“ADAPs remain at the forefront of adapting HIV care and treatment services to an evolving public health landscape. Supporting clients in public and private insurance coverage under the ACA is a tremendous opportunity to improve the overall health of clients and maximize Ryan White Program resources. These figures represent a huge success for ACA enrollment and implementation, demonstrating the ability of our ADAP and Ryan White Program system of care to transition vulnerable populations to new insurance coverage and keep them engaged in the health system in order to achieve healthy outcomes and ultimately prevent new infections,” summarized the National Alliance of State & Territorial AIDS Directors' (NASTAD) Executive Director, Murray Penner, upon releasing some important findings on July 24, 2015.[1]
Penner's statement was in response to the AIDS Drug Assistance Programs (ADAPs) assisting 68,000 clients living with HIV/AIDS being served by the program gain access to health insurance coverage under the Affordable Care Act (ACA). That figure included 48,000 patients enrolled in a Qualified Health Plan (QHP), funded by ADAP, and an additional 20,000 patients transitioned to Medicaid.[2]
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| Source: NASTAD [3] |
Clearly, ADAPs remain a vital safety net for thousands of people living with HIV/AIDS nationwide, and that fact is unlikely to change into the foreseeable future. Despite robust ADAP programs, and overall increased access to care under the ACA (as demonstrated by this latest news), systemic challenges remain for patients living with HIV/AIDS. Among them, waiting lists and other cost containment measures persist; not to mention new challenges such as marketplace discrimination and roadblocks to the ACA's full implementation.
With the uneven rollout of the ACA's Medicaid expansion, particularly in southern states controlled by Republican governors and/or Republican legislatures, many public health advocates have routinely expressed concern over the number of patients potentially falling through the cracks of the new law. This news has major implication for people living with HIV/AIDS, as well as people living with Viral Hepatitis.
ADAP, under Part B of the Ryan White CARE Act, is designed to be the “payer of last resort,” meaning that it should only be accessed if there are no other options available to HIV-infected clients. Since the Ryan White CARE Act’s inception in 1990, the definition of “last resort” has been continually updated to reflect current Wholesale Acquisition Costs (WACs) and Average Wholesale Prices (AWPs) of medications, primarily by adjusting the income threshold in relation the to the Federal Poverty Limit (FPL). This is expressed as a percentage of the FPL (e.g. 400% of FPL).
This creates an uneven landscape among the 59 ADAPs. While a client’s annual income may allow them to qualify for benefits in one state or territory, they may not be eligible for coverage in another state.
One significant challenge of the Ryan White CARE Act is that funds allocated for the program are prohibited by law from covering the costs of inpatient hospital care.[4] This means that, while prescription drugs and outpatient care (such as check ups and physician visits) are covered, any visits to hospitals, clinics, or physicians fall on the shoulders of the client. The lack of inpatient coverage means that Ryan White clients must have some form of supplemental coverage, as well, such as Medicaid, Medicare, or private insurance.
It has prompted many ADAPs (Colorado, Louisiana, and West Virginia, for example) to use their funds to help clients purchase and pay for primary health insurance coverage. Clients choose from a list of available health insurance providers, and Ryan White funds are used to pay the cost of premiums, deductibles, and/or co-payments for prescriptions and/or visits.
Whether or not these ADAPs will cover HCV drug therapies for clients whose primary insurance does not cover them varies from program to program, and is dependent upon available funds, at the time. Colorado, for example, may step in to provide coverage for HCV drug therapies if the primary insurer does not cover or rejects coverage for HCV drug therapies, but does so only with a Prior Authorization and if funds are available to do so.
It appears likely that more ADAP programs will move toward helping clients purchase and pay for primary insurance coverage over time, as it may serve as a cost-containment measure – it may be less expensive for ADAPs to pay for the cost of insurance and co-pays for clients, rather than paying directly for medications. While more programs may move over to this model that should not suggest that every state is considering doing so, at this time.
[1] National Alliance of State & Territorial AIDS Directors, "AIDS Drugs Assistance Program Supports 68,000 People Living with HIV in Gaining ACA Coverage," July 24, 2015.
[2] National Alliance of State & Territorial AIDS Directors, "AIDS Drugs Assistance Program Supports 68,000 People Living with HIV in Gaining ACA Coverage," July 24, 2015.
[3] National Alliance of State & Territorial AIDS Directors, "ADAP SUPPORTS EXPANDED ACCESS TO CARE," July 24, 2015.
[4] National HIV/AIDS Initiative at the O’Neill Institute for National and Global Health Law, Georgetown University Law Center, "HIV Policy Experts Offer Recommendations for Updating the Ryan White HIV/AIDS Program," June 26, 2015.
You might also consider the role of Ryan White Part A EMAs in supporting enrollment and support in ACA plans. In Florida, the 5 EMAs and 1 TGA worked over a year with the ADAP program to develop a coordinated system of enrollment and support. The EMAs collectively agreed to cover medicaal copays and deductibles for clients enrolled in ACA plans (ADAP is covering premium payments and medication copays/deductibles). Each EMA also worked with local ADAP staff to facilitate client enrollment. In a state where the Governor is ideologically opposed to ACA, the EMAs were instrumental in providing leadership to move the process forward, when the state ADAP program was politically constrained to act.
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