited mental health services

31 Figure 31 Thoughts on Expanding Health Insurance Coverage Efforts to expand access to health coverage—and achieve universal coverage—are important Recent state efforts to achieve universal coverage are encouraging—but likely insufficient –Federal leadership and new resources are needed –Close attention to low-income populations is needed –Focus has been on working people, with little to no attention on needs of people with chronic conditions Access to coverage alone, however, is not a solution –Coverage also must be adequate and affordable –Many current state efforts appear to fudge the affordability issue and do not fully address the adequacy issue

32 Figure 32 In Any Reformed Health System, the Ryan White Programs Are Still Needed The Ryan White programs fill in gaps left by private coverage, Medicaid, and Medicare If a major universal coverage initiative were enacted, the gaps to be filled by Ryan White programs may change, but these programs would still be necessary Nearly all universal coverage initiatives are predicated on building on existing financing and delivery systems—i.e. they assume the Ryan White programs are here to stay Nearly all so-called universal coverage proposals leave gaps related to HIV/AIDS care: consider access, adequacy, and affordability

33 Figure 33 Will we be on offense or defense in the coming year? —Reform and expansion or retrenchment? Many believe that universal coverage will be built on three legs: bolstering existing employer-sponsored insurance, asking individuals to fairly contribute to the cost of their care, and targeting expansions of public programs for low- income and costly/complex populations Severe economic downturn will likely lead to temporary increase in Medicaid FMAP (Many policy makers would prefer to build this into law to deal with counter-cyclical nature of program) As states face budget pressures and cut back, we will likely hear Medicaid scapegoated

34 Figure 34 Medicaid Issues to Consider Medicaid’s Role in the Broader Health System Remove categorical distinctions and cover all poor people or all poor seniors and people with disabilities? Re-think medically needy coverage to better permit people with catastrophic needs to spenddown into Medicaid? Flexibility versus Uniformity Is the current variation across states acceptable? How do we improve the delivery system across 50+ programs? Long-Term Services Policy and Medicare Medicaid is our de facto national long-term care program, not intended to play this role—how do we expand other sources of financing for long-term care? How do we rebalance LTC to expand community services? What is the proper responsibility of Medicaid for Medicare beneficiaries (huge burden from waiting period and LTC)

35 Figure 35 Medicare Issues to Consider Does the program match the populations it serves Is the benefits package appropriate for a population of seniors and people with disabilities? Can modest changes be made to meet LTC needs? Financing How do we deal with cost pressures and demographic change? Do we believe the program is too generous or do we need to broaden financing? Leveling the playing field between traditional Medicare and Medicare Advantage Delivery system improvements How do we adopt evidence-based practices and new technology? What are model approaches for integrating care for duals?

36 Figure 36 Opportunities in Health Reform Major role for the HIV/AIDS community: There are significant efforts underway to enact major health reform legislation. Many people want to assume people with disabilities are protected. HIV/AIDS advocates need to fight for a role in the debate. Potential to expand Medicaid eligibility: Policy makers are considering options ranging from moving all people into private coverage and eliminating Medicaid to expanding Medicaid to all low-income people without categorical distinctions. Need to tell policy makers why Medicaid often works better than private insurance: Policy makers do not understand Medicaid’s unique roles. We must tell the good news story about how Medicaid can be improved, but that it works.


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