As discussed in this chapter, Medicaid is an important vehicle for paying for care for people with HIV/AIDS. The variation among Medicaid programs, however, is a significant challenge to ensuring access to comprehensive care without disparities. The Centers for Medicaid & Medicare Services (CMS, formerly known as the Health Care Financing Administration), the federal agency that oversees Medicaid, states that there are “essentially 56 Medicaid programs—one for each state, territory, and the District of Columbia” (HCFA, 2000.) As might be expected, the differing economics, politics, and attitudes among states have produced widely varying Medicaid programs.
In general, individual states’ Medicaid policies have a profound impact on access to care for individuals with HIV/AIDS (Morin et al., 2002). In addition, if a state’s Medicaid program has narrow eligibility rules and a limited benefits package, other programs, particularly Ryan White, may be expected to fill the gaps in Medicaid coverage (Levi et al., 2000). Because Ryan White is allocated on a discretionary basis, the amount of funds does not expand automatically according to need; thus, the larger the gap, the more likely that Ryan White funds will not be adequate. When examined from a national perspective, these variations in policies create disparities and discontinuities in care that are at odds with the stated federal goal to reduce HIV infection (Kates, 2004).
To illustrate the implications of variations in state Medicaid programs at an individual level, a series of text boxes will run throughout this chapter on the experiences of Joe and Nancy, two fictional individuals with HIV. Their experiences in five states—Florida, Georgia, Illinois, New York, and Texas—as they move through the Medicaid system show the gaps and disparities in coverage caused by the variation among Medicaid programs.
Medicaid varies not just among the states but within them, sometimes from county to county. In addition, eligibility and benefits rules change from year to year, particularly during times of economic downturn. Therefore, any representation of the experience of accessing HIV health care through Medicaid, no matter how nuanced, would fall short. Unless otherwise cited, the information in these text boxes is drawn from an analysis of the five Medicaid programs contained in Lubinski et al. (2002). These scenarios were developed in 2003 and may not reflect recent changes in state Medicaid law or policies.
Meet Joe and Nancy
The characters of Joe and Nancy are representative of some individuals living with HIV/AIDS in the United States who do not have access to private insurance. Joe has developed AIDS and suffers from a serious mental illness, bipolar disorder. He is considered disabled, thus qualifying for a $546 per month Supplemental Security Income (SSI) payment. The SSI payment is his only income.
Nancy is a single mother of two with asymptomatic HIV and active substance abuse disorder. Nancy’s HIV diagnosis does not qualify her for Medicaid, although receiving care now could prevent progression of the disease. Because she is the mother of two children, however, she does qualify for Temporary Assistance to Needy Families (TANF), which makes her eligible for Medicaid under specific circumstances.