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The AIDS Drug Assistance
Program: Findings from the
National ADAP Monitoring
Project Annual Survey
Presented at a Policy Forum to Release the Annual Report of
the National ADAP Monitoring Project
April 10, 2007 ■ Washington, DC
Presented by:
Jennifer Kates, Kaiser Family Foundation
Murray Penner, NASTAD
Additional co-authors:
Alicia L. Carbaugh, Kaiser
Beth Crutsinger-Perry, NASTAD
Celeste Davis, NASTAD
Britten Ginsburg, NASTAD
Angela Seegars, NASTAD
Chart 1
The National ADAP Monitoring
Project and Survey
• Partnership between Kaiser and NASTAD since 1996
• All ADAPS receiving federal earmark surveyed
– 54 in FY 2006*; 51 responded
– Non-responders represent <1% of estimated living AIDS cases
• Data from:
– June 2006 for most indicators; offers monthly “snapshot”
comparisons to earlier periods
– FY 2006 for budget indicators and some policy variables
– More recent data from supplemental data collection for
formularies, Medicare Part D policies, waiting lists, other cost-
containment measures
• Full report on www.kff.org and www.NASTAD.org
• State-level data on www.statehealthfacts.org/hiv
*In FY 2007, 58 state and territorial jurisdictions will receive federal ADAP earmark funding.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 2
Highlights and Major Themes
• ADAPs are the nation’s prescription drug safety-net for
people with HIV/AIDS who have limited or no access to
needed medications
• A variable safety-net: what one gets depends on where one
lives
• States have come to the fore as major source of ADAP
funding, key driver of budget increases
• But states find themselves in a delicate balance
– Between program capacity and client demand
– Limited set of “levers” available
• Waiting lists: fewer in number than in recent years but they
continue; potential signs of increase?
• Part D: significant impact, relieving pressure on ADAPs, but
some uncertainty remains
• Ryan White reauthorization: opportunities & challenges
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
June 2006 “Snapshot” Findings
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Chart 3
ADAP Clients, June 2006
• Nearly 142,000 enrollees;
about one quarter of
people with HIV/AIDS in
care
• 68% of those enrolled
received Rx in June 2006;
thousands of others
141,856 received insurance
coverage
96,121 • Ten states accounted for
most clients served (68%) –
13,744
range from 25 to more than
17,000
• Client utilization stable
Clients Enrolled Clients Served Clients Served between June 2005 and
(Medications) (Insurance) June 2006; 21 states had
increases, 27 had
decreases (Part D)
Notes: 51 ADAPs reported data. Some clients receiving insurance coverage through ADAP may
also be receiving medications.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 4
Profile of ADAP Clients, June 2006
>300% FPL 5% • Almost two-thirds were
White
201-300% FPL 10% people of color (61%)
36% • Most low-income (82% at or
101-200% FPL
27%
below 200% FPL)
• Most uninsured (71%)
African • Most were men (78%) and
American between the ages of 25-44
33%
(54%)
<100% FPL
55%
• More than half with
Hispanic indications of advanced
26% HIV disease (CD4 count
Unknown/ Unknown <350)
Other 5% 2%
Race/Ethnicity Income
Note: 51 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 5
ADAP Drug Expenditures & Per Capita Drug
Spending, June 2006
• Drug spending totaled $95.3
Monthly Drug million in June 2006
Expenditures $95.3 • ADAPs also spent $5.4
million million on insurance
coverage in June 2006; $83.5
million in FY 2006
• 10 states accounted for most
drug spending (77%); range
from $22K to nearly $20
All
Other
million
Per Capita ARVs
8% • Drug spending 7% less in
Drug 89% "A1" OI June 2006 compared to June
Spending 3% 2005 (Part D)
$991
Note: 51 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 6
ADAP Drug Expenditures & Prescriptions
Filled, by Drug Class, June 2006
"A1" OI
9%
Protease "A1" OI
Protease
Inhibitors 3%
Inhibitors
30%
NNRTI 20%
All Other
11% All Other
NNRTI 28%
8%
10%
Fusion
NRTI NRTI Inhibitors
47% Fusion 33% <1%
Inhibitors
1%
Total = $95.3 million Total = 344,904
Drug spending Prescriptions Filled
Note: 51 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 7
ADAP Expenditures Per Prescription,
by Drug Class, June 2006
$1,260
$392 $399 $410
$276 $306
$76 $82
Total "A1 OIs" All All ARVs NRTIs NNRTIs PIs FIs
Drugs Other
Note: 51 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 8
ADAP Income Eligibility,
as of June 2006
VT NH
WA ME
MT ND
MN MA
OR WI NY RI
ID SD MI
CT
WY
PA NJ
NE IA
IN OH
IL DE
NV WV
UT VA
CO KS MO MD
CA KY
NC DC
TN
OK
AZ AR SC
NM
GA
MS AL
AK
TX LA
FL Guam
Puerto Rico
HI
Virgin Islands (U.S.)
