The federal government should expand its role in the financing of HIV/AIDS treatment for low-income Americans to ensure that the thousands of HIV-infected people currently not receiving care through existing programs gain access to the services they need, says a new report from the Institute of Medicine of the National Academies. Effectively reaching this population and ensuring that all low-income infected individuals have access to necessary services will require a new national program with uniform eligibility and benefits, said the committee that wrote the congressionally mandated report.
"With the development of highly active antiretroviral therapy and other tools, we now have the ability to extend lives and improve quality of life for all Americans with HIV," said committee chair Lauren LeRoy, president and CEO, Grantmakers In Health, Washington, D.C. "Failing to provide these cost-effective, life-saving drugs to all Americans who need them -- including individuals who lack insurance or cannot afford them -- is indefensible. Current programs are characterized by limited state budgets, limited services, and a confusing array of eligibility requirements -- all of which undermine the nation's goals for preventing and treating HIV/AIDS. After thoroughly assessing several options for improving care delivery, the committee concluded that a greater federal role is required to ensure an effective response to the HIV epidemic here at home."
Roughly 950,000 people are living with HIV or AIDS in the United States and about 40,000 more become infected with the virus each year. Medicaid, which is financed jointly by states and the federal government, covers the majority of treatment for low-income individuals with HIV/AIDS who do not have private health insurance. In addition, funding provided through the Ryan White CARE Act supports state and local care programs for low-income, HIV-infected individuals with little or no coverage. Although these programs provide antiretroviral drug therapy and other services to thousands of needy HIV-infected people, thousands more go without necessary treatment because of eligibility requirements and limitations in covered benefits. The committee estimated that almost 58,700 more people would receive antiretroviral treatment if the proposed federal program were implemented.
Under the new entitlement program proposed by the committee, the federal government would assume all costs related to providing HIV/AIDS services to low-income individuals. By relieving state Medicaid programs of the burden of financing HIV/AIDS care, the new program would ease uncertainties about the adequacy of funding for this care, the report said.
In addition, the program would establish uniform eligibility requirements, consistent reimbursement of health care providers, and a standard set of services to be provided in all states. Currently, each state or local area determines what services it will provide with Medicaid and CARE Act funding, and whether support services -- such as mental-health and substance-abuse treatment, case management, and prevention strategies -- will be offered in addition to antiretroviral drug therapy. Because HIV/AIDS is a complex condition, the new program should emphasize support services in addition to drug therapy, the report urges.
All HIV-infected U.S. citizens who have incomes less than 250 percent of the federal poverty level -- $22,500 for an individual in 2003 -- should be eligible for the new program, the report says. Those who earn more but do not have access to private health coverage should be allowed to participate in the new program by paying a monthly premium based on their income.
The committee estimated that providing antiretroviral therapy and a standard level of additional support services to all individuals eligible for the new program will increase current federal spending on HIV/AIDS care for low-income individuals by $5.6 billion over 10 years. Cost-saving strategies available to the federal government could reduce this expense. For example, the federal government could negotiate discounted prices from drug manufacturers in the same way that agencies such as the Veterans Health Administration do. Purchasing antiretroviral drugs at the discounted Federal Ceiling Price would save an estimated $419.3 million per year, the report says.
In addition, federal funds already allocated for HIV/AIDS care through Medicaid, as well as some CARE Act funds, should be shifted to the new program. The CARE Act should be refocused to support enrollment in the new program and to provide services not covered by the new program, such as voluntary HIV counseling and testing. Remaining CARE Act funds also could be used to provide care for low-income immigrants who would not be eligible for enrollment.
HIV/AIDS treatment provided by the new program would be cost-effective in terms of achieving reduced mortality and increased quality of life, the committee determined. The program also compares favorably with other health interventions that society has decided to implement.
A new model of care delivery is needed to improve the quality of HIV/AIDS care for low-income individuals, the report adds. The committee focused on the potential for establishing new HIV/AIDS centers of excellence, which would serve as integrating hubs for providing comprehensive and coordinated care for HIV-infected patients throughout the wider community. The new program should earmark sufficient funding to test the effectiveness of these centers in delivering HIV/AIDS care to low-income Americans.
The study was sponsored by the U.S. Department of Health and Human Services' Health Resources and Services Administration at the request of Congress. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
Pre-publication copies of Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White
are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu
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