State AIDS Drug Assistance Programs (ADAPs): A National Status Report on Access
The ADAP Survey
In an effort to monitor the impact of the environment on ADAP programs and the individuals they serve, the Henry J. Kaiser Family Foundation funded a two-year project, the National ADAP Monitoring Project, with the National Alliance of State and Territorial AIDS Directors (NASTAD). NASTAD is an association of the individuals who direct AIDS prevention, care and treatment services at the state level. NASTAD’s partner in the project is the AIDS Treatment Data Network (ATDN), a highly respected HIV/AIDS treatment information center, which maintains both an on-line information library as well as detailed information on publicly- and privately-funded sources of reimbursement for HIV treatments.
NASTAD/ATDN developed a written survey for distribution to state AIDS directors and ADAP program managers in the fifty states, the District of Columbia and Puerto Rico. An eleven-member project advisory committee provided input on the survey design, implementation, and reporting. The survey contained thirty-six questions to assess program operations/trends in the following areas:
- Program Administration
- Drug Purchasing and Distribution Mechanisms
- Program Eligibility Requirements/Client Access
- Drug Formularies
- Program Budget (FY 1996 and FY 1997)
- Program Cost-containment Strategies
- Program Monthly Enrollment, Utilization, and Expenditures
- Barriers to the Provision of Service
The survey was fielded in mid-January 1997 and a total of 52 responses were received by mid-March. Follow-up telephone interviews were conducted to clarify submitted information and verify reported budget, expenditure, and utilization figures. States were asked to provide the total number of ADAP enrollees, the total number of utilizing ADAP clients and total monthly expenditures on pharmaceuticals for the months of July 1996 and December 1996. A “utilizing client” was defined as a client who received at least one prescription through the program during the given month. Actual and percentage increases/decreases in program client utilization and expenditures were calculated over the six month period.
NASTAD/ATDN took a snapshot of all state ADAPs in terms of clients served and program expenditures for the months of July 1996 and December 1996. In future surveys, we will be examining utilization trends by gathering information on the number of prescriptions filled and specific drug expenditures.
Recent Trends Among ADAPs: Clients Served and Expenditures
Based on the survey, the 52 ADAPs served 31,317 individuals during July 1996; that number increased by 23% to 38,500 individuals in December 1996. During the last six months of 1996, forty-two state ADAPs experienced increases in the number of utilizing clients (clients actually having prescriptions filled through the program). Some state ADAPs experienced a 50% percent or more increase in the number of clients served, including Arkansas (50%), Connecticut (64%), Kentucky (53%), Maryland (67%), and Utah (68%). During calendar year 1996, the national estimate of the number of clients served by ADAP was 80,000. (Annual estimates are limited due to monthly reporting and variable lengths of client tenure in the program.)
ADAPs also experienced significant increases in monthly expenditures during the last half of 1996. Program expenditures were reported to be $14.9 million in July 1996; expenditures grew 37% to $20.4 million. From June 1996 through December 1996, forty-four state ADAPs saw increased monthly program expenditures. Thirty-two ADAPs experienced increases of 20% or more and fourteen state programs saw expenditures rise by 50% or more in the last half of 1996. Several state ADAPs’ monthly expenditures rose by more than 100%, including Arkansas (104%), Connecticut (137%), Idaho (113%), Kentucky (103%), Maryland (116%), Mississippi (411%), North Dakota (101%), Texas (114%) and Utah (114%). The average per client cost among ADAPs nationally over the last six months of 1996 was approximately $506 per month or $6072 annualized.
These significant increases in program utilization and monthly expenditures occurred within the context of the discovery and approval of new treatments. They also occurred, at least initially, within the context of stable or incrementally increasing ADAP budgets. By mid-1996, it was apparent that the increasing demand for access to new therapies through ADAP would outstrip the financial resources of many of these programs.
