August 30, 2004
In a study of 1,495 people, HIV patients who qualified for Medicaid cost North Carolina less than HIV patients who had slightly higher incomes but were excluded from Medicaid coverage until they spent the required amount for their health care.
When spend-down HIV patients can no longer afford medication and are poor enough for Medicaid eligibility, they access the program in poorer health. "We found that the people who make even a little more money than those categorically eligible for Medicaid end up costing about twice as much," said lead researcher Kathryn Whetten, a Duke University public policy professor and director of Duke's health inequalities program.
Legislators in many states see spend-down programs as a way to make recipients share the financial burden, Whetten said. North Carolina's eligibility ceiling for Medicaid, at 125 percent of the federal poverty level, is also the nation's most restrictive, she said.
More residents in North Carolina and many other states are increasingly "working poor," holding jobs that do not provide health insurance but that pay too much for employees to be eligible for Medicaid. Compounding the problem, hospitals often charge these patients at least twice as much as insured patients receiving the exact same service. If the working poor are unable to pay their bill on time, patients' credit ratings can be affected, with some patients landing in bankruptcy.
Expanding Medicaid eligibility would save $11,500 per patient over five years by treating patients earlier, the study found. Spend-down patients currently cost the program $5,475 more per patient. The full study, "Do United States-Based Medicaid Spend-Down Programmes Make Public Sense for Persons with HIV/AIDS?" was published in AIDS Care (2004;16(6):781-785).