Many Southeastern states lack adequate ADAP funds to meet Medicaid needs
Officials predict $163 million shortfall for 2001
While rising HIV drug costs, coupled with federal funding shortfalls, created dwindling AIDS Drug Assistance Program (ADAP) budgets last year, an AIDS advocacy group is predicting a $163 million ADAP budget shortfall in fiscal year 2001.
Also, a new report on ADAP shows that some states, particularly in the Southeast, are struggling with inadequate ADAP funding that results in waiting lists and more stringent enrollment criteria.1
The ADAP Working Group of Washington, DC, predicts that ADAP will have a $163 million shortfall next year.
"We have some problems, but not a programwide disaster by a long shot," says Bill Arnold, chair of the ADAP Working Group. "Across the board, you have to give ADAP a very high mark, especially when you think that back in 1995, this was a dinky program that gave people medicine that made things easier while they were dying, and now there’s 10 times that amount of medication activity, six times the number of clients, and eight times the amount of money."
Most states have emerged in good shape from several years of growing pains as ADAP funding increased to cover antiretroviral medications for a growing number of HIV-positive people, Arnold says. For instance, the national ADAP budget ballooned from $207.5 million in fiscal year 1996 to $665.5 million in fiscal year 1999.1
ADAP finally is able to provide a basic range of antiretroviral therapy to low-income, uninsured, or underinsured people, says Arnold Doyle, MSW, director of the HIV Treatment Program for the National Alliance of State and Territorial AIDS Directors (NASTAD) in Washington, DC. Doyle is a co-author of "National ADAP Monitoring Project: Annual Report March 2000," funded by The Henry J. Kaiser Family Foundation of Menlo Park, CA, and produced by NASTAD and the AIDS Treatment Data Network in New York City. (See story on the ADAP report, p. 67.)
The ADAP Working Group estimates that the average cost of treatment per person on ADAP will be a little more than $10,000 for fiscal year 2001. This includes the costs of treating and preventing opportunistic infections. Based on this estimate, the advocacy coalition, which includes AIDS advocacy groups and pharmaceutical companies, projects that it will cost $895 million to adequately fund ADAP in fiscal year 2001. The projected base budget is $732 million, which is how the group arrives at its $163 million shortfall figure.
Doyle says he doesn’t necessarily agree that ADAP’s remaining problems could be solved by a large increase in federal funding. "Because of the way it’s run through the formula and trickled down to smaller states, they don’t see huge increases that will make a dent in their budget problems," Doyle says.
"I think the situation is good in terms of the fact that the programs are reaching a lot of people, and they’re reaching a lot of racial and ethnic minorities," Doyle says. "But there are persistent limitations in some states, like the Southeast and frontier states."
State funding is key to problem areas
Problems remain in the states that put no or very little state money into the program, such as the Dakotas, which provided no state ADAP funding in 1999, and in Southern states that have less expansive Medicaid programs combined with smaller contributions to ADAP than are needed, Doyle explains.
"ADAPs and Ryan White programs are meant to be gap fillers, to fill in gaps in access to treatment for lower-income people," Doyle says. "If you have a less expansive Medicaid program, you have more people in that gap, and the gap that ADAP has to cover will be larger."
For example, South Carolina, which is one of the resource-poor states when it comes to Medicaid funding, has an ADAP with a three-month-long waiting list of 150 HIV-positive people. Moreover, South Carolina is one of a handful of states that still require people with HIV to meet a medical requirement of having a low CD4 cell count (less than 500) before they qualify for ADAP coverage.
Compounding South Carolina’s problem is a growing AIDS population. The state began to receive additional federal money this year because of its growing number of AIDS cases, says Joann Lafontaine, MPH, program manager for Ryan White Title II, South Carolina Department of Health and Environmental Control in Columbia.
While the waiting list is longer than what it has been in the past, it still is a short enough period of time that patients on the list can receive antiretroviral drugs from the state’s HIV consortia, which provide regional support medical services to HIV patients. The consortia receive their own Ryan White Title II funds. "What happens when the waiting list gets long is we eat up money in the consortia," Lafontaine says. "This is not good in the long run because it’s not the best use of funding."
AIDS rate stays level, but ADAP funding falls
The largely rural southern state has the fifth-highest rate of AIDS cases per 100,000 in the nation, and this is part of the reason the state has a waiting list, Lafontaine adds. "And our HIV rate has stayed fairly level, but you see most everyone else’s HIV rate going down."
To make matters worse, infectious disease specialists in the state are reporting many cases in which HIV patients’ drug regimens are failing, Lafontaine says.
"We don’t know if it’s actually a drug failure or a patient who is not able to comply with the drug regimen," she adds.
