STATE AND FEDERAL IMPLEMENTATION OF HEALTH CARE REFORM
PUBLIC HEALTH LAW AND POLICY
This project is a collaborative effort led by SASI, with CHLPI, SAC, and HIV PJA. Support from the Elton John AIDS Foundation will enable SASI and its partners to work with stakeholders in Southern US states to protect the health and well-being of people living with HIV/AIDS in the South and to help integrate HIV services providers into the new healthcare landscape. We propose to work on issues of healthcare access and advocacy in nine states that will not expand Medicaid coverage during the first year of ACA implementation: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas. As noted, these states have some of the highest rates of new HIV diagnoses, and are among the states with the highest rates of uninsured residents. This project will focus on maximizing resources available through the ACA and the Ryan White Program to address the care and treatment needs of low-income, uninsured people living with HIV.
In collaboration with the Center for Reproductive Rights, CHLPI drafts and files amici (friend of the court briefs) in support of access to healthcare for women around the globe. For example, CHLPI is currently drafting amici to be filed with the Inter-American Commission of Human Rights challenging El Salvador’s absolute ban on abortion as well as Costa Rica’s ban on abortion even when the mental health of the woman is endangered, both of which have resulted in human rights violations.
Partly in response to recommendations in CHLPI’s Arkansas SHARP report, the Arkansas legislature passed House Bill 2100, authorizing an interim study on barriers to HIV testing and potential implementation of routine, opt-out HIV testing. CHLPI assisted the Arkansas HIV/AIDS Minority Task Force and Arkansas Minority Health Commission in conducting the study on behalf of the General Assembly’s House and Senate Public Health, Welfare, and Labor Committees. CHLPI staff helped design and analyze surveys to learn more about patients’ and providers’ knowledge about HIV testing, researched existing Arkansas law, and produced a report detailing the research findings and making recommendations for reducing barriers to voluntary HIV testing. The report was presented to the Arkansas legislature and governor in June 2013.
Over the past few years, there have been numerous regulations defining how the Affordable Care Act is to be implemented (released by the Center for Medicare and Medicaid Services (CMS), and other federal agencies). To increase public awareness and understanding of the law, CHLPI summarized each major regulation, drawing out the most important issues for advocates working to assist low-income individuals living with chronic health conditions as they transition into new health programs. These documents serve as a guide for advocates, allowing individuals to point to specific legal requirements when holding states accountable to ensure increased access to care.
CHLPI researched, developed, and produced this toolkit and training presentation to provide community-based advocates and others with the information needed to ensure that state Medicaid managed care programs meet the care, treatment, and support services needs of people living with mental health issues. With a growing number of Medicaid beneficiaries being enrolled in managed care programs, advocates need to be able to identify key issues and potential problems, and understand options for resolving them.
The State Healthcare Access Research Project (SHARP) examined successes, challenges, and opportunities to improve access to care for people living with HIV. The project developed comprehensive state-level research reports by conducting a series of focus groups and one-on-one interviews with people living with HIV/AIDS, community-based AIDS services providers, healthcare providers, faith leaders, state and federal government officials, and other researchers and advocates. The insights gained from these meetings were supplemented with independent research. SHARP had three main goals: (1) improve access to care and treatment, with an emphasis on addressing state-level barriers to care; (2) share information and advocacy strategies that reduce barriers to care within and among states; and (3) support coalition development and self-sustained, grassroots advocacy capacity in states. SHARP reports were produced in collaboration with community partners in Alabama, Arkansas, California (Los Angeles County), Northern Florida, Georgia, Illinois, Louisiana, Mississippi, North Carolina, South Carolina, and Texas.
The Affordable Care Act drastically expands access to health insurance, allowing individuals who had historically relied on the Ryan White Program to transition onto Medicaid or private insurance plans, many for the first time in history. To help advocates and legislators understand how this transition would affect access to HIV treatment and services, CHLPI modeled this transition, examining the numbers that would qualify for different subsidies or benefits under the new law, as well as how new plans would compare to Ryan White funded services and prescription drugs.
