AIDS Home- and Community-Based Waivers: Effects on Use of Services, Expenditures, And Survival (Antiretroviral Drug Therapies‪)‬

1. Introduction The prognosis, survival, and quality of life for persons living with HIV/AIDS (PLWHAs) improved dramatically in recent years due to the development of highly active antiretroviral drug therapies (Hogg et al. 1998; Palella et al. 1998). Concomitantly, advances in medical treatment enabled the majority of PLWHAs to obtain care on an outpatient basis or in their home. Currently, state Medicaid programs are the primary payers of medical care services for PLWHAs. To illustrate, Medicaid spending on care for PLWHAs amounted to about $3.3 billion in 1997, compared to $1.3 billion by Medicare and around $1.2 billion under the Ryan White Comprehensive AIDS Relief Emergency (CARE) Act (Sambamoorthi et al. 1999). In an effort to control increasing Medicaid expenditures yet simultaneously provide high-quality care, a number of state Medicaid programs implemented home- and community-based waiver initiatives for persons with AIDS (PWAs) during the early 1990s. Currently, 13 states provide waiver services for PWAs; these states are identified in Table 1. Enrollment in the program by PWAs in these state Medicaid programs ranges from a low of 17 enrollees in Iowa to a high of 6700 in Florida. Initially authorized under section 2176 of Omnibus Reconciliation Act (OBRA) 1985, the Medicaid 1915c waiver enables states to expand the array of home- and community-based services that are available to Medicaid beneficiaries with AIDS. Waiver services are regarded as an add-on, that is, an additional bundle of up to 24 services that include case management, nursing care, meals-on-wheels, personal care services, and homemaker services that are not available to beneficiaries under the traditional Medicaid program. The services provided under the waiver are summarized in Table 2 for the 13 states currently participating in the program.