PrEP Access & Healthcare Coverage: What’s At Stake?

Preparing for the Worst
HIV/AIDS advocates say PrEP access would be a casualty of ACA replacement
by Larry Buhl

The GOP replacement for the Affordable Care Act (ACA), which was introduced in early March to near universal boos, appears to be dead for the time being. The non-partisan Congressional Budget Office predicted the Republican bill, the American Health Care Act, would lead to twenty-four million more uninsured people by 2026. But it’s not a moot point to explore what any Republican replacement of the ACA, or Obamacare, will mean to those with HIV/AIDS and for those trying to prevent HIV/AIDS.

HIV/AIDS policy experts say there is no good news to report in any Republican replacement, because all of the players on Capitol Hill are gunning for a phase-out of Medicaid expansion. That part of the ACA was a game-changer in health insurance access, at least for thirty-one states that opted for the expansion.

And the rollout of the ACA coincided with Gilead Science’s drug Truvada approved by the FDA in 2012 as an HIV pre-exposure prophylactic, or PrEP. PrEP can reduce the risk of HIV infection by more than ninety percent (and some say ninety-nine percent) when taken as recommended. There are no statistics yet on how many cases of HIV have been prevented by using PrEP.

After a slow start, PrEP’s use has increased dramatically among MSMs. Part of the reason is access. The average price of a thirty-day supply of Truvada was $1,700 in 2015, according to the Treatment Action Group (TAG). For those with health insurance, including many single young men who could not afford coverage before the ACA, the price is often under $100/month.

“The untold story of the ACA is that it closed the coverage gap for single gay men, MSMs, and trans women who would not have qualified for Medicaid previously,” says Kenyon Farrow, U.S. and global health policy director for TAG.

Farrow shared that his own out-of-pocket cost for Truvada had been $30/month until this year when it doubled to $60. That’s in New York state.

Because of the patchwork quilt of state assistance and regional insurance plans in certain markets, the cost of Truvada and wraparound medical services of PrEP vary widely. People are already scrambling to pay for PrEP if they live in states opting not to take Medicaid expansion dollars, and don’t offer PrEP access programs, and don’t aggressively negotiate a lower statewide price for Truvada.

Farrow is especially critical of block granting Medicaid, a centerpiece of the ACA overhaul proposed by House Speaker Paul Ryan and Department of Health and Human Services Secretary Tom Price.

“[Block granting] means that states control the funding for Medicaid any way they want. They can use federal dollars to fill in holes in the budget instead of helping people if they choose.”

Gilead’s drug assistance program could pick up some of the slack, to a point. The program helps people in paying for the drug, but generally it’s used to cover the co-pays and for undocumented people, according to Phil Curtis, director for government affairs at APLA Health in Los Angeles. Curtis says that Gilead isn’t likely to pick up the cost for everyone who can’t afford Truvada.

“The bottom line is, the current [GOP replacement plan] means lower income people without employer-based insurance will be paying much, much more out of pocket for PrEP,” Curtis tells A&U.

And likely, many people would be forgoing PrEP under a GOP-written ACA replacement.

There have been other, less tangible benefits from affordable access to PrEP, according to Ramon Gardenhire, vice president of policy and advocacy for AIDS Foundation of Chicago.

“People who access PrEP through the marketplace also go in for STD testing and other services,” Gardenhire tells A&U. “PrEP gets many of these young ‘invincibles’ through the door to start using the health care system for preventative services.”

Having far fewer people able to access PrEP would delay the ambitious plan of eliminating new HIV infections, something known as “getting to zero,” Gardenhire adds.
People with HIV/AIDS would have faced major challenges under the GOP bill that died in March.

In California, thousands of people with HIV who made too much money to qualify for MediCal, the state version of Medicaid, but are not on the health care exchanges, will lose access to comprehensive coverage according to Curtis.

“Prior to 2014, people with HIV who were able to access MediCal were generally disabled,” Curtis says.

“With ACA and Medicaid expansion, non-disabled, lower income people without employer insurance suddenly had access to affordable and comprehensive health coverage. Most of those people won’t afford coverage without the exchanges and the subsidies [under the ACA].”

Curtis added that every idea coming out of D.C. for replacement of the ACA is “a disaster” for people with HIV and those who want to prevent HIV.

Larry Buhl writes the column, Hep Talk, for A&U. Follow him on Twitter @LarryBuhl.