Since January 1, 1994, all states have had the option to expand Medicaid coverage to persons with tuberculosis meeting the income criteria, similar to coverage for AIDS patient. This option permits states to expand Medicaid eligibility to the uninsured poor with TB, and subsequently receive Federal matching funds through the Medicaid program to reimburse the cost of treatment of TB patients. Physician services, laboratory services, and chest x-rays, as well as TB case-management including Directly Observed Therapy (DOT) and Directly Observed Preventive Therapy (DOPT), can be reimbursed through Medicaid. Directly Observed Therapy, where a health care worker or some other responsible person watches the patient take medication, ensures that patients complete the entire multiple-month course of TB treatment and has been shown improve treatment compliance and reduce TB transmission, as well as prevent the development of costly drug-resistant TB. DOT is recommended as the standard of care for all patients with TB by the Centers for Disease Control and Prevention as well as the World Health Organization.

Among the 12 states with the highest rates of TB in the United States, Georgia is the only state in which TB-related inpatient or outpatient costs for indigent patients are not reimbursed through Medicaid. Although DOT has been the standard of care in Georgia since 1995, existing resources cannot support the full expansion of DOT to all TB patients in Georgia. In 1996, only 81% of TB patients were receiving DOT through the county health departments. In 1995, of the 226 children under age 15 started on preventive therapy, fewer than 60% completed the full course of preventive therapy. DOPT can prevent the often devastating effects of TB disease in children.

Georgia ranks among the top 10 states for TB case rates and TB cases reported. In 1996, 790 cases of TB were reported statewide; 46% of TB cases were reported among males between the ages of 25-64. Annually approximately one out of ten TB cases are homeless; 36% are unemployed. As a result, hundreds of thousands of dollars in uncompensated care occurs statewide annually for patients with TB.

The expansion of Medicaid to cover indigent TB patients will not result in any net increase in TB costs to the state, because existing state funds are in place that can serve as the state “match” to draw down additional Federal dollars. Approximately $2,000,000 in matching federal funds could have been received annually by Georgia since 1994 had the state requested that TB be a Medicaid-covered service. In other states with similar TB case rates as Georgia ( New York, Florida, California), and Southern states such as Tennessee, TB treatment services are reimbursable under Medicaid; these states have seen dramatic decreases in the number of TB cases reported. With the number of TB patients being treated in the private sector increasing from 15% of cases in 1994 to 50% in 1996, the compliance with DOT and DOPT will decline further. As a result, patients treated solely in the private sector will fail to complete their TB treatment, increasing the likelihood of continued transmission of disease in the community as well as promoting the development of multi-drug resistant disease -- a complication with treatment costs many-fold higher than the health services related to drug-sensitive TB.

Expanding Medicaid coverage for the few hundred TB patients not currently covered would facilitate the early diagnosis and treatment of TB in Georgia, and will help ensure completion of treatment, all with no additional state expenditures. Expanding Medicaid to include TB treatment is rational and cost-effective policy choice for Georgia.