HIV/AIDS and the GOP Medicaid Bill
Questions and Answers
June 7, 1996
- Does the GOP Medicaid bill protect coverage for those who are currently eligible for Medicaid and for people who might become eligible in the future?
NO. The bill ends the individual guarantee to health care coverage currently provided by Medicaid. This bill eliminates the federal protections and regulations that currently constitute the Medicaid entitlement. Current beneficiaries, whether poor families with children, low-income seniors, or people with disabilities, would not be guaranteed health services because states would be allowed unprecedented authority to determine who is eligible for benefits, what benefits, and at what level. Under the bill, states would have the authority to define disability for the purpose of Medicaid eligibility. Further, states could also set additional income, asset, or residency requirements that would effectively deny or delay coverage to currently eligible individuals. People living with HIV/AIDS who meet current Medicaid eligibility standards could find themselves denied eligibility because of a restricted definition of disability, or changed income or residency requirements. Access to the new Medicaid program for people with AIDS could vary dramatically state by state.
- Does the GOP bill mandate a comprehensive benefit package?
AdvertisementNO. The GOP bill gives states the discretion to limit or deny benefits solely on the basis of diagnosis or illness and could set arbitrary limits on physician visits, hospital stays, or prescription drugs, without regard to what is medically necessary or appropriate to treat the condition. States could offer different benefits to different categories of beneficiaries, based on cost and not on medical need; and could offer different benefit packages to Medicaid recipients living in different parts of the state. Individuals living with HIV/AIDS who are deemed eligibility for a state's Medicaid program could see benefits restricted on the basis of an HIV diagnosis for be faced with benefits which are so limited that they are unable to get comprehensive health care.
- Does the bill protect beneficiaries from being subjected to high out-of-pocket costs for health care services?
NO. States are offered complete discretion in charging premiums and copayments for covered services. Under current Medicaid law, premiums, cost-sharing levels, and deductibles must be "nominal." The GOP bill eliminates this protection --allowing states to effectively deny coverage by pricing benefits and services out of reach. In addition, the GOP bill would allow health care providers to require Medicaid patients to pay the difference between the Medicaid reimbursement rate and their higher fees -- a practice known as "balance billing." This practice is illegal under current law. Cost sharing can be an insurmountable barrier to adequate health care for individuals with complex and multiple health needs like individuals and families living with HIV disease.
- Does the bill protect the ability of Medicaid beneficiaries to have access to providers with specialized expertise in the treatment of HIV/AIDS?
NO. The GOP bill would allow states to move Medicaid beneficiaries into managed care arrangement with no minimum quality protections required and without requiring managed care plans to demonstrate their ability to provide services for chronically ill populations, including people living with HIV/AIDS? The bill would eliminate the current federal Medicaid waiver process that allows states to impose mandatory managed care on Medicaid populations with federal oversight and approval -- a process which is responsive to the concerns of consumer advocacy groups aimed at assuring quality care to all Medicaid beneficiaries, including individuals with high cost and complex health care needs.
- Does the GOP bill ensure the right of beneficiaries to challenge states in federal court if the state fails to deliver medically necessary services to all Medicaid beneficiaries?
NO. The GOP bill eliminates current mechanisms that allow individuals to utilize the federal justice system to hold states accountable for complying with Medicaid law. Health care providers would have no recourse under the courts and individuals would only be allowed to seek a claim against a state for the denial of benefits. The individuals would then be required to first exhaust a state administrative appeals process followed by judicial review in state court. If these avenues fail, individuals could petition the U.S. Supreme Court or request the Secretary of Health and Human Services to bring action in federal court on their behalf. This bureaucratic process offers little promise of protecting the rights of health care consumers by holding states accountable. In addition, since the GOP bill limits individual claims to the denial of benefits, individuals would not be able to challenge the quality of health care or other grievances. The federal right of action has been a critical tool for people living with HIV/AIDS and their advocates to ensure the availability of all medically necessary care, including access to life-prolonging AIDS drugs.
- Does the GOP bill lay out a funding mechanism that would ensure that states with a high incidence of HIV/AIDS, particularly an increase in incidence, have enough money to meet the needs of persons with HIV/AIDS?
NO. In addition to the base allocation to the states, the bill establishes an "umbrella" fund to defray, on a one-time basis only, the cost of certain unanticipated enrollment growth. The "umbrella" funds would not be added to the state base allocation funding and would be inadequate to cover cumulative enrollment increases. Under what is ostensibly a block grant funding mechanism, even individuals with HIV/AIDS who meet state eligibility criteria could be denied access to Medicaid if the state has exhausted its annual Medicaid allocation.
- Does the GOP bill require states to continue to make their current expenditures on care for beneficiaries?
NO. The GOP bill caps federal Medicaid funding and reduces state "matching" requirements. The combined effect could reduce Medicaid funding nationally by over $250 billion over six year. The federal cap would be set below current federal Medicaid expenditures under current law. Therefore, the amount of "matching" funds that states would need to contribute in order to receive the maximum federal funding allotment would be less than under current law. States would be able to reduce the state portion of Medicaid funding without affecting the level of federal funds. Without an adequate funding base of federal and state expenditures, the health care of over 50 percent of adults and 90 percent of children living with HIV/AIDS will be jeopardized.
For more information, contact
AIDS Action Council
1875 Connecticut Avenue NW #700
Washington DC 20009