Critics denounce Bush’s proposed budget for HIV prevention and care
For second year, Bush proposes flat funding
By late winter, about 700 HIV/AIDS patients were placed on waiting lists to receive antiretroviral drugs in the Southeast, and the problem is expected to grow worse through the next year as HIV funding falls short of need. President George W. Bush’s proposed FY 2003 budget provides no additional funding for the Ryan White Care Act, HIV prevention, or global HIV/AIDS initiatives. National Institutes of Health (NIH) research funding received an additional $300 million in the proposal. (See FY 2003 HIV/AIDS portfolio from AIDS Action, Washington, DC, below.)
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If the nation’s goal is to treat everyone with HIV who needs treatment and to cut new HIV infections by half within the next three years, then this budget clearly won’t get the job done, critics say. In fact, the proposed budget could be devastating for many HIV-infected people who do not qualify for Medicaid and have no private insurance to cover their antiretroviral medications. Typically, they are helped by the AIDS Drug Assistance Program (ADAP), which now needs $162 million to cover shortfalls for FY 2002 and FY 2003, says Bill Arnold, chairman of the ADAP Working Group in Washington, DC. "For the last two years, ADAPs have picked up close to 600 new clients each month on average," Arnold says. "Now there are official waiting lists for enrollment in six or seven states, and some states have unofficial waiting lists."
Cash-strapped states are struggling with their own dire financial problems and cannot be expected to pick up the federal government’s slack when it comes to ADAP funding, says Laura Hanen, director of government relations for The National Alliance of State and Territorial AIDS Directors in Washington, DC. "We are clearly concerned because for the past couple of years, the money that ADAPs have received from the federal government has been less than the need that’s out there," Hanen says.
ADAPs provide chief safety net in Southeast
States that appear to be having the most difficulty with ADAP funding are in the Southeast and include Georgia, Alabama, and North Carolina, Hanen says. New York, California, and many states in the Northeast have liberal Medicaid programs, which helps ease the burden on ADAP. But many southern states place so many restrictions on who is eligible for antiretrovirals through Medicaid that ADAPs are the chief safety net, Arnold explains.
Prevention funding also is a major disappointment because it flies counter to the Centers for Disease Control and Prevention’s focus last summer on improving HIV prevention efforts, says Tanya Ehrmann, director of public policy for AIDS Action in Washington, DC. "The president’s proposed budget certainly is a disappointment, and it gives us an uphill battle to try and obtain some increases in programs that desperately need more money," Ehrmann says.
More people are learning their HIV status as a result of a national push to increase HIV testing, but now these newly infected people will walk into a care system that’s grossly underfunded, Ehrmann says. Flat funding makes no sense when several trends are taken into account, Ehrmann explains. "We have medical inflation of 11%, increasing numbers of people identified as HIV-positive, and since 1996 people with HIV are living longer lives," she says. "So there are all those factors that lead to additional needs of the HIV care system."
AIDS activists also are concerned about HIV funding at the state level, particularly as states react to reduced tax revenues and balanced budget statutes by cutting many programs. In Florida, activists were able to convince the state legislature to abandon proposed budget cuts to ADAP and the Patient AIDS Care waiver (PAC). "PAC’s $23 million program was scheduled to be completely eliminated, and through budget meetings we were able to prevent that," says Gene Copello, PhD, MSW, executive director of Florida AIDS Action in Tampa. PAC is a Medicaid program that provides care for the state’s most ill AIDS patients. It was designed to reduce nursing home and hospital admissions through increased home health care, Copello says.
The legislature and state ended up cutting some of the program’s services, which will have an impact on people with AIDS, but the program will continue, Copello says. "We also have another program called the AIDS Insurance Continuation Program [AICP]," Copello says. The AICP provides money to continue insurance for people who used to receive private insurance coverage but who lost their coverage when they lost their jobs. "We requested $750,000 new dollars for AICP, and fortunately Gov. Jeb Bush does have that in his budget," Copello says. "So we’re working with the legislature to make sure that happens."
However, each year is a new and difficult battle to maintain and improve HIV funding, and now Florida AIDS groups are asking the legislature to put an additional $5 million in ADAP funding. The state will need another $5 million from the federal government, or else a drug waiting list will be inevitable, Copello says.
