Index

A

Access to care

CARE Act programs, 12–13, 17

case management and, 130–131

current system, 5, 13, 268–269, 271

demographic disparities, 129–130

goals, 6–7, 14–15, 16, 33, 36, 50, 134

HAART, 11–13, 14, 129–130, 136, 181, 218–223

insurance access and, 272–274

mental illness and, 55–56, 252, 258, 259–260, 263

outreach to improve, 304

provider participation in federal programs and, 12, 14, 19, 111, 136, 203

public perception, 27–28

shortcomings of current system, 6, 11–12, 14, 19, 135–136

state-to-state disparities, 11, 14, 75, 110, 112, 113, 114–117, 118, 119–122, 284–290, 291, 292, 300, 326

See also Barriers to care

Accountability, 13, 14, 136

in Centers of Excellence, 171–174

criteria for assessing programs, 142

goals, 15, 134

in Medicare, 146

Acute infection

care trends, 6

clinical features, 40

Adherence to HAART

clinical significance, 5, 9, 46, 47, 63

current rate, 46

determinants of, 46, 47–49

drug resistance and, 9, 46–47

mental illness and, 47, 49, 56–57, 91–93, 254, 256–257, 260

patient–provider relationship and, 47, 49, 163

predictive factors, 49

requirements for success, 9, 46, 162–163

substance abuse and, 59, 91–93, 320–321

AIDS Drug Assistance Program, 109, 299

barriers to access, 13, 118, 145, 300

drug purchases, 20, 125, 204, 270, 306

eligibility, 13, 17, 197

HIV-CCP and, 197–198, 207

purpose, 80, 299

resource allocation, 13, 145, 248, 299

spending, 80, 84, 297–298

AIDS Education and Training Centers, 29, 81, 190, 300

Alternative delivery and financing systems, 195

assessment criteria, 16, 142, 214



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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White Index A Access to care CARE Act programs, 12–13, 17 case management and, 130–131 current system, 5, 13, 268–269, 271 demographic disparities, 129–130 goals, 6–7, 14–15, 16, 33, 36, 50, 134 HAART, 11–13, 14, 129–130, 136, 181, 218–223 insurance access and, 272–274 mental illness and, 55–56, 252, 258, 259–260, 263 outreach to improve, 304 provider participation in federal programs and, 12, 14, 19, 111, 136, 203 public perception, 27–28 shortcomings of current system, 6, 11–12, 14, 19, 135–136 state-to-state disparities, 11, 14, 75, 110, 112, 113, 114–117, 118, 119–122, 284–290, 291, 292, 300, 326 See also Barriers to care Accountability, 13, 14, 136 in Centers of Excellence, 171–174 criteria for assessing programs, 142 goals, 15, 134 in Medicare, 146 Acute infection care trends, 6 clinical features, 40 Adherence to HAART clinical significance, 5, 9, 46, 47, 63 current rate, 46 determinants of, 46, 47–49 drug resistance and, 9, 46–47 mental illness and, 47, 49, 56–57, 91–93, 254, 256–257, 260 patient–provider relationship and, 47, 49, 163 predictive factors, 49 requirements for success, 9, 46, 162–163 substance abuse and, 59, 91–93, 320–321 AIDS Drug Assistance Program, 109, 299 barriers to access, 13, 118, 145, 300 drug purchases, 20, 125, 204, 270, 306 eligibility, 13, 17, 197 HIV-CCP and, 197–198, 207 purpose, 80, 299 resource allocation, 13, 145, 248, 299 spending, 80, 84, 297–298 AIDS Education and Training Centers, 29, 81, 190, 300 Alternative delivery and financing systems, 195 assessment criteria, 16, 142, 214