Income eligibility greater than 300% FPL (21 ADAPs)
Income eligibility between 201% FPL and 300% FPL (19 ADAPs)
Income eligibility at 200% FPL or below (11 ADAPs)
Not reported (3 ADAPs)
Notes: 51 ADAPs reported data. The 2006 Federal Poverty Level (FPL) was $9,800
(slightly higher in Alaska and Hawaii) for a household of one.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 9
ADAP Formulary Coverage of Antiretroviral
Drugs, as of November 2006
VT NH
WA ME
MT ND
MN MA
OR
WI NY
SD MI RI
ID
CT
WY
PA NJ
IA
NE OH
NV IL IN DE
UT WV
VA
CO MO MD
CA KS KY
NC DC
TN
OK AR SC
AZ NM
MS AL GA
AK
Guam
TX LA
Puerto Rico
FL
Virgin Islands (U.S.)
HI
Covers all ARVs in all four drug classes, NRTIs, NNRTIs, PIs, and Fusion Inhibitor (35 ADAPs)
Covers all NRTIs, NNRTIs, PIs, but not Fusion Inhibitor (1 ADAP)
Covers Fusion Inhibitor but not all NRTIs, NNRTIs, and PIs (13 ADAPs)
Does not cover Fusion Inhibitor or all drugs in other classes (5 ADAPs)
Notes: 44 ADAPs reported data. For the states that did not report, last year’s information was used.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 10
ADAP Formulary Coverage of “A1” Drugs
for OIs, as of November 2006
VT NH
WA ME
ND
MT
MN MA
OR
WI NY
ID SD RI
MI CT
WY PA
NJ
IA
NE OH
IL IN DE
NV
UT WV
VA MD
CO MO
CA KS KY
DC
NC
TN
OK AR SC
AZ NM
AL GA
MS
AK
TX LA Guam
Puerto Rico
FL
Virgin Islands (U.S.)
HI
Covers all 29 “AI” OI drugs (4 ADAPs)
Covers 15-28 “AI” OI drugs (33 ADAPs)
Covers less than 15 “AI” OI drugs (16 ADAPs)
Does not cover any “A1” OI drugs (1 ADAP)
Notes: 44 ADAPs reported data. For the states that did not report, last year’s information was used.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 11
ADAPs With Waiting Lists,
as of March 2007
VT NH
WA ME
MT ND
(20) MA
MN
OR NY
WI
ID MI RI
SD CT
WY
PA
NJ
IA OH
NE
IL IN DE
NV WV
UT VA
CO KS MO MD
CA KY
NC
TN DC
OK SC
AZ NM AR (463)
GA
AK MS AL
(13) Guam
TX LA
FL Puerto Rico (75)
Virgin Islands (U.S.)
HI
Waiting list (4 states; 571 individuals)
No waiting list
Note: 52 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 12
ADAPs with Cost-Containment Measures,
Instituted in FY 2006 (4/06-3/07)
(Other than waiting lists)
3
2 2
1
Reduced Eligibility Cost-Sharing Capped
Formulary Restrictions Enrollment
Note: 52 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
7
Chart 13
National ADAP Budget, by Source,
FY 2006
Drug Rebates
Other $230,304,885
State/Federal (17%)
$14,538,586
(1%)
Title I
$18,392,900
(1%)
State Title II ADAP Earmark
$304,905,005 $779,750,980
(22%) (56%)
Title II Base
$28,615,120
(2%)
Title II ADAP Supplemental
$9,795,020
(1%) Total = $1.39 billion
Note: 51 ADAPs reported data. Title II earmark and supplemental funding data available for all 54 jurisdictions.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 14
Number of ADAPs, by Budget Source,
FY 2006
54
40 39
20 21
12 14
Title II Title II Title II State Title I Other Drug
ADAP ADAP Base State/Fed Rebates
Earmark Suppl.
Notes: 51 ADAPs reported data. Title II earmark and supplemental funding data available for all 54 jurisdictions.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
8
Chart 15
Number of ADAPs with Funding Decreases, by
Budget Source, FY 2005-2006
20 20
13
10
7 8
6
Overall Title II Title II Title II State Title I Drug
Budget ADAP ADAP Base Rebates
Earmark Suppl.
