Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 53
2
Implications of Health Care Reform for
People with HIV in the United States
Health spending in the United States reached $2.79 trillion (seasonally
adjusted annual rate) in April 2012, approximately 18 percent of the gross
domestic product (GDP) (Center for Sustainable Health Spending, 2012),
up from $2.59 trillion, 17.9 percent of the GDP, in 2010 (CMS, 2012,
Table 1). U.S. health expenditures are the highest among 13 industrialized
nations, whose health expenditures accounted for 12 percent or less of their
GDPs in 2009 (Squires, 2012). Despite much higher spending, health care
quality in the United States is not significantly better than that provided
in less expensive systems (Squires, 2012). Higher health spending in the
United States is likely a result of higher prices and, perhaps, more accessible
technologies and greater levels of obesity (Squires, 2012).
At the same time as U.S. health expenditures continue to soar, 48.6
million people nationally (15.7 percent) lacked health insurance in 2011
(DeNavas-Walt et al., 2012),1 and 29 million adults under 65 years of age
1"For reporting purposes, the U.S. Census Bureau broadly classifies health insurance cover-
age as private coverage or government coverage. Private health insurance is a plan provided
through an employer or a union or purchased by an individual from a private company.
Government health insurance includes such federal programs as Medicare, Medicaid, and
military health care; the Children's Health Insurance Program (CHIP); and individual state
health plans. [Types of insurance are not mutually exclusive; people may be covered by more
than one during the year.] People were considered `insured' if they were covered by any type of
health insurance for part or all of the previous calendar year. They were considered `uninsured'
if, for the entire year, they were not covered by any type of health insurance" (DeNavas-Walt,
2012, p. 21).
53
OCR for page 54
54 MONITORING HIV CARE IN THE UNITED STATES
were underinsured in 2010 (Schoen et al., 2011).2 Although the number
and percent of uninsured decreased between 2010 and 2011, millions of
people in the United States, including approximately one-third of those with
HIV, still lack health insurance (HHS, 2012a). It is against this background
that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148),
as amended by the Health Care and Education Reconciliation Act of 2010
(P.L. 111-152), was signed into law on March 23, 2010. This chapter is
not designed to provide a comprehensive and detailed review of all aspects
of the ACA that have implications for people living with HIV but rather to
highlight the aspects of the ACA that the committee anticipated would be
most pertinent to its task, such as those that are likely to effect changes in
sources of health coverage for that population and to establish the basis for
the selection of data systems that would be most relevant to tracking the
impact of the ACA on health coverage and care for people with HIV (e.g.,
Medicaid, Medicare, Ryan White HIV/AIDS Program, private insurers).
AFFORDABLE CARE ACT
The ACA has the potential to significantly improve access to and qual-
ity of health care for the majority of people living with HIV in the United
States. The law sets out numerous provisions that will be implemented
over time, with major changes occurring in 2014. Most notably, the law
includes both a provision that most citizens and legal residents of the United
States must have qualifying health insurance coverage by 2014 or pay a tax
penalty and a provision for the expansion of Medicaid coverage to most
nonMedicare eligible individuals under age 65 with incomes less that 133
percent of the federal poverty level (FPL) (KFF, 2011a).3 The ACA includes
additional provisions of particular importance to people with HIV, such
as increased access to private health insurance and consumer protections,
establishment of state or regional health insurance exchanges (the legisla-
tion uses the term "health benefit exchange"), gradual elimination of the
Medicare Part D prescription drug coverage gap, and development of an
"essential health benefits package" and improved coverage for preventive
care services.4
2Individuals were identified as underinsured if they had health insurance for the full year but
also had very high medical expenses relative to their income (Schoen et al., 2011). In this study,
"health insurance" referred to private health insurance, Medicaid or some other type of state
medical assistance for low-income people, Medicare, and "health insurance through any other
source, including military or veteran's coverage" (Commonwealth Fund, 2010, Questionnaire).
3A "mandatory income disregard" equal to 5 percent of the FPL will make the "effective
income limit 138 percent of the FPL" (Natoli et al., 2011).
4Other major provisions of the ACA are not discussed here, including the development of
accountable care organizations, increased payments for primary care providers, and expanded
OCR for page 55
IMPLICATIONS OF HEALTH CARE REFORM 55
In response to enactment of the ACA, Florida and 25 other states, the
National Federation of Independent Business, and other interested parties
filed suit challenging the constitutionality of the health insurance coverage
requirement ("individual mandate") and the Medicaid expansion, ques-
tions that were ultimately appealed to the U.S. Supreme Court. The Court
heard oral arguments pertaining to the case in late March 2012 and issued
its ruling upholding the insurance coverage requirement on June 28, 2012,
finding that Congress has the authority to levy a tax on individuals who
choose to forgo such coverage. With respect to the Medicaid expansion
provision, the Court ruled that "Congress is not free ... to penalize States
that choose not to participate in that new program by taking away their
existing Medicaid funding" but that "[n]othing in our opinion precludes
Congress from offering funds under the Affordable Care Act to expand the
availability of health care, and requiring that States accepting such funds
comply with the conditions on their use."5
In practice, the Court ruling makes it optional for the states to adopt
the Medicaid expansion provision. Although some states already have taken
steps to expand Medicaid before 2014 (as permitted by the ACA), other
states, in the wake of the Supreme Court ruling, may choose not to do so
at all. A compilation of statements by lawmakers, press releases, and media
coverage indicates that as of September 12, 2012, 12 states and the District
of Columbia had opted to expand Medicaid and 6 states had elected not to
do so (Daily Briefing, 2012).