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White block grant program, 153–157 enhanced or expanded Medicaid, 148–153, 195, 213–214, 230, 231 expanded CARE Act programs, 144–145 goals, 16, 141–142 HAART modeling for evaluation of, 214–216 inputs for modeling, 217–225 Medicare expansion, 145–148, 195 projected enrollment, 224–225 projected utilization, 223–224 prospects, 174–175 range of, 15–16, 141, 142, 213 sensitivity analyses, 234–243 state participation, 142–144 See also HIV Comprehensive Care Program American Public Health Association, 47 Antiretroviral drugs access disparities, 129–130 alternative therapies, 46 for children, 90 costs, 20, 21, 204, 270 effectiveness, 42, 43–44 technical evolution, 42–43 See also Highly active antiretroviral therapy Anxiety disorders adherence to HIV treatment and, 91 prevalence, 251, 253 risk behavior and, 54–55, 255 Assessment adherence prediction, 49 depression, 55 insurance status and time of diagnosis, 274 role of primary care, 98 Asymptomatic infection, 40–41 At-risk populations, 37 implications for health care delivery, 50 trends, 9, 10, 38, 50, 63 Automobile restraints, 187 Awareness of HIV status, 156, 181, 218, 226 AZT, 42–43, 269, 299 B Bailey Boushay House, 333 Balanced Budget Act, 18, 197 Barriers to care in CARE Act programs, 118–122, 300 conflicting goals among programs, 133–134 coordination among programs and, 127–129, 136, 268, 305–306, 328 cost of care, 132–133 in current system, 6, 14, 19, 27, 133–134, 280–283, 304–307 in Medicaid, 12, 17, 109–114, 132–133, 291–293 in Medicare, 117, 295–297 mental illness, 55–56, 131 in private insurance programs, 107–109, 301, 302–303 provider reimbursement, 19, 111, 325–326 sources of, 129 for substance abusers, 58–59, 313, 318–323, 325–327, 330–332 for women of color, 59 See also Access to care Bipolar disorder, 251 Block grants advantages, 154 disadvantages, 155–157 structure, 153–154 substance abuse treatment, 324 C Cancer, 44 Candidiasis, 42 Capitation rates, 111, 114 CARE Act. See Ryan White CARE Act Care coordination model of service, 170 Care-seeking behavior cost of care and, 132 substance abuse and, 58, 94, 319 Case management, 127 benefits, 96, 130–131 CARE Act coverage, 298–299 Centers of Excellence model, 170 definition, 96 delivery models, 96 HAART utilization and, 224 modeling service needs, 223–224 CD4 lymphocyte levels course of HIV, 41, 42 depression effects, 93–94 HAART guidelines, 44, 89

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White CD8 lymphocyte levels, depression effects, 93–94 Center for Substance Abuse Treatment, 324 Centers for Medicare & Medicaid Services, 114, 128–129, 233–234 Centers of Excellence for HIV care accountability mechanisms, 171–174 existing programs, 168–169 features, 168 functions, 7, 170–171 HIV-CCP demonstration project, 180, 206 reimbursement practice, 168, 169, 171–174, 188 structural models, 169–170 Childcare services, 322 Children and adolescents CARE Act services, 80–81, 202 HIV transmission at childbirth, 19, 90 HIV treatment, 90–91 Medicaid coverage, 278 mental illness among, 61–62, 252 sexual abuse as HIV risk factor, 255 unsupervised youths, 61–62 Chronic care clinical model, 162–164 definition of chronic illness, 161 HIV/AIDS requirements, 161–162 implications for health care delivery, 6, 12, 31, 88, 161–164, 165 integrated and coordinated model, 165–168 trends, 6, 12, 63, 88, 100 Colorectal cancer screening, 186–187 Community health centers, 303–304 Co-morbidity among HIV-infected youth, 61–62 HIV-CCP coverage, 201, 202 infections, 59–60. See also Opportunistic infection recommendations for federal care program, 19 social conditions as, 54, 60–63 trends, 5–6, 10, 38–39 types of, 52–54 See also Mental illness; Substance abuse; specific disorders Consolidate Omnibus Reconciliation Act, 109, 302 Coordination among HIV/AIDS programs need for, 127–129, 268 research needs, 305–306 Coronary angioplasty, 187 Cost effectiveness current HIV care, 270 HAART, 89, 179, 196 HIV-CCP, 16, 22–23, 24, 179, 180–181, 185–188, 231–232 program evaluation methodology, 185–186, 214 Cost of care as barrier to care, 132–133 buy-in provisions, 18, 111 care-seeking behavior and, 132 drugs, 19–21, 203–205, 270, 306 enhanced Medicaid program, 234 goals, 134 HAART, 23, 179, 185, 196, 204–206, 223, 269–270 HIV care as portion of all health care spending, 270 HIV-CCP budget, 233–234 inputs for modeling alternative programs, 217–218, 223–224, 234–243 preventive intervention outcomes, 193 private insurance premiums, 107–108, 302 provider reimbursement rates, 111 psychopharmacotherapy, 262 recommendations for federal program, 21 spend-down eligibility in federal programs, 18, 326 subsistence purchases and, 131 substance abuse treatment, 327–328 trends, 276 for uninsured HIV/AIDS patients, 189 Course of disease, 40–42 disease state-transition model, 215 initiation of HAART, 226–227 insurance coverage and, 87 insurance status and time of diagnosis, 274 mental illness effects, 93–94, 257 oral manifestations, 98 D Data collection on CARE Act program performance, 13, 14, 122–123, 126–127, 136, 145 current inadequacies, 13, 14, 136

