Posted by: Allison Rice | September 3, 2014

How the ACA is working out in North Carolina in 2014

The Department of Health and Human Services has a good summary of how enrollment happened in North Carolina (overall). They note NC had the 5th best enrollment in the country! Unfortunately, enrollment for people living with HIV/AIDS appears to have been quite low. We’re told that only about 103 AIDS Drug Assistance Program clients moved over to insurance, out of about 1200 who might have qualified and gotten subsidies. Why? Reasons are many, but several stand out:

  • Cost — paying for something that has been free up until now.
  • High drug cost sharing for HIV drugs
  • Confusion and lack of information

We hope next year will be better. But here’s the over all report for 2014, from HHS.

How the Health Care Law is Making a Difference for the People of North Carolina

The Affordable Care Act is working to make health care more affordable, accessible, and high quality for the people of North Carolina by:

Better Options

The Health Insurance Marketplace

Through the Health Insurance Marketplace North Carolinians can compare qualified health plans, get answers to questions, find out if they are eligible for lower costs for private insurance or health programs like Medicaid and the Children’s Health Insurance Program (CHIP), and enroll in health coverage.

At the end of the first annual open enrollment period, enrollment in the Marketplace surged to eight million people nationwide. In North Carolina alone, 357,584 individuals selected a Marketplace plan between October 1, 2013 and March 31, 2014 (including additional special enrollment period activity through April 19, 2014).

Of the 357,584 North Carolinians who selected a plan:

  • 56% are female and 44% are male;
  • 35% are under age 35;
  • 28% are between the ages of 18 and 34;
  • 74% selected a Silver plan, while 16% selected a Bronze plan; and,
  • 91% selected a plan with financial assistance.

Although open enrollment for 2014 coverage is over, the next open enrollment period begins on November 15, 2014 for coverage that can begin as early as January 1, 2015.  Click here to learn more about your coverage options outside of open enrollment.

North Carolina has received $87,357,314 in grants for research, planning, information technology development, and implementation of its Marketplace.

 

Medicaid

Thanks to the Affordable Care Act, states have new opportunities to expand Medicaid coverage to individuals with family incomes at or below 133 percent of the federal poverty level (generally $31,322 for a family of four in 2013). This expansion includes non-elderly adults without dependent children, who have not previously been eligible for Medicaid in most states.

 

North Carolina has not expanded Medicaid and as of June, only 65,833 North Carolinians have gained Medicaid or CHIP coverage since the beginning of the Health Insurance Marketplace’s first open enrollment period in October, 2013. If North Carolina expanded Medicaid, an additional 377,000 of uninsured people would gain coverage. The expansion would be paid 100% by federal funds for the first three years and federal funds would never fall below 90% of costs thereafter. Across the nation, more than 7.2 million more Americans are now enrolled in Medicaid and CHIP.

 

Mental Health

The Affordable Care Act increases access to comprehensive coverage by requiring most health plans to cover ten essential health benefit categories, to include hospitalization, prescription drugs, maternity and newborn care, and mental health and substance use disorder services.  The health care law expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans nationwide, including 1,897,489 North Carolinians.

 

New coverage options for young adults

Under the health care law, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old. Thanks to this provision, over 3 million young people who would otherwise have been uninsured have gained coverage nationwide, including 95,000 young adults in North Carolina.

 

Ending discrimination for pre-existing conditions  

As many as 4,099,922 non-elderly North Carolinians have some type of pre-existing health condition, including 539,092 children.  Today, most insurers can no longer deny coverage to anyone because of a pre-existing condition, like asthma or diabetes, under the health care law.  And they can no longer charge women more because of their gender.

 

Better Value

Providing better value for your premium dollar through the 80/20 Rule

Health insurance companies now have to spend at least 80 cents of your premium dollar on health care or improvements to care, rather than administrative costs like salaries or marketing, or they have to provide you a refund.  This means that 182,517 North Carolinians with private insurance coverage benefited from $8,488,477 in refunds from insurance companies, for an average refund of $77 per family because of the Affordable Care Act.

 

Scrutinizing unreasonable premium increases 

In every State and for the first time under Federal law, insurance companies are required to publicly justify their actions if they want to raise rates by 10 percent or more. North Carolina has received $4,984,080 under the new law to help fight unreasonable premium increases. Since implementing the law, the fraction of requests for insurance premium increases of 10 percent or more has dropped dramatically, from 75 percent to 14 percent nationally.  To date, the rate review program has helped save Americans an estimated $1 billion.