The six states identified as not participating in Medicaid expansion
under the ACA had uninsurance rates above the national average of 44
percent for adults 19 to 64 years of age with incomes less than 139 per-
cent of the FPL in 2010 (KFF, 2012e). One of the concerns raised by the
variation in state adoption of Medicaid expansion is the potential lack of
health coverage options for individuals who remain ineligible for Medicaid
in states that opt out of Medicaid expansion but who have incomes below
the level of eligibility for federal subsidies to purchase insurance coverage
through the state exchanges (KFF, 2012a).
Despite the uncertainty surrounding what states ultimately might do,
a number of the ACA's provisions are expected to improve access to health
care coverage not only for people living with HIV, but also for individuals
living with other chronic medical conditions, such as diabetes, hyperten-
sion, rheumatoid arthritis, and the like. Several of these provisions have
service capacity at community health centers, including federally qualified health centers,
which are an important source of care for people living with HIV who are less able to access
traditional sources of medical care.
5National Federation of Independent Business v. Sebelius, 567 U.S. ___ (2012), 55, slip
opinion.
OCR for page 56
56 MONITORING HIV CARE IN THE UNITED STATES
been implemented already, and others are slated for implementation in
2014.6
HEALTH REFORM AND PEOPLE WITH HIV
Among people with HIV in the United States, almost 30 percent have
no health care coverage and only 17 percent have private insurance: the
remaining 53 percent are covered by government programs such as Medic-
aid, Medicare, and the Ryan White HIV/AIDS Program (HHS, 2012a). As
the ACA is implemented, most people with HIV in the United States will
move into or shift between sources of care coverage. Figures 2-1, 2-2, and
2-3 depict the pathways to care coverage for people with HIV before, dur-
ing, and following implementation of the ACA. As shown in Figure 2-2, as
of 2010, the ACA gave states the option to expand Medicaid coverage to
low-income adults up to 133 percent of the FPL regardless of disability or
other status, which some states have done. In addition, individuals without
access to employer-based coverage or who cannot purchase insurance in the
individual market and are not eligible for Medicaid or Medicare can now
purchase insurance through Preexisting Condition Insurance Plans (PCIPs)
created under the ACA. PCIPs are high-risk pools operated by states or
the federal government to provide insurance for individuals who are U.S.
citizens or reside legally in the United States, have a preexisting condition,
and have been without health coverage for at least 6 months.7 As depicted
in Figure 2-3, beginning in 2014, low-income adults up to133 percent of the
FPL become a new Medicaid-eligible group, although the Supreme Court
has limited the authority of the federal government to enforce this provi-
sion, and therefore, eligibility for Medicaid coverage is likely to vary across
states. Individuals without access to employer-based coverage who are not
eligible for Medicaid or Medicare but are eligible for tax credits to purchase
insurance and/or can afford to pay for health insurance may do so through
state health insurance exchanges established to facilitate the purchasing of
health insurance by qualified individuals and employers. As it did prior to
the enactment of the ACA, the Ryan White HIV/AIDS Program continues
to serve as a payer of last resort for people with HIV who are under- or
uninsured. Federal funding is provided to states, cities, and providers but
does not always match the number of people who need services or the cost
of their care.
6Some provisions of the ACA apply to all health care plans, others (e.g., coverage for preven-
tive care without cost sharing) do not apply or apply differently for grandfathered plans (i.e.,
those in which an individual was enrolled on March 23, 2010, the date the ACA was enacted).
7These criteria apply to people living in states served by the federally run PCIP (HHS,
2012b). State-run PCIPs have their own eligibility criteria.
OCR for page 57
IMPLICATIONS OF HEALTH CARE REFORM 57
FIGURE 2-1 Pathways to coverage for people with HIV: Prior to the ACA, before
2010.
aMedicaid eligibility (state-based): low-income and categorically eligible (dis-
abled, pregnant women, children, medically needy); states may seek waivers to
cover other groups (such as nondisabled, childless adults); must be a U.S. citizen
or legal resident for at least 5 years. For current state eligibility requirements, see
Kaiser Family Foundation (KFF), State Health Facts, Medicaid Income Eligibility
Limits for Adults as a Percent of Federal Poverty Level, http://statehealthfacts.org/
comparereport.jsp?rep=130&cat=4. For more information on Medicaid, see KFF,
Medicaid: A Primer, http://www.kff.org/medicaid/7334.cfm.
bMedicare eligibility (national): 65, disabled (Social Security Disability Insurance
[SSDI]) or end-stage renal disease; must be a U.S. citizen or legal resident for at least
5 years. For more information on Medicare, see KFF, Medicare: A Primer, http://
www.kff.org/medicare/7615.cfm.
cState high-risk insurance pools: Prior to the ACA, health plans were permitted to
deny coverage to individuals with pre-existing conditions or to charge them higher
OCR for page 58
58 MONITORING HIV CARE IN THE UNITED STATES
premiums. Because of this, several states operate high-risk insurance pools, which
provide health insurance to residents who are considered medically uninsurable and
are unable to buy coverage in the individual market. See KFF, State Health Facts,
State High Risk Pool Programs and Enrollment, http://www.statehealthfacts.org/
comparetable.jsp?ind=602&cat=7.
dRyan White: The Ryan White HIV/AIDS Program, the single largest federal pro-
gram designed specifically for people with HIV in the United States, provides care
and services for people with HIV who are uninsured or underinsured, serving as
payer of last resort. It includes the AIDS Drug Assistance Program (ADAP). Federal
funding is provided to states, cities, and providers but may not match the number of
people who need services or the cost of their care. For more information, see KFF,
The Ryan White Program, http://www.kff.org/hivaids/7582.cfm.
