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Although it’s still a long way from becoming a reality, a Medicare prescription drug bill could be one solution to funding problems experienced by AIDS Drugs Assistance Programs (ADAPs), which have client lists that are growing faster than their funding.
Medicaid expansions through waiver programs would also be useful, but those types of efforts require committed state governments and completion of a lengthy bureaucratic process. As the recent National ADAP Monitoring Project Report notes, federal-level initiatives to allow states to expand Medicaid coverage to low-income, non-disabled people living with HIV have not succeeded.
Further, Medicaid waivers and expansions probably will not be the solution for cash-strapped ADAPs because the Medicaid programs in most states are facing their own budget problems, says Tanya Ehrmann, director of public policy for AIDS Action in Washington, DC. "A lot of states in the last few months have become very concerned about being able to meet the needs of their current Medicaid population over the long term," Ehrmann says. "Some states have caps on prescription drugs and don’t provide adequate payment for Medicaid beneficiaries to have access to the best HIV doctors."
The more important change would be for Medicare to start offering drug benefits, which would move some of the most vulnerable members of the HIV-infected population over to Medicare funding of their drugs, Ehrmann says. However, President Bush, Congress, and interested parties are a long way from agreeing on how a Medicare drug plan should be designed.
In March, Congressional Budget Office (CBO) Director Dan Crippen said President Bush’s proposal for Medicare reform and a prescription drug benefit would provide only a "fairly thin" benefit. The CBO estimates that the $153 billion over 10 years that Bush proposes is a fraction of the $1.1 trillion needed to provide a full drug benefit, which would have a $1,000 annual deductible.
"How this Medicare prescription drug program will be designed is critical," Ehrmann says. "There has certainly been a lot of talk about providing prescription drugs only to low-income Medicare beneficiaries, and I haven’t heard anything in that discussion about the disabled population that’s low-income and that is spending tremendous amounts of money out-of-pocket on prescription drugs."
Ehrmann and others say the federal government cannot expect states to throw more money at HIV treatment when their budgets are already so tight, and this leaves the bulk of responsibility with ADAPs. However, a Medicare drug benefit would help both elderly HIV patients and younger patients who receive Medicare because they are disabled by AIDS.
"Medicare drug benefits would relieve pressure on ADAP," says Lanny Cross, director of the ADAP Program at the New York State Department of Health in Albany. "Disabled people on Medicare who are earning above the Medicaid income level could receive Medicare drugs if this is passed."
Ironically, there were some Medicare HMOs in Florida that did provide prescription coverage to some HIV patients, but recently there has been a trend of those plans curtailing their pharmacy benefits. This has forced more people to apply for ADAP assistance, says Joseph May, ADAP manager with the Bureau of HIV/AIDS in the Florida Department of Health in Tallahassee. "We’ve documented needs of over $1 million from people who have health insurance without adequate pharmacy benefits," May says, adding that a Medicare drug benefit would have a positive effect of taking many of those clients off ADAP rolls.
A Medicare drug benefit would benefit HIV-infected people like Rae Lewis-Thornton, a spokeswoman for AIDS Action in Chicago. Lewis-Thornton has lived with HIV infection for 16 years. For the past seven years, she has received federal disability checks, which now amount to $800 a month. Because she is disabled, Medicare pays for her hospitalization and outpatient medical treatment.
Lewis-Thornton’s disability income places her in an income bracket too high to qualify for Medicaid, so she has no insurance coverage for her medications. Until recently, she had received her $2000-per-month drug regimen at no charge through the Core Center in Chicago. Core Center is a state-of-the-art infectious disease center founded as a collaborative effort between Cook County Hospital and St. Luke Rush Presbyterian Hospital, both of Chicago.
"I was told yesterday that the clinic is not going to provide medicine anymore, only in special situations, and we all have to apply for ADAP," Lewis-Thornton reports. She says the change concerns her because she has no idea if the state’s ADAP formulary would cover all of the medications she needs, or how long it will take for ADAP to approve her application.
All of this uncertainty could be alleviated if Congress passed a Medicare drug benefit that would cover disabled people with HIV infection, Lewis-Thornton says. She has told her story to members of Congress, and she emphasizes that a Medicare drug benefit would not only be humane, but also cost-effective in many cases.
For example, several years ago Lewis-Thornton was hospitalized with pneumonia. She is allergic to the standard treatment, and this was her third round with the disease, so her physicians decided she would need to receive a 21-day treatment with an intravenous antibiotic. The treatment could be given to her at home by a home health nurse, which would be approximately 80% cheaper than a hospital stay for those same three weeks. However, her physicians had to change their minds and keep her admitted in the hospital because Medicare would not pay for the $275 per day medication regimen while she was at home.
"The best HIV treatment has to look at what is more cost-effective," Lewis-Thornton maintains.