 

Removing lifetime limits on health benefits 

The law bans insurance companies from imposing lifetime dollar limits on health benefits – freeing cancer patients and individuals suffering from other chronic diseases from having to worry about going without treatment because of their lifetime limits. Already, 3,091,000 people in North Carolina, including 1,186,000 women and 804,000 children, are free from worrying about lifetime limits on coverage. The law also restricts the use of annual limits and bans them completely starting in 2014.

 

Better Health

Covering preventive services with no deductible or co-pay

The health care law requires many insurance plans to provide coverage without cost sharing to enrollees for a variety of preventive health services, such as colonoscopy screening for colon cancer, Pap smears and mammograms for women, well-child visits, and flu shots for all children and adults.

 

Because of the Affordable Care Act, 76 million Americans with private health insurance gained preventive service coverage with no cost-sharing, including 2,266,000 in North Carolina. And women can now get coverage without cost-sharing of even more preventive services they need.  Of the 76 million Americans with expanded access to free preventive services, 29.7 million are women, including 917,000 in North Carolina receiving expanded preventive services without cost-sharing.

 

Increasing support for community health centers

The Affordable Care Act increases the funding available to community health centers nationwide. Health Center grantees in North Carolina have received $179,288,547 under the health care law to offer a broader array of primary care services, extend their hours of operations, hire more providers, and renovate or build new clinical spaces.

 

Of the $179,288,547 awarded to North Carolina, $6,358,944 was awarded to North Carolina health centers to help enroll uninsured Americans in the Health Insurance Marketplace.  North Carolina health centers used these funds to train 500 outreach and enrollment assistance workers who helped more than 97,290 North Carolina residents with enrollment into affordable health insurance coverage. These investments ensure that health centers continue to be a trusted resource for assistance with enrollment in the Marketplace, Medicaid and CHIP in North Carolina.

 

In North Carolina, 34 health centers operate 203 sites, providing preventive and primary health care services to 454,675 North Carolinians, including 129,322 Latinos and 149,601 African Americans.

 

Investing in the primary care workforce

As a result of historic investments through the health care law and the Recovery Act, the numbers of clinicians in the National Health Service Corps are near all-time highs with 8,900 Corps clinicians providing care to more than 9.3 million people who live in rural, urban, and frontier communities.  The National Health Service Corps repays educational loans and provides scholarships to primary care physicians, dentists, nurse practitioners, physician assistants, behavioral health providers, and other primary care providers who practice in areas of the country that have too few health care professionals to serve the people who live there.  As of September 30, 2013, there were 202 Corps clinicians providing primary care services in North Carolina, compared to 68 in 2008.

 

Preventing illness and promoting health

Through Fiscal Year 2013, North Carolina has received $67,576,623 in grants from the Prevention and Public Health Fund created by the health care law. This fund was created to support effective policies in North Carolina and nationwide, such as initiatives focused on tobacco cessation, obesity prevention, health coverage enrollment assistance, and increasing the primary care and public health workforce, so that all Americans can lead longer, more productive lives.

 

A Stronger Medicare Program

Making prescription drugs affordable for seniors 

In North Carolina, people with Medicare have saved nearly $359,091,609 on prescription drugs because of the Affordable Care Act.  In 2013 alone, 148,288 individuals in North Carolina saved over $132,810,532, or an average of $896 per beneficiary.  In 2014, people with Medicare in the “donut hole” received a 53 percent discount on covered brand name drugs and a 28 percent discount on generic drugs. And thanks to the health care law, coverage for both brand name and generic drugs will continue to increase over time until the coverage gap is closed.  Nationally, over 8.2 million people with Medicare have saved over $11.5 billion on prescription drugs since the law’s enactment, for an average savings of $1,407 per beneficiary.

 

Covering preventive services with no deductible or co-pay

With no deductibles or co-pays, cost is no longer a barrier for seniors and people with disabilities who want to stay healthy by detecting and treating health problems early. In 2013 alone, an estimated 37.2 million people benefited from Medicare’s coverage of preventive services with no cost-sharing.  In North Carolina, 1,290,585 individuals with Medicare used one or more free preventive service in 2013.

 

Protecting Medicare’s solvency

Medicare is stronger today because of the Affordable Care Act.  The Medicare Trustees projected that the trust fund that finances Medicare’s hospital insurance coverage will remain solvent until 2030, four years beyond what was projected in last year’s report. Just a few years ago, the Medicare Trust Fund was projected to run out of money by 2017.

