The State of Maine will expand Medicaid coverage to people who are HIV— positive but do not yet have a diagnosis of AIDS. It is the first state to do so. The Health Care Finance Administration ( HCFA ) , which administers both Medicaid and Medicare, granted Maine a waiver for the change on Feb. 24.
AIDS advocates have been fighting for this expansion of coverage for years. They thought they had won the political battle in April 1997 when Vice President Al Gore voiced his support. But that fall an administration study found that expansion would not be "revenue neutral." In other words, it would cost money. White House support vanished.
When advocates challenged assumptions made in that analysis, the Clinton administration responded that it might grant a Medicaid waiver to states proposing expansion demonstration projects. A handful of state Medicaid agencies looked at creating such waiver programs. Maine submitted theirs last spring, and revised it significantly in the fall to take HCFA concerns into account.
The Maine plan will begin in September and run for five years. To qualify, one must be HIV— positive and have an annual income of less than three times the federal poverty level, which is about $25,000 a year for a single person living in Maine. State officials estimate that about 300 people will qualify.
"One down, 49 more states to go," said Claudia French, acting executive director of AIDS Action in Washington, in welcoming the news. The group has led the fight for expansion.
"Increasing access for a handful of people in Maine is a great step for those people," said Terje Anderson, policy director for the National Association of People With AIDS ( NAPWA ) . "But we need to figure out how to turn this into a national effort."
He praised the state for its initiative and HCFA for standing firm on no enrollment cap and for requiring nearly a full benefits package rather than a stripped down version as initially proposed.
"These applications are hard, they're complex, they take a lot of activity within different parts of state government to make it happen," said Anderson. Massachusetts is preparing a waiver application and at one point so was California. "The fear is that we are not going to get a lot of other applications submitted."
Conditions also have changed since the push for expanded access to Medicaid began. It is no longer so clear that early intervention with currently available therapy is the route to go. Associated side effects also give pause.
Other ways for some people with HIV to gain access to Medicaid have opened up, says Tom McCormack. He is an expert on entitlement programs and author of "The AIDS Benefits Handbook."
The 1997 Balanced Budget Act and the Work Incentives Improvement Act, signed on Dec. 17, 1999, "allow states to give Medicaid cards to people who are working and who are clinically disabled."
Other options allow the "pre— disabled and ex— disabled" to gain access to Medicaid, even without a diagnosis of AIDS. Income requirements for these provisions are $43,000 or higher at the discretion of each state.
McCormack sees utilization of these new provisions as the best and easiest ways to gain access to care for those who are working.
