Reducing the Odds Preventing Perinatal Transmission of HIV in the United States (1999) / Chapter Skim
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B Context of Services for Women and Children Affected by HIV/AIDS
B Context of Services for Women and Children Affected by HIV/AIDS
Pages 155-189
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From page 155... ...
After describing the population of women and children affected by HIV and discussing what we know about where women and children go for care, the appendix profiles a variety of providers offering services to this population. It then discusses the major sources of funding for HIV-related services and the implications of a number of policy issues, including welfare reform, changes in Medicaid, public and private sector managed care, the Health Insurance Portability and Accountability Act, and the Americans with Disabilities Act.
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From page 156... ...
Most adolescents receive health care at community teen clinics, school-based clinics, community family practices, private family practices, and private pediatric practices (Blum et al., 1996~. The poor or nearly poor, the population most affected by HIV infection, is more likely to use publicly funded providers or programs (public and nonprofit hospitals, community health centers, family planning clinics, and public health clinics (Lyons et al., 1996~.
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From page 157... ...
1. Public and Nonprofit Providers State and Local Public Health Services and Clinics Local Health Departments1 These administrative and service units of local and/or state governments employ at least one full time person and carry some responsibility for the health of an area smaller than the state.
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From page 158... ...
Services relevant to maternal and child health are listed in Table B.2. Funding: Local health departments access a variety of funding sources, including, for example, state funds (including maternal and child health program funds)
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From page 159... ...
Community Health Centers3 These public and private nonprofit community-based organizations directly or indirectly, through contracts and cooperative agreements, provide primary 2Data from the American Hospital Association (1998)
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From page 160... ...
Less than 1% of patient encounters included HIV testing, although 85% of grantees report providing this service. Funding: Sources of funding for community, migrant, and homeless health centers include, in order of frequency, the Bureau of Primary Health Care, Medicaid, the Ryan White CARE Act, state and local grants, private insurance, Medicare, patient fees, and foundation grants and contracts.
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From page 161... ...
Clinic sites include state and local health departments, hospitals, university health centers, Planned Parenthood affiliates, independent clinics, and other public and nonprofit agencies. Title X clinics are community-based, located in every state and in three-fourths of U.S.
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From page 162... ...
Although some are located at family planning clinics and hospitals, most are located in state and local public health departments. These clinics are the primary source of HIV testing in public facilities.
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From page 163... ...
There is no available information on what percentage of these health centers provides HIV counseling and/or linkage to testing and treatment services, but these centers are often the first and may be the only contact with medical services for adolescents. 6Data provided by "School-Based Health Centers.
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From page 164... ...
Drug Treatment Facilities Funded primarily through the Federal Substance Abuse, Prevention, and Treatment Block Grant, totaling $1.3 billion, and state and local funds, this public 7Much of the data in this section was obtained in an interview with Theodore Hammett, ABT Associates, Boston, MA, April 9, 1998. 81995 funding sources obtained from state Resources and Services Related to Alcohol and Other Drug Problems: Fiscal Year 1995, National Association of State Alcohol and Drug Abuse Directors, Inc.
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From page 165... ...
The movement of Medicaid recipients into managed care has resulted in a reduction of coverage for substance abuse treatment services. There has also been an increase in cases of criminal prosecution for pregnant women who are substance abusing and in mandatory testing, reporting, and treatment (Chavkin et al., 1998~.
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From page 166... ...
Thirty percent of the sites are dedicated, mostly anonymous, and are frequently linked to medical facilities; 30% are located in STD clinics, and the remainder are a mix of provider sites, including community health centers, hospitals, prisons, family planning clinics, drug treatment centers, and, occasionally, private providers. Private Providers The following providers are important sources of primary care and obstetrical care for women.
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From page 167... ...
are educated in nursing and midwifery and provide primary care to women of childbearing age, including prenatal, labor, and delivery care, postpartum care; gynecological exams; newborn care; assistance with family planning decisions; preconception care; menopausal management; and counseling in health maintenance and disease prevention. Nurse midwives attended more than 205,000 births in the United States in OData provided by the AAP.
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From page 168... ...
Practice settings include private offices, community health centers, public health clinics, hospital clinics, and family planning clinics. Approximately 67% of nurse practitioners practice in a private setting and 33% work in a public setting.
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From page 169... ...
Most ASOs are located in cities receiving funds from the Ryan White Title I Emergency Relief Grant Program for Eligible Metropolitan Areas areas with a high incidence of HIV/AIDS although there are also many in smaller cities and towns throughout the country. Population served: This generally includes the affected population as a whole, although some organizations may focus their efforts on a particular segment of the population (homosexual men, minorities, women)
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From page 170... ...
The fact that an individual or family does not have health insurance significantly influences their access to health care services and, therefore, the ability to access important preventive health services such as counseling and testing for HIV. The uninsured are less likely to see a
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From page 171... ...
Federal funds consist of project or program dollars that support administrative and/or clinical and support services (e.g., Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, Title V MCH, Community Health Centers)
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From page 172... ...