The health care law helps stop fraud with tougher screening procedures, stronger penalties, and new technology. Over the last five years, the administration’s fraud enforcement efforts have recovered $19.2 billion from fraudsters. For every dollar spent on health care-related fraud and

 

 

Posted by: Allison Rice | September 2, 2013

Insurance Marketplace opens October 1

One of the Affordable Care Act’s key provisions is about to come online. Beginning October 1, people in North Carolina who need insurance can begin to shop for coverage in the Insurance Marketplace. Subsidies will be available for people with incomes between 100% and 400% of the federal poverty level (about $12,000 to $46,000 for a single individual).

We’ve created a resource page for the HIV community in North Carolina with links to materials for consumers and providers. We hope these materials and tools will help make the outreach and enrollment process go more smoothly.

Check out the new page here.

Posted by: lesleyhamming | May 8, 2013

NC Senate Bill 675: Hindering Teen Access to Health Services

Senators Daniel, Randleman, and Newton are sponsoring N.C. Senate Bill 675, which seeks to prohibit physicians from providing health services to minors for the prevention, diagnosis, and treatment of venereal and communicable diseases including HIV without written parental consent.  On April 3, 2013, the bill passed a first reading and was referred to the Health Care Committee.  The bill was approved by the Health Care Committee yesterday (May 7). [Update – late Wednesday the bill was pulled before reaching the House floor and sent to the Judiciary Committee.)

Should the General Assembly enact this bill,  North Carolina will become the only state to completely prohibit minors from consenting to STD services.  Eleven states require minors to reach a certain age, typically 12 or 14, and eighteen states allow, but do not require, physicians to notify parents that the minor is seeking these services. The NC Bill is unique in requiring written parental consent before a minor of any age can receive these medical services.

NC Senate Bill 675 will undermine efforts to create an “AIDS free generation.”  Currently, the southern states, including NC, have the highest rates of new HIV infections among youths aged 13-24 over any other region in the U.S.[1]  At-risk adolescents will be less likely to get tested and treated for HIV if they have to get parental consent.  A survey of adolescents at two pediatrics practices in North Carolina found that while 92% would undergo STD testing if their parents “definitely would not” find out about the test, only 35% would undergo STD testing if their parents “definitely would” find out about the test.[2]  Moreover, the Connecticut Department of Public Health saw an increase in HIV testing of 151% for males and 90% for females the month after Connecticut removed a parental consent requirement for STD testing.[3]

The reduced rates of testing that will occur if NC Senate Bill 675 passes will lead to increased HIV transmissions.  The longer a person delays diagnosis and treatment for HIV, the higher the risk he/she will transmit the disease to others.  A landmark study from UNC at Chapel Hill demonstrated that HIV-infected people who started antiretroviral drug treatment early in the course of their disease were 96% less likely to infect their partners than those HIV-infected people who delayed drug treatment until they experienced a decline in CD4 count or the onset of HIV-1-related symptoms.[4]

These increased HIV transmissions will increase public health costs.  About 25% of HIV-positive individuals in NC receive Medicaid[5] and the average lifetime medical costs to treat each person ranges from $567,000-618,900 with higher costs resulting when HIV is diagnosed late in the disease progression.[6]

Supporters of Senate Bill 675 may believe the parental consent requirement will strengthen parent-teen communication.  Parent-teen communication is important, but passing this bill in an effort to force any teenager to discuss sex with his parents will not succeed.    Faced with such a threat, a teen is much more likely to continue his risky behavior and forgo testing.  A survey found that not only would 59% of sexually active girls stop seeking sexual healthcare services if they had to get parental consent, but also only 1% said they would stop having sexual intercourse.[7]

A better course of action is to support parents in communicating with their sons and daughters about sexual decisions while at the same time giving them access to confidential health care.  Physicians know that offering confidential services is key to adolescent willingness to seek treatment.  Indeed, the American Academy of Pediatrics recommends that “Pediatricians should be prepared to offer confidential, nonjudgmental education and risk-reduction counseling around issues of sexuality for adolescent patients, including teens with chronic illnesses and/or disabilities.”[8]

Should the NC General Assembly pass Senate Bill 675, many adolescents will forgo testing and medical treatment leading to greater STD transmission to their peers and greater economic costs to society.

For more information, see Rose Hoban’s report, Teen Medical Restrictions Bill Passes House Committee, in North Carolina Health News


[1] CDC, Vital Signs: HIV Infection, Testing, and Risk Behaviors Among Youths – United States, 61 Morbidity & Mortality Weekly Rep. 971 (2012), http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6147a5.htm.

[2] Carol Ford & Dana Best, Confidentiality and Adolescents’ Willingness to Consent to Sexually Transmitted Disease Testing, 155 Arch. Ped. & Adolescent Med. 1072 (2001).

