This guest blog post is the second blog in a series on discrimination in health plans. In this blog we highlight how discrimination in health plans affects people living with HIV/AIDS and policy recommendations to address the issue.

While the ACA expanded access to private health insurance plans for low-income individuals through the creation of the health insurance Marketplace and the provision of subsidies, increasingly industry practices are preventing people with chronic conditions like HIV from fully benefiting from the law. The barriers to meaningful health insurance coverage can be summed up in three categories:

  1. Lack of Transparency: One of the goals of the Marketplaces was to permit consumers to compare health insurance plans and make an informed decision about which plan best covered their health care needs. However, failure to include cost information (such as the actual price of a medication when a consumer is expected to pay co-insurance), lack of standardization of plan formulary information, inadequate information on drug coverage and essential provider networks, inconsistencies between the Marketplace and plan websites, and changes to plan design subsequent to enrollment seriously undermine the ability of consumers to select the right plan for them.

    Recommendations for Advocates: Further legislation and regulations are needed to strengthen transparency at the state and federal level. For example, in Nevada, the Department of Insurance proposed a regulation to limit the ability of plans to reclassify drugs after the end of open enrollment.  Consumers should also be educated on what kinds of information to ask for when selecting a plan, such as drug pricing and mail order pharmacy requirements.
  2. Inadequate Coverage of HIV Medications: Despite early advocacy efforts, many health insurance plans do not cover all HIV medications, including single tablet regimes (STRs), in accordance with the standard of care as recommended by the Department of Health and Human Services (HHS). In many states, plans are covering fewer protease inhibitors, the class of antiviral drugs widely used to treat HIV and hepatitis C, than required in the mandatory essential health benefits package (EHB) that plans offered on the exchanges are required to provide. In a recent assessment of the qualified health plans offered on 15 different health insurance Marketplaces, 28 percent of plans did not cover all HIV medications and 19 percent of plans did not cover STRs. The plans that do cover these medications may impose burdensome utilization review and prior authorization requirements, increasing the difficulty of accessing these medications for consumers.

    Recommendations for Advocates: To ensure consumers have access to adequate coverage of specialty drugs, an amendment to the EHB rule is needed to require coverage of specialty drugs where no generic alternatives exists that are widely accepted in treatment guidelines or best practices. In addition, HHS must strengthen the non-discrimination provisions of the ACA to protect people living with HIV/AIDS against formulary designs that do not serve their needs. Insurers should be educated about the health and cost benefits of STRs and consumers should be educated about the importance of checking plan formularies to make sure their required medications are covered.
  3.  Unaffordable Cost-Sharing Structures: Many plans are placing all HIV medications on formulary tiers with very high levels of cost-sharing. According to Avalere’s recent analysis, 50 percent of HIV/AIDS drugs covered on plans offered through the exchanges and eligible for tax credits and subsidies are subject to an average of 36 percent co-insurance. The high levels of co-insurance required can make HIV medications prohibitively expensive for consumers, even with health insurance coverage. Adding to the cost burdens of individuals living with HIV/AIDS, health plans in North Dakota and Louisiana stopped accepting premium payments on behalf of their enrollees from Ryan White/AIDS Drug Assistance Programs (a special federal and state partnership program for individuals living with HIV/AIDS that can help individuals pay premiums and co-pays in some states).

    Recommendations for Advocates: To ensure consumers have access to affordable medications under the plans offered, further regulations at the state and federal level are needed to prohibit excessive co-insurance for specialty drugs where no generic alternatives exist that are widely accepted in treatment. Specifically, HHS should amend the EHB rule to prohibit excessive co-insurance for specialty drugs where no generic alternatives exists that are widely accepted in treatment guidelines or best practices. Regulators should clarify that all Marketplace plans must accept private co-payment assistance. Additionally, there is a need for state and federal laws that limit cost-sharing for specialty and brand-name (when there is no generic alternative) drugs and a requirement to provide information on co-insurance requirements so that consumers can understand the actual price of medications under the plans offered

Continued Advocacy is Critical: What Can Advocates Do?

Advocates can help mobilize provider groups and consumers to demand that insurers and regulations address individual consumer needs and end discriminatory practices that pose a barrier to meaningful coverage.