Thirty-four states offer a "medically needy" option that permits those with too much income to otherwise qualify by offsetting their excess income with medical or remedial expenses. Medicaid covers only 62% of the poor, and since the 1996 legislation, coverage for legal immigrants, children with disabilities, and individuals with substance abuse and alcoholism has been either eliminated or restricted (AIDS Action Council, 1998b)
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From page 173... ...
About $40 billion in federal funds will be provided over the next 10 years with a requirement for matching state funds. States may expand the Medicaid program and/or create or expand a separate state health insurance program.
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From page 174... ...
Amendments to the Ryan White CARE Act in 1996 intensified the focus on prevention of perinatal HIV transmission and provided additional funding to states adopting the new CDC guidelines for offsetting costs related to such activities as outreach, voluntary testing for HIV, and mandatory testing of newborns. Title I: HIV Emergency Relief Grant Program for Eligible Metropolitan Areas.
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From page 175... ...
Grants are awarded to the state agency designated by the governor, usually the health department. Services may include home- and community-based health care and support services, continuation of health insurance coverage, and pharmaceutical treatments through the AIDS Drug Assistance Program (ADAP)
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From page 176... ...
To date, 166 facilities in 34 states, Puerto Rico, and the District of Columbia have been awarded funds. Nearly half of the funds have been given to community and migrant health centers; the other half have been distributed to homeless programs, local health departments, family planning programs, diagnostic and treatment centers for hemophilia, federally qualified health centers, and private nonprofits.
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From page 177... ...
While some states directly provide services in the community or on a regional level, the bulk of support for service delivery is provided indirectly through grants and contracts with community-based providers, including local health departments, community health centers, hospitals, university medical centers, school-based and school-linked health clinics and programs, public and private community agencies, and private providers. Total Title V appropriations for FY 1998 were $683 million, with $564.9 million allocated to states on a formula basis in the form of a block grant.
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From page 178... ...
The total appropriation for FY 1998 is $826 million. Services required of health centers includes primary care services, diagnostic laboratory and radiologic services, preventive health services (prenatal and perinatal services, screening for breast and cervical cancer, well child services, immunizations, screening for communicable diseases, elevated blood lead levels and cholesterol, pediatric eye, ear, and dental screenings, family planning services, preventive dental services)
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From page 179... ...
Other sites include some family planning clinics and hospitals. These clinics are the primary source of HIV testing in public facilities, although the population using these clinics is primarily male, poor, uninsured, and experiencing symptoms of an STD.
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From page 180... ...
CSAT administers the block grant program supporting the 10,000 substance abuse treatment facilities throughout the country that receive federal funds, and is responsible for residential and treatment programs for pregnant and postpartum women; demonstration projects that target special populations, including those with HIV; and programs that address the needs of people under the criminal justice system. CSAP has a number of projects focused on women that are ending this year.
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From page 181... ...
CDC prevention dollars are provided for testing, counseling, and outreach; Ryan White Title II dollars are provided with the requirement that community planning groups determine how funds are to be distributed; and state funds are provided at state discretion. State AIDS programs fund testing and counseling services, education, and outreach services in existing community-based service settings through grants and contracts; some testing and counseling centers are run directly by the state.
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From page 182... ...
There is currently a new collaboration with the Ryan White Title IV grantees to establish linkages to research sites related to nutrition research. National Institute of Allergy and Infectious Diseases National Institute of Allergy and Infectious Diseases (NIAID)
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From page 183... ...
The variability that has always existed from community to community in the organization, structure, and funding of health care services has increased accordingly, creating important challenges to mounting an effective effort to reduce HIV perinatal transmission. IMPORTANT ISSUES AFFECTING SERVICES There are a number of important issues that significantly affect the structure, funding, and the delivery of services to women, children, and youth affected by HIV.
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From page 184... ...
Although many states have attempted to ease access to Medicaid for those applying for TANF benefits by creating a single application for TANF and Medicaid, access has been made more complicated for those not eligible or interested in TANF benefits because separate routes to Medicaid have not been effectively established in many jurisdictions. With access to both welfare and health care services restricted to certain categories of legal immigrants and unavailable for the undocumented, opportunities for prevention and treatment are more limited.
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From page 185... ...
The movement into managed care represents a fundamental change in the way health care services are delivered in both the public and the private sector, raising issues of access to care and quality of care. · Through public sector managed care arrangements, women, children, and
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From page 186... ...
Some of the problems encountered by persons with HIV enrolled in MCOs include reduced access to specialty care providers, including HIV specialists; reduced access to specific drug formularies and specific services; clinical decisions with the appearance of cost as the dominant factor; limitations placed on the information providers can provide; and insufficient time to meet with providers. Relationships need to be built with the type of providers that adolescents seek out teen clinics, school health clinics, community family practice sites, and family planning clinics.
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From page 187... ...
The law did not specify what benefits a health plan must include and did not guarantee that health insurance coverage would provide adequate care or be affordable. In addition, there are a number of issues involving AIDS and private insurance coverage that remain unresolved at this time.
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From page 188... ...
August 1997 George Washington University. School-Based Health Centers.
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From page 189... ...
Uninsured in America: Key Facts About Gaps in Health Insurance Coverage Today.
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