[Congressional Record Volume 153, Number 43 (Tuesday, March 13, 2007)]
[Senate]
[Pages S3070-S3072]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. SMITH (for himself, Mrs. Clinton, Mr. Schumer, Mr. Brown, 
        Ms. Stabenow, Ms. Cantwell, Mr. Leahy, Mr. Specter, Mr. Nelson 
        of Florida, Mr. Coleman, Mr. Menendez, Mr. Lautenberg, Mr. 
        Durbin, Mr. Kennedy, Ms. Collins, Mrs. Lincoln, Mr. Wyden, Mr. 
        Bayh, Ms. Snowe, Mr. Sanders, and Mr. Bingaman):
  S. 860. A bill to amend title XIX of the Social Security Act to 
permit States the option to provide Medicaid coverage for low-income 
individuals infected with HIV; to the Committee on Finance.
  Mr. SMITH. Mr. President, I rise today to introduce the Early 
Treatment for HIV Act, or ETHA. I ask unanimous consent that the full 
text of this bill, along with the numerous letters of support I have 
received from advocacy organizations, be printed in the Record. I am 
pleased that Senator Clinton is joining me once again to introduce 
ETHA. I thank her for the steadfast support she has shown people living 
with HIV. This terrible illness knows no party affiliation, and I am 
pleased to say that ETHA's 20 cosponsors span both sides of the aisle.
  ETHA provides States the ability to extend Medicaid coverage to low-
income, HIV-positive individuals before they develop full-blown AIDS. 
Today, the unfortunate reality is that most patients must become 
disabled before they can qualify for Medicaid. Nearly 50 percent of 
people living with AIDS who know their status lack ongoing access to 
treatment. In my home State of Oregon, there are approximately 5,700 
persons living with HIV/AIDS. It is estimated that approximately 40 
percent of these Oregonians are not receiving care for their HIV 
disease. I believe it is our moral responsibility to do everything we 
can to ensure that all people living with HIV--regardless of their 
income or their insurance status--have access to timely, effective 
treatment.
  Unfortunately, safety net programs across the country are running out 
of money, and as a consequence, they are generally unable to cover all 
of the people who need assistance paying for their medical care. For 
instance, Oregon's Ryan White funded AIDS Drug Assistance Program 
(ADAP) is experiencing significant financial hardship due to years of 
inadequate funding. As a consequence, the program has been forced to 
impose burdensome cost-sharing requirements and limit the scope of 
drugs it covers on its formulary. Fortunately, Oregon's ADAP has not 
had to resort to service waiting lists, a cost control mechanism that 
many States have been forced to adopt. As safety net programs like ADAP 
continue to struggle, ETHA gives States another way to reach out to 
low-income, HIV-positive individuals.
  I believe ETHA represents a promising opportunity to turn the tide 
against this devastating epidemic. In 2005, there were 220 newly 
infected HIV cases reported in my home State of Oregon. If we were able 
to provide even a fraction of those individuals access to early 
treatment, we could prevent the progression of their condition to full-
blown AIDS. Experience has shown that current HIV treatments are very 
successful in delaying the progression from HIV infection to AIDS, and 
help improve the health and quality of life for millions of people 
living with the disease.
  Studies conducted by Pricewaterhouse Cooper (PWC) support providing 
early healthcare to individuals diagnosed with HIV because it has both 
the potential to save lives and control costs. Specifically, providing 
individuals coverage through ETHA could reduce the death rate of 
persons living with HIV by more than half. Similarly encouraging is the 
potential cost-savings ETHA could generate in the Medicaid program. Due 
to its preventive aim, ETHA is estimated to begin saving the Medicaid 
program $31.7 million each year after the effects of expanded access to 
care are fully realized.
  I believe ETHA is a key example of the type of reform Congress needs 
to be implementing to the federal entitlements. The short term 
investment required to expand Medicaid coverage will ultimately result 
in significant long-term savings to the program--at no harm to the 
beneficiary. But most importantly, ETHA takes an important step toward 
ensuring that all Americans living with HIV can get the medical care 
they need to lead healthy, productive lives for as long as possible.
  One of the strongest features of ETHA is the enhanced Federal 
Medicaid match rate it provides to encourage States to expand coverage 
to individuals diagnosed with HIV. This provision closely models the 
successful Breast and Cervical Cancer Treatment and Prevention Act of 
2000, which allows States to provide early Medicaid intervention to 
women with breast and cervical cancer. We can build upon this success 
by passing ETHA and extending similar early intervention treatments to 
people with HIV.
  HIV/AIDS touches the lives of millions of Americans from a variety of 
backgrounds. Some get the proper medications they need to keep healthy, 
but far too many do not. The inability to access life-saving treatment 
literally creates a ``life and death'' situation for many of our most 
vulnerable citizens. Fortunately, ETHA can give those individuals 
access to the care they need so they can look forward to a long, 
healthy life.
  I again want to thank the strong group of bipartisan Senators that is 
joining me as original cosponsors of ETHA. I also wish to thank all of 
the organizations around the country that have expressed support for 
this bill, in particular, Oregon's Cascade AIDS Project. The work they 
do on behalf of individuals living with HIV/AIDS in my home State is 
truly commendable, and I appreciate the support they have shown ETHA 
over the years.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 S. 860