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White HAART use and need, 218–223 HIV population characteristics, 218 inputs for modeling alternative programs, 217–225 Medicare, 146 privacy and confidentiality issues, 196 records management in Centers of Excellence, 169–170 on substance abuse, 315–317 Delivery of care case management services, 96 consideration of substance abusers in policy planning, 314 coordination among programs, 124, 125, 127–129, 268, 305–306, 328 current system, 5–6, 12, 34, 63, 99, 100 demographic factors, 50 financing of care and, 10 functions of system, 167 future challenges, 36, 38–39 goals, 14–15, 16, 33, 36, 88, 133–134, 161, 178 historical development, 87–88 integrated and coordinated model, 165–167 organizational structure, 167–168 primary care, 98–99 prospects for reform, 174–175 shortcomings of current system, 13–14, 107, 134–136, 165, 167, 194–195 system evaluation, 32 trends, 6, 12, 36 See also Alternative delivery and financing systems; specific programs Demographic patterns access disparities, 129–130, 305 geographic distribution, 51–52 implications for service delivery, 50 infection rate, 9–10, 38, 51 insurance access, 272 mental health care utilization, 258 mental illness risk, 251 mortality, 9 trends, 50, 51–52, 63, 194–195, 270, 307 See also Racial/ethnic minorities; Women Dental health. See Oral health Dental Reimbursement Program, 30, 81 Department of Defense, 19, 203, 304 Department of Veterans Affairs, 33, 282–283, 303, 327 drug purchases, 19, 20, 203 Depression adherence to HIV treatment and, 56–57, 91, 256 HIV progression and, 93–94 identification, 55 immune function and, 257 prevalence, 251, 253 risk behavior and, 54–55, 255 Diabetes, 47, 162 Drug-resistant viral strains adherence and, 5, 9, 46–47 screening for, 89 trends, 9, 47 Dysthymia, 253 E Early Treatment for HIV Act, 292 Education and training of health providers CARE Act programs, 29, 81, 190, 300 care for substance abusers, 321 in Centers of Excellence, 168 Medicaid providers, 111–114 Efficiency of service delivery, 134. See also Cost effectiveness Eligibility, 278, 280–283 alternative block grant program, 153–157 asset testing for, 198–199 buy-in provisions, 18 CARE Act, 17, 82, 144–145, 196, 197, 207, 249, 298 criteria for assessing programs, 142 current status, 17 expansion of Medicaid eligibility, 149–153, 217 HIV-CCP, 7, 18, 157–158, 178, 179, 181–182, 190, 196–201, 207, 217, 226 Medicaid, 17, 18, 75–76, 109, 114, 196, 197, 201, 278, 279–290, 291–292, 305, 325 Medicare, 78, 145–146, 147, 294–295, 305 modeling prospective enrollment in alternative programs, 224–225 mortality outcomes, 130

