Viral load as low as 400 copies/ml six months after starting ART is associated with a significant ten-year mortality risk

Michael Carter
Published: 05 July 2017

A viral load as low as 400 copies/ml six months after starting HIV therapy is associated with a substantial ten-year mortality risk, investigators from the United States report in the online edition ofAIDS. People with a viral load between 400 and 999 copies/ml had a 20% mortality risk, similar to the 23% risk observed in people with a viral load between 1000 and 4 million copies/ml. In contrast, the mortality risk was only 14% for individuals who rapidly achieved complete viral suppression – a viral load below 20 copies/ml.

“A single viral load measurement collected six months after initiating ART [antiretroviral therapy] remains highly informative regarding the risk of death over 10 years,” write the authors.

The aim of ART is rapid and sustained suppression of viral load to below the limit of detection (between 50 to 20 copies/ml depending on testing assay). Treatment guidelines suggest that viral load should be undetectable six months after the initiation of treatment. Newer antiretroviral drug combinations, especially those containing an integrase inhibitor, suppress viral load more rapidly.

Ongoing low-level viral replication despite therapy is associated with the emergence of drug-resistant virus, causing treatment failure and an increase in the risk of HIV- and non-HIV-related illnesses. Small increases in viral load once complete suppression has been achieved, above the limit of detection on occasional tests, so-called viral load `blips`, do not predict treatment failure and are not problematic. This study looked at the failure of treatment to achieve viral suppression after six months.

Analysing viral load measurements taken six months after ART initiation, a team of US investigators sought to determine the level of low-level viraemia (up to 1000 copies/ml) which was associated with an increased risk of all-cause mortality over ten years.

Their study population consisted of approximately 8000 adults who initiated ART between 1998 and 2014. Study participants were followed until death or for up to ten years.

Median age at baseline was 40 years; 83% of participants were male; 62% were in the men who have sex with men risk group; 45% were white and 12% reported ever injecting drugs. The median pre-ART viral load was 75,000 copies/ml and the median year of ART initiation was 2007. Approximately a third of people had been diagnosed with AIDS before starting treatment.

The median period of follow-up was 6.2 years, during which time there were 863 deaths.

Over half (57%) of viral load measurements six months after starting therapy were below 20 copies/ml, with 15% measured at 1000 copies/ml or higher.

As expected, compared to a viral load below 20 copies/ml, a viral load above 999 copies/ml was strongly associated with an increased risk of all-cause mortality over ten years (HR = 1.96; 95% CI, 1.56-2.46). A slightly increased risk of mortality was discernible at a viral load as low as 130 copies/ml (HR = 1.39; 95% CI, 1.02-1.88).

“While we observed an increased hazard of death with low-level viral loads, discernible at 130 copies/ml,” write the authors, “this association was largely driven by the elevated mortality risk experienced by patients with viral load between 400 and 999 copies/ml.”

The average ten-year mortality risk for people with a viral load below 20 copies/ml was 13%, similar to the 14% risk observed in individuals with a viral load between 20 and 400 copies/ml. The ten-year mortality risk was 20% for people with a viral load between 400 and 999 copies/ml, comparable to the 23% risk for people with a viral load of 1000 copies/ml or higher.

“Low-level viral loads between 400 and 999 copies/ml shortly after starting ART appear to place patients at a significantly higher 10-year risk of death than patients with viral loads under 20 copies/ml, and occurrences of viral loads in this range may need to be treated similarly as viral load that exceed 1000 copies/ml,” conclude the authors. “Given the importance of rapidly achieving virologic suppression after initiating treatment, further investigation of the causes of unsuppressed viral loads between 400 and 999 copies/ml is warranted.”

The authors suggest that incomplete viral suppression six months after starting treatment may be a marker for several problems. Apart from lack of adherence to treatment or poor retention in care, incomplete viral suppression might be a consequence of undetected drug resistance, or of drug-drug interactions that lead to low levels of antiretroviral drugs. Planning in advance to prevent these problems from undermining treatment, and prompt investigation of any problems, are likely to improve the chances of viral suppression

Medicaid Value

Medicaid is big and growing — but should it be reined in? Alexandrta Bachert, Staff writer for MedPage, discussed the value of Medicaid and I thought that it would be important in light of the budget and new health care policy cutting back on Mecicaid. The House Republicans and the White House have recently proposed massive reductions in the Medicaid program, which could shave more than $1 trillion from projected expenditures over the next 10 years.

Much of the debate over these cuts has centered around the effects on children and the poor, but about 40% of the Medicaid budget pays for long-term care for the elderly, many of whom are poor only on paper. In this edition of “Friday Feedback,” experts discuss the critical role Medicaid plays in the healthcare system, particularly for America’s increasingly numerous seniors, and what might happen if funding is slashed.

