The 21,000 Texans who rely on the state’s AIDS Drug Assistance Program (ADAP) for their HIV medications, as well as their service providers, are freaking out in the face of the program’s $104 million budget shortfall. And it’s a situation just made worse by the Texas Department of State Health Services (DSHS) revealing that $35 million of that shortfall is due to a computer glitch in the program’s software that still hasn’t been fully fixed.
Amid the panic, on Monday, March 29, Texans living with HIV (plwHIV) and service providers plan to have a virtual (because of COVID) HIV Advocacy Day to pressure the state legislature to provide funds to fill in the shortfall—and to pressure the DSHS to be fully transparent about what’s happened.
That’s according to Mike Gifford, CEO of Vivent Health, which operates HIV health centers nationwide, including one in Austin, Texas.
“DSHS came clean this week on what is a really serious crisis facing people who rely on the Texas ADAP program, a very significant funding shortfall that threatens access to meds for more than 20,000 people,” he said.
According to both Gifford and Januari Fox, policy and advocacy director for Dallas HIV service provider Prism Health, the Texas Senate has earmarked $35 million and the House $100 million to make up the shortfall, and now both chambers must go into reconciliation to come up with one figure.
“We need to do a bit more advocacy work with the Senate to show why we need more than $35 million,” said Fox, adding that she saw no reason why Texas Gov. Greg Abbott would not sign off on the funding.
Gifford called the situation “a rotten onion that we’re peeling layer by layer. There has not been the transparency we need from DSHS. We need an external audit of the Texas HIV Medication Program. They get about $150 million for that program from the federal government [which co-manages ADAP programs with each state] and only have to put in about 25% of their own revenue.”
On March 22, Texas DSHS announced the $104 million shortfall, blaming the problem on a 30% increase in ADAP enrollment due to people losing their job-supplied health coverage during the COVID pandemic.
In addition to the $104 million, which is actually to shore up the program through 2023, advocates are also asking for $52 million to support it through August. That’s according to Fox, who says that $34 million has already come in through funding from last year’s federal CARES Act. Additionally, nearly $18 million has come in from federal agency HRSA, and more than $5 million has come in through federal ADAP Supplementary Emergency Relief Funds.
The program began cutting off coverage for some people in December—something it continued to do until February. In addition to a COVID-driven enrollment spike, the program blamed the high cost of single-pill HIV medication formulas and a rollback in drugmaker rebates to governments.
But Gifford questions that. “Don’t they have a process for budgeting and planning? Single-tablet regimens have been around for a while now. Nobody should’ve been surprised by their costs.”
Fox said that DSHS told advocates in a March 24 virtual town meeting with advocates that the computer glitch resulted in program managers thinking they had more medication inventory on hand than they actually did.
“If the discrepancy were about $300,000, that’s one thing,” Fox said. “But how do you not know you’re missing $35 million in meds?”
Chris Van Deusen, head of media relations for the Texas DSHS, confirmed in an email that that was indeed the nature of the computer glitch. “Yesterday’s town hall meeting was just the first step in increasing transparency with clients and other interested parties,” he wrote. “We’re going to continue to have similar conversations and will make sure that we involve the Medication Advisory Committee [made up of plwHIV and providers throughout Texas] in issues as they arise.”
Whereas federal underfunding of ADAP in the mid-2000s caused enrollment waiting lists in many states, Texas currently appears to be the only state contemplating ADAP cuts due to a funding crisis, even with the added stress of COVID.
That’s according to Tim Horn, director of health care access at NASTAD, which works with state and local health departments on administering federally funded HIV programs.
“We’ve been engaging with Texas regarding its various proposed cost-containment measures,” he wrote in an email, “along with the development and implementation of longer-term solutions to ensure the sustainability of the program.”
The Texas ADAP program is already one of the stingiest in the country, demanding enrollees show a maximum income of only 200% of the federal poverty level (about $25,000 for an individual), whereas many states allow a max income of 500% of the federal poverty level, or about $64,000.
Texas is also one of 12 states, many Republican-controlled and in the U.S. South, that have chosen not to expand their Medicaid eligibility under the Affordable Care Act, a limitation that puts yet more burden on a state’s ADAP as a program of last resort for plwHIV who can’t get meds or care any other way.
“Trust between the DSHS and people living with HIV and their providers is at an all-time low,” said Fox. “People feel like they’re being duped because the process has been completely non-transparent. As advocates, we’re happy to push the legislature for more funding, but we can’t do that without all the information.”