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The History and Status of the ADAP Funding Crisis -- as of August 2003
The Current ADAP Crisis Status as of Month #5 of the FY '03 Funded Program Year (August 2003)

August 28, 2003

The growth in ADAP need is fueled by the success of HAART in extending the lives of people living with HIV/AIDS and compounded by HIV-positive patients losing public health insurance access (e.g., Medicaid) and/or private health insurance coverage (e.g. losing jobs and hitting private policy caps.) plus successful testing and outreach efforts, additions of drugs to complicated HAART regimens, significant new HIV infections each year and a certain amount of "medical cost inflation." With reasonable resource stability and well recognized US AIDS epidemic trends the ADAP program can be expected to generate an increased need of $100 to $200 Million each year. If resources are not increased by that amount each year "structural deficits" begin to show up in the programs at the State level which are dealt with by creating "waiting lists," capping program expenditures, removing drugs from ADAP formularies, reducing eligibility and the like. The historical national monthly increase of about 600 additional surviving and utilizing HIV-positive ADAP clients has been reasonably steady for some years now. Patients thus continue to look to ADAP when other access routes to HIV care and treatment are closed to them. When patients do try to enroll they either are provided access to care through ADAP -- or NOT.

ADAP was generally well funded from FY '96 through FY '00 with active and open bi-partisan Congressional support. ADAP-related crises did occur but tended to be a function of new programs, rapid scale up, State level resource needs, or local health care delivery issues. Underfunding on a serious nationwide federal level started in FY '01 and continues.

We deal with some aspects of this progression below with the emphasis based on our annual ADAP program data collections as part of the Kaiser Family Foundation supported annual "ADAP Monitoring Report" carried out by our members, NASTAD (National Alliance of State and Territorial AIDS Directors) and ATDN (AIDS Treatment Data Network). We use early data from this process to generate our yearly "need" forecast which we express in terms of an assessment of the year we are in plus the year which must be covered in the next ADAP appropriations cycle.


Projection Methods

The ADAP Working Group's data committee utilizes a computer model developed by respected pharmacoeconomists (Mauskopf J.A., Tolson J.M., Simpson K.N., Pham S.V., Albright J. The Impact of Zidovudine-Based Triple Combination Therapy on an AIDS Drug Assistance Program. JAIDS 2000;23(4) Apr 1: 302-313). The model uses real world information about the immune system status of ADAP clients to project the need for preventive and acute treatment with outpatient drugs. Actual ADAP monthly utilization data collected by the ADAP Monitoring Project provides the basic growth trend for the model. The cost of providing the standard of care to these utilizing ADAP clients on a month-by-month basis are projected out to March 31, 2005.


Base Case Assumptions

Starting with a base ADAP population from June 02, a monthly average growth is applied to the model. Utilization patterns for antiretrovirals and OI Prophylaxis are provided by Pennsylvania and Florida ADAPs. The cost of ARVs are based on an average of actual prices paid by ADAPs, including discounts mandated by the 340 B program, inflation rate adjusted. In keeping with the current standard of care for the treatment of HIV disease, the cost of management of treatment side-effects is also included.


ADAP Cost Containment

Increasing number of ADAP clients are being maintained on their existing health insurance through the use of ADAP funds. This is a much more cost-effective use of ADAP dollars. In FY 2002, the average cost of insurance premiums for an ADAP client is $3,546 per year.


Program Structural Deficits

Individuals who are eligible for ADAP, but were not served by the program due to funding shortfalls, are expected to enter into the program at the start of a new fiscal year. The number of people waiting to access treatment through ADAP is dependent on the size of the shortfall each year.

The Forecast Period: Is from today's date through the end of the FY '04 Funded ADAP Program Year, March 31st, 2005. A total of 22 Months of HIV/AIDS treatment access.