To what extent has Medicaid gone off the rails, relative to its original intent? Or was the original intent faulty?

Diane Rowland, ScD, Kaiser Family Foundation: The original intent was that Medicaid would be a companion to Medicare in meeting the health needs of the nation’s poor and disadvantaged population — a role it has filled well.

Hemi Tewarson, JD, MPH, National Governors Association: Medicaid is now the largest public payer of health insurance, covering 1 in 5 Americans in 2016 and half of all births nationally. The magnitude of the program and its complicated structure has certainly evolved since the program’s inception. However, the program is still serving our nation’s most vulnerable populations, through a federal-state partnership, which was the original intent of the program.

Leighton Ku, PhD, MPH, George Washington University: Medicaid always had a broad mission to serve the needy, including low-income children, adults, the elderly, and the disabled. It has kept that mission, but broadened it over time as it became necessary — as we learned of the importance of home and community-based care and of difficulties that low-income adults have getting insurance.

Sara Rosenbaum, JD, George Washington University: Medicaid’s purpose always has been to help people gain access to medically necessary care. Over a half century, Congress has repeatedly and steadily expanded the range of people in need who can qualify for Medicaid. What makes it so unique is its ability to evolve over time. There is nothing about the adult expansion that in any way is at cross-purposes with its original “intent.”

Tom Buchmueller, PhD, University of Michigan: I wouldn’t describe Medicaid as going off the rails. Going back to the program’s origins, it was political considerations that led to Medicare being a universal program and Medicaid being means-tested. Very quickly, Medicare became a cherished and politically sacrosanct institution, while Medicaid has struggled for political support. But now that Medicaid is the larger program in terms of enrollment, we need to recognize it for what it is: a critical part of the healthcare system.

Kenneth Brummel-Smith, MD, Florida State University: I don’t think it has. The original intent was to help states provide medical care to poor residents. Prior to 1965, old and poor people were more likely to die from treatable conditions than after Medicare and Medicaid were passed. The problem with Medicaid is that the states (and the feds to some degree) have never put enough cars on the tracks to handle the need.

Chris Pope, Manhattan Institute: The original intent of Medicaid was somewhat nebulous. The program has always given enormous discretion to states – in terms of which services are covered, who is eligible for them, and how they are delivered. That said, the program has been expanded by Congress over time, and the 1999 Olmstead Supreme Court decision greatly expanded the entitlement to long-term care in the home.

Matt Salo, National Association of Medicaid Directors: Medicaid didn’t set out to be the largest payer of long-term care in the country, but since Medicare doesn’t offer a comprehensive benefit; we’re there to pick it up. Medicaid probably should be “less necessary” in the healthcare system than it is today, but the fault doesn’t lie within Medicaid and that certainly doesn’t mean that Medicaid is broken and needs knee-jerk fixing. It means that the broader healthcare system is broken. To really fix Medicaid, you have to ensure that the roles it plays today are adequately and affirmatively picked up somewhere else.

How much of a problem is it that so much of eldercare is now dependent on Medicaid?

Brummel-Smith: It’s huge and going to get bigger. The aging of the population means more will need help with medical care and the older population is high consumers of healthcare. Here’s the paradox of providing good care — people live longer which means they’ll need more long-term services and supports. They don’t want to buy long-term care insurance, or they can’t afford it. And the size of families is decreasing meaning they’ll be fewer family caregivers. And we have an anti-immigration attitude, yet immigrants are the main people who are willing to work in these jobs. A perfect storm.

Buchmueller: The patchwork system we have for financing long-term care has many problems that will only become more challenging as the population ages. It is too bad that we are spending so much time and energy fighting about Obamacare — and trying to undo its real successes — instead of trying to address the issue of long-term care and other real issues that the U.S. healthcare system faces.

Pope: Family has always taken most of the responsibility for caring for older adults, largely uncompensated, and often at substantial personal cost. This remains the case, but families are more fragmented than they used to be and people are moving further for work — this increases the need for paid care. There will not be enough money for the government to cover all long-term care services for everyone, and so it is essential to limit Medicaid long-term care to those who have no other sources of assistance, and find ways of leveraging alternative resources wherever possible.

Tewarson: As Medicare and other commercial plans do not cover most nursing facility services and home and community based services, Medicaid is often the only option and as a result, is now the single largest payer of long-term services and supports (LTSS) in the U.S. If federal Medicaid funding was capped, states may need to consider different options, which could include reducing the number of individuals receiving LTSS in states that have a rapidly growing elderly population.

Rowland: Medicaid was always intended to help those on Medicare who were low-income and needed assistance with filling Medicare’s gaps — especially for long-term services. Because efforts to broaden long-term services beyond Medicaid have not succeeded, Medicaid remains the primary source of help for elders in nursing homes or needing help with long-term care in the community.