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Early Treatment for HIV Act 
     of 2007''.

     SEC. 2. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-INFECTED 
                   INDIVIDUALS.

       (a) In General.--Section 1902 of the Social Security Act 
     (42 U.S.C. 1396a) is amended--
       (1) in subsection (a)(10)(A)(ii)--
       (A) by striking ``or'' at the end of subclause (XVIII);
       (B) by adding ``or'' at the end of subclause (XIX); and
       (C) by adding at the end the following:

       ``(XX) who are described in subsection (dd) (relating to 
     HIV-infected individuals);''; and

       (2) by adding at the end the following:
       ``(dd) HIV-infected individuals described in this 
     subsection are individuals not described in subsection 
     (a)(10)(A)(i)--
       ``(1) who have HIV infection;
       ``(2) whose income (as determined under the State plan 
     under this title with respect to disabled individuals) does 
     not exceed the maximum amount of income a disabled individual 
     described in subsection (a)(10)(A)(i) may have and obtain 
     medical assistance under the plan; and
       ``(3) whose resources (as determined under the State plan 
     under this title with respect to disabled individuals) do not 
     exceed the maximum amount of resources a disabled individual 
     described in subsection (a)(10)(A)(i) may have and obtain 
     medical assistance under the plan.''.
       (b) Enhanced Match.--The first sentence of section 1905(b) 
     of the Social Security Act (42 U.S.C. 1396d(b)) is amended by 
     striking ``section 1902(a)(10)(A)(ii)(XVIII)'' and inserting 
     ``subclause (XVIII) or (XX) of section 1902(a)(10)(A)(ii)''.
       (c) Conforming Amendments.--Section 1905(a) of the Social 
     Security Act (42 U.S.C. 1396d(a)) is amended in the matter 
     preceding paragraph (1)--
       (1) by striking ``or'' at the end of clause (xii);
       (2) by adding ``or'' at the end of clause (xiii); and
       (3) by inserting after clause (xiii) the following:
       ``(xiv) individuals described in section 1902(dd);''.
       (d) Exemption From Funding Limitation for Territories.--
     Section 1108(g) of the Social Security Act (42 U.S.C. 
     1308(g)) is amended by adding at the end the following:
       ``(3) Disregarding medical assistance for optional low-
     income hiv-infected individuals.--The limitations under 
     subsection (f) and the previous provisions of this subsection 
     shall not apply to amounts expended for medical assistance 
     for individuals described in section 1902(dd) who are only 
     eligible for such assistance on the basis of section 
     1902(a)(10)(A)(ii)(XX).''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to calendar quarters beginning on or after the 
     date of

[[Page S3071]]

     the enactment of this Act, without regard to whether or not 
     final regulations to carry out such amendments have been 
     promulgated by such date.
                                  ____