[3] Thera Neehan et al., The Impact of Parental Consent on the HIV Testing of Minors, 87 Am. J. Pub. Health 1338, 1339 (1997).

[4] Cohen et al., Prevention of HIV-1 infection with Early Antiretroviral Therapy, 365 N. Eng. J. Med. 493, available at www.nejm.org/doi/full/10.1056/NEJMoa1105243#t=articleTop.

[5] Medicaid Enrollment and spending on HIV, FY2009 Kaiser Family Foundation, http://www.statehealthfacts.org/comparereport.jsp?rep=133&cat=11.

[6] Schackman, et al., The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States, 44 Med. Care 990 (2006).

[7] Diane Reddy et al., Effect of Mandatory Parental Notification on Adolescent Girls’ Use of Sexual Health Care Services, 288 JAMA 710 (2002).

[8] Contraception and Adolescents, 120 Pediatrics 1135 (2007), http://pediatrics.aappublications.org/content/120/5/1135.full (emphasis added).

Posted by: Allison Rice | April 15, 2013

Much ado about Medicaid

It’s been a while since our last post.  That’s how things go in the life of the semester – gets a little crazy about two thirds in. Today’s the last day of classes at Duke, and maybe things will settle down.

While we’ve been focused elsewhere, the NC Medicaid program has continued to be in the news. A couple weeks ago Governor McCrory and DHHS Secretary Aldona Vos announced their plan to privatize the program. This idea continues the “broken” rhetoric that McCrory et al have been been parroting, following the lead of Bobby Jindal and other GOP luminaries.

That rhetoric has been questioned in several excellent pieces.  Rose Hoban of North Carolina Health News, with her usual thoughtful reporting, has examined the “broken” myth specifically. In her piece, “How ‘Broken’ is NC Medicaid” today, she takes a closer look at claims of budget over-runs and excessive administrative costs.  She spoke with Jonathan Oberlander, a health researcher at UNC, who pointed out that Medicaid spending is countercyclical. That is, its costs are higher when the economy tanks, because more people are out of work and no longer have employer health insurance. Says Oberlander,

“. . . Medicaid did what it was supposed to do in the last decade: It acted as a safety net for a lot of people. What’s been driving spending is that Medicaid has been covering more people, because more people in North Carolina needed Medicaid when they lost jobs.”

Check out Rose’s piece for a discussion of administrative costs, including the incentive to charge expenses to that category to get federal matching funds.

Last week, Rose reported on an interview with Secretary Vos and Medicaid director Carol Steckel, in which these leaders defend the “broken” label.  The story and the extremely interesting transcript of the interview, present leaders who appear to see private enterprise as a panacea for all ills. If you read the interview transcript you’ll see more of their foundational ideological position: “government: bad; private: good.” You’ll also see some amazing double-speak, incoherent mumbo jumbo from the Secretary.

Adam Linker from the Justice Center responds to the magical thinking about private enterprise in a “point/counterpoint” with Secretary Vos in the Star News Online.  

This initiative will save money because the private companies will get a set budget from the state. The insurers will then use the magic of the free market to cut expenses, provide superb care, and still turn a tidy profit. That’s the theory. This is never how it works in reality.

We have seen this exact plan play out in a number of states. Most recently, Kansas and Kentucky have implemented this proposal. In Kansas, the rollout is too recent to judge, although some early problems are emerging. In Kentucky, there is chaos. The state auditor there began a probe when he heard reports that small medical providers needed new lines of credit to stay open. In the first several months of implementation, the auditor discovered, managed-care companies received $708 million from the state and paid out just $420 million in claims.

The auditor in Kentucky announced that he would form a new unit dedicated to investigating the Medicaid managed care companies. He also released a series of scathing recommendations, including one that mental health services be removed from managed care. Legislators in that state want to give the Department of Insurance authority to directly regulate the Medicaid companies.

These results are tragic but predictable. The truth is that managed care companies don’t have any secret sauce to saving money. To keep their executives and shareholders well- compensated, these corporations delay payments to providers and deny care to patients

Secretary Vos’s piece is a retread of a press release from a couple weeks ago.

Posted by: Allison Rice | March 28, 2013

Lions and tigers and premium increases…

Come October 1 of this year, people who don’t have private or public health insurance will be able to enroll in coverage through the new health insurance marketplace. There are a few things we know about what will be on offer. For starters, there will probably be quite a few plans to choose from.  But we also know that the actual benefits offered in the plans will be quite similar. Under the Affordable Care Act, plans offered in the marketplace must offer 10 categories of “essential health benefits.” In North Carolina, those benefits are pegged to the Blue Cross Blue Shield “Blue Options” plan.

