Oregon Health Authority Medicaid Waiver Comments

[email protected]

Health Policy and Analytics Medicaid Waiver Renewal Team

Attention: Michelle Hatfield

500 Summer St. NE, E65

Salem, OR 97301

Dear Director Allen:

Since 1999, HealthHIV has made its mission to advance effective prevention, care, support, and health equity for people living with, at risk for, or acquisition of HIV and viral hepatitis—particularly within LGBTQ and underserved communities who are often enrolled in state Medicaid programs, like yours. We do this by providing education, capacity building services, health services research, and advocacy to state health departments, organizations, communities, providers, professionals, and community advocates, alike. 

And we appreciate the opportunity to submit comments to the Oregon Health Authority (OHA), regarding the proposed Application For Renewal And Amendment Oregon Health Plan 1115 Demonstration Waiver—the Oregon 2022-2027 Medicaid 1115 Demonstration Application. 

As we highlight what modern-day HIV treatment, care coordination, and prevention services has meant to our communities, even today—with all our improvements in health outcomes and quality of life—HIV can be a challenge to “live with, regardless of what (public or private) health plan a person is on. And while providers are clearly adept at addressing the challenges that go along with getting people engaged in medical care and virally suppressed; or help meet their supportive service or HIV prevention challenges, for the 7,962 People Living with HIV (PWH) in Oregon (2021 OHA HIV Dashboard), these needs will always be present—until there’s a cure.

To that, Oregon has repeatedly been a champion for health care access throughout the 41 year HIV crisis; and we congratulate the Oregon Health Authority (OHA) for initiating its own efforts to end HIV in the state—and involving the community at large. In fact, the “End HIV Oregon” (EHO) initiative was launched, following a two-year, community-based participatory planning process, after being facilitated by the state’s own Program Design & Evaluation Services staff. This shows the deep investment—and partnership—the state has with its community.

At its pillars, the EHO strategy seeks: to enhance access to all available forms of HIV testing; accelerate prevention efforts (including HIV Pre-Exposure Prophylaxis (PrEP)); end broader health and HIV-related disparities through a more “equitable public health system”; and improve access to effective HIV treatments. In EHO’s own words: “HIV treatment saves lives”. 

But not all PWH get onboarded into the private or public health system in the same impartial manner that the EHO broadly seeks to define. As a matter of economic and social determinants of health circumstance, HIV is a highly individualized disease. Often viral suppression depends upon what treatment a person can equitably access. It is that personal, lifelong (cumulative effect) journey with HIV that requires a reasonable expectation that a PWH’s prescribing provider have the maximum flexibility allowed to design a treatment regimen that is specific—that is optimal—for them, regardless of their ability to pay.

At a time when communities, providers, practitioners and EHO advocates alike are working—together—to improve health outcomes and equity for all communities, open (and full) formulary access to all FDA and USPTF-approved HIV medications should not be made more difficult, especially for those most deeply affected by this epidemic (those on public health plans). 

To that, Medicaid plays a critical role in the efforts to reach our EHO goals. In fact, nearly half of all PWH in Oregon who are engaged in medical care have incomes at or below the Federal Poverty Level; and the state’s Medicaid program is an essential (if not primary) source to HIV treatment and care coordination. 

But to the community affected, the Oregon 2022-2027 Medicaid 1115 Demonstration Application represents a significant step backwards in the state’s—the OHA’s—progess on access to HIV antiretrovirals drug therapies, while simultaneously working to “ensure that PLWH have medical care and all the medications they need” under the CAREAssist (AIDS Drug Assistance) Program. Inherently, it’s creating an inequitable access to state resources through cost-affordability barriers and utilization management techniques. 

Although we appreciate—comprehend, empathize, understand–the state’s fiscal goals in proposing a closed formulary, this inequitable move would have a significant and negative impact on PWH covered by Medicaid, and on Medicaid beneficiaries at risk for HIV who access PrEP medications. 

Think about that. The entire rationale for expanding Oregon’s state Medicaid program under the Patient Protection and Affordable Care Act (PPACA) was intended to combine both aspects of those federal considerations, protections with affordability. The EHO’s accomplishments—particularly its high viral suppression rates—may be in jeopardy if this application is approved and HIV antiretrovirals (for both care and prevention) are subjected to a closed formulary.

Under its demonstration waiver is the recommendation—and ultimately state Medicaid policy—that HIV medical intervention should always start with a less costlier treatment, irrespective of the patient-provider’s decision-making. OHA is already keenly aware that there is always variability in prescribing practices and patient needs, especially within high-acuity, high-utilization communities. 

It is through that lens, that we encourage the OHA to be bold and set the standard that its policies are in alignment with both the DHHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV and the state’s EHO initiative—especially as we look to a future of injectables, or time-released, active ingredient, or dosage formulas. These therapeutics often provide benefits not just to viral suppression metrics of PWH, but they fundamentally reduce secondary, onward transmission. I

In fact, since COVID-19, we’ve already in Oregon fewer PWH who are virally suppressed (2019: 81.9% | 2020: 76.7%). Just because the vast majority of the state’s 7,962 PWH are undetectable today does not mean as people churn on-and-off Medicaid, ADAP, employer-sponsored, or ACA marketplace plans that rates of suppression won’t inch upward. Something that will result in newer incidences. And as they face potential medication switches—because of access challenges to preferred medicaitons—our EHO goals will be pushed even farther out.

We’ve already seen that happen under implementation of the Medicare Part D prescription drug coverage benefit design changes. A 2009 study in the AIDS and Behavior Journal (Issue 13)  found that PWH who faced drug benefit design changes were almost six times more likely to face treatment interruptions than those with more stable coverage. It’s why protecting access to treatments for Medicare patients with the most complex conditions has resulted in the “Six Protected Classes” Policy as a way to safeguard viral suppression successes. The same should apply to Oregon’s state Medicaid program, much as they did under its Pharmacy & Therapeutics Committee’s findings of August 2015, which recommended a “voluntary Preferred Drug List class for HIV ARVs and combination products and to designate all drugs as preferred” at that time. ​And without open access protections to HIV PrEP through that same lens of patient protection under the PPACA.

It is across all these rationale that we ask the OPHA to reconsider its options under this proposed waiver.

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