An ongoing dialogue on HIV/AIDS, infectious diseases,
March 20th, 2008
How to Solve at Least One Part of the Healthcare Mess: ADAP for All
The presidential elections have once again made our Byzantine healthcare system a regular feature in the news. A recent film also made quite a splash, and though Michael Moore offered no plausible solutions (Cuba? c’mon!), he certainly made me wonder what I’d do if I had two severed fingers that needed to be reattached and only enough money to cover one procedure.
Everywhere, you hear the usual complaints: increasing numbers of uninsured, highly variable (but mostly mediocre) quality of care, “skyrocketing” (interesting how often that adjective is used) costs, misaligned incentives leading to overuse of expensive procedures and medications, greedy insurers denying coverage, and (always) unfavorable comparisons with outcomes in other industrialized countries. Reading the various candidates’ solutions to this quagmire, I get that same heavy-lidded feeling I had in medical school when lecturers tried to “explain” how the immune system works — yes, you have a theory and a lot of nice figures, but could anything so complicated really work? Many of those immunology theories have long since been discarded, and it would not surprise me a bit to see the same happen with the presidential hopefuls’ proposals.
It is with great magnanimity, therefore, that I offer the candidates — free of charge — a model of how to fix one aspect of our healthcare mess, the high cost of prescription drugs.
What we need is an AIDS Drug Assistance Program — ADAP — for everyone, and everything. Yes, ADAPs are far from perfect (4 states had ADAP waiting lists in the last year, some patients can’t get their $2000 viral tropism test paid for), but what they’ve accomplished is truly extraordinary. Some highlights:
- Provision of HIV-related prescription drugs to low-income people with HIV in all 50 states, the District of Columbia, Puerto Rico, the US Virgin Islands, and Guam. Some states use ADAP funds to provide insurance coverage as well.
- Each state runs its own ADAP, determining eligibility criteria and coverage — so no one-size-fits-all problem.
- Funding is derived from an imaginative mixture of federal and state sources.
- ADAPs participate in the 340B program, enabling them to obtain prescription drugs far below commercial prices.
- Careful review (and often denial) of medications that have marginal indications for HIV treatment but high cost, such as recombinant growth hormone or erythropoeitin. In other words, cost-containment at its sensible best.
It’s possible (ok, likely) that my rosy view of ADAPs is colored by practicing HIV medicine in Massachusetts, which has one of the more generous ADAP programs in the country. Nonetheless, just think of the typical ADAP beneficiary, and what it would be like caring for him or her without this program — 64% are people of color, 71% are completely uninsured, and over half have an annual income <$9800 (the Federal Poverty Level). Oh yes, more than half are also severely immunosuppressed due to HIV — one could never argue that ADAPs have cherry-picked the “easy” patients.
So go with it, Hillary, Obama, and John — take the best of ADAP, change the name, and make it your plan. Just make sure to leave the real ADAP alone — it’s much too good a program to ruin with national politics.