ADAP Budgets: Federal and State Resources
The FY 1997 national ADAP budget totals $385 million and is composed of a variety of funding sources. These sources are:
- Ryan White CARE Act Title II grants to states — including dedicated federal ADAP support ($167 million) and discretionary Title II funding ( $59.9 million) which states may allocate to ADAP — totaling an estimated $226.9 million;
- State funding which 30 states draw from their general revenue and contribute to their ADAP — totaling an estimated $109 million;
- Ryan White CARE Act Title I funding which Eligible Metropolitan Areas (EMAs) in 13 states opt to contribute to state ADAPs totaling an estimated $22.7 million;
- Pharmaceutical manufacturer rebates for drug purchases/reimbursement in 21 states totaling an estimated $18.5 million;
- Private health insurance recovery of costs was reported by 3 states totaling $7.4 million;
- Other funding sources such as transfers from other discretionary sources and back-billing of Medicaid for the period for which an ADAP client is in the process of applying for state Medicaid eligibility was reported by 4 states — totaling $0.5 million.
In response to the shortages and the new demands for HIV/AIDS therapies, the national ADAP budget increased by $174 million (85% growth) between FY 1996 and FY 1997. The two most significant developments in the national ADAP budget picture in FY 1997 were the substantial increase in dedicated ADAP supplemental funding ($167 million total, representing a 221% growth over the previous year) and the doubling of state general revenue contributions nationally ($109 million total reported to NASTAD/ATDN, representing a 103% growth over FY 1996).
National ADAP Funding Source Changes Between 1996 and 1997 Funding Source FY 1996 FY 1997 % Change Title II Base (Federal): $58.2 million $59.9 million +3% Title II ADAP (Federal): $52.0 million $167 million +221% State Funds: $53.7 million $109 million +103% Title I (Federal): $25.9 million $22.7 million -12% Drug Rebates: $11.9 million $18.5 million +55% Insurance Recovery: $5.0 million $7.4 million +48% Other: $0.8 million $0.5 million -37% Total: $207.5 million $385 million +85%
Congress appropriated an additional $115 million for Title II ADAP dedicated (or “supplemental”) funding for FY 1997. Federal ADAP supplemental funding has become the single most significant source of funding for most of the nation’s ADAPs, representing 43% of the national ADAP budget in FY 1997. As a line item, it represents the majority of state ADAP budgets in 32 states; in three states (Iowa, Minnesota and Tennessee) ADAP supplemental funding represents 100% of the total ADAP budget.
Thirty states contributed state-specific funding to ADAPs in FY 1997 totaling $109 million and representing 29% of the national ADAP budget. California is expected to provide the most substantial level of funding from its state general revenue fund to ADAP — $40.2 million. California’s state ADAP contribution represents 46% of its total FY 1997 ADAP budget of $87 million.
While at least 30 states are expected to provide funding for ADAP in FY 1997, at least 22 jurisdictions will not be providing state funding or are uncertain about contributions for FY 1997. The substantial growth in overall state funding of ADAPs nationally in FY 1997 is largely occurring within states that have previously provided state ADAP support. Variability in prescription drug benefits in state Medicaid programs — in terms of monthly limits on the number of prescriptions — represents an additional issue which complicates the ADAP budget picture in some states where ADAPs fill in the gaps in Medicaid coverage.
Emergency Measures to Sustain Programs
Despite the growth in ADAP budgets, the increase in client demand detailed in the survey has led numerous states to take emergency measures to sustain coverage of existing clients or make newer antiretroviral agents available. Thirty-five states reported taking at least one emergency measure in the last year in response to the crisis in ADAP funding and increased demand for combination therapies. Among the major emergency actions reported by state ADAPs:
- Seventeen states transferred funds from other AIDS-specific services or other discretionary health department funds to ADAP;
- Sixteen states instituted waiting lists (formal or informal) for access to their ADAP and/or access to protease inhibitors;
- Thirteen states capped ADAP client enrollment;
- Fifteen states capped or restricted access to protease inhibitors for active clients;
- Eleven states reduced the number of drugs covered by ADAP formularies;
- Seven states capped or restricted access to other formulary drugs (besides protease inhibitors);
- Seven states revised ADAP financial eligibility criteria by lowering income levels; and
- Six states canceled planned drug formulary expansions.