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White recommendations for improving access, 18 Social Security Disability Insurance, 294 spend-down provisions, 18, 197–198, 279, 326 substance abuse treatment, 325 Supplemental Security Income, 279, 325 Eligible Metropolitan Areas, 119, 122–123, 246–247, 298–299, 329, 331 Emergency room admission, 59 current utilization, 99 modeling service needs, 223 substance abuser care-seeking behaviors, 319 Entitlement programs, 73, 153, 156, 276 Evidence-based practice, 163 F Federal Ceiling Price, 20, 21 recommendations for HIV-CCP, 179–180, 203, 205 Federal Employee Health Benefits, 304 Federal programs for HIV/AIDS care, 278, 280–283, 328 barriers to access, 132, 133–134 benefits, 280–283 Centers of Excellence oversight, 174 current spending, 73, 75, 78, 188, 274–277 eligibility, 280–283 financing mechanisms, 73, 100 goals, 8, 133–134 mandatory vs. discretionary spending, 276 origins and development, 8 problems of federal–state partnership, 6, 11, 14, 136 recommendation for new program, 6–7, 16. See also HIV Comprehensive Care Program substance abuse treatment in, 95 See also specific programs Federal Supply Schedule, 20, 21 recommendations for HIV-CCP, 179–180, 203, 205 Fee-for-service care, 12 Financing system Centers of Excellence, 171–174 community-based services, 304 coordination among programs, 305–306 criteria for assessing programs, 142 current HIV spending, 73, 188, 274–277 current system, 5, 11, 73, 100, 216, 268 delivery system and, 10 federal block grant program, 153–157 geographic variation, 122 goals, 14–15, 16, 178 insurance coverage distribution, 271–274 prevention services, 306–307 problems of federal-state partnership, 6, 11, 14, 136 shortcomings of current system, 6, 11, 14, 134–136, 194–195, 268–269, 304–307 substance abuse services, 323–326, 327–328 See also Alternative delivery and financing systems; Cost of care; specific programs Fusion inhibitors, 37 G Geographic distribution CARE Act spending, 122 disease prevalence, 51–52 drug use patterns, 316 uninsured population, 129 Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, 44–46, 89 H HAART. See Highly active antiretroviral therapy Health Insurance Portability and Accountability Act, 85–87, 107, 108, 301–303 Health Resources and Services Administration, 7, 165 Hepatitis C, 42, 59–60 Heterosexual transmission trends, 10, 51 Highbridge Woodycrest, 334 Highly active antiretroviral therapy (HAART), 100 access under HIV-CCP, 159, 178–179, 182–183, 217, 226–230 adverse effects, 44

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White assessment for, 49 cost-effectiveness, 89, 179, 196 costs, 20–21, 23, 159, 179, 185, 196, 204–206, 223, 269–270 criteria for evaluating alternative delivery and financing systems, 214–215 current access, 11–13, 14, 129–130, 136, 181, 214–215, 218–223, 226 disease status of recipients, 226–227 dosing schedule, 48–49 drug interactions, 127, 320 effectiveness, 5, 8, 31, 37, 43–44, 130, 184–185 implications for care delivery system, 6, 31, 36, 39, 88 income levels of recipients, 222 insurance status of recipients, 181, 222 Medicaid coverage, 77, 217, 230 in pregnancy, 90 requirements for clinical effectiveness, 18 substance abusers and, 320 transmission risk and, 8, 37–38, 135 treatment guidelines, 44–46, 89 viral resistance to, 9 See also Adherence to HAART High-risk pools, 304 HIV/AIDS Integrated Services Project, 306 HIV/AIDS Mental Health Services Demonstration Program, 95 HIV Comprehensive Care Program, 213 administrative structure, 157, 159 benefit package, 18–19, 157, 158, 179, 186, 201–202, 215–216, 217 Centers of Excellence demonstration project, 180, 206 cost-effectiveness, 22–23, 24, 179, 180–181, 185–188 disadvantages, 159–160 drug purchases, 21, 159, 179–180, 203–206 eligibility, 7, 18, 157–158, 178, 179, 181–182, 190, 196–201, 207, 217, 226 financing, 157, 158–160, 196, 217, 233–234 goals, 6–7 HAART access and use under, 159, 178–179, 182–183, 217, 226–230 inputs for modeling, 217–225 maintenance of effort requirements, 160 morbidity and mortality outcomes, projected, 16, 22, 179, 183–184, 225, 230–231 prevention effect, 192–193 private insurance market effects, 181, 199–200 projected enrollment, 22, 178, 182–183, 190, 217, 224–225, 226 projected service utilization, 217–224 projected spending, 23, 160, 179, 188–189, 233–234 provider payment, 19, 158, 179, 185, 188, 202–203, 217 quality of care goals, 21 rationale, 16, 23–24, 33, 158–159, 179, 193–194, 208–209 recommendation for establishment of, 17, 179, 194–196 Ryan White CARE Act and, 21–22, 160, 180, 189–191, 206–208 state participation, 159–160, 195, 196, 234 Home and community-based services, 223, 303–304 CARE Act coverage, 329 Medicaid coverage, 114, 290–291 Homelessness, 61 Housing Opportunities for Persons with AIDS, 276 I Immigrant population, 62, 200 Immunophysiology AIDS, 41–42 chronic stage infection, 40–41 co-morbid disease infection, 60 depression effects, 257 HAART, 44–45 primary infection, 40 tuberculosis risk, 60 Incarcerated populations, 62–63, 200–201, 326 Incidence current rate, 5, 7–8, 27, 36–37 demographic patterns, 9–10, 38, 307 trends, 9–10, 37–38, 194–195, 307

