States across the U.S. have either implemented or are considering measures that limit access to life-saving medications for tens of thousands of low-income people living with HIV. The moves, experts warn, are likely to lead to economic and public health crises.

According to new data published this week by the National Alliance of State and Territorial AIDS Directors (NASTAD), 17 states and D.C. have already taken steps to cut costs for their AIDS Drug Assistance Programs (ADAP), while five others are considering similar measures.

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Florida cuts off life-saving HIV medication program to tens of thousands of people

Since 1996, federally funded ADAPs have helped low-income, uninsured, and underinsured people afford HIV and AIDS medication, primarily through federal grants via the Ryan White Comprehensive AIDS Resources Emergency Act of 1990.

But as NASTAD’s report notes, “Federal funding for ADAPs has remained relatively unchanged over the last decade, while client enrollment and healthcare costs, including prescription drug, insurance premium, and cost-sharing expenditures, have continued to increase.” According to nonprofit health policy research group KFF, congressionally allocated funding for ADAPs “has not kept pace with inflation, even before accounting for enrollment growth and increased costs.”

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According to both NASTAD and KFF, the expiration of enhanced premium tax credits for the purchase of insurance through the Affordable Care Act marketplaces is another key factor driving up costs for ADAPs.

“Effectively, programs are being asked to do more with less federal funding,” Lindsey Dawson, associate director of HIV policy at KFF, told the New York Times.

That has led to 10 state ADAPs reporting budget deficits for the current fiscal year, while 19 ADAPs expect to face deficits in the upcoming fiscal year, according to NASTAD.

NASTAD reports that five states — including Pennsylvania, Kansas, Delaware, and Rhode Island — have already lowered income eligibility for the ADAP.

By far the most drastic change took effect in Florida on Sunday. The state’s move to reduce income eligibility for its ADAP from 400% of the federal poverty level to 130%. That means people living with HIV in Florida who make more than approximately $20,500 annually — down from around $64,000 prior to the change — are now ineligible to receive ADAP assistance for medication that can cost more than $5,000 per month. By one estimate, 16,000 people living with HIV in Florida are now at risk of losing access to HIV/AIDS medications.

Other states, including Arkansas, Louisiana, New Jersey, Virginia, and Washington, are similarly considering changes to financial eligibility criteria. Others have or are considering other measures, including reducing formularies (the list of drugs covered), annual spending caps, restricting or ending health insurance assistance, and implementing recertification requirements that will likely lead to disenrollment, according to KFF. NASTAD reports that Arkansas, Louisiana, and New Jersey are also considering implementing waitlists for assistance.

Such cost-cutting measures “could leave growing numbers of people with HIV ineligible for safety-net services,” according to KFF.

Esteban Wood, director of AIDS Healthcare Foundation, which is suing to block Florida’s ADAP changes, warned the New York Times this week that the changes represented not only a “moral disaster,” but would likely lead to both public health and economic disasters. HIV medications not only keep people living with the virus healthy, they also make it essentially impossible to transmit it, and cutting off access to those meds will inevitably lead to an increase in new infections. The Times also notes that if people begin rationing their pills, the likelihood that the virus becomes resistant to medication increases.

The untold costs of such outcomes will have to be absorbed by other parts of the U.S. public health system, according to the Times.

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