Students work to inform cutting-edge policy recommendations at the state and national levels in both the legislative and regulatory arenas. State level work is conducted in Massachusetts as well as other states—currently, projects are ongoing in Alabama, Arkansas, California, Illinois, Louisiana, Mississippi, North Carolina, South Carolina, Florida, and Texas. Students in the Center for Health Law and Policy Innovation often travel to help facilitate trainings and meetings with state elected and appointed officials, participate in national law and policy advocacy conferences, and facilitate issue-based meetings with community partners. Over the course of a semester, students can expect to accumulate a wealth of hands-on experience in current and emerging health law and policy issues. Students conduct legal and fact-based research to inform policy recommendations that take shape as student-generated fact sheets, in-depth reports, comment letters, testimony, presentations, and draft legislation or regulatory guidance.
The passage of health care reform in March 2010 has had and will have a significant impact on our work. Health care reform implementation includes many opportunities to remove barriers to care, put in place integrated and coordinated care systems for chronic disease management, and support community initiatives and advocacy work that focus on early access to care and preventive health. We are working with national, state, and local partners to ensure that implementation at all levels of government is carried out in ways that address the health care needs of low-income people living with chronic illness. Our projects include:
Collaborating with Advocacy Community on a Coordinated Health Care Reform Implementation Response/Health Care Reform Defense
We are working in coalition with national advocates and service providers of those living with chronic medical conditions (particularly HIV and AIDS) to: lead the community’s comments on regulatory proposals; develop infrastructure to tap into grassroots mobilization efforts to keep state advocates informed about federal implementation issues and to better inform federal advocacy; partner with federal agencies and state leaders to identify and pursue strategies to secure access to health care for low-income individuals and families prior to the full implementation of health care reform in 2014; and ensure comprehensive planning to achieve integrated, coordinated deployment of health care reform with the new National HIV/AIDS Strategy.
Healthcare Reform Partnership Project
Assuring the successful implementation of health care reform is crucial for the HIV/AIDS community and depends on the efforts that are and will be undertaken by the HIV advocacy community and our allies in the broader low- income, chronic illness, and disability communities. To maximize coordination and enhance such efforts, Harvard Law School Health Law and Policy Clinic, along with AIDS United and the HIV Medicine Association have initiated a Healthcare Reform Partnership Project to advance collaborative opportunities across and with other critical national coalitions and partners.
Assessing the Adequacy of State Based Exchange to Meet the Needs of Individuals Living with Chronic Disease(s)
CHLPI, in collaboration with a national chronic disease coalition, has advised HHS in the development of regulations relating to EHB. Now, nine state based exchanges have been approved. Beyond analyzing the benchmark plan that the state has set forth to define EHB on its exchange(s), we need to assess the exchange blueprint itself – will the exchange meet the needs of those living with chronic disease? Will necessary services and medications be covered and affordable? In addition to researching these questions, students will develop guidance directed toward HHS to inform federal regulatory reform that is expected in 2016.
Privacy and Information Sharing Project
Healthcare reform, at both the state and federal levels, depends on vastly increasing coordination of patient care, both to control costs and improve quality. Yet data sharing (i.e., sharing medical records) implicates substantial privacy concerns. Harmonizing privacy laws and care coordination goals will be one of the greatest challenges of Affordable Care Act implementation – a challenge that has not been solved. Students are researching federal and state privacy law relating to patient medical record sharing, as well as existing proposed solutions to reconciling data sharing goals with privacy laws. The end goal is to propose a workable solution for any state developing a health information organization, which multiple providers and payers would access.
Providing Outreach and Technical Assistance to State Advocates and Government Officials on State Law and Policy Development and Health Care Reform Implementation
We are conducting educational outreach to grassroots advocates, state-level organizations and state appointed and elected officials to explain effects of reform legislation on existing state and federal programs and funding, timelines for program implementation, and implications for state budgets. Technical assistance includes developing resources and training on the following topics: implementing health care reform in ways that work for people living with HIV and AIDS, including design of exchanges, patient navigation programs, prevention and wellness initiatives, and community health center expansion; defending Medicaid and ensuring that the program works for people living with HIV and other chronic conditions (including Medicaid managed care tool kit/training); utilizing medical homes to provide coordinated care for people living with HIV; and ensuring that health care reform is implemented in ways that expand care for women living with HIV and AIDS.