                                     HIV Medicine Association,

                                 Alexandria, VA, January 30, 2007.
     Hon. Gordon Smith,
     Russell Senate Office Building,
     Washington, DC.
     Hon. Hillary Clinton,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senators Smith and Clinton: I am writing on behalf of 
     the HIV Medicine Association (HIVMA) to offer our strong 
     support for the Early Treatment for HIV Act (ETHA). HIVMA 
     represents more than 3,500 HIV medical providers from across 
     the United States. Many of our members serve on the front 
     lines of the HIV epidemic providing care and treatment in 
     communities ranging from the rural South to the large urban 
     areas on the east and west coasts of the nation.
       As you know, ETHA would allow states to expand their 
     Medicaid programs to cover people with HIV disease, before 
     they become disabled and progress to AIDS. This important 
     program change would allow more people with HIV disease to 
     benefit from the remarkable HIV treatment available today--
     treatment that has reduced mortality due to HIV disease by 
     nearly 80 percent.
       Many of our members still report high percentages of 
     patients with HIV presenting at their clinics with advanced 
     stage disease. These patients are often sicker; less 
     responsive to treatment and more costly due to the need for 
     more intensive interventions, such as inpatient 
     hospitalization. With earlier access to medical care and 
     treatment through Medicaid, these patients could remain 
     relatively healthy and enjoy longer and more productive 
     lives.
       Now is the time to help these patients and the many new 
     ones that will enter HIV care systems as a result of the 
     Centers for Disease Control and Prevention's (CDC) new 
     recommendations to make HIV testing a routine component of 
     medical care. While we are strong supporters of routine HIV 
     testing as a tool to promote earlier diagnosis and linkage to 
     care, we are concerned that our current federal and state 
     health care safety-net programs are ill-equipped to care for 
     the influx of patients that we expect to be identified 
     through routine HIV testing. Passage of ETHA would be a 
     critical step forward in the battle to ensure that all low-
     income Americans with HIV disease have the healthcare 
     coverage that will allow them to benefit from the lifesaving 
     HIV treatment widely available in the U.S. today.
       Thank you very much for your continued commitment to expand 
     access to care for low-income persons living with HIV/AIDS 
     and other vulnerable Americans. Please consider HIVMA a 
     resource as you move forward with the passage of this 
     important legislation.
           Sincerely,
                                              Daniel R. Kuritzkes,
     Chair.
                                  ____

                                        National Alliance of State


                                 & Territorial-AIDS Directors,

                                Washington, DC, February 16, 2007.
     Hon. Gordon Smith,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Smith: On behalf of the National Alliance of 
     State and Territorial AIDS Directors (NASTAD), I am writing 
     to offer our support for the ``Early Treatment for HIV Act.'' 
     NASTAD represents the nation's chief state and territorial 
     health agency staff who are responsible for HIV/AIDS 
     prevention, care and treatment programs funded by state and 
     federal governments. This legislation would give states an 
     important option in providing care and treatment services to 
     low-income Americans living with HIV.
       The Early Treatment for HIV Act (ETHA) would allow states 
     to expand their Medicaid programs to cover HIV positive 
     individuals, before they become disabled, without having to 
     receive a waiver. NASTAD believes this legislation would 
     allow HIV positive individuals to access the medical care 
     that is widely recommended, can postpone or avoid the onset 
     of AIDS, and can enormously increase the quality of life for 
     people living with HIV.
       State AIDS directors continue to develop innovative and 
     cost-effective HIV/AIDS programs in the face of devastating 
     state budget cuts and federal contributions that fail to keep 
     up with need. ETHA provides a solution to states by 
     increasing health care access for those living with HIV/AIDS.
       We would also like to commend the hard work of your staff, 
     particularly Matt Canedy who has been extremely helpful on a 
     myriad of HIV/AIDS policy issues. We look forward to working 
     with him to gain support for the legislation.
       Thank you very much for your continued commitment to 
     persons living with HIV/AIDS.
           Sincerely,
                                                Julie M. Scofield,
     Executive Director.
                                  ____



                                           The Aids Institute,

                                 Washington, DC, January 29, 2007.
     Re the Early Treatment for HIV Act (ETHA).

