CDC to research coverage gaps for gay people of color

The Centers for Disease Control and Prevention wants to research whether gay and transgender people of color could receive better access to care and experience reduced HIV infection rates if they discuss insurance coverage with their providers earlier.

The agency is seeking approval from the White House’s Office of Management and Budget to launch the study in Chicago, focusing on black and Hispanic males who have sex with men and transgender persons. The CDC will work with community partners to help people connect to coverage.

Gay men accounted for 81% of new HIV infections among males and 65% of all new HIV infections, according to the CDC. Researchers have also found HIV rates among black and Hispanic transgender women to be 56% and 16%, respectively.

The CDC wants to evaluate whether these individuals will experience better health outcomes if providers talk with them about coverage options during sexually transmitted disease testing. Currently, these conversations tend to take place after patients receive their test results.

The agency wants to determine whether the change will lead to more participants obtaining health insurance, experiencing better health by achieving viral suppression or remaining HIV-free and improve retention rates for HIV care including using medications known as pre-exposure prophylaxis, or PrEP, and other HIV-associated health services like mental health counseling and substance use treatment.

Research has shown that individuals who start antiretroviral therapy on the same day that they are diagnosed with HIV are more likely to be engaged in their care over the long term, according to Jeffrey Crowley, who served under President Barack Obama as director of the Office of National AIDS policy and now oversees infectious disease initiatives at Georgetown University.

However, there are too many barriers to same-day starts to treatment, Crowley said. A primary hurdle is lack of health insurance.

“If this study is able to demonstrate that getting people who test for HIV enrolled in coverage when they test, it could improve their health generally no matter their HIV test result,” Crowley said.

Others agreed the study could be an important step to making sure marginalized individuals are getting the coverage they need.

“People who are HIV-negative are great candidates for PrEP, and we have seen very low uptake among populations most vulnerable to HIV in Chicago and nationally,” said John Peller, CEO of the AIDS Foundation of Chicago. “The opportunity to sign these most vulnerable populations up for health insurance and connect them to primary care could address a major gap in the system.”

A third of gay young men who take PrEP medication discontinue it within six months, according to a May 2018 study published in the AIDS and Behavior Journal.

Common reasons for stopping included being unable to get an doctor appointment and problems with insurance coverage.

The CDC’s proposed study could affect the practice of medicine by engaging individuals in care earlier and thus improving the support these populations receive, according to Ethan Morgan, a research fellow at Northwestern University who co-authored the May 2018 study.

In addition to improving access to coverage, there is hope that promising findings from the CDC study will lead to an increase in federal funding for coverage navigators, according to Erin Loubier, senior director for health and legal integration and payment innovation at Whitman-Walker Health, a community health center in Washington, D.C., that specializes in caring for LGBTQ patients.

Federal funding for navigators that help people search the individual market or Medicaid programs for coverage dropped 41% or by $62.5 million between 2016 and 2017.

“If the CDC finds it makes a difference to have these conversations it begs the question if it will help drive more funding for insurance enrollment assistance,” Loubier said.

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Narrow Focus on Opioid Crisis Leads to More Law Enforcement & Lack of Funding

Over the past few months, many members of Congress who find themselves in tight Congressional races have spent a great deal of time and effort rallying behind their legislative response to the opioid crisis in an attempt to influence voters in the Fall elections. Unfortunately, the zeal with which these vulnerable members of Congress have been promoting a recently passed House bill and the likely impact of the contents of the bill itself are not in sync, as it avoids addressing the glaring funding needs that must be met if any substantial progress is to be made on the issue.

Last week, the House of Representatives passed the bipartisan SUPPORT for Patients and Communities Act (H.R. 6), which collects the chamber’s meek opioid response to send to the Senate in one comprehensive package. As reported earlier this month, the legislative aims are narrowly focused on limiting the supply of opioids through prescription monitoring, expansion of SUD treatment, innovations on non-addictive pain treatments, and harsher criminalization of illicit drugs like fentanyl.

Following the passage of the bill, Politico reporter Adam Cancryn wrote a piece looking at a small collection of health care and pharmaceutical companies that spent millions lobbying Congress this year and who would bring in a windfall if H.R. 6 becomes law. Drug companies who sell medications for SUDs or chronic pain have spent hundreds of thousands, if not millions of dollars, aiming to get their slice of the pie since Congress passed the Bipartisan Budget Deal in late March, which authorized $6 billion over two years toward fighting the opioid crisis.

