Several Studies in American Journal of Public Health Examine Feasibility of Expanding Medicaid to Cover HIV Treatment

The September issue of the American Journal of Public Health features several studies that examine the feasibility of expanding HIV treatment access among the uninsured and Medicaid beneficiaries. In most states, Medicaid covers only patients with an AIDS diagnosis. The full texts of the articles, summarized below, are available online on the AJPH Web site.

Modeling Medicaid Expansion
In "Health and Federal Budgetary Effects of Increasing Access to Antiretroviral Medications for HIV By Expanding Medicaid," researchers from the University of California-San Francisco developed a model, funded by the Kaiser Family Foundation, of the costs and effect on antiretroviral drug use associated with Medicaid expansion and consequently on new AIDS diagnoses, deaths and life-years ("cumulative years of life for all individuals who are HIV infected, unadjusted for quality of life"). The researchers modeled expansion of Medicaid coverage for HIV-positive individuals in two different benefit packages -- a full benefit that would include medications and all patient care or a limited benefit that would only cover medications and outpatient care. To be eligible under the model expansion, beneficiaries would have to have a CD4+ cell count of less than 500/mm3 or a viral load greater than 10,000 HIV RNA copies/mL, "absent or inadequate" medication insurance and an annual income of less than $10,000. The model estimated that 38,000 people, 45% of whom had never received antiretroviral therapy, would be enrolled in the expansion. Seventy percent of enrollees would not yet have an AIDS diagnosis, with 60% showing signs of HIV-related illness and 10% still asymptomatic. The model also predicted that enrollment would grow to 51,000 by the end of five years. New AIDS diagnoses under the model Medicaid expansion would decrease by 13,108 over five years, and more than 2,600 deaths would be averted over the same time period. The number of life-years added by the expansion would be 5,816 over five years.

Federal Spending Under Model
The researchers estimated that total federal spending on HIV/AIDS through Medicaid, Medicare, the AIDS Drug Assistance Program, Supplemental Security Income and Social Security Disability Insurance over the next five years will be $24.5 billion without a Medicaid expansion. The model predicted that the net federal costs to all five programs would be $739 million over the next five years for a full benefit expansion and $480 million for a limited benefit expansion. Total spending on Medicaid alone would increase by $1.43 billion under a full expansion and $1.17 billion under a limited expansion. While Medicaid spending would increase with both packages, spending for all other programs would decrease as HIV-positive individuals shifted from ADAP to Medicaid, and they experienced improved health and slower disease progression. The researchers suggest that budget neutrality -- a prerequisite for Medicaid waivers -- to all federal programs could be achieved by securing additional drug discounts of 9% to 15% and by moving beneficiaries into "community-rated" health insurance plans. They conclude, "Despite the challenges of implementing a Medicaid HIV expansion, we believe it is an important strategy for improving access to highly active antiretroviral therapy" that can eliminate the "gaps in coverage" currently faced by those with HIV (Kahn et al., American Journal of Public Health, September 2001)

Early Treatment
Researchers from the Harvard University Center for Risk Analysis used a computer simulation model of HIV progression to determine the cost-effectiveness and government cost of providing HIV-positive individuals with early antiretroviral therapy through the Medicaid program, reporting their results in " Cost-Effectiveness of Earlier Initiation of Antiretroviral Therapy for Uninsured HIV-Infected Adults." The researchers used three different strategies to treat HIV-positive individuals with CD4+ cell counts of 500 cells/mm3: immediate treatment with antiretrovirals, initiating treatment only after their counts fell below 200 cells/mm3 or not treating them at all. Beginning therapy at 500 cells/mm3 instead of 200 cells/mm3 resulted in a higher mean CD4+ cell count (383 cells/mm3 versus 238 cells/mm3), 51 fewer deaths and 72 fewer opportunistic infections per 1,000 patients over five years. Over the same time period, total undiscounted medical costs per patient were $29,100 for delayed therapy and $40,600 for early therapy. The undiscounted costs per patient for antiretroviral drugs and prophylaxis medication were $3,300 for deferred therapy and $21,500 for early therapy over five years. Although the drug costs were $18,200 higher for early therapy, the additional cost was only $11,500 more because of savings from improved health and averted HIV-related morbidity. The cost of providing early antiretroviral therapy would be $17,300 per Quality Adjusted Life Year -- a standard measure that assigns a value to number of years of life saved and quality of life during those years -- according to the model.

Budget Impact
The researchers then examined the impact on the budgets in Massachusetts, New York and Florida if either all patients were enrolled in an ADAP and transferred to Medicaid when their CD4+ cell counts dropped below 200 cells/mm3 or if a Medicaid waiver covering all individuals with CD4+ cell counts of 500 cells/mm3 or less was instituted. The analysis found that state costs varied widely because of different cost-sharing formulas. Florida would have paid more under a waiver scenario because it pays a higher percentage of drug prices under Medicaid than it does under the ADAP, while Massachusetts would have paid less because the waiver would make available additional funding for nondrug direct medical costs. Early antiretroviral therapy "appears to offer good value for resources spent" and should be considered by some states, the authors conclude, noting that the budgetary impact of the programs will vary and needs to be assessed before implementation (Schackman et al., American Journal of Public Health, September 2001).

Waiver Program Participants Receive Better Care
Researchers from the Institute for Health, Health Care Policy and Aging Research at Rutgers University analyzed the Medicaid claims data of 2,089 adults with AIDS in New Jersey from January 1996 to December 1998 to compare the use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors among different ethnic groups with similar health coverage. The researchers, reporting their findings in "Use of Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors Among Medicaid Beneficiaries With AIDS," found that in 1996, when the drugs were first introduced, there were "sharp disparities in PI/NNRTI use among racial minorities, with 61.9% of whites using the drugs, compared to 38.2% of African Americans and 44.8% of Hispanics." The disparities were consistent with other findings related to treatment for cancer and cardiac care and may have resulted from treatment preferences and knowledge and positive impressions of PI/NNRTI use. By 1998, PI/NNRTI use had increased "markedly" among all ethnic groups, with 75.9% of whites, 68.7% of African Americans and 65.8% of Hispanics using the drugs. However, the study found that Medicare beneficiaries were twice as likely to use PI/NNRTIs as those with only Medicaid coverage. Those participating in the state's HIV/AIDS-specific home- and community-based waiver program, which provides a variety of home care services, were also more likely than those with traditional Medicaid alone to use PI/NNRTIs. Case management is a "major component" of the waiver program, the authors note, and may account for the wider use of PI/NNRTIs, as may the greater choice of providers available to Medicare patients. The findings suggest a need for further research on "nonfinancial barriers specific to traditionally disadvantaged subpopulations," the authors conclude (Sambamoorthi et al., American Journal of Public Health, September 2001).