Guaranteeing Treatment Access
If anything can match the complexity of AIDS itself, it may be the slipperiness of the public policy designed to address it. While gains are made in treatment, bettering the lives of those with access to it, the proportion of HIV infection is ironically -- and tragically -- shifting toward the very communities who are financially excluded from the healthcare system.
That disparity may finally be redressed if Congress passes new legislation to provide Medicaid coverage for low-income people with HIV disease. The bill, entitled The Early Treatment for HIV Act, has been introduced in identical form to both houses by Representative Nancy Pelosi (D-CA) and Senator Robert Torricelli (D-NJ). Cosponsored by House Minority Leader Richard Gephardt (D-MO), the bill would give states the option of providing Medicaid coverage for anyone with HIV disease -- before the development of full-blown AIDS.
Under current Medicaid policy, a person with HIV must become sick and disabled in order to be eligible for benefits, unless he or she is impoverished enough to meet standard Medicaid criteria. Yet, withholding treatment until an individual develops full-blown AIDS (and hence qualifies as "disabled") directly contradicts the recommendations of the U.S. Department of Health and Human Services. Its prestigious guidelines panel urges early treatment with antiviral combinations of at least three drugs before symptoms develop, both to slow viral growth and to help prevent opportunistic infections. Needless to say, this possibility is out of the question for lower income people without adequate insurance. Postponing treatment increases the risk of serious illness. In a disturbing parallel, AIDS Action Council Executive Director Daniel Zingale suggests, "If automobile safety regulations followed the current [Medicaid] model, air bags would only be required in cars that have already crashed."
Medicaid is not the only federally funded program available to the HIV community, but it is the only comprehensive healthcare system available to low-income people. Other federal programs, such as the AIDS Drug Assistance Program (ADAP), a re much more limited in scope. The state-run ADAPs offer prescription drug coverage for uninsured and underinsured people with HIV and AIDS, but many of the state ADAPs suffer from insufficient state funding and a limited formulary. Except in New York, ADAPs do not provide any other healthcare services beyond the limited number of drugs in their formulary. Other programs financed under the federal Ryan White CARE Act are similarly hampered by restrictions in the types of services they can provide and typically do not serve asymptomatic people with HIV.
Medicaid coverage for early treatment of HIV disease has long been a goal of AIDS Action Council and other advocacy groups. In fact, the Pelosi Bill is not the first time the federal government has expressed interest in addressing the issue. The Clinton administration introduced the idea of expanded Medicaid coverage in 1997, but was unable to implement a change because it could not ensure that the expansion would be cost-neutral. In Washington's balanced-budget climate, the policy change could be approved only if it could demonstrate a dollar-for-dollar savings in Medicaid hospitalization costs within five years. Savings in other areas are overlooked in this calculation. That early treatment would delay disability and keep people in the workplace longer -- thereby decreasing Social Security disbursements and increasing tax revenue -- was an unconsidered factor. Unable to meet these narrow budgetary requirements, the administration reluctantly withdrew its proposal.
That effectively placed the burden on individual states, several of which began developing initiatives to address the needs of low-income HIV-positive people. Massachusetts, for example, began investigating how to structure a program to deliver primary HIV care, drug therapy, and diagnostic services to every HIV-positive resident below a certain income ceiling.
Partial progress in this struggle may be made through the Work Incentives Improvement Act, which is currently awaiting debate in both houses of Congress. Unanimously approved by the House Commerce Committee, the bill would allow disabled people -- including those with HIV and AIDS -- to return to work without losing Medicaid coverage. It would also allow the disabled who earn more than 250% of the poverty level to buy into the Medicaid program. The bill has wide support in both parties, as well as in the White House.
Although Rep. Pelosi supports this bill, her office points out that it is not as comprehensive as the proposed Early Treatment Act. For example, the Work Incentives Improvement plan would not require states to include HIV coverage, and it grants them the option of implementing programs in distinct areas rather than statewide. While it may provide excellent assistance for the disabled, its scope -- particularly regarding HIV disease -- is limited.
The Early Treatment Act, on the other hand, would loosen Medicaid's financial eligibility criteria for all persons with HIV, regardless of their employment status or the extent to which they are disabled. Anyone with HIV would qualify for Medicaid should their financial resources fall below the current limits established for disabled persons. The bill has 60 cosponsors in the House and has been referred to the House Subcommittee on Health and the Environment. Rep. Pelosi's office has high hopes for passage of the bill. According to Chris Collins, Appropriations Associate for the Congresswoman, cost is the issue most likely to spark debate. Clearly, he adds, the bill would save and extend lives: "It only makes sense that, if our government's doctors are recommending early treatment, our government policy should catch up."
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.