By Barrett White
The numbers are clear: HIV affects people in the South at much higher rates than elsewhere in the nation. Within the southern demographic, the virus disproportionally affects BIPOC southerners. And right here in Texas—where we have the highest uninsured rate in the nation—the state legislature would like to cut funding for the Texas HIV Medication Program (THMP).
THMP is the official AIDS Drug Assistance Program (ADAP) for the State of Texas. THMP has provided medications for HIV and AIDS, and for other opportunistic infections that may come as a result of them, to Texans since 1987. Further, THMP operates the Texas HIV State Pharmaceutical Assistance Program (SPAP), which helps people living with HIV with their out-of-pocket costs associated with Medicare Part D prescription drug plans, including co-payments, deductibles, and coinsurance.
HIV medication isn’t cheap—many people living with HIV in the U.S. are unable to pay for their life-saving medications without the assistance of ADAP.
In December 2020, health advocates and providers statewide were dealt a sucker punch when the state eliminated the “spend down.” According to the Texas Department of State Health Services, to “spend down” meant that the THMP would consider the cost of medications provided to applicants and spend down client income based on this cost. “This generates an adjusted [federal poverty level] that is used for program eligibility determination,” the site says. This came after a Health Resources and Services Administration (HRSA) audit found that the spend down was not being applied equitably across all applicants.
Instead of adjusting the spend down to make it equitable, Texas opted to eliminate it.
“That was not HRSA’s suggestion,” says Januari Fox, the Director of Policy & Advocacy at Prism Health. The department continued to double down on the assertion that it was due to the HRSA audit, but health advocates had already read the HRSA report and knew differently.
On January 29, the Medication Advisory Committee (MAC) held a meeting, and, after a month of dishonesty with the lives of people living with HIV in the balance, the truth came out: the department simply didn’t have the funds to continue. “That changes the direction of things,” says Fox. “The larger issue became that the program itself was in a severe budget deficit.” The numbers are staggering for a single state—$52 million in the red. If they didn’t get funding by March, the department said, they would have to cut more than just the ADAP part.
The cause of the deficit was reduced to three main causes, per the THMP:
- The department saw a $34 million uptick in the use of the program during the COVID-19 pandemic. Between March and December 2020, many Texans lost their jobs—and therefore their insurance plans—and required other means of accessing medications. Naturally, they flocked to the THMP.
- The department saw an increase in cost of single-tablet regimens. There have been leaps and bounds in the advancements of HIV-treating (and preventing) drugs over the last few decades. Presently, there are many single-tab treatments available, as opposed to multi-pill drug cocktails. These new medications however are getting pricier to supply.
- The third reason provided was that they’re getting fewer pharmaceutical rebates.
“I don’t know about the latter two reasons,” Fox says. “But the first is fair.”
THMP applied for funds from the CARES Act and HRSA, and made minor cuts to other departments to fund ADAP instead. “Which is something we never want to see,” says Fox. “We never want to see ‘Robin Hood’ cuts that take funds from other deserving programs.”
Fox and fellow advocates from other health organizations met with state lawmakers ahead of the current legislative session to express their concerns. “We all met with Representatives Toni Rose (D-TX-110), Donna Howard (D-TX-48), and Julie Johnson (D-TX-115) really early in the [legislative] session—maybe before session started,” Fox says. “They have been fantastic. They have sent letters to the Commissioner of the DSHS and have been a crucial part of this as we move forward.”
Ultimately, the spend down was reinstated with the promise that the department would revisit the issue in June. While not yet in the clear, advocates are hopeful, if not weary. Though it is a win that the spend down was brought back from the legislative grave, it begs the question—how? What did the department do to make this possible? How could it be unaffordable, but then reinstated for a several-month run before talks resume in June? Fox and advocates have yet to receive a solid answer.
The state brought in an actuary to analyze the program’s finances, uncover the holes in its budget, and figure out where to go from here. But it wouldn’t be Texas politics if there wasn’t yet another surprise around the corner: while the actuary’s discoveries were not revealed to Spectrum South, we were informed that the aforementioned $52 million deficit was, unfortunately, a lowball.
What we do know is that THMP has put in a budget request for $104 million over the next biennium—and that’s just to keep the program stable.
The future certainly looks less grim, but the mist hasn’t cleared completely. Advocates are still vying for a clear path to victory, but much of their success thus far, they say, has come from the work of the community. “From an advocacy perspective, people have rallied around this amazingly,” Fox says. “It has been a beautiful thing to see. People came together very quickly, identified their legislators, and visited with them, rallied their troops on the ground.”
“Rallying the troops,” includes events like HIV Advocacy Day at the Capitol on March 29, 2021, made possible by the Texas HIV/AIDS Coalition. Organizations like Legacy Community Health invite community members to join them virtually to speak with Texas lawmakers about HIV treatment and prevention, HIV education, HIV criminalization, and, of course, funding for ADAP. You can sign up to participate with Legacy at this link. Fox says that so far, thankfully, no changes have taken place that would impact Texans living with HIV—yet. Fox concluded, “The human component of all of this is that should drastic changes be made, this is ultimately going to affect and target BIPOC communities, which are already overwhelmingly affected by HIV, and overwhelmingly affected by COVID-19.”
