public and private funding streams. Estimates from a nationally representative sample of HIV-infected persons receiving ongoing care found that one-third were covered by private insurance, 29 percent by Medicaid, and 20 percent by Medicare (Bozzette et al., 1998).6 These estimates varied by race, with a larger percentage of African Americans and Hispanics covered by Medicaid (Bozzette et al, 1998). Many uninsured or underinsured individuals living with HIV also obtain services through the Ryan White CARE Act and Community and Migrant Health Center (CHC) programs, which are administered by HRSA.
Policy initiatives designed to increase the level of prevention offered in clinical care settings can be targeted to private as well as public programs. According to the Health Care Financing Administration (HCFA), Medicaid covers over half of people living with AIDS (HCFA, 2000).7 Many of these individuals, however, are also eligible for Medicare. CARE Act programs are “payers of last resort” and, therefore, serve primarily low income and indigent populations. Nonetheless, the CARE Act represents the third largest public program paying for care for people living with AIDS, and makes funds available through four titles to states, metropolitan areas, and nonprofit entities. Title I of the Act provides emergency assistance funds to metropolitan areas disproportionately affected by AIDS. Title II provides funds to states to improve the quality, availability, and organization of health care and support services for people with HIV. Title III provides grants to community-based clinics for early intervention services. Title IV provides funds for pediatric AIDS programs (see Appendix C for a more detailed description of CARE Act programs). In fiscal year 2000, CARE Act spending totaled $1.6 billion, compared with an estimated $4.1 billion of federal and state Medicaid HIV/AIDS spending and an estimated $1.7 billion of federal HIV/AIDS Medicare spending (HCFA, 2000). Although the precise number of people served by CARE Act programs is unknown, there may be significant overlap among individuals served by the CARE Act, Medicaid, Medicare, and private insurers.
The Community and Migrant Health Center (CHCs) program is another source of care for people living with HIV. While many CHCs are also HRSA-funded CARE Act grantees, CHCs without CARE Act support are significant providers of federally financed HIV-related primary care to low income populations. In 1998, CHCs conducted over 218,000 HIV