HIV/AIDS Care in a Changing Healthcare Landscape Medicaid Expansion Medicaid Expansion: The Basics The Patient Protection and Affordable Care Act (ACA) provides for an unprecedented expansion of Medicaid. In 2014, 8 million people will become eligible for Medicaid, and by 2016, the program could cover as many as 11 million people currently without insurance.1 What is happening, and when? Currently, Medicaid eligibility is based on population categories. Children, pregnant women, parents with dependent children, people with disabilities, and low-income seniors may qualify for Medicaid benefits, depending on their income.2 Nondisabled adults without children, however, are ineligible for Medicaid, regardless of income (although some states provide some coverage via federal waivers).3 Beginning January 1, 2014, Medicaid eligibility will be based solely on income in states that are expanding Medicaid. US citizens and legal immigrants with incomes of 138% of the Federal Poverty Level (FPL) or less (about $15,000 per year4) will qualify for Medicaid benefits,2,5 and in some states, income thresholds may be higher than 138% FPL.2 Young, childless, low-income men — who make up a sizeable portion of the HIV/AIDS population — will now qualify for Medicaid benefits. Who is entering the Medicaid program? To develop strategies for caring for this patient population, it is important to understand the demographics of Medicaid expansion. Who is coming in?6 Median age: 31 Median income: 65% FPL Education level: 89% do not have a college degree 2 Patients with advanced disease or multiple comorbidities Experience with previous Medicaid expansions suggests that these patients’ initial demand for healthcare services will be high,6,7 owing to their previous lack of access to care. Moreover, because of socioeconomic status, the Medicaid population can be expected to have higher levels of physical and behavioral comorbidities.6 Why is this important? Because many HIV/AIDS patients are currently ineligible for Medicaid8 and are considered uninsurable in the private market,9 a sizeable number of patients rely on a patchwork of safety net programs to obtain care. Such services, including Ryan White programs and the AIDS Drug Assistance Program (ADAP), however, are narrowly focused and are not designed to treat a patient’s total medical and behavioral health needs. Nor are these programs insurance mechanisms that can provide access to comprehensive healthcare services. Studies of previous Medicaid expansions in selected states have documented improvements in access and health status.7,10 Shortly after the passage of the ACA, the federal government released a comprehensive national HIV/AIDS strategy for reducing new infections and improving access to care. The strategy relies on the ACA’s expansion of coverage as a means for achieving its goals.8 Uninsured Eligible for Medicaid 3 The Complexities of Medicaid Expansion Medicaid expansion presents an opportunity to provide more comprehensive care for people with HIV/AIDS. It also creates considerations for physicians who care for this population. Shift in how HIV/AIDS patients get care Medicaid expansion does not necessarily mean that many more people with HIV/AIDS will enter the healthcare system. Most people with HIV/AIDS who will gain Medicaid eligibility now receive some sort of care through Ryan White clinics. Thus, Medicaid expansion offers people with HIV/AIDS the potential for improvements in their care through access to medical and pharmacy benefits. Nationally, almost 6 in 10 people who are HIV-positive, uninsured, and who get services through ADAP may qualify for Medicaid.5 In some areas, the proportion may be even higher. Percentage of ADAP clients newly eligible for Medicaid5,a Colorado 62% Illinois 62% Texas 65% Florida 65% Virginia 71% Tennessee 78% North Carolina 80% 100% Puerto Rico a Not all of the localities shown have agreed to participate in Medicaid expansion. Transitioning patients to Medicaid Most people who become eligible for Medicaid will have to choose a primary care provider who accepts Medicaid patients. Potential gaps in care that may occur when patients change providers include8: • Risk of poor or no transition-of-care planning • Providers without specific HIV/AIDS expertise • Possible change in treatment regimens • Potential to drop out of care entirely 4 Medicaid expansion affects where people with HIV/AIDS will get their care and what their benefits will be. Challenges to Medicaid expansion A 2012 Supreme Court ruling on the constitutionality of the ACA denied the federal government the authority to enforce Medicaid expansion.8 As a result, several states signaled their intention to not expand their Medicaid programs.11 This situation is in flux, and some states that initially declared an intention to not expand Medicaid may yet do so, now or after January 1, 2014 — or may choose to not expand at all.12 Implications of not expanding In states where Medicaid does not expand, the safety net system may face new challenges.8 Medicaid expansion has the potential to move patients out of ADAP, easing pressure on a program that is chronically underfunded and has a history of instituting waiting lists and caps on assistance.13 There is also a risk that, in these states, a substantial number of people may remain uninsured because of their inability to afford commercial coverage. Some 45% of ADAP clients who might otherwise qualify for Medicaid have incomes below FPL.5 The ACA provides subsidies for low-income individuals who purchase coverage through the health insurance marketplaces. However, the architects of healthcare reform did not envision that Medicaid might not expand in every state, so these subsidies were not extended to people below FPL.14 • • • • 5 Case Studies in Medicaid Expansion Massachusetts The healthcare reforms in Massachusetts, on which much of the ACA was modeled, enabled coverage for low-income individuals — through either expansion of Medicaid or a subsidized private insurance program (Commonwealth Care) — to cover low-income residents ineligible for Medicaid.15 Among people with HIV/AIDS today, visits to healthcare providers and antiretroviral treatment use are more than double the national averages.16,17 Expansion allowed Ryan White