1. The AIDS Institute Federal and State Update Florida Patient Care Planning Group April 3, 2013 Michael Ruppal, Executive Director

2. Budget Sequestration 5% cuts for Sequestration Spending plans due in 30 days Partial awards issues to grantees FY12: $3.06 billion FY13: Continuing Resolution through 9/30/13 ADAP - $35 million from President not included FY14 Community Request: $3.6 billion (+$540 million)

4. Budget Sequestration NIH: Loss of $157 million in AIDS research funding 297 AIDS research grants would go unfunded, including 32 specifically funding AIDS vaccine research CDC: Loss of $163 million in AIDS research funding; 297 AIDS research grants would go unfunded ADAP: 10,000 PLWHAs will lose access HOPWA: 1,360 fewer households would receive permanent housing, and 1,870 fewer households would receive short-term assistance to prevent homelessness Source: amFAR and NMAC, 2-20-13

5. Impact of Sequestration on CDC HHS Secretary Letter to Senate Appropriations on impacts of Sequestration: “Sequestration would impair the Department's ability to prevent and treat HIV/AIDS. The cuts to the Centers for Disease Control and Prevention (CDC) translate into approximately 424,000 fewer HIV tests conducted by CDC's health department grantees.” 5.1% cut = $40 million

6. Ryan White Program Provides Care, Treatment & Support Services to 546,000 low- income, uninsured and underinsured individuals with HIV/AIDS Many people with HIV not insured Many do not qualify for Medicaid & Medicare; if they do those programs not always adequate Funding distributed to States and Large Cities by formula and Clinics through competitive grants First authorized in 1990; last authorized in October 2009

8. Total = $2.392 b

9. Ryan White Program Appropriations History 1991-2012 $0 $ 100 $ 200 $ 300 $ 400 $ 500 $600 $ 700 $800 $ 900 1991199219931994199519961997199819992000200120022003200420052006 Millions Part A Part B Base ADAP Part C Part D Dental Reimb. AETCs 2007 Source: HRSA HIV/AIDS Bureau; The AIDS Institute 2008 2009 20102011 2012

10. Ryan White Program FY12: $2.342 billion +$13 million to ADAP All other Parts: Small Across the Board Cuts Plus World AIDS Day Emergency Funding by President Obama: ADAP: +$35 million Part C: +$15 million

11. Community Request: 10% increase for all Parts, except ADAP (+$133 m) ADAP Enrollment Grew by 13,500 in 2012 or 8% ACA Coverage begins Jan. 1, 2014 Fiscal Year begins Oct. 1, 2013 Enrollment will take time All States Not Expanding Medicaid Ryan White Program FY14

12. Ryan White Program Expires (not Sunset) 9/30/13 Funding will still be necessary 70% of Ryan White clients currently have some coverage, but it is not adequate and Ryan White services will continue for them ACA benefits will not be complete & differ from state to state Ryan White can assist with premiums, co-pays, deductibles 29 million will still be uninsured Coverage does not equal access & adherence Need time and analysis before any changes made Ryan White Program in the Future

13. Kaiser (Crowley / Kates) Paper on Ryan White Collapse Parts A & B Collapse Parts C & D Ryan White Program in the Future

14. HHS Letter to Senate Appropriations on Impacts of Sequestration: “Sequestration would impair the Department's ability to prevent and treat HIV/AIDS…The Health Resources and Services Administration estimates that 7,400 fewer patients would have access to life-saving HIV medications through the AIDS Drug Assistance Program (ADAP). This would cause delays in service and drug provision to people living with HIV and potentially lead to ADAP wait lists for HIV medications.” 5.1% cut = $122 million Impact of Sequestration

15. NIH AIDS Research New Drug Development Treatment as Prevention Basic Science Microbicides Behavioral Research Vaccine Cure

16. NIH AIDS Research FY12: $3.06 billion (Flat) FY14 Community Request: $3.6 billion (+$540 million) 5.1% cut = $156 million

17. Housing Opportunities for People with AIDS Administered by HUD Provides Housing Assistance to over 63,000 households Distributed by formula to 138 Jurisdictions An additional 147,000 households eligible for HOPWA

18. Housing Opportunities for People with AIDS FY12: $332 million (-$2.3 million) FY14 Community Request: $365 million (+$33 million)

19. Secretary Donovan Testimony to Senate Appropriations: “Not only HOPWA (7,300 households will lose assistance) but 125,000 housing choice voucherholders, ½ of whom are disabled or elderly, will lose assistance and 100,000 homeless or formerly homeless will lose support and risk return to homelessness. The cuts to these programs as well can’t be good for people with HIV/AIDS.” 5.1% cut = $17 million Impact of Sequestration

20. Despite significant overall budget cuts, so far HIV programs have been mostly spared Domestic HIV programs have been a priority for Obama Administration & many in the Congress At current spending levels, we can not realize our goals anytime soon Decisions now will determine the future of HIV/AIDS President’s budget April 10, 2013 HIV/AIDS Programs & the Budget

21. Florida 2013 Legislative Session  The Florida House and Senate released their proposed budgets, which are headed to the full appropriations committees on Wednesday, April 3.  There is a sense of optimism that has not been felt in recent years with some modest increases this year.  House proposes to allocate about $31.3 billion on health and human services spending.  Senate would spend nearly $30.8 billion, with Medicaid being the largest budget item in HHS.

