# Presentation: 829179

## Public Financing of HIV/AIDS Care and Treatment

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

## 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://](http://www.cms.hhs.gov/hiv/default.asp)__[www.cms.hhs.gov/hiv/default.asp](http://www.cms.hhs.gov/hiv/default.asp)_
- Federal Funding for HIV/AIDS: The FY 2005 Budget Request, Kaiser Family Foundation, February 2004, _[http://www.kff.org/hivaids/7029.cfm](http://www.kff.org/hivaids/7029.cfm)_

- FACT SHEET: Medicaid and AIDS and HIV Infection, Centers for Medicare & Medicaid Services, January 2004,  _[http://](http://www.cms.hhs.gov/hiv/default.asp)__[www.cms.hhs.gov/hiv/default.asp](http://www.cms.hhs.gov/hiv/default.asp)_
- Federal Funding for HIV/AIDS: The FY 2005 Budget Request, Kaiser Family Foundation, February 2004, _[http://www.kff.org/hivaids/7029.cfm](http://www.kff.org/hivaids/7029.cfm)_

## 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://](http://www.cms.hhs.gov/hiv/default.asp)__[www.cms.hhs.gov/hiv/default.asp](http://www.cms.hhs.gov/hiv/default.asp)_
- Federal Funding for HIV/AIDS: The FY 2005 Budget Request, Kaiser Family Foundation, February 2004, _[http://www.kff.org/hivaids/7029.cfm](http://www.kff.org/hivaids/7029.cfm)_

## 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.

## Ryan White CARE Act Appropriations, 

- Ryan White CARE Act Appropriations,
- FY 2004 - $2.0 Billion

## 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

## Programs within the RWCA

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

## 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?

## 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

## 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

## Slide 11

## Slide 12

## 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
- _<_3% is reserved for areas with “severe need”

## 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.

## ADAP is the Most Rapidly Growing CARE Act Program

## History of the ADAP Earmark

## 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

## 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.

## 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*

## 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*

## 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*

## 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

## 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

## Contact Information

- Deborah Parham Hopson, PhD, RN
- RADM, USPHS
- HIV/AIDS Bureau, HRSA
- 5600 Fishers Lane, Room 7-05
- Rockville, MD 20857
- 	Phone – (301) 443-1993
- 	Fax – (301) 443-9645