ADAP Budget Shortfalls
NASTAD/ATDN asked states if they expect to encounter a shortfall in their ADAPs before the end of the Ryan White Title II FY 1997 budget period (April 1, 1997 — March 31, 1998). Despite the emergency measures undertaken to prevent funding shortages, eleven states responded that they predict a shortfall in FY 1997. The states reporting anticipated shortages are: Alabama, Arizona, Arkansas, Colorado, Montana, New Mexico, Puerto Rico, Texas, Vermont, Washington State and West Virginia. Anticipated shortages reported by the eleven states total over $8.5 million in FY 1997.
It is important to note that some respondents are reluctant to report anticipated shortfalls in ADAP budgets since some state laws/regulations prohibit overspending of federal or state resources. In addition, state administrations may not wish to publicize program shortages before making formal appeals to state legislatures for increased appropriations. Instead, some states will scale back ADAP services — by limiting enrollment or drug coverage — rather than report budget shortfalls. Several states, including Florida, Mississippi and South Dakota, have recently been forced to severely limit access to their ADAPs or substantially cut back on client services in order to sustain limited program operations for the coming year.
Additionally, every state has recently received significant infusions of Ryan White Title II base and/or supplemental funding for FY 1997 programs. It may be too early to predict program budget shortfalls in FY 1997. Several factors may hasten additional states to report shortages before the end of 1997. These include: 1) failure to obtain proposed state and other funding increases for ADAPs; 2) approval of additional high-cost HIV/AIDS therapies before the close of the fiscal year; and 3) the impact of the federal HIV clinical practice guidelines which may drive a greater demand for expanded treatments.
How Accessible and Comprehensive Are ADAP Services?
This section examines the eligibility criteria states establish for client entry into ADAPs based on financial and medical need, as well as the extent of pharmaceutical drug coverage across the states. In addition, the variety of ADAP drug purchasing and distribution structures that exist are described — structures that often determine the accessibility and fiscal status of programs. Finally, barriers to client access — typically resource shortages — are illustrated, including a gross estimate of potential ADAP demand.
Program Eligibility Criteria
Eligibility criteria for access to ADAPs are developed by each state and, therefore, vary from program to program. Eligibility criteria are established at the local level within the guidelines established by the Ryan White CARE Act. Eligibility criteria generally fall into two broad categories: financial eligibility and medical eligibility. Some ADAPs, however, have developed additional eligibility requirements for access to specific formulary drugs. All of these factors contribute to a picture of uneven access to ADAPs across the nation.
The majority of ADAPs use federal poverty guidelines when assessing financial eligibility. The exceptions are Maryland, Massachusetts, New Jersey, New York, Pennsylvania and Puerto Rico. These programs have specific income criteria that do not change annually unlike the federal poverty levels. Montana requests that an applicant provides evidence that the cost of the covered medications will create a severe financial burden on his/her household.
All other state ADAPs specify a percentage of the current federal poverty levels for determining financial eligibility. These percentages can be absolute, or eligibility can be tiered to allow sliding-scale co-payments based on the applicant’s income. Some programs will take into account out-of-pocket medication expenses when determining income, a practice known as “spenddown.”
The ADAPs with the most restrictive income criteria are Arkansas and Utah, which specify an income below 100% of the federal poverty level for full admission to their programs. This would currently mean an annual income of $7,890 or less for one person. However, Arkansas takes into account medical expenses when assessing financial eligibility for their program. Utah operates a sliding scale co-payment system which relates to how much over 100% of the federal poverty level (FPL) the applicant earns.
