Houston, We Have a Problem: Texas ADAP Clients in Jeopardy

Jen Laws, Board Member, ADAP Advocacy Association, and HIV/transgender health advocate

**** ADVOCACY UPDATE BEGIN: February 23, 2021 ****

Texas HIV Medication Program - Spend Down Discontinuation Delayed for ADAP 

**** ADVOCACY UPDATE END ****

On October 16th, 2020, Texas Department of State Health Services (DSHS) let its HIV Medication Program Advisory Committee (THMP-MAC) know revenue cuts and the probability of a program budget shortfall and that they would provide more detailed information at the next quarterly meeting that was held January 29, 2021. A change local advocates and the state estimates will impact at least 2700 clients.

On January 5th, 2021 DSHS emailed THMP-MAC members of drastic changes to client financial eligibility that took effect on December 28th, 2020. 

Advocates summarize the previous spend down policy regarding eligibility as follows: “For decades, the state has taken into account the cost of medications when determining eligibility for the ADAP program. For instance, if an HIV positive individual was applying for the THMP program and was at 203% of the federal poverty limit, the cost of their medication would be deducted from their salary and they then could qualify for the program.” 

Artwork provided by The Feminist Farmwife

In making the move, DSHS cited a 2019 Health Resources and Services Administration (HRSA) audit finding the state "’making eligibility determination based on a factor that is not equal to all clients and is out of the client's control, such as the applicant's medication needs’ and therefore was not utilizing consistent eligibility standards”. However, during the January, 2021 THMP-MAC meeting, DSHS admitted the issue is far more dire and not necessarily the direct result of any HRSA finding.

In summary, the state of Texas, like many other states, is finding itself in a revenue shortfall as a direct result of COVID-19’s economic impacts. Facing higher than usual unemployment, thus more people being financially eligible for a wide range of state-funded assistance programs, and lower than usual revenue, the state has responded by cutting budgets across programs and adjusting programmatic parameters, including eligibility. The state’s ADAP is no exception…except the projected shortfall for THMP is $52 million dollars. DSHS officials cited a rising cost in certain single-pill regimens and a 28% higher than expected rise in client enrollment as the driving factors. Simply put, medications are more costly and more people need help getting them.

The state of Texas has already taken to adjusting THMP’s formulary and coverage; removing coverage of Hepatitis C medications, returning to in-person recertification requirements, requiring clients to pick up medications in person, and reducing ARV fills from 60 and 90 days to 30 days. Additionally, DSHS has made some internal transfers toward THMP, is requesting clarification on unspent CARES Act funding in terms of allowable expenses, using unspent dollars from previous years’ grant awards, and supplemental HRSA awards. If these moves fall through, the state may enact additional “cost-containment” measures as allowed under Texas Code; including reducing eligibility from 200% federal poverty level to 125% FPL or, most drastically, cease new client enrollment and return to an ADAP waitlist.

Most of the solutions suggested only work short-term. And there’s the rub…economists have projected some extremes in terms of the economic recovery, ranging anywhere between the end of 2021 or up to 5 years.

Long-term survivor, aaa+ member, and THMP-MAC vice-chair, Frank Rosas, speaking only in his personal capacity stated, “One of my biggest concerns about the ADAP eligibility changes in my State is that it will disproportionately affect marginalized people, especially people of color living with HIV and in rural areas. These proposed actions are not in alignment with national initiatives such as EHE(End HIV Epidemic) and Fast-Track Cities, which all of the major cities in Texas belong to.”

Indeed, in the age of “undetectable equals untransmittable”, with the knowledge lifetime costs of a mere 1% increase in new HIV diagnoses would outweigh any temporary savings, and with the national effort toward Ending the HIV Epidemic, these moves fail to meet their goal: there is no “savings” to be had by a state at the cost of client quality of life and access to medications for those most in need. Indeed, the most direct path toward state savings is the same path to Ending the Epidemic and meeting the humanitarian need of the moment: fully funding THMP.

State legislators would be better served advocating for the next federal COVID relief package to include specific earmarks for ADAPs and/or explicit allowable reimbursements from relief funds for ADAPs and appropriate allocations for the same. 

If COIVD has taught us anything, it should be that prioritizing access to care on the individual level serves the interests of public health, especially in the case of infectious diseases. We won’t beat this pandemic by sacrificing the survivors of the last.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.