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White L Low-income population care delivery system goals, 14–15 challenges for service delivery, 50 crowd-out response to government programs, 181 current estimates, 218, 270 current HIV/AIDS care system, 34 definition, 197 eligibility for federal care programs, 17, 18, 197 eligibility for Medicaid HIV benefits, 109, 111, 279, 290 expansion of eligibility for Medicaid HIV benefits, 149–153 HAART access among, 222 HIV-CCP eligibility, 179, 181–182, 196, 197–199 infection risk, 38 mental illness risk, 251 poverty level, 181, 196 recommendations for CARE Act programs, 22 social co-morbidities, 54, 60–61 substance abuse treatment access among, 58–59 M Mammography, 187 Managed care, 117 Centers of Excellence model, 170 Medicaid, 111–113, 293 Medicaid barriers to access, 12, 17, 109–114, 132–133, 272–273, 291–293, 305 benefits, 76–77, 290–291 capitation rates, 111, 114 case management services, 96 community-based services, 304 coordination with other programs, 128–129 coverage for privately-insured individuals, 199 coverage for working individuals, 109–111, 291–292 current participation, 10, 73, 75, 129, 218, 271, 272, 274, 278–279 definition of “disability,” 279 demographic patterns in HIV care, 272 dental services, 130 drug purchases, 20, 21, 203–204, 270, 293, 306 dual enrollment, 271, 294 eligibility for AIDS/HIV care, 17, 18, 75–76, 109, 114, 149–153, 196, 197, 201, 278, 279–290, 291–292, 305 enhanced or expanded models, 15–16, 141, 148–153, 195, 213–214, 217, 230, 231, 234 managed-care services, 111–113, 293 mental illness treatment, 115 performance evaluation, 32 preventive interventions, 97 primary care services, 98 provider participation and reimbursement, 12, 19, 111, 114, 202–203, 325–326 quality of care, 273–274 role in HIV care system, 7 Section 1115 waivers for HIV care prior to disability, 7, 15, 109, 111, 149–150, 291–292, 305 spending, 75, 274–275, 276, 279, 328 state cost control strategies, 293 state-to-state disparities, 11, 14, 75, 110, 112, 113, 114–117, 284–290, 291, 292, 305 strategies for improving service delivery, 114 structure, 75, 278 substance abuse treatment, 95, 115, 325–326 Medicaid Managed Care Organizations, 205 Medicare access, 19 barriers to access, 117, 295–297, 305 benefits, 79, 117, 147–148, 295 coverage, 77–78, 293 current enrollment, 10, 73, 78, 129, 218, 271, 272, 293–294, 328 dual enrollment, 271, 294, 296–297 eligibility, 78, 145–146, 147, 294–295, 305 expansion of, to improve care, 141, 145–148, 195 financing sources, 146 prescription drug coverage, 79, 147–148, 294–295, 296–297, 305, 306