Other programs with a low financial threshold for admission are Georgia and North Carolina, both requiring an income at or below 125% of the federal poverty level (FPL). In both states, this requirement is absolute and there is no provision for sliding scale co-payments or the consideration of out-of-pocket medical expenses. This is in contrast to the next most restrictive states, North Dakota and Oklahoma, which both require income to be at or below 150% of FPL. North Dakota allows sliding scale co-payments up to 200% of FPL. Oklahoma allows out-of-pocket medication costs to be taken into account when determining income. Florida reports that the income requirement for their program is 200% of FPL, but notes that applicants with incomes between 100% and 200% of FPL will be assessed for a sliding scale co-payment.
At the opposite end of the spectrum, ADAP programs in California, Hawaii, Idaho and Rhode Island require an income at or below 400% of FPL. California allows people earning more than this to make a sliding scale co-payment based on their annual state income tax liability and family size, up to a ceiling of $50,000 per year. It has been observed, however, that even in states that have relatively more generous eligibility criteria, the majority of ADAP clients are earning less than 200% of FPL.
Medical Eligibility Criteria
The basic medical criteria for enrollment into any ADAP is a diagnosis of HIV infection. Alabama, Florida, Georgia, Idaho, Indiana, Mississippi, Nevada and South Carolina also require that an applicant have a CD4 cell count of less than 500, although this can be waived for pregnant women and neonates needing AZT (for the reduction of perinatal HIV transmission). South Carolina also notes that the CD4 requirement can be waived but does not specify under which circumstances.
Kentucky currently requires a CD4 count of under 550 or a history of confirmed pneumocystis carinii pneumonia for enrollment in the program, although again this can be waived for pregnant women and neonates. Iowa requests that applicants have a recent CD4 count result available, but there is no specific CD4 requirement for entry into the program.
A new prognostic laboratory test known as the HIV viral load test is now being used to determine medical eligibility for some ADAPs. The viral load test measures the amount of viral genetic material, known as HIV RNA, in a blood sample. Maine states that a CD4 count of under 400 or a viral load test result of over 20,000 copies/ml is required for admission into the program. Mississippi requires a CD4 count under 500 or a viral load test result of over 30,000 copies/ml. Puerto Rico specifies that the CD4 count be under 500 or the viral load be over 10,000/ml. Louisiana and Virginia require that new applicants have a recent viral load test result available but there is no specific viral load requirement for program entry.
ADAP Drug Formularies
States determine both the number and type of drugs that are available on their state ADAP formulary. Hence, there is a significant variation in the size and composition of ADAP formularies from state to state. ADAP formulary drugs fall into two main categories: antiretrovirals, which target HIV directly, and drugs to treat and/or prevent opportunistic infections.
New York’s ADAP offers the most comprehensive formulary, totaling 214 drugs, hepatitis vaccines and a variety of nutritional supplements and vitamins. This is commensurate with having the largest budget of any ADAP next to California. At the other end of the spectrum is the Louisiana ADAP which covers three drugs — all of which are protease inhibitors. An additional HIV drug formulary, however, is available to low-income state residents through several ambulatory care sites throughout the state, provided under the auspices of the Louisiana Health Care Authority (LHCA). There are plans to combine the state-funded LHCA program with the federally-funded ADAP in order to provide a more uniform HIV pharmaceutical assistance program for people living with HIV in Louisiana.
Although HIV incidence within a state, number of clients served and total budget might be expected to impact upon the comprehensiveness of an ADAP drug formulary, this is not always the case. North Dakota currently offers one of the largest formularies in the nation, although it has the smallest budget of any ADAP. North Dakota also served just fourteen clients during January 1997, making it the second smallest program next to Alaska in terms of clients served.
At the time of our survey, three protease inhibitors were commercially available: saquinavir (Invirase), ritonavir (Norvir) and indinavir (Crixivan). Saquinavir was approved in December 1995, with ritonavir and indinavir approved by the Food & Drug Administration in March of 1996. On March 14, 1997, following the completion deadline for the ADAP survey, a fourth protease inhibitor, nelfinavir (Viracept), received FDA approval.
