Do United States-based medicaid spend-down programmes make public sense for persons with HIV/AIDS?

Abstract

Medicaid is a US government insurance programme designed primarily for poor individuals, with expenditures that rose more than 13% in 2002. Thirty-five states have programmes allowing individuals to incur medical expenses at a rate that would make them poor enough to meet Medicaid eligibility criteria. This paper examines the cost of providing care to those spending-down to Medicaid compared to those eligible without spending-down. This longitudinal cohort study compiled inpatient, outpatient and Medicaid data from three academic Infectious Diseases clinics serving approximately 40% of the reported HIV-positive population in North Carolina. Participants included all HIV-positive patients who received care in one of three clinics and received Medicaid coverage at any time from 1996 to 2000 (1,495 individuals). Overall, those who needed to spend-down to Medicaid incurred higher medical costs, following a distinctive pattern of high costs when initially qualified and when ending coverage, and low costs while on spend-down. US states may wish to consider expanding Medicaid's categorically eligible criteria or significantly reducing the frequency with which persons must spend-down to become eligible for Medicaid.

Acknowledgments

This work was supported in part by the HIV/AIDS Bureau's Special Projects of National Significance Project, Domestic Assistance number 93-928, from the Health Resources and Services Administration, Department of Health and Human Services, and a research training grant to Zhu from the NIH (5T32 AG00029). The paper's contents are solely the responsibility of the authors and do not necessarily represent the official view of the funding agency. We would like to thank Stephanie Harrell for her excellent background work, Rachel Stevens, Kristin Lowe and Andrea Rosenberg for their editing assistance and Dr. Nathan Theilman for his clinical advice.