STATES STEPPING UP TO THE PLATE TO HELP THOSE WITH HIV/AIDS

Volume 28, Issue 490 April 30, 2007

Matthew Gever

States and territories are taking a more active role in providing HIV/AIDS medications to their neediest residents. In FY 2006, states contributed $304.9 million of their general revenues to AIDS Drug Assistance Programs (ADAPs), an increase of 21 percent over FY 2005. “We’ve really seen the states step up,” said Murray Penner of the National Association of State and Territorial AIDS Directors (NASTAD).

Nevertheless, some people who qualify for coverage continue to wait for it. In March 2007, four states reported waiting lists, totaling 571 people, the highest number of people on waiting lists in more than 12 months.

Those and other figures are contained in a recently released annual report on trends in ADAPs from NASTAD and the Henry J. Kaiser Family Foundation. ADAPs are state/federal discretionary “payers of last resort” that cover prescription drugs for low-income people with HIV/AIDS. About 142,000 individuals are currently enrolled in ADAPs, accounting for one-fourth of all people with the virus. Just over half of enrollees have incomes at or below the federal poverty level (FPL), and 61 percent are people of color.

States have great flexibility in administering the programs, including the right to set their own income requirements. In June 2006, those requirements ranged from 125 percent of the FPL in North Carolina to 500 percent of the FPL or more in Maryland, Massachusetts, New Jersey and Ohio. (North Carolina changed its formulary to 200 percent of FPL in November 2006, after the period of the report.)

The federal government provides the largest share of funds for ADAPs. However, as the report indicates, many states have increased their contributions. “One of the trends that we’ve tracked over time and really wanted to highlight this year…was the role played by states in terms of providing budget support to ADAPs,” said Jennifer Kates of the Kaiser Family Foundation at a press conference.

Another key finding marks a first for ADAPs: overall drug expenditures decreased in FY 2006 compared to the same period in FY 2005. The report attributes much of this to Medicare Part D, which picked up the drug costs of approximately 17,000 ADAP enrollees. This allowed ADAPs to shift some of their costs to Medicare, as well as enroll more clients and reduce waiting lists.

“I think we saved about $300,000 or more the first year with Medicare Part D, which allowed us to actually expand our eligibility,” said Beth Dillon, who is with the HIV section of the Colorado Department of Public Health and Environment. “Medicare Part D was our saving grace,” added Jay Adams of West Virginia’s ADAP.

However, given that this is a one-time transfer of some clients to Part D, there is concern that the savings may not last, especially once Part D eligibles reach the “doughnut hole”—the coverage gap that requires eligibles to pick up 100 percent of their drug costs until they have spent about $5,450 on medications. “What we don’t know is. . .what happens when clients reach the doughnut hole,” said Kates. “The uncertainty of the future with Medicare Part D is scary,” added Adams.

Another unknown is what will happen after July 1, 2007. Currently, states may set their own formularies and coverage varies widely, ranging from 19 drugs covered in Guam to nearly 500 in New York, as well as open formularies in three states. But after July 1, federal law will require that states cover at least one medication from each approved antiretroviral drug class. The new requirement will force one state to add at least one protease inhibitor to its list and six to add the only approved fusion inhibitor, currently one of the most expensive antiretrovirals available.

Regardless of what happens with the new federal rules, states will still have an active role in supporting ADAPs. “We had a waiting list of 300 people, and our state contributed almost $3.5 million in state funds, which allowed us to eliminate the waiting list,” said Dillon.

“Legislatures are continuing to look at their role in providing HIV/AIDS medication in states,” said Penner. “And we’re happy to see that state legislatures are stepping in and saying, ‘Yes, we need to be a part of this solution.’”