AIDS Care Group

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AIDS Service Organization Blog

Friday November 16, 2012 at 7:43

How will healthcare reform change health insurance for people living with HIV/AIDS?

By Kevin Moore, Psy.D. on 11/16/12

Even though current Ryan White services fund a complete spectrum of medical services from medical and dental care to receiving HIV medications, it is always a good idea to get health insurance. One never knows when she or he might need to go to the emergency room. Besides, the current way that Ryan White services are certified in the Commonwealth of Pennsylvania and other States, Ryan White recipients are required to apply for benefits such as Medicaid, if they are eligible. Given this state of things, what will change?

First of all, about 50% of people who are currently eligible for Medicaid are not receiving this entitled benefit, primarily because they have not applied but also because of bureaucratic difficulties.  This percentage should go down.  While a high percentage of people living with HIV/AIDS are receiving the Medicaid coverage, also called Medical Assistance or MA, they are sometimes kicked off of their coverage because the state declares that they have failed to keep current documentation or have exceeded the income limits or other eligibility criteria.  One of the aims of the Medicaid expansion is to reduce the sometimes adversarial nature of public benefits.  This change will be a tricky one as it will depend on each states’ Medicaid administration to conform to a yet to be determined standard.  Pennsylvania’s Department of Public Welfare has dropped hundreds of thousands of enrollees for new technicalities since the Corbett Administration, though many of these were able to regain coverage with additional documentation.  Healthcare reform should reduce the amount of gaps of Medicaid coverage by current recipients.

Second of all, for states that accept Medicaid expansion from the federal government, people up to 133% of the Federal Poverty Level (FPL) will be eligible to receive Medicaid.  This will be a significant benefit to a group sometimes called “the working poor.”  For states, such as Pennsylvania, who have indicated they will not accept the Medicaid expansion, this 100-to-133% FPL group are in danger of not being eligible for Medicaid but still being mandated to have health insurance.  It is extremely unclear how this will play out, and this may be the single most fractious, partisan, hot-button issue of healthcare reform implementation.  This should be a primary target of advocacy for people living with HIV/AIDS as they could end up in the worst case scenario of having neither Medicaid nor the current Ryan White care system and face a penalty for not having health insurance.

Third, for people above 133% and up to 400% FPL, state health care exchanges will be established so they can have both access to new groups of insurance pools and assistance in deciding which plan is right for them.  Depending of level of income, there are maximum percentages of the cost of insurance that can be charged.  To be clear, a working class American in 2014 will be able to individually purchase health insurance whose coverage far exceeds what the individual must contribute.  Curious how this might work out for you or your loved ones?  Try this easy to use subsidy calculator: http://healthreform.kff.org/en/SubsidyCalculator.aspx. Some states, like Pennsylvania, will not choose to set up healthcare exchanges themselves and thus an arm of the federal government, the Department of Health and Human Services, will set it up for that state.  In either case, each health exchange will have to decide how they will cover people living with HIV/AIDS.  As they cost on average about five times as much per year as the average Medicaid recipient, it will require massive advocacy on a state level to ensure that people living with HIV/AIDS are well cared for in the state exchanges.

Finally, people above 400% of the FPL will not receive subsidies for their insurance, but they will enjoy other benefits of healthcare reform such as not being rejected for insurance because of a pre-existing condition such as HIV/AIDS, no lifetime caps on insurance spending, and other protections previously unavailable.  Whatever your income, healthcare reform will directly benefit you in multiple ways.

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Friday November 09, 2012 at 16:43

Act like a non-profit, and think like a for profit organization

By Fungisai Nota, PhD

The Patient Protection and Affordable Care Act (ACA) brings a wealth of good news for those living with HIV/AIDS in the United States:

  • 1. Insurance companies will no longer be able to deny coverage based on pre-existing conditions.
  • 2. Insurers can no longer rescind coverage for adults or children because of changes in health status.
  • 3. The proposed expansion of Medicaid will insure some coverage of the estimated 25% of those living with HIV/AIDS without insurance.
  • 4. And, by 2014 there will no longer be lifetime spending caps from insurance companies.

These upcoming changes imply the need for well managed “organizational change” within AIDS Service Organizations (ASOs). With the expansion of medical insurance coverage, Ryan White funding is likely to be reduced to cover wrap-around services – about 25 percent of the current funding. Therefore, the leadership of ASOs should start asking themselves the following questions:

  • i) If most of our patients gain insurance coverage will they be asked to be treated by someone other than ourselves?
  • ii) If all of our patients have Medicaid insurance, and Ryan White funding goes down to 25 percent, can we survive financially?
  • iii) What do we do best (comparative advantage in economics), and can we scale it up in a fee for service framework to create financial sustainability?
  • iv) How can ASOs optimize their current services, human capital skills, and infrastructure to remain relevant and keep providing the much needed HIV/AIDS services?

