April 19, 2013
On April 1, the Kaiser Family Foundation (KFF) released a report by Jeffrey Crowley from the O'Neill Institute for National and Global Health Law at Georgetown University and Jen Kates, Vice President and Director of HIV Policy at Kaiser Family Foundation. Mr. Crowley, of course, is well known as the former Director of the Office of National AIDS Policy in the Obama Administration and Ms. Kates is a well known researcher with a reputation for independence who has served on numerous Institute of Medicine panels regarding HIV. The report is likely to be important not only because Mr. Crowley continues to have ties to the Obama Administration, giving hints at how current officials may view the future of the Ryan White Program (RWP), but also because the report continues to reflect the strong evolution of thinking about the early provision of treatment and care in the United States.
As such, the report in many ways is a continuation of the National HIV/AIDS Strategy (NHAS), which was released in July of 2010 after passage of the Affordable Care Act (ACA) while Mr. Crowley was the Director of ONAP. The NHAS called for reducing HIV incidence, increasing treatment efforts and focusing on health outcomes, reducing health disparities in the HIV field and for integrating the response to HIV of various government agencies. The report explicitly cites three trends since the previous reauthorization of the RWP in 2009, including scientific evidence that viral suppression not only helps individual patients but reduces the risk of HIV transmission, passage of the ACA and introduction of the NHAS as reasons to contemplate some change to the program. The authors acknowledge that questions about the timing of reauthorization have been raised, particularly in that the far reaching ACA changes in 2014 remain unpredictable since some states will not expand Medicaid.
The new report suggests key issues and potential strategies for policymakers to consider that are strongly suggestive of the NHAS. The four issues are:
Several key issues in the report bear further thought. Among them is linking the RWP to the steps of the well known HIV treatment cascade. In a series of steps (diagnosis, linkage to HIV care, retention in care, on anti-retroviral therapy, suppression of viral load), the cascade shows that over three quarters of people living with HIV in the U.S. are not achieving sustained viral suppression. The report suggests using the cascade specifically for measuring clinical and HIV indicators and potentially updating rules about the provision of core and supplementary medical services that might interfere with providing support along the cascade.
A second point of interest is that the Affordable Care Act should not supplant Ryan White Services but rather discusses the many ways that the Ryan White Program will likely be needed to supplement the increased health coverage and access after the introduction of health exchanges and Medicaid expansion in January 2014. An interesting point made in the report is that this is already the role that the RWP plays. In fact, 70% of Ryan White Program clients today have insurance coverage of some type. The authors write that, "This suggests that insurance coverage, on its own, is often insufficient to protect against the high cost of HIV care or to provide the range of services needed to keep people with HIV engaged in care and on treatment." In fact the authors note that the demand for Ryan White Services could actually increase and require additional resources going to the Ryan White Program to better achieve the goals of reducing incidence and maintaining people in treatment and care.
Another strong point is the desire to retool the Ryan White Program to better reach the most marginalized populations. The authors strongly note that one success of the RWP is that it is grounded in community response and that some core aspects of the response should be retained. Among these roles is building and sustaining HIV care networks in underserved communities. The authors suggest that three programs, the Minority AIDS Initiative, the Part D program and the AIDS Education and Training Centers (AETCs) have the potential to provide collaborative roles in developing "evidence based models for intervening to improve outcomes for targeted populations." The authors suggest strengthening the focus on gay and bisexual men, particularly young and racial and ethnic minority men who are at significant risk of infection. They also suggest considering focused programs for high-cost cases and especially vulnerable populations. One issue that comes up but is not resolved is the role of Community Based Organizations (CBOs); it is suggested that CBOs will need assistance in adapting to changing roles and suggest that in some cases consolidation will be needed.
There are several points of contention. Among them are calls for a reconsideration of funding formulas for Parts A and B, review of assertions that Part D is more generously funded than Part C and modifications to the SPNS program and potential changes to how planning is done at the local community including planning councils. These controversies are likely to be at least somewhat balanced by calls for greater transparency, greater integration and reductions of administrative burden.
Ultimately the report is likely to be a useful tool for new ideas and helping to guide administrative and legislative changes as the Ryan White Program continues its mission of care completion in the age of expanded health care coverage under the Affordable Care Act.