22. Florida 2013 Legislative Session  House budget includes about $20.4 million in anticipation that the Affordable Care Act will lead to more people enrolling in Medicaid who are already eligible but not enrolled.  Anticipated increase in Medicaid enrollment as the ACA is fully implemented in 2014.

23. Florida 2013 Legislative Session HB 365 |SB 732 Prescription Drugs; Authorizing a pharmacist to substitute a biosimilar product for a prescribed product if certain requirements are met, etc. HB 195 | SB 520 Emergency Medical Services: Deletes requirement that EMTs, paramedics, & 911 public safety telecommunicators complete course on HIV & AIDS.

24. Florida 2013 Legislative Session HB 735 | SB 808 Needle and Syringe Exchange Program: Authorizes DOH to establish needle & syringe exchange program. HB 735 was amended in the Health Quality Subcommittee and is now limited to a pilot project in Miami-Dade County.

25. Florida 2013 Legislative Session HB 1003 Prescription Drug Benefit Plans: Creates specialty tier prescription drug moratorium & study; requires report to Governor & Legislature. SB 1010 Health Insurance Coverage for Prescription Drugs; Prohibiting higher copayments, deductibles, coinsurance, or similar charges for nonpreferred prescription drugs as compared to preferred prescription drugs; requiring the Agency for Health Care Administration, with the assistance of the Office of Insurance Regulation, to conduct a study and submit a report to the Governor and Legislature.

26. Florida 2013 Legislative Session HB 1139 | SB 1250 Medical Cannabis: Authorizes qualifying patient to possess & administer medical cannabis. HB 1255 | SB 1328 Testing for Human Immunodeficiency Virus: Provides that informed consent to perform HIV test must be obtained from legal guardian or other person authorized by law for certain persons; revises situations in which test results may be released.

27. Florida 2013 Legislative Session SB 7038 | SB 1816 Healthy Florida – Senator Negron’s Alternative to Medicaid Expansion Revising the components of the Florida Kidcare program; revising the eligibility of the Medikids program component. SB 7144 (aka “The Bean Alternative) Health Choice Plus Program; Authorizing the Florida Health Choices, Inc., to accept funds from various sources to deposit into health benefits accounts, subsidize the costs of coverage, and administer and support the program; requiring the corporation to manage the health benefits accounts and provide the marketplace of options that an enrollee in the program may use; specifying healthy living performance goals; providing for payment for achieving health living performance goals, etc.

28. Affordable Care Act Implementation Healthy Florida – Senator Negron’s Alternative to Medicaid Expansion SB 7038 (a proposed committee bill) became SB 1816 by the Senate Appropriations Committee would create a system for newly eligible Medicaid recipients up to 138% PFL under the Florida Healthy Kids Corporation, not the Agency for Health Care Administration, with the ability to draw down the 100% federal match for the first three years. The plan would include modest co-pays and incentive accounts for healthy behaviors. The House, on the other hand, has repeatedly stated that it will not accept federal funds and will not expand Medicaid.

29. Affordable Care Act Implementation SB 1816 http://www.flsenate.gov/Session/Bill/2013/1816/BillText/Filed/PDF  Use Medicaid dollars to extend private health-insurance to 1 million individuals/families  Up to 138 percent of the federal poverty line  $15,000 for an individual  $26,000 for a family of three  Coverage would be contracted through Florida Healthy Kids, a state plan that now provides subsidized private coverage for about 250,000 low-income children.  Would have to offer "benchmark" benefits, including preventive care such as;  Yearly physicals  Emergency care  Maternity care  Mental health  Substance abuse treatment  It would not include preventive dental care

30. Affordable Care Act Implementation SB 7144 by Health Policy Relating to Health Care (aka “The Bean Alternative) This “Health Choice Plus” bill would expand Florida Healthy Choices, would not draw down federal funds, would subsidize premiums, and would apply to individuals up to 100% FPL. http://www.flsenate.gov/Session/Bill/2013/7144/BillText/Filed/PDF

31. Health and Human Services Budget Appropriations Bills Released ADAP: Total funding is identical in both the House and Senate bills. The proposal to roll $10 million achieved from drug rebates into the program is spending authority. AICP: Increase of $3.6 million in both the House and Senate bills.

32. Questions? Thank You Michael Ruppal MRuppal@theaidsinstitute.org