More states are expanding Medicaid reimbursement for poor HIV patients
More states are expanding Medicaid reimbursement for poor HIV patients
HIV/AIDS advocates press for more coverage
Now that new technology and medications are making HIV a treatable, chronic disease, clinicians and AIDS service organizations are frustrated that many of the newly infected people have no insurance to cover such treatment.
Federal Medicaid legislation, recently sponsored by Sen. Robert Torricelli (D-NJ) and Rep. Nancy Pelosi (D-CA), would have allowed states to expand their Medicaid coverage to all low-income people who have HIV. However, the legislation died an early death in 1999.
The good news is that some states are beginning to pass their own legislation to expand Medicaid coverage and to request waivers from the federal law governing Medicaid access.
"There is no question we could do a better job of preventing the progression of HIV disease by providing treatment to uninsured people who don’t have access to Medicaid," says Robert Greenwald, director of public policy and legal affairs for the AIDS Action Committee of Massachusetts in Boston.
The oldest and largest AIDS service organization in New England, the AIDS Action Committee of Massachusetts has successfully lobbied the state legislature to expand Medicaid access to people with HIV. Massachusetts, which passed the bill last fall, is one of the first states to pass legislation aimed solely at expanding Medicaid coverage for HIV patients.
"The program will expand Medicaid coverage for people who have HIV but are not sick enough to be labeled disabled,’" says Joe Carleo, associate director for public policy with AIDS Action Committee of Massachusetts. "These are people in the early stages of HIV infection who have not become sick yet and are in need of access to treatment that will prevent them from getting sick."
Under the state’s old program, Medicaid would cover people with HIV who had incomes of up to 133% of the federal poverty level, but only when they became ill enough to be diagnosed as having AIDS.
HIV patients stay sick without Medicaid
"It’s a Catch-22 in the way the system works traditionally," Carleo says. "You didn’t have access to health care until you became sick, while with the success of new HIV treatments, it makes more sense to keep people healthy."
Massachusetts will fund the program with $10 million in tobacco settlement money during its first year, Carleo says. About 2,000 people are expected to be enrolled once it is under way.
The program eventually should become budget-neutral because by funding early treatment, the state may prevent many of the costs associated with AIDS, such as hospitalization, skilled nursing care, hospice care, and other treatment, Greenwald says.
Maine and other neighboring states have watched Massachusetts’ new bill with interest and could soon be following in its footsteps, Greenwald says.
"I think they’ll look at our model because the bottom line is that people are increasingly recognizing that we have a stated standard of care for HIV disease, published by the federal government, and their own Medicaid programs don’t address giving people access to that standard," he explains.
Some states are seeking federal waivers or expansions of their current Medicaid waivers so they can provide coverage to people with HIV, says Arnold Doyle, MSW, director of HIV treatment programs for The National Alliance of State and Territorial AIDS Directors, based in Washington, DC.
Some states, including Tennessee, Oregon, Florida, and New York, already have Medicaid programs that entitle low-income, HIV-positive people to receive health coverage for clinical care. (See story on what some state Medicaid programs offer, p. 4.)
The way the Medicaid law currently works, only people whose HIV has progressed to AIDS, defined by two opportunistic infections and a low CD4 cell count, may receive Medicaid coverage. Some states have expanded this coverage to any uninsured and low-income person who has HIV by relying on Medicaid waivers under section 1115a. (See story on Medicaid waiver program, p. 5.)
ADAP funds drugs, but more help needed
The federal AIDS Drug Assistance Program (ADAP) has been successful in providing anti ret roviral treatments to many low-income people with HIV, but access varies from state to state. Also, ADAP money primarily covers drugs, and any clinical care for the uninsured is left to Medicaid or charitable institutions. (See story on ADAP funding in AIDS Alert, September 1999, p. 97.)
Medicaid’s general requirement of covering only HIV-infected people who have a disability has left a void in medical coverage that some health care providers have been trying to fill by scraping together federal and private funding sources.
For example, the AIDS Healthcare Foundation of Los Angeles provides comprehensive health care to uninsured HIV-infected people in California through the use of government grants and private funding, says Ged Kenslea, the foundation’s community relations director. The nonprofit, community-based provider has six clinics and a hospice program and provides skilled nursing care.
"We provide medical care to about 5,000 people in Southern California, regardless of their insurance status," Kenslea says.
The AIDS Healthcare Foundation has spent several years lobbying California legislators to pass a bill that would expand the state’s Medicaid program, called Medi-Cal, to cover asymptomatic HIV-positive people. The bill died in committee in September, but may be resurrected this year, Kenslea says.
Although ADAP funding covers most of the medically indigent individuals who need HIV antiretroviral drugs, these people still need adequate clinical care to help them adhere to their medication regimens and to prevent opportunistic infections, Kenslea says.
Kenslea points to the AIDS Healthcare Foundation’s START program (Success Through Antiretroviral Treatment) as an example. The program provides training for people who have just started HIV antiretroviral therapy. Target ing people who are at risk for not complying with their drug regimen, the program provides them with beepers, pill boxes, psychosocial support, and other interventions that encourage them to stay on track. The $2 million program, funded with a federal grant, is necessary to prevent the spread of drug-resistant virus, Kenslea says.
"By way of comparison, back in the mid-to-late 1980s, President Reagan cut back on funding to inner-city health clinics, and it inadvertently led to the development of antiviral medicine-resistant tuberculosis," he says. "What happened is that when clinics saw their budgets slashed, they cut back on compliance programs, such as directly observed therapy, and patients would stop taking the entire regimen of antibacterial TB drugs.
"So with a $6 per month per patient cutback, you ended up with a superstrain of TB," he concludes, adding that this is one public health reason why Medicaid should provide clinical care and services to HIV-infected individuals.
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