Despite Growth in National ADAP Budget, Some States Face Shortfalls in Program Funding, Report Says
As Congress prepares to debate legislation (HR 1298) that would authorize $15 billion over five years for AIDS prevention and treatment programs in Africa and the Caribbean, many U.S. states are facing budget shortfalls that are forcing them to place limits on their AIDS Drug Assistance Programs, which are state-managed, federally funded programs that offer antiretroviral drugs to low-income people who lack health insurance, NPR's "Morning Edition" reports. Despite growth in the national ADAP budget over the past six years, most of which followed the advent of highly active antiretroviral therapy in 1996 and 1997, 16 states have had to restrict access to their ADAPs, according to the annual National ADAP Monitoring Report, which was released yesterday by the Kaiser Family Foundation, the National Alliance of State and Territorial AIDS Directors and the AIDS Treatment Data Network (Wilson, "Morning Edition," NPR, 5/1). The annual monitoring report tracks ADAP spending and access over the past year and examines long-term trends in the program. The 2003 report found that the national ADAP budget, drug expenditures and the number of clients served by ADAPs all increased between 1996 and 2002. The number of clients served by ADAPs grew 4% last year, a rate of growth smaller than in previous years. ADAP drug expenditures grew to more than $70 million in June 2002 -- a 12% increase from June 2001 -- and total ADAP drug expenditures grew 370% between 1996 and 2002. The national ADAP budget reached $878.6 million in fiscal year 2002, rising 8% from the year before and 366% since FY 1996. ADAP budget increases have allowed programs to expand their formularies, with most states offering all approved antiretrovirals and 15 states covering all drugs highly recommended for the prevention of opportunistic infections.
Shortfalls and Solutions
Despite overall trends toward increased capacity, several states face budget shortfalls and program restrictions, such as waiting lists and limited formularies. Thirteen states capped or limited enrollment and/or restricted access to antiretrovirals in at least five of the last seven years. In addition, access to ADAPs "continues to vary greatly" by client location. Meanwhile, uncertainty about the availability of new resources and a changing clinical environment often make it challenging for ADAPs to prepare for changes, such as the introduction of new and potentially higher-priced medications. However, ADAPs are addressing fiscal pressures and uncertainty by taking advantage of drug discount mechanisms, such as working together to form coalitions to address drug prices (National ADAP Monitoring Report 2003, April 2003). ADAP representatives from California, Florida, Maryland, Massachusetts, New Jersey, New York, North Carolina and Texas -- states that collectively account for 75% of the more than $850 million in annual ADAP drug expenditures -- for two months have been negotiating with representatives from Roche, GlaxoSmithKline, Merck, Pfizer, Abbott Laboratories, Boehringer-Ingelheim, Gilead Sciences and Bristol-Myers Squibb to discuss ways of alleviating the budget shortfalls that state ADAPs are currently facing. According to the National Alliance of State and Territorial AIDS Directors, the ADAPs have reached agreements with Gilead, Abbott and Merck to freeze drug prices and provide rebates on the companies' antiretroviral drugs. Negotiations are ongoing with Pfizer/Agouron, GlaxoSmithKline, Bristol-Myers Squibb and Boehringer Ingelheim (Kaiser Daily HIV/AIDS Report, 4/24).
Bill Arnold, director of the ADAP Working Group, said that ADAPs have been underfunded for the last three years, adding, "People are piling up on waiting lists, while Medicaid is dumping people who used to get coverage, and private insurers, in their quiet way, are getting rid of high-cost patients" (Russell, San Francisco Chronicle, 5/1). Jennifer Kates, director of HIV policy for the Kaiser Family Foundation, said, "Every single state practically is experiencing a significant crunch in their Medicaid programs and are looking to reduce costs in that program, largely through pharmacy controls and other mechanisms. The relationship between Medicaid and ADAP is a very important one to understand, because ADAP fills the gaps when Medicaid can't" ("Morning Edition," NPR, 5/1). According to California ADAP officials, the state's program will cost about $24 million more than was budgeted for the fiscal year beginning July 1, causing the state to consider limiting access to medications. Michael Montgomery, chief of the California Department of Health Services Office of AIDS, said, "We are going to have to look at a waiting list, as well as removing some drugs from the formulary," adding that although the state has a "robust" ADAP program, the state is "facing a very serious budget deficit" (San Francisco Chronicle, 5/1). Montgomery said that congressional members he met with this week to discuss the state ADAP funding crisis did see a "potential conflict" in coming up with billions to make medicines available overseas through Bush's global AIDS initiative but not finding an additional $280 million so that U.S. residents also have access to HIV/AIDS treatments, NPR reports ("Morning Edition," NPR, 5/1). Arkansas' ADAP, which was entirely federally funded until the state Legislature allocated $661,000 for the program in 2002, grew 72% in 2002 and eliminated a waiting list for treatment. According to Lola Thrower, HIV services team leader for the Arkansas Department of Health, although the increase in state and federal funding allowed the ADAP to serve more clients, the state legislature could still eliminate a future contribution because of possible budget cuts in the state. However, Thrower said such a scenario would not decrease the level of care, adding, "We have no idea what that's going to look like at this point, and we're just kind of waiting to see what happens" (Smith, Arkansas Democrat-Gazette, 5/1).
CBS' "Up to the Minute" today interviewed Kates about the report ("Up to the Minute," CBS, 5/1). The full segment is available online in RealPlayer.
The full NPR "Morning Edition" segment, which includes comments from Kates, Montgomery and Steve Sherman, director of North Carolina's ADAP, is available online in RealPlayer.