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White program accountability, 146 project growth in enrollment, 78, 294 provider participation and reimbursement, 12, 19, 111, 146, 203 spending, 78, 274–275, 276, 294, 328 strategies for improving service delivery, 117 utilization patterns, 127–128 Medicare Prescription Drug, Improvement and Modernization Act, 147, 294–295 Medigap policies, 117, 296 Mental illness access to care, 252, 263 adherence to HIV treatment and, 47, 49, 56–57, 91–93, 254, 256–257, 260 among HIV-infected youth, 61–62 barriers to care, 55–56, 131, 258, 259–260 challenges for service delivery, 50 clinical features, 251 co-morbid substance abuse, 251, 327 disability outcomes, 251, 252 HAART utilization and, 224 HIV-CCP coverage, 201 HIV detection in people with, 55, 258 HIV risk, 54–55, 94, 252–253, 254–256 impact on course of disease, 93–94, 257 implications for HIV treatment, 95, 250, 261–263 Medicaid coverage, 115 modeling service needs, 223–224 mortality, 251–252 pharmacotherapy, 261–262 prevalence, 54, 250, 251, 252–253 severe forms, 252 socioeconomic status and, 251 standard of HIV care, 10, 19 stigmatization and discrimination, 260 trends, 10, 253–254 Montefiore Substance Abuse Treatment Center, 333 Mortality cause of death in HIV disease, 42 co-morbid depression, 94 course of HIV, 42 current rate, 5, 7–8, 37 demographic patterns, 9, 51 HAART outcomes, 5, 8, 37, 130, 184 HIV-CCP goals, 16 HIV-CCP projected outcomes, 22, 179, 183–184, 230–233 insurance coverage and, 130 mental illness, 251–252 obstacles to greater reduction, 5–6, 12 treatment effectiveness, 43 trends, 8, 42 Multidisciplinary treatment approach, 163–164 N National health insurance, 33 Natural history. See Course of disease Nonmedical services, 190 Medicare coverage, 117 modeling service needs, 223 NorthSTAR Behavioral Health Pilot Program, 334 O Obstetric care, 19, 90, 201, 223 Omnibus Budget Reconciliation Act, 203–204, 279 Opportunistic infection, 42, 89–90 guidelines for prevention and treatment, 90 HAART effectiveness, 44 modeling service needs, 223 types of, 90 Oral health access to care, 130 CARE Act provisions, 30, 81, 98–99, 190, 202, 299 disease progression, 98 Medicaid services, 130 modeling service needs, 223 primary care, 98 Origins of HIV, 40 P Panic disorder, 91, 253 Patient–provider relationship discrimination against client with mental illness, 260 HAART adherence and, 47, 49, 163 substance abusing patients, 321–322

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White Pneumonia, 42 Posttraumatic stress disorder, 253, 255 Pregnancy HAART and, 90 HIV transmission prevention in, 19, 90–91 Prescription drugs CARE Act coverage, 118, 204 costs, 19–20, 270, 306 goals for federal purchasing, 7 HIV-CCP drug purchases, 21, 159, 179–180, 203–206 Medicaid benefits, 76–77, 113, 203–204, 290, 291, 293, 328 Medicaid spending, 270 Medicare benefits, 79, 117, 147–148, 294–295, 296–297, 305 pharmacy assistance programs, 304 psychotropic medications, 261–262 research and development, 20–21 See also AIDS Drug Assistance Program; Highly active antiretroviral therapy Prevalence CARE Act EMA eligibility, 246–247 childhood sexual abuse, 62, 255 co-morbid disease infection, 60 co-morbid mental illness, 54, 252–253 co-morbid substance abuse, 57–58, 253, 316–317 current estimates, 218, 226 geographic distribution, 51–52 homelessness, 61 mental illness, 54, 250, 251 socioeconomic distribution, 270 trends, 37–38 Preventive interventions among HIV-positive individuals, 97 antiretroviral therapy, 97 financing, 306–307 HIV-CCP coverage, 201, 202 HIV-CCP effects, 192–193 with mentally ill individuals, 262–263 Primary care access, 10 advantages of health care delivery in, 98 CARE Act provisions, 98–99, 118, 126 HIV-CCP coverage, 201 Medicaid coverage, 98 role in HIV care system, 98 scope of services, 98 Primary infection, 40 Prisons. See Incarcerated populations Privacy and confidentiality issues, 196 Private insurance, 33 anti-discrimination protections, 301–302 barriers to care, 107–109, 301, 302–303 CARE Act purchases, 108–109, 302 COBRA extensions, 302 consumer costs, 107–108 coverage over course of disease, 87 crowd-out response to government programs, 181, 199–200 current coverage, 10, 73, 85, 100, 108, 129, 218, 271, 272, 274, 301 demographic patterns in HIV care, 272 denial of service, 108, 301 HIV-CCP eligibility and, 199 Medigap policies, 117, 296 portability protections, 301 regulation, 85–87, 108, 301–302 state-by-state variation in care, 108 PROTOTYPES, 332–333 Public perception and understanding of HIV/AIDS care, 27–28 stigmatization of HIV-infected persons, 260 Q Quality-adjusted life years evaluation of alternative care systems, 22, 215, 216 HIV-CCP goals, 16 HIV-CCP projected outcomes, 22–23, 179, 184–185, 186–188, 231–233 Quality of care CARE Act programs, 118, 123 current system, 305 goals, 15, 134, 164–165 HIV-CCP goals, 21 insurance access and, 273–274 in managed-care organizations, 111–113 Medicaid providers, 111–114 mental illness and, 260, 262–263 promptness of diagnosis, 274 in rural areas, 99 specialists in HIV care, 113, 114 strategies for improving, 164–165 substance abuse and, 319–320