SOURCE: Adapted from KFF, 2012b.
FIGURE 2-2 Pathways to coverage for people with HIV: ACA transition period,
2010-2013.
OCR for page 59
IMPLICATIONS OF HEALTH CARE REFORM 59
NOTE: The ACA provides new dependent coverage for children up to age 26 for all
individual group policies. In addition, insurers are prohibited from denying coverage
to children with preexisting conditions.
aMedicaid Eligibility (state-based): low-income and categorically eligible (dis-
abled, pregnant women, children, medically needy); states may seek waivers to cover
other groups (such as non-disabled, childless adults); must be a U.S. citizen or a legal
resident for at least 5 years. As of 2010, the ACA gave states the option to expand
coverage to low-income individuals up to 133 percent of the federal poverty level
(FPL), regardless of disability or other status (which some states have done). For
current state eligibility requirements and information on which states have moved
to expand Medicaid as permitted by the ACA, see, Kaiser Family Foundation, State
Health Facts, Medicaid Income Eligibility Limits for Adults as a Percent of Federal
Poverty Level, http://statehealthfacts.org/comparereport.jsp?rep=130&cat=4. For
more information on Medicaid, see, Kaiser Family Foundation, Medicaid: A Primer,
http://www.kff.org/medicaid/7334.cfm.
bMedicare Eligibility (national): 65, disabled (SSDI), or end stage renal disease;
must be a U.S. citizen or a legal resident for at least 5 years. Medicare beneficiaries
are getting discounts on drugs while in the Medicare coverage gap and preventive
services are covered without cost sharing. For more information on Medicare, see,
Kaiser Family Foundation, Medicare: A Primer, http://www.kff.org/medicare/7615.
cfm.
cState High-Risk Insurance Pools: Prior to the ACA, health plans were permit-
ted to deny coverage to individuals with pre-existing conditions or to charge them
higher premiums. Because of this, several states operate state high risk pools which
provide health insurance to residents who are considered medically uninsurable and
are unable to buy coverage in the individual market. See Kaiser Family Foundation,
State Health Facts, State High Risk Pool Programs and Enrollment, http://www.
statehealthfacts.org/comparetable.jsp?ind=602&cat=7. In addition, the ACA cre-
ated the temporary PCIP program in 2010 (see below).
dPre-Existing Condition Insurance Plan (PCIP): Created by the ACA, PCIP is a
temporary program that runs from 2010-2014 to provide health coverage to indi-
viduals with pre-existing medical conditions who have been uninsured for at least
six months. The plan will be operated by the states or the federal government. For
more information on the current status of PCIPs, see, Kaiser Family Foundation,
State Health Facts, Pre-Existing Condition Insurance Plan: Operation Decisions
and Preliminary Funding Allocations, http://www.statehealthfacts.org/compare
mapreport.jsp?rep=67&cat=17.
eRyan White: The Ryan White HIV/AIDS Program, the single largest federal
program designed specifically for people with HIV in the United States, provides
care and services for people with HIV who are uninsured or underinsured, serv-
ing as payer of last resort. It includes the AIDS Drug Assistance Program (ADAP).
Federal funding is provided to states, cities and providers but may not match the
number of people who need services or the cost of their care. For more informa-
tion, see, Kaiser Family Foundation, The Ryan White Program, http://www.kff.org/
hivaids/7582.cfm.
SOURCE: Adapted from KFF, 2012b.
OCR for page 60
60 MONITORING HIV CARE IN THE UNITED STATES
FIGURE 2-3 Pathways to coverage for people with HIV: Full implementation of the
ACA, 2014 and beyond.
NOTE: The ACA provides new dependent coverage for children up to age 26 for all
individual and group policies. Also, as of 2014, the ACA prohibits health plans from
being able to deny coverage to people with pre-existing health conditions. Individu-
als with pre-existing conditions will be able to obtain insurance in the exchange or
non-group market (the temporary PCIP program will no longer be needed).
aMedicaid eligibility (state-based): low-income and categorically eligible (dis-
abled, pregnant women, children, Figure 2-3 replaced
medically needy); states may seek waivers to
cover other groups (such as nondisabled,bitmapped
childless adults); must be a U.S. citizen or
legal resident for at least 5 years. Under the ACA, as of 2014, low-income adults up
to 133 percent of the FPL become a new Medicaid-eligibility group. The Supreme
Court has limited the authority of the federal government to enforce this provi-
sion, making it uncertain whether all states will comply. For current state eligibility
requirements and information on which states have moved to expand Medicaid as
permitted by the ACA, see KFF, State Health Facts, Medicaid Income Eligibility
OCR for page 61
IMPLICATIONS OF HEALTH CARE REFORM 61
Limits for Adults as a Percent of Federal Poverty Level, http://statehealthfacts.org/
comparereport.jsp?rep=130&cat=4. For more information on Medicaid, see KFF,
Medicaid: A Primer, http://www.kff.org/medicaid/7334.cfm.
bMedicare eligibility (national): 65, disabled (SSDI) or end-stage renal disease;
must be a U.S. citizen or legal resident for at least 5 years. For more information
on Medicare, see KFF, Medicare: A Primer, http://www.kff.org/medicare/7615.cfm.
