A presentation by Laura Hanen (NASTAD) and Rachel McLean (California Department of Public Health) on what health care reform means for harm reduction and drug user health. Presented at the Harm Reduction Coalition's 8th National Conference, November 18-21, 2010 in Austin, Texas.

1. Health Care Reform and Harm Reduction
8th
National Harm Reduction Conference, Austin, TX
November 18, 2010
Laura Hanen, Director, Government Relations, NASTAD
Rachel McLean, Adult Viral Hepatitis Prevention Coordinator, STD
Control Branch, California Department of Public Health

2. • Major provisions of health reform
• Limitations of health reform
• Health Reform and Harm Reduction:
Preparing for 2014 and Beyond
Overview

3. • 45-50 million Americans uninsured
• 65% of all bankruptcies are health related
• 50% of people with HIV in the US
do not have reliable access to HIV care
– 29% who are uninsured
– 21% who don’t know they are infected
• 75% of people with HCV in the US don’t know
they are infected, many who do are not in care
How did we get here?

4. • Health insurance overhaul package was signed
into law by President Obama on March 23, 2010
– “Patient Protection and Affordable Care Act”
• Most far reaching health legislation since the
creation of the Medicare and Medicaid programs
in the 1960s
– Implications for every system of care
The Affordable Care Act

5. • Establishes a mandate that all U.S. Citizens and Legal
Residents maintain health insurance coverage
– Provides subsidies to help low income people maintain
insurance and exemptions for people for whom it would
be a hardship
• Legislation makes significant changes/improvements to
major components of our health care system:
– Private health insurance
– Medicaid
– Medicare
• Elements phased in over the next ten years
• Most significant changes are enacted in 2014
The Affordable Care Act

6. Coverage for < Age 65, in Millions
Estimated Coverage, 2019
162 159
35 51
30
25
2454
23
0
50
100
150
200
250
300
Current Policy New Law
Uninsured
Exchange
Nongroup/other
Medicaid/SCHIP
Employer
Source: Congressional Budget Office, March 20, 2010
Plus 5 million
employees in exchanges
through employer
plans

7. Overview of Key Health Coverage
Expansion Components

8. Coverage Expansion Under Health Reform, by Income
> 400% Federal Poverty Level
• Able to purchase insurance through the exchanges
if not already covered
133 – 400% Federal Poverty Level
• Offered subsidies, tax breaks to purchase
insurance through the exchanges
< 133% Federal Poverty Level
• Covered by Medicaid Expansion

9. Key Improvements Through Reform: Medicaid
• Expanded to all under 65 with incomes up to 133%
FPL ($14,400) in 2014
– Uniform minimum eligibility across states
• State option to expand coverage now
• Federal funding for Medicaid expansion: 2014
• Newly eligible have benchmark benefits package
that includes MH, SA, Rx, and preventive services
– Envisions drug treatment, mental health care
happening in primary care settings

10. Key Improvements Through Reform:
Insurance Exchanges
• Centralized, state-based marketplaces to
purchase insurance
• Goal is to create healthy market competition
–Better benefits package/coverage
–Lower costs passed on to consumer
• Established with federal funds and must meet
national standards

11. Key Improvements Through Reform:
Insurance Exchanges
• Open to individuals and small group employers with
income over 133% FPL to purchase insurance
• More affordable and better coverage options for
individuals without group coverage
• Federal premium and cost-sharing subsidies for
individuals with incomes133% - 400% FPL
– Around $19,000 to $57,616/per year for an
individual based on 2010 federal poverty level

12. Insurance Exchanges:
Essential Benefits Package
• Preventive and wellness services and chronic disease
management
• Mental health and substance use disorder services,
including behavioral health treatment
• Prescription drugs
• Laboratory services
• Ambulatory, emergency, and hospitalization patient services
• Rehabilitative and habilitative services and devices
• Maternity and newborn care
• Pediatric services, including oral and vision care

13. Improvements to Group Insurance Coverage:
2010
• Eliminates discrimination based on health status for
children (adults in 2014)
• Encourages employers to provide insurance
coverage (small business tax credits)
• Extends dependant coverage to age 26
• Eliminates lifetime insurance caps on policies and
plan rescissions

14. Improvements to Group Insurance Coverage:
2010
• Requires new plans to cover services that receive a
Grade A or B from the U.S. Preventive Services
Task Force with no cost sharing
• Establishes a temporary national high-risk
insurance pool to cover the uninsured with pre-
existing conditions (until 2014)

15. Key Improvements Through Reform:
Temporary High Risk Pool Programs
• Purpose is to provide coverage between now and 2014
• Eligible if have a pre-existing condition and have not
had creditable coverage during the previous 6 months
• $5 billion available for program starting July 1, 2010
• 27 states opted for the feds to run the pool
– Requires a letter of denial of coverage
• Premiums and out of pocket costs are limited but still
costly for low-income individuals (CA: $575/mo.)
• Uptake has been limited; HHS reducing costs in 2011

17. Key Improvements Through Reform:
Clinical Preventive Services
• Coverage of clinical preventive benefits under all
forms of insurance
– Eliminates co-pays for services with A or B under
U.S. Preventive Services Task Force
• Does not include routine HIV testing or HBV/HCV
testing for IDUs, other at-risk adults
– 1% increase in Medicaid federal matching funds
for providing these services in 2013
– Medicare annual visit and personalized
prevention plan
• Expanded access to immunizations for adults
– Includes hepatitis A and hepatitis B vaccination

