The Washington Blade, November 13, 1998
Kai Wright

While some AIDS service organizations said that the changes would not impact large numbers of people with AIDS, the National Association of People with AIDS stressed it will affect patients who they don't fit into the broad categories that government safety net programs are designed to catch--that is, it will affect many people who are already falling "fall through the cracks" of various AIDS service programs.

In a letter mailed to members this month, Kaiser announced benefit and rate changes for members in individual plans -- those who do not receive insurance via their employer but pay for it directly. Among those changes, the letter explained, is a $1,500-per-member/per-year ceiling on how much the insurance company will pay for prescription drug services, and an increase in how much the patient must "co-pay" for each prescription. Previously, the Kaiser plans had no cap on prescription drug services.

People with HIV and AIDS who take the drug regimens recommended by the U.S. Department of Health and Human Services often need medications that cost much more than $1,500 per month--more than $18,000 per year.

Kaiser's Mid-Atlantic States division boasts more than half a million subscribers in D.C., Maryland, and Virginia. A Kaiser spokesperson said about 30,000 of those people are in direct-pay, individual plans.

NAPWA's Jeff Crowley said the changes will be devastating to any people with HIV or AIDS among that group. But, he added, the damage done by Kaiser's changes will be limited somewhat by the fact that most people with AIDS would ultimately not need such a plan. He said that those who may need direct-pay plans -- people who have left their jobs and transitioned into an individual health insurance plan -- probably left work because of a deterioration in their health. Those people, he said, would qualify for Medicaid due to their disability status. And while there is also a maximum income level for Medicaid eligibility, many people with incomes above that mark end up qualifying when their incomes drop after leaving their jobs for health reasons, Crowley explained.

Other people with HIV may qualify for the federally funded AIDS Drug Assistance Program (ADAP), which subsidizes AIDS drugs for people with low incomes who are too healthy for Medicaid and don't have adequate private insurance.

Still, Crowley stressed, there are those who "fall through the cracks." These people could fit into any number of categories that don't fall neatly under one of the broad programs designed to help people with AIDS pay for life saving drugs. Some have left work for non-medical reasons and aren't disabled. Others, disabled or not, have too high an income for ADAP or Medicaid but still cannot afford the bill for a year's worth of medications.

People in these situations who have direct-pay Kaiser plans are now angrily asking how they will continue to afford vital medications.

"That's the question," said one HIV-positive policyholder, Virginia resident Greene Ferguson. "What am I gonna do, die?"

Working part-time as a caterer, Ferguson said his income varies, but ranges from the mid- to upper $30,000s per year û about $5,000 to $10,000 above the income level that would allow him to qualify for Virginia's ADAP. He's not disabled, largely due to the fact that he has been taking the recommended drug treatments, and thus wouldn't qualify for Medicaid either.

"I've got to begin to die now before I hit any of these other nets," he said.

Said Crowley of people like Ferguson: "They have very limited options."

Under a federal law created by a 1996 health care reform bill, all states must insure access to some sort of individual coverage for anyone who has transitioned out of a group plan offered by a former employer, doesn't qualify for Medicare, Medicaid, or other state health insurance programs, and is without private health insurance. Thus, one option for people like Ferguson would be to investigate individual health plans mandated by the state government to meet this requirement.

In D.C. and Virginia, Blue Cross Blue Shield guarantees individual coverage in order to fill the federal requirement. In Maryland, a number of private HMOs participate in a state-mandated program to offer individual health plans for people eligible under the federal law.

But the federal law does not regulate fees for these state programs. So, while an eligible person cannot be denied coverage in any state, he or she may be charged astronomical amounts for it and those charges can be set based on the cost of the customer's health problem. Crowley said that, regretfully, for someone in Ferguson's condition the only solution may very well be to shop around from state-to-state to find a new locale that offers the cheapest individual coverage.

Another option, Crowley said, is to investigate drug purchasing assistance programs offered by some AIDS drug manufacturers.

Mary Woods, a spokesperson for Kaiser, said that the company has created a similar program for people in direct-pay plans that have high prescription drug costs. Currently, three people with AIDS have signed up for it. Admission is on a case-by-case basis and interested people should contact Kaiser's membership services to find out if and how they can qualify.

"We do have an institutional commitment to help people so people don't fall through the cracks," Woods said. She said the benefit changes were the result of a "convergence" of issues surrounding direct-pay plans. Kaiser realized it was one of very few private insurers that had no cap on prescription drug services in direct-pay plans, she explained. And with prescription drug costs going up, she said, Kaiser had to find ways to cut spending.

Woods stressed that, in addition to their drug purchasing assistance program, Kaiser is committed to helping members who suffer from the new cap find alternative ways to afford prescription drugs.
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