Impact of the Affordable Care Act on Access to HIV Medications

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ACA and HIV

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HIV is a disease with several unique characteristics; stigma may be unfairly attached, vulnerable populations are often affected (such as the economically disadvantaged), and effective treatment requires strict adherence to a combination of medications. These characteristics can act synergistically to challenge one’s ability to access effective treatment. This is not only a problem on the individual level, but also a problem of great public health concern, as effective HIV treatment through medication-induced suppression of the virus is not only life-saving to the individual, but has also been proven an effective method of infection prevention (preventing transmission of the virus to uninfected individuals).

Despite great advances in the treatment of HIV, of the 1.1 million HIV-positive individuals within the US:

  • Less than 40% are retained in regular medical care, with only 25% having undetectable levels of the HIV virus in their blood (signifying effective medication-induced suppression of the virus)
  • Almost half depend on Medicaid for medical coverage, which has been limited to those who either qualify financially or qualify due to a disabling AIDS diagnosis
  • Less than 15% have private health insurance coverage, but even these individuals often face challenges of preferred HIV medications being placed on high cost-sharing tiers, making them unaffordable

The Affordable Care Act

The Affordable Care Act (ACA) was passed in an effort to support health for all, with the expectation that all Americans would have health insurance. Changes within the health insurance industry that came as a result of the ACA include:

  • Private Market Reforms, which:
    • Prohibit insurers from denying coverage and/or charging higher premiums based on pre-existing conditions
    • Limit annual out-of-pocket expenses to $6,350 per individual and $12,700 per family
    • Mandate coverage of certain preventative health services without cost-sharing
  • Expansion of Medicaid Eligibility – State-specific inclusion of adults ages 19-64 at or below 133% of the Federal Poverty Level (FPL) (individual states to choose whether to expand their Medicaid programs)
  • Establishment of Health Insurance Marketplaces (or Exchanges) – To provide a “one-stop shop” for individuals to:
    • Compare qualified health plans to find that which best fits their health needs
    • Determine eligibility for affordability programs (such as Medicaid)
    • Determine eligibility for cost-sharing reductions and/or premium tax credits to help pay for private health insurance (available to certain individuals with incomes of 100-400% of the FPL)

As a result of the ACA, qualified health plans are also mandated to provide essential health benefits (EHB), including certain prescription drugs. When it comes to the coverage of prescription drugs, health plans are determined to provide EHB if they provide the greater of the following two options:

  • Coverage for at least one drug within each category/class of drugs in the United States Pharmacopeia (USP) OR
  • Coverage for the same number of drugs within each USP category/class as compared to the EHB benchmark plan (a benchmark plan is selected by each state to determine EHB that must be offered within that respective state)

Unintended Consequences

While the ACA prevented the exclusion of those with HIV as a pre-existing condition, ultimately expanding medical coverage for thousands of people within the US, prescription drug costs to HIV-positive patients continue to be unaffordable. This often comes as a result of these medications being placed on high cost-sharing tiers, with patients required to pay a percentage of the drug cost (up to 50%), as opposed to a flat copay (approximately $30-$45 per prescription for most other medications). To put these “unaffordable” costs into perspective, two of countless examples are provided below:

  • Within Ohio, Blue Cross Blue Shield, Coventry, Humana, and Medical Mutual placed all HIV medications on the highest cost-sharing tiers and/or categorized them as specialty medications, leading to patient copayments of 20-50% of the drug costs after satisfying deductibles. For example, one patient prescribed Isentress plus Truvada (a recommended first-line regimen in the National HIV Treatment Guidelines) could be expected to pay $1,200 per month after meeting a $6,000 deductible, under Humana’s qualified health plan.
  • Within Illinois, Aetna, Coventry, Health Alliance, and Humana placed most HIV medications on the highest cost-sharing tiers, requiring copayments of up to 50%, leading to out-of-pocket expenses for Atripla (again, a recommended first-line regimen in federal treatment guidelines) of over $1,100 per month.

Concern has been voiced regarding the potential of these high cost-sharing designs being used by health insurance companies as a means to discourage HIV-positive people from enrolling in their specific health plans, a practice that is not only discriminatory but also illegal. Much attention has also been given to pharmaceutical companies for high drug pricing. While pharmaceutical companies state the need to support new research and development, it has been noted that the costs of some medications to treat HIV have increased substantially. For example, the newest combination medication, Stribild, was recently given a price 33% higher than that of the older, yet comparable combination medication, Atripla.

Recommendations

  • Comprehensive HIV Medication Coverage – Another unique characteristic of HIV is that the medications to treat HIV are not interchangeable, meaning one medication cannot be automatically substituted for another medication, even within the same class. Therefore, the ACA mandate of coverage for at least one drug within each class of drugs in the USP is not sufficient in the setting of HIV, as it may be for other disease states, such as high blood pressure or cholesterol. The HIV Medicine Association (HIVMA) and the American Academy of HIV Medicine (AAHIVM) recommend coverage of all HIV medications according to the nationally recognized treatment guidelines.
  • Access to HIV Medications – The HIVMA and AAHIVM urge all stakeholders to work together to do their part in promoting access to HIV medications, often required by the United States’ most vulnerable populations. This includes insurance companies implementing reasonable cost-sharing designs, with recommendations for flat-fee copayments over those consisting of a certain percentage of the HIV medication cost. This also includes pharmaceutical companies setting prices that support access for populations most in need, as well as sustaining and expanding their copay assistance programs to be available for all HIV medications, especially supporting those patients facing high cost-sharing copayments. The HIVMA and AAHIVM also bring attention to the significant adverse consequences that come as a result of HIV treatment delay and/or interruption, including drug resistance and the development of opportunistic infections, which lead to hospitalizations and other interventions more costly than that of monthly prescription drug costs.

While the ACA has had the positive effect of providing insurance coverage to those who were often previously excluded due to having pre-existing conditions, the unintended consequence of unaffordable prescription drug coverage needs to be addressed. Optimism lies in the fact that there have been steps forward in promoting access to HIV medications; within Maryland a bill passed that limits cost-sharing for specialty drugs to $150 per month, and within Illinois a bulletin was published to notify insurers that plans with unreasonable prescription restrictions could be considered discriminatory. With the continued acknowledgement of the unintended shortcomings of the ACA and a teamwork approach to solving them, health insurance for all Americans, including prescription drug coverage, can become an affordable reality. HIV patients often unfairly face many challenges simply as a result of their HIV diagnosis; access to medications need not be one of them.

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2 Responses to “Impact of the Affordable Care Act on Access to HIV Medications”

  1. ftchiang Says:

    Fantastic blog post about HIV and the ACA! I currently rotate at the Hopkins HIV Moore Clinic, and despite the majority of patients being on the Ryan White program prior to the ACA roll-out, several still fall through the cracks and complain about prices of medications. Some then become non-adherent or are lost to follow-up, which not only jeopardizes their own immunocompromised health status, but also increases the likelihood of infecting others because their viral loads are not suppressed. Mandating insurance and medication coverage for PLWH will ultimately save healthcare costs by curbing disease transmission rates, but obtaining sufficient political and legislative clout will be a challenge.

  2. ryomiyakawa Says:

    Great post regarding HIV and ACA. I think this kind of issue needs to be supported by cost-analysis study of HIV care after the implementation of ACA. Even with such result, it will still be hard to convince pharmaceutical company. As the HIV meds are different from other medications, say antibiotics, in that it is often non-interchangeable, academic societies like HIVMA needs to lobby on this issue to expand insurance coverage as people often need to switch insurances.

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