Trends and responsiveness in national resource allocation for needed HIV services: a five year (1996-2000) analysis

A recent study conducted by the Institute of Medicine concluded that there are approximately 1,200 to 1,400 avoidable deaths per year in the U.S. among people living with HIV (PLWH) who do not have health insurance (Institute of Medicine, 2002). The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed by the U.S. Congress in 1990 to provide funding for community-based HIV care services for uninsured and underinsured PLWH--the only Federal program to provide such funding. There is substantial local autonomy in the allocation of CARE Act funds, with planning processes that take place in both States and metropolitan areas. The purpose of this study is to examine trends in the allocation of such funds from 1996 through 2000, the first five years during which effective antiretroviral medications were available for HIV. The study also considers whether these trends were responsive to the evolving modalities of care and the service needs of a changing population of PLWH.     

Study underscores need for increased ADAP funding

A study conducted by the National Alliance of State and Territorial AIDS Directors and the AIDS Treatment Data Network for the Kaiser Family Foundation determined that state-run AIDS drug assistance programs (ADAPs) are in the midst of financial crisis. The number of new ADAP clients was growing at the rate of 1,000 per month during the final six months of 1996. The study also found that 23 States have imposed cost-containment regulations because of the growing need for the protease inhibitor cocktails that have become the standard of care for HIV treatment. While the House Appropriations Committee recommended allocating $2 million more than the $297 requested, the Senate approved $217 million in Title II ADAP funding under the Ryan White CARE Act. President Clinton did not propose a funding increase. The study also found that where a patient lives impacts upon his or her treatment; only New York and North Carolina currently cover all approved antiretroviral drugs.     

Bringing the mountain to Mohammed: a mobile dental team serves a community-based program for people with HIV/AIDS

In spite of the direct referral system and family-centered model of primary oral health care linking medical and dental care providers, most HIV-positive patients at the Columbia Presbyterian Medical Center received only emergency and episodic dental care between 1993 and 1998. To improve access to dental care for HIV/AIDS patients, a mobile program, called WE CARE, was developed and colocated in community-based organizations serving HIV-infected people. WE CARE provided preventive, early intervention, and comprehensive oral health services to minorities, low-income women and children, homeless youths, gays and lesbians, transgender individuals, and victims of past abuse. More efforts to colocate dental services with HIV/AIDS care at community-based organizations are urgently needed.     

Lessons for coverage expansion: a Virginia primary care program for the uninsured reduced utilization and cut costs

The Affordable Care Act will expand health insurance coverage for an estimated thirty-two million uninsured Americans. Increased access to care is intended to reduce the unnecessary use of services such as emergency department visits and to achieve substantial cost savings. However, there is little evidence for such claims. To determine how the uninsured might respond once coverage becomes available, we studied uninsured low-income adults enrolled in a community-based primary care program at Virginia Commonwealth University Medical Center. For people continuously enrolled in the program, emergency department visits and inpatient admissions declined, while primary care visits increased during the study period. Inpatient costs fell each year for this group. Over three years of enrollment, average total costs per year per enrollee fell from $8,899 to $4,569--a savings of almost 50 percent. We conclude that previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage but that it may take several years of coverage for substantive health care savings to occur.     

Budget deal taps Medicaid to pay for new tax cuts

AIDS advocates are relieved that Congress and the White House have agreed on a $15 billion reduction in the Medicaid budget. While this cut is significant, a previously proposed plan would have cut Medicaid even further and instituted an annual cap on the amount of health-care dollars a patient could receive. It now appears that capping Medicaid spending per Medicaid beneficiary is no longer a component of the budget agreement. The Clinton Administration anticipates a 6 percent increase of the Federal share of AIDS-related medical costs to $1.9 billion. AIDS Action recommended increasing funding for the Ryan White CARE Act by $393.9 million; the Clinton administration suggests a $40 million increase. AIDS Action also proposed biomedical and behavioral research funded by the National Institutes of Health (NIH) to rise by $134.5 million; the Clinton administration proposes a $39 million increase. A recent survey found that almost 70 percent of Americans support the notion that Medicaid should extend AIDS drug therapies to low-income people in the early stages of HIV infection. These findings will be used to bolster AIDS Action's argument that the Federal Health Care Financing Administration should extend Medicaid to more low-income people who lack private insurance.     

Title X family planning clinics confront escalating costs,increasing needs

Since 1970, the Title X family planning program of the US Public Health Service act has helped low-income American women avoid unintended pregnancies, abortions, and unwanted births. In addition to averting a million pregnancies (and half as many abortions) each year, the 4400 Title X clinics provide an array of reproductive health services. Funding for the program, however, has never recovered from Reagan-era cuts, and President Clinton's proposal for a $25 million increase will only begin to allow the program to achieve Clinton-administration objectives. The clinics face a financial challenge in maintaining the full range of contraceptive choices, especially in light of the high up-front costs of long-acting contraceptives, such as Depo-Provera, which can consume 50% of a budget for 15% of the clients. New diagnostic technologies have made routine screening desirable but expensive, and clinics must struggle to maintain quality of care. Title X clinics also have a clear need to expand their service capacity to reach the million low-income women who continue to risk unintended pregnancy and to serve low-income salaried workers without health insurance. Currently, two-thirds of Title X clients are so impoverished that their care is totally subsidized, and only 20% are covered by Medicaid. A portion of the $25 million increase has also been earmarked to promote reproductive health among the hard-to-reach population, such as substance abusers and the homeless, and to expand service provision to males. While the increase is needed, it represents only a portion of the cost of facing these challenges.     