OIs cost more than antiretrovirals
The cost of antiretroviral drugs paid through ADAP continues to rise. ADAP now pays an average of $893 per month per covered person, Arnold says. "ADAPs probably have the most advantageous pricing available, or very close to it," Arnold says. "In addition to various mandatory discounts, almost all suppliers have a voluntary rebate that goes back to ADAPs, and it can be recirculated for more medications. "Some combinations are more expensive than others, and some people are on salvage therapy, where they have four or five expensive drugs," Arnold says.
While the antiretroviral cost continues to be the biggest expense of the program, there is considerable cost to society when HIV patients develop opportunistic infections. For example, the average treatment cost of cytomegalovirus retinitis is $65,734, which is more than six times the cost of ADAP’s average antiretroviral therapy. (See opportunistic infection cost chart, below.)
| Average Annual Treatment Costs for Opportunistic Infections | |
| Cytomegalovirus retinitis | $65,734 |
| Non-Hodgkin’s lymphoma | $22,181 |
| Tuberculosis | $17,938 |
| Leukoencephalitis | $17,578 |
| Toxoplasmosis | $16,116 |
| Cryptococcal meningitis | $16,557 |
| Mycobacterium avium complex | $11,052 |
| Cryptosporidiosis | $10,721 |
| Pneumocystis carinii pneumonia | $8,842 |
| Kaposi’s sarcoma | $3,794 |
| Candida esophagitis | $3,246 |
| Genital herpes episode | $2,560 |
| Source: ADAP Working Group, 1775 T St. NW, Washington, DC 20009. Telephone: (202) 588-1775. | |
Treating HIV patients with antiretrovirals is extremely cost-effective for society, although people rarely think anything about the money that’s spent on opportunistic infections when AIDS patients become sick, Arnold says. In the last few years, state ADAPs have found a variety of ways to become more cost-effective. For example, some states have insurance continuation programs in which ADAP money is used to pay for COBRA insurance premiums that keep some HIV patients covered through private insurers.
In Indiana, there is a high-risk insurance pool that receives state funding partially from a tax on every health insurance premium. This pool will cover all high-cost residents who are in need of health care by providing them insurance that will pay for their medical care and drugs, Arnold says. ADAPs will pay the insurance premium for HIV-positive people who are in the insurance pool. "We spend about $15 million a year just on insurance continuation," Arnold says. "Next year the cost will run up to $25 million a year."
AIDS advocates hold out hope that during an election year, Congress will improve the president’s proposed budget, as it has in the past. (See chart on FY 2002 and 2003 HIV/AIDS budgets, below.)
| ADAP Budget Projections | |
| Fiscal Year 2002 | |
| Projected ADAP budget need for FY 2002 | $1,050,767,246 |
| Base budget (from FY 2001) | $885,945,624 |
| Projected increase in need for FY 2002 | $164,821,622 |
| Expected state share increase (20% of need) | $32,964,324** |
| Federal increase approved for FY 2002 | $50,000,000 |
| Current projected FY 2002 shortfall | ($81,857,298) |
| Fiscal Year 2003 | |
| Projected ADAP budget need for FY 2003 | $1,171,094,860 |
| Projected base budget for FY 2003 | $968,909,948 |
| Current projected ADAP shortfall for FY 2003 | ($202,184,912) |
| * Source: Connors, Medicaid Working Group (data from Community Medical Alliance, Santa Barbara, CA, 1993). The inflation-adjusted annual cost of treating advanced AIDS, based on this data, would be $53,056. | |
| ** The model assumes a 20% state match of the annual increase in need ($32,964,324 in FY 2002 and $40,436,982 in FY 2003). The actual amounts may vary, dependent upon state legislative ADAP budget actions during calendar 2002 and 2003. | |
| Source: ADAP Working Group, 1775 T St. NW, Washington, DC 20009. Telephone: (202) 588-1775. | |
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Still, even during the Clinton years of budget surpluses, the final budget typically fell short of what most AIDS groups said was needed. "I think that the fact we’re back to deficit spending makes the conversation that much harder," Ehrmann says. "There’s a small pool of money left after defense funding and new homeland security, so I think it’s going to be a tough fight," Ehrmann adds. "We lose more people each year from AIDS than we lost from the World Trade Center and Pentagon terrorist attacks," Ehrmann says. "That’s not to say that wasn’t an absolutely horrific event, but it is only to point out that other tragedies occur every day in this country, and we need to fight AIDS with as much vigor as we fight terrorism."
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