April 1, 2020

What Does Safety Cost for People with HIV in the US Now?

The onset of the COVID-19 emergency has all of us concerned about how people with HIV are being affected. The inevitable questions include not only “how do we avoid getting Covid-19?” and “how do we make sure people with HIV don’t run out of meds without leaving the house?” but also “how can they/we even afford to stock up on HIV meds?”

POZ magazine’s pragmatically advises people with HIV to make sure they have, “at least a 30-day supply of medications” and are “keeping up to date with flu and pneumonia vaccines, and establishing a plan for clinical care if isolated or quarantined.” It’s all sound advice but it omits some financial and logistical questions including what to do if you are uninsured or, are insured but can’t afford the larger co-pay associated with getting a 90-day supply of your ARV. Covid-19 has made it urgently necessary for privately insured people with HIV to take a look at their policies and see what is and is not covered and when.

Dr. Steve Pergam of the Fred Hutchinson Cancer Research Center encouragingly notes that, “People often lump HIV patients with other immunosuppressed patients, but HIV is a different disease than it was years ago. For people who have a reconstituted immune system because of treatment, I think the risk is not going to be tremendously different.” That is good news, but less promising for older people with HIV who live with less robust immune systems.

Surrounded by major insurance company executives on March 10, Vice President Pence spoke at a press conference where he assured us that these companies have all, “agreed to waive all copays on coronavirus testing and extend coverage for coronavirus treatment in all of their benefit plans.” He also assured Medicare and Medicaid beneficiaries that coronavirus testing and treatment would be covered, as would private insurance carriers, and that “these CEOs have also agreed to no surprise billing.” But what support would be available for privately insured people with HIV who now have to get advance supplies of their HIV drugs?

The CDC is now recommending that people acquire a several-week supply of the prescription drugs they routinely take for chronic conditions to reduce the risk of running out of essential medicines should circumstances change. But how is this actually playing out with regard to their access to insurance coverage?

In a recent NPR interview, Dr. Peter Jacobson of the University of Michigan School of Public Health said that, “Most insurance companies have rigid schedules for authorizing refills.” NPR added that, “Typically, that means if you have a one-month supply you can’t refill it until the 24th day, or if you have a 90-day supply you can’t refill it until the 85th or even 88th day.” Asking assistance from one’s pharmacist or primary care provider can sometimes help to expedite access, they acknowledge, but this does not help people who simply can’t afford the copay cost of investing in a stock-pile of medications.

NASTAD acknowledges that, regarding ARVs, “while federal, state, and payer policies are being loosened to support early refills and 60- or 90-day fills as a part of COVID-19 quarantine requirements and social distancing efforts, pharmacies may experience challenges meeting this demand.” This suggests to Academy members that, within their HIV practice, it is now increasingly important to find out if their patients can afford to stockpile the HIV medications they need to stay healthy. If they do not, it may be useful to point them toward social services for assistance in either paying the heightened insurance copays or coping with their uninsured status. Both of these can block a patient’s uninterrupted access ARVs during this crisis, making it impossible for them to stay home and protect themselves.

A third, future recommendation from the Academy is to remember all of this when going to the polls next November. Vox.com observes that, “there is a real concern that Americans, with a high uninsured rate and high out-of-pocket costs compared to the rest of the world, won’t seek care because of the costs. Before the crisis even began, the United States had fewer doctors and fewer hospital beds per capita than most other developed countries.”

As Jen Kates, Director of Global Health and HIV Policy at the Kaiser Family Foundation, summarized, “Everyone working in this space would agree that no matter how you measure it, the US is far behind on this.”