A Conversation With Michael Saag, M.D., and Michael Wong, M.D.
The Affordable Care Act: The name alone is enough to make the eyes of clinicians and patients alike glaze over. Yet the impact of the ACA (colloquially called Obamacare) has the potential to be massive when it comes to access to clinical care for HIV-infected people in the U.S. And with more ACA-related changes on the near horizon, the importance of staying informed has never been greater, particularly for health care providers who work in settings supported by Ryan White CARE Act funding.
To discuss the real-world effects of the ACA and offer guidance to HIV health care professionals, we spoke by phone with two leading experts: Michael Saag, M.D., a professor of medicine and the director of the Center for AIDS Research at the University of Alabama at Birmingham, as well as a former chair of the HIV Medicine Association; and Michael Wong, M.D., an associate professor of medicine at Harvard Medical School and the board chairman of HealthHIV, an education and advocacy organization for frontline care providers.
Inside This Discussion
For Better or for Worse
Myles Helfand: Let's dive right in with a question that is probably unfairly binary, because this does not seem like the kind of issue that is easy to parse in yes-or-no terms. But from each of your perspectives -- and let's start with you, Dr. Saag -- is the Affordable Care Act ultimately a good thing for HIV patient care?
Michael Saag: I think, overall, it's a good thing. Number one, it will put, generally speaking, more people into insurance plans, be it Medicaid or some other kind of plan. And it creates more options. In essence, there's more money flowing to clinics and flowing to cover the costs of medications, so it will give some relief to the Ryan White CARE Plan -- and we'll get back to that, I'm sure, later. But the bottom line is, it's a good thing.
Myles Helfand: Dr. Wong?
Michael Wong: I have to agree with Dr. Saag completely. I think with some of the other experiments that other cities and states have been able to do to date, it's proven to be a really positive approach. I think the devil will be in the details of the transition from our current state of affairs into a full implementation of the Affordable Care Act across the country, though.
ACA Impact to Date, and the Massachusetts Example
Myles Helfand: Looking back over the past few years since the ACA was first approved, and the changes that have been implemented in that time, can either of you discuss how the ACA has already altered HIV care?
Michael Saag: You may want to take that, Michael, because you're in Boston and you guys have been experiencing something similar to it for quite a while now.
Michael Wong: For us in Massachusetts, it's not so much ACA; the state has been ahead of the health care reform game. We've had almost-complete, universal health care coverage -- either a combination of state-federal insurance or private insurance -- for over six years. And that portion of the coverage has been helpful.
But taking a step back a little bit: Even before this started, I think there were some fortunate decisions that were made, both legislatively and through our department of public health. Prior to our foray into health care reform and health care payment reform, certain conditions were recognized as being high-cost, high-profile conditions. And existing payment schemes, including safety net programs, weren't going to be quite sufficient to cover the population that was projected to exist. So, some of the things that Massachusetts did early on was to recognize HIV as a chronic condition and put it into the state Medicaid program so that it became covered under state Medicaid. This was probably a good seven or eight years before health care reform was even discussed in the state.
By doing that, the state opened the opportunity -- as Dr. Saag was referring to -- for patients, particularly those who were economically or medically disenfranchised, to actually have coverage, and have the opportunity to enter into care.
At the same time, the state started investing fully into the AIDS Drug Assistance Program. Actually, rather than calling it an ADAP, because of the inclusion of HIV into the state Medicaid program, they actually called it HDAP: the HIV Drug Assistance Program. It very quickly evolved to the point where they used that money, and leveraged that money, to help pay for insurance premiums and insurance copays. So, rather than just drugs, it actually managed the access-to-care portion, and had the medications paid for out of the plans that the patients enrolled in. By doing this, it really amplified the ability for that money to go far.
Then we moved into our equivalent of the Affordable Care Act: payment reform. And in doing this, it's been really impressive, in terms of how we've been able to keep patients in care -- actually reach out farther, engage patients and get them into care.
So I think, in the states that have been able to roll out their insurance programs, and critically looked at their payment coverage schemes and created programs that allow their insurances to be very portable -- but also looked at what they really want to include, in terms of important medical conditions with associated programs that need to be covered, and thoughtfully defined their essential health benefits -- those states are going to be moving ahead very nicely, and probably encounter relatively little pain in the process.