programs to be used to provide co-payment and premium assistance for people in subsidized programs and to address gaps in support services.15 California After the adoption of the ACA, California moved to expand Medi-Cal (the state’s Medicaid program) to 500,000 new individuals, including people with HIV/AIDS.18 The efforts to expand Medicaid, however, created several challenges. California’s Medi-Cal expansion also exposed planning and coordination challenges for people with HIV/AIDS and Ryan White providers. A stakeholder advisory committee was formed to advise the Department of Health Care Services on program development. The state failed to include HIV/AIDS care expertise or to coordinate between Medi-Cal services and the California State Office of AIDS.18 At the federal level, the Centers for Medicare and Medicaid Services did not engage the Health Resources and Services Agency in the waiver review.18 The lack of understanding of the role of Ryan White programs in providing services to people with HIV/AIDS and the “payer of last resort” requirements resulted in counties not planning to cover people with HIV/AIDS under the new Low Income Health Programs.18 The oversight was discovered approximately 2 months prior to implementation in the first counties. Counties engaged in up to a year-long planning process and other strategies (such as lowering income eligibility in their programs) in order to be able to serve people with HIV/AIDS in their expansion programs. 6 Practice Considerations In states where Medicaid will expand in 2014, many people with HIV/AIDS may gain access to a basic level of comprehensive care previously unavailable to them. In states where expansion is delayed or does not occur, however, safety net programs may continue to be their only real source for treatment. Both scenarios have implications for your practice. Depending on events in your state, consider the following: Patients’ socioeconomic status may play a role in their health status. This can be an opportunity to improve a patient’s care — or it can create difficulties in managing patients’ complex health needs. Patients who become eligible for Medicaid will have to choose a primary care provider who accepts Medicaid. Under Medicaid expansion, formulary options could change depending on a Medicaid agency’s benefit structure and formulary.8 Should you let patients know if they are eligible for Medicaid expansion? Most people don’t know whether their state is expanding Medicaid19 — and among those who would qualify for Medicaid benefits, the vast majority are unaware of it.20 Lack of patient familiarity with the system affects your office staff. Millions of new patients entering the healthcare system won’t have had experience using a managed care plan — and may not know what their benefits are, how to use them, or how to find a doctor.21 What will happen to your patients if your state doesn’t expand Medicaid? How could this affect your practice? Let your Janssen Therapeutics Account Manager be an information resource for you on how Medicaid expansion may impact access and care for people with HIV/AIDS. 7 References 1. Congressional Budget Office. The Budget and Economic Outlook. February 5, 2013. 2. Centers for Medicare and Medicaid Services. Medicaid.gov. Eligibility. http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Eligibility/Eligibility.html. Accessed May 23, 2013. 3. Centers for Medicare and Medicaid Services. Medicaid.gov. Non-disabled adults. http://www.medicaid.gov/MedicaidCHIP-Program-Information/By-Population/By-Population.html. Accessed May 23, 2013. 4. Centers for Medicare and Medicaid Services. 2013 Poverty Guidelines. http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Eligibility/Downloads/2013-Federal-Poverty-level-charts.pdf. Accessed May 23, 2013. 5. National Alliance of State and Territorial AIDS Directors. National ADAP Monitoring Project Annual Report, Module One. January 2013. 6. PriceWaterhouseCoopers. Medicaid Expansion: New Patients, New Challenges. October 2012. 7. Sommers BD, Baiker K, Epstein AM. Mortality and access to care among adults after state Medicaid Expansions. N Engl J Med. 2012;367:1025–1034. 8. Crowley JS, Kates J. The Affordable Care Act, the Supreme Court, and HIV. What Are the Implications? Kaiser Family Foundation. September 2012. 9. Department of Health and Human Services. At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans. http://aspe.hhs.gov/health/reports/2012/pre-existing/index.pdf. Accessed May 17, 2013. 10. Courtemanche CJ, Zapata D. Does Universal Coverage Improve Health? The Massachusetts Experience. National Bureau of Economic Research. March 2012. 11. The Advisory Board Company. http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap. Accessed May 24, 2013. 12. Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013. http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed July 12, 2013. 13. Kaiser Family Foundation. AIDS Drug Assistance Programs. Fact Sheet. April 2008. 14. Urban Institute Health Policy Center. Opting Out of the Medicaid Expansion Under the ACA: How Many Uninsured Adults Would Not Be Eligible for Medicaid? July 5, 2012. 15. Center for Health Law and Policy Innovation, Harvard Law School. Health Reforms Lead to Improved Individual and Public Health Outcomes and Cost Savings. June 27, 2012. 16. JSI Research and Training Institute. Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study. Final Report, December 2011. 17. Cohen SM, Van Handel MM, Branson BM, et al. Vital signs: HIV prevention through care and treatment — United States. MMWR. 2011;60:1618–1623. 18. Project Inform. Health Care Reform Lessons: CA Lessons Learned. July 18, 2012. http://www.projectinform.org/pdf/ hcr_lessons_ca.pdf. Accessed May 24, 2013. 19. Kaiser Health Tracking Poll. March 2013. http://kff.org/health-reform/poll-finding/march-2013-tracking-poll. Accessed May 22, 2013. 20. Kliff S. Millions will qualify for new options under the health care law. Most have no idea. Washington Post. November 12, 2012. 21. Dalzell MD. Will ‘essential benefits’ break the bank? Manag Care. 2011;20(11):22–28. Distributed by: Janssen Therapeutics, Division of Janssen Products, LP, Titusville, NJ 08560 © Janssen Therapeutics, Division of Janssen Products, LP 2013 07/13 K28JT13042B