Coverage, treatment improves for individuals with HIV

Individuals with HIV are more knowledgeable about their health insurance options than they were in 2014, and many are receiving care that meets their needs, according to a report by the Kaiser Family Foundation (KFF). While those who gained coverage under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reported using their coverage regularly to treat their HIV, the expansion of Medicaid in states that have not yet done so would improve the health of HIV-positive individuals in those states. While the Ryan White program helps them manage their HIV, other health issues are going unaddressed.

The ACA and individuals with HIV

The ACA expanded access to affordable health insurance to millions of Americans, including those with HIV. Many individuals with HIV faced exclusions and other discriminatory road blocks in gaining health insurance before the ACA. Provisions that largely affected individuals with HIV include the creation of health insurance marketplaces and the availability of subsidies, the expansion of Medicaid in certain states, prohibitions on discriminatory market practices such as rate setting based on health status, preexisting condition exclusions, and the use of annual and lifetime coverage limits.

KFF studied focus groups of HIV-positive individuals in California, Florida, Georgia, New York, and Texas in mid-2014 to examine the care experiences under the ACA of people with HIV. As a follow-up, KFF took a second look at the same focus groups to see how the ACA affects individuals with HIV two years later. The focus groups consisted of HIV-positive individuals who gained health insurance coverage through marketplaces or Medicaid expansion, as well as those who remained uninsured because they fell into the coverage gap.

Increased understanding and security

KFF found that, in 2014, participants with new insurance coverage were in the early stages of learning how to use their insurance. In this round of research, participants reported that they used their coverage regularly to meet their care and treatment needs. The participants also reported that their health was easier to manage after gaining coverage and that they found relief and security in being covered. However, some still worried about being able to maintain coverage. However, those with Medicaid find recertification to be stressful.

Knowledge of insurance

Despite being better able to navigate using insurance compared to their 2014 counterparts, some participants remained unsure of how to fully assess plan options and, thus, relied on case managers to help them make enrollment decisions. These individuals continued to lack some basic insurance literacy, but KFF found that the individuals were more knowledgeable about how access to health care varied across the U.S.

Medicaid expansion

Individuals in states that did not expand Medicaid who remained uninsured because they fall into the coverage gap feel like they can meet their care and treatment needs through the Ryan White Program, but they feel like other health problems are unaddressed. Nearly every participant—especially those with past Medicaid coverage—said if their state later expanded Medicaid, they would enroll.

Highlight on New York: State guidance supports ACA initiatives

The New York Department of Financial Services (NYDFS) recently released guidance to ensure that insurers are following through on Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and CMS mandates to provide preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) at no charge to patients and to facilitate enrollment during special enrollment periods (SEPs). Specifically, it circulated guidance requiring issuers to provide coverage for maternal depression screening and to allow victims of domestic violence to apply for health insurance coverage, both on and off the exchange, year-round.

Maternal Depression Screening

Section 1001 of the ACA amended section 2713 of the Public Health Service Act (42 U.S.C. § 300gg-13) to require nongrandfathered health plans to provide certain preventive services, without copays, to plan recipients. The services fall into four categories, one of which covers evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF.  In 2009, the USPSTF recommended screening all adults for depression when staff-assisted depression care supports were in place and suggested selective screening based on professional judgment and patient preferences when such supports were not in place.  Since that time, depression care supports have become more commonplace.  As a result, the task force updated its recommendations in 2016 to omit the recommendation regarding selective screening and recommend depression screening for all adults, specifically including pregnant and postpartum women; the rating carries with it a ‘B’ recommendation. The USPSTF noted that the American Academy of Pediatrics recommends postpartum depression screening at infants’ one-, two-, and four-month visits, while the American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period.

