Are ACA Exchange Plans Fair to People Living with HIV/AIDS?

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

On April 25th, Avalere Health published a comprehensive study on marketplace exchange plan formularies offered under the Affordable Care Act ("ACA"); it includes a cross-condition analysis addressing formulary coverage, cost sharing and access. The study, which was prepared for the Pharmaceutical Research and Manufacturers of America® (PhRMA), suggests that certain disease classes -- including HIV/AIDS -- experience bias under many of the plans.

Most of the law’s major provisions were phased in by January 2014, with other provisions phased in by 2020. The ACA has numerous implications generally on the United State’s health care delivery system, but more specifically on the access to healthcare afforded to people living with HIV/AIDS, as well Viral Hepatitis. What’s more, ongoing Medicaid expansion and the implementation of insurance exchanges will also impact nearly all health care providers, as well as their patients.

According to the Avalere study, formulary access for patients with HIV/AIDS has expanded though other barriers remain. The study included the following summary:[1]

Classes Included:

• Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs), Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTIs), Protease Inhibitors (PIs), and HIV-Other

Coverage for Key HIV Classes:

• In high-enrollment states, the average exchange plan covers at least 43 of 51 HIV/AIDS medications
• Single-source products in the therapeutic area appear on formulary at least 65% of the time in all states other than Utah, which has coverage 25% of the time

Utilization Management for HIV Classes:

• Exchange plans have continued to reduce their use of UM for HIV/AIDS medications. Now, exchange plans use UM less frequently than employer plans for these medicines

Tiering and Cost Sharing for Key HIV Classes:

• Preferred placement has increased for HIV/AIDS medications in 2016 exchange plans, though employer plans still use the specialty tier far less often than exchange plans do. And, a portion of plans continue to place all HIV drugs on the specialty tier
• Copays are common across HIV classes, with an average copayment of $66. When used, coinsurance is 35% on average

Photo Source: PhRMA

One of the more alarming findings demonstrates that many of the marketplace exchange plans require high cost sharing, which could be discriminatory. In 2016, about 1 in 10 health plans are placing all HIV medicines in certain classes on the specialty tier.[2]

This discriminatory practice took center stage in 2014, when four insurance carriers were sued by the National Health Law Program (NHeLP) and the AIDS Institute. The complaint charged “inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS" against Coventry Health Care Inc., Cigna Corp., Humana Inc. and Preferred Medical.[3]

Additional findings include:[4]

• In states with high exchange enrollment, average plans cover at least 43 of 51 drugs.
• Across classes, plans cover HIV/AIDS innovators at least 76% of the time, except Utah.
• In 2016, exchange plans use Prior Authorization for HIV meds less often than before, but still more than employer plans.
• Exchange plans’ placement of HIV/AIDS drugs on the preferred tier rises to more than half of the time in 2016.
• Copays are more common than coinsurance, though when used, coinsurance averages 35%.
• Exchanges have lower coverage for STRs than for other single-source NTRIs.
• Ten percent or fewer plans in 44 states and D.C. require coinsurance above 30% for all covered NNRTIs.
• New Jersey has the highest proportion of plans requiring coinsurance of 30% or more for all covered NRTIs.
• Alaska, Minnesota, and New Jersey have the highest percentage of plans requiring coinsurance above 30% for all protease inhibitors.
• Coinsurance above 30% for all covered therapies in HIV-other class is most common among plans in Alaska, New Jersey, Utah.

The ACA has largely benefited patients living with HIV/AIDS by expanding access to care, and lowering the ranks of the uninsured and under-insured. That said, despite some marked improvements in many exchange plans there remain ongoing barriers facing too many patients. Among them, higher deductibles, co-payments and co-insurance.

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[1] Avalere Health, "PlanScape® Review of Patient Access to Medicines in Exchange Plans, By Condition," p. 62, April 2016.

[2] Pharmaceutical Research and Manufacturers of America®, "New Avalere Study: Health plan formularies continue to suggest bias against individuals with certain health conditions," April 2016.

[3] Insurance Business Magazine, "Insurers accused of HIV discrimination in ACA marketplace," June 3, 2014.
[4] Avalere Health, "PlanScape® Review of Patient Access to Medicines in Exchange Plans, By Condition," p. 63-73, April 2016.

The Unaffordable No-Care Act: Why the ACA has outlived its usefulness

By: Sue Saltmarsh, Blogger

Despite the spin of the White House and most Democrats, when you look at the goals of the Patient Protection & Affordable Care Act (otherwise known as the Affordable Care Act, or ACA) compared to the realities people are facing every day, you will find that the ACA, or Obamacare as it’s called, has failed in all but a few of its original intentions. The reasons for this failure are many, but ignoring it on one side and squawking, “Repeal and replace!” on the other does nothing to address the truth. The ACA has failed because it wasn't enough; not brave enough to confront the greed of insurance companies, not visionary enough to change the way we approach healing in this country, and certainly not compassionate enough to actually help the people who needed it most. Bottom line – it “protects” profit, not people, and is only affordable for those who can already afford to pay.