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White R Racial/ethnic minorities, 38 barriers to care, 59, 129–130, 131, 132–133 CARE Act services, 82, 247, 249 co-morbid disease infection, 60 HIV risk, 9, 38 infection patterns, 51, 307 insurance access and utilization, 272 mental health care utilization, 258 mental illness risk, 251 mortality patterns, 9 substance use in HIV transmission among, 57, 315 Reimbursement alternative block grant program, 156 carve-out programs, 114, 170 Centers of Excellence, 168, 169, 171–174 criteria for assessing programs, 142 disincentive programs, 173–174 HIV-CCP, 19, 158, 179, 185, 188, 202–203, 217 Medicaid, 12, 14, 19, 114, 132–133, 202–203, 293, 325–326 Medicare, 12, 19, 111, 146, 203 obstacles to access, 12, 14, 19, 132–133, 136, 203, 293 risk-adjusted capitation, 114 state-to-state variation, 326 Research and development in pharmaceutical industry, 20–21 Rivington House, 334 Rural areas, 323 Centers of Excellence in, 173 quality of care in, 12, 99 substance abuse treatment in, 326 Ryan White CARE Act, 7, 11, 28 barriers to care, 12–13, 118–122, 300 benefits, 202, 298–300 case management services, 96 clients, 30, 35, 81–82, 298 coordination with other programs, 124, 125, 128–129 dental program, 30, 81, 98–99, 190, 202, 299 early intervention services, 80, 119, 202, 207–208, 299 education and training centers, 29, 81, 190, 300 effectiveness, 31–32 eligibility, 17, 82, 144–145, 196, 197, 207, 298 Eligible Metropolitan Areas, 119, 122–123, 298–299, 329, 331 emerging communities awards, 249, 299 expansion of, to improve care, 141, 144–145 funding, 118, 145, 297–298, 300, 328 HIV-CCP and, 21–22, 160, 180, 189–191, 206–208 HIV treatment evolution and, 30–31 performance evaluation, 13, 14, 122–123, 126–127, 136, 145 planning bodies, 13, 84–85, 123–127, 144, 329, 331 primary care services, 98–99, 118, 126 private insurance purchases under, 108–109, 302 purpose, 8, 11, 28–30, 50, 79, 268, 297 services and components, 29–30, 80–81, 82–84 spending, 80, 81, 119, 125, 276, 298, 299, 300 state and local administration, 13, 80, 144, 145, 248, 298, 299, 329 state-to-state disparities, 17, 118, 119–122, 144–145, 284–290, 298, 300, 305 substance abuse treatment, 95, 314, 328–331, 334–335 Title I, 13, 29, 80, 82, 84, 85, 96, 119, 123, 125, 145, 190, 207, 246–247, 298–299, 328–330 Title II, 13, 29, 80, 82–84, 96, 108–109, 119, 122, 190, 207, 248–249, 299, 328–330 Title III, 29, 80, 119, 190, 202, 207–208, 299 Title IV, 29, 80–81, 119, 190, 202, 299 See also AIDS Drug Assistance Program Ryan White Planning Councils and Consortia, 123–127 S Schizophrenia, 251, 253, 255, 261 Screening cost-effectiveness, 186–187 for drug-resistant viral strains, 89 HIV detection in people with mental illness, 55, 258

