Journal: What do you consider to be the principal federal and state obstacles
regarding access to timely and appropriate HIV care for the medically indigent
in the US?

CL: The primary obstacle to access to timely and appropriate HIV care for the
medically indigent in the United States is the absence of a universal health care
system that provides both easy access to preventive and diagnostic services as
well as comprehensive treatment for HIV disease. The HIV/AIDS epidemic has
clearly uninsured and underinsured. It is a safety net that is not available to
medically indigent persons with other diseases.

It fills critical gaps in care provided by other public health care programs, most
notably the Medicaid and Medicare programs. In the absence of universal health
care access, the majority of people with HIV/AIDS depend on the Medicaid program
for their health care needs. The wide variability in eligibility and benefits among
states creates disparities in access and services based on where an individual lives .
Additionally, Medicaid is a notoriously poor payer of services, which limits the
numbers of providers—especially providers of specialty care—who are willing to
treat Medicaid patients. Medicare is a more generous payer than Medicaid, but the
program provides a very limited number of services and does not currently
reimburse for outpatient prescription drugs. Some prescription drug coverage
will be available to beneficiaries beginning in 2006.

The glaring deficits in the nation’s health care delivery system frequently overshadow
other issues, but it is also important to highlight the shortage or complete lack of
experienced HIV providers in some communities. There is a substantial body of
scientific data that demonstrates the association between HIV experience and
expertise and patient morbidity and mortality. HIV disease is a condition that is
complex to treat and may become more complex as time goes on. The prevalence
of comorbid conditions in persons living with HIV disease, including mental illness,
addiction, and hepatitis C, to name a few, creates even greater challenges for health
care providers.

Even more alarming is an administration proposal to essentially end the individual
entitlement by capping federal contributions to the Medicaid program in exchange for
offering states wide latitude to restructure benefits and eligibility requirements in ways
that reduce state expenditures. Persons with HIV/AIDS who need a range of costly
health care services and prescription drugs would be especially vulnerable if such a
proposal was enacted into law.

HIV disease often requires a multidisciplinary approach. There are already areas of
the country—both low and high prevalence areas—where the number of experienced
providers is inadequate. As the group of physicians who entered HIV medicine in the
early days of the epidemic moves to retirement, we might expect even greater
challenges in ensuring an adequate number of providers with appropriate expertise.
It is important that we respond now.

Journal: You presented an excellent overview of Medicaid and People Living with
HIV/AIDS at the National Policy Forum on Future Funding for HIV Care last November.  
Would you please summarize the principal challenges to Medicaid funding that you
detailed in your presentation?

CL: Adequate financing for Medicaid is challenged primarily by state and federal
budget deficits and by ideological views that seek to limit health care spending on
low-income persons and to reduce the coverage available to populations
characterized by poverty, disability, and advanced age to more closely resemble 
commercial health care coverage for healthy working people.

Medicaid spending is generally the second largest expense on most state budgets,
|and states are reducing Medicaid spending by restricting eligibility levels, reducing
benefits and limiting outreach and education programs. These reductions can
translate into loss of coverage or gaps in critical services and threats to continuity
of care.  On the federal level, the Bush Administration has offered states the Health
Insurance Flexibility and Accountability (HIFA) waiver program which provides states
an avenue to bypass many of the basic requirements of federal Medicaid law and
further restrict access to care through monthly premiums and higher cost-sharing, in
exchange for demonstrating some expansion of health care coverage. In the current
fiscal climate, a number of states have viewed these waivers as another opportunity to
reduce Medicaid spending as well as a vehicle to transform the program into a
commercial model.

Journal:  What are the principal problems with Medicaid Prescription Drug
Coverage?

CL: Although all states cover prescription drugs, it is an optional benefit (or one that
states are not required to cover to receive the federal medical assistance matching
funds). If states do choose to cover prescriptions, they generally must cover medically
|accepted indications of FDA-approved drugs. However, states use a variety of cost
control mechanisms to limit Medicaid prescription drug expenditures including monthly
drug limits, higher co-payments for brand-name drugs and preferred drug lists. As
states face tougher budget constraints and prescription drug costs continue to rise,
the Medicaid prescription drug benefits are vulnerable. According to a study
commissioned by the Kaiser Family Foundation, 50 states planned to take actions to
control Medicaid prescription in 2004. Medicaid’s geographic disparities are illustrated
by differences in the drug coverage available to Medicaid beneficiaries, e.g., at least
14 states impose limits on the number of prescriptions that beneficiaries can fill in one
month, ranging from 3 to 10 prescriptions

Journal: In your opinion, what were the philosophical differences in the Democratic
and Republican responses to the defeated Schumer amendment?