18. USPSTF Recommendations:
STI Screening
Nonpregnant Women Pregnant Women Men
STI Not at
increased
risk
At
increased
risk*
Not at
increased
risk
At
increased
risk*
Not at
increased
risk
At
increased
risk**
Chlamydia C A C B I I
Gonorrhea D B I B D I
Syphilis D A A A D A
HIV C A A A C A
Hepatitis B D D A A D D
Hepatitis C D I - - D I
HSV D D D D D D
* Increased risk for pregnant and nonpregnant women is defined as high-risk sexual behavior for all
STIs; as age younger than 25 years for chlamydia and gonorrhea; and as high community
prevalence for chlamydia, gonorrhea, and syphilis
** Increased risk for men is defined as high-risk sexual behavior for all STIs and as high community
prevalence for syphilis

19. Opportunities for Harm Reduction
Programs: Patient-Centered Medical Homes
• Option for Medicaid beneficiaries with 2+ chronic conditions
to designate a medical home
• Supports pilot projects that have the potential to reduce
costs while preserving or enhancing quality
– HRSA and CMS could develop a pilot to evaluate cost
effectiveness of coordinated drug user health services
(HIV/HCV testing & care, syringe access, buprenorphine,
overdose prevention, soft tissue infection treatment, etc.)
• Workforce training targeted to patient-centered medical
home and to physicians working with vulnerable populations
(e.g., IDUs)

20. Opportunities for Harm Reduction
Programs: Investment in Prevention
• Community Health Centers
– Receiving $11 billion over next 5 years
– Presents an opportunity to ensure that CHCs can
expand access to prevention and care services
• Prevention and Public Health Fund
– $500 million in FY10 growing up to $2 billion in FY15
– FY10: $30M for HIV prevention
– Public health infrastructure, lab and epi capacity,
workforce training, community transformation grants
– Primary care physician capacity
• National Prevention Strategy

21. Limitations of Health Reform
• Specifically excludes undocumented immigrants
• Does not apply to people who are incarcerated
• Insurance coverage ≠ access or quality
• Not enough primary care physicians for everyone
• Will not suddenly make health professionals culturally
competent with the people we serve
• Requires continued funding / support from Congress

22. Health Care Reform and Harm Reduction:
Preparing for 2014 and Beyond

23. What does health reform mean for
harm reduction organizations?
• Financial impact
– Potential for clients to eligible for high risk pool
programs/Pre-Existing Condition Insurance Plans
– Many clients (single, uninsured, “non-disabled” adults) to be
covered by Medicaid or private insurance as of 2014
– Siloed funding streams may diminish as preventive
services, drug treatment, move into primary care settings
– Need for services will remain for uninsured individuals
– Monitor Public Health Prevention Fund for opportunities

24. What does health reform mean for
harm reduction organizations?
• Systems Impact
– Need to build relationships with primary care providers
• FQHCs, homeless / rural health centers
• State and regional primary care associations
– Advocate for drug user health services in primary care:
• HIV, HCV, HBV testing, clinical management
• Hepatitis A and B vaccination
• Syringe access
• Overdose prevention (naloxone prescription)
• Opiate replacement therapy (buprenorphine, methadone)
– Market skills in serving “hard to reach populations”?

25. What does health reform mean for
harm reduction organizations?
• Systems Impact
– Case management intake process will need to be altered
to include screening for additional benefits
– Health care, drug treatment providers will need to ensure
that they’re included in Medicaid managed care,
Medicare, and private insurance provider networks
– Providers will need to ensure infrastructure in place for
billing of various payers

26. National HIV/AIDS Strategy:
Ryan White Will Still be Needed
“Gaps in essential care and services for people living
with HV will continue to need to be addressed along
with the unique biological, psychological and social
effects of living with HIV. Therefore, the Ryan White
HIV/AIDS Program and other Federal and State HIV-
focused programs will continue to be necessary after
the law is implemented.”
National HIV/AIDS Strategy for the United States: July 2010 (page ix).

27. Future of Health Reform

28. Future of Health Reform
• Educate policymakers on what is good about the
law and why you want to keep it
– Investments in prevention
– Expansion of coverage to low-income, middle-
income people
• Participate in implementation
– Federal and state
• Educate clients, providers

29. Priorities for Implementation
• Increasing Community Health Center’s role in harm
reduction service delivery
• Weighing in on the Essential Benefits Package for
the exchanges and Medicaid
• Medical Home pilots in Medicaid and the Center for
Medicare and Medicaid Innovation
• Tracking implementation of National HIV/AIDS
Strategy and National Viral Hepatitis Action Plan

30. Priorities for Implementation
• Seek health workforce development opportunities
to address workforce shortage, cultural competency
• Modify U.S. Preventive Svs. Task Force
recommendations for HIV and hepatitis testing
• Ask for HIV, HCV dollars in Prevention and Public
Health Fund for FY2011 and FY2012
• Leverage Community Transformation Grants
• Meet with HHS health reform implementers
• Client organizing; provider, policymaker education

31. Resources
• Trust for America’s Health
• Kaiser Family Foundation
• www.healthcare.gov
• The Commonwealth Fund
• National Alliance of State and Territorial AIDS
Directors www.nastad.org

32. Questions for Clarification
• What stands out as the most significant aspect of
health reform for your community/organization?
• What is still unclear about health reform?
• What challenges and opportunities does health
reform present for your organization?

34. Questions for Discussion
• How have you been tracking reform
implementation in your state?
• How do you envision your role in ensuring that
the implementation of health reform benefits drug
users and other communities we serve?
• What other considerations should we keep in
mind between now and 2014?

35. Contact Information
Laura Hanen
Director, Government Relations
National Alliance of State and Territorial AIDS Directors
P: 202.434.8091
lhanen@nastad.org
Rachel McLean, MPH
Adult Viral Hepatitis Prevention Coordinator
STD Control Branch
California Department of Public Health
P: (510) 620-3403
Rachel.McLean@cdph.ca.gov
www.cdph.ca.gov/programs/pages/ovhp.aspx