Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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Prologue and Executive Summary
Prologue and Executive Summary
Pages 1-26
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In addition, it is treatable with highly active antiretroviral therapy (HAART) , and such treatment can substantially reduce mortality and morbidity from HIV.
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The HIV Comprehensive Care Program is designed with a strong focus on comprehensive and continuous primary care, substance abuse treatment, and mental health services to support adherence to HAART. The Committee took a holistic approach when considering the delivery of services to its targeted group because HIV/AIDS is a complex, multi-system illness that is heavily influenced by other aspects of the individual -- general health, behaviors, and state of mind.
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The Committee is firm in its conviction that this nation can do more to treat individuals with HIV and to reduce the risk of HIV transmission. The HIV Comprehensive Care Program, if implemented, would secure the legacy of Ryan White and would indicate a continued federal commitment to address the financing and delivery of care for people with HIV/AIDS.
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The fact that about 40,000 new AIDS diagnoses and 16,000 deaths occur each year further indicates that our current system is failing to ensure adequate health care for persons living with HIV infection. A similar number of new HIV infections each year indicates that the threat to the public's health from HIV continues.
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The Committee's assessment leads to several conclusions. First, although current public financing strategies for HIV care have provided care to, and extended the lives of many low-income individuals, significant disparities remain in assuring access to the standard of care for HIV across geographic and demographic populations.
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This report presents the results of an assessment of the public financing and delivery of HIV care. The study was initiated in response to the second reauthorization of the Ryan White CARE Act (CARE Act)
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· Through the Ryan White CARE Act, the federal government provides funding for primary medical care and support services for low-income, uninsured, and underinsured populations with HIV disease. In 1996, HAART became (and remains)
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. Whereas HIV was once considered a disease of white men who have sex with men, people of racial and ethnic minority groups now represent the majority of Americans in the categories of new AIDS cases, new HIV cases, people living with AIDS, and AIDS-related deaths (CDC, 2002)
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. Finding: The standard of care for HIV/AIDS includes HAART, other drug therapies that prevent complications and that support retention in care, ob stetrics and reproductive health services for HIV-infected women, pediatric care for infants and children with HIV, primary care services, substance abuse and mental illness treatment, case management services directly re lated to clinical care, and HIV prevention services.
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Disparities and variations in access to care are the signs of a system that does not equitably meet the needs of the HIV-infected population. Findings: · Government, through public insurance programs, is responsible for covering the care for half of all individuals with HIV/AIDS.
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CARE Act programs, specifically designed to serve those with HIV disease and to fill the gaps left by Medicaid programs, also encounter difficulties in providing care. Access to HAART and primary care, for
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There are also lingering conflict of interest concerns about local planning councils because many of their members are service providers who receive CARE Act funds. CONCLUSIONS After examining the current direction of the epidemic, the advances in treatment, and the status of the current system of financing and delivery of HIV care, the Committee reached a number of conclusions.
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Under the current patchwork of public programs that finance HIV care, many HIV-infected individuals have no access or limited access to the standard of care for HIV. Fragmentation of coverage, multiple funding sources with different eligibility requirements that cause many people to shift in and out of eligibility, and significant variations in the type of HIV services offered in each state do not allow for comprehensive and sustained access to quality HIV care.
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These approaches included entitlement programs, block grants, and discretionary programs. The Committee considered the following seven alternative approaches: · Expand the Ryan White CARE Act · Provide Medicare coverage to all HIV-infected individuals · Expand the use of the 1115 Waiver for HIV care · Create an optional Medicaid eligibility category for people with HIV · Expand Medicaid coverage for HIV-infected individuals via enhanced federal match
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The Committee is aware that its recommendations mark a radical departure from the way that public financing and delivery of HIV care is currently organized. It believes, however, that in light of the dramatic developments in treatment and troubling demographic trends in the HIV epidemic this departure is warranted and necessary.
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Eligibility for ADAP within the program is generally offered to individuals with HIV infection with incomes typically under 300 percent of the federal poverty level (FPL) although a few states set eligibility at under 500 percent of FPL.
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Recommendation 2: The new program should extend coverage for treatment to individuals determined to be infected with HIV whose family incomes do not exceed 250 percent of the federal poverty level. Individuals with HIV infection whose family incomes exceed this stan dard should be allowed to establish eligibility for coverage by spending down or by buying in on a sliding scale basis.
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Accordingly, the Committee recommends: Recommendation 3: The new program should entitle each eligible indi vidual with HIV to a uniform, federally defined benefit package that reflects the standard of care for HIV/AIDS. Provider Payment Even where programs exist for HIV/AIDS care, such as Medicaid and the Ryan White CARE Act program, access to sustained care has been undermined by erratic and uncertain provider participation in the programs.
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By replacing and expanding upon both Medicaid and ADAP, the new federal HIV program would be this country's single largest purchaser of the prescription drugs that make possible effective HAART therapy. The Committee recognizes that pricing policy of public programs can affect the research and development investment decisions of pharmaceutical manufacturers, particularly when, as in this instance, the public program is a dominant purchaser.
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, the Committee asserts that HIV care delivery systems must provide medical management that is coordinated and integrated. The Committee acknowledges that a system of HIV care needs to (1)
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This would free up remaining CARE Act funds for other purposes, such as assisting individuals in enrolling in the new federal program, filling in any remaining service gaps, and supporting delivery system improvements. Accordingly, the Committee recommends: Recommendation 7: The new program should coordinate closely with the Ryan White CARE Act, which should be refocused to meet the needs of low-income individuals who are not eligible to be served by the new program.
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Adding the cost of the other elements for comprehensive care that the Committee recommends -- complete benefits package for all enrollees (including case management, substance abuse treatment, and mental health care services) , Medicare rate for reimbursement for outpatient services, and Medicare plus 5 percent for services provided through Centers of Excellence -- the incremental cost from a societal perspective is estimated to be $5.56 billion, discounted, over 10 years.
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2001. Time to initiating highly active antiretroviral therapy among HIV-infected injection drug users.
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Paper prepared for the Committee on Public Financing and Delivery of HIV Care, Institute of Medicine. Wash ington, DC: Kaiser Family Foundation.
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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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