George Grossberg, MD, Saint Louis University: People are too dependent on Medicaid to pay for long-term care, especially nursing home care. Far too few have long-term care insurance or use family resources or save over a lifetime to pay for needed long-term care in the future. This places an inordinate burden on taxpayers, especially with our booming older adult population.

As for the rest of Medicaid, with the growing cost due mainly to the increasing costs of healthcare, won’t budget cuts simply deprive the poor of access to care?

Brummel-Smith: Absolutely. The biggest concern is that these folks are not good advocates for themselves — they are sick, frail, and often demented. I’m afraid that the government’s response will be following the words of Ebeneezer Scrooge — “They had better die and decrease the surplus population.”

Grossberg: Yes. Medicaid is insurance for the poor. Medicaid cuts will hurt those without personal/family resources the most, whether children or adults.

Daniel Derksen, MD, Arizona Center for Rural Health: You don’t save money by throwing millions off of coverage. That strategy shifts costs to states, to individuals and their families, and to physicians, hospitals, clinics and nurses through uncompensated and charity care. It strains credulity to cut almost a trillion dollars of federal funding to state Medicaid programs over the next 10 years, and claim that bill gives states more autonomy.

Joanne Lynn, MD, Altarum Institute: Cuts in Medicaid for the disabled elderly mean that people with no other options will be desperate before they get help, and the help will be inadequate. We will nearly triple the number of frail elderly Americans in the first half of this century. When we are old and frail, we will most likely have few financial resources and volunteer caregivers. The country should be making plans for an aging population and building more reliable and efficient systems in the few years before the Boomer generation starts hitting their years of disability. Simply cutting Medicaid won’t accomplish that.

Stephanie Woolhandler, MD, MPH, Hunter College: Rising Medicaid costs have been due to a large extent to the increasing number of people covered by that program. As employer-based insurance covered a shrinking share of the population, Medicaid filled the gap. Cuts to Medicaid are likely to result in both worse quality of care for those who remain covered, and cuts in the number covered. Many will suffer.

Rowland: With rising health costs and a growing elderly populating, reductions in the federal financing of Medicaid will place serious strains on state’s ability to maintain coverage and services for their low-income population. Both coverage and access to care are at risk.

Rosenbaum: Medicaid’s costs in the coming years are heavily driven by rising enrollment. In terms of covering the poor, Medicaid is the most cost effective means of doing so — 50% lower than private insurance for the same basket of services. Those who qualify for Medicaid because they are poor will go without access to affordable coverage if benefits are taken away. Just compare the uninsured rate among the poor in non-expansion states to that for the poor in expansion states. All of our gains will be lost.

Ku: It is very clear that Medicaid costs per person grow more slowly than per person costs in private insurance and Medicare. Medicaid is already very efficient and pays less than other forms of insurance. Federal efforts to shift costs to states will generally be problematic for states, which must balance their budgets. It may be possible to modify benefits or payment rates to become more efficient, but this is hard to do and takes time, trial, and assessment. It’s not clear that conservative politicians have the patience or temperament to figure out what works best while harming the fewest number of beneficiaries.

