results in CARE Act programs with widely different eligibility criteria. This variation is inconsistent with a uniform, minimum standard of eligibility.

Similarly, CARE Act benefits vary substantially from state to state, for many of the same reasons that eligibility standards vary. Access to life-extending comprehensive antiretroviral therapy also varies significantly by state. Individuals in one state may be ineligible because of income level or have access to a fewer number of drugs or types of drugs than an individual with the same disease status in another state. This variation is also inconsistent with access to the standard of care for HIV/AIDS regardless of state of residence.

Another disadvantage of this approach concerns financing. As a discretionary program, the CARE Act program is subject to the uncertainties of the annual congressional appropriations process. States, localities, and private providers cannot predict with any confidence that the funds required to meet the standard of care for those with HIV in need of program assistance will be available in any given fiscal year. Currently, CARE Act dollars do not match the need for services, and some grantees have been unable to serve all those in need. Budget shortfalls for the AIDS Drug Assistance Program (ADAP) in particular have resulted in waiting lists, caps on enrollment, and/or limitations on benefits available to individuals already in the program. Although an expansion of federal appropriations consistent with this proposed approach could, if enacted, annually address these shortfalls, this would not resolve the related problem of allocation.

The community planning process associated with CARE Act Title I funds has provided important community input into how funds are allocated at the local level. This process does not, however, necessarily result in funding allocation decisions that reflect the greatest areas of need over time. This is partly because of inadequate and inconsistent data sources and measures used to describe severity of need for the Title I Supplemental Application (IOM, 2003b). Furthermore, current program data collection activities do not adequately support accountability or evaluation. It is currently impossible to determine national estimates of the number of clients served or the types of services received because programs do not provide unduplicated counts of clients and the services they receive. In short, there is no guarantee, even if the necessary funds were actually appropriated each year, that these funds would be allocated in a manner that enables the standard of care for HIV/AIDS for all those in need of public program assistance in each state.

Option 2: Extend Medicare to Individuals with HIV

Under this approach, individuals found to be infected with HIV would be eligible for Medicare coverage, subject to the same premium, deductible, and coinsurance requirements as other Medicare beneficiaries. This approach



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