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President Bush's $20 Million ADAP Initiative
  October 6, 2004
Source: NASTAD- National Association of State & Territorial AIDS Directors
ADAPs provide HIV treatments to low income, uninsured, and underinsured individuals living with HIV/AIDS in all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, three U.S. Pacific territories (Guam, the Northern Mariana Islands, and American Samoa) and one Associated Jurisdiction (the Republic of the Marshall Islands). ADAPs are a discretionary grant program funded through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Because ADAPs are not entitlement programs, funding levels are not based on the number of people who need prescription drugs or the cost of medications. In addition to federal funding, ADAPs may also receive state general revenue support and other funding, but these other sources are highly variable and dependent on local decisions and resource availability.
What is the President's $20 million ADAP Initiative?
On June 23, 2004, President Bush announced immediate availability of $20 million in drug therapies for ten states with waiting lists as of June 21, 2004. The ten states eligible to participate in this program are: Alabama, Alaska, Colorado, Idaho, Iowa, Kentucky, Montana, North Carolina, South Dakota and West Virginia. The Health Resources and Services Administration (HRSA) is coordinating the program with the ten states. Details have been slow to emerge about the implementation of this program. HRSA was originally working with the Veterans Administration (VA) to directly purchase and distribute the drugs to individuals on waiting lists. However, HRSA's negotiations for an agreement with the VA failed to materialize and HRSA is now contracting with a pharmacy benefits manager (PBM) to directly purchase and distribute the drugs to individuals on the waiting lists.
What are the details of the President's ADAP Initiative?
As of October 6, 2004, details of the direct purchase program include: • There are 1,750 available slots for the program, allocated only to the ten states by the number of individuals on their respective waiting lists as of June 21, 2004. As three months have passed since the program was announced, there are now nearly 1,300 persons awaiting enrollment that will benefit from this initiative. As new clients join waiting lists in the 10 states, they will be allowed to join this program, as long as funding is available.
• HRSA has signed a contract with Chronimed Statscript Pharmacy, a PBM, to administer the program. The contract will run from approximately September 28, 2004 to September 28, 2005, or until the money is expended, whichever comes first.
• Drugs will be sent directly to the client or the client's physician by the PBM.
• The PBM will only purchase drugs that were on the client's state's formulary as of June 21, 2004.
• The drugs will not be purchased through the 340B program or through other cost-saving mechanisms. Costs of administering the program and dispensing fees have not been disclosed.
• It is unclear how long it will take to begin distribution of the medications to eligible individuals even though the contract for the PBM is in place.
Have there been developments in state ADAPs since the announcement of the initiative?
State ADAPs are ever-changing programs due to a variety of factors, including changes in demand, changes in state Medicaid programs and the variability of state and federal funding. Since the President's announcement, developments that have implications for this program include:
• Two states, Arkansas and Utah (not eligible for the President's initiative), report 22 people on ADAP waiting lists (as of September 29, 2004). Two more states (Nebraska and Wyoming, also not eligible for the initiative) began waiting lists on October 1, 2004.
• Fifteen states (13 of which are not eligible for the President's initiative) report having instituted costcontainment strategies such as capped enrollment, limited formulary, annual expenditure caps and cost-sharing (co-pays).
• Five additional states (none eligible for the President's initiative) report anticipating new or additional cost-containment strategies during ADAP's FY2004 (ending March 31, 2005).
• Colorado and North Carolina have received additional state appropriations that have allowed them to clear or substantially decrease their ADAP waiting lists. HRSA has directed that any unused slots from the ten states cannot be transferred to other states with severe need in their ADAP programs.
Waiting Lists and Cost-Containment Measures Continue

Washington, DC -- The National Alliance of State and Territorial AIDS Directors (NASTAD) has released its latest ADAP Watch, a listing of AIDS Drug Assistance Programs (ADAPs) that have implemented or anticipate implementing cost containment strategies to maximize program resources and maintain fiscal viability (see attached NASTAD ADAP Watch for details). These strategies all have a significant impact on client access to life-saving medications.
With current program funding falling far short of meeting the demand of those in need, 1,307 people are currently on ADAP waiting lists in eleven (11) states, awaiting access to life-sustaining drugs. On June 23, 2004, President Bush announced a plan to immediately provide one-time funding of $20 million to provide medications to people on ADAP waiting lists in ten (10) states (registered as of June 21, 2004). All but 22 of the individuals on these waiting lists will be covered under this initiative. While covered individuals have yet to receive medications, NASTAD applauds the President's commitment to increasing access to lifesaving medications for low-income Americans living with HIV/AIDS. The ten states eligible to participate in this program are Alabama, Alaska, Colorado, Idaho, Iowa, Kentucky, Montana, North Carolina, South Dakota and West Virginia. The Health Resources and Services Administration (HRSA) is coordinating the program with the ten states (see attached NASTAD fact sheet for additional details).