Notes: 51 ADAPs reported data. Title II earmark and supplemental funding data available for all 54 jurisdictions.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Major Trends & Key Issues
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Chart 16
Trends in ADAP Clients & Drug Expenditures,
1996-2006
(Percent Change)
528%
Drug Spending Clients Served
242%
203%
115% 105%
39% -7% -1%
1996-2006 1996-2000 2000-2006 2005-2006
Note: Comparisons over time based on 49 ADAPs reporting in each comparison period.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 17
Trends in ADAP Clients & Drug Expenditures,
Continued….
• Client utilization (number receiving medications)
– Increased significantly over time, but at a decreasing rate
• Drug expenditures
– Have grown at approximately twice the rate as client utilization
over decade-long period
• Part D Impact: For first time, client stabilization between
monthly snapshots (June 2005 and June 2006) and decrease in
drug spending
– One-time shift
– Timing of Part D (May 15, 2006) and ADAP monthly snapshot
survey (June 2006)
– Uncertainty about ongoing effect – clients? expenditures?
– Other indicators suggest continued growth in some areas:
growing client enrollment, increase in insurance
purchasing/continuation
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
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Chart 18
Number of People on Waiting Lists by Survey
Period, July 2002-March 2007
1,629
1,518
1,307
1,108 1,263
Part D
1,110 Enrollment
925 Deadline
726 866
791 813 791
622 628 571
626 568 684 558
PAI 647
630 Begins 592
552 552 537 541 435
453 331 340
PAI
310 302
Announced
Jul-02
Jan-03
Feb- 03
Mar- 03
May- 03
Jun-0 3
Jan-0 4
Mar- 04
May -04
Jul-04
Jan-05
Mar- 05
May- 05
Jul-05
Jan-06
Feb- 06
May- 06
Jul-06
Jan-0 7
Mar- 07
Oct-02
Dec-02
Sep -03
Nov-03
Sep-04
Nov-04
Sep-05
Nov-05
Sep-06
Nov-06
Apr-03
Aug -03
Notes: PAI is “President’s ADAP Initiative”. ADAPs were required to enroll Medicare Part D eligible clients,
or stop paying for Part D covered services, by May 15, 2006.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 19
Medicare Part D:
ADAP Policies, as of November 2006
33
27 27 25
23
Pay Part D Pay Part D Pay Part D Disenroll Clients Provide
Premiums Deductibles Co-pays in at Least One Medications
Beneficiary During
Category Coverage Gap
Note: 48 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
11
Chart 20
The National ADAP Budget,
FY 1996-2006
$1,600
$1,386.3
$1,400 $1,299.0
$1,186.9
Millions of Dollars $1,200 $1,070.5
$961.7
$1,000 $870.2
$779.0
$800 $711.9
$543.7
$600
$393.4
$400
$200.4
$200
$0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
120%
100% 96%
Percent Change
80%
60%
38%
40% 31%
12% 11% 11% 11%
20% 9% 9%
7%
0%
96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06
Notes: 51 ADAPs reported data. Title II earmark and supplemental funding data available for all 54 jurisdictions.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
Chart 21
State Funding for ADAPs,
FY 1996-2006
$350
$304.9
$300
$252.8
Millions of Dollars
$250 $226.6
$200 $171.9
$149.6 $160.4
$150 $117.4 $119.4 $125.5 $128.8
$100
$50.4
$50
$0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
140%
133%
120%
100%
Percent Change
80%
60%
32%
40%
16% 12%
20% 5% 7% 7% 21%
2% 3%
0%
96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06
Note: 51 ADAPs reported data.
Source: Kaiser & NASTAD, National ADAP Monitoring Project Annual Report, April 2007.
12
Chart 22
Ryan White Reauthorization:
Changes for ADAPs
• Minimum formulary
– At least one ARV from each approved class of ARV medications
(currently four classes)
• ADAP supplemental
– Increase from 3% to 5% of the ADAP earmark
– Matching requirements can be waived in some instances
– Change in eligibility
– Hold harmless “delinked” from ADAP supplemental
• Funding formula
– Incorporation of living HIV cases in addition to actual (previously
estimated) living AIDS cases
• Changes to other parts of Ryan White
– 75% of funds must be spent on core medical services
– Part B base formula modifications
– All territories eligible for ADAP
Chart 23
The Outlook
• Critical role of ADAPs will continue
– Growing population of people living with HIV/AIDS
– Filling the “gap”
• Key areas to monitor include:
– Impact of Part D has been significant
• Relief of pressure on ADAPs; contributed to reduction in waiting lists
• But is it a time-limited effect? What will happen when clients reach the
doughnut hole?
– Ryan White reauthorization impacts?
• Some states will have to change their formularies; also, new ARV
classes?
• Potential funding shifts
– Waiting lists over time
– Role of States
– Other factors such as the CDC’s new recommendations for
routine testing
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