There are two key things we don’t know. One is how extensive the provider networks will be. How hard will it be to find a plan that includes your regular doctor, a local hospital, and other needed services within a reasonable distance from your home? The other big question is how much this will cost. We won’t know for sure until the marketplace goes live in the Fall.

But that hasn’t stopped predictions, projections, and pure speculation. A few weeks ago, Brad Wilson, the CEO of Blue Cross Blue Shield of North Carolina told a group of insurance agents and brokers that he expected insurance premiums in North Carolina to rise. As reported in the Triad Business Journal,

Wilson predicted that the short-term impact of the Affordable Care Act, which expands insurance coverage to millions beginning in 2014, will be to drive premiums up for individuals and small groups as the health insurance industry takes on new taxes and fees and health care spending increases. . . .When asked by a broker Tuesday if estimates that say some small groups could see premiums rise by as much as 50 percent, Wilson said he expects increases would vary, but such a large increase wouldn’t surprise him.

The latest addition to the premium discussion comes from the Society of Actuaries. In a report issued this week, “Cost of the Future Newly Insured under the Affordable Care Act (ACA)” the Society concluded that insurance claims costs would increase by 32 percent nationally by 2017.  This would vary by state, with North Carolina projected to have quite a modest increase. The report ran two models – one in which all states expanded Medicaid, and another in which none did.  In the no-states-expand model, North Carolina’s claims are predicted to increase by 8.5%. In the all-states-expand, the increase would be 13.5%. Neither model reflects the reality, which is that some will expand and others not. And, as discussed below, claims costs are not the same as premiums.

As would be expected, the media has run with the Society of Actuaries study.  Some reports have done a more thoughtful job of assessing what the study really means. A good discussion is posted over at Kaiser Health News.  The report first clarifies that insurance claims aren’t the same as premiums, and the SOA did not make any claims about premiums.  As claims costs go up, there are other factors that will affect how those costs influence premiums.

Q: But if medical claims go up, shouldn’t insurance prices also go up? How much difference could there be?

A: In the individual market designed under the health law, quite a bit, say supporters. The ACA limits insurer profits and also gives government regulators oversight of rate increases, both of which could hold premiums down.

Even if sticker prices rise, an important feature of the health law is subsidies for people to buy insurance, through tax credits for those with lower incomes. So what many newly-insured people actually end up paying themselves won’t be the same as what the insurance company bills.

Thanks partly to subsidies, “many people buying individual coverage today will see decreases in costs,” said Larry Levitt, senior vice president at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Insurers who end up signing lots of sicker members will also be partly reimbursed for several years by a reinsurance pool designed to lower their risk. That will lower their expenses, and it wasn’t accounted for by the SOA study.

Another important point made in the Kaiser piece is that the products on the market starting in 2014 are very different animals from the ones on the market currently. Many currently offered insurance plans provide very little coverage. Adding the essential health benefits will cost more. Subsidies will help keep costs down for many, though they may not cover all increases. Also, competition should have an effect on prices. As reported by Kaiser, many insurers are looking at creating lower-cost networks that could bring prices down. (That could create problems with access and provider reimbursements.)

For now, this is all speculation. We’ll have to wait and see what comes down the road in October.

Posted by: Allison Rice | March 27, 2013

Even USA Today endorses Medicaid expansion

An editorial in USA Today bemoans the intransigence of most Republican governors on Medicaid expansion.  This is the newspaper that awaits American business travelers outside their hotel room each morning. When Medicaid expansion is endorsed by America’s wonder-bread newspaper, that’s really saying something. Sure looks pretty mainstream.

Titled, Medicaid expansion fight harms you: Our view, the piece makes the familiar arguments for Medicaid expansion, and points out that the governors who are the most outspoken opponents come from states with among the highest numbers of uninsured residents.

Thanks to last June’s Supreme Court ruling that made the expansion optional for states, a group of Republican governors and legislators has opened a new front in their ideological war against ObamaCare — at the expense of their poorest residents, their state’s hospitals and their own state budgets.

This is remarkably crass politics, especially when you consider that some of the governors leading the charge — Rick Perry of Texas, Bobby Jindal of Louisiana and Nikki Haley of South Carolina – preside over states with some of the nation’s highest percentages of uninsured residents.

Texas is No. 1 (27% uninsured), and Louisiana and South Carolina are tied for No. 5 (23% uninsured). Handed a golden opportunity to fix this, Perry, Jindal, Haley and more than a dozen other governors are saying no, blocking an estimated 5 million people from obtaining coverage.

