Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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4 Barriers to HIV Care
4 Barriers to HIV Care
Pages 107-140
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From page 107... ...
Act [CARE Act]
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From page 108... ...
If other states follow suit, federal programs such as Medicaid and the CARE Act could play an even more important role as a safety net insurer.4 As their illness progresses, individuals with HIV often face difficulties maintaining coverage if they become unemployed due to illness. The Health Insurance Program (HIP)
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From page 109... ...
HIP also allows funds to be used to pay family health insurance premiums to ensure insurance continuation for a family member and to pay for public or private copayments and deductibles for persons with HIV disease. MEDICAID Certain elements of the Medicaid program create access problems for people living with HIV/AIDS, most notably, the eligibility criteria (Boxes 414-5)
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From page 110... ...
. In addition, if a state's Medicaid program has narrow eligibility rules and a limited benefits pack age, other programs, particularly Ryan White, may be expected to fill the gaps in Medicaid coverage (Levi et al., 2000)
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From page 111... ...
By influencing provider participation, low reimbursement rates have been shown to affect access to care for Medicaid beneficiaries in particular (Perloff et al., 1995; Adams, 2001; Kaiser Commission on Medicaid and the Uninsured, 2001; Cunningham, 2002; GAO, 2002; Santerre, 2002)
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From page 112... ...
If she makes too much money, for example, by working full time earning the minimum wage, she is ineligible for Medicaid coverage even in the states with the most generous eligibility requirements.
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From page 113... ...
. Moreover, the longer a physician has been treating patients for HIV infection and the higher the volume of these patients in the physician's regular practice, the higher the physician's confidence in assessing patient status, prescribing treatment regimens, and inter BOX 4-3 Variation in Medicaid Programs: Prescription Drugs Joe's bipolar disorder adds yet another dimension to his already complex AIDS care.
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From page 114... ...
. State Medicaid programs are also experimenting with other strategies to mitigate inadequate provider reimbursement, including health-based payment systems that set capitation rates based on health status and "carveout" programs that exclude some expenses from the capitation rate (Conviser et al., 1998, 2000)
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From page 115... ...
BOX 4-5 Variation in Medicaid Programs: Substance Abuse Treatment Even though as a recipient of TANF Nancy is eligible for Medicaid, her active substance abuse presents a barrier to her seeking and remaining in HIV care. Not surprisingly, her opportunities to receive substance abuse treatment within the differing Medicaid programs would vary.
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From page 116... ...
116 HCBS, HCBS Waivers: TWWIIA, TWWIIA, 5,6 HIV-Specific 1115, 2002 HCBS 1115, HCBS -- HCBS 1115 -- -- -- - limit Month, Month: Per 3,4 annual Prescription Limitations Per No. 2001 6 4 5 -- -- Yes: -- 3 10 State, 1,2 209(b)
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From page 117... ...
Medicare has relatively high deductibles relative to Medicaid and no limits on out-ofpocket spending, which means that some individuals may not be able to afford services. Furthermore, at this time Medicare does not cover outpatient prescription drugs, so Medicare beneficiaries with HIV/AIDS must find other means to pay for highly active antiretroviral therapy (HAART)
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From page 118... ...
The number of people living with HIV/AIDS continues to grow, as does the cost of care and the demand for CARE Act services. As a discretionary grant program, the CARE Act depends on annual appropriations by Congress (and often by states and municipalities)
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From page 119... ...
. All states receive Title II HIV Care formula grants for ADAP and health care and support services, but some states receive additional CARE Act funding through other CARE Act programs.
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From page 120... ...
120 States Health Insurance Program, 2001, 37 -- Yes -- -- Yes Yes -- Yes -- Yes Yes Yes Yes Yes Yes Yes Yes Yes -- Yes Yes Yes Yes III EIS) Site, States Title EIS 2001, 50 (310 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes I Ryan Title 2001, states, EMAs)
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From page 121... ...
121 -- Yes Yes Yes Yes Yes Yes Yes Yes -- -- Yes -- Yes -- Yes Yes Yes Yes Yes Yes Yes -- Yes Yes Yes -- -- -- - Yes Yes Yes Yes Yes -- Yes Yes Yes Yes -- Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes -- Yes Yes - -- Yes -- -- Yes Yes Yes -- Yes -- -- Yes -- Yes Yes -- -- -- -- Yes -- -- Yes Yes Yes Yes -- Yes -- - restrictions list list enrollment list list list -- -- Waiting Waiting -- -- -- -- -- Capped -- -- Other Waiting -- -- -- Waiting -- Antiretroviral -- -- -- Other Waiting -- Other -- -- - 43 270 49 18 55 32 Open 60 463 51 86 69 65 56 69 57 48 41 43 36 18 69 51 137 27 43 51 115 26 26 indigent as 400 300 300 200 400 300 500 300 <$44,000/yr 125 400 300 200 200 <$30,000/yr 400 300 300 300 200 200 200 300/333 300 250 300 200 Certified 200 200 . 2004 Kates, Carolina Dakota Island Rico Islands Hampshire Jersey Mexico York Carolina Dakota Virginia Mississippi Missouri Montana Nebraska Nevada New New New New North North Ohio Oklahoma Oregon Pennsylvania Rhode South South Tennessee Texas Utah Vermont Virginia Wash.ington West Wisconsin Wyoming Puerto Virgin Guam SOURCE:
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From page 122... ...
