ADAP report offers sobering view of programs
10 states/territories have restrictions in place
AIDS Drug Assistance Programs (ADAPs) are facing growth problems that have resulted in restricted access to drugs and capped enrollment in at least 10 U.S. states and territories, according to the April 2002 annual ADAP report of the National ADAP Monitoring Project, prepared by the Henry J. Kaiser Family Foundation of Menlo Park, CA.
States and territories that had restrictions as of February 2002 included Alabama, Georgia, Idaho, Kentucky, Maine, North Carolina, South Dakota, Texas, Wyoming, and Guam. Among these states, Maine, Texas, and Guam reported capped or restricted access to antiretroviral drugs. Others had expenditure caps and capped enrollment.
In Texas, funding problems have resulted in an expected $7 million ADAP deficit in 2003, a $12 million ADAP budget shortfall in 2004, and a $16 million budget need in 2005, according to an April 22, 2002, letter signed by I. Celine Hanson, MD, chief of the Texas Bureau of HIV and STD Prevention of the Texas Department of Health in Austin. As a result, Hanson writes, the bureau may have to modify its current drug formulary, limit the cost per client of medications provided, or close the program to new clients.
Problems for states like Texas have surfaced even as the national ADAP budget grew by 12% to $810 million in fiscal year 2001, according to the report. This is a fourfold increase since FY 1996. State funding to ADAPs also increased by an average of 12% to $149.6 million in FY 2001, although 16 states provided no state funding and relied solely on federal funds, the report says. The latest ADAP report makes it clear that even double-digit funding increases are not keeping pace with the need. Among the ADAPs with complete client information, the overall growth rate between 1996 and 2001 was 144%.
"Despite the overall growth in the national ADAP budget, access to ADAPs continues to vary greatly depending upon where one lives, as indicated by wide variations in income eligibility criteria and formulary coverage across states, and the continued use of waiting lists and other access restrictions by some jurisdictions," the report says.
Ten states carry the bulk of the ADAP burden, serving 77% of all clients, according to June 2001 data, and the top five of these states serve 61% of all clients. Nearly the same 10 states had the biggest ADAP expenditures as of June 2001, although there were some notable differences.
For example, by far the top two states in drug expenditures for June 2001 were California with $13,959,151 and New York with $13,530,163. However, Florida, which is No. 3 in expenditures with $4,837,867 for the month, actually served more clients than did New York.
The difference in spending might be partially explained by the very different formularies in the two states. Florida’s financial eligibility is 350% of the federal poverty level (FPL), which for a household of one amounts to a little more than $30,000. New York’s cap is $44,000 in income. Both states cover all nine nucleoside reverse transcriptase inhibitors (NRTIs) approved at the time, six protease inhibitors (PIs), and three non-nucleosides, but New York provides coverage for 16 opportunistic infection (OI) prophylaxis drugs, whereas Florida provides coverage for eight OI prophylaxis drugs. New York also covers 437 other medications, and Florida covers 27. (To see a state-by-state summary ADAP profile, click here.)
Florida does contribute a greater amount to its ADAP budget as a percentage of the total budget, but the total FY 2001 estimated budget from both federal and state sources is considerably higher in New York, where it amounts to more than $140 million, nearly double Florida’s total budget of $73.1 million.
Here are some other key findings from the ADAP report:
• ADAP clients as of June 2001 were primarily people of color, with 34% African Americans, 24% Hispanic, and 38% white non-Hispanics.
• Eighty percent of ADAP clients were men.
• Nearly 80% of clients served by ADAPs reported incomes at or below 200% of the FPL, which means incomes of less than $17,200 per year. Those reporting incomes of less than the FPL of $8,590 per year accounted for 44% of ADAP clients.
• Most ADAP clients are uninsured, with 6% receiving Medicaid, 10% receiving Medicare, and 11% having some sort of private insurance coverage.
• States reporting capped enrollment and waiting lists included Alabama, Georgia, Kentucky, North Carolina, and South Dakota.
• States reporting restricted access to PIs/ antiretrovirals include Texas, Maine, and the territory of Guam.
• Idaho has a monthly per capita expenditure cap, and Wyoming has a yearly per capita expenditure cap.
• ADAP drug expenditures by dollar amount in June 2001 were distributed as follows: 46% for NRTIs; 29% for PIs; 12% for non-nucleoside reverse transcriptase inhibitors; 8% for OIs/others; and 5% for the 16 drugs recommended for OI prophylaxis.
• ADAP formularies ranged from 18 drugs covered in Louisiana and Utah to New York’s coverage of 471 drugs. Massachusetts and New Jersey changed to an open formulary since last year’s report.
• Nineteen states provide coverage for resistance testing, and 15 of these provide coverage for both genotypic and phenotypic testing.
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