Health care reform offers a critical opportunity to reduce the significant disparities in access to care that exist for people with HIV across the country (half of whom now lack access to reliable care) and to offer everyone with HIV the opportunity to benefit from early and reliable access to lifesaving HIV care and treatment. Early and stable access to care and treatment for HIV and its co-morbidities helps people with HIV live healthy, productive lives, is more cost effective for the health care system and improves the public health of the community. We believe that, for patients with HIV, the availability of a public plan option as one choice offered through the proposed "National Health Care Exchange" or "Gateway" is important for the following reasons:
- Our patients' health and lives depend on stable and reliable health coverage. A public health plan insurance option would offer greater dependability, stability, consistency and security than private plans which can close or merge and change benefits covered and cost sharing requirements at will.
- Private insurers have a history of discouraging enrollment of patients with HIV by excluding HIV clinicians and programs from their provider networks. Even if safeguards were in place, it would be difficult to ensure access and monitor the adequacy of HIV provider networks in numerous private plans across the country.
- Even in a well-regulated private insurance market, such as Medicare Part D, private plans have a history of imposing cost-sharing levels that impede access to medically necessary medications for people with HIV. For example, under Part D, antiretroviral medications are likely to be on the "Specialty Tier" 50 percent of the time. Drugs on the specialty tier have co-payments ranging from 25 to 33 percent of full drug costs and may not be challenged through the exceptions process. Access to medically necessary medications has been further impeded by burdensome prior authorization requirements and other utilization management techniques.
- While HIV treatment is cost effective and allows our patients with HIV to live long, productive lives, it is required over the course of a patient's entire lifetime and is grounded in access to high-cost medications and services.
- A public insurance option is easier to monitor and evaluate for outcomes and for compliance with rules than a multitude of private plan options that vary by state and region across the country.
- Traditionally, public programs, such as Medicare, have been leaders in developing best practices for health care services delivery and a public plan is more likely to be compelled to support best practices, such as the medical home model for care delivery. Serious mental illness, hepatitis C and substance use disorders are common among our patients with HIV and the coordinated, comprehensive approach offered by medical homes is critical to keeping them in care and addressing their complex health care needs.
- Patients with chronic, intense medical needs are disproportionately burdened by even seemingly nominal levels of cost sharing. The purchasing power offered by a public plan option offers greater opportunity to lower the overall cost of prescription drugs and other services to ensure they are accessible to our patients with HIV.