1. Health Care Reform in Massachusetts:
Opportunities and Obstacles
in HIV Prevention
Kevin Cranston, MDiv
Director, Bureau of Infectious Disease
Massachusetts Department of Public Health
National HIV Prevention Conference
August 16, 2011

2. Overview
• Review of MA health reform law and coverage
• Major HIV/STD/Hep C program changes in
recent years
• Challenges of maximizing benefits of
universal health insurance coverage
• New and ongoing opportunities inherent in
universal coverage

3. MA Health Reform
• Massachusetts in 2006 expanded health insurance
coverage statewide by:
– Expanding Medicaid to 150% FPL (200% for HIV due to
1115 Medicaid waiver)
– Creating an individual mandate (income tax penalty)
– Creating an employer mandate (11 employees or more)
– Defining minimum creditable coverage
– Offering subsidies for adults 150-300% FPL
(Commonwealth Care)
– Establishing a state-managed authority to broker access to
insurance (Health Care Connector)

4. Clear Benefits of MA Health Reform
• Over 98% of MA residents have health
insurance
• Pre-existing condition exclusions eliminated
• Insurers cannot drop coverage due to emergent
health conditions
• Annual and lifetime coverage caps eliminated
• Preventive care and screenings covered

5. Observed Challenges
• Short-term pressure on state budget; savings are in
the long term
• Anecdotal reports of limited primary care providers
and extended wait times for appointments
• Transformation of health care seeking habits by the
previously uninsured (replacing urgent care with care
in the medical home)
• Developing the skill of primary care clinicians in
public health screening and priority treatment
• Questions remain for the coverage of certain
immigrant and refugee populations

6. Practical implications
• Availability of coverage for most routine
health screenings
• Availability of expanded third-party
reimbursement for many services previously
billed to discretionary contracts
• Reconsideration of value of discrete, walk-in
public health services in clinical settings
• New role of public health in supporting
primary care providers

7. Recent evolution of MA
HIV/STD/Hep C screening programs
• Creation and expansion of integrated counseling, testing, and
referral programs (ICTRs): comprehensive HIV, STD, and
Hepatitis C screening at 14 sites
• Loss of state funding for STD clinical services; closure of
eight dedicated STD clinics
• Transformation of role of STD Disease Intervention Specialist
• Recent creation of PICTR-Ts (addition of behavioral
prevention and priority treatment for STDs)
• Through CDC Expanded Testing Initiative resources,
expansion of clinic-based routine HIV screening
• Creation of Hepatitis C medical management service

8. Monthly HIV Testing Volume in a Routine Screening
Clinical Environments Supported by MDPH
600
Number of HIV Tests per Month
Routine screening at Routine screening at Routine screening at
Codman begins 11/08 Dorchester begins 03/09 Baystate ED begins 02/09
500
400
300
200
100
0
8
8
8
9
9
9
9
9
9
9
9
9
9
9
9
0
0
0
0
0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/0
/1
/1
/1
/1
/1
10
11
12
01
02
03
04
05
06
07
08
09
10
11
12
01
02
03
04
05
Time Period (Month/Year)
Baystate Emergency Codman Square Dorchester House

9. Questions for discussion
• Will CBOs delivering HIV services be able to
adapt to a changing reimbursement structure?
• How will health reform transform the HIV
prevention work force? Will CHWs have a
greater or lesser role?
• To what degree does the new CDC funding for
states and cities anticipate national health
reform?

10. Questions for discussion
• Will HIV screening ever become universally
covered health care component?
• If it does, what will be the role of discretionary
funding for HIV testing and screening?
• Will many states will seek Medicaid waivers
to expand HIV treatment?
• If they don’t how will treatment be provided
for all the individuals identified through
expanded screening?