Maine tries early intervention for HIV-positive individuals
It’s no longer necessary for HIV-positive people to be disabled or in grinding poverty to get Medi caid benefits in Maine, thanks to a federal waiver recently approved by the Health Care Financing Admin is tration in Baltimore.
Program administrators hope to reduce costs at the end of an AIDS patient’s life sufficiently to break even over the five-year life of the demonstration project. The waiver approval marks the first time a Medicaid program has removed the disability criteria for HIV-positive enrollees. Until now, eligibility has required a disability determination under Social Security requirements that apply only when a patient has full-blown AIDS and does not cover those infected with HIV.
The waiver approval was applauded by AIDS advocates who say they want to see it in all 50 states. The waiver "will prolong the lives of low-income Mainers with HIV, but we want all HIV-positive Americans to have access to drugs that could keep them from developing full-blown AIDS," says AIDS Action acting executive director Claudia French. The group has long advocated reinventing Medicaid to allow disadvantaged Americans living with HIV, but asymptomatic, access to the newest drugs that have been shown to stem the effects of the virus, she says.
Some 20 states already have in place or are implementing section 1115 Medicaid waivers to expand Medicaid coverage for people with AIDS. Some permit those who meet very restrictive income requirements but are not considered disabled by AIDS or other diseases to receive Medicaid coverage. The Maine program will enroll patients with incomes higher than those in other states, recognizing that the income of HIV-positive persons often declines quickly with the progression of the disease. The hope is to maintain the health and income of such persons as long as possible.
Keeping people employed
When income limits are set at 100% of the poverty level, patients sometimes have to choose between working and not being able to afford medication, or going on Medicaid to receive needed prescription drugs, says Moe Gagnon, a health administrator with Maine’s Department of Medical Services who helped write the waiver application. By setting a higher income cutoff and providing health care services, Maine hopes to enable patients to remain employed and enjoy a higher quality of life. The goal of the demonstration program is to make drug therapies and treatment programs available to patients earlier in the course of their disease, effectively delaying the onset of disability for many patients.
To be eligible for the five-year demonstration that will open in September, participants must be HIV-positive and have an income of less than 300% of the federal poverty level, or about $25,000 in 1999. The benefit package will include highly active anti-retroviral therapy, office visits, lab services, case management, hospitalizations, mental health, and substance abuse services.
The Maine Medicaid program anticipates that 170 to 200 people will enroll in the first year and that there will be an ongoing caseload of approximately 300 patients, says state Medicaid director Fran Finnegan. The five-year cost for the demonstration project is $55 million, with the state paying one-third. "That’s close to but less than our current spending on AIDS," he says, "and that was the key to being able to get the waiver. Our projections show that we’re very close to break-even over five years."
The waiver application promises to enroll patients into Medicaid earlier in the disease process than is currently the case and to assume the high front-end costs associated with that strategy, with the savings coming at the end of life. Mr. Gagnon says the state’s application was predicated on a belief that by treating HIV-positive persons early, many can avoid contracting full-blown AIDS and thus never become as sick as those brought into the program only after they have contracted AIDS. "With the improvements in drugs that are coming, it could be possible for many people to live with HIV as a chronic illness and die from something else," he says.
He acknowledges that increasing longevity for HIV-positive patients necessarily increases the total cost to Medicaid and could threaten the waiver’s goal of breaking even financially. "With a seven- or eight-year cycle for many people from infection to full-blown AIDS, five years [the length of the waiver] really is too short to tell the impact of this effort. It appears there can be significant savings over 10 years, but I’m still a bit uncomfortable with that number. We have an ironic technical problem in that an increased life expectancy from therapy makes achieving cost neutrality very difficult."
He says the state recognizes that AIDS treatment continues to evolve, and future changes could help the cost equation even more. "If drugs can be combined and the dosing schedule reduced, patients’ tolerance should go up, and the rate of transition to full-blown AIDS should go down. We’ve built in a very advanced decision-support system and will be monitoring this program intensively."
Because he was not asking for new money to fund a new program, Mr. Finnegan says, he was able to convince the Maine legislature to provide the state’s share. "We only needed to prove revenue neutrality. We needed to show that expanding the requirements so we can reach people earlier should save money at the far end. We calculated our experience without the waiver over five years, and we should end up paying what we’re paying now."
Mr. Finnegan says he first thought about the possibility of covering HIV-positive patients earlier in their disease progression late in 1996, when the combination anti-retroviral therapies were introduced, radically changing the pattern of expenditures. "Medicaid was not designed to accommodate benefits with that type of therapy," he says. "Essentially, we’ve been telling people, Wait until you get full-blown AIDS, and then we’ll give you everything you need.’ This waiver attempts to rationalize Medicaid’s policy so we can take advantage of the new medications."
Contact Mr. Finnegan at (207) 287-2093, Mr. Gagnon at (207) 624-5527, and Ms. French at (202) 530-8030.
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