CL: That is a complicated question, because I am not convinced that the amendment
went down because of ideological differences between Democrats and Republicans.
Funds available for discretionary spending in the Labor-HHS-Education funding bill
were more limited than ever, and there are many important competing priorities in the
bill from education to medical research to job training programs. Members on both
sides of the isle had many complaints about the limited funding available for a range
of programs. I don’t think that philosophical differences between the two parties are as
compelling with the care funding as they are for HIV prevention. Inmost communities
and states, Ryan White funded programs have become an integral part of the health
care infrastructure. No senator or member of Congress is interested in seeing
reductions in federal funding in their districts or states. The strong vested interest
of powerful pharmaceutical companies in generous funding for the ADAP program
has also engendered Republican support for the program. Unfortunately, the Ryan
White budget has become a victim of a struggling economy and the diminishing
available resources as a result of huge federal tax cuts and the costly war in Iraq.

Journal: How important is physician advocacy to members of Congress and state
legislatures in effecting improved access to timely an appropriate HIV care for the
medically indigent?

CL: HIV physicians offer a critical and potentially powerful advocacy voice to the
policy debate about domestic and international HIV/AIDS policies. Hearing from
physicians is critical for members of Congress and state legislatures to realize how
policies translate into practice and affect access to HIV care. Physicians can serve
as an important resource for legislators by offering knowledge and expertise gained
through their practice experience. Moreover, many of the leading physicians in HIV
medicine and their HIV clinical practices are located at prestigious academic
institutions that are important to the legislators who represent those districts and
states. Those associations can open doors and minds to the need for comprehensive
and humane policies. Physicians have credibility on Capitol Hill, particularly when
hey are not lobbying for policies that enhance their own salaries or reimbursement,
but rather serving as an authoritative voice for policies grounded in science,
sound public health principles, and compassion. The involvement of HIV physicians
in the HIV advocacy community is long overdue, and especially vital now that there
re effective medical interventions to respond to HIV infection.

HIV Medicine Association (HIVMA) Backgrounder

The HIV Medicine Association (HIVMA), nested within the Infectious Diseases
Society of America (IDSA), represents 2,600 physicians and other health care
providers who practice HIV medicine.  We represent the interests of our patients
by advocating for policies that ensure a comprehensive and humane response to
the AIDS pandemic informed by science and social justice.

IDSA created the HIV Medicine Association (HIVMA) in fall 2000 to provide an
|organizational home for medical professionals engaged in HIV medicine.  Through
its activities, HIVMA supports clinicians in overcoming the challenges inherent in
|providing high quality health care to patients living with HIV disease.  IDSA is a
national medical society that represents more than 7,500 infectious diseases
physicians and scientists devoted to patient care, education, research, and
community health planning in infectious diseases. 

HIVMA embodies the diversity of medical subspecialties practicing HIV medicine --
including internal medicine, family practice, infectious diseases, oncology, and
obstetrics-gynecology. Our 2,600 members represent 49 states, the District of
|Columbia, Puerto Rico, the Virgin Islands, and 36 countries outside of the United
States.

HIVMA’s Primary Goals

• Advocate for U.S. policies that support HIV/AIDS providers who practice HIV
  medicine in the United States and abroad.

• Endorse policies that promote an adequate and well-trained medical workforce
  to respond to the AIDS pandemic.

• Encourage a comprehensive response to HIV/AIDS in the United States
  through adequate funding for HIV research, prevention, care, treatment and
  provider training and resources.

• Promote a comprehensive U.S. response to the HIV/AIDS pandemic in
  resource-limited countries that includes policy development and resources
  |for research, prevention, treatment, provider training and other health care
  infrastructure essential for delivery of services.

• Support U.S. policies based on science, public health and social justice for
  persons living with, or at risk for, HIV/AIDS in the United States and abroad.

• Advocate for the preservation and enhancement of the health care safety
  net for persons in the United States who are living with HIV/AIDS.