cHealth insurance exchange: A key component of the ACA, exchanges are entities
that will be set up in states to facilitate the purchasing of health insurance by quali-
fied individuals and employers. All legal, non-incarcerated residents are eligible to
purchase insurance through the exchanges. Additionally, all legal, non-incarcerated
residents are eligible for subsidies, in the form of tax credits, if they do not have
access to employer-sponsored insurance, Medicaid, or Medicare, and their incomes
are between 100 and 400 percent of the FPL. In addition, if an employer plan does
not cover at least 60 percent of average health expenses or the employee must pay
more than 9.5 percent of his/her income for the premium, individuals, depend-
ing on income, may be eligible for a tax credit to offset premiums for coverage
purchased through an exchange. Exchanges are required to be fully operational
in every state by 2014. See KFF, State Health Facts, State Action Toward Creating
Health Insurance Exchanges, http://www.statehealthfacts.org/comparemaptable.
jsp?ind=962&cat=17.
dRyan White: The Ryan White HIV/AIDS Program, the single largest federal pro-
gram designed specifically for people with HIV in the United States, provides care
and services for people with HIV who are uninsured or underinsured, serving as
payer of last resort. It includes ADAP. Federal funding is provided to states, cities,
and providers but may not match the number of people who need services or the
cost of their care. For more information, see KFF, The Ryan White Program, http://
www.kff.org/hivaids/7582.cfm.
SOURCE: Adapted from KFF, 2012b.
The provisions of the ACA discussed in the following sections are likely
to have the greatest impact on care and care coverage for people with HIV.
Pre-Existing Conditions, Rescission, and Limits on Coverage
Currently, children with pre-existing medical conditions (e.g., HIV/
AIDS, diabetes) no longer can be denied health care insurance coverage
(Keith et al., 2012; KFF, 2011a).8 Beginning in 2014, insurers also will no
longer be able to deny coverage to or charge higher premiums for adults
8In addition, coverage must now be extended for dependent children on parental policies up
to age 26 (Keith et al., 2012; KFF, 2011a). Since young adults, ages 20 to 29, have the highest
rates of new HIV diagnoses among all age groups in the United States (CDC, 2012, Table
1a), extension of coverage for older dependent children is a potentially important source of
coverage for HIV care for this population.
OCR for page 62
62 MONITORING HIV CARE IN THE UNITED STATES
with pre-existing conditions. In the interim, adults with pre-existing con-
ditions who have been without health coverage for at least 6 months are
eligible to purchase coverage through federal or state-run, high-risk PCIPs
(Figure 2-2; KFF, 2011a). In addition, insurance providers no longer can
rescind coverage due to health status, except in cases of fraud or intentional
misrepresentation (Keith et al., 2012; KFF, 2011a). The ACA also prohib-
its the imposition of lifetime dollar limits on coverage for essential health
benefits and restricts and phases out annual dollar limits on coverage for
essential health benefits, unless waived by the Department of Health and
Human Services (HHS).9 Waivers for annual dollar limits on coverage will
be discontinued in 2014, eliminating annual dollar limits on coverage for all
plans in small- and large-group markets (Keith et al., 2012).
Medicaid Expansion
Medicaid currently is the largest single source of health care coverage
for people living with HIV, providing coverage for 47 percent of HIV-
infected individuals estimated to be receiving regular medical care (Kates,
2011, p. 1). In fiscal year 2007, 212,892 Medicaid beneficiaries were HIV-
positive (Kates, 2011, p. 1). In states that choose to expand their Medicaid
program as allowed under the ACA, Medicaid eligibility will be extended to
most "non-Medicare eligible individuals under age 65 (children, pregnant
women, parents, and adults without dependent children)" with incomes
up to 133 percent of the FPL (Figure 2-3; KFF, 2011a).10 Currently, most
Medicaid beneficiaries with HIV (74 percent) qualify through the disability
pathway, meaning their disease is sufficiently advanced to preclude them
from working (Kates, 2011, p. 4). With Medicaid expansion, as passed
by law under the ACA, low-income individuals who have HIV, including
those without dependent children ("childless adults"), will be eligible for
Medicaid before their disease becomes disabling. For those who become
newly eligible for Medicaid, the federal government will assume 100 per-
cent of Medicaid costs during 2014-2016, phased down to a minimum of
90 percent thereafter.
Where Medicaid is expanded, particularly if coupled with more effective
enrollment of currently eligible individuals, it is expected that there could
be as many as 11.6 million new people entered into the Medicaid system
in 2014 and 20 million by 2019, representing 21 and 34 percent increases,
respectively, over pre-ACA projections (CMS, 2010). It is anticipated that
the majority of individuals with HIV who currently receive clinical or related
9A discussion of "essential health benefits" is included later in the chapter.
10Recent (less than 5 years in the United States) and undocumented immigrants will remain
ineligible for Medicaid.
OCR for page 63
IMPLICATIONS OF HEALTH CARE REFORM 63
supportive service care and prescription drug assistance through the Ryan
White HIV/AIDS Program (>500,000) will become eligible for Medicaid in
2014 (KFF, 2011b; NASTAD, 2012b; Project Inform, 2012). The implica-
tions of this coverage shift are discussed later in this chapter.