Four state ADAPs report that they do not cover any protease inhibitors: Arkansas, Nevada, Oregon, and South Dakota. Arkansas notes that formulary expansion is planned, but mentions no specific date. Nevada is considering adding new drugs if state funding can be secured. Oregon’s ADAP reports that formulary expansion may be possible if the ADAP can successfully move more ADAP clients on to more comprehensive health insurance coverage. South Dakota estimates that the program would require an additional $150,000 a year in funding to provide protease inhibitors to eligible clients. Two state ADAPs (Mississippi and Idaho) cover only one of the four approved protease inhibitors as of July 1997. Another thirty-two state ADAPs cover all four protease inhibitors; two of those states (New York and North Carolina) also cover all available antiretroviral drugs.
All ADAP programs, with the exception of Louisiana, offer all five approved nucleoside analog antiretroviral drugs: zidovudine (AZT, Retrovir), didanosine (ddI, Videx), zalcitabine (ddC, HIVID), stavudine (d4T, Zerit) and lamivudine (3TC, Epivir). Some programs, however, may restrict access to these drugs based on specific medical criteria.
Opportunistic Infection Medications
Drugs for the treatment and prevention of opportunistic infections (OIs) have significantly improved the length and quality of the lives of people with AIDS. The preventive treatments available for pneumocystis carinii pneumonia (PCP), for example, have extended survival after an AIDS diagnosis.
Most ADAPs offer some of the available OI drugs, but it is in this category of drug coverage that the widest variability is found across the states. In 1995, the Infectious Disease Society of America (IDSA) in conjunction with the U.S. Public Health Service (PHS) issued Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. The drugs referenced in these guidelines as “strongly recommended” for the prevention of OIs include: TMP/SMX, dapsone, pentamidine, pyrimethamine, leucovorin, sulfadiazine, clindamycin, fluconazole, itraconazole, isoniazid, foscarnet, ganciclovir and acyclovir. Currently, five ADAPs (10%) report that they have these drugs available on their formularies: Illinois, New York, North Dakota, Pennsylvania and Wyoming.
Currently, there are three drugs approved for the prevention of another common OI, Mycobacterium avium complex (MAC): rifabutin, clarithromycin and azithromycin. All of these treatments have demonstrated a clear ability to prevent MAC and two have also been associated with a distinct survival benefit. Thirty ADAPs cover all three of these drugs. Five ADAPs offer two of these drugs while six ADAPs cover only one.
A revised, updated ISDA/PHS document was released on June 27, 1997, containing fourteen drugs which are strongly recommended for the prevention of OIs. Two state ADAPs (New York and Illinois) currently cover all fourteen drugs on their formularies. Nine additional state ADAPs cover 80% or more of the highly recommended drugs. Five state ADAPs cover none of the highly recommended OI prophylactic drugs.
Drug Purchasing And Distribution Systems
The drug purchasing and distribution systems of state ADAPs have been under increasing scrutiny from Congress, the Administration and HIV/AIDS advocacy organizations over the past several months. The heightened interest is focused on state ADAPs’ ability to take advantage of available drug discounting mechanisms. In order to serve increasing numbers of potential clients while covering new and promising therapies (protease inhibitors in particular), states must carefully evaluate their drug purchasing and distribution systems in order to meet these challenges with finite resources.
The methods that state ADAPs use to purchase formulary drugs may be classified generally as either:
- direct purchasing with central drug purchasing (by the ADAP, or through a state pharmacy, purchasing agent or public agency/hospital); or
- indirect purchasing via contracts with a pharmacy network, mail order pharmacy, or pharmacy benefits management company (PBM) that purchase drugs and are subsequently reimbursed by the ADAP.
