The Effect of Insurance Coverage Changes on Drug Utilization in HIV Disease

Changes in insurance coverage can produce a significant change in access to health care. Given the chronic and often debilitating nature of HIV disease, affected individuals in the United States, where health insurance is largely dependent on either employment or participation in an indigent insurance program, may lose or change health insurance with changes in employment. Previous studies have shown that as HIV disease progresses, individuals have a greater likelihood of losing employment. Increasing the financial loss is the increased need for prescription drugs to manage the disease and treat associated complications. Hence, changes in insurance coverage may be important in explaining patient access and adherence to medications in the treatment of HIV disease.

The investigators hypothesized that patients with HIV disease who have a change in health insurance coverage will have lower drug use rates over time as compared with those whose benefits remain unchanged. They examined the use rate data of antiretroviral (ARV), antipneumocystic (drugs for prophylaxis of Pneumocystis carinii pneumonia, PCP) and antidepressant (ADP) drugs in a heterogeneous cohort of people living with HIV disease by adults participating in the AIDS Cost and Services Utilization Survey (ACSUS). ACSUS was an 18-month panel survey (March 1991 through August 1992) of patients in care for HIV/AIDS at 26 sites in the United States.

Poisson regression analyses with estimating equations were conducted to determine the effects of demographic and socioeconomic variables on the acquisition rate of the three medicines. The sample included 1,566 respondents who provided 6,518 interviews to ACSUS.

Changes in insurance coverage were common in the population. Yet, complete loss of insurance was reported in only 1.5 percent of the interviews, whereas gaining insurance was reported in 3.3 percent of interviews. Having no insurance was associated with significantly lower rates of antiretroviral use (rate ratio, 0.73), antipneumocystic use (rate ratio, 0.58) and antidepressant use (rate ratio, 0.58). Gaining insurance coverage was associated with lower antiretroviral use (rate ratio, 0.75) and antipneumocystic use (rate ratio, 0.70), whereas losing insurance was associated with lower antiretroviral use (rate ratio, 0.58). In multivariate analyses, these associations remained.

Even after adjusting for socioeconomic factors, according to the authors, "individuals who gained, lost, or had no coverage still acquired ARVs at a significantly lower rate than those with stable overall insurance coverage. Loss of overall coverage was associated with an even greater reduction in ARV use than that observed among the uninsured." Notably, the transition in Medicaid coverage was similar to the transition in overall insurance coverage, emphasizing the importance of Medicaid coverage for access to medication in HIV disease.

The investigators concluded the study indicating that the hypothesized relationship between change in health insurance coverage and lower prescription drug use for ARVs was upheld but not the relationship between insurance coverage and PCP and ADP. The difference in drug category, coupled with the facts that uninsured patients with HIV disease report worse access to medical care, and "the uninsured are less likely to receive or be offered ARV treatment," signify the broad need for an insurance safety net for patients with HIV disease.

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