Currently, one in five HIV positive individuals in the United States are uninsured. Of those with HIV who are uninsured, African-Americans and Latinos are disproportionately uninsured. These patients have higher rates of progression to AIDS and suffer increased hospitalizations. One method to increase the number of individuals with HIV who are insured is to increase their access to Medicaid. Unfortunately, Medicaid eligibility for HIV positive individuals is contingent upon meeting both income and disability requirements as defined by the Federal Supplemental Security Income Program (SSI) for people who are blind, aged, or disabled. This poses a significant barrier for most individuals with HIV because disability almost inevitably requires an AIDS diagnosis. If a person with HIV has not yet progressed to AIDS, they may not have access to comprehensive care or anti-retroviral therapy. To overcome this obstacle and provide pre-AIDS, pre-disability access to primary care and anti-retroviral therapy, the state of Massachusetts has instituted the MassHealth HIV Expansion Program which expands Medicaid eligibility to include an increased number of HIV positive individuals. Massachusetts is the first state in the nation to provide Medicaid access to pre-disabled, low-income individuals with HIV. Since the program’s inception in 2000, there have been 593 enrollees.
To determine whether or not the MassHealth HIV Expansion Program has been successful in providing benefits to those populations who are eligible
To assess quality of care and patient satisfaction amongst enrollees in the program
Part I - An analysis of Division of Medical Assistance (DMA) and Department of Public Health data was performed to assess the demographics of HIV by race and ethnicity in Massachusetts. Secondly, levels of uninsurance by race were correlated with the demographics of the enrollees of the MassHealth HIV Expansion Program.
Part II – Pilot Study: A telephone survey of 60 MassHealth Expansion Program enrollees was performed. Patient recruitment was solicited through a letter sent to all enrollees. This letter informed patients that they could volunteer to participate and that they would be paid $25 in consideration of their time and effort. Surveys were conducted in Spanish and English as appropriate. The survey content included an evaluation of current functional status, patient-provider relationship, risk-reduction counseling, diagnostic care, clinical care, medication adherence and access to care. The surveys were comprised of a total of 67 questions.
In the statistical analysis overall percentages were calculated for each question. Comparisons were also made between males and females, whites and non-whites, and blacks v.s. Latinos and whites. Chi-Squared and Fishers Exact Test were used to test for significance.
Part I – Considering the distribution of uninsurance in Massachusetts, blacks and Latinos are seemingly underrepresented within the MassHealth HIV Expansion Program. Greater underrepresentation was noted when race and gender variables were combined. To further determine the cause of this data it is imperative that the “other” racial category which encompassed 40% of the enrollees is disaggregated and characterized. It would also be informative to examine the enrollment outreach process.
Part II – No statistically significant differences between races or in gender were noted in the statistical analysis of the responses to the survey questions. However, in several areas percentage differences between groups of respondents suggest that those areas may require further evaluation. The most significant of these differences is in the area of hepatitis C treatment where 62% of non-whites with co-infection had not received treatment and 37% of whites had. To further elucidate the question of quality of care provided I recommend that a study be conducted with a larger sample size. It is also important, as noted above, that standardization of the measures used to record race be undertaken. In addition, a medical and claims chart review will be undertaken to further clarify possible differences experienced by enrollees in clinical and diagnostic care.
Robert Greewald and Linda Clayton, MD
Division of Medical Assistance in Massachusetts