“Medicaid probably should be ‘less necessary’ in the healthcare system than it is today, but the fault doesn’t lie within Medicaid and that certainly doesn’t mean that Medicaid is broken and needs knee-jerk fixing.” — Matt Salo, of the National Association of Medicaid Directors, on the current debate over whether Medicaid has grown too big.                                                                                                                               “The scientists, the physicians in our country are under assault with this Trump budget.” — Sen. Ed Markey (D-Mass.), addressing a rally organized by the American Thoracic Society in Washington. Providers are now asking- how much pain will per capita caps in Medicaid bring?                                                                                                                        The administration released what it calls a “Taxpayer First” budget on Tuesday. “This is, I think, the first time in a long time that an administration has written a budget through the eyes of the people who are actually paying the taxes,” White House Budget Director Mick Mulvaney told reporters in a briefing on Monday. The plan was crafted with a skeptical eye toward programs that serve the needy. Over a decade, it calls for hundreds of billions of dollars in cuts to Medicaid, food stamps and disability benefits. Marie Lee, last week, reported that the end of Medicaid as an entitlement program is a coming, provider sand political observers say. Now the question is how much will the federal government seek to reduce its spending on the insurance program that covers 70 million people—and how much will senators listen to providers who say that care could ultimately become unattainable for people if the House version of a per capita cap is approved. 
The American Health Care Act, passed by the House in early May, aims to cut federal spending on Medicaid by $834 billion by 2026, and it’s hard to know exactly how that will play out for patients and providers, said Grady Health System CEO John Haupert.
“You would have to look at every channel Medicaid flows through,” he said. “Long-term care. Outpatient—what will be covered? What won’t? It has to come from somewhere.”
Grady sees 650,000 visits each year at six clinics and a specialty HIV/AIDS clinic, and has 27,000 inpatient admissions. It also has a 300-bed skilled-nursing facility.Medicaid covers the vast majority of patients in the nursing home, and 30% of all patients are enrolled in the program.
What he knows is that Georgia isn’t going to step in and increase funding to replacethe declining federal share.
Combined state and federal spending on Medicaid in Georgia is about $4,000 a person, 48th in the country. “There’s a reason why we’re 48th, put it that way,” Haupert said of the state’s willingness to spend on medical care for the poor. 
Cleveland’s MetroHealth system has about 280,000 patient visits a year, with half covered by Medicaid. Dr. Akram Boutros, CEO of the public hospital and its health system, fears that what will be left for Medicaid will not be enough to cover the cost of treating the population, which tends to have a higher disease burden than the general population. 
Boutros understands that providers need to find ways to bend the cost curve, whether in Medicaid or any other patient group, noting that the health system did a medical home demonstration with 28,000 Medicaid expansion patients in 2013 that resulted in $41 million in reduced costs. Ohio cut payments for outpatient Medicaid services by 5% in 2016.
“And remember,” he said, “We’ve been through this before. The American hospital system was asked to take Medicare cuts to fund Medicaid expansion.”
Katherine Hayes, director of health policy at the Bipartisan Policy Center, agreed. “Providers were asked to pay for a lot of the health reform, and now they’re paying for it again—more than paying for it again—with less coverage.”
Hayes, who worked for both Democrats and a moderate Republican senator in her time on the Hill, said the structure of a per capita cap isn’t necessarily a problem, it’s how much the federal government aims to reduce its share of spending.
“When you are putting in $834 billion in Medicaid cuts, you cannot make up the difference by scaling back eligibility of the Medicaid expansion,” she said.
Georgia never did a Medicaid expansion, which Grady estimates would have brought $25 million in revenue to the system. Still, Grady reduced its uncompensated care by $68 million, going from the equivalent of 41% of total revenue to now 28%. The system hired navigators to get qualified patients enrolled in Medicaid.
Because the ACA’s phase-out of disproportionate-share hospital payments was delayed, Grady still receives $80 million a year. The phase-out would have reduced it by $45 million a year.
To soften the blow of Medicaid cuts, House GOP leaders would make disproportionate-share payments permanent, for a nationwide price tag of $43 billion. Haupert said that would not nearly make up for the effects of the per capita cap.
When he was lobbying in Washington against the AHCA, he asked a Georgia Republican lawmaker why the savings couldn’t come both from Medicare and from Medicaid. He said the member replied: “If you mess with Medicare, you don’t get re-elected; if you mess with Medicaid, no one really cares. ”
Haupert said as he sees the political backlash against the AHCA, it seems that sentiment’s not totally wrong. Nearly all of the focus has been on the individual market, which is 4% to 5% of his system’s patients. Will people in the individual market who are sick have access to insurance they can afford to buy? Will modest-income older customers be able to buy plans?
He said he knows many people whose parents’ nursing home or other long-term care costs have exhausted their savings, ultimately sending them to Medicaid. Most people never think that will be them, he said, and many wrongly assume Medicare pays for assisted living and nursing home stays.
Still, Haupert believes senators are open to hearing from providers about what kinds of changes are too radical for the system.
“I think in general the Senate is doing a bit more due diligence around this,” he said. “I still sense this high level of pressure to get it done, get it done. When you’re in a hurry, that’s when you make mistakes.”
Hayes said she believes providers’ lobbying will make a difference. And, she said, senators are paying attention to the Congressional Budget Office’s scoring that showed the changes to the ACHA did little to move the dial on the number of people who would become uninsured. The most recent report estimated that 23 million people would lose coverage by 2026; scoring of the original bill in March put the number at 24 million.
Besides the direct financial implications for providers, the potential loss of coverage poses another challenge, says Dr. Nick Turkal, president and CEO of Aurora Health Care, a 15-hospital system based in Milwaukee. “The other thing that concerns me is that we’ll be going back to people coming to the emergency department in a crisis rather than getting the care they need in preventive services and primary-care services. That’s not an efficient way of getting care,” he said.
Haupert said he hopes the per capita cap allows below-average spending states to catch up to more generous states, or at least that there will be special consideration for safety-net systems like his. For Grady, the cuts to Medicare were very minor, just $8 million in the last four years. “Our margin, with county support, is around 4%,” he said, and they received $55 million from the counties they serve last year. “Without county support we’d be at about a negative 1%.”
He said when he talks with county officials about what’s happening in Washington, he can see they fear if the federal government steps back, then the bill will come due first to states, and then, they’re asking themselves, “Is this going to land in our lap?”