The Massachusetts Executive Office of Health and Human Services (EOHHS) hired CHLPI to provide guidance on state and federal privacy laws applying to the creation of a state EMR HiWay (a portal that will connect all hospitals and providers across the state, regardless of the interoberability of EMR systems). In spring 2013, CHLPI produced privacy recommendations for EOHHS based on provider practices, the law, and the capacity of the system. CHLPI is now drafting guidance for healthcare providers relating to obtaining patient consent to opt into the new state HiWay.
Individuals living with schizophrenia or other psychosis are overrepresented in prisons, largely due to lack of access to treatment. In response, the greater Boston area is implementing mental health courts, to divert undiagnosed or untreated criminal defendants with mental illness from arrest and/or criminal charge to care. CHLPI is assessing the efficacy of this program as it is implemented in the West Roxbury trial court. Factors analyzed include retention in care, adherence to medication, transition from homelessness to group or individual housing, and rates of re-arrest and/or re-offending.
Undocumented immigrants are a major group which has been shut out of all reforms included within the Affordable Care Act. Immigrant advocacy groups, as well as health centers that work with this population across the country are looking for ways to improve access to care for undocumented immigrants in light of this significant federal policy gap. CHLPI is assisting organizations in several states by conducting research on policies on immigrant health that have been implemented by state and local governments, with a focus on identifying those practices which have the potential to be implemented on a larger scale. The final products will be state-specific policy briefs to be given to several key immigrant health and advocacy organizations to help them with their legislative and policy advocacy efforts.
CHLPI is analyzing the Parity Law to assess the implications reproductive healthcare restrictions have had on the meaning of true parity between physical and mental health. For example, attempts to curb access to comprehensive reproductive healthcare have restricted access to abortion after viability – or at any time with the use of federal funds – except in the case of rape, incest, or where the physical health of the woman is in danger. Since the Supreme Court reads health to include mental health, legislators have increasingly added the word physical as a qualifier when drafting bills relating to abortion restriction. This is one example of the failure to achieve true parity - in mental health and women's health - in the healthcare system. If a woman were told her fetus would not survive outside of the womb for even a few months, she still would not have the option to abort, despite the toll such trauma might take on her emotional health.
In November 2013, the federal government released the final regulation implementing the Mental Health Parity law passed in 2008. This regulation has been long awaited and gives teeth to the law itself, which is critical as the ACA defers to the parity law wherever mental health or substance use disorder (SUD) benefits arise. CHLPI is analyzing the regulation and working on a white paper that will provide guidance for states looking to maximize ACA opportunities to improve availability and quality of community based mental health and SUD treatment and care. Deinstitutionalization continues to be an ongoing struggle across the nation, despite the fact that the Supreme Court ruled it a violation of the ADA to institutionalize an individual who could live in the community with proper supports.
In Massachusetts, pediatricians must screen any child enrolled in MassHealth (Medicaid) at least annually for behavioral health concerns, and refer a child to appropriate care where relevant. However, state data shows that a very low percentage of referred children go to a mental health provider, and some even turn down the initial pediatric screening. CHLPI is researching the factors that contribute to this underutilization of pediatric mental health services, and is developing guidance materials for pediatricians who often lack training in talking to patients and parents about a mental health referral. Specifically, the dialogue should vary for different demographics, as evidence shows that utilization rates and beliefs about mental health services vary by income and race.
To help Massachusetts residents navigate a comprehensive but complex system of healthcare coverage, CHPLI prepared consumer-oriented pamphlets outlining healthcare services and the structure of available coverage that provides access for individuals of varying conditions and means. CHLPI is disseminating the pamphlets through internet publication, health care systems, and local advocacy groups, as well as informing the public via speaking engagements at senior centers and other venues with interested consumers.