At present, only one in ten patients who need treatment receive it, and a reportfrom the Administration’s opioid commission identified a lack of willing providers as one the main barriers. Congress needs to do more to influence providers to treat people who use drugs – coming from criminalized communities means they face stigma, discrimination, and denial of services in health care and beyond. Even after the Comprehensive Addiction and Recovery Act of 2016 (S. 524 (114)) expanded the limits on buprenorphine-prescribing, only a fraction of the workforce got on board.

Meanwhile, ease of access to opioid crisis-related data by law enforcement is leading to increased prosecutions and harsher criminal sentencing among people who use drugs and health care providers. Prescription monitoring programs have been touted for their role in detecting pill mills, which is a subsiding problem, but they are being over-used by investigators in some states.Calibri;mso-hansi-font-family:Calibri;mso-bidi-font-family: Calibri”> In Oklahoma – where authorities searched the state’s database 10 times more often than investigators in Texas – the queries result in criminal charges against 7 to 10 providers a year, and investigations of 50 to 100 patients suspected of doctor shopping, forging prescriptions, or street sales. Worse, when someone dies of an overdose, police are increasingly arresting their friends and families on charges relating to murder.

As neither chamber of Congress has committed itself to addressing the opioid crisis as the public health emergency that it is, criminalization of drug use will continue to mire the response.

Posted By: AIDS United, Policy Department – Friday, June 29, 2018

Get to Know the In It Together Health Literacy Project

 

Event Date: Thursday, June 14, 2018 – 2:00pm to 3:00pm EDT

Event Type: Webinar / Teleconference

ACE TA Center

Register for the Webinar

Better health starts with health literacy!

Register and join(link is external) this webinar to learn about:

  • How limited health literacy impacts the health of people living with HIV
  • How to identify when a client is struggling with health literacy
  • Approaches and resources you can use to promote health literacy for your clients
  • The cultural, social, and environmental factors that can impact the health literacy of racially, ethnically, culturally, and linguistically diverse people
  • How In It Togetherresources could benefit your organization or community

In this webinar, two In It Together trainers will also share their experience providing the community health literacy training in their own communities. Join the webinar to learn how you or someone at your organization can to become a health literacy community trainer.

Intended Audience954627 954627

This training webinar will be especially useful to program managers, clinical staff, health educators, case managers, staff that conduct outreach, as well as other staff that provide HIV care or supportive services.

 

HRSA Awards $2.8 Million in Grants to Community-based Organizations to Help Americans Get HIV/AIDS Care and Support Services

Congress is hyperfocused on opioids. Is it focusing enough on addiction?

Controversy over one bill that could fragment care for people with substance use disorder raises serious questions.

Still life. Oxycodone. Oxycodone is a narcotic pain reliever. Oxycodone has a high abuse potential and is prescribed for moderate to high pain relief associated with injuries, bursitis, dislocation, fractures, neuralgia, arthritis, and lower back and cancer pain. OxyContin, Percocet, Percodan, and Tylox are trade name oxycodone products. (Photo by: Education Images/UIG via Getty Images)
STILL LIFE. OXYCODONE. OXYCODONE IS A NARCOTIC PAIN RELIEVER. OXYCODONE HAS A HIGH ABUSE POTENTIAL AND IS PRESCRIBED FOR MODERATE TO HIGH PAIN RELIEF ASSOCIATED WITH INJURIES, BURSITIS, DISLOCATION, FRACTURES, NEURALGIA, ARTHRITIS, AND LOWER BACK AND CANCER PAIN. OXYCONTIN, PERCOCET, PERCODAN, AND TYLOX ARE TRADE NAME OXYCODONE PRODUCTS. (PHOTO BY: EDUCATION IMAGES/UIG VIA GETTY IMAGES)

Congress is trying to pass legislation that addresses the opioid crisis in an election year, so they’re moving fast, passing a bill through committee Thursday that would free up Medicaid dollars for opioid addiction treatment in institutionalized care. But it could be more harmful than lawmakers realize.