These are tough questions that will challenge the leadership of ASOs to marry their public service vision with business acumen. For the first time in a long time, ASOs have to examine their strengths, weaknesses, opportunities and threats – knowing full well that if they do not strategically adapt to the changing health care environment, they may lose their patients and potentially cease to exist.

As one public health expert rightly said to HIV providers, “Don’t expect anything to be handed to you on a silver platter. Don’t wait to be invited. Get Involved”. And I would add: develop your strategic plan; learn the required essential health benefits for private insurance plans in your state; ensure that your provider team is informed about ACA changes that will affect your patients, and understand the process of enrolling your newly eligible patients in Medicaid.

Look deep, and identify for-profit ventures within your non-profit organization. The sustainability of your organization depends not only on your ability to manage the organizational change, but also creativity in replacing potential loses in Ryan White funding.

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Wednesday November 07, 2012 at 12:59

Does Obama’s Re-election endanger AIDS Service Organizations?

By Kevin Moore, PsyD, and Howell Strauss, DMD, on 11/8/2012

Obama’s re-election means the Affordable Care Act will be implemented.  As millions of Americans gain health care insurance, either under Medicaid expansion or through State insurance exchanges, the main funding for AIDS Service Organizations (ASOs) through Ryan White programs is unlikely to continue in the manner that is known today.  The reason is that Ryan White Care Act funds are to be a “payer of last resort,” and predominantly for uninsured people.  While very few people will remain uninsured after 2014, the reasoning behind the existence of the Ryan White Care Act will be questioned, resulting in a logical and significant reduction of current funding levels.  The current Ryan White Treatment Extension Act of 2009 expires in October 2013, and while it will likely be re-authorized, the federal sources who have spoken to these authors have indicated the next Ryan White Care Act will likely have less funding; fewer services funded; and for a shorter time frame.  These changes may dramatically redefine how much money will be available; to what organizations; providing what care; and not the status quo as is known today.  Administration and regulation of funding that is left will be far different from what is defined in today’s Ryan White environment.

ASOs are a vital safety net to hundreds of thousands of people living with HIV/AIDS who would not have access to life-sustaining medical services otherwise.  If ASOs lose some or most of their backbone funding, many may be forced to dramatically reduce the services provided; or possibly go bankrupt.  By definition, under the Ryan White Care Act, ASOs are non-profit organizations. Some of the funded agencies reside within the huge infrastructure of hospitals.  Others are small grassroots organizations that have difficulty adapting to changing funding streams.  The ability to voice opinion or to carry out administrative requirements such as achieve accreditation may not exist in grassroots organizations.  Many ASOs have been serving the same clients for multiple decades and the changing healthcare environment may severe these relationships.  Worse, some people living with HIV/AIDS may keep access to a primary care physician, but lose access to health care from an HIV specialist.  Paradoxically, healthcare reform, in providing increased access to care, also risks degrading the comprehensiveness of healthcare currently being delivered to vulnerable populations.

The first Obama administration has shown leadership in creating the first National HIV/AIDS Strategy, a variety of HIV care initiatives, and modest increases in funding.  All indications suggest a second Obama administration will do what they can to ensure that people with HIV/AIDS receive good care.  However, the demands of changing the overall healthcare system are so great that current ASOs may not be financially viable to provide care that they are currently funded to do.  Also, many states which do not want to participate in health care reform are likely to take actions beyond federal control, such as refusing Medicaid expansion, which could further disrupt care systems.

What can be done so that ASOs are not endangered?  This blog seeks to engage providers of HIV/AIDS services to participate with a community of people who care about providing services for people with HIV/AIDS.  It is also reaching out to recipients of health care services with emphasis on those who know that they have received their care from agencies funded through Ryan White programs.  Dialogue posted on this website will serve as a reference for needs that must be addressed in the upcoming health reform environment.  All of the key stakeholders must have representation prior to consequential changes within the new environment of the Affordable Care Act.  We cannot afford to have change enacted without the voice of providers and recipients of care being heard. The future of healthcare remains unclear, but we know that advocacy is the only way to ensure our interests are addressed.  Please look for future posts on what can be done so that ASOs survive - and hopefully thrive - for the continuing efforts to address the clinical care and social supportive services for those living with HIV/AIDS.  

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