Equally concerning, many states have instituted other cost-containment measures that limit access to HIV medications for low-income Americans. Since April 2003, fifteen (15) ADAPs have capped enrollment and/or initiated other cost-containment measures. In addition, five (5) states anticipate the need to implement new or additional cost-containment measures during the ADAP 2004 fiscal year, ending March 31, 2005.
The overall future prospect of funding for ADAPs is bleak, as are the prospects for transitioning individuals from the President's $20 million initiative onto ADAP when the funding runs out. "We are extremely troubled that there is no apparent plan to continue to provide medications for these people on waiting lists," remarked Julie Scofield, NASTAD Executive Director. "This is an ongoing, severe crisis in which many states are struggling desperately to provide these life-saving medications to people in need. A one-time infusion of funds, while greatly appreciated, does not solve the ongoing ADAP fiscal crisis that began three years ago. Unfortunately, programs will continue to make difficult decisions to keep programs solvent," Scofield added.
Federal funding for ADAPs in FY2003 and FY2004 has been insufficient to meet the needs of those eligible and has led to this fiscal crisis for many state ADAP programs. AIDS treatment policy experts have determined that a $217 million increase is needed for ADAPs in FY2005 in order to alleviate restrictions and address the nation's ADAP crisis. NASTAD is very concerned that the funding levels approved in the House and Senate provide only a small portion of the $217 million recommended increase for ADAP programs. In addition, neither the House nor the Senate has included OMB-requested language that would provide continuation of the $20 million in medications to the individuals in the ten eligible states. The House included the reprogrammed $20 million in the FY2004 ADAP earmark. The Senate bill currently treats the $20 million as one-time-only funding. Therefore, there is no guarantee that individuals receiving medication through this program will be covered by ADAPs when the FY2005 ADAP fiscal year begins on April 1, 2005.
NASTAD reports the following nine (9) state ADAPs with waiting lists covered under the President's Initiative, as of September 29, 2004:
• Alabama: 393 on waiting list
• Alaska: 12 on waiting list
• Idaho: 34 on waiting list
• Iowa: 46 on waiting list
• Kentucky: 191 on waiting list
• Montana: 14 on waiting list
• North Carolina: 524 on waiting list
• South Dakota: 36 on waiting list
• West Virginia: 35 on waiting list
NASTAD also reports the following two (2) state ADAPs with waiting lists not covered under the President's Initiative, as of September 29, 2004:
• Arkansas: 11 on waiting list
• Utah: 11 on waiting list
NASTAD reports the following fifteen (15) ADAPs with other cost-containment strategies in place (instituted since April 2003):
• Alabama: Client inactivity now necessitates re-enrollment and subject to waiting list
• Arkansas: Reduced formulary and cost sharing
• Hawaii: Reduced formulary
• Indiana: Capped enrollment
• Louisiana: Capped enrollment for Fuzeon access; 5 people on Fuzeon waiting list
• Minnesota: Cost sharing between 100%-300% FPL (drug co-pays); reapplication every 6 months
• Missouri: Reduced formulary
• Nebraska: Capped enrollment (waiting list begins October 1, 2004)
• New Hampshire: Medical eligibility and formulary restrictions
• Oklahoma: Annual per capita expenditure limit
• South Dakota: Annual per capita expenditure limit
• Texas: Capped enrollment for Fuzeon access; 16 people on Fuzeon waiting list
• Utah: Reduced formulary and lowered FPL eligibility
• Washington: Reduced formulary, lowered FPL eligibility, and increased/expanded cost-sharing
• Wyoming: Capped enrollment (waiting list begins October 1, 2004)
Finally, NASTAD reports the following five (5) ADAPs as anticipating new or additional restrictions during FY2004 (ends March 31, 2005):
• Hawaii
• Louisiana
• Massachusetts
• Oregon
• Wyoming
NATIONAL ALLIANCE OF STATE AND TERRITORIAL AIDS DIRECTORS 444 N. Capitol Street, NW #339 Washington, DC 20001-1512 FAX 202-434-8092 PHONE 202-434-8090 WWW.NASTAD.ORG
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