MEDICAID: ‘Early Treatment for HIV Act’ Seeks to Expand Coveragefor HIV Patients
Reps. Nancy Pelosi (D-Calif.) and Richard Gephardt (D-Mo.) are resuming their fight to add the Early Treatment for HIV Act (H.R. 1591) language to the Beneficiary Improvement and Protection Act of 2000 (H.R. 5291) before Congress adjourns this session. H.R. 1591 and the identical bill sponsored in the Senate ( S. 902) by Sen. Robert Torricelli (D-N.J.) would allow states to expand Medicaid coverage to those infected with HIV. Currently, Medicaid eligibility is based on income and categorical requirements, including disability. While some low-income people with HIV who are not yet disabled can qualify for Medicaid if they meet other categorical requirements (e.g., because they are pregnant or the low-income parent of a dependent child) childless adults must usually be low-income and fully disabled to qualify. In other words, they must meet the income and disability criteria of the federal Supplemental Security Program, which provides cash assistance to low-income individuals who are "unable to engage in any substantial gainful activity by reason of a medically determined physical or mental impairment expected to result in death, or that has lasted or can be expected to last for a continuous period for at least 12 months." Some may also qualify for coverage if they are determined "medically needy" by meeting one of the categorical Medicaid requirements and using their medical expenses to "spend-down" to meet their state's income threshold; 34 states have such programs. According to a Pelosi release, "asymptomatic individuals with HIV generally do not qualify for SSI and do not have access to preventive medical care or medicines [such as highly active antiretroviral therapy] that could prevent the onset of opportunistic infections or the decline of the immune system" (Pelosi, "Medicaid Explanation" release, 9/18). Indeed, national treatment guidelines recommend that treatment be offered early. Several states have been looking into using 1115 waivers as one solution to this "catch-22." States must seek waivers from the Health Care Financing Administration of federal Medicaid rules to make certain changes to their Medicaid programs. An 1115 waiver, if approved, would allow a state to change its Medicaid eligibility rules to expand access to people with HIV before they are disabled. Yet waiver requirements, particularly the need for the waiver to be "budget neutral" to the Medicaid program, are difficult to meet. Only Maine has received approval for such a waiver. National legislation, like the Early Treatment Act, would eliminate the need for states to apply for such waivers and meet the federal neutrality requirement. Significant Support Supporters of the Early Treatment Act hold that "there is a pressing need to eliminate barriers to early drug therapy for vulnerable populations." Proponents also emphasize the importance of "[c]ost-effective programs that can delay the onset of AIDS and increase the quality of life and time spent in asymptomatic stages." According to a Pelosi release, the following are the benefits of early access to HIV treatment:
- Reduced new AIDS cases. Viral load is a predictor of HIV disease progression and survival. By reducing viral load, which can be achieved through the use of HAART, disease progression is slowed.
- Increased quality of life and gains in life years. Lower viral loads improve the quality of life by reducing the number of opportunistic infections and increasing the number of years lived.
- Reduction in the number of new infections. Recent studies show that lower HIV viral loads are associated with a decreased likelihood of HIV transmission.
- Reducing breaks in treatment. Expanding health care coverage through Medicaid can reduce the risk of breaks in medication from occurring. These breaks increase the likelihood of resistance to existing drugs both in an individual and in the general population as drug resistant strains of HIV are transmitted. Drug resistant strains are likely to increase the long-term costs of care.
- Medicaid treatment savings. By delaying the progression from HIV to AIDS, savings in treatment costs are realized. Treatment costs are at their highest between an AIDS diagnosis and death. Antiretroviral regimens containing a protease inhibitor can significantly lower the costs of inpatient hospitalization, community care, terminal care and the costs of treating opportunistic infections.
- AIDS Drugs Assistance Program savings. These savings will occur through the movement of eligibles from ADAP to Medicaid, thereby reducing the burden on ADAP, which is dependent on discretionary funding.
