Painting Roses in the Desert: Despite Medicaid Expansion, Gaps Remain in Arizona

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

It shouldn’t be a surprise to anyone that many AIDS Drug Assistance Program advocates are in favor of Medicaid expansion. Indeed, as noted in last week's blog, those same advocates view Medicaid expansion as an opportunity to strengthen health care access for the most vulnerable people living with HIV, meet needs unaddressed by a state’s ADAP coverage, and help ADAPs remain financially stable. For ambitious advocates (I’m talking about myself), when sufficient support exists to support those at or below the expanded Medicaid eligibility threshold of 138% of the federal poverty level, state ADAPs could consider expanding income eligibility above 400% of the federal poverty level. Indeed, Louisiana is one such state.

However, like all health care policy, the details matter.

In Arizona, the state’s Medicaid formulary is restrictive and slow to adapt to the needs of qualified people living with HIV, shifting financial pressure to the state’s ADAP and requiring the most impoverished clients to manage interacting programs in order to achieve coverage of certain medications. As the payer of last resort, when ADAP clients have other coverage (ie. Medicaid), conflicting payment processes are most often felt at the point of medication delivery or when a client gets told, inadvertently, their medication is not paid for. The process of correcting this mistake can take a matter of days or weeks, depending on a pharmacy’s experience with co-occurring payers. 

In that time, patients can fall out of care, drastically reducing their likelihood of achieving an undetectable viral load.

Artwork provided by The Feminist Farmwife

For ADAP formulary advisory committees, for states that have them, the process of adding and adjusting formularies is sometimes relatively expedient. Relatively, in part, because those medical experts and community experts understand the need and nature for ensuring access to an expansive list of antiretroviral medications and modern advancements. Arizona’s Medicaid formulary lacks several single tablet regimens and, in the opinion of Glen Spencer, executive director of Aunt Rita’s Foundation, favor outdated “cocktails” (or multi-tablet regimens), complicating daily care for people living with HIV and accessing Medicaid, often subjecting clients to greater experiences of toxicity, and ultimately interjects an unnecessary interruption in both patient choice and provider care.

In aiming to impress the need of Arizona’s Medicaid formulary to expand in both supporting the sustainability of the state’s ADAP and meeting national initiatives Mr. Spencer stated, “It is critically important that Arizona’s Medicaid program include all single-tablet regimens on its formulary to offer patients the right medication for them, and to provide medical providers with the flexibility they need to prescribe the right medication for each patient.”

To this end, Aunt Rita’s advocacy efforts are also expanding with proposed legislation addressing the failure of Arizona’s Health Care Cost Containment System (AHCCCS) to take up the issue. According to Mr. Spencer, the bill is not likely to make it out of committee this year and lacks any great deal of interest for legislators battling over other budgetary and policy concerns and does not currently have a companion bill in the state Senate. On the other hand, the bill is sponsored in the Arizona House by a bipartisan coalition of 9 legislators.

“In order to end the HIV epidemic, both the patient and provider community will need all therapies available to them to support persons living with HIV, save lives, and get patients to an undetectable viral load.” Mr. Spencer added, “This policy not only promotes patients’ ability to lead a robust life, but also prevents new infections given the science behind U=U.”

Arizona’s situation offers a critical reminder that even with the value of Medicaid expansion, in order to achieve the greatest reach of ADAPs and tackle the absolutely critical inclusion of treatment and retention in prevention efforts, the details matter and advocates will need to adapt old fights to new environments.

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. 

Georgia on My Mind: ADAP Short-Term Success, Long-Term Issues Remain

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

In September 2020, the National Alliance of State and Territorial AIDS Directors (NASTAD) released details from their request for information from their members and partners regarding COVID-19 impacts on HIV prevention programs, hepatitis programs, and Ryan White HIV/AIDS Programs (RWHAP). While the findings were promising in terms of federal flexibilities, the details of impacts among Ryan White HIV/AIDS programs, in particular State AIDS Drug Assistance Programs (ADAPs), were quite concerning. Among reported impacts, NASTAD stated “A majority of respondents also reported anticipating increased burden to the RWHAP as people lose their health insurance and income due to the economic downturn.”

Georgia ADAP advocates took note and began investigating the status of the state’s ADAP. However, despite requests, the state provided no information until a November meeting. At that time, Georgia’s Department of Public Health (DPH) shared they anticipated an $11 million funding gap for the program. Similar to the situation in Texas, DPH cited a HRSA rule on state matching funds and an “increase in enrollment” in order to justify introducing cost containment measures (e.g., reducing formulary inclusion, lowering income limits for eligibility, waitlists). However, under closer scrutiny, advocates ran into a familiar problem: the state had not increased funding for ADAP in over a decade, despite the program having grown by about 130% since the last increase. So why now the issue?

Georgia, like every other state, is grappling with the economic impacts of COVID-19 on tax revenues and appropriately planning their budgets.

Artwork provided by The Feminist Farmwife

Highlighting Georgia’s new HIV diagnosis rates, efforts aimed at Ending the HIV Epidemic, and the necessity to provide HIV medications as both treatment and a prevention activity, Equality Georgia lead the effort of asking the state legislature to finally increase funding for the state’s ADAP. Legislators in the House were widely amenable to the necessary increases, but Senators were skeptical and required a bit more effort. State Senators visited service sites and spoke with providers and PLWH about the funding and program concerns. Senators found what advocates and PLWH already know: federally funded providers already maximize their federal dollars – the issue in Georgia isn’t the use of federal funds at the provider level, it is lack of regular program funding increases on both the state and federal level to match the needs of the moment. Indeed, no one is paying the same for medications or care as they did a decade ago.

Advocates also organized four days of community-based “lobbying” including phone calls and emails to members of the Senate appropriations committee before finding success. A key, they said, was being selective: focusing on messaging regarding longer term costs of failing to act now and only targeting Senators on the appropriations committee. 

Jeff Graham, Executive Director of Equality Georgia said, “It is the value of keeping people healthy and in many instances, that means that people are able to retain their jobs.

“People are able to continue to be productive members of society by having this support, and frankly, the cost of medications itself is far lower than the cost of providing the intensive medical care if people don’t have access to medications early on and get sick and get hospitalized,” he added.

Ultimately, advocates argue, this wouldn’t have been an issue if the state were maximizing its use of 340B rebate dollars and had expanded Medicaid – a talking point expansion advocates across the state would benefit from latching onto.

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. 

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.