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White incarcerated persons, 63 prenatal, 90–91 rapid testing, 37 Sensitivity analysis, 234–243 Settings for care current utilization, 12, 99, 100 insurance coverage and, 10, 268 for substance abusers, 59, 319–320 trends, 6, 87–88, 165 Sexual abuse HIV transmission risk and, 255 prevalence, 62, 255 Sexual behavior HAART and, 135 mental illness and, 54–55, 94, 254–256 prevention of transmission-risk behaviors, 97 prior sexual abuse and, 255 substance use and, in HIV transmission, 315 Sexually transmitted diseases, co-morbid, 59–60 Social co-morbidity, 54, 60–63 Social Security Disability Insurance eligibility, 294 Medicare eligibility and, 78, 294 spending, 275–276 Social services access, 10 Special Projects of National Significance, 29, 81, 190, 300 Standard of care, 10, 88–89, 100 alternative block grant program, 155–156 criteria for assessing programs, 142 current delivery system, 6 HIV-CCP, 158, 179, 201–202 recommendations for federal program, 18–19 State Children’s Health Insurance Program, 142, 153–154, 155, 200, 201 State governments alternative block grant program, 153–157 CARE Act administration, 80, 119, 122, 248, 298, 299 drug purchases, 203–204 eligibility for AIDS/HIV care, 17 expansion of Medicaid eligibility, 149–153 health care for incarcerated persons, 200–201 HIV care spending, 276, 279, 328 in HIV-CCP, 17, 157–158, 159–160, 189, 195, 196, 234 inadequacies of current care system, 6, 7 insurance regulation, 108 Medicaid administration, 11, 75, 76–77, 279–290, 291, 328 problems of federal–state partnership, 6, 11, 14, 136 purchase of private insurance by, 108 role in alternative delivery and financing systems, 142–144 substance abuse treatment programs, 323–324 State-to-state variation in services CARE Act programs, 118, 119–122, 144–145, 284–290, 298, 300, 305 current system, 6, 7, 305 Medicaid programs, 11, 14, 75, 110, 112, 113, 114–117, 284–290, 291, 305 private insurance, 108 reimbursement policies, 326 Stigmatization, 260, 318 Substance abuse abuser attitudes toward health care, 321–322 among HIV-infected populations, 57–58, 61–62, 253, 316–317 barriers to HIV/AIDS care, 313, 318–323, 330–332 CARE Act provisions, 314, 328–331, 334–335 care-seeking behavior and, 58, 94, 319 challenges for service delivery, 50, 57, 58–59 co-morbid mental illness, 251, 327 considerations in HIV policy planning, 314 current research base, 315–317 current treatment system, 323–332 denial of services based on, 322 effective programs, 331–335 funding for treatment services, 323–326, 327–328 HAART utilization and, 224, 320 hepatitis infection and, 60 HIV-CCP coverage, 201 HIV course and, 91, 93–94 HIV transmission and, 57, 94, 313, 315 Medicaid coverage, 115, 325–326

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White modeling service needs, 223–224 patterns, 315–316 provider attitudes, 321 recommendations for federal care program, 19 service needs of HIV-infected substance abusers, 91, 95, 317–318 standard of HIV care, 10, 19 syringe exchange program, 314 treatment adherence and, 47, 49, 59, 91–93, 320–321 treatment capacity, 326–327 treatment for, 322–323 Substance Abuse and Mental Health Services Administration, 95, 315–316, 324 Substance Abuse Prevention and Treatment Block Grants, 95 Supplemental Security Income, 18, 76, 112, 197, 275–276, 279, 305, 325 Syringe exchange program, 314 T Teaching hospitals, 99 Temporary Assistance for Needy Families, 112 Testing. See Screening Therapeutic relationship. See Patient–provider relationship Ticket to Work/Work Incentives Improvement Act, 109–111, 114, 291–292, 305 Transmission, HIV among injection drug users, 57 HAART therapy and, 8, 37–38, 135 heterosexual, 10, 51 HIV-CCP effects, 192–193 mental illness and, 54–55, 94, 252–253, 254–256 mother-to-child, 90–91 projections, 37–38 stage of disease and risk of, 10, 41, substance abuse and, 57, 94, 313, 315 See also Incidence; Preventive interventions Tuberculosis, 42, 60 U Underinsured/uninsured population, 33 among individuals with HIV/AIDS, 11, 100, 129, 226, 271, 272, 274 CARE Act coverage, 79, 82, 297 costs of HIV care, 189 demographic patterns, 272 geographic distribution, 129 HAART access and utilization, 181 HIV-CCP projections, 189 infection trends, 38, 50 settings for care, 10, 268 substance abuse treatment access among, 58–59 V Viral load, 41–42, 43 depression effects, 93–94 W Women barriers to care, 59, 322 CARE Act services, 80, 82, 202 depression risk, 251 infection patterns, 9–10, 51 insurance access and utilization, 272 obstetric care, 90 substance use in HIV transmission among, 315 Z Zidovudine, 90