Health Insurance Exchanges
The ACA also mandates the establishment of state or regional health
insurance exchanges by January 2014 (Figure 2-3). The exchanges are
meant to provide a marketplace in which eligible individuals and small busi-
nesses (less than 100 employees) can easily obtain and compare informa-
tion on different health insurance options and purchase insurance coverage
(KFF, 2011a). Individuals and families with incomes between 100 and 400
percent of the FPL will be eligible for federal subsidies to help cover insur-
ance premiums and out-of-pocket health care costs (KFF, 2011a).
Medicare Part D Drug Coverage Gap
Medicare Part D prescription drug plans currently contain a coverage
gap ("donut hole") that can impose significant financial burdens on enroll-
ees. Prior to the enactment of the ACA, Medicare Part D beneficiaries were
required to pay the full cost of their prescription drugs while in the cover-
age gap between the time they and their drug plans spent a specified dollar
amount on covered drugs and the time beneficiaries' "true out-of-pocket"
(TrOOP) costs reached the threshold catastrophic coverage. Of importance
specifically for people with HIV, AIDS Drug Assistance Program (ADAP)
benefits now count toward Medicare Part D recipients' TrOOP costs for
medications, allowing them to move through the coverage gap more quickly.
Additional ACA provisions will ease the burden of out-of-pocket drug costs
for all individuals in the donut hole. Currently, pharmaceutical manufactur-
ers are required to provide a 50 percent discount on prescriptions of brand
name medications filled in the gap, and the beneficiary coinsurance rate will
be reduced from 100 percent to 25 percent by 2020 (KFF, 2011a).
Essential Health Benefits Package and Preventive Care
The ACA charges HHS with establishing an "essential health benefits
package" within specified parameters whose scope "is equal to the scope
of benefits provided under a typical employer plan, as determined by the
[HHS] Secretary" (P.L. 111-148, Sec. 1302 [42 U.S.C. 18022]). At a mini-
mum, the essential health benefits package must include items and services
in 10 areas of care: ambulatory patient services; emergency services; hos-
pitalization; maternity and newborn care; mental health and substance use
OCR for page 64
64 MONITORING HIV CARE IN THE UNITED STATES
disorder services, including behavioral health treatment; prescription drugs;
rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pe-
diatric services, including oral and vision care (P.L. 111-148, Sec. 1302 [42
U.S.C. 18022]). HHS decided to allow each state the flexibility to select a
plan from several options to serve as the benchmark for the essential health
benefits package in that state.11 Services covered by the benchmark plan in
each of the 10 mandated areas become the essential benefits for plans in
that state (Cassidy, 2012).
Health plans within and outside of the health insurance exchanges,
except grandfathered plans, must provide, at a minimum, coverage for the
essential benefits package of at least 60 percent of the actuarial value of the
covered benefits, with limits on annual cost sharing (KFF, 2011a). Medic-
aid programs within states that implement the expansion provision of the
ACA also must provide benefits comparable to those in the essential health
benefits package to newly eligible adults (KFF, 2011a).
As of 2010, the ACA improves preventive care coverage by eliminating
cost sharing within Medicare for preventive services recommended by the
U.S. Preventive Services Task Force (USPSTF) (i.e., services rated A or B)
and requiring health plans to provide the same services without cost shar-
ing, as well as recommended immunizations, pediatric and adolescent pre-
ventive care, and preventive care and screenings for women (KFF, 2011a).
The ACA also offers incentives to states in which Medicaid covers USPTF
A- and B-rated services and recommended immunizations without cost
sharing (KFF, 2011a).
STATE IMPLEMENTATION
Although the ACA establishes federal mandates and standards re-
garding health insurance, states are among those entities responsible for
implementing some of the most significant changes, such as establishment
of state health insurance exchanges and whether to accept the Medicaid
expansion provision.12 Box 2-1 lists some of areas in which state variation
in implementation of the ACA is anticipated.
11States may choose as their benchmark "one of the three largest small group plans in the
state by enrollment, one of the three largest state employee health plans by enrollment, one
of the three largest federal employee health plan options by enrollment, or the largest health
maintenance organization (HMO) plan offered in the state's commercial market by enroll-
ment" (Cassidy, 2012).
12Most of the consumer protection and insurance reform provisions of the ACA apply to
the U.S. territories as well as states and the District of Columbia, although there are some dif-
ferences (NASTAD, 2012a). People residing in the territories are exempt from the individual
mandate, and the territories are not required to establish health insurance exchanges, although
OCR for page 65
IMPLICATIONS OF HEALTH CARE REFORM 65
BOX 2-1
Possible Variation in Patient Protection and Affordable
Care Act Implementation Across States
· Expansion of Medicaid to childless adults up to 133 percent FPLa
· Specific services included in "essential benefits" packages
· Restrictions on Medicaid-covered servicesb
· Federal versus state oversight of pre-existing conditions insurance plans
· Federal versus state oversight of health benefits exchanges
· Mechanisms (e.g., websites) to facilitate client enrollment into public
and private insurance
· Inclusion of pilot programsc
1. Regionalized Systems for Emergency Care Pilots: Sec. 3504
2. Healthy Aging, Living Well Pilot Program: Sec. 4202
3. Environmental Health Hazards Primary Pilot Program: Sec. 10323
4. National Pilot Program on Payment Bundling: Sec. 3023
aEligibility requirements currently vary widely from state to state and likely will continue to
do so. Some states have programs with FPL cutoffs higher than 133 percent, and others will
continue to have less generous eligible criteria.
bThis already occurs, such as limits on the number of prescriptions per month, or pre
authorization for specific medications.
cThe implementation of pilot programs is not subject to state choice.