State ADAPs that purchase drugs directly usually have a centralized mechanism for dispensing drugs to clients. For example, drugs purchased through a central state pharmacy may be distributed through a network of local public health clinics/hospitals, sent directly to clients, or distributed through clients’ physicians. These “direct purchase” ADAPs participate in federal discount drug pricing programs such as Section 602 of the Veteran’s Health Care Act.1 Another mechanism for state drug distribution is to allow ADAP eligible clients to receive drugs through their neighborhood drug store or local pharmacy networks. These “indirect purchase” ADAPs may in turn obtain rebates from pharmaceutical manufacturers to achieve cost containment and recovery. All states currently report using one or more cost containment measures — which include use of purchasing discounts, rebates or other cost savings mechanisms — or are making progress toward achieving the lowest possible costs for formulary medications.
Barriers to Serving Potential Clients
ADAPs, by statute, are intended to provide pharmaceutical assistance to low-income, uninsured and underinsured individuals. This may include lower-income individuals who: have no private insurance coverage, have inadequate prescription coverage through their private insurance or do not meet financial, disability or other criteria for Medicaid. There has been little effort in the past to identify the barriers that ADAP programs face in attempting to serve intended client populations.
States were asked to list the barriers, in order of severity, that impact on their ability to serve intended client populations. Twenty-four states indicated that inadequate funding is the primary barrier. Six states cited various administrative issues as another barrier to adequate service delivery and six indicated that lack of adequate service coordination with other providers — especially in rural areas — was a barrier to the adequate provision of service. Four states identified lack of coordination with the state Medicaid program as a barrier.
There are currently no national projections of the potential universe of ADAP clients who could be served in the absence of the identified barriers. According to the Centers for Disease Control and Prevention (CDC), twenty-eight states collect data on HIV infection rates in addition to AIDS cases, and two of these states only collect information on new HIV infections for infants. The lack of sufficient data on reported HIV infection in all states, in addition to a lack of a current and complete assessment of the numbers of HIV-infected individuals and individuals with AIDS who have adequate private insurance and/or Medicaid, makes a precise estimate of the potential ADAP client population problematic.
A gross estimate of potential demand for ADAPs nationally, however, can be extrapolated from existing published data sources. CDC estimates that there were 650,000-900,000 individuals with HIV in the U.S. in 1992. Based on a 1994 published study on AIDS cost and services utilization (ACSUS) from the federal Agency for Health Care Policy Research (AHCPR), approximately 21.4% of persons with symptomatic HIV disease receiving care in the U.S. have no health insurance coverage.2 This population would represent those for whom triple therapy would be uniformly recommended and who would generally be eligible for an ADAP program (although no income information is available). This number is likely an underestimate of those who are uninsured who would be eligible for HIV therapy and does not include any estimates of the number of underinsured. This number is likely an overestimate of those who are aware of their HIV status and in care. Based on these estimates, between 140,000 to 280,000 individuals could potentially be eligible for the ADAP program. This number represents a two- to four-fold increase from the current estimate of 80,000 clients being served nationally on an annual basis.
Future Opportunities and Challenges
The information obtained from this survey paints a complex and often paradoxical picture of state ADAP programs. Although federal and some state contributions to these programs have increased dramatically over the past two years, evidence from many states indicates that resources remain insufficient to adequately serve people living with HIV/AIDS. As promising new treatments have become available, many ADAPs have sought to include these drugs on their formularies, yet many ADAPs are also faced with making difficult decisions regarding who may have access to these treatments due to severe budget constraints. Some state ADAP formularies offer a large menu of HIV and OI drugs, while others offer only a few.
For many individuals, ADAPs represent the primary — and sometimes the sole — source of access to medications which may significantly improve the quality and length of their lives. The high cost of combination antiretroviral therapy may be out of reach for individuals who continue to work and have no or inadequate insurance coverage, and who are not ill or poor enough to qualify for Medicaid. These individuals may also be excluded from eligibility for ADAPs based on financial or medical eligibility restrictions.
