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HEALTHWATCH

HIV/AIDS

Early Treatment Saves Lives

By James Allen
LEF Web Contributor

The Early Treatment for HIV Act (ETHA), currently pending in Congress, aims to solve a shortcoming in the current Medicaid approach to HIV coverage. Many low income individuals need Medicaid assistance to help pay for expensive HIV treatments. Without Medicaid, they can't afford the $10,000-$18,500 yearly cost for HIV medication and monitoring.

Currently, Medicaid will only pay HIV treatment costs for people who (1) are defined as low income and (2) are parents, minor children, elderly, or disabled. However, many low income HIV positive individuals are not parents, minor children, or elderly, so they are covered only if they meet the Supplemental Security Insurance (SSI) definition for disability. Unfortunately, the SSI disability definition includes only those HIV positive individuals who have developed full-blown AIDS. Accordingly, Medicaid currently offers no help until a person has AIDS.

Waiting to treat an HIV positive person until they have full blown AIDS flies in the face of common sense, compassion and current medical guidelines, which stress the importance of treatment in the earlier stages of HIV. Right now, HIV positive individuals must wait until they get very sick before Medicaid will cover them. The situation is as unwise as it is cruel.

ETHA will allow states to develop Medicaid programs that offer treatment options for low income HIV positive individuals long before they develop full-blown AIDS. The legislation is patterned after the Breast and Cervical Cancer Prevention Treatment Act of 2000 (BCCPT), which has allowed states to expand Medicaid coverage to include women who are in the early stages of breast or cervical cancer. Forty-eight states and the District of Columbia have implemented BCCPT programs, and there is no reason to believe that they would not do the same with ETHA.

ETHA Saves Lives

ETHA will help save lives by both extending the lives of HIV positive individuals and reducing the transmission of the virus. Under current Medicaid rules, low income HIV positive individuals become eligible for coverage only when they have developed AIDS. By this time, they have either contracted an opportunistic infection (including certain forms of cancer and pneumonia seen only in individuals with compromised immune systems) or manifested some other overt symptom of AIDS. Waiting to treat HIV until the onset of AIDS defies current Centers for Disease Control (CDC) guidelines, which recommend that treatment begin much earlier to avoid the serious complications associated with AIDS. Under the current guidelines, low income HIV positive individuals must suffer the cruelty of knowing that they are becoming sicker, knowing that they should be on an HIV treatment program, and knowing that they will not get the help they need from Medicaid until they are terribly ill.

ETHA will correct the existing approach and keep more low income HIV positive individuals alive and healthy. A recent Price Waterhouse Coopers (PWC) study says that over a ten year period, ETHA will reduce the death rate for HIV positive individuals on Medicaid by 50 The study also estimates that over ten years, ETHA will result in thousands more individuals with healthier immune systems than under the current Medicaid program. A Stanford study indicates that the health benefits of ETHA may be even greater. In any event, both studies show that ETHA will lead to more low income HIV positive individuals living longer and feeling better.

ETHA will also help prevent the transmission of HIV. Early treatment of HIV significantly reduces a person's viral load (the amount of virus inside a person's body), and a 2004 study published in AIDS indicates that HIV therapies reduce HIV positive individuals' infectiousness by 60 This reduction makes it more difficult for them to transmit HIV to another person. Accordingly, ETHA will likely prevent some individuals that might otherwise have contracted the disease from doing so.

ETHA Is Cost-Effective

PWC's economic analysis of ETHA demonstrates that the legislation is cost-effective. PWC estimates that the dollar-amount cost of ETHA will be $359 million over five years and $2.4 billion over ten years. It is important to note that $192.8 million of the costs associated with ETHA are the result of HIV-positive individuals living longer. This cost is a testament to ETHA's success; people will be receiving treatment longer because they will be living longer, so the treatment cost rises.

The benefits of ETHA far outweigh the costs. First, this legislation would reduce unnecessary and costly hospital admissions for opportunistic infections that early HIV treatment would prevent. After all, it costs a great deal less to provide early HIV treatment than to deal with the opportunistic infections and other conditions associated with full-blown AIDS. Second, it would increase federal tax revenue by allowing HIV positive individuals to live longer and work longer. More people working means more people paying taxes. Third, the reduced transmission rate will save Medicaid from ever having to cover some individuals who, without ETHA, might have contracted HIV. Taking these and other savings into account, PWC forecasts that ETHA will actually save Medicaid $31.7 million over ten years.

Medicaid Section 1115 Waivers and the CARE Act Are Not Enough

Currently, Medicaid Section 1115 allows states to develop demonstration programs that explore new Medicaid policies and uses. In 1997, the Clinton administration suggested that section 1115 be used to develop HIV treatment programs. Since then, at least ten states have applied for section 1115 waivers, but only Massachusetts, Maine, and the District of Columbia have received approval.

The problem with section 1115 waivers is that it can take years for states to get them approved and implemented. They are also subject to rigid requirements, including budget neutrality within five years. ETHA, because it would allow states the traditional flexibility they enjoy in developing Medicaid programs, would cover more low income HIV positive individuals in a shorter period of time.

The Ryan White Care Act is equally unable to deal with Medicaid's current shortcomings. Since 1996, the act has tried to provide coverage for low income individuals who do not qualify for Medicaid assistance. However, CARE was never meant to serve as a primary provider of HIV treatment services. Rather, it was intended to fill gaps in existing services that were preventing HIV positive individuals from receiving the best treatment. Because of the strain that the current Medicaid approach to HIV is exerting on the CARE Act, several states have placed restrictions on treatment access, and others have waiting lists for medications. ETHA would take the strain off the CARE Act and allow it to resume its intended role as a gap-filler in HIV care.

We Need ETHA Today

Medicaid's current approach to HIV treatment leaves low income individuals in the earlier stages of the disease without coverage. ETHA will save lives and reduce HIV transmission. Over a ten-year period it will actually save the Medicare program millions of dollars. ETHA will eliminate the rigidity of the section 1115 waiver programs and remove the strain put on the CARE Act. In the final analysis, ETHA is a win-win for everyone. It makes fiscal sense. It will lower HIV infections. And the program will improve the lives of tens of thousands of people living with HIV.