The potential impact of health care reform on public health HIV-related activities.

This article observes that, despite the clear potential benefits of health care reform's expanding health insurance coverage for people with human immunodeficiency virus (HIV) disease, there is a real danger of losing existing acquired immunodeficiency syndrome (AIDS) services if federal categorical public health programs are cut. It discusses the considerable accomplishments of the Ryan White CARE Act and of Centers for Disease Control and Prevention (CDC) prevention funding. The funding for these current efforts will not be assumed by near universal insurance coverage for a variety of reasons, including the need to care for populations who are neglected by health care reform, to continue services unlikely to be reimbursable, and to offer care in a range of locations other than licensed health care facilities.     

Report outlines State-run insurance continuity programs

The National Alliance of State and Territorial AIDS Directors (NASTAD) issued a brief that analyzes States' responses to health insurance continuity programs for people with HIV. The government makes premium payments for individuals who cannot afford to maintain their existing private health insurance in at least 35 States. The insurance continuity programs rely on Federal Ryan White CARE Act or State funds, and are more affordable than covering expenses directly through public programs such as Medicaid or State AIDS drug assistance programs. The NASTAD report provides strategies for developing, administering, and monitoring insurance continuity programs, and includes case studies from key States.     

Public funding of contraceptive, sterilization and abortion services, 1982

The federal government and the states spent $328 million to support the provision of contraceptive services in fiscal 1982, 13 percent less than they had spent the previous year. Federal funds for family planning services came from Title X of the Public Health Service Act, Title XIX of the Social Security Act (Medicaid), and the Maternal and Child Health (MCH) and Social Services block grants, which are administered by the states. Title X continued to provide the largest, although a diminishing, share of public funds for contraceptive services--36 percent of all such funds in 1982. (In 1980, Title X had accounted for 44 percent of public funding.) Medicaid expenditures for family planning totaled $94 million; $17 million was spent under the MCH block grant, and $46 million under the Social Services block grant. State governments contributed an additional $53 million, about the same figure reported for the previous year, indicating that the states did not use their own funds to soften the impact of cuts in federal expenditures for contraceptive services in 1982. The federal government and the states spent an estimated $55 million, almost all of it through Medicaid, to provide sterilization services for poor women. The states spent $67 million and the federal government spent $1 million to provide abortions for 210,000 indigent women. These figures come from the 11th annual survey of state health and welfare agencies and state Medicaid programs by The Alan Guttmacher Institute (AGI). The AGI conducted this survey in January 1983 to determine the levels and sources of public funding for contraceptive, sterilization and abortion services in each state during FY 1982.     

Model safety-net programs could care for the uninsured at one-half the cost of Medicaid or private insurance

Because the reforms under the Affordable Care Act of 2010 will leave an estimated twenty million or more people still uninsured, some Americans will continue to seek care at low or no cost through existing safety-net systems. To identify appropriate care models, this comparative case study assessed the costs of care provided by four large, well-structured, comprehensive safety-net programs for the uninsured in Colorado, Michigan, North Carolina, and Texas. The average monthly resource cost-including the value of referred, donated, and in-kind services-in these model programs was $141-$209 per adult in 2008. This was 25-50 percent less than the estimated cost of care for comparison groups covered by local Medicaid programs or by private insurance that provided similar services. Although these programs' services are somewhat less comprehensive than those of generous insurance plans, the findings suggest that these model safety-net programs could be adapted to provide an alternative type of coverage for the uninsured, including both low-income and middle-class people.     

Health services for immigrant children: opportunities under Title XXI

This article notes the health care risks for immigrant children and describes recent restrictions on their ability to apply for Medicaid. It is reasonable to estimate that by the year 2001, there could be as many as two million immigrant children in the United States who are ineligible for Medicaid simply due to their immigration status. The article also describes the opportunities under the new federal law, Title XXI of the Social Security Act, which enables states to develop health care programs specifically for low-income immigrant children who are ineligible for Medicaid. Pediatricians, advocates for children, and health care providers who serve immigrant communities can use their knowledge of the opportunities in this new law to work with state lawmakers and health policy officials to help provide services to needy immigrant children.     

Compassionate conservatism: federal funding for the Ryan White CARE Act during the Bush administration

President George W. Bush has proposed modest increases, when he has proposed any at all, in funding for the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act during his administration, and Congress has appropriated little funding increase since fiscal year 2004. Growing numbers of Americans living with HIV or AIDS, 40 000 people newly infected with HIV each year, and Centers for Disease Control and Prevention-recommended efforts to identify people with undiagnosed HIV infection indicate an increasing need for services funded by CARE Act programs. Inadequate CARE Act funding harms the most vulnerable people with HIV.     