The Committee also found that Southern states receive about $318 less per case of HIV/AIDS than non-Southern states. Because the Ryan White CARE Act program wraps around other federal and state programs, Medicaid in particular, CARE Act spending is highly influenced by state Medicaid programs.
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From page 123... ...
The IOM Committee on the Ryan White CARE Act: Data for Resource Allocation, Planning, and Evaluation explored a number of data issues as part of its review. Among its findings, the Committee noted that not all states were equally capable of providing high-quality data on HIV infection for planning purposes as required by the 2000 reauthorization of the CARE Act.
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From page 124... ...
Particularly in states with lots of Title I planning processes going on, it is very hard to coordinate that, to build a system that makes sense, [where] you can finance it with a public financing system that will work, that you can get funded in the larger legislative environment.
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From page 125... ...
Broad policy issues are also not within the authority of HIV planning bodies or CARE Act grantees" (researcher)
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From page 126... ...
There are some EMAs where primary care is primarily paid by another source. So, they have decided-rightly so -- not to focus CARE Act dollars to support primary care, but to focus those dollars on other supportive services that aren't covered.
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From page 127... ...
Eichner (2001) , a researcher at the National Academy of Social Insurance, conducted a case study analysis that described the complexity of coordinating health coverage for Medicare enrollees with HIV/AIDS in the state of California.
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From page 128... ...
In 1996, amendments of the Ryan White CARE Act recognized that there was a need for coordination between the CARE Act program and Medicaid. Requirements for coordination were established that placed a representative from the state Medicaid agency on the Ryan White Planning Council associated with the Title I program.
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From page 129... ...
. Coordination between Medicaid and CARE Act programs and their providers can eliminate duplication of services, save the States' and the Ryan White Program's limited funds, and ultimately serve individuals with HIV more effectively and efficiently." Since the promulgation of the CARE Act Amendments and the CMS directive to state Medicaid directors, individuals with HIV/AIDS continue to wrestle with the coordination of multiple systems, programs, and benefits.
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From page 130... ...
The researchers also found that states with Medicaid programs with less restrictive eligibility rules and more generous drug coverage had significantly lower death rates than states with more restrictive eligibility rules and less generous drug coverage. Demographic variables and comorbidities also play an important role in accessing HAART.
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From page 131... ...
. Other studies have shown that receiving treatment for mental illness is associated with a higher probability of receiving antiretroviral treatment; thus, the barriers to receiving care for mental illness are relevant when considering access to HIV care (Turner et al., 2001; Cook et al., 2002; Sambamoorthi et al., 2000)
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From page 132... ...
Rice supports this relationship with findings from the RAND Health Insurance Experiment (Manning et al., 1987; Newhouse and Insurance Experiment Group, 1993)
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From page 133... ...
. COMMITTEE OBSERVATIONS AND CONCLUSIONS In assessing the current factors that affect access to HIV care, the Committee recognized that there are many actors in the care system-including people living with HIV, providers of medical care, Ryan White planning councils, and policy makers at the federal, state, and local levels-and these actors do not view themselves or act as interrelated elements of a complex whole.
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From page 134... ...
Goals for the HIV/AIDS Care System The Committee believes the primary goal of the publicly funded system of HIV care should be to improve the quality and duration of life for those with HIV and promote effective management of the epidemic by providing access to comprehensive care to the greatest number of individuals with HIV infection. The Committee defined four secondary objectives of the system around the essential concepts of access, quality, efficiency, and accountability: · Ensure HIV-infected individuals early and continuous access to an appropriate, comprehensive set of medical and ancillary services that meet the standard of care (access)
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From page 135... ...
. Based on its analysis of the trends in HIV infection, demographics of the disease, treatment advances, and the current systems of financing and delivering care, the Committee concludes the following: Conclusion 1: Current public financing strategies for HIV care have provided care and extended the lives of many low-income individuals.
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From page 136... ...
Conclusion 6: The lack of nationwide data on the unduplicated number of individuals served and the services they received under the Ryan White CARE Act hinders accountability, quality monitoring, and out comes evaluation, and impedes the improvement of the program. Conclusion 7: The majority of HIV care is publicly financed, providing a strong incentive and opportunity for the federal government to finance and deliver care more effectively.
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From page 137... ...
HIV Cost and Services Utilization Study Consortium. Health Services Research 35(2)
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From page 138... ...
2003. Measuring What Matters: Allocation, Planning and Qual ity Assessment for the Ryan White CARE Act.
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From page 139... ...
2000. The Impact of State-by-State Variability in Entitlement Programs on the Ryan White CARE Act and Access to Services for Underserved Popula tions.
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From page 140... ...
1999. Variations in the care of HIV infected adults in the United States: results from the HIV Cost and Services Utilization Study.
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