There is a growing body of literature which suggests that the use of combination therapy including protease inhibitors is a potentially cost-effective means of providing care for people living with HIV/AIDS. In fact, when compared with the cost-effectiveness of other commonly-used medical interventions, combination antiretroviral therapy is shown to be an economically sound investment in terms of cost per year of life saved.3 Making appropriate treatment available to people living with HIV/AIDS is not only medically and ethically supported, it may also make sound economic sense as well.
Given the growing demand upon ADAP programs and the resulting cost implications — coupled with the tightening federal and state budget scenarios over the next several years — it appears likely that ADAPs, as they currently exist, are not prepared to fill the ever-increasing coverage gap for people living with HIV. From its inception, ADAP was designed to fill in a service gap and that gap is widening. Several proposals have recently been forwarded to help improve access to treatments for people living with HIV/AIDS. One such proposal would allow states to extend limited Medicaid benefits, including coverage for antiretroviral therapy, to individuals with HIV who do not meet disability criteria for access to Medicaid.
Among the major opportunities and challenges facing ADAPs in the future:
- Significant additional federal and state resources will be needed to enable ADAPs to maintain pace with demand to deliver the standard of care for HIV therapy. Although 30 states supplement federal support for ADAPs, 22 states do not contribute to this program. Diversity of federal, state and other resources is a likely predictor of fiscal stability for ADAPs in the future.
- Federal guidelines for HIV antiretroviral therapy will likely result in increased pressure on ADAPs to expand drug coverage and keep pace with expected client growth. Although the policy and budget implications of implementing these new guidelines have not been established, they will have a critical impact on state ADAPs.
- There is clearly room for improvement for many ADAPs to squeeze additional cost containment out of existing purchasing mechanisms, such as: federal drug discount pricing, pharmaceutical manufacturer rebates and better drug distribution systems. The challenge will be to effectively implement additional initiatives to enhance the purchasing power of ADAPs, including pharmaceutical rebates and a prime vendor system (under development at the federal level).
- Enhancing the ADAP interface with state Medicaid programs represents an additional opportunity and challenge. There is increased pressure to assure that ADAP represents the payer of last resort and that Medicaid programs are not inappropriately limiting prescription drug coverage. Limitations on Medicaid drug coverage — where states place a monthly cap on per client prescriptions — applies increased pressure on financially strained ADAPs to pick up the burden of paying drugs for underinsured Medicaid-eligible populations.
- Many states are exploring other innovative strategies for broadening access to HIV/AIDS therapies such as health insurance continuity programs and purchasing insurance through state risk pools. Paying health insurance premiums that provide access to care and medications can, in many cases, be more cost effective for states than covering expenses directly under ADAP or Medicaid. For states such as Minnesota and Oregon, insurance purchasing and continuity programs represent the bulk of their efforts to provide access to medications for low-income people living with HIV/AIDS. These and other initiatives may narrow the gap that state ADAPs would need to fill to provide uninterrupted medication coverage for eligible individuals with HIV/AIDS.
1 Section 602 of the Veteran’s Health Care Act stipulates that state ADAPs, along with certain other federally-funded programs, can purchase covered drugs at discounted prices. The discount rate available to ADAPs under the 602 program is equal to the rebate amount that manufacturers are mandated to pay to state Medicaid programs.
2 Schur, C.L., and Berk, M.L.: Health Insurance Coverage of Persons With HIV-Related Illness: Data From the ACSUS Screener. AIDS Cost and Services Utilization Survey (ACSUS) Report, No. 2. AHCPR Pub. No. 94-0009. Rockville, MD: Agency for Health Care Policy and Research, 1994.
3 Moore, R.D. and Bartlett, J.G.: Combination Antiretroviral Therapy in HIV Infection: An Economic Perspective. PharmacoEconomics, 1996, Aug: 10(2): 109-113.