Current public financing strategies for HIV care have provided care and extended the lives of many low-income individuals. Significant disparities remain, however, in assuring access to the standard of care for HIV across geographic and demographic populations. The current federal–state partnership for financing HIV care has been unresponsive to the fact that HIV/AIDS is a national epidemic with consequences that spill across state borders. State Medicaid programs that provide a significant proportion of coverage for HIV care have widely varying resources and priorities, which in turn produce an uneven and therefore ineffective approach to managing the epidemic.

Under the current patchwork of public programs that finance HIV care, many HIV-infected individuals have no access or limited access to the standard of care for HIV. Fragmentation of coverage, multiple funding sources with different eligibility requirements that cause many people to shift in and out of eligibility, and significant variations in the type of HIV services offered in each state do not allow for comprehensive and sustained access to quality HIV care. The lack of sustained access to HAART, in particular, is an indicator of poor quality care. Without access to HAART, individuals face increased illness, disability, and death. Moreover, low provider reimbursement in Medicaid (including Medicaid managed care) delivery systems can discourage experienced physicians from treating patients with HIV infection.

The Committee also concludes that the lack of nationwide data on the unduplicated number of individuals served and the services they received under the CARE Act hinders accountability, quality monitoring, and outcomes evaluation, and impedes the improvement of the program. The fact that the majority of HIV care is publicly financed provides a strong incentive and opportunity for the federal government to finance and deliver care more effectively.

IMPROVING THE FINANCING AND DELIVERY OF HIV CARE

The review of the evidence also led the Committee to determine that a systemwide set of objectives was necessary to improve the financing and delivery of HIV care. There are many actors in the current system and little recognition that each is an interrelated part of a complex whole. The Committee believes that defining the goals of the publicly funded HIV care system would help each part of the system to balance competing needs and priorities.

The Committee believes the primary goal of the publicly funded system of HIV care for low-income individuals should be to improve the quality and duration of life for those with HIV and to promote effective manage-



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