Some states are in a better starting position than others to implement
the ACA. Massachusetts, for example, enacted health reform legislation in
2006 that is similar to the ACA, including an individual mandate, Med-
icaid expansions, subsidized private insurance coverage, and a purchasing
pool (Long and Masi, 2009). Vermont enacted single-payer health care
legislation in 2011. Although the Vermont system, when implemented,
may provide benefits equivalent to or better than those provided under the
ACA, the state has also established a health insurance exchange to fulfill
the ACA mandate until it can apply for a waiver once the single-payer sys-
tem is implemented (Hsiao et al., 2011; KFF, 2012d, Vermont). New York
State already has in place a number of the protections for health insurance
tablish an insurance exchange will receive additional funding for their Medicaid programs.
Medicaid programs in the territories operate under broad federal guidelines but with different
funding and coverage requirements. The ACA does increase the amount of federal Medicaid
cap in these areas, resulting in more federal money for their Medicaid programs. Among the
U.S. territories and dependent areas, health reform in Puerto Rico and the U.S. Virgin Islands
will have the greatest effect on people living with HIV due to the high prevalence of HIV in
those areas.
OCR for page 66
66 MONITORING HIV CARE IN THE UNITED STATES
consumers included in the ACA (NYS, 2012), such as guaranteed issue. In
1974, Hawaii became the first state to create a near universal health care
system, requiring most employers to provide health care coverage to eligible
employees and setting minimum standards for the coverage benefits (State
of Hawaii, 2012).
States have used waivers to extend Medicaid benefits to at least some
portion of their "childless adult" population (MACPAC, 2012, pp. 108-
110, Table 10). In addition, states have different income thresholds for
eligibility, ranging from well below 100 percent of the FPL to well above
133 percent of the FPL, although in some cases the benefits covered may be
more limited than those provided under the regular state plan (KFF, 2012f).
Among the states that choose to implement the Medicaid expansion provi-
sion of the ACA, those that already have more generous Medicaid eligibility
requirements may experience fewer changes in their programs than those
that have not. State Medicaid programs also vary in the scope of their ben-
efits. For example, some states limit the number of prescriptions covered
per month or require preauthorization for certain medications.
States also are at different stages regarding implementation of their
health insurance exchanges. Table 2-1 summarizes state action on establish-
ing exchanges as of November 19, 2012. At that time, seventeen states and
the District of Columbia had established exchanges; six states had decided
to pursue the establishment of a federalstate partnership exchange; and
sixteen states had defaulted to a federal exchange (KFF, 2012c). Eleven
states were still undecided (KFF, 2012c).13
OPPORTUNITIES, CHALLENGES, AND LIMITATIONS
The ACA offers great opportunities for significant expansion of access
to health care, improved health outcomes, and emphasis on preventive
care for millions of Americans including most of the almost 30 percent of
people living with HIV who currently lack any form of health care coverage
(CMS, 2010; HHS, 2012a). States such as Massachusetts and Vermont have
enacted sweeping health reform initiatives independent of the ACA, and
many other states have taken various actions to increase access to health
care. Despite their promise to increase access to health care and improve
the health of people living with HIV, health reform efforts under the ACA
also raise numerous challenges.
Economic sustainability is one challenge of health reform efforts that
include expanded access, guaranteed coverage, and the removal of dollar
limits on benefits. The requirement that most individuals be insured or pay
13Detailed health exchange profiles for each state are available at http://healthreform.kff.
org/State-Exchange-Profiles-Page.aspx (accessed June 26, 2012).
OCR for page 67
TABLE 2-1 State Action Toward Creating Health Insurance Exchanges, November 19, 2012
Declared State-Based Planning for Default to
Exchange (17 + DC) Partnership Exchange (6) Federal Exchange (16) Undecided (11)
California, Colorado, Arkansas, Delaware, Illinois, Alabama, Alaska, Georgia, Arizona, Florida,b Idaho,
Connecticut, Hawaii, Michigan, North Carolina, Kansas, Louisiana, Maine, Indiana, Montana, New
Iowa, Kentucky, Maryland, Ohio Missouri, Nebraska, New Jersey, Pennsylvania,
Massachusetts,a Minnesota, Hampshire, North Dakota, Tennessee, Utah,a Virginia,
Mississippi, Nevada, New Oklahoma, South Carolina, West Virginia
Mexico, New York, Oregon, South Dakota, Texas,
Rhode Island, Vermont, Wisconsin, Wyoming
Washington
District of Columbia
aPassed laws prior to the enactment of the ACA in March 2010, but not yet decided on implementing an ACA-compliant exchange.
bAlthough not compliant with the ACA, Florida is proceeding with plans that predate passage of the ACA to establish an insurance marketplace
for small businesses (KFF, 2012d, Florida).
SOURCE: KFF, 2012c.
67
OCR for page 68
68 MONITORING HIV CARE IN THE UNITED STATES
a tax is designed to bring young and healthy individuals into the insur-
ance pools, which will help to offset the increased costs associated with
expanded access and increased benefits. To be economically sustainable,
sufficient numbers of such "low-risk" individuals will have to enter the
insurance pools or the tax levied on those who fail to do so will have to be
sufficient to offset the additional cost burden.