FY 2003 (April 2003 - March 2004) and FY 2004 (April 2004 - March 2005)


Assumptions Based on New Developments in Treatment


History of ADAP Program Restrictions Due to Federal Funding Shortfall

At the End of FY 2001 -- $57 Million Federal Funding Shortfall

Ten ADAPs reported program restrictions as of February 2002:

Alabama: capped enrollment (300 on waiting list)

Georgia: capped enrollment (700 on waiting list)

Guam: capped enrollment

Idaho: capped enrollment

Kentucky: capped enrollment

Maine: (ARV restrictions)

North Carolina: capped enrollment

South Dakota: capped enrollment (22 on waiting list)

Texas: (ARV restrictions)

Wyoming: capped enrollment


At the End of FY 2002 -- $82 Million Federal Funding Shortfall

13 ADAPs reported program restrictions as of March 2003, including 4 ADAPs lowering financial eligibility criteria.

Alabama: capped enrollment (104 on waiting list)

Guam: capped enrollment (4 on waiting list)

Idaho: capped enrollment (no waiting list) and monthly expenditure cap

Kentucky: capped enrollment (116 on waiting list)

Nebraska: capped enrollment (24 on waiting list) and reduced formulary

New York: reduced formulary; mandatory generics; prescription limits

Oregon: capped enrollment; reduced formulary; lowered financial eligibility (145 on waiting list)

South Dakota: capped enrollment and annual expenditure cap (49 on waiting list)

Texas: restricted access to antiretroviral medication (ARV)

U.S. Virgin Islands: lowered financial eligibility

Washington: lowered financial eligibility criteria; reduced formulary; imposed cost-sharing

West Virginia: capped enrollment (4 on waiting list)

Wyoming: capped enrollment (3 on waiting list); lowered financial eligibility; reduced formulary; 90-day waiting period


As of August 2003/Mid FY 2003 -- $145 Million Federal Funding Shortfall

17 ADAPs reported program restrictions as of August 2003.

Alabama: capped enrollment (89 on waiting list)

Alaska: capped enrollment (1 on waiting list)

Arkansas: capped enrollment

Colorado: capped enrollment, reduced formulary (80 on waiting list)

Idaho: capped enrollment, monthly expenditure cap

Indiana: capped enrollment (48 on waiting list)

Kentucky: capped enrollment (165 on waiting list)

Montana: capped enrollment (4 on waiting list)

Nebraska: capped enrollment, reduced formulary (30 on waiting list)

New York: reduced formulary, mandatory generics, prescription limits

North Carolina: capped enrollment

Oklahoma: reduced formulary and annual expenditure cap

Oregon: capped enrollment, reduced formulary, lowered financial eligibility (228 on waiting list)

South Dakota: capped enrollment (50 on waiting list)

U.S. Virgin Islands: lowered financial eligibility

Washington: lowered financial eligibility criteria, reduced formulary, imposed cost-sharing

West Virginia: capped enrollment (14 on waiting list)


N.B.

Extensive additional materials are available from The ADAP Working Group and our members upon request.


History and Data at a Glance

Program Restrictions
 February '02February '03August '03
States With Restrictions101317
States With Capped Enrollment7913
States With Reduced Financial Eligibility 43
States With Reduced Formulary or Access Limitations686
Total Number on Waiting Lists1,022449709


Clients and Expenditures
 June '98June '99June '00June '01June '02
ADAP Monthly Clients Served52,77361,82269,40776,74384,489
ADAP Monthly Expenditures$36,636,193$46,778,490$58,465,169$63,789,458$70,705,142


Budget
 FY 98FY 99FY 00FY 01FY 02
Reported Total Annual Budget*$510,181,254$665,530,408$724,493,196$810,202,138$878,610,754
ADAP Earmark Funds$285,500,000$460,600,000$527,600,000$571,300,000$619,830,000
Sate Funds$119,400,000$125,500,000$128,800,000$149,600,000$160,385,979
* National ADAP Monitoring Report


Growing Deficit
 FY 01FY 02FY 03FY 04
Projected Federal Shortfall$57,000,000$82,000,000$145,000,000$283,000,000




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