State Health Reform Implementation Project
CHLPI provides frequent technical support to states as they implement the Affordable Care Act. This spring, we traveled to Arkansas, Texas, Mississippi, Alabama, and South Carolina to assist community partners to advocate state legislators to implement the Medicaid expansion, and to create exchanges that meet the needs of those living with chronic disease(s). A key component of these efforts was the launch of several “Modeling Projects,” which diagram how the healthcare landscape will change for low-income people living with HIV as a result of the ACA (i.e., as individuals on Ryan White programs transition onto Medicaid or subsidized private insurance plans). Through analyzing public and private health plans for people living with HIV in 22 states, the Modeling Project identifies gaps in access to healthcare and the ways in which the ACA can address the needs of people living with HIV. By estimating the proportion of AIDS Drug Assistance Program clients in 50 states who will be eligible for Medicaid and subsidized private insurance in 2014, the Modeling Project also presents a picture of just how dramatic a change healthcare reform will be for this population’s access to healthcare. The data and estimates included in Modeling reports inform state advocates and officials as they work towards implementing health reform, including Medicaid expansion. Other CHLPI tools will also be instrumental in this effort (e.g., Medicaid expansion fact sheets and SHARP reports).
Mental Health & the Affordable Care Act: Opportunities for Further Deinstitutionalization
CHLPI has produced state specific analyses on the importance of Medicaid expansion in Alabama, Louisiana, Texas, Florida, North Carolina, Arkansas, and Mississippi. Now, we are focusing on mental health, which historically has been paid for at the state level, to examine opportunities created by the Affordable Care Act (ACA) for improved access to care, particularly community based care. The final product will be a white paper that provides states with concrete examples of ACA created funding (e.g., grants, pilot programs) that can be used to maximize deinstitutionalizaiton of patients capable of living and accessing treatment in the community.
Securing the Future of Ryan White Programs
At the United States Health Resources Service Administration’s request and in collaboration with the President’s Advisory Council on HIV/AIDS (PACHA), we are developing a white paper addressing how programs under the Ryan White Care Act can evolve over the next four years and beyond as national health care reform changes the landscape of the public and private health care and service delivery systems for low-income individuals living with HIV and AIDS.
Ensuring that that Health Care Reform is Implemented in Ways that Preserve Existing Programs and Ensure Seamless Access to Care for Vulnerable Populations in Massachusetts
We are working with the ACT!! Coalition here in Massachusetts, made up of a wide variety of health care advocacy stakeholders, to advocate for a state health care reform implementation plan that preserves the programs and health systems on which thousands of low-income and vulnerable populations depend. Over the coming months, the ACT!! Coalition will be making recommendations to state policymakers concerning the future of MassHealth and state implementation of the Affordable Care Act Medicaid expansion and subsidized insurance provisions. The Clinic will be working to identify areas of concern around certain vulnerable populations, such as people living with HIV and AIDS.
Analyzing the Massachusetts Experience: A Post-Health Care Reform State in Pre-Health Care Reform World
In many ways, Massachusetts offers an important blueprint for implementation of the Patient Protection and Affordable Care Act. Working in collaboration with the Massachusetts Department of Public Health this project will identify the benefits of expanding access to insurance (and early medical intervention) for people living with HIV and AIDS through both the Massachusetts health care reform law as well as the Massachusetts 1115 Medicaid waiver.