I think the smaller states, or those that have not been able to tackle this in any real, big-picture vision, are going to be the ones that are going to have some problems trying to implement. [Our next steps need to focus on] really trying to help bring those states along in a way that allows them to have more reasonable care across the board for their HIV-infected population, and their marginalized self-care population as a whole.
Michael Saag: If I were in charge, I would model a system after Massachusetts' experience. Oh, wait; that's what the Affordable Care Act is.
Massachusetts has been a great standard-bearer model for the actual basis of the Affordable Care Act. The success that's been there has been continued. If we can somehow depoliticize the whole implementation of the Affordable Care Act, I think everybody would be better off. That probably will never happen.
But even as recently as this week, more and more states are waking up to the benefits of having the federal government help underwrite the costs of adding these additional people onto the Medicaid rolls. That delta -- that difference between what they're currently paying for through their state coffers (in our case, it's about 20% of the federal poverty level) -- if we could get an additional 80% of people into the system, why is that a bad thing, especially with the federal government paying for it? If we can wake up and depoliticize this a little bit, we could go a long way to helping people who really need the help.
Myles Helfand: And you're saying this in the context of your practice in Alabama, where I believe the last word was that the governor did not want to expand Medicaid with the Affordable Care Act because the money wasn't there.
Michael Saag: Yeah. That was one reason. Later, this shifted to: "We didn't have the right infrastructure within Medicaid." And actually, that's a true statement. So, at the last legislature session here -- not to get too much into the weeds in Alabama, but I think it does speak to a lot of other states -- Medicaid was revamped structurally. Now, I think it is in a position, or will be in a position, to participate in the ACA. Hopefully, other states will act and, ultimately, come around.
If we think back to the implementation of Medicare in the '60s, there was probably equal resistance to implementation in several states. Ultimately, folks came around, because they saw the benefit of it and stripped away the politics more and more. Hopefully, that will happen here.
Michael Wong: I'm sitting here, silently nodding my head up and down.
Michael Saag: [Laughs.] I saw that.
Implementation in Alabama, and the Hospital Gap
Myles Helfand: Dr. Saag, have you seen, in the interim, an impact on HIV care in your area? Have you seen more people getting into care? Have you seen the quality of care improve?
Michael Saag: I can't say that I have, yet, because it's been kind of slow. The types of things that have been implemented so far are very incremental, such as increasing the coverage of people's children to age 26.
Frankly, our basic health care to HIV patients in the state of Alabama is mostly carried by the Ryan White CARE Act. There are several Part C clinics very nicely distributed across the state. We get some support from our Part B money -- that is, beyond ADAP -- to help support these clinics. There are also a few community health centers that are participating, but it's mostly the Ryan White CARE clinics. So there hasn't been a lot of change yet. Over the next two to three years, there will be some changes, and I think that will play out.
One other thing I forgot to mention: All of the patients who are seen as outpatients in the Ryan White CARE clinics, that's working OK. But when those patients need hospitalization, the Ryan White CARE Act does not cover that. And that's where Medicaid coverage will help enormously.
One of the leverage points to the states is this notion that it's expected that the states will implement the Medicaid expansion -- and, therefore, that disproportionate share payment to certain hospitals for taking care of a large number of indigents will be ratcheted down. That's part of the way that the Affordable Care Act pays for itself. For places like Birmingham -- and I'm sure there are several other hospitals around the country, especially in the Southeast, who are really dependent on disproportionate share funding to their hospitals -- that will start going away. It's been delayed because the implementation has been a little slower. But ultimately, that's the leverage point.
I can promise you that the state of Alabama cannot afford, for example, UAB Hospital to go out of business. And I'm not saying they for-sure would do so without disproportionate share, but we take care of a lot of indigent patients. The biggest difference, I think, that the Affordable Care Act brings to the table for HIV -- and for all types of care to indigent patients -- is hospitalization coverage.
Michael Wong: I couldnt agree with Dr. Saag more on that, too. As the Chapter 224 Payment Reform bill went through a couple of years ago, some of our safety net hospitals had real concerns that they were going to go bankrupt. Some of these are big institutions that are well-known across the country.
Fortunately, with reform -- and, as he had mentioned, the indigent care population that previously were what we refer to in this state as "free care" -- they got either into the state or the federal government's insurance programs, or actually managed to get into some of these private/public partnership insurance programs. It offset a lot of the "free care" dollars; those actually ended up getting freed up. The payments to the hospitals continued. And they haven't closed.