Bay Windows - Local News, May 3, 2001
Laura Kiritsy, Bay Windows Staff

Advocates say the expanded eligibility will allow physicians to treat people with HIV earlier and more comprehensively, thus slowing the progression of the disease and allowing infected people to live longer and healthier lives. "I think it has great potential," said AIDS Action Committee Executive Director Larry Kessler of the expansion. "I'm proud of the fact that we're the first state in the country to get that potential." Kessler points out, for instance, that previously, access to life-saving drugs such as protease inhibitors, the most powerful anti-HIV/AIDS medication available, for poor or uninsured patients, was restricted only to those with an AIDS diagnosis. "Now we can work with people earlier," said Kessler. "An AIDS diagnosis is much more complex [than an HIV diagnosis]."

The DMA began accepting applications under the expanded eligibility criteria as of April 1. Under the new guidelines, people who are HIV positive and under the age of 65, with incomes at or below 200 percent of the federal poverty level -- roughly $17,184 for a single person -- will receive direct coverage or insurance premium assistance through MassHealth. According to Dr. Jean McGuire, an assistant commissioner of health and director of the AIDS bureau, nearly 30 people have already been enrolled since the coverage became available.

Roger Lacoy, a 37-year-old Lowell man, was one of the first to enroll in MassHealth since its expansion. Lacoy was actually diagnosed with AIDS in 1993. In 1995 he was forced to stop working due to his condition and began receiving Supplemental Security Income (SSI) payments, which included insurance premium assistance through MassHealth to help pay for his Harvard Pilgrim First Security HMO. Lacoy was unable to receive complete MassHealth coverage because -- due to his previous work history -- his SSI payments exceeded the poverty level guidelines. Nevertheless, he struggled to pay for his AIDS medication under the limited coverage provided by Harvard Pilgrim First Security.

According to Lacoy, Harvard Pilgrim provided only $600.00 per year, or $150.00 every three months, for prescription drug coverage along with a $10.00 to $25.00 co-payment for each prescription. With his limited income and health care coverage, Lacoy once found himself struggling to pay the cost of antibiotics -- at a price of $67.00 for seven pills -- when he contracted pneumonia. Lacoy did find some relief from the HIV Drug Assistance Program (HDAP), the Ryan White Care Act-funded program to assist middle- and low-income people in paying for medication.

Under the expansion, Lacoy is now eligible to receive direct health insurance coverage through MassHealth, which covers not only the complete cost of his medications and alleviates his $35.00 co-payment on doctor visits, but will allow him access to other important services, for instance, physical therapy, as well. Under his previous HMO plan, said Lacoy, "If it wasn't medically necessary, you don't get it."

The comprehensive health care Lacoy will now receive is crucial to treating the disease, said the DPH's McGuire, however, without health insurance many patients historically have not received it. Often, the uninsured are blocked from receiving certain treatments at certain points in their care, she said, for instance, doctors may hesitate to do certain medical testing or in making referrals to specialists. Though organizations such as the Fenway Community Health Center provide free services to the uninsured, "no clinical setting is capable of providing full care without insurance," said McGuire, most importantly when patients need emergency room care or admission to a hospital. The MassHealth expansion "removes those kinds of barriers people face on a regular basis."

Annette Hanson, medical director of the DMA, would agree. Though she says programs like HDAP have been important to help HIV infected people get necessary medications, such programs do not provide the primary health care to round out the treatment of HIV. If people are being treated with anti-HIV medication, she says, "don't you think they ought to see a doctor every now and again?"

Hanson was one of a core group of about 30 HIV/AIDS specialists, advocates, people with AIDS/HIV and administrators from both the DMA and DPH who began a series of hundreds of meetings in 1997 to hammer out a workable plan to expand MassHealth benefits to individuals based on their HIV status. McGuire acknowledges that the expansion is costly, however, she notes that the first dictum in devising the plan was that "everyone is better off with insurance, whether public or private." Furthermore, both she and Hanson say that extending health benefits to eligible HIV infected individuals will free up money allotted to the state through the Ryan White Care Act, which can now be used in other areas of prevention, for instance outreach and education efforts to at-risk populations, transportation to medical appointments and medication compliance programs. McGuire illustrates the point by noting that currently there are roughly 1,800 people on the Ryan White-funded HDAP program, however, roughly 500 of them are now eligible to move over to the expanded MassHealth program.

Though he "applauds and supports" the expanded access previously uninsured HIV infected persons will now have to comprehensive health care, Dr. Stephen Boswell, executive director of the Fenway Community Health Center, says the DMA must now turn its attention to the difficult task of ensuring that those covered under MassHealth, particularly those in rural parts of the state, receive care from experienced providers. "There may be issues around quality of care," said Boswell, a nationally recognized leader in the field of AIDS/HIV treatment. "We need to watch whether the quality of care they're receiving is adequate. Are providers experienced enough?" Though Boswell notes that the DMA is aware of the issue, the difficulty lies in striking a balance between "the need for care and the need for ideal care. I'm not sure where the right meeting place is between those two demands."

McGuire acknowledges that although the insurance benefits expansion is a tremendous advancement, "we can't sit on our laurels." The issue of quality care for DMA consumers is one of the many HIV/AIDS related problems they are now beginning to address. "The questions continue," said McGuire. "The disease isn't going away and frankly, it's growing more complex."
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