- Savings through increased tax revenues. Individuals are able to return to work, or continue working as disability is delayed, leading to increased productivity.
- Cost savings to SSI. As early intervention slows the progression from HIV infection to a disability diagnosis, cost savings to SSI are realized as individuals enter the program at a later date.
- Complements the Ryan White CARE Act. By expanding Medicaid, Ryan White resources used to provide primary care and medications can be freed up and reallocated to support services. Support services provided under Ryan White are essential both to assist patients with treatment adherence and to maximize access to the medical care system. Effective and accessible support services also play an important role in the effort to eliminate racial and ethnic disparities in care.
- National Organizations Responding to AIDS: Citing an estimated "250,000-350,000 people living with HIV/AIDS in the United States [who] are currently not in care," many of whom are poor people of color, NORA implored President Clinton to "push for [the] enactment" of the ETHA to achieve "our shared goal of eliminating racial and ethnic disparities in health outcomes" (NORA letter, 10/19).
- Presidential Advisory Council on HIV/AIDS: "Three years ago the Council underscored the inherent contradiction between the goal of early care and treatment for HIV/AIDS and current Medicaid eligibility rules that require HIV-infected individuals to have a disabling AIDS condition before they are eligible for the program." The council adds that ETHA "is a policy long advocated by members of the council" (Advisory Council letter, 10/11).
- Rainbow/PUSH Coalition: "By simplifying the process for states to extend Medicaid coverage to people who do not meet the Social Security definition of disability, we will then be taking a critical step in ensuring that our overreaching goal, which is to improve both the health and the quality of life for people living with HIV, is accomplished" (Rainbow/PUSH Coalition letter, 10/18).
- AIDS Action: "Early access to HIV treatment through Medicaid, as provided by the Act, will result in a reduction of new AIDS cases, increase the quality of life of thousands living with HIV, reduce high-cost medical interventions such as inpatient hospitalizations and terminal care, increase tax revenues and reduce costs in the SSI and SSD programs" (AIDS Action letter, 10/4).
- Human Rights Campaign: "Earlier this year, [HCFA] granted a waiver to the State of Maine to expand Medicaid coverage to certain HIV-positive individuals in their state. While we appreciate this incremental step in covering this vulnerable population and applaud your administration for taking this step, we strongly believe that it should be a national health care policy to provide Medicaid coverage to HIV-positive individuals" (Human Rights Campaign letter, October/2000)
- AIDS Alliance for Children, Youth & Families: "The ETHA will help eliminate racial and ethnic disparities in health outcomes by making early care and treatment accessible to thousands of poor and low-income people living with HIV in the United States through the expansion of Medicaid eligibility" (AIDS Alliance letter, 10/24).
- San Francisco AIDS Foundation: Under the current system, "[to] expand coverage and provide treatment to people in the earlier stages of HIV disease, states must undertake the burdensome process of applying for a Medicaid waiver. The ETHA eliminates the need for this process and allows states to readily provide Medicaid coverage to people who desperately need this coverage to obtain medical care and drug therapies" (SF AIDS Foundation letter, 10/6).
- Title II Community AIDS National Network: "[V]ice president [Al Gore] disagrees with the current Medicaid policy that provides coverage for antiretroviral therapy only to those who have AIDS, thus neglecting early treatment. Gore 'understands that it ... makes no sense for the individual because his/her health suffers, and it makes no sense for the community because it costs the government and thus taxpayers more to treat individuals later rather than sooner.' Gore wants to apply 'expanded coverage to Medicaid recipients across the country'" (Network letter, 10/13).
- Treatment Access Expansion Project: "New HIV/AIDS treatments, such as highly active antiretroviral therapy (HAART), are successfully delaying the progression from HIV infection to AIDS. These advances along with access to comprehensive health care have improved both the health and the quality of life for many people living with HIV. Without access to early intervention health care and treatment through Medicaid these advances will remain out of reach to thousands of poor and low-income people living with HIV" (TAEP letter, October/2000).