Public Financing of HIVAIDS Care and Treatment

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Public Financing of HIV/AIDS Care and Treatment

• Presidential Advisory Committee of HIV/AIDS
• March 29, 2004
• Deborah Parham Hopson, PhD, RN

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Federal and State Dollars for HIV/AIDS CARE

• Medicaid, Medicare, and Ryan White CARE Act are
  the three largest payers of HIV/AIDS care in the
  U.S.
• The total Federal HIV/AIDS domestic spending was
  15.3 billion in FY 2003 and will be an estimated
  16.3 billion in FY 2004. It comprises .7 of
  the total Federal budget.
• In 2003, Federal and State Governments spent
  approximately 8.5 billion on HIV/AIDS care and
  assistance alone (Medicaid).
• Medicaid, a Federal-State program that covers
  more than 50 million low-income individuals,
  spent 4.8 billion in FY2003 and will spend an
  estimated 5.4 billion in 2004 on HIV/AIDS health
  care.

FACT SHEET Medicaid and AIDS and HIV Infection,
Centers for Medicare Medicaid Services, January
2004, http//www.cms.hhs.gov/hiv/default.asp Fede
ral Funding for HIV/AIDS The FY 2005 Budget
Request, Kaiser Family Foundation, February 2004,
http//www.kff.org/hivaids/7029.cfm
FACT SHEET Medicaid and AIDS and HIV Infection,
Centers for Medicare Medicaid Services, January
2004, http//www.cms.hhs.gov/hiv/default.asp Fede
ral Funding for HIV/AIDS The FY 2005 Budget
Request, Kaiser Family Foundation, February 2004,
http//www.kff.org/hivaids/7029.cfm
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More Federal and State Dollars for HIV/AIDS Care

• States share of Medicaid amounted to 3.7
  billion annually in FY 2003.
• Medicare, a federally funded health insurance
  program which provides health care services for
  an estimated 34 million Americans over the age of
  65 and nearly 6 million non-elderly adults with
  permanent disabilities, spent 2.1 billion in
  2002 on HIV/AIDS health care.
• The new Medicare prescription drug bill, passed
  in December 2003, will add new prescription drug
  benefits that will substantially increase
  HIV/AIDS drug expenditures from 2006 on.

FACT SHEET Medicaid and AIDS and HIV Infection,
Centers for Medicare Medicaid Services, January
2004, http//www.cms.hhs.gov/hiv/default.asp Fede
ral Funding for HIV/AIDS The FY 2005 Budget
Request, Kaiser Family Foundation, February 2004,
http//www.kff.org/hivaids/7029.cfm
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Financing HIV/AIDS Care The Ryan White CARE Act

• The Ryan White CARE Act (RWCA) was first
  authorized by Congress in 1990, reauthorized in
  1996 and in 2000.
• Purpose to improve the quality and availability
  of care for individuals and families with HIV
  disease
• The RWCA is the third largest funding source for
  critical therapeutics, health care and support
  services.
• An estimated 533,000 uninsured and underinsured
  persons living with HIV/AIDS receive care
  annually through RWCA federally at a cost of
  over 2.0 billion in FY 2004.

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Ryan White CARE Act Appropriations, FY 2004 -
2.0 Billion
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Programs within the RWCA

• Title I Formula grants to EMAs
• Title II Formula grants to states, DC and
  territories, includes ADAP
• Title III Discretionary grants to community
  based organizations
• Title IV Discretionary grants to support care
  for women, infants and youth

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Programs within the RWCA

• Part f
• AIDS Education and Training Centers
• Dental Reimbursement Program
• Community Based Dental Partnership Program
• Special Projects of National Significance

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RWCA Questions

• Why did 40 Title I EMAs receive less funding in
  FY 2004 than they did in FY 2003?
• What is the status of the AIDS Drug Assistance
  Program?
• How is the RWCA responding to the Southern
  Manifesto?
• How is the HRSA responding to the new CDC
  Advancing HIV Prevention initiative?

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Why did 40 EMAs receive less funding in FY2004?

• Distribution of estimated living cases of AIDS
• Decrease in available funding from FY 2003 to FY
  2004
• Effects of the hold harmless provision in the
  statute

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Why did 40 EMAs receive less funding in FY2004?

• EMAs demonstrated need for supplemental funds
• Amount of funds designated by Congress for the
  Minority AIDS Initiative

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What is the status of the ADAP?

