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Publix Grocery Chain Denies PrEP Coverage to Its Employees

January 29, 2018

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Publix store

Credit: Michael Rivera [CC BY-SA 4.0], via Wikimedia Commons

Some parts of the country have weather that signals the arrival of the winter holiday season, but the South has Publix commercials. The Florida-based grocery store chain has made a Christmas tradition of its sentimental short films exalting family, fireplaces, and food bought from its stores and prepared with your love. "Whatever your tradition may be, we're grateful to be a part of it," a narrator with a delicate rasp says in the 2017 ad, "Traditions. A Publix Christmas story."

However, Publix is showing a cooler, less compassionate side to some of its 188,000 employees. One of the more prominent supermarket brands in the southeast, it has taken a hard line against including the HIV-prevention medication known as pre-exposure prophylaxis (PrEP) in the insurance coverage it offers workers. But it remains a mystery whether the company is blocking coverage for PrEP due to cost concerns or the growing cry of employers (such as Hobby Lobby) that don't want to cover medical care for issues or people they deem morally objectionable.

The company's rejection of what is widely considered a major breakthrough in HIV prevention is as unique as it is puzzling, said David Holland, M.D., M.H.S., an assistant professor of medicine at Emory University and director of the Fulton County PrEP clinic in Atlanta, who unsuccessfully tried to get Publix to cover PrEP for one of the company's employees. "We've started 255 people on PrEP at our clinic alone, and this is the only person that we weren't able to get PrEP for," Holland said.

Publix representatives were contacted numerous times for an explanation of the company's decision, and they responded with a brief statement noting that "the health plans offered by Publix provide generous medical and prescription coverage." "Annually, we evaluate benefits covered under our health plans," Publix spokesperson Brenda Reid wrote in the statement. "There are numerous medications covered by the plan used in the treatment of HIV." "There are some medications that have coverage limitations or require prior authorization," Reid added. "Any Publix associate with questions regarding his or her coverage can contact our benefits department directly."

Related: Will the Hobby Lobby Decision Open the Door for HIV-Related Health Insurance Restrictions?


The employee Holland assisted appealed the initial denial, was rejected twice more, and "was the only one we were not able to resolve through an appeal," Holland said. "What we found out from the insurance company was that it came, ultimately, from the employer," he added. "It wasn't just an insurance issue; it was [that] the employer did not want it covered in the insurance."

Publix officials did not respond to written questions about the company's rationale for omitting coverage of PrEP for its employees, but Holland and public health advocates believe it was unlikely due to costs. Blogger Josh Robbins first reported in November 2016 that Publix was denying its employees access to PrEP, and the reasoning behind it is still unclear.

"It's not like every single employee is going to go out and get PrEP, so it can't be cost," said Devin Barrington Ward, a social justice advocate and strategist who works with Georgia legislators on behalf of the National Black Leadership Commission on AIDS. "And I guarantee you, if you did a cost analysis, it would cost them less on their insurance premiums if they covered PrEP for someone who is HIV negative versus that person becoming HIV positive. We know that the cost for providing that person care increases exponentially because it's not just one PrEP prescription."

The lack of justification offered by Publix has led some to wonder whether the company is refusing to cover the drug on moral grounds.

"Frankly, I'm shocked that, in a day like today, a company like Publix wouldn't recognize the benefits of PrEP," said Amistad St. Arromand, who has worked closely with Fulton County health officials on HIV/AIDS-related issues and serves as executive director of The Gentlemen's Foundation, a black gay non-profit in Atlanta.

PrEP is the common name for a new application of the drug Truvada (tenofovir/FTC), which has long been part of some regimens for people living with HIV. Within the past decade, research has shown that Truvada is also highly effective at preventing the contraction of HIV when used daily by HIV-negative individuals, with the Centers for Disease Control and Prevention (CDC) estimating that it can virtually eliminate the odds of sexually contracting HIV.

"Publix is a billion-dollar corporation, and so if they really wanted to [provide coverage of PrEP] they could," Arromand said. "I do believe it's probably a lack of education, a lack of awareness or even probably ignorance -- and I'm hoping it's education and awareness. This is reminding me of the women's debate that we've been having for years where a company is choosing to control what and how its employees access health care."

Is the "Religious Freedom" to Deny Health Care to Blame?

Such concerns come during an era when more American employers and service providers are asserting their "religious freedom" to set workplace policies on moral grounds. The U.S. Supreme Court's 2014 decision in Burwell v. Hobby Lobby Stores, Inc., ruled that privately held companies can be exempted from the Affordable Care Act (ACA)'s mandate to provide contraception based on their owners' religious views.

"This idea that an employer's religious beliefs may trump an individual employee's well-being and right to access important medical technologies, services, and drugs, I think is absolutely a lasting legacy of that case," said Anne Tucker, associate professor at the Georgia State University College of Law. "The message of that particular case was [that] if employers disagree on personal moral bases and want to make health insurance coverage decisions based on that individual morality, [then] that, when it is sufficiently tied to a religion, can be a justification."

All states set their own mandates for what insurance coverage must include beyond the essential benefits of the ACA. While Georgia requires insurance packages to include a prescription drug plan, insurers and employers determine what medicines are included in that plan, said Glenn Allen, a spokesperson for Georgia's Office of Commissioner of Insurance. The Georgia legislature determines what services are mandated and adding any new mandates, such as PrEP coverage, to the list requires legislative action, Allen said.

Tucker said that if Publix's decision is motivated by morality, it continues "the narrative of Hobby Lobby," but it is not an exact comparison since there is neither a state nor a federal mandate for insurance plans to include PrEP, unlike the ACA's birth control requirements. While U.S. Supreme Court Justice Samuel Alito wrote that the majority opinion in Hobby Lobby "should not be understood to hold that insurance-coverage mandates ... must necessarily fall if they conflict with an employer's religious beliefs[,]" businesses like Publix stand on solid legal ground due to longstanding attitudes toward health care in the United States.

"The idea [is] that health coverage is voluntary, is an additive benefit and that it is [provided] by the good grace of employers," Tucker said. "[It] is not considered a baseline right. That's the default setting; that's the frame of reference most people have."

Other fronts in the "religious freedom" debate include the Trump administration's implementation of new rules at the civil rights division of the U.S. Department of Health and Human Services (HHS) earlier this month permitting medical providers to deny service based on their religious beliefs. The HHS rules were the third "religious freedom" measure enacted by the administration in its first year, and White House lawyers also argued on behalf of "religious liberty" when the U.S. Supreme Court heard oral arguments in Masterpiece Cakeshop, Ltd. v. Colorado Civil Rights Commission last November.

In that case, owners of a Christian bakery requested an exemption from the state's non-discrimination law because they felt making a cake for a same-sex wedding went against their religious beliefs. Tucker thinks this involves the same dynamics as the Hobby Lobby case. "That is another way of [asking], can an individual or group of individuals, through their business, use their individual religious beliefs as grounds to exempt the business entity from an otherwise generally applicable law," Tucker said.

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