While the state’s federal funding has increased, its contribution to ADAP is lagging behind. South Carolina’s contribution to the total ADAP budget is about 8%, down from 13% in 1998, according to the report.
When Hurricane Floyd struck North Carolina last fall, causing disastrous flooding and other storm damage, the state diverted more than $4 million of state ADAP funding to flood relief efforts. North Carolina still will have enough money to handle all eligible HIV cases in fiscal year 2000, says Arthur Okrent, manager of the AIDS Care Unit ADAP of the North Carolina Department of Health and Human Services in Raleigh.
In November 1998, the North Carolina legislature approved giving $8 million to ADAP, making it one of the few states to provide more than 50% of the total ADAP budget.
The state had only begun to explore expanding its ADAP financial eligibility from among the lowest in the nation at 125% of poverty level to 250% of poverty level when the hurricane struck. The report on expanding eligibility still needs to be reviewed by the state legislature. Meanwhile, there were not as many people added to the ADAP rolls as anticipated, so the program can survive without the state money that was diverted to flood relief, Okrent says.
"We’re cautiously optimistic and have no waiting list," Okrent adds. "We’re accepting all comers who qualify for the program."
Georgia, Florida eliminate waiting lists
Georgia has headed off ADAP funding problems by changing the way the program is administered and by doing budget forecasting, Doyle says.
"Georgia had a persistent waiting list for years, and recently was able to pull everyone off the waiting list and put them on the program," he adds. "Georgia also has expanded its formulary to cover opportunistic infections treatment, which it hadn’t covered in the past."
Florida also has improved its program’s access with these changes:
• eliminating its waiting list two years ago;
• improving access by making drugs available to people earning up to 300% of the poverty level;
• adding 20 drugs to the formulary list.
"We have a pretty good chance of getting additional state funds," says Joseph May, AIDS Drug Assistance Program Manager for Florida ADAP in Tallahassee.
The only hitch is that Florida Gov. Jeb Bush has proposed a billion-dollar cut in Medicaid expenses. If Medicaid is squeezed, there could be an indirect effect on ADAP, which picks up HIV patients who are ineligible for Medicaid, Arnold says.
May says the governor’s proposed Medicaid cuts, particularly any pharmaceutical reductions, are a big concern.
"It’s really odd in this booming economy that we have such talk of massive cutbacks in social services," May says.
Still, the Florida legislature gave ADAP an additional $8 million for fiscal year 1999, and there still is the possibility that state officials could raise that to $12 million this year, May adds. "We could lose some federal funds if we don’t receive that additional matching money," he says.
But, the state with the most dire prospects this spring is Tennessee, which may be forced to close its statewide TennCare program. TennCare, the state’s managed health care program for low-income families, needs $200 million more in state money or it might close, says William L. Moore Jr., MD, state epidemiologist and acting director of Ryan White AIDS Support Services in Nashville.
"The problem with TennCare is that it’s been underfunded according to managed care organizations and providers," Moore says.
TennCare, which received a 1115b waiver from the Health Care Financing Administration in 1993 to cover Medicaid-eligible people and Medicaid-ineligible underinsured and uninsured, enrolled 1.2 million people. Nine managed care companies contracted with TennCare to provide all health care needs for TennCare enrollees. But as of June 30, contracts expire for the biggest insurers, including Blue Cross/Blue Shield. And the insurers have said they will not renew unless the state puts $200 million more into the program, Moore says.
"Unfortunately, the governor’s budget projects a $380 million shortfall next year, and that’s not including the $200 million," he adds.
If TennCare closes, ADAP could encounter major problems because TennCare provides coverage for many HIV patients’ drugs and medical care. Currently, ADAP is used to cover drugs for HIV patients for 120 days or less, depending on how quickly they can become enrolled in TennCare, Moore explains. For this reason, Tennessee has not had to provide any state funding to the ADAP program. But if TennCare closes, the $5.4 million ADAP budget likely will be strained to cover everyone eligible.
For example, South Carolina and Tennessee receive a similar amount of federal ADAP funding, but while South Carolina served about 650 HIV-infected clients in 1999 through ADAP, Tennessee served about 160 people. Tennessee’s ADAP expenses were one-fourth those of South Carolina in 1998.
Still, problems like those in Tennessee can be solved with more state funding and an increase in federal ADAP money, Arnold says.
"States that don’t throw in state money to help out and are just using federal money, run into the problem of having too few drugs on the formulary, or they set eligibility criteria very low, or they end up with a waiting list," Arnold says.
Reference
1. Doyle A, Jefferys R. "National ADAP Monitoring Report: Annual Report March 2000." The Henry J. Kaiser Family Foundation, the National Association of State and Territorial AIDS Directors, and the AIDS Treatment Data Network. Web site: http://www.kff.org/content/2000/1582/.
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