  • Focus on consumer education during this upcoming open enrollment period: Consumers must be educated about a range of issues, including understanding terms like “co-insurance” and “deductible’ as well as checking plan formularies to make sure their required medications are covered. This plan assessment tool allows enrollment assisters to evaluate plans for their clients living with HIV and to empower advocates to monitor the Marketplaces for potential discrimination.
  • Emphasis on consumer voices: When barriers to care—lack of transparency, inadequate coverage, or discriminatory cost sharing—are observed, advocates should consider filing complaints with state departments of insurance and demanding the enforcement of the non-discrimination protections in the ACA, which prohibit plans from employing discriminatory marketing practices and benefit designs or failing to meet EHB requirements. Advocates should also consider filing complaints with the Office of Civil Rights and to use the court system to put pressure on insurers to forgo discriminatory practices.

While there is much work to be done, advocates in several states have successfully protected and secured access to health care coverage that does not discriminate against people with HIV/AIDS. Stay tuned for the next blog in this series to learn more.

-- Carmel Shachar and Malinda Ellwood, Center for Health Law and Policy Innovation, Harvard Law School

Navigators and assisters have hit the streets for round two of open enrollment for health insurance plans available as a result of the Affordable Care Act. With more people gaining access to care, this is a crucial time to strengthen the way we provide and pay for health care. Integrating services for drug and alcohol problems with other care can play a big role in transforming the health system and meeting goals of better care, better health and lower costs. The Centers for Medicare and Medicaid Services (CMS) are promoting this change in Medicaid, following a few states that are leading the way. Improving care for substance use disorder under Medicaid, which now covers at least 8 million people with substance use disorders, has the potential for profound change nationwide.

Let’s take a look at some service delivery innovations already underway. Washington state is using a prevention and early intervention model called SBIRT – screening, brief intervention, and referral to treatment to help prevent and treat drug and alcohol problem. This initiative reduced hospitalizations among Medicaid enrollees and led to significant savings for the state. Massachusetts saved money and improved care for Medicaid enrollees through medication-assisted treatment (MAT), which combines counseling with prescription drugs that blunt addiction. The research for MAT is strong but states are often reluctant to support it because it conflicts with traditional abstinence-based treatments. Massachusetts has opened the door for other states to use this evidence-based practice.

CMS is launching an initiative to promote more of this type of innovation by highlighting state successes, providing technical assistance and building a cross-state learning community. CMS spotlighted these best practices in a recent memo:

  • Provide a comprehensive benefit package for substance use disorders ranging from prevention to treatment to recovery services.
  • Integrate care for physical and behavioral conditions, incorporating the whole health of the patient by using health homes, primary care medical homes, and other integrated care models.Coordinate care across transitions in both physical and behavioral health care.
  • Implement prevention efforts and strategies to alleviate prescription drug misuse.
  • Head off alcohol and drug misuse in youth, including strategies in primary care such as Screening, Brief Intervention, and Referral to Treatment (SBIRT).

Advocates should urge their states to sign up for the Medicaid Innovation Accelerator Program (IAP) to learn from other states and get technical assistance from CMS. The program will feature monthly calls and webinars as well as hands-on support in preparing the technical documents (waivers or state plan amendments) that may be needed to help transform Medicaid to better treat substance use disorders. The deadline for submitting an "Expression of Interest" is this Friday, November 21. CMS is requiring stakeholder input from states that are selected to participate.

This initiative in Medicaid, coupled with other transformation projects, such as Accountable Care Organizations and the demonstration projects for people eligible for both Medicaid and Medicare, will help make our health system work better for all of us, including individuals with substance use disorders.

Impressive enrollment and reenrollment efforts are expected over the next few months. Let’s leverage this momentum and ensure all consumers – especially those with behavioral health care needs – have access to a coordinated and effective health care system.

Melissa Ough, policy analyst
and Alice Dembner, project director

We’re Calling the Play: Ready, Set, Enroll!

 The Affordable Care Act’s second open enrollment period starts tomorrow! On Saturday, November 15, millions of Americans can begin enrolling in and renewing their quality, affordable health coverage through the Marketplaces. Consumer health advocates and enrollment assisters have been planning for months, further developing the strategies they employed last year to reach the remaining uninsured and assist them with enrolling in coverage. To view the immense impact of their work last year, please watch our video: Getting to Covered.

 They are up to the task and will use innovative tactics, tools and tested messages to meet the goal for this open enrollment period.  Like a head coach before kickoff, we know advocates and enrollment assisters are fine tuning their game plans for this open enrollment season. Perhaps the biggest difference for this season is that advocates and enrollment assisters have two important audiences during this enrollment season: 1) the currently enrolled who need to renew and 2) the remaining uninsured. To reach these groups, we’ll have to use two playbooks.

