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Legislation May Allow Early Access to HIV Care for Low-Income Patients

May 4, 2009 (Washington, DC) — The Early Treatment for HIV Act
(ETHA) will fix a major flaw in Medicare and Medicaid coverage of that
disease — that low-income patients must be diagnosed with AIDS before
coverage kicks in.

The Centers for Medicare & Medicaid Services (CMS) is the
largest payer of HIV care in the United States, and AIDS advocates have
sought to correct this flaw for more than a decade.

"This is our year" to enact that change Robert Greenwald, told a
congressional briefing last week. He is director of the Treatment
Access Expansion Project, the Harvard-based coalition of 84
organizations pushing for the legislation.

Medical breakthroughs have turned HIV from a virtual death sentence
to a treatable disease, "yet treatment remains out of reach for
hundreds of thousands of people living with HIV," he said. "That is
unacceptable."

"AIDS is when we have failed to do our job," said Richard Elion, MD,
director of clinical research at the Whitman-Walker Clinic in
Washington, DC. Current federal treatment guidelines call for
initiating treatment long before an AIDS-defining illness is likely to
occur. The CMS requirement is a relic from the era before highly-active
antiretroviral therapy that keeps the government from being in
compliance with its own treatment guidelines.

"What kind of stupidity is it that only people with full-blown AIDS
be treated," said Rep. Eliot Engel (D-New York), one of the legislative
leaders in the push for ETHA. He said early treatment "is better for
the person, better for the society, better in terms of money for the
government."

"It's a win-win-win all around and yet the stupidity of not doing
it, I believe, comes from the old taboo" associated with those most
affected by the infection — gays, drug users, and sex workers, Mr.
Engel said.

The Bill

ETHA gives states the option of amending their Medicaid program for
low-income persons to allow for early treatment of HIV "the moment they
test positive for HIV," said Mr. Greenwald.

Mr. Engel emphasized the fact that the program is voluntary, not
mandatory, and is modeled after an existing program for breast and
cervical cancer. Many states with the largest HIV caseloads are
clamoring for the change, but it is not clear that all states would
take advantage of the opportunity.

ETHA has strong bipartisan support in both the House (S.R.1616) and
Senate (S.833) versions of the bill. Speaker of the House Nancy Pelosi
was an initial champion of the legislation, and the way now seems
cleared for passage.

What has stalled the concept of ETHA for nearly a decade has been
lack of political will to move it forward when Republicans controlled
Congress, and money.

Hopes for enactment rose when Democrats regained control of
Congress. In 2007, supporters tried to include ETHA as part of SCHIP
legislation expanding health coverage to children. That did not happen.
As Mr. Engel said at the time, "It comes down to money, I don't want to
whitewash it."

Under the budgetary restraints adopted by the Democrats known as
"pay as you go," new spending had to be offset by cuts elsewhere or new
revenue had to be raised. But "pay as you go" disappeared with the
recession and efforts to stimulate the economy.

"As we look at the prospects this year, it's a whole new world in
terms of what is possible on the healthcare front," said Scott Boule, a
senior appropriations advisor to Speaker Pelosi.

Healthcare Reform

The situation is complicated this year by moves for general healthcare reform.

"Medicaid programs currently vary by state," said Mr. Greenwald.
"Through healthcare reform we need to make sure that the minimum
benefits package that is available through Medicaid in every state
meets the standard of care for treating people living with HIV."

Currently under Medicaid, prescription drugs, mental health, and
substance abuse treatment are optional benefits that vary by state.
Coverage of some or all of those may become mandatory, and the income
level to qualify for the program may change under broader healthcare
reform.

"Finally, we have to deal with the issue of provider reimbursement
rates. Otherwise, despite treatment advances, there will be no
healthcare providers available to provide the care and treatment that
people living with HIV need," Mr. Greenwald said.

Ryan White AIDS programs will still be needed to fill gaps in
regular healthcare programs; however, those gaps may change, depending
on the final shape of healthcare reform legislation, he said.

Laura Hanen, with the National Alliance of State and Territorial
AIDS Directors (NASTAD), called ETHA "another option for states to
expand access to healthcare."

She said they want to expand screening for HIV, make it part of
routine care, and get people who do not know they are infected into
proper care. "We want to be able to say to people, get tested and we
will take care of you if you find out you are positive," but states
cannot guarantee that now.

Increased access to Medicaid "expands the quilt of availability of
coverage to people living with HIV. It is a critical piece for the
states," said Ms. Hanen. When ETHA passes, the next step will be to get
state agencies to take advantage of the increased opportunities for
coverage that it offers, she said.

LINK: http://www.medscape.com/viewarticle/702284