So, budgeting is going to impact a number of programs in all areas including health care. We need to look carefully at where the money goes and whether it is worth decreasing those programs that serve as safety nets. If we want to cover all we need to come to grips with the fact that some where we are going to find a way to pay for it all and maybe lowering taxes will impact all programs as well as health care. What other ways to we have to pay for 24 million people who need financial assistance? Think about it and yes I will be discussing this aspect further in my answer to our health care dilemma.

Happy Memorial Day to all and remember why we have set aside this day- to remember those who gave their lives for all of us., to protect our freedoms..

Florida Phasing Out Project AIDS Care, Other Medicaid Waivers

Thousands of Floridians living with AIDS could be losing financial assistance they say is essential to living a normal life, and some AIDS groups are worried the state won’t carry through on its promises.

On a recent Tuesday morning, Brandi Geoit sits at a conference table at the West Coast Aids Foundation headquarters. Across from her in the small New Port Richey office with butter-yellow walls is Dwight Pollard, a 61-year-old man living with AIDS.

Geoit tells him a new Florida law means patients like him could lose some of the financial help they’re getting through Medicaid.

“We’re not sure if you would keep your Medicaid because you’re still pending for your social security. And you haven’t qualified for Medicare yet because you’re still not old enough,” Geoit said.

Pollard no longer works, and depends on a special Medicaid waiver to cover his health care costs. Medication alone can cost $15,000 a month.

His partner, Ed Glorius, was sitting next to Pollard as he heard the news.

“It just doesn’t make sense,” Glorius said. “It doesn’t make sense to put people’s lives in turmoil. We’re better off than most and I’m freaking out. I’m waking up first thing in the morning thinking about this every day.”

Pollard is one of about 8,000 Floridians with AIDS who get help paying for doctor visits, medications and various home health services through this Medicaid waiver fund, which is called Project AIDS Care. Last month, Gov. Rick Scott signed a bill formally eliminating this waiver for AIDS, along with waivers for cystic fibrosis, developmental disabilities and elder care.

Florida’s Agency for Health Care Administration said while the waiver is going away, AIDS patients in Florida will not see a loss or gap in services. The agency declined repeated requests for interviews, but issued a written statement, explaining transition into a Medicaid Managed Medical Assistance plan.

“We will continue to provide the same services through the same providers for these individuals. The PAC (Project AIDS Care) waiver is essentially a waiver that expanded Medicaid eligibility to those diagnosed with HIV/AIDS and allowed the recipients to access needed medical services (e.g., physician services) and drugs. Given the advances in pharmaceuticals available to treat HIV/AIDS, most PAC recipients in the waiver only need those medical services and case management. With this transition, their eligibility will be maintained and they will continue to have access to the medical services, drugs and case management under the MMA waiver through the health plans. They will see no reduction in services and will be able to continue to see the medical professional they always have.”

The agency said patients will go into the Medicaid Long Term Care program starting this month. Everyone will be transitioned into it by Jan. 1, 2018.

But Geoit estimates 90 percent of her clients will not meet the requirements for long term care, which normally applies to people needing round the clock nursing.

She said her clients will definitely lose certain services that Medicaid doesn’t cover. Massages for those with neuropathy? Gone. Pest control? Gone. And services that are currently covered – like delivered meals, adult diapers and wheelchair ramps – could be lost, too.

So, she’s asked the state to clarify how it’s now different.

“When we asked them, they said, ‘Don’t worry. Reassure your client that they’ll be taken care of.’ And when we asked them point-blank what happened, you know, we were under the impression that a single adult still does not qualify for Medicaid. Has this changed? And they ended the conference call,” Geoit said.

Her program – a non-profit – exists only to manage the Project Aids Care waiver money for 325 clients in seven counties including Pasco, Pinellas and Hillsborough. With the new law, Geoit said her foundation will shut its doors by the end of the year.

For Dwight Pollard and his partner, the State Agency for Health Care Administration’s lack of answers is a concern.

“You don’t need the stress of how you’re going to pay or how you’re going to do this,” Pollard said.

But that’s his reality. And Pollard said until the state agency can give clear answers, he’ll keep searching for other programs that can help pay for his life saving medications.

AIDS United’s Statement on President Trump’s Budget for FY 2018

AIDS United is shocked by President Trump’s Fiscal Year 2018 budget request released today. It threatens to roll back the progress in the fight against the domestic HIV epidemic. Now more than ever we must maintain and strengthen our progress towards our national goals and priorities of reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, and reducing HIV-related health disparities.