The piece also takes issue with an idea that is gaining traction among those who put their faith in the private market: cover the uninsured by paying for private insurance, rather than Medicaid. The USA Today editorial board correctly notes that this is a much more expensive way to pay for coverage, given the much higher administrative costs (including profit and marketing) for private insurance, as compared to government-run Medicaid:

Other governors want to let private insurance participate in the Medicare expansion, and the Obama administration hasn’t ruled this out. But it’s hard to see how adding a middleman would be more efficient. The Congressional Budget Office says Medicaid can cover a patient for $6,000 a year in 2022, while the cost of private insurance would be $9,000, or fully 50% more.

No doubt we’ll see more on this topic. I’ll be interested to see how private insurance can be a cost effective solution.

 

Posted by: Allison Rice | March 13, 2013

Bob Etheridge: NC will regret saying no to Medicaid

Bob Etheridge has an op-ed piece in today’s Fayetteville Observer about the state’s decision to turn down Medicaid expansion.  There’s little here that hasn’t been said elsewhere. But the former congressman, whose vote in favor of the Affordable Care Act didn’t help him politically, says it well.  One point that hasn’t figured widely in the debate is the importance of Medicaid expansion for recently returning veterans, about a quarter of whom are uninsured and unconnected to a VA health facility:

In our state those without insurance are most often working hard at low-wage jobs without benefits. Many of them are veterans. Surveys show that more than a quarter of all service members recently returned from Iraq and Afghanistan do not have insurance and are not connected to the Department of Veterans Affairs health system.

National estimates show that Medicaid expansion would benefit half of all uninsured veterans. If those numbers held true for North Carolina, expanding Medicaid would insure more than 25,000 veterans in our state. It is hard to imagine how we could decline to help more than 500,000 of our brothers and sisters in need; but it is unconscionable to leave behind our nation’s heroes.

Etheridge also calls out the politics that have driven the expansion debate:

National organizations have spent millions of dollars in an unprecedented smear campaign against health reform. When I voted for the legislation three years ago, I knew it could cost me an election. But some principles are bigger than politics; some causes are larger than one campaign. It is now time to leave the misinformation and the talking points behind and do what we all know is right for our community.

Well said.  Let’s hope cooler heads will prevail next year.

After waiting over a week, Governor McCrory signed into law the bill rejecting Medicaid expansion in North Carolina.  The HIV community is disappointed in the governor’s lack of leadership and vision. We had hoped for better.

Last Friday, I gave a presentation on health reform at the UNC Infectious Diseases Friday conference. In the audience were HIV physicians, providers, students, researchers, and others involved in HIV/AIDS work.  After I updated the group about the status of the “No Medicaid Expansion” bill, someone in the audience asked whether there was any chance Governor McCrory would follow the lead of other Republican governors, including Christie of New Jersey, Brewer of Arizona, Kasich of Ohio, and Scott of Florida, and veto the bill.  I replied that I doubted it.  No one I talk to had seen any sign that Governor McCrory would show leadership and compassion on this issue.  Later, on my drive back to Durham, I thought more about that question, and realized there was still a little part of me that held out hope that maybe my answer was wrong.  Maybe McCrory would come around.

Yesterday, hours before McCrory signed the bill, I was giving another presentation.  This time, I met with an HIV support group in Durham. I was giving my quick and dirty update on health reform for non-wonks, and was interrupted with a question from a young woman in the group. I’ll call her Sherry.  Sherry gets her HIV care at Lincoln Community Health Center’s Early Intervention Clinic.  She conscientiously takes her life-saving HIV medications every day. She gets her HIV drugs through the AIDS Drug Assistance Program, for which she is grateful.  But when it comes to other medications and services, she faces great challenges, applications, paperwork, and lot of lost time. Thanks to her HIV medications and expert treatment at Lincoln, she is healthy and able to work part-time. But she doesn’t have enough income to afford insurance and has been repeatedly turned down for Medicaid, even though her income is below 100% of the federal poverty level.  The problem? She can’t qualify for the existing Medicaid program because she isn’t the parent of a minor child and, thankfully, isn’t disabled.

I told Sherry, “You are a poster child for Medicaid expansion.” And that’s right. Sherry is exactly the kind of person who would benefit from getting full insurance coverage through Medicaid. With Medicaid, she could get drugs for her other conditions without having to beg. She could go to the hospital without running up a bill that will ruin her credit, making it difficult for her to rent an apartment or get credit to buy a car or house. She could access specialty care when needed.  Sherry’s doctors and the hospital would like it if she could pay for her care, too.