Our work involves federal and state law and policy analysis as well as state and local law and policy advocacy infrastructure development to support efforts to reduce barriers to access to care for low-income people living with chronic medical conditions. Our current projects include:
The State Healthcare Access Research Project (SHARP)
The State Healthcare Access Research Project is conducted in collaboration with in-state community partners and other national organizations. SHARP examines states’ capacity to meet the healthcare needs of people living with HIV and AIDS and other chronic illnesses. SHARP has three main goals: (1) to improve access to care and treatment, (2) to build advocacy capacity in SHARP partner states and communities, and (3) to share information and effective strategies among SHARP partners. To date, SHARP reports for Alabama, Arkansas, Illinois, Louisiana, Los Angeles County, Mississippi, North Carolina, and South Carolina are complete and technical support to state health law and policy advocates is ongoing. The reports for Florida and Texas will be published by the end of 2011.
Hepatitis C and Veterans Massachusetts Advocacy Initiative
This project will assess access to care and treatment of Hepatitis C (as well as common co-morbidities) in Massachusetts, with a focus on veterans. Massachusetts was selected as the focus area because of its robust health care system and its potential to serve as a model for what the rest of the United States will be confronting through the implementation of the Affordable Care Act. Additionally, HCV disproportionately impacts the veteran demographic, making it an essential focal point. The project will bring together diverse community stakeholders who will help to identify successes, challenges, and recommendations to improve access to care. Activities include: initial coalition building and report research; conducting interviews, meetings, focus groups, and background research; all culminating in the production of a comprehensive report. The report would be used to describe what is working through the reformed Massachusetts health system as well as the barriers that continue to need to be addressed in Massachusetts and other states as they implement healthcare reform. As is true for the State Healthcare Access Research Project, collaboration with community partners—including people living with HCV, support services providers, government officials, health care providers, academics, faith-community leaders, and private industry representatives—is integral to the success of this project.
Collaborating with the HIV/AIDS Community to Implement the National HIV/AIDS Strategy
We are working with the President’s Advisory Council on HIV/AIDS (PACHA), national HIV advocacy community leaders, and federal agencies (including the United States Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS), and the Health Resources Service Administration (HRSA)), to support agencies’ efforts to collaborate, coordinate, and take specific actions to meet the three primary NHAS objectives: (1) improved prevention; (2) increased access to healthcare and services; and (3) elimination of health disparities. We are spearheading the community’s effort to work with the Centers for Medicare and Medicaid Services (CMS) to promote state awareness of Medicaid § 1115 waivers to increase access to healthcare and treatment for non-disabled people living with HIV and other chronic illnesses prior to the expansion of Medicaid in 2014 under national healthcare reform. In addition, we are identifying specific goals in the NHAS Implementation Plan and engaging the responsible federal agencies to ensure those goals are meaningful and that there are specific action plans for achieving them.
Providing Access to Healthy Solutions (PATHS)
PATHS is a state-based project focused on access to diabetes treatment and effective self-management. Because diabetes, obesity, and inadequate access to healthy food are inextricably linked, PATHS also includes a food policy component. The goals of the project are to improve access to care and diabetes self-management systems for people living with diabetes, and to reduce the incidence of obesity and obesity-related chronic illnesses (e.g., type 2 diabetes). Resulting reports will analyze state statutory, regulatory, and policy frameworks to understand where challenges and barriers exist; propose law and policy reform to improve access to care and to healthy foods; and collaborate with state-based stakeholders to advocate for, and implement, change. PATHS is initially being conducted in North Carolina and New Jersey, where students are carrying out state-specific research, synthesizing and analyzing data obtained during in-state interviews with stakeholders, and drafting different sections of final reports.
Facilitating Joint Use of School Facilities to Prevent Childhood Obesity
CHLPI and the Food Law and Policy Clinic (FLPC) are partnering with the Massachusetts Department of Public Health and the Harvard School of Public Health to investigate and facilitate community use of school and other recreation facilities during non-school hours with the aim of increasing leisure time physical activity and combating and reducing rates of childhood obesity. The Joint Use Project works with stakeholders in three Massachusetts communities to design and implement effective Joint Use Agreements (“JUAs”) between schools and municipalities. The CHLPI/FLPC team is researching and analyzing joint use initiatives in Massachusetts and other United States locations to understand the statutory, regulatory, and policy frameworks implicated in joint use. Together with our partner organizations, the team will conduct meetings with stakeholders to identify challenges and barriers unique to each community. In addition to providing technical assistance in implementing JUAs to the target communities, the team is publishing a joint use toolkit and conducting trainings to guide other communities across the state of Massachusetts in replicating best practices as they develop their own joint use initiatives. Finally, the team will draft model regulations and statutes that will facilitate community use of school and other facilities during non-school hours.