The deep proposed cuts to domestic HIV and STD prevention cannot be reconciled with the goal of preventing new HIV transmissions and the rising rates of STDs. The proposed $59 million cut to the Ryan White HIV/AIDS Program, coupled with a fundamental restructuring of the Medicaid program capping federal spending for the first time to the tune of a $610 million funding reduction over the next decade, diminishes every community’s ability to deliver quality health care to people living with HIV by eliminating AIDS Education and Training Centers and Special Programs of National Significance (SPNS).

“AIDS Education and Training Centers (AETCs) are essential to the HIV care continuum and the success of the national goals and priorities to end the epidemic,” said AIDS United President & CEO Jesse Milan, Jr. “AETCs assure that providers know and apply the best standards of care for people living with and at risk for HIV.”

Further, AIDS United is particularly concerned that the President’s budget eliminates SPNS and reduces funding for Minority AIDS Initiative (MAI) programs. SPNS and MAI programs address the HIV epidemic by developing targeted, innovative approaches to reach chronically underserved people.

“Investment in targeted approaches are effective and save money, at a time when 1 in 2 and 1 in 4 Black and Latino gay and bisexual men respectively are at substantial risk for HIV infection in their lifetime. How can we reduce funding to programs that address these disparities? The President’s budget isn’t just a set of numbers, it’s a disturbing statement of values. Every voter must send their own message to Congress to express that they value the health of our people,” said Milan.

AIDS United urges Congress to reject the draconian cuts proposed in the President’s budget request and support funding for Medicaid, HIV programs, and STD prevention. Congress cannot idly allow the return of reduced, sequester discretionary spending caps for fiscal year 2018. These restrictive caps must be raised so that non-defense discretionary programs, which include HIV programs, can be adequately funded in fiscal year 2018. A bipartisan budget agreement that provides relief from the sequester spending caps while preserving parity between defense and non-defense discretionary programs must be achieved for 2018.

“The president’s budget would turn back the clock for years and years on progress to end the HIV epidemic. We call on Congress to keep the country moving forward,” said Milan.

New Administration, Old Approach: Trump advocates Medicaid Block Grants & ACA Repeal

 

As the shifting legislative landscape of President Trump’s first 100 days continues, two major developments emerged in the health care reform world: that the Trump administration plans to block grant the Medicaid program and that President Trump signed an initial executive order weakening the ACA.

 

From its inception in 1965 under President Lyndon Johnson until the present day, Medicaid has served as a public insurance program for low-income individuals, families, and people with certain disabilities. Unlike Medicare, which was created at the same time and is both federally funded and administered, Medicaid is a federal-state partnership program in which each individual state administers their own Medicaid program using a mixture of state and federal funds, provided that certain services and populations are covered. For the entirety of its existence, Medicaid has been an entitlement program, which means that the government is required to provide coverage for anyone who meets the eligibility rules for enrollment. This means that the amount of money being spent on a state’s Medicaid program fluctuates from year-to-year based on how many people qualify for coverage.

 

Every Republican President since Ronald Reagan has tried, and so far failed, to turn Medicaid from an entitlement program into a discretionary block grant program. Block granting Medicaid would mean the federal government would present states with a predetermined amount of money to serve their low-income and disabled residents at the beginning of each year. Most plans to block grant Medicaid would determine the amount of funding based on previous state and federal Medicaid spending in a given state, with slight changes each year to account for inflation. The states would then be allowed to determine exactly how to spend that money with many fewer requirements than in the current system. This means that if there were a recession, an unexpected disaster, disease outbreak or if general health care costs continued to rise faster than inflation, state governments would not be given extra federal funds.

 

In such a situation, states would address the health care needs of their low income and disabled residents through a variety of means, but most would reduce or eliminate covered services, restrict access to the program, or introduce higher cost-sharing mechanisms. Taken together, this would adversely affect the health and wellbeing of those in need of care. In a best case scenario, states would take on the excess costs themselves. However, this might prove difficult since many states are required to balance their budgets which might require tax increases or additional sources of revenue to meet these increased Medicaid costs. As a result, many states would choose to avoid added costs by changing the Medicaid eligibility criteria, reducing Medicaid benefits, and simply not providing care to people who are eligible. According to an analysis of a previous Republican proposal from 2012, the block granting of Medicaid could wind up dropping anywhere between 14.3 million and 20.5 million people from care.

 

It is nearly impossible to overstate how devastating Medicaid block granting would be for people living with or at risk of contracting HIV. Right now, Medicaid is the largest source of insurance coverage for people living with HIV, covering more than 40% of people with HIV who are in care. At the same time, Medicaid accounts for 30% of all federal HIV spending and when combined with state Medicaid spending, represents the 2nd biggest source of public HIV financing, trailing only Medicare. Under block grant funding, people living with HIV could bear some of the largest burdens of all impacted populations, because state governments may choose benefit designs that disproportionately affect pricey HIV medications. Given the amount of stigma regarding people living with HIV, LGBT people, and lower income populations, it is possible that some states would choose to do so. Although it may sound unlikely that a state government would discriminate against the provision of medical treatment for certain populations, it has been suggested in the past. For example homophobic legislators in Tennessee openly questioned providing funds to treat people living with AIDS due to their “bizarre lifestyle.” AIDS United strongly opposes block granting Medicaid and we urge readers to call their legislators with that message.

