North Carolina's Medicaid Program Offers AIDS Patients Revolving-Door Care, Duke Research Shows

Inefficiencies in North Carolina's Medicaid program are wasting money and may be contributing to the spread of drug-resistant strains of HIV, according to a four-year study of the state's HIV-positive patients. 

The research was conducted by Duke public policy professor Kathryn Whetten, director of Duke's Health Inequalities Program, and researcher Carolyn Zhu of the Health Policy Research Center at New School University in New York City. Their findings are published in the August issue of the journal "AIDS Care."

The study of 1,495 patients showed that low-income or unemployed patients who qualify for Medicaid cost the state less than patients with slightly higher incomes who are excluded from Medicaid coverage until they spend a required amount on health care.

North Carolina's "spend-down" program requires patients to incur a required amount of out-of-pocket health care expenses over a six-month period to qualify for Medicaid for the subsequent six-month period. With inconsistent access to treatment and medications, these "spend-down" patients enter the Medicaid system in poorer health, the research showed.

"This is creating a dangerous public health situation," Whetten said. "HIV patients who cycle in and out of the Medicaid system don't take their medications consistently, making it possible for them to transmit drug-resistant HIV to others." Studies have shown that drug adherence lower than 95 percent creates resistant strains of HIV.

Thirty-five states have similar "spend-down" programs, Whetten said, and all warrant close examination. To save money and improve health care, states could reduce the frequency with which individuals must meet the spending threshold, or simply expand eligibility to include these individuals, she said.

The study analyzed data from three state clinics representing 40 percent of North Carolina's HIV population, and measured the average per-patient daily charges for Medicaid-eligible and spend-down patients. The average yearly cost was $5,475 more for the spend-down patients because interruptions in care and medication complicated their conditions and made it more expensive to treat them.

Expanding Medicaid eligibility would improve health outcomes and be more cost-effective, the study found, because early treatment saves $11,500 per patient over a five-year period and delays the progression of AIDS. The research was funded by the Special Projects of National Significance arm of the Health Resources and Services Administration.

"While these results represent data from one disease in one state, they indicate the need for policymakers in the 35 states with spend-down programs to examine the efficacy of this program," Whetten said. "I would expect results would be similar for persons with other chronic diseases, such as diabetes."

More information

A list of states with "spend-down" programs can be found here.