Another challenge raised by health care reform is that increased access
to health care coverage under the ACA will facilitate but not ensure link-
age to, retention in, and provision of quality clinical HIV care for people
living with HIV. Although the number of uninsured HIV-infected individu-
als will decrease, people near the eligibility borders may be expected to
"churn" (i.e., move back and forth) between different sources of coverage,
which may affect the continuity of their care and the package of benefits
for which they are eligible at any given time. Such movement may be
especially pronounced between Medicaid and state insurance exchanges,
affecting individuals at 125 to 135 percent of the FPL. Ensuring continuity
of clinical HIV care and supportive services throughout movement across
sources of coverage is important for improving individual health outcomes
and reducing the risk of transmitting the virus to others. Maintaining for-
merly incarcerated individuals in clinical HIV care as they transition from
the prison health care system to mainstream sources of health coverage is
similarly important.
Movement of individuals from the Ryan White HIV/AIDS Program
(as their primary source of coverage for HIV care) into Medicaid or other
sources of coverage may affect the scope of services they receive. Given
the significant interstate variation in Medicaid benefits, for example, some
Ryan White HIV/AIDS Program clients might experience a reduction in
services under Medicaid. In addition, the Ryan White HIV/AIDS Program
covers many nonclinical services, such as food and nutrition, transporta-
tion, child care, and case management services, that are important to the
success of clinical HIV care. To the extent that individuals no longer receive
such supportive services when they move to other sources of coverage, their
clinical service utilization and health outcomes may be negatively affected.
In addition to concerns about individuals maintaining access to con-
tinuous, high-quality clinical HIV care and supportive services, some people
living with HIV in the United States, such as recent and undocumented
immigrants, will remain ineligible for health coverage under the ACA and
will continue to face challenges in accessing needed health care services.
Another challenge pertains to the availability of sufficient health care
services to meet the anticipated increase in demand. The influx of new
patients into the health care system, especially individuals with chronic
diseases such as HIV who were previously unable to obtain coverage, can
be expected to place additional burdens on an already strained system. A
OCR for page 69
IMPLICATIONS OF HEALTH CARE REFORM 69
2011 Institute of Medicine report assessing the capacity of the U.S. health
care system to accommodate increased HIV testing and provision of care
found that the HIV health care "workforce is decreasing relative to the
number of individuals expected to require care" (IOM, 2011, p. 39). The
number of HIV-infected individuals needing care will continue to grow with
ongoing new infections; increases in HIV testing, diagnosis, and linkage to
care; increased survival; and increased access to care as a result of health re-
form efforts. At the same time, many professionals engaged in HIV care are
nearing retirement, and insufficient numbers of new practitioners proficient
in HIV care are entering the workforce to accommodate the growing need
(HRSA, 2010; IOM, 2011). Fiscal constraints are further decreasing the
system's capacity to provide care for more people with HIV (IOM, 2011).
The possibility of "churning" between coverage sources, the movement
of individuals from the Ryan White HIV/AIDS Program into other subsi-
dized programs, and concerns about the availability of competent health
care services sufficient to meet the needs of people living with HIV under-
score the importance not only of tracking changes in health care coverage
for people with HIV but also of monitoring service utilization and care
quality using indicators such as those recommended in the committee's first
report (IOM, 2012).
REFERENCES
Cassidy, A. Health Policy Brief: Essential health benefits. Health Affairs, April 25. http://
healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_68.pdf (accessed July 17,
2012).
CDC (Centers for Disease Control and Prevention). 2012. Diagnoses of HIV infection and
AIDS in the United States and dependent areas, 2010. HIV Surveillance Report. Volume
22. March. http://www.cdc.gov/hiv/surveillance/resources/reports/2010report/index.htm
(accessed July 3, 2012).
Center for Sustainable Health Spending, Altarum Institute. 2012. Health Sector Economic
Indicators.SM Insights from Monthly National Health Expenditure Estimates through
April 2012. Spending Brief #12-06: April 2012 Data (June 7). http://www.altarum.org/
files/imce/CSHS-Spending-Brief_June%202012_060612.pdf (accessed June 20, 2012).
CMS (Centers for Medicare & Medicaid Services). 2010. 2010 Actuarial Report on the
Financial Outlook for Medicaid. https://www.cms.gov/ActuarialStudies/downloads/
MedicaidReport2010.pdf (accessed March 29, 2012).
CMS. Office of the Actuary, National Health Statistics Group. 2012. National Health Care
Expenditures Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
Trends-and-Reports/NationalHealthExpendData/downloads/tables.pdf (accessed June
20, 2012).
Commonwealth Fund. The Commonwealth Fund 2010 Biennial Health Insurance Survey.
http://www.commonwealthfund.org/Surveys/2011/Mar/2010-Biennial-Health-Insurance-
Survey.aspx (accessed August 16, 2012)
OCR for page 70
70 MONITORING HIV CARE IN THE UNITED STATES
Daily Briefing. 2012. Where Each State Stands on ACA's Medicaid Expansion: A Roundup
of What Each State's Leadership Has Said About Their Medicaid Plans. http://www.
advisory.com/Daily-Briefing/2012/07/05/Where-each-state-stands-of-the-Medicaid-
expansion (accessed September 17, 2012).
DeNavas-Walt, C., B. D. Proctor, and J. C. Smith. 2012. Income, Poverty, and Health In-
surance Coverage in the United States: 2011. U.S. Census Bureau, Current Population
Reports, P60-243. Washington, DC: U.S. Government Printing Office.
HHS (U.S. Department of Health and Human Services). 2012a. How Does the Affordable
Care Act Impact People Living with HIV/AIDS. http://aids.gov/federal-resources/policies/
health-care-reform/ (accessed July 16, 2012).