 

President Trump’s executive order intended to weaken the ACA may be more important for what it suggests than for what it actually accomplishes. The executive order directs federal agencies to use their current regulatory authority to “minimize the economic burden” and minimize or remove “any provision…that would impose a fiscal burden on any State, or a cost, fee, tax, penalty, or regulatory burden on an individual.” The order would also grant waivers to states that undercut the cost of consumer protections, encourage the sale of health insurance across state lines, and encourages agencies to use discretion to avoid expanding the ACA.

 

By himself, Mr. Trump doesn’t have the power to repeal or directly impede the implementation of the ACA. However, he can instruct the employees of federal agencies to begin chipping away at the law’s effectiveness. For example, the Trump administration can’t formally strike down the ACA’s individual mandate that all Americans be insured, but he can instruct the IRS to simply not fine anyone who doesn’t abide by the mandate, rendering it useless. Similarly, the executive order instructs the Department of Health and Human Services (HHS) to provide states with considerable leeway when it comes to the implementation of their health care programs and encourages HHS to accept waivers from states that would help them get around ACA regulations that they find overly restrictive.

 

On Thursday, the administration reportedly took another step to undermine the ACA. White House officials ordered the Department of Health and Human Services to halt all advertising and outreach efforts encouraging enrollment in ACA health plans purchased on the Healthcare.govmarketplace during the last days of the 2017 open enrollment period. This is significant because in previous ACA open enrollment periods, the final days were among the heaviest for signing up for health coverage. The White House action does not affect people’s ability to sign-up for coverage on the website; open enrollment ends Tuesday, Jan. 31.

 

AIDS United believes that the ACA must remain in place and that no effort to make changes, including this executive order, should attempt to repeal the law without an immediate and effective replacement in place. AIDS United will continue to provide concise analysis of the what’s happening in Washington regarding health care reform and why it should matter to people living with HIV.

 

Posted By: AIDS United, Policy Department – Friday, January 27, 2017
Search Tags: Affordable Care Act , HIV Policy

In Congress, Obamacare Replacement Plans Start To Emerge

 

Just twenty-five days into the 115th Congress, the Republican congressional majority has made significant steps to make good on campaign promises to repeal the ACA and setup President Trump for swift action on his other top priorities. Republicans kicked off a policy retreat in Philadelphia Wednesday that extends through Friday evening where they hope to hash out how to repeal and replace Obamacare.
While Republicans have had the last six years, and five-dozen attempts to overturn the ACA and plot a replacement, no clear consensus has risen on what to do following repeal. Adding to the uncertainty of how they might repeal and replace Obama’s signature law, is the assertion by President Trump that he will send his own plan to Congress, once his Health and Human Services (HHS) Secretary nominee, Tom Price is confirmed. The notion of the White House sending legislation to Congress is unnerving for many lawmakers and calls into question the separation of powers. Senator Rand Paul M.D. (R-KY), who introduced The Obamacare Replacement Act (S.222) this week, said in a statement that, “Sometimes you get ideas from the White House,” which underscores the atypical nature of President Trumps desired path toward repeal.

The Paul Replacement 

Sen. Paul’s bill has several provisions including an immediate repeal of the individual and employer mandates, the essential health benefits requirement, and other insurance mandates. Further the bill would allow unlimited deposits into Health Savings Accounts and broaden options for using those funds; allow the purchasing of insurance across state lines; and create voluntary associations for insurance pooling.

Cassidy-Collins replacement 

Sens. Bill Cassidy (R-LA) and Susan Collins (R-ME) held a press conference Monday to propose three options states could consider moving forward with health care coverage. States could either keep the Affordable Care Act (ACA) but with reduced federal funding for subsidies, switch to a different system to purchase insurance coverage, again with reduced subsidies , or go forward with an alternate plan that does not include federal assistance. The Cassidy-Collins proposal is in direct contrast to plans discussed by House and Senate leadership, which would not let the ACA continue in any form. Cassidy notes that this proposal serves as a middle-way approach that could potentially bridge Democrats’ and Republicans’ concerns. However, the Cassidy-Collins one-page compromise still needs legislative language.

Cassidy noted:
“At some point in this process, we will need a bill that can get to 60 votes. Now you can say to a blue-state senator who is invested in supporting Obamacare, ‘You can keep it, but why force it on us?’” Collins, affirms saying, “I believe most states would embrace this option, which allows states to cover the uninsured by providing a standard plan that has a high-deductible, basic pharmaceutical coverage, some preventive care and free immunizations.”