Playbook 1: Helping Insured Consumers with Renewals

While recent research shows that the majority of consumers who enrolled last open enrollment season are satisfied with their plan, this same research also shows that most of the currently-insured are unaware of the renewals process. Though many consumers will be auto-enrolled in their 2014 plan, the features and benefits of their plan may change beginning in 2015, as well as the amount of financial assistance they may receive. To help ensure consumers enroll in the plan that best meets their needs, advocates and enrollment assisters should encourage currently-insured consumers to review the features of their current plan. In addition, we should work with people who have Marketplace plans to update their information so they continue to receive financial assistance. Lastly, consumers who need to renew should be encouraged to shop around to see if a different plan better meets their needs. Since the currently-enrolled value their coverage and are motivated to keep it, helping them renew hinges on letting them know what they need to do and when.

Playbook 2: Reaching the Remaining Uninsured

While the uninsured rate has dropped from 18.1 to 13.4 percent, which is the lowest uninsured rate since 2008, there are still millions of uninsured Americans in need of affordable coverage. Recent focus group research concluded that the remaining uninsured are less motivated to enroll than the those who were uninsured last year. In addition, they report that cost remains their main barrier to enrollment. However, many of the remaining uninsured are still unaware of the availability of financial assistance to help pay for the cost of premiums and cost-sharing obligations. Messages emphasizing that low-cost plans and financial help are available, as well as in-person application assistance, will be most effective at galvanizing the currently uninsured to explore their Marketplace plan options.

Knowing messages about financial help and in-person assistance are the most likely motivate consumers, what are the best ways to spread this message? Last year we learned that meeting consumers where they are, such as local, highly-frequented venues within the community, was a highly-efficient approach to reaching large amounts of community members in a small period of time. Additionally, using trusted messengers to spread enrollment messages, such as faith leaders, local or ethnic media sources, and family members, was a successful strategy to ensure those messages resonated with consumers. Lastly, lifting up the voices of those who’ve successfully enrolled through story banking can be a compelling way to motivate the remaining uninsured to explore their options.

Having groups of consumers with distinctly different enrollment needs is a change from last year’s open enrollment period, but the tools to achieve both goals are already in the hands of those who contributed to open enrollment’s success last year. Spreading the word about things that matter most to consumers – the renewal process, financial help, and in-person assistance – and using these messages by building on last year’s successful  tactics and strategies, is the playbook to follow to ensure millions of Americans gain or keep quality, affordable health coverage.

 “The healthcare world is changing; providers who have been serving a certain population are now serving a completely new population, a more diverse population. When you talk about cultural competency, what you really need to look at is what the customs, beliefs and values of these individuals are.”

Dr. Terri Mack-Biggs, Geriatrician, Hospice of Detroit, Michigan

There is a significant demographic shift taking place in the United States, particularly for older adult populations. According to the Diverse Elders Coalition, the older population will grow far more diverse in racial, ethnic and cultural dimensions over the coming few decades, as the cohort of Americans age 65 and older doubles in size from 2010 to 2050. A particularly vulnerable population within this broad demographic shift is the Medicare-Medicaid enrollee population, sometimes referred to as “dual eligibles.” According to data from 2008, 61 percent of dual eligible beneficiaries are 65 and over. They have trouble navigating through these two complicated health care systems, often feeling lost in a maze of multiple doctors, medications and programs, and these challenges are often exacerbated for individuals from communities of color.

The Centers for Medicare and Medicaid Services’ financial alignment demonstration projects currently underway in more than a dozen states seek to integrate and coordinate care across Medicare and Medicaid for dual eligibles, and to redress many of the problems experienced in the current disjointed system.

Dual eligibles generally have poorer health status and account for a significant and disproportionate cost burden on Medicare and Medicaid, totaling more than $300 billion annually. People of color comprise 44 percent of the Medicare-Medicaid enrollee population, compared to 17 percent of the Medicare-only population. Diverse dual eligibles face a particularly great challenge in finding culturally and linguistically competent care.

A new paper by Community Catalyst examines provisions in the documents guiding the demonstration projects as they relate to addressing racial and ethnic health disparities and lays out a set of recommendations to move toward achieving health equity for dual eligibles. There is much work to be done. As Patrick Aitcheson of the Diverse Elders Coalition explains, “Equitably meeting the health care needs of diverse populations first requires gaining a deeper understanding of the range and richness of the cultural and linguistic groups you are serving. That is the necessary starting point for delivering culturally competent services.”