HHS. 2012b. Who's Eligible for PCIP Coverage? https://pcip.gov/Who's_Eligible.html (ac-
cessed September 17, 2012).
HRSA (Health Resources and Services Administration). 2010. Workforce capacity in HIV.
HRSA Care Action (April):1-12.
Hsiao, W. C., A. G. Knight, S. Kappel, and N. Done. 2011. What other states can learn from
Vermont's bold experiment: Embracing a single-payer health care financing system.
Health Affairs 30(7):1232-1241.
IOM (Institute of Medicince). 2011. HIV Screening and Access to Care: Health Care System
Capacity for Increased HIV Testing and Provision of Care. Washington, DC: The Na-
tional Academies Press.
IOM. 2012. Monitoring HIV Care in the United States: Indicators and Data Systems. Wash-
ington, DC: The National Academies Press.
Kates, J. 2011. Medicaid and HIV: A National Analysis. Washington, DC: Henry J. Kaiser
Family Foundation. http://www.kff.org/hivaids/upload/8218.pdf (accessed January 11,
2012).
Keith, K., K. W. Lucia, and S. Corlette. 2012. Implementing the Affordable Care Act: State
action on early market reforms. Issue Brief 6 (March). Publication 1586. Commonwealth
Fund.
KFF (Kaiser Family Foundation). 2011a. Focus on Health Reform: Summary of the New
Health Reform Law. Publication 8061. http://www.kff.org/healthreform/upload/8061.
pdf (accessed March 30, 2012).
KFF. 2011b. The Ryan White Program. HIV/AIDS Policy Fact Sheet. Publication 7582-06.
http://www.kff.org/hivaids/upload/7582-06.pdf (accessed June 26, 2012).
KFF. 2012a. Focus on Health Reform: A Guide to the Supreme Court's Affordable Care Act
Decision. Publication 8332. http://www.kff.org/healthreform/upload/8332.pdf (accessed
July 18, 2012).
KFF. 2012b. How the ACA Changes Pathways to Insurance Coverage for People with
HIV. http://healthreform.kff.org/notes-on-health-insurance-and-reform/2012/september/
how-the-aca-changes-pathways-to-insurance-coverage-for-people-with-hiv.aspx (accessed
September 18, 2012).
KFF. 2012c. State Action Toward Creating Health Insurance Exchanges, as of November 19,
2012. http://statehealthfacts.kff.org/comparemaptable.jsp?ind=962&cat=17 (accessed
November 20, 2012).
KFF. 2012d. State Health Exchange Profiles. http://healthreform.kff.org/State-Exchange-
Profiles-Page.aspx (accessed June 27, 2012).
KFF. 2012e. State Health Facts: Health Insurance Coverage of Adults (19-64) with Incomes
Under 139% of the Federal Poverty Level (FPL), States (2009-2010), U.S. (2010). http://
www.statehealthfacts.org/comparetable.jsp?ind=779&cat=3 (accessed July 18, 2012).
OCR for page 71
IMPLICATIONS OF HEALTH CARE REFORM 71
KFF. 2012f. State Health Facts: Income Eligibility Limits for Working Adults at Application
as a Percent of the Federal Poverty Level (FPL) by Scope of Benefit Package, January
2012. http://www.statehealthfacts.org/comparereport.jsp?rep=54&cat=4#notes-1 (ac-
cessed March 29, 2012).
Long, S. K., and P. B. Masi. 2009. Access and affordability: An update on health reform in
Massachusetts, Fall 2008. Health Affairs 28(4):w578-w587.
MACPAC (Medicaid and CHIP Payment and Access Commission). 2012. Report to the
Congress on Medicaid and CHIP. March. http://www.macpac.gov/reports (accessed
September 5, 2012).
NASTAD (National Alliance of State and Territorial AIDS Directors). 2012a. Frequently
Asked Questions on Health Reform, August 2012. http://www.nastad.org/Docs/014950_
NASTAD,%20Health%20Reform%20FAQs%20August%202012.pdf (accessed Sep-
tember 17, 2012).
NASTAD. 2012b. National ADAP Monitoring Project Annual Report. http://www.nastad.
org (accessed June 26, 2012).
Natoli, C., V. Cheh, and S. Verghese. 2011. Who will enroll in Medicaid in 2014? Lessons
from Section 1115 Medicaid waivers. Medicaid Policy Brief (1). Mathematica Policy
Research.
NYS (New York State). 2012. Federal Health Care Reform in New York State: Summary of
Health Care Reform. http://www.healthcarereform.ny.gov/summary (accessed March
29, 2012).
Project Inform. 2012. Frequently Asked Questions: Health Care Reform and People Living
with HIV. http://www.projectinform.org/pdf/hcr_faq.pdf (accessed March 30, 2012).
Schoen, C., M. M. Doty, R. H. Robertson, and S. R. Collins. 2011. Affordable Care Act
reforms could reduce the number of underinsured U.S. adults by 70 percent. Health
Affairs 30(9):1762-1771.
Squires, D. A. 2012. Explaining high health care spending in the United States: An inter-
national comparison of supply, utilization, prices, and quality. Issues in International
Health Policy 10 (May). Publication 1595. Commonwealth Fund.
State of Hawaii. Department of Labor and Industrial Relations. 2012. About PrePaid Health
Care. http://hawaii.gov/labor/dcd/aboutphc.shtml (accessed September 17, 2012).
OCR for page 72