Food as Medicine:
Community Servings (CS) is a not-for-profit food and nutrition program providing free services throughout Massachusetts to individuals and families living with critical and chronic illnesses who are unable to cook for themselves. In addition to delivering meals, CS supports local food systems and provides nutrition education/counseling and food service job training. Both the food and health law and policy clinics worked on a draft paper looking at potential options for covering CS’ food services under public health and food programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP). We are now finalizing the paper, doing additional research into some of the options that were identified, and providing technical assistance and support to CS as it moves forward with recommendations from the paper.
Improved Access to Healthcare in Massachusetts
The ability of the elderly and poor to access healthcare coverage and resources in MA is impeded by complex regulations, poor information, and the absence of helpful public pathways. This project aims to simplify the current maze making healthcare coverage and resources difficult for the elderly and poor to navigate. Students are researching the nature and extent of the problem, producing consumer-friendly resource guides, and proposing systemic solutions. This includes interviewing clients to understand challenges in accessing coverage and resources; identify resources for provision and/or payment of healthcare services for the elderly, the poor and other uninsured or underinsured groups in MA; review websites and brochures for regional resource-identifiers in MA; identify other reliable agencies and economical consultants to assist in finding available coverage and resources; create one or more manuals with steps for obtaining access to Social Security, veterans’ benefits, MassHealth or other resources; and propose legislative, administrative or social remedies for the gaps.
The goal of the initiative is to develop policy and strategy recommendations aimed at securing a federal commitment for implementation of the National HIV/AIDS Strategy (NHAS) in the parts of the Southeastern United States most impacted by the HIV/AIDS epidemic. The NHAS’s 12 Cities Project, for example, will support comprehensive HIV/AIDS planning and cross-agency response in 12 urban communities with the highest estimated AIDS prevalence. While the 12 Cities Project is an important strategy for addressing the epidemic in these high-prevalence cities, there must be a corresponding strategy for addressing the epidemic in southern states with the highest estimated incidence rates. To ground our advocacy in data and research related to HIV/AIDS in the South, we will work with the Duke Center for Health Policy and Inequalities Research, a leading research center on HIV Infection in the South. Work will involve coalition-building among and between leaders in the following states: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.
High unemployment means that rates of uninsured and under-insured individuals and families are climbing while state revenues are plummeting. These two phenomena are straining state Medicaid programs, and many states are responding to that strain and seeking to balance their budgets by cutting Medicaid spending. Our projects aimed at shoring up state Medicaid programs include:
Medicaid Toolkit Training
We are using our Medicaid Toolkit to provide state advocates and government officials with policy-based, active strategies to avoid harmful Medicaid cuts—even in the current economic crisis. We will be conducting trainings throughout 2011 and 2012 at national conferences and in-state meetings to orient those in support of protecting state Medicaid programs to the new Medicaid landscape under health care reform and how to use the Toolkit to secure and strengthen Medicaid in their respective states.
Medicaid Managed Care and Access: Landscape Analysis and Advocacy Training Tools
More states are using managed care as a way to contain costs in their Medicaid programs. While pharmacy benefits have often been exempted from Medicaid managed care, a shifting economic landscape means that comprehensive access to medications, including mental health and HIV medications, is at risk. We will research and analyze the various Medicaid managed care models currently being used in state Medicaid programs and the impact on access to care. Using case studies from various states, we will examine some of the different approaches used to manage pharmacy benefits and contain costs in Medicaid managed care programs. After assessing the current landscape of state approaches to Medicaid managed care, we will identify best practices and develop a set of advocacy tools to help state advocates participate in important policy decisions with regard to the structure of Medicaid.