Medicaid, the joint federal-state program that provides health care to more than half of the nation's AIDS patients, is heading in the next few months for what Christopher Gonnella, an HIV financial counselor at the University of Cincinnati, calls a 'perfect storm.' Efforts by state governors to reduce their Medicaid budgets; a looming $10 billion cut in federal Medicaid spending; the shifting of thousands of AIDS patients from Medicaid into the new Medicare prescription drug program on January 1; and proposed flat-funding of the Ryan White Act are all about to collide. Thus, HIVers are perched precariously at the center of the converging tempest.
'Most HIV-positive people are in for something they've never seen before in terms of major changes, major cuts,' Gonnella warns. 'I'm thinking 2006 is going to be the worst year we can remember in [the history of the care of HIV disease].'
Possibly foreshadowing the nationwide crisis are recent Medicaid changes in Mississippi. To cut costs, state officials limited the monthly number of prescriptions Medicaid participants could fill to just five medications'only two of which could be brand-name drugs. After intense lobbying from panicked activists, at the last minute lawmakers exempted HIVers'who need at least three antiretrovirals, almost all of which are brand-name drugs.
'These kinds of caps, unfortunately, are getting more and more widespread,' says Tom McCormack, public benefits policy consultant for the Title II Community AIDS National Network. 'We might be facing a lot of similar situations as to what we had to go through in Mississippi.'
Another cost-cutting measure under consideration is higher copays for Medicaid-provided drugs. Because Medicaid enrollees typically take home less than $600 a month, federal regulations limit such copays to $1 to $3, but the National Governors Association is pushing for federal Medicaid reform that would allow them to increase copays to $5 or more. Most state governors'Democrats and Republicans alike'also would like to either implement copays on doctor visits, lab tests, and hospital stays or set a limit on how many times these services can be accessed. This would be disastrous for people with AIDS, who need regular routine care and often require lengthy or multiple hospitalizations, warns Damon Dozier, congressional liaison for the National Minority AIDS Council.
Already well under way are state-level efforts to trim Medicaid rolls by cutting financial eligibility requirements, McCormack notes. Under federal law, anyone earning $579 a month or less'the monthly amount of the federal Supplemental Social Security Income benefit'automatically qualifies for Medicaid coverage. Many states, however, had set more generous income limits in the 1980s and 1990s that they're now scaling back to reduce costs. This could result in hundreds of thousands of low-income people being arbitrarily cut from Medicaid rolls.
In Tennessee, for example, as many as 323,000 residents could be forced from the state's TennCare program, McCormack says. In Mississippi, 65,000 people are slated to lose coverage; in Florida, as many as 77,000 people could be cut from Medicaid rolls. Drastic cuts are also being considered in North Carolina, Pennsylvania, and Minnesota. No one knows yet just how many AIDS patients will lose Medicaid coverage, but these figures back up some advocates' assertions that the total could be in the thousands.
And here's where the 'perfect storm' becomes more apparent. Most of those who lose Medicaid coverage'or who need assistance in meeting new drug or service copays'will turn to the Ryan White system for help, says Terje Anderson, executive director of the National Association of People With AIDS. But Republicans in Washington are proposing flat-funding virtually all federal Ryan White spending, and the program'particularly its AIDS Drug Assistance Program component'is already on shaky financial footing. If former Medicaid enrollees also flood the Ryan White system, Anderson says, thousands of HIVers could be forced onto already burgeoning ADAP waiting lists, and services could be further scaled back at organizations around the country to accommodate the increased load.
Pharmaceutical company patient assistance programs will pick up some of the drug access slack, says Christine Lubinski, executive director of the HIV Medicine Association. But it's likely some HIVers will simply forgo treatment, try to stretch the few medications they can afford, or make such difficult choices as whether to buy the pills they need to stay alive or to pay their rent or buy food for the month.
'As advocates, a lot of us at this point are simply trying to mitigate the harm being done to the program,' says Michael Carrigan, government affairs associate at AIDS Action. 'Ultimately, there's going to be a price that's going to be paid by people living with HIV. But right now it's unclear exactly how high that price will be.'