Sherry also asked me if she maybe she could get help to buy insurance in the new marketplace that will come online January 1, 2014. She was glad to know that at least she couldn’t be refused because of her pre-existing condition, and wondered if she could get the financial assistance that will be offered to help people afford insurance from the marketplace.  Again, I had to disappoint her.  Because the law was originally designed with Medicaid expansion being mandatory, everyone assumed that people under the poverty level would have Medicaid. So the law didn’t include financial help for people under the poverty level (currently $11,490).  So people like Sherry are left uninsured.

Sherry asked what she could do. All I could say was that she needs to let the people making decisions know how their decisions affect people like her.  Sherry was ahead of me on this one. She’d called Governor McCrory’s office repeatedly in the last few weeks to tell him she needs Medicaid.  Sherry and the rest of the folks in the support group wondered if the lady answering the phone even relays their messages. I had to tell them that she probably does.  But their voices don’t seem to be the ones the governor is listening to.

The proof came later in the day when McCrory signed the bill his people wanted. No Medicaid for Sherry in 2014.

News & Observer: McCrory misses chance to lead on Medicaid issue

Posted by: megkrupa | March 1, 2013

Sequestration, ADAP, and PLWHA in North Carolina

Budget sequestration is scheduled for today.  In other words, “a series of automatic, across-the-board cuts to government agencies, totaling $1.2 trillion over 10 years,” and split evenly between defense and domestic discretionary spending, will take effect. (Source)

Overall, budget sequestration will reduce critical funding for HIV/AIDS programs. The dire consequences of sequestration for PLWHA has been articulated by the National Alliance of State & Territorial AIDS Directors (NASTAD) in The Impact of Budge Sequestration on Federal Funding for State HIV/AIDS and Viral Hepatitis Programs in FY2012and The Foundation for AIDS Research (amfAR) and the National Minority AIDS Council (NMAC) in The Effect of Budget Sequestration on HIV/AIDS in the United States: Protecting the Human Impact in Fiscal Year 2013.

Additionally, NASTAD recently released a one-page fact sheet entitled, The Devastating Impact of Sequestration on ADAP in the South: Sequestration Would Leave Thousands of People without Access to Life-saving Medications.  This fact sheet highlights that, of the approximately 15,000 clients losing access to ADAP, “[a]lmost half of the people that will be disenrolled live in the South, which as of 2010 accounted for 45 percent of all new AIDS diagnoses in the U.S.”  (Source)

Specifically, in North Carolina, it is anticipated that 301-1,000 clients will be impacted.  This is disheartening news, particularly considering that North Carolina recently implemented a formulary increase to 300% of the federal poverty level (Source) and then “re-expand[ed] coverage to include medications for heart disease, Hepatitis C, mental illness, and other conditions that commonly accompany HIV” (Source).

In addition to ADAP cuts, North Carolina will not be expanding Medicaid (Source), which would “provide coverage for the many people living with HIV…who are currently uninsured.”  (Source)

ADAP underfunding will thus have far reaching consequences, including the exacerbation of existing structural barriers to health, as well as an increase in new infections, “particularly in the South and among people of color who are already disproportionately impacted by the HIV epidemic.”  (Source)

Yesterday, Dr. Grant Colfax, Director of the Office of National AIDS Policy (ONAP), and Dr. Ron Valdiserri, Director of the Office of HIV/AIDS and Infectious Disease Policy at the U.S. Department of Health and Human Services (HHS), hosted a National HIV/AIDS Strategy Implementation Assessment meeting in Chapel Hill, North Carolina. At this meeting, they addressed steps taken to fulfill the goals of the National HIV/AIDS Strategy (NHAS), as well as next steps and challenges.

Additionally, members of the North Carolina Division of Public Health and medical provider community, as well as LeRoi Lattie, a patient access coordinator for the Lincoln Community Health Center, addressed the audience, which was filled with medical professionals, health providers, HIV/AIDS advocates, academics, PLWHA, and other stakeholders from across North Carolina. Discussions focused on local and state responses to reaching the National HIV/AIDS Strategy goals, as well as current challenges. This blog posts focuses primarily on North Carolina. For more information on Dr. Colfax and Dr. Valdiserri’s updates on the NHAS and ACA, please see my corresponding blog post on the Southern HIV/AIDS Strategy Initiative (SASI) website.

