In the news ... 2007
Medicaid is Our Nation’s Safety-Net
for People with HIV/AIDS
by the HIV Medicare and Medicaid Working Group
Provide Medicaid Coverage that Meets the HIV Standard of
Care to all Low-Income Persons Living with HIV/AIDS
Medical progress has revolutionized HIV/AIDS treatment, yielding
an 80% reduction in HIV-associated deaths and related complications.
As the largest payer of AIDS care in the U.S., Medicaid has allowed
many low-income people with HIV disease to benefit from these life-saving
treatment advances. The program provides access to medical treatment
to 44% of adults living with HIV disease, 55% of all people living
with AIDS, and 90% of children with AIDS nationwide. Medicaid is
the cornerstone of the broader publicly-supported health system
response to the care and treatment needs of low-income people living
with HIV/AIDS.
Medicaid must remain an entitlement program, but this entitlement
must also include low-income persons in earlier stages of HIV disease.
Unfortunately, Medicaid’s strict eligibility criteria effectively
deny access to many poor and low-income adults with HIV infection
who are not yet disabled by AIDS. This policy must be changed to
ensure that low-income persons diagnosed with HIV infection have
earlier access to Medicaid to prevent the disabling and life-threatening
infections that characterize HIV infection late in disease progression.
Access to medical care is also a public health imperative given
the demonstrated reduction in transmission-related behaviors noted
in persons with HIV/AIDS receiving primary care, and the potential
reduction in transmission associated with viral suppression in individuals
effectively treated with antiviral therapy.
Medicaid must provide comprehensive coverage to all who
qualify.
The Medicaid benefit package must be sufficient to meet the medical
needs of persons with disabilities and chronic illnesses, such as
HIV/AIDS. Reduced benefit packages, designed to cut costs rather
than provide health care, make the entitlement to Medicaid-covered
services an empty promise. In particular, Medicaid must offer access
to treatment consistent with the HIV standard of care and other
basic standards of medical practice. These necessary health care
services must be affordable to the poorest among us, without the
financial barriers of premiums and cost-sharing. Cutting or capping
an efficient health care program that low-income seniors, children
and people with disabilities depend on is unfair and unacceptable.
Yet, the Deficit Reduction Act gave states unprecedented latitude
to define benefits and cost-sharing to different classes of Medicaid
beneficiaries. Already, a number of states limit benefits in ways
that compromise medical care and health outcomes, such as limiting
physician visits, placing arbitrary limits on the number of covered
prescriptions or offering different benefit packages to different
groups. Comprehensive and affordable health coverage that promotes
the health and well-being of low-income people with HIV and millions
of other Medicaid beneficiaries must be federal Medicaid policy
and a budget priority.
Below are key program components that must be maintained or adopted
if the Medicaid program is to continue to serve as a viable health
care safety net for people with HIV:
1) Expand Medicaid to provide early coverage to all low-income
persons with HIV disease. Currently, most poor single adults with
HIV must develop AIDS before they are eligible for the medical treatment
that would prevent them from developing AIDS. Congress should promote
early access to health services for people with HIV by enacting
the Early Treatment for HIV Act and encouraging states to cover
non-disabled, low-income individuals with HIV through Medicaid.
For any beneficiary with HIV/AIDS, Congress should also require
states to provide benefits in sufficient amount, duration and scope
to ensure that beneficiaries receive the standard of care for treatment
of HIV infection and related co-morbidities.
2) All Medicaid beneficiaries should be counseled about the risks
of HIV transmission and infection, offered an HIV test, and linked
to quality HIV care. One recent study has shown that as many as
22% of persons recently diagnosed with HIV infection were Medicaid
beneficiaries at the time of their diagnosis. As many as one-third
of persons infected with HIV in the U.S. are unaware of their infection.
This vital federal-state health care safety net program can and
must play an important role in counseling individuals about their
risk of contracting HIV infection, offering confidential, voluntary
HIV testing, and identifying those already infected and linking
them to quality HIV care. The Center for Medicare and Medicaid Services
should issue a State Medicaid Directors (SMD) letter about the new
CDC guidance encouraging routine testing in healthcare settings,
and urge states to expand HIV counseling and testing in Medicaid-financed
primary care settings and to require HIV counseling and testing
in state Medicaid managed care contracts.
3) Maintain the federal commitment to fully share in the cost of
Medicaid coverage. States must be able to count on the federal government
as a reliable partner in sharing Medicaid’s costs. If more
people become eligible for Medicaid, if health care costs rise,
if new medical technologies become available, or if states choose
to make new investments to better meet the needs of their residents,
the federal government must maintain its commitment to providing
ongoing matching financing. Over the past four decades, this financing
structure has been critical to ensuring stability in coverage as
states’ cycle through good and bad economic times and it has
been critical to supporting states that are committed to implementing
innovative programs that expand access to more people in need of
health care services.
4) Provide federal leadership to ensure that state Medicaid programs
provide adequate health care coverage by establishing prescription
drug coverage as a mandatory benefit and conducting careful oversight
of state Medicaid programs. Given the major role of federal financing,
it is appropriate for federal policy to minimize variability across
states and assure adequate benefits coverage in all states. State
flexibility should be focused on improving the delivery of services
and should not entail flexibility to provide sub-standard care.
Some key services, such as prescription drug coverage, are “optional”
under current Medicaid rules—but prescription drugs are an
essential component of medically necessary care for most beneficiaries,
including persons living with HIV/AIDS.. Current flexibility permits
states to make arbitrary and dangerous decisions that eliminate
or limit coverage to essential health services. It is critical that
the federal government assert new leadership to ensure that states
provide a level of coverage that meets the needs of the diverse
and needy populations served by Medicaid.
5) Ensure that coverage is affordable to low-income HIV-positive
individuals and that care is not denied due to an inability to pay.
Near perfect adherence to antiretroviral medications is required
for successful treatment of HIV infection. Poor adherence can result
in the development of drug resistant strains of the virus, which
may then be passed on to other individuals, compromising effective
control of the epidemic and presenting a serious threat to public
health. Medicaid serves a very low-income population and many beneficiaries,
including persons with HIV/AIDS, require extensive care and numerous
medications. For the impact on an individual’s health, as
well as the public health at large, no one should be dissuaded from
seeking care or denied coverage for prescriptions due to the inability
to pay a co-payment or other forms of cost-sharing.
6) Expand Medicaid to cover all low-income seniors and people with
disabilities up to 100 percent of the federal poverty level. In
most states, mandatory coverage for persons with disabilities and
seniors is set at 74% of the federal poverty level. Roughly twenty
states cover people with income up to the poverty level and thirty-five
states plus the District of Columbia offer “medically needy”
coverage that permits higher-income individuals to qualify by using
their medical bills to “spend-down.” (Spending down
often leaves Medicaid beneficiaries with $100-300 per month for
food, rent and all necessities of life.) It is time to raise the
bar and, at a minimum, establish mandatory eligibility for all seniors
and people with disabilities up to the federal poverty level.
The HIV Medicaid and Medicare Working Group (HMMWG)
HMMWG is a coalition of more than 100 national and community-based
AIDS service organizations that represent HIV medical providers,
advocates and people living with HIV/AIDS and provide critical HIV-related
health care and support services. For more information, contact
the HMMWG co-chairs Laura Hanen with the National Alliance of State
and Territorial AIDS Directors at 202.434.8091 or Robert Greenwald
with the Treatment Access Expansion Project at 617.390.2584.