Photo Source: The White House

There are five things the ACA has inarguably achieved:

• The elimination of the onerous “pre-existing condition” clause
• The end of lifetime caps on benefits
• No more charging women more than men
• Eliminating age-based discrimination
• Enabling children to be included on their parents’ policy until age 26

It has also achieved:

• The growth of insurance company profits
• The decrease of access to care even among those who are insured
• The increase of out-of-pocket costs
• The increase of the number of people who are underinsured

The “why” of it
There are probably more reasons why we’ve come to this crisis in healthcare than any of us could know, but to me, it comes down to two things. First, then-Senator Obama made the mistake of leaving the authorship of healthcare policy to academics, think-tankers, and so-called economists with no input from the People or a variety of medical providers. I know this because the policy was already written when I accepted the invitation to serve on his campaign’s Healthcare Policy Committee thinking I could contribute to the creation of a single-payer system. Instead, it soon became clear that no input was welcome – our job was to sell what had already been written to the voting public.

Secondly, whether you approve of him or not, I believe that Barack Obama went into the “negotiations” of writing the legislation in a room filled with Republicans and healthcare industry hit men out for blood, when he naïvely assumed that they were there in good faith, as he was. Instead, he had to settle for what he could get and he got no help from his own party or the voices of single-payer advocates, who weren’t even allowed in the room.

Couple that rocky start with the blatant obstructionism of racist Republicans and the ACA became a shell of what it was intended to be. The medical industrial complex got a pathway to more riches and the ability to justify mergers which are now creating monopolies the kind of which may bring Teddy Roosevelt back from the dead (not a bad idea for a new zombie-themed TV show!). And the People? We got royally screwed.

The true cost
Back in 2012, I went through the process of calculating the cost to me if my employer dropped our insurance and I was forced to go to the “marketplace” (doesn’t that sound quaintly friendly like you put on your gingham and sling your hand-woven basket over your arm and go to market?). As the insurance companies began to publish charts of what their plans would provide for what cost, there was nothing close to the $120 premium with a $500 deductible and, at that time, no co-insurance that I was paying with my employer-based Blue Cross Blue Shield insurance. OK, so what about a subsidy? My income was low enough to qualify for one, but as it turned out the $230-some I would get wouldn’t even put a dent in the $675 premium and $1500 deductible, higher co-pays, and co-insurance that left me holding the bag for 20% of everything. I resolved right then and there not to ever buy that kind of raw deal. And just let them try to pry that punitive fee for not having insurance out of my cold, dead hand.

Since that investigation, I’ve Iost my job, my incurable (except by a transplant) liver disease has progressed, and I’m now gratefully on Medicaid, which I guess I’m supposed to be ashamed of. But like single-payer, I’ve paid into the Medicare/Medicaid fund (1.75% of my wages) my entire working life and now that I need it, it’s there for me. I never have to pay a premium, never have to meet a deductible before insurance will pay a penny, never have to postpone an appointment or prescription refill because I don’t have the co-pay, and never have to spend hours on the phone fighting insurance company bureaucrats to get the bills paid. It has its downside – narrow networks and I’m limited to making $13,300 per year to keep it, but that gives me time to run my organization and help get Bernie elected so everyone can enjoy unfettered access to the same level of healthcare, no matter their economic reality.

The HIV/AIDS community and healthcare
Even before the ACA, the HIV/AIDS community was smart enough to demand a system whereby those in need could get the drugs they must have to survive – ADAP. But ADAP, like the ACA, is at the mercy of the appropriations process of Congress and as evidenced by Trump’s success, hatred and discrimination is trending on the Right and has always been behind the attempts to strip the ACA of anything that would cut into the profits of the insurance companies. If the Louie Gohmerts, Diane Blacks, and Ted Cruzes become the majority with Trump in the White House, imagine the potential harm to Ryan White, including ADAP.

Universal, single-payer healthcare would be publically funded, not victim to the appropriations process. And, life-saving as it’s been, ADAP will no longer be needed because every person living with HIV will get the care and drugs they need at no cost to them except the 2.2% (Bernie’s plan) or 3.75% (H.R. 676) most (making under $250,000) will pay out of their paycheck.

The dedicated activists who’ve watched over all things ADAP since its inception will be free to turn their commitment and skills toward the many other HIV-related issues that need strong, knowledgeable voices – transgender discrimination; prevention; training for both current providers in underserved areas and a new generation of HIV specialists; research involving women; job, housing, and employment discrimination; disability rights, etc., etc.

The ACA is a wolf in lamb’s clothing and unfortunately, the majority of the American public, including those living with HIV, don’t see past the costuming. It’s one of my deepest disappointments that HIV/AIDS community leaders have chosen to perpetuate the myth of the ACA as “the solution” or to parrot the defeatist cynicism of “It’s a nice idea, but it will never happen.” You are the people who showed us the impossible could happen, that unleashing the power of the united people could make big pharma and the FDA do what you wanted and move the government to not just acknowledge you, but legislate in your behalf. You proved that activism CAN work. So why would you not be in this fight?

As people who are getting sicker, even dying, people who have become bankrupt, even homeless, and those who have lost loved ones begin to coalesce around the injustice of the profit-driven system we have now, I hope the long-term survivors will guide a new generation of activists to ignite the spirit of ACT UP and join the rest of us in fueling the political revolution we’ll need to get this done. This country will never be lacking in wrongs to right and problems to solve, but it would be awesome to be able to check healthcare off the list.

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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.