Medicaid directors (CMS, 1998) to implement strategies to improve coordination between the two programs. As stated in the letter, “There are considerable opportunities for the Medicaid and CARE Act programs to work together to effectively coordinate the services each program provides. … Coordination between Medicaid and CARE Act programs and their providers can eliminate duplication of services, save the States’ and the Ryan White Program’s limited funds, and ultimately serve individuals with HIV more effectively and efficiently.”

Since the promulgation of the CARE Act Amendments and the CMS directive to state Medicaid directors, individuals with HIV/AIDS continue to wrestle with the coordination of multiple systems, programs, and benefits.

ACCESS BARRIERS

Barriers that reduce or restrict access to care are created by the financing and organization of care, characteristics of the individuals including comorbidities, and characteristics of the providers. These problems were examined by the HIV Cost and Services Utilization Study (HCSUS) conducted in the late 1990s. HCSUS remains the only nationally representative sample of HIV-infected individuals that can provide an overview of the problems faced in accessing HIV care. A number of other studies also address barriers to care (Morin et al., 2002; Cook et al., 2002; Turner et al., 2001; Sambamoorthi et al., 2000).

The HCSUS study found large variations in insurance coverage for HIV infection, in part reflecting the relative restrictions on the Medicaid programs in different states. Overall, 20 percent of adults in care for HIV lacked health insurance, 50 percent received care through Medicaid and Medicare (about 15 percent of these had both Medicare and Medicaid), and 31 percent received care through private insurance. Geographic differences were also quite striking: the proportion uninsured was 11 percent in the Northeast, compared to 30 percent in the South. In the Northeast, 50 percent of patients had Medicaid as primary payer, compared to 28 percent in the South (Bozzette et al., 1998).

HCSUS also demonstrated that there were substantial disparities in treatment across affected groups. Although disparities decreased as the decade progressed, blacks, women, the uninsured, and Medicaid beneficiaries all were less likely to receive protease inhibitor therapy when it became the standard of care (Shapiro et al., 1999). Medicaid insurance also continued to predict a lower likeliness of receiving HAART more than two years into its availability (Cunningham et al., 2000). With respect to access to experimental drug therapy, Gifford et al. (2002) found that blacks and Hispanics were less likely to have received experimental HIV therapy or to have participated in an HIV clinical drug trial, and that these findings could



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