Findings from Community Catalyst’s survey of the dual demonstration project documents published to date reveal that while the addressing of health disparities is often present as a broadly stated goal, details of how this goal will be operationalized are largely missing. The paper makes recommendations in the following areas:

Cultural Competency in Care Delivery - The rapidly changing landscape calls for increased training of health care professionals and organizations to provide effective, high-quality care that is responsive to the very diverse cultural and linguistic needs of dually eligible beneficiaries of color.

Language Access - Implementing appropriate language access services can reduce barriers and create clearer pathways for dual eligibles to access the right services, which in turn can improve their health,   their satisfaction with the care they receive, and very often reduce costs by more efficiently connecting beneficiaries to the proper services for their needs.

Quality and Monitoring – Ongoing monitoring and development of appropriate quality measures can lead to a more effective demonstration project.

Consumer Engagement – Having representatives from communities of color participating in consumer engagement opportunities is  critical  to ensuring consumers receive the right services, at the right time in the right setting.

The Centers for Medicare and Medicaid Services, participating states, health plans and providers have a unique window of opportunity in these demonstration projects to improve care for dual eligible beneficiaries of color and point the way forward for the health care system more widely. But success will depend on these stakeholders taking concrete, targeted steps to address health disparities, as well as on strong ongoing involvement by consumers from communities of color and their advocates.

Adolescent drug and alcohol abuse is a major public health issue that has been gaining national attention recently as more and more young people die from opioid overdoses. The prevalence of adolescent drug use is staggering. Imagine a classroom of high school seniors. Using national data, we can estimate that in a class of 30, about 12 adolescents used alcohol and seven used marijuana in the past month. Five adolescents abused prescription drugs in the past year. This is especially troubling given that 90 percent of adults with drug or alcohol dependence began using before age 18.

There are many efforts under way to address this epidemic. The latest is a guide from the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to help state agencies enhance the adolescent addiction treatment and recovery systems, maximizing the opportunities afforded by the Affordable Care Act (ACA). The ACA expands coverage for behavioral health treatment, promotes prevention efforts, and encourages the integration of physical and behavioral health. This generates new opportunities for providers to tackle adolescent substance use; but providers can’t do it alone.

The State Adolescent Substance Use Disorder Treatment and Recovery Practice Guide outlines principles of good care, specific guidance for providers on delivering treatment, and considerations for decision makers who coordinate services for adolescents. Treatment standards and guidelines from 24 states were used to craft these recommendations. Though targeted to the state agencies that oversee substance abuse treatment, the underlying principles are relevant for state officials, providers and advocates alike.

Most importantly, we need to catch adolescents upstream, before a problem begins. Simple, quick screenings can be conducted by a wide range of people, from school counselors to community outreach workers to pediatricians. One specific approach that fulfills the recommendations from the report is called SBIRT (screening, brief intervention, and referral to treatment). SBIRT is an effective prevention tool that can be used in a variety of medical and nonmedical settings. It involves asking young people a few questions about their drug and alcohol use and providing guidance or referring to treatment, if a problem exists. Community Catalyst is leading a national project to promote SBIRT for youth.

For young people who require treatment, we need to recognize that the available treatments for addiction are largely designed for adults. Adolescents benefit the most from specialized services geared toward their emotional and physiological development.

States should adopt systems of care that are recovery-oriented and promote best practices for reaching and treating young people. Services provided using this philosophy are person-centered—the young person directs their treatment as they draw on their own priorities and personal goals for recovery. This approach often employs peer support and mentors, which are key ingredients in a young person’s recovery.

It’s also important to remember that adolescents with addiction often receive fragmented services through multiple state systems (e.g., child welfare and juvenile justice). States can address this through better coordination of services across youth agencies, and a more streamlined continuum of care.

These are just a few key takeaways from the report, which provides a roadmap to addressing adolescent substance use statewide. Only with a coordinated approach, supported by best practices from the field, can we begin to tackle this epidemic. The ACA means that more young people will have insurance coverage, access to screening and expanded and improved behavioral health treatment. States should seize this opportunity to build comprehensive, state of the art systems of care, which will protect young people now and head off future addiction among this generation. 

--- Melissa Ough, policy analyst