You could say Chad (not his real name) is lucky. The Chicago HIVer, 36, is healthy enough to work, earns $48,000 a year as a hospital nurse and pays a mere $70 a month for his comprehensive, employer-provided health plan. Compared to countless HIVers who either suffer pricey private plans or rely on a crazy-quilt of public and private programs, Chad has a benefits bonanza.
Or you could say Chad is a chump. Currently he puts in overtime (making for an average total of 50-60 work hours a week) just to offset his ever-rising copays. Maybe if he had the time to sit down and study all the federal and state benefits available to low- and mid-income HIVers, he might decide to go part time and cobble together a decent health-care plan care of Uncle Sam. He'd make less money, but he might shell out less in health costs, too. And he'd have time for himself as well as the patients he loves.
How'd it get so bad for Chad, anyway? Well, in 1999, when Chad started on his health plan, his out-of-pocket copays for monthly prescriptions were $5 for generics, $10 for brand names on his plan's preferred drug "formulary" and $15 for off-formulary brands. In 2001, they shot up to $10, $25 and $35, respectively. For the dozen meds (HIV and other) he takes every day, he now shells out about $200 a month. Add his $70 share of the premium, copays for doctor visits, and vitamins and other supplements not covered by his plan, and health care chomps up to $400 out of his after-tax salary of $2,500 a month.
In one sense, Chad is just another case study in what's become a drearily familiar 6 o'clock news story: Health-care costs spiking so dramatically that even fully insured Americans are feeling the pinch via higher premiums, deductibles and "three-tiered copay" systems designed to discourage you from requesting the most expensive drugs. Such increases are easy to brush off when all you need is a routine yearly checkup and the occasional antibiotic. But if a chronic, complicated illness such as HIV forces you to use your health plan like others do a gym membership, you're right up there with the elderly in wallet fatigue. That's why David Wunsch, head of health policy at New York City's Gay Men's Health Crisis (GMHC), calls HIVers "canaries in the coal mines" -- warning of a system that threatens to cave.
Unfortunately, even as health-care reform regains momentum for the first time since Hillary Clinton played doctor in the early '90s, costs show no signs of abating. Meantime, how can HIVers divert dollars toward nicer treats -- like, well, a gym membership? Check out these options:
1. Shop till you drop. If you have the luxury of choosing from more than one plan, you may find that copays vary dramatically from plan to plan. Howard Schwartz, GMHC's coordinator of managed-care access, says you should add up each plan's copay for every drug you're already on, then factor the totals against monthly premiums, deductibles, visit copays and covered/not-covered services in making your final choice.
The big picture? Know thy plan inside out before signing up. "One of the biggest problems that consumers have is they don't understand how their health plan works," says Alwyn Cassil of the Center for Studying Health System Change. "The time to find out what's covered is not when you're sick -- it's when you're well, and going into your open-enrollment period." In other words, read, read, read! Don't understand the small print? Seek counsel from a local ASO, which may be listed at www.thebody.com/hotlines.html (along with helpful hotlines).
2. What's up, Doc? Ask your friendly physician which of your brand-name meds can be replaced with cheaper generics. This won't include the antiretrovirals in your combination, for which generics are not available in the U.S., but may include many others, such as Prozac's generic fluoxetine. "Generics are fine with me unless there's some absolute contraindication," says New York City HIV doc Antonio Urbina, who adds that he tries to keep a patient's pocketbook in mind when choosing between brand-names, too: "I may prefer Pravachol for high cholesterol, but if Lipitor is on their formulary, hence cheaper for them, I'll go with it."
3. Go postal. Find out if your health plan has a mail-order program, which can often deliver a three-month supply of a long-term med for just one or two copays. HIVer Thomas (not his real name) of LA saves $560 a year by ordering his 18 (yikes!) meds via the mail -- though he finds the process so time-consuming that "I'm kind of reduced to being a serf." But New York City's Howard Grossman, MD, suggests that if you need to start a med pronto, ask your doc for a traditional pharmacy "script" to tide you over till the mail arrives.
4. Double your pleasure. If Doc thinks they're right for you, combo pills like three-in-one Trizivir will cut cocktail copays. These "bundled" drugs now exist for high blood pressure and diabetes, too. Limp biscuit? Since 50 mg and 100 mg Viagras cost the same, ask Doc to prescribe 100s, which can be halved. Still hard up? Doc may write other scripts with the same sleight-of-hand: "A script that's meant to be taken one to four times a day can legally and ethically be written as 'four times a day or as directed,'" says one top doc off the record.
5. Face the nation. Can't cut back your copays? Maybe it's time to look into your state's AIDS Drug Assistance Program (ADAP), which may cover your HIV and other meds even if you already have a plan (Call AIDS Treatment Data Network at 212.260.8868 for your state's ADAP number, or look it up at www.atdn.org/access/states). Some states also cover pricey supplements like Juven that HMOs usually don't. Self-employed or soon unemployed? See if you live in one of the 37 states whose ADAPs include a HIP (Health Insurance Program) to pay those mad monthly premiums on your COBRA or private plan.
Unlike Medicaid, ADAP doesn't demand near-poverty, but your income must still fall below a certain level, which varies from state to state, as do ADAP formularies and other specifics -- and keep in mind that, at POZ presstime, 12 states had ADAP waiting lists!
And cheer up, Chad. Eddie Meraz, a benefits specialist at the San Francisco AIDS Foundation, says that a tax expert can often help you work it out so your taxable income qualifies you for ADAP next year. (All it may take is a tax-deductible donation -- perhaps to the very ASO that's giving you all that free counsel in the first place.) ADAP can also be a godsend to the self-employed. Take Jim Pickett, 36, a Chicago freelance writer who claims just enough deductions on his earnings to meet Illinois' roughly $35,000 ADAP income cutoff. But unless you're a tax wiz, make sure you have a good accountant to work this numbers magic. Your job? Easy: Save every receipt!
OUT OF POCKET, OUT OF CONTROL
Do your monthly copays leave you shrieking "Mo' Pay? No way!"? In no time at all, these three trusty tips will turn your big payouts into bigger paydays. POZ promises!
1. Come clean about copays. Let your doctor know about the bite they take out of your income. "So many people are afraid to say, 'I can't afford these things,'" says GMHC's Howard Schwartz. "The doctor might say, 'Look, you really don't need this seventh medication.'" Do your part by rethinking how much you pay for noncovered supplements. Says Bay Area HIV-pro Mary Romeyn, MD, "The difference between $120 a month in boutique vitamins and $22 a month in mass-produced ones, while real, is probably less than $100."
2. Beg pharma for freebies. Drug companies often provide meds free to the verylow-income through "patient-assistant programs" (PAP) -- good to checkout as a last resort should you not be able to get HIV and other essential therapies through some mix of private and public plans. But PAPs also provide drugs as relatively "frivolous" as the antibalding wonder Propecia. For a complete list of PAPs, click on the Pharmaceutical Research and Manufacturers of America's www.phrma.org, or call 202.835.3400.
3. Get mad! Get even! As long as health-care costs keep spiraling out of control, so will "cost sharing" -- the insurance industry's euphemism for shoveling high costs onto you by way of premiums and copays. So if you've exhausted all cost-cutting tricks andstill feel the crunch, the only satisfaction left is to lobby your state and federal reps for an overhaul of the whole U.S.health-care system. Check out the health-care reform group www.familiesusa.org for info on whom and how to push.