• The AIDS Drug Assistance Program (ADAP) accounts
  for the largest RWCA expenditure with a budget of
  748.9 million in FY 2004.
• For the 16 municipalities that participated, over
  23 million in Title I funding was earmarked for
  HIV/AIDS drugs through local AIDS Pharmaceutical
  Assistance Programs (APAP) in the CARE Act in FY
  2003.
• ADAP pays medications, health insurance with a
  drug benefit and adherence support
• lt3 is reserved for areas with severe need

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ADAPs -- National Overview

• 57 ADAPs, including the District of Columbia,
  Puerto Rico, Virgin Islands, Guam, Marshall
  Islands, Northern Mariana Islands, and the
  American Samoa Islands.
• Wide variation in program characteristics due to
  individual State administration of each ADAP and
  HIV/AIDS prevalence in each State.
• Differences most pronounced in areas of funding,
  eligibility criteria, formulary size, and
  cost-saving strategies.

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ADAP is the Most Rapidly Growing CARE Act Program
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History of the ADAP Earmark
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Financial Challenges for ADAPs

• As persons with HIV/AIDS live longer, there is an
  increase in the demand, utilization, and cost of
  care, especially for AIDS drugs
• Increases in the number of new HIV cases
  (estimated 40,000 new cases annually) adds to the
  numbers of persons seeking care
• Medicaid is caught between the downturn in State
  revenues and increased health care spending. As
  a result, all 50 states and the District of
  Columbia implemented Medicaid cost containment
  measures in FY 2003 and plan to put in additional
  spending caps in FY 2004
• ADAP is the payor of last resort for PLWH who are
  poor, uninsured some of whom have lost Medicaid
  and other local benefits as those programs
  tightened their enrollment and eligibility

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Financial Challenges for ADAPs

• HIV/AIDS drugs are expensive!
• An HIV/AIDS drug regimen costs an estimated
  11,000-15,000 annually.
• A new class of drugs called fusion inhibitors,
  released in March 2003, costs over 20,000 per
  year.
• In addition, Highly Active Antiretroviral Therapy
  (HAART) therapies often require expensive
  laboratory diagnostic tests to identify drug
  resistance early on in treatment.

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State ADAPs with Waiting Lists

• State On Waiting List State On Waiting
  List
• Alabama 290 Montana 6
• Alaska 8 North Carolina
  425
• Colorado 280 South Dakota 43
• Idaho 7 West Virginia 33
• Kentucky 122
• Total 1214
• State ADAP status as of 03/22/04
• Source HIV/AIDS Bureau, Health Resources and
  Services Administration

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Cost Containment Strategies

• 340B Direct Purchase States (22 States and 3
  Territories) AL, AR, AZ, CO, DE, FL, GA, GU, HI,
  IA, IL, KY, LA, MS, MT, NE, NM, NV, OH, PR, SC,
  TN, TX, VA, and VI
• 340B Rebate States (26 States) AK, CA, CT, ID,
  IN, KS, MA, MD, ME, MN, MO, NC, NH, NJ, NY, ND,
  OK, OR, RI, SD, UT, VT, WA, WV, WI, and WY
• Mandated Rebate States (1 State) PA
• Voluntary Rebate States (1 State) MI
• Other (District of Columbia) Wash., DC (FSS)
• HIV/AIDS Bureau, Health Resources and Services
  Administration

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State Cost Containment Strategies

• Capped Enrollment
• Alabama, Alaska, Arkansas, Colorado, Georgia,
  Idaho, Kentucky, Montana, North Carolina, South
  Dakota, and West Virginia
• Capped Expenditures
• Illinois, Indiana, Missouri, Oklahoma, and South
  Dakota
• Medical Criteria
• Florida, Georgia, Louisiana, Montana, Ohio,
  Puerto Rico, south Dakota, Texas, Virginia
• HIV/AIDS Bureau, Health Resources and Services
  Administration

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How is the RWCA responding to the Southern
Manifesto?

• All RWCA programs provide services in manifesto
  states
• Emerging Communities (ECs)
• 3 (of 4) Tier I ECs are in Baton Rouge, Memphis
  and Nashville
• 12 (of 25) Tier II ECs are in southern states
• Title III EIS
• During 2001-2003, 44 (of 111) new EIS programs
  were established in southern states

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How is HRSA responding to the new CDC Advancing
HIV Prevention Initiative?

• RWCA Programs
• Community and Migrant Health Centers
• Rural Health Programs
• Maternal and Child Health Programs

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Contact Information

• Deborah Parham Hopson, PhD, RN
• RADM, USPHS
• HIV/AIDS Bureau, HRSA
• 5600 Fishers Lane, Room 7-05
• Rockville, MD 20857
• Phone [phone]
• Fax [phone]