Method: Retrospective analyses of cART access were conducted on state Medicaid and AIDS Drug Assistance Programs (ADAP) policies, using data from ADAP Monitoring Reports, the Kaiser Family Foundation, and the Centers for Medicare and Medicaid Services over 2001-2010. The survival effects and lifetime health care expenditures for policies were quantified based on the clinical and cost-effectiveness literature. The effect of cART access on employment, disability and earnings were analyzed with probit and Poisson regression analyses of data from the HIV Cost and Service Utilization Study.
Result: As expected, stricter eligibility requirements based on income, assets or medical status, as well as the lack of a medically needy program, reduce the number of individuals with access to cART through ADAP and Medicaid. In turn, decreased cART use results in higher mortality by 1.4 quality-adjusted life years (QALYs) per beneficiary. For example, in a scenario in which the ADAP income eligibility cutoff is decreased by 50 percentage points nationally, there would be 4,876 fewer individuals with cART access. Based on a $34,900 cost per QALY from the literature, this policy would save $325 million in health care expenditures (2012 dollars), but result in 6,729 QALYs lost. Assuming a $100,000 value of a statistical life-year, the cost of reduced cART access in terms of decreased QALYs would be 2.9 times as large as the benefits in terms of decreased health care spending. In addition, reduced access would lead to a 13% increase in work-limiting disabilities, an 11% decrease in employment, and a 3% decrease in individual earnings.
Conclusion: In the face of increasing budget pressures, state legislators may be considering cuts to programs that increase access to cART for low-income HIV/AIDS patients. While such an approach may be financially advantageous in the short term, it overlooks the longer term advantages not only to patients in terms of improved clinical outcomes, but the economic benefits that derive from increased employment and earnings and decreased disability.