Rep. Greg Walden (R-OR) is aiming for the House to take up legislation in June. So to keep with schedule, the House Committee on Energy and Commerce — on which Walden serves as chairman — advanced 32 bills on Thursday, after unanimously advancing another 25 bills last week. The Senate health committee passed its legislative package in April

While lawmakers agree it’s critical to address an epidemic where more people died of a drug overdose in 2016 than the aggregate of the Vietnam War, they don’t always jibe on how.

A question some lawmakers and journalists often ask is whether Congress is too closely targeting opioids, as the epidemic is a problem of polydrug misuse. Bloomberg’s editorial board warned “lawmakers need to take benzodiazepines seriously, before it’s too late.” (Overdose deaths associated with benzodiazepines are fewer than opioids, but still eight times what it was in 1999.)

“I’m concerned that here in Congress we’re so focused on opiates as the drug de jure, if you will, and that in five years or so when this crisis ends or abates or tapers that we’re going to have a bunch of federal programs that are specifically aimed at a problem that may not be as significant,” said Sen. Lisa Murkowski (R-AK) in April.

This point was raised again on Thursday when House members debated, largely along partisan lines, whether to advance the bill to allow Medicaid dollars to be used for opioid addiction treatment in certain treatment facilities.

“With 115 Americans dying each day, we have to focus on the opioid crisis,” said Rep. Mimi Walters (R-CA), the bill’s sponsor. “While we agree that all substance use disorders are important, we’re prioritizing our resources to address the opioid crisis.”

Walters was immediately met with resistance from Democrats.

“I’m troubled that this bill would expand treatment only to people with opioid use disorder as opposed to those with other substance use disorders like alcohol, crack-cocaine, methamphetamine,” said Rep. Jan Schakowsky (D-IL). “This bill is not only blind to the reality faced by people suffering from substance use disorder but it’s also discriminatory.”

Given that the bill exclusively helps those struggling with opioid use disorder, lawmakers are making it clear they only care when white constituents are dying, said Rep. Bobby Rush (D-IL).

“Too often, Mr. Chairmen, this committee and this House have paid attention to issues only when they affect the majority — the majority of the white population,” said Rush. “This leaves too many Black Americans behind.”

The measure would partially and temporarily repeal Medicaid’s Institutions for Mental Disease (IMD) exclusion, meaning it would allow federal Medicaid dollars to pay for opioid use disorder treatment up to 30 days in facilities with more than 16 beds. It would only repeal the ban until December 2023.

Currently states seek federal permission, by waiver, to relax the IMD exclusion for substance use disorder (SUD) treatment. Ten states have these waivers, with California being the first in 2015 to get the okay from the Obama administration.

“We don’t yet know what the utilization of this service looks like, as the program is so new, but it’s worth noting that the IMD exclusion exemption in California’s program is just one piece of a larger system,” said senior program officer at the California Health Care Foundation Catherine Teare, who worked extensively on the state’s waiver. “It’s not specific to opioids or any other particular substance, and it’s embedded within a system that provides access to a full continuum of evidence-based SUD services — based on the American Society of Addiction Medicine criteria.”

Sometimes that care is residential, and sometimes it’s not. People might start their recovery process in inpatient rehab, but then need community-based services to maintain sobriety. In 11 California counties, Medicaid not only pays for residential treatment but a host of other services:

Screenshot of The Drug Medi-Cal Organized Delivery System Pilot Program
SCREENSHOT OF THE DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM PILOT PROGRAM

It also forced relationship-building between primary care, mental health, and substance use treatment providers.

This is another reason why health experts are wary of Walters’ bill.

“I’m fine with paying for the residential component of care, but only if linked to an enduring care plan, such that a person would get more than that,” said Keith Humphreys, a drug policy expert at Stanford University. “Otherwise I think we’ll just spend a lot of money on expensive inpatient stays that don’t have any follow-ups, and the history of that is it’s actually worse than nothing because a person loses their tolerance and they’re even at a higher risk for overdosing than they were when they started.”

It just doesn’t work to build a system where people cycle in and out of institutions, Humphreys added.

Various Republican lawmakers pointed out during the hearing on Thursday that it took months for states to get the federal government to approve their waivers — which is concerning given how many people die a day on average from drug overdoses. For example, West Virginia applied in December 2016, but didn’t get approved until October 2017. For that, Republicans reasoned it just makes sense to lift the ban altogether.

