I got sidetracked in my last post, which was originally supposed to be about what a disaster the new Medicare bill is for HIV care.

Medicare covers health costs for many people with disabilities, including people who are disabled by HIV/AIDS. 50,000 indigent Americans with HIV have dual coverage: Medicare, to pay their major medical bills, and Medicaid, to pay for services - like prescription drugs - not covered by Medicare. When the Medicare prescription drug "benefit" comes into effect in 2006, they'll be required to use it - their Medicaid prescription benefits will be dropped entirely.

Why is this a particular problem for people with HIV?

- Under the Medicare bill, patients can only receive coverage for two drugs at a time in any given therapeutic class. Controlling the replication of HIV requires a "triple cocktail" - at least three drugs. Monotherapy and two-drug therapy consistently lead to treatment failure.

It's not clear to me how "therapeutic category or class" will be interpreted - are "antiretrovirals" (anti-HIV drugs) all in the same therapeutic category, or will the different kinds of antiretrovirals (such as NRTIs and protease inhibitors) be considered separate categories? The first interpretation would essentially mean that the bill doesn't cover HIV care at all - a two-antiretroviral regimen is clinically worthless. It's marginally less of a disaster if they mean the second interpretation, because a lot of HIV cocktails include, for example, two NRTIs and a protease inhibitor. But salvage regimens (used late in the course of the disease) might include 3 protease inhibitors, and all-NRTI regimens are often recommended for new patients.

- Also, the bill lets insurance companies offering Medicare benefits establish a formulary - a list of drugs they cover. They're required to include at least two drugs in each therapeutic category - a generic and a name-brand. That's it. If you need a drug that's not on the formulary, you can appeal - but Medicare won't necessarily pay for it. If you find some other way to buy it - keeping in mind, as I said in my last post, that purchasing Medigap coverage to do so will be illegal - your expenses won't be counted as part of the $3,600 out-of-pocket limit. Sure, probably most companies will choose to cover more than two antiretrovirals - but there's nothing in the law that says they have to, and there's certainly nothing to say they have to cover the newest drugs most needed by the sickest patients.

What all of this means, in the end, is that the cost of prescription drugs for people with HIV will be pushed back onto state AIDS Drug Assistance Programs. And ADAPs are already so overloaded and underfunded that many states are rationing access to AIDS drugs - including, thanks to Gov. Schwarzenegger, California. From now on, in California as in poorer states such as West Virginia, new HIV patients won't be able to get their drugs paid for by the state until an existing patient dies or gets private health insurance. And that's before all the Medicare/Medicaid patients get kicked back into ADAP.

It's an unmitigated disaster.