     Senator Gordon Smith,
     U.S. Senate,
     Washington, DC.
     Senator Hillary Clinton,
     U.S. Senate,
     Washington, DC.
       Dear Senators Smith and Clinton: The AIDS Institute 
     applauds you for your continued leadership and commitment to 
     people living with HIV/AIDS in our country who are in need of 
     lifesaving healthcare and treatment. While the HIV/AIDS 
     epidemic in sub-Sahara Africa and other parts of the world 
     often overshadow the epidemic in the United States, we must 
     not forget about the approximately 1.1 million people living 
     in the U.S. who have HIV or AIDS.
       Those infected with HIV are more likely to be low-income, 
     and the disease disproportionately impacts minority 
     communities. In fact, the AIDS case rate per 100,000 for 
     African Americans was 10 times that of whites in 2006. 
     According to a recent Institute of Medicine report titled, 
     ``Public Financing and Delivery of HIV/AIDS Care: Securing 
     the Legacy of the Ryan White CARE Act'', 233,000 of the 
     463,070 people living with HIV in the U.S. who need 
     antiretroviral treatment do not have ongoing access to 
     treatment. This does not include an additional 82,000 people 
     who are infected but unaware of their HIV status and are in 
     need of antiretroviral medications.
       One reason why there are so many people lacking treatment 
     is because under current law, Medicaid, the single largest 
     public payer of HIV/AIDS care in the U.S., only covers those 
     with full blown AIDS, and not those with HIV. The Early 
     Treatment for HIV Act (ETHA), being re-introduced in this 
     Congress under your leadership, would rectify an archaic 
     mindset in the delivery of public health care. No longer 
     would a Medicaid eligible person with HIV have to become 
     disabled with AIDS to receive access to Medicaid provided 
     care and treatment.
       Providing coverage to those with HIV can prevent them from 
     developing AIDS, and allow them to live a productive life 
     with their family and be a healthy contributing member of 
     society. ETHA would provide states the option of amending 
     their Medicaid eligibility requirements to include uninsured 
     and under-insured, pre-disabled poor and low-income people 
     living with HIV. No state has to participate if they choose 
     not to. As all states have participated in the Breast and 
     Cervical Cancer Prevention and Treatment Act, upon which ETHA 
     is modeled, we believe all States would opt to choose this 
     approach in treating those with HIV. States will opt into 
     this benefit not only because it is the medically and 
     ethically right thing to do, but because it is cost 
     effective, as well.
       A recent study prepared by PricewaterhouseCoopers found 
     that if ETHA was enacted, over 10 years:
       --the death rate for persons living with HIV on Medicaid 
     would be reduced by 50 percent;
       --there would be 35,000 more individuals with CD4 levels 
     above 500 under ETHA versus the existing Medicaid system; and 
     it would
       --result in savings of $31.7 million.
       The AIDS Institute thanks you for your bipartisan 
     leadership by introducing ``The Early Treatment for HIV Act 
     of 2006''. It is the type of Medicaid reform that is 
     critically needed to update the program to keep current with 
     the Federal Government's guidelines for treating people with 
     HIV.
       We were very pleased the US Senate passed an ETHA 
     demonstration project during the last Congress. In this 
     Congress, we hope ETHA will finally become a reality. We look 
     forward to working with you and your colleagues as it moves 
     toward enactment.
       Thank you very much.
           Sincerely,
                                              Dr. A. Gene Copello,
     Executive Director.
                                  ____

                                                  American Academy


                                              of HIV Medicine,

                                    Washington, DC, Jan. 22, 2007.
     Hon. Gordon Smith,
     Russell Senate Office Building,
     Washington, DC.
     Hon. Hillary Clinton,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Smith and Senator Clinton: The American 
     Academy of HIV Medicine is an independent organization of HIV 
     specialists and others dedicated to promoting excellence in 
     HIV/AIDS care. As the largest independent organization of HIV 
     frontline providers, our 2,000 members provide direct care to 
     more than 340,000 HIV patients--more than two thirds of the 
     patients in active treatment for HIV disease.
       The Academy would like to thank and commend you for co-
     sponsoring the Early Treatment for HIV Act (ETHA). We believe 
     this legislation would allow many HIV positive individuals 
     access to the quality medical care vital towards postponing 
     or avoiding the onset of AIDS, and be cost-effective in doing 
     so.
       ETHA addresses a flawed anomaly in the current Medicaid 
     system--that under current Medicaid rules people must become 
     disabled by AIDS before they can receive access to 
     Medicaidprovided care and treatment that could have prevented 
     them from becoming so ill in the first place. The U.S. Public 
     Health Service guidelines have consistently recommended for 
     several years that the treatment of HIV patients, before 
     their immune systems have been severely damaged by HIV, will 
     greatly or even prevent the disabling effects of HIV disease.
       ETHA would bring Medicaid eligibility rules in line with 
     the clinical standard of care for treating HIV disease, which 
     has changed dramatically over the last twenty

