Though routine HIV screenings are recommended by America’s foremost public health authorities and tens of thousands of people are living in the United States with undiagnosed HIV, according to the Centers for Disease Control and Prevention (CDC), half of state Medicaid programs don’t cover preventive testing.
Medicaid’s coverage of routine HIV screening is a mess at the moment. According to an article published in Health Affairs last month, 24 states' Medicaid fee-for-service and managed-care programs cover the tests; seven states order routine HIV screenings only as part of broader family planning visits; and in a number of states, it’s unclear whether routine STD screenings include HIV testing or not.
“These kinds of Medicaid services are optional. States have to choose to cover them,” says Jennifer Kates, the vice president of HIV policy for Kaiser Family Foundation. “That sort of public health mentality has been hard to filter into Medicaid.”
According to a year-old Kaiser report, which researchers are currently in the field to update, 23 states cover routine HIV screenings under Medicaid, while 24 states cover screenings only when a doctor determines it's medically necessary. (Three states didn't respond to Kaiser's inquiry).
The Affordable Care Act muddies the issue further. Starting in 2014, private health insurance plans must cover routine HIV tests as a preventive service. That also applies to the roughly 5 million newly eligible Medicaid enrollees in the 20-plus states that expanded the program under the law, but it excludes the more than 70 million current Medicaid recipients.
HHS, however, has offered states an incentive: If they change their coverage for current Medicaid enrollees to include the preventive services that the ACA dictates for new ones, the feds will increase their Medicaid matching rate by 1 percent for those services. That could mean hundreds of thousands of extra federal dollars for some states, and three states (Nevada, New Hampshire, New York) have taken the deal so far.
Part of the problem is that the public health sphere only recently came to the consensus that routine screens should be the norm. The CDC has recommended coverage of routine testing since 2006, but another critical player—the U.S. Preventive Services Task Force—didn’t recommend routine screenings until this April.
The task force’s recommendations serve as a benchmark for insurers, including Medicaid, as they decide what to cover. Advocates hope its endorsement will encourage states to add routine HIV testing to their Medicaid coverage. The AIDS Institute, the leading advocacy group in the United States, sent a letter to U.S. Health and Human Services Secretary (HHS) Kathleen Sebelius in June, asking her to send a letter officially notifying states of the task force’s new policy and persuading them to change their Medicaid programs accordingly. Lobbying efforts are also picking up in individual states.
“There’s a dichotomy in the states. This obviously gives a hook to activists to organization on the ground to renew that conversation,” says Bill McColl, political director at AIDS United, another top advocacy group. “We're trying to get things going in a new direction, and this was one of the only ways we were ever going to do that.”
States Debate Whether Change is Necessary
Some of the states that don’t currently cover routine testing for their Medicaid recipients are mulling changes, but some see no need for it.
In Maryland, for example, Medicaid director Chuck Milligan says he believes his state effectively covers preventive HIV screenings, even if Kaiser Family Foundation and Health Affairs disagree. The state only covers screenings when a doctor determines it's medically necessary, but its "utilization criteria" for those tests is very loose, according to Milligan, so he argues it works as a preventive one.
“We're reviewing it,” Milligan says, “but it's not driving a lot of immediate steps because we think we cover preventive services.”
In South Carolina, officials are also confident that people who need to be tested get tested under the “medically necessary” provision, but the federal task force’s April declaration has inspired the state to start reevaluating its coverage. With 50,000 new cases of HIV diagnosed in the United States every year, the case for routine screenings is compelling, acknowledges the state's medical director for Medicaid, Marion Burton. He adds that medical advances that have improved management of HIV also bolster the argument for more aggressive testing so the disease can be detected earlier. A small clinical group is formulating a report to present to top state officials in the near future. It wouldn’t be a surprise if they recommended moving from medically necessary to routine testing.
"We do have a fair number of ticking time bombs walking around the country, people who may be having relations with folks,” Burton says. “We’ve still got a problem.”
There is one other important consideration for Medicaid officials: Socioeconomic factors, such as poverty, are consistently linked with a higher risk for HIV infection. If that trend holds true, that means that the Medicaid population is at a higher risk of contracting HIV but lacks health coverage that guarantees routine testing for it. No specific research on Medicaid enrollees and their rate of HIV infection currently exists. But if that hypothesis could be proven conclusively, it would likely expedite the movement toward coverage of routine screenings.
“If I knew that for sure,” Burton says, “that would give us another thrust toward universal screening.”
Checking Up on Health News: links to stories you may have missed from around the Web
Continue to think the regulation of e-cigarettes will be a mounting challenge for states. The Columbus Dispatch reports on the latest developments in Ohio. The U.S. Justice Department has sued Florida for showing "deliberate indifference to the suffering" of disabled children who were institutionalized in nursing homes alongside elderly people, the Tampa Bay Times reports. This new GAO report offers a pre-Obamacare baseline for insurance premiums in every state. Invaluable resource. A new survey finds doctors think lawyers and insurers, among others, are more responsible for lowering health care costs than they are, according to Kaiser Health News. A periodical reminder that the Medicaid expansion debate isn't finished: Politico reports on how the Virginia governor's race could affect that state's final decision.