One of the primary focuses of the National HIV/AIDS Strategy is alleviating the burden of HIV in communities most disproportionately impacted by HIV/AIDS, including gay men, MSMs, and people of color. In 2010, black North Carolinians were nine times more likely to be newly diagnosed than whites in 2010, and Hispanics were almost four times as likely. [Source] Also in 2010, the HIV rate in North Carolina for black females was approximately 17 times greater than the HIV rate of white females, and 75% of new HIV cases among males were attributed to MSMs. [Source] “In 2010, MSM accounted for 87 percent of white non-Hispanic male HIV reports, 72 percent of black non-Hispanic male reports and 62 percent of reports for other minority males.” [Source]

The Care and Prevention in the United States (CAPUS) grants, part of the Secretary’s Minority AIDS Initiative, focus on enhancing HIV/AIDS diagnosis, and linkage to and retention in care, among minority communities most impacted by the epidemic. North Carolina was one of eight recipients of this funding, and one of the five southern state recipients. Although still in the early planning stages, North Carolina’s proposal includes plans to hire additional bridge counselors; enhance health outcomes for PLWHA in prison and upon release; introduce telehealth programs, primarily for rural populations; and enhance health surveillance. Additionally, North Carolina is creating a community-driven Men’s Clinic to target minority communities disproportionately impacted with HIV/AIDS. The NC Communicable Disease Branch of the Division of Public Health recently announced the corresponding RFA, with applications due March 11, 2013.   

Jacquelyn Clymore, the State AIDS/STD Director, highlighted North Carolina’s rural epidemic. The numbers are staggering—20% of HIV in North Carolina is rural and 13% is among African Americans. According to the CDC, in 2006, “North Carolina had the highest number of reported cases in rural areas for both AIDS (among 46 states) and HIV (non-AIDS, among 33 states).” [Source] Rural populations face huge barriers to health, including the need to travel longer distances to obtain care, fewer specialized services, a limited health infrastructure, and stigma. [Source] Dr. Michelle Ogle, who serves a rural population and who was featured in Dan Rather Reports, It’s A Southern Thing, noted yesterday that a significant number of rural patients are uninsured. Approximately one-third of her patients are uninsured, relying on programs like Ryan White. [Source]

As part of its CAPUS funding, North Carolina will implement telehealth initiatives, including distance medical learning, to help rural providers, especially those who are not infectious disease doctors, increase their knowledge of HIV/AIDS care. These telehealth initiatives will also expand the number of health providers available to treat people living with HIV/AIDS, ultimately making it easier to access rural HIV/AIDS health care. To combat stigma and other forms of discrimination, North Carolina aims to increase the cultural sensitivity of its health providers, including those serving minorities and transgender individuals in rural areas. This reflects recent research demonstrating that Minorities With HIV Fare Better With Culturally Competent Doctors. North Carolina is also striving to add peer navigators and to better address syphilis/HIV comorbidity, particularly among minority MSMs.  Additionally, CAPUS funding will help fund safe space facilitators, an idea originally facilitated through discussions with NC’s statewide MSM Task Force.

Evelyn Foust, Director of the NC Communicable Disease Branch, emphasized the North Carolina HIV/AIDS Treatment Cascade, which she referred to as “our roadmap” to ending the epidemic. She highlighted that many North Carolinians living with HIV only have one care visit, illustrating both a large need to get people linked and retained to care, as well as recent developments in health surveillance. Foust also noted that organizations looking for state funding should demonstrate where their efforts fall on the cascade and stressed that “in order to leave AIDS in the next generation, we leave no patient behind.”

Stigma in North Carolina was highlighted as a barrier to treatment through an anecdote told by Dr. Colfax. When speaking with a woman living with HIV during his recent visit to NC, he asked what she would like President Obama to know. She responded: “There is still so much stigma and discrimination around HIV.” Stigma is a huge barrier to receiving health care, and “[t]he stigma surrounding AIDS is a key reason that the South is the epicenter of new HIV infections in the United States.” [Source] Foust emphasized that “stigma and discrimination absolutely unacceptable because we are one North Carolina.”

Yesterday, members of the North Carolina Division of Public Health and medical provider community also discussed the state’s many strengths in combatting HIV, including early involvement in the epidemic, a high level of dedication to achieving an AIDS free generation, and the high degree of collaboration and cooperation among and between universities, community health providers, CBOs, and local public health departments. The North Carolina SPNS Integration Project and CAPUS Project were highlighted as illustrations of this collaboration. Additionally, Dr. David Wall highlighted that North Carolina is the first state to integrate all of its health reporting systems into one. However, he highlighted that a more robust electronic health record system across providers was needed, including one that allows the exchange of real-time information with health providers.

Overall, while North Carolina has made much progress combatting HIV/AIDS, there is still much work to be done. In the words of Dr. Ron Valdiserri: “Everyone has role to play in ending HIV epidemic in America.”

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