States expand Medicaid coverage for HIV-positive patients

Effective clinical treatment demands early intervention

With technology and medications making HIV infection a treatable, chronic disease, state Medicaid programs are being pressed to provide early and aggressive coverage for HIV-positive patients.

"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, AIDS Action Committee of Massachusetts, has successfully lobbied the Massachusetts legislature to expand Medicaid access to people with HIV. A Massachusetts bill passed last fall makes the state among the first to expand Medicaid coverage specifically 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, 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," Mr. 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, Mr. Carleo says. About 2,000 people are expected to be enrolled once it is under way.

Eventually the program 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, Mr. Greenwald says.

Maine and neighboring states have watched Massachusetts’ new bill with interest and could soon be following in its footsteps, Mr. Greenwald says. "I think they’ll look at our model because the bottom line is 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 says.

Various states are seeking federal waivers or expansions of their current Medicaid waivers for the purpose of providing coverage to people with HIV, says Arnold Doyle, MSW, director of HIV treatment programs for the National Alliance of State and Territorial AIDS Directors in Washington, DC.

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. 3.)

Conventional Medicaid coverage insures only people whose HIV infection has progressed to AIDS, defined by two opportunistic infections and a low CD4 cell count. Some states have expanded this coverage to any uninsured and low-income person who has HIV by relying on Section 1115 Medicaid waivers.

Federal legislation sponsored in 1999 by Sen. Robert Torricelli (D-NJ) and Rep. Nancy Pelosi (D-CA) that would have allowed states to expand their Medicaid coverage to all low income HIV-positive people has stalled in Congress.

More help needed from ADAP

The federal AIDS Drug Assistance Program (ADAP) has been successful in providing antiretroviral treatments to many low income people with HIV, but access varies from state to state. ADAP money primarily covers drugs, and any clinical care for the uninsured is left to Medicaid or charitable institutions. Some health care providers have been trying to fill gaps in Medicaid coverage by scraping together federal and private funding sources.

For example, in California, the AIDS Healthcare Foundation of Los Angeles provides comprehensive health care to uninsured HIV-infected people through the use of government grants and private funds, says Ged Kenslea, community relations director for the nonprofit, community-based provider with six clinics, a hospice program, and skilled nursing care.

"We provide medical care to under 5,000 people in Southern California, regardless of their insurance status," Mr. Kenslea says.

AIDS Healthcare Foundation has spent several years lobbying California legislators to pass a bill that would expand the state’s Medicaid program, Medi-Cal, to cover asymptomatic HIV-positive people. The bill died in committee in September, but may be resurrected this year, Mr. Kenslea says.

Although ADAP funding covers most of the medically indigent individuals who need HIV antiretroviral drugs, such people still need adequate clinical care to help them adhere to their medication regimens and to prevent opportunistic infections, Mr. Kenslea says.

He points to the AIDS Healthcare Foundation’s program, Success Through Antiretroviral Treatment (START), as an example. The program provides training for people who have just started HIV antiretroviral therapy. Targeting 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, Mr. Kenslea says.