[[Page S3072]]

     years due to the revolutionary and increasingly more 
     simplified life-saving drug regimens. The science of HIV 
     medicine is clear on this point: Today, when appropriately 
     treated, HIV can be managed as a serious chronic illness; 
     however, appropriate treatment requires early and continuous 
     access to highly-active antiretroviral therapy (HAART). 
     Preserving an immune system is much more effective, if even 
     possible, than rebuilding one already destroyed. Patients who 
     do not receive proper treatment until they are diagnosed with 
     AIDS may not fully respond or benefit from treatment once it 
     begins.
       The benefits of early treatment also extend to the 
     population at large. Good data (Quinn et al.; Porco et al.) 
     now supports what we have long suspected--that successful and 
     consistent treatment of the infected individual decreases a 
     patient's infectivity, further benefiting the health of the 
     American public and reducing the number of individuals 
     ultimately needing costly medical care.
       Beyond the public's health, the cost-benefits of this 
     bill's implementation are similarly clear. States that adopt 
     this option to their Medicaid program would likely see cost-
     savings to Medicaid by limiting costly hospital admissions 
     and reducing unnecessary, preventable illness. With reduced 
     morbidity, mortality and inpatient costs as a result of 
     state-of-the-art outpatient treatment, receiving early, 
     quality outpatient care is cost-effective (Valenti, 2001; 
     Freedberg et al. 2001) compared with the alternatives.
       Passage of the Early Treatment for HIV Act will save lives, 
     increase the length and quality of life for people living 
     with HIV/AIDS, help ensure their medical coverage, and save 
     money over time.
       We will work in vigorous support of this legislation, and 
     we appreciate your impressive leadership in doing the same.
           Sincerely,
                                                    Jeff Schouten,
     Chair.
                                  ____



                                               Project Inform,

                             San Francisco, CA, February 28, 2007.
     Re Support for Early Treatment for HIV Act

     Hon. Gordon Smith,
     U.S. Senate,
     Washington, DC.

       Dear Senator Smith: On behalf of Project Inform, a national 
     HIV/AIDS health care and treatment advocacy organization 
     based in San Francisco, we are writing to express our strong 
     support for the Early Treatment for HIV Act (ETHA). We 
     commend you for your leadership in reintroducing this 
     important bipartisan legislation.
       ETHA would address a cruel irony in the current Medicaid 
     system. Currently most individuals with HIV must become 
     disabled by AIDS before they can receive access to Medicaid's 
     care and treatment programs that could have prevented them 
     from becoming so ill in the first place.
       ETHA would modernize this system by allowing states to 
     extend Medicaid coverage to low-income, pre-disabled people 
     living with HIV. It would assure early access to care and 
     treatment for thousands of people living with HIV across the 
     country. It would also help relieve the financial crisis 
     facing many discretionary HIV/AIDS programs, such as the AIDS 
     Drug Assistance Program (ADAP) and other services funded by 
     the Ryan White CARE Act.
       Access to healthcare and treatment is a high priority for 
     Project Inform as it ranks in the top concerns we hear from 
     people through our treatment hotline and community meetings. 
     We need long-term solutions like ETHA to ensure that people 
     have the care and treatment they need to remain healthy and 
     productive for as long as possible.
       We greatly appreciate your longtime efforts on behalf of 
     people living with HIV/AIDS. If there is anything we can do 
     to help you with your efforts to pass this legislation, 
     please do not hesitate to let us know.
           Sincerely,
     Anne Donnelly,
       Director, Health Care Advocacy.
     Ryan Clary,
       Associate Director, Health Care Advocacy.
                                 ______