The question is, what does the rest of Congress think?

Senate Minority Leader Chuck Schumer (D-NY) described the proposal as “an empty facade that would create chaos.” Schumer wasn’t the only Democrat that predicted insurmountable challenges in the Cassidy-Collins proposal. Democratic leadership call into question the idea of giving some states the option to dismantle the current health care law and replace it with something else or nothing at all, for that matter. Conversely, Republican leadership hasn’t publicly commented much on the generality of the bill. Furthermore, Republicans have persistently supported the dismantling of the current health care law’s taxes and fees.

Presidential Executive Order 

As one of his first actions last Friday, Trump signed an executive order intended to minimize the economic burden of the ACA, pending its repeal. The order allows the U.S. Department of Health and Human Services (HHS) and other federal agencies to use their existing powers “to the maximum extent permitted by law” to weaken the ACA. HHS and agencies such as the IRS “were given vast discretion over key parts of the law including the individual and employer mandates,” per Pro Health Care’s Brianna Ehley. What this could mean is that it is possible to stop the individual mandate from being enforced.

In addition to President Trump’s actions, there was a congressional hearing, at which Republican members sought to expose what they perceive to be a decrease in marketplace competition and affordability. The hearing examined the “Failures of Obamacare.” There was also a hearing on theACA Individual Mandate. The hearing on the Price Nomination for HHS Secretary was also a forum for Republican senators to air their ACA-related grievances.

As HIV advocates we remain vigilant in the changing landscape and continue to seek intelligence and influence the proposed changes to our health care systems. It is imperative that the ACA not be repealed without a replacement that protects the expanded access the law has brought. We must insure vulnerable population, including people living with or at risk for HIV, are provided the access to care they deserve.

Posted By: AIDS United, Policy Department – Friday, January 27, 2017

5 Things To Know About Rep. Tom Price’s Health 

Rep. Tom Price has introduced his own alternative to the Affordable Care Act four times. The legislation provides an idea of how he might lead the Department of Health And Human Services.

Andrew Harrer/Bloomberg via Getty Images

Georgia Rep. Tom Price has been a fierce critic of the Affordable Care Act and a leading advocate of repealing and replacing the 2010 health care law.

Price, an orthopedic surgeon from the suburbs of Atlanta, introduced his own legislation to repeal and replace Obamacare in the current Congress and the three previous sessions. Price’s plan, known as the Empowering Patients First Act, was the basis for a subsequent health care proposal unveiled by House Speaker Paul Ryan, with Price’s endorsement, in June.

Price’s major complaint about the ACA is that it puts the government in the middle of the doctor-patient relationship.

“They believe the government ought to be in control of health care,” Price said in June at the American Enterprise Institute event where Ryan unveiled theRepublican proposal to replace Obamacare. “We believe that patients and doctors should be in control of health care,” Price continued. “People have coverage, but they don’t have care.”

Now that President-elect Donald Trump has tapped Price to lead the Department of Health and Human Services, here are five key planks in his own health care proposal.

  1. Price’s plan offers fixed tax credits so people can buy their own insurance on the private market. The credit starts at $1,200 a year and rises with age, but isn’t adjusted for income. Everyone receives the same credit whether they are rich or poor. People on Medicaid, Medicare, the military health plan known as Tricare, or the Veterans Affairs’ health plan could opt instead for the tax credit to buy private insurance.
  2. Price advocates for expansion of health savings accounts, which allow people to save money before taxes to pay for health care. This includes allowing people who are covered by government health programs including Medicare and the VA to contribute to health savings accounts to pay for premiums and copayments. These proposals are included in Ryan’s plan.
  3. People with existing medical conditions couldn’t be denied coverage under Price’s plan as long as they had continuous insurance for 18 months prior to selecting a new policy. If they didn’t, then they could be denied coverage for that condition for up to 18 months after buying a new plan.
  4. The Price proposal limits the amount of money companies can deduct from their taxes for employee health insurance expenses. Companies can deduct up to $20,000 for a family health insurance plan and $8,000 for an individual. The goal is to discourage companies from offering overly generous insurance benefits to their workers. Ryan’s plan proposes a cap on the employer tax deduction but doesn’t specify the level of the cap.
  5. States would get federal money to create so-called high-risk pools under Price’s plan. These are government-run health plans for people with existing medical conditions who can’t get affordable health insurance on the private market. Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded.

Price has said he’s not wedded to his own ideas and is open to compromise, so the final proposal to replace Obamacare is likely to be a hybrid of his ideas and those hammered out with other Republican House members and presented as Ryan’s plan.

Still, with Price on track to be at the helm of HHS, he would be the one writing the rules to implement whatever legislation is eventually passed.