But it’s also important to remember that Congress only has a limited amount of money dedicated to this drug crisis, and IMD repeal could be expensive.

“The cost of inpatient care typically ranges from $6,000 for a 30-day program to $60,000 for 90-day programs, while community-based outpatient services cost around $5,000 for three months of services. That means that any repeal of the IMD would require significant offsets,” according an analysis by the Center on Budget and Policy Priorities (CBPP). Experts at CBPP don’t support a repeal.

Hannah thank you for saying like it is.

Hannah Katch@hannahkatch

Repealing ‘s restriction against payment for institutional care, known as the “IMD exclusion,” would not solve the epidemic — it would risk worsening care for people who need treatment. @JudyCBPP and I explain: https://www.cbpp.org/research/health/repealing-medicaid-exclusion-for-institutional-care-risks-worsening-services-for 

Repealing Medicaid Exclusion for Institutional Care Risks Worsening Services for People With…

Opioid use caused over 42,000 deaths in 2016, and drug overdose deaths rose by statistically significant amounts in 27 states that year, according to the Centers for Disease Control and Prevention….

cbpp.org

The Congressional Budget Office is reportedly working on a score for the bill, but a GOP committee aide told Modern Healthcare that the agency has said repeal is in the “low single digit billions.” IMD exclusion for both mental health and SUD services without day limits would cost up to $60 billion over 10 years.

The worry is money will go to measures that further fragment care for people with substance use disorder, rather than investing in the continuum of care model. Alternatively, for states to secure a SUD waiver, they need to show how inpatient and residential care will supplement community-based services. This can work really well, just look at Virginia.

The House Committee on Energy and Commerce did pass several measures that seem small, but could do a lot of good. Some even addressed fentanyl, which is now the dominant cause for drug overdoses, with fentanyl-laced cocaine potentially becoming the next wave of the opioid crisis. For example the STOP Fentanyl Deaths Act of 2018 authorizes grants for federal, state, and local agencies to create or operate public health laboratories to detect the illicit, synthetic opioid.

Humphreys’ advice: Congress should pass targeted bills addressing the supply side of opioids — but aim for more comprehensive bills when it comes to treatment.

After a Big Buildup, the Trump Administration’s Drug Pricing Plan Doesn’t Deliver

 

Last Friday, President Trump and Secretary of the Department of Health and Human Services Alex Azar unveiled the administration’s plan to lower prescription drug prices, but health policy experts are warning that the proposals fall short of the promises he made on the campaign trail and will do little to address the root causes of the issue. The plan received criticism for being too easy on pharmaceutical companies for their role in the seemingly exponential recent rise in drug prices. President Trump, who once accused the pharmaceutical industries of “getting away with murder” sang a more sympathetic tune last week. Several central tenets of his plan actually support the industry by aiming to increase competition and negotiating power – though not, however, directly for Medicare Part D, as then-candidate Trump touted as his plan during his campaign.

Secretary Azar further clarified the President’s plans in a speech Monday, focusing mostly on the role of Pharmacy Benefits Managers (PBMs), companies that act as middlemen in drug negotiations between insurers and manufacturers. Azar will seek to restrict how much and from where PBMs can collect revenue during their negotiations. The lack of action regarding pharmaceutical manufacturers comes as no surprise to most, considering Secretary Azar’s history as a former industry leader himself.

Also as a part of the administration’s overall efforts to decrease drug prices, the Food and Drug Administration released new data on Thursday about which pharmaceutical companies were potentially “gaming” the drug pricing system by blocking access for other corporations to develop generic (and cheaper) versions of their products.

This national conversation about drug pricing is one that has been ongoing in the HIV community for years, from the creation of the AIDS Drug Assistance Program to subsidize exorbitant HIV medication costs in the 1980s to the prohibitively high cost of one of the only FDA-approved PrEP drugs, Truvada. Most people living with and at risk for HIV are able to get the medications they need thanks to what HIV activist Tim Horn terms the “patchwork of coverage” in place to pay for HIV-related treatments; however, AIDS United will continue to monitor any legislative or regulatory changes proposed by this administration regarding drug pricing and will work to ensure access to these lifesaving drugs is only increased.

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