The NYDFS issued guidance to insurers on April 25, 2016, reminding them that the USPSTF granted maternal depression screening a ‘B’ rating and that they are required to covers such services pursuant to 42 U.S.C. § 300gg-13. According to Governor Cuomo’s office, issuers should begin providing coverage as soon as possible, but no later than six months from the date of the notice. Furthermore, the NYDFS noted, Chapter 199 of the Laws of 2014 (which added §§ 3217-g, 4306-f, and 4406-f), requires that insured women are entitled to direct access to screening and referral  for maternal depression treatment by an obstetrician/gynecologist (OB/GYN) or pediatrician of their choice. In addition, existing law requires that mental health services have parity in insurance coverage.

SEPs for Victims of Domestic Violence

Qualified individuals or enrollees and their dependents are eligible for special enrollment periods, pursuant to 45 C.F.R. 155.420(d)(9), if they meet specified exceptional circumstances. As of July 27, 2015, CMS opened a permanent SEP for any household members victim to domestic abuse, victims of spousal abandonment, and their dependents, for 60 days following an individual’s request for enrollment. CMS also noted that victims who are married to their abuser or abandoner and are applying for coverage separately may be eligible for advance premium tax credits (APTCs) and cost-sharing reductions (CSRs); the federally-facilitated marketplace will  allow them to indicate that they are unmarried without fear of penalty, but other marketplaces may also elect to attest to an expected filing status of Married Filing Separately.

The NYDFS notified all insurers and health maintenance organizations (HMOs) offering comprehensive health insurance coverage in the individual market that they should honor this SEP, whether they offer coverage on or off New York State of Health (NYSOH), the state exchange. The governor’s announcement noted that the SEP began April 15, 2016. Coverage for applications received through the 15th of any month will go into effect on the first day of the following month, while applications received after the 15th will be effective the first day of the second following month.  Although insurers and HMOs may request a separate statement or include an item on the application regarding eligibility, they may not require proof of eligibility or other overly burdensome requirements, nor may they require that applicants have been a victim of domestic violence or spousal abandonment with a specific timeframe.

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Lingering recession, early ACA provisions, expiring patents slowed health spending growth

In recent years, slower growth in health care spending has been somewhat attributed to a check on growth in costs for treating diseases. The Kaiser Family Foundation and the United States Bureau of Economic Analysis reviewed health spending in the last several years, finding that the recession, the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), and expiring drug patents worked together to slow health spending in 2011 and 2012.

Disease spending

The brief notes that information on disease spending has only been analyzed in recent years, which does not allow for much comparison over time. Health spending growth overall during 2011 and 2012 was around 4 percent per capita, comparable with the “slowdown period” (2005 to 2010), but cost per case, known as the disease-based price index, grew even slower: 2.3 percent in 2011, and 2.1 percent in 2012.

Cost growth varied by disease. During the slowdown period and in recent years, cost per capita remained about the same for routine care. However, cost for nervous system treatment dropped from 6.54 percent to 4.43 percent, while cost to treat neoplasms (cancer) went from 4.69 percent to 1.90 percent.

Factors

Evidence shows that while there were some immediate effects on health care spending due to the recession (2008 to 2010), there was also a lagged effect in which health care spending in 2011 and 2012 grew in a similar level to the recession. Some of this can be attributed to drops in employment resulting in shifts away from private insurance toward enrollment in Medicaid or uninsurance, which usually results in lowered use of health care services.

The ACA also impacted health spending in 2011 and 2012, even though some key provisions were not yet implemented. For example, Medicare reduced provider reimbursement rates and the ACA expanded coverage of preventive care services, many of which are classified as routine care. This caused a sharp increase in use of preventive services.

The brief also analyzed the “patent cliff” observed between 2010 and 2012. Many brand-name drugs saw their patents expire during this period, allowing patients to switch to affordable generic versions. This correlated with a drop in cost per case. The major drugs Effexor XR® and Adderall® lost patent exclusivity in 2010 and 2009, respectively. The costs for treating mood disorders fell during this period while more people were being treated, and the costs for treating attention deficient and hyperactivity disorders grew more slowly than in previous years, while more people were seeking treatment.