President seeks 3 percent increase in AIDS funding for '98

President Clinton's spending proposals for 1998 include increased funding for AIDS research, care, and treatment, as well as initiatives to help people return to work if their multidrug therapy is effective. Some AIDS advocates are still disappointed with this funding level and predict that there will be a shortage of funds available to provide adequate services to HIV/AIDS patients. Advocates also expressed concern over reduced Medicaid spending since many AIDS patients rely completely on Medicaid for health care. The spending proposal keeps Federal funding for the network of State AIDS drug assistance programs at $167 million despite the demand for multidrug treatments. The budget includes $634 million for AIDS-related programs at the Centers for Disease Control and Prevention (CDC) and $1.54 billion for AIDS-related research directed through the National Institutes of Health (NIH) Office of AIDS Research. The total cost of AIDS care, research, and prevention reaches nearly $8.9 billion. Funding proposals for each agency and allocations for the Ryan White CARE Act are outlined.     

Congress approves 17 percent increase in CARE Act funds

On April 24, 1996, Congress and President Bill Clinton agreed on a stopgap spending bill that increases funding for the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act by 17 percent. The budget provides $738.4 million for the CARE Act in fiscal year 1996. Funding for all four titles of the Act will be increased. The final budget also approves $12 million for the AIDS education and training centers and $583.4 million for HIV prevention programs sponsored by the Centers for Disease Control and Prevention (CDC). HIV-related research programs sponsored by the National Institutes of Health (NIH) total $1.4 billion.     

Improving HIV/AIDS services through palliative care: An HRSA perspective

There has been a dramatic shift of the human immunodeficiency virus/acquired immunodeficiency syndrom (HIV/AIDS) epidemic into poor, marginalized, and minority communities in the US. At the same time, the availability of new highly active antiretroviral treatments has made it possible for a large number of individuals to live for a much longer time with their disease. A net result is that the US is faced with an increasing number of people who are living with HIV/AIDS and are dependent on publicly supported health care services. In this paper, we review the palliative care efforts of the federal agency, the Health Resources and Services Administration (HRSA), responsible for providing Ryan White CARE Act HIV/AIDS care to medically underserved populations. In addition to supporting traditional hospice care, HRSA's HIV/AIDS Bureau has begun a series of initiatives that apply a broader concept of palliative care to its HIV programs in hospital-and community-based settings. Our interest is not to substitute palliation for access to new HIV therapies, such as highly active antiretroviral treatments, but to ensure that our health delivery systems attend to the alleviation of symptoms and suffering along with the provision of antiretroviral and other necessary treatments. HRSA's HIV/AIDS Bureau is organizing a broader provision of palliative care for its clients and actively contributing to improving care for the disenfrachised internationally. The authors are from the HIV/AIDS Bureau, Health Resources and Services Administration, HRSA.     

Expanding insurance coverage and access for low-income people

Medicaid provides health insurance for 40 million low-income women and children, elderly, blind, and disabled people. In 1996, state initiatives covered nearly a million more people who have very low incomes but aren't eligible for Medicaid. This issue of States of Health looks at the extent to which such programs to expand insurance coverage actually improve access to care. How many of those who are eligible are enrolled? How many receive appropriate care? And how can we increase those numbers to the limit?     

Chances dim for fiscal '97 boost in AIDS drug funds

Congressional leaders rejected a proposal to supplement Federal funding for State-run AIDS drug assistance programs (ADAP), and President Clinton refused to intervene. A proposal by Rep. Nancy Pelosi (D-CA) that included $68 million in additional ADAP funding was part of a supplemental appropriations bill aimed largely at paying for flood relief. Some State ADAP programs remain financially sound following the latest round of Ryan White CARE Act grant allocations. Several States have curtailed new enrollments or adopted other cost-saving measures. Almost all of the States' budgets are being rapidly depleted as more people demand access to expensive medicines. The worst problem is in Mississippi, where State funds are not used to cover AIDS programs. AIDS policy advocates and State public health officials were disappointed that President Clinton declined to support Rep. Pelosi's request. The President's AIDS policy director, Sandra Thurman, explained that the funding request could not be developed without taking into account two factors. First, the Department of Health and Human Services is seeking ways to extend Medicaid eligibility to more low-income people living with HIV, reducing the ADAP budget. Second, upcoming treatment guidelines could affect the amount of funding needed to adequately fund the ADAPs. The guidelines are expected to recommend combination drug therapy using a protease inhibitor.     

Ryan White CARE Act and eligible metropolitan areas

Title I of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides emergency assistance to eligible metropolitan areas (EMAs) to provide a continuum of care and services to people living with HIV disease. This article presents the results of a 2000-2001 survey of the 51 Title I Planning Councils. EMAs are serving significant numbers of females, with black and Hispanic persons constituting a majority of people served in 33 EMAs. Among the difficult to serve are substance abusers, people with chronic mental illness, multi-diagnosed people, the homeless, black males who have sex with males, and Hispanic persons.