Expanding and Adapting ADAP Service Delivery in a Dynamic Healthcare Environment

ADAPs must continually navigate a dynamic healthcare environment to not only ensure continuity of medication access for clients, but also to meet the evolving and comprehensive needs of low-income PLWHA. The need to expand and adapt ADAP service delivery is not without opportunities, including those associated with the Affordable Care Act and a slow-but-steadily growing number of states moving to expand their Medicaid programs. But there are also challenges, particularly when it comes to coordinating with other highly complex components of the U.S. healthcare system straining under the weight of high prescription drug and insurance costs.

Full-Pay Medication Programs

Full-pay medication assistance for uninsured and underinsured PLWHA – including insured individuals with limited coverage of clinically necessary medicines – remains a core service provided by state and territorial ADAPs. In CY2022, more than 130,000 clients served required ADAP medication purchasing support to ensure access to at least one prescription drug essential to comprehensive HIV care. These include antiretroviral drugs products; medications to prevent and treat AIDS-related opportunistic diseases; curative direct acting antivirals for hepatitis C virus coinfection and antiviral therapeutics for chronic hepatitis virus infection; medications for substance use disorders, including overdose prevention; medications to manage cardiovascular, metabolic, and pulmonary diseases that are more common among PLWHA; as well as medications to support mental health and gender-affirming care.

Prescription drug purchasing accounted for more than $1.4 billion in net ADAP spending (pre-rebate and other third-party payments) in CY2022, accounting for approximately 63% of all ADAP program expenditures. While a breakdown of prescription drug expenditures was not requested as part of the 2023 annual survey in support of the 2024 Annual Report, these data were provided in association with the 2022 annual survey. Antiretroviral drug products represented 93% of all CY2021 ADAP drug expenditures.

Federal funds used by ADAPs to pay for prescription drugs must be utilized “in the most economical manner feasible.” This includes securing statutorily required discounts on outpatient prescription drugs available to certain federal grantees through participation in the 340B Drug Pricing Program, including state and territorial ADAPs. ADAPs also have access to supplemental 340B discounts and/or rebates, depending on the ADAP’s drug purchasing mechanism (Table 18 includes a review of purchasing mechanisms employed by state/territorial ADAPs for both their full-pay medication programs and ADAP-funded insurance programs), including those secured by the Apexus Prime Vendor Program and negotiated by the ADAP Crisis Task Force. The resulting savings has allowed ADAPs to maximize their eligibility criteria, establish comprehensive formularies, and fund treatment support services essential to achieving health equity among PLWHA.

ADAPs have considerable flexibility in determining not only the composition of their formularies, with some ADAP formularies required to match state Medicaid formularies (5 ADAPs in CY2022), but also the implementation of cost-containment measures, such as maximum cost-per-client caps, maximum prescription number caps, and prior authorization requirements (including clinical criteria, resistance testing, and step therapy requirements).

ADAP-Funded Insurance Programs

The Affordable Care Act, signed into law by President Barack Obama in March 2010, has enabled tens of thousands of PLWHA, including ADAP clients, to transition to expanded Medicaid and private insurance available through the federal and state Marketplaces. The ACA’s public and private insurance expansions have had a profound impact on ADAPs and the clients they serve despite fluctuations in federal and state policy affecting Medicaid and private insurance. ADAPs continue to support more clients than ever to afford insurance coverage.

In CY2022, all 51 ADAPs responding to the survey reported using funds for insurance purchasing/continuation, including premium, deductible, and/or copayment/coinsurance payments for multiple insurance types, representing $698 million in estimated expenditures (32% of the total ADAP budget for the year) for 132,379 ADAP-funded insurance clients, with an average cost per client of $5,272. For a five-year comparison, the average premium and cost-sharing support expenditure per ADAP-funded insurance program client was $3,610 in CY2017, representing a 46% increase in per-client spending.

In CY2022, 34% of ADAP clients served were enrolled in private insurance (e.g., individual market plans purchased on or off Marketplaces and employer-sponsored coverage). Among clients served who were enrolled in private insurance, 50% were enrolled in a qualified health plan (QHP) on the ACA Marketplace – an 11% increase compared with the number of ADAP clients with private insurance with known Marketplace QHQ coverage in CY2017.