Normal is not a cure for HIV

One night coming back from a Board Meeting of a nonprofit in the Castro I snapped this photo through the window of the Duboce Cafe. Normal. All those bottles of pills behind the glass, which over a year cost more than a new BMW, that is the price of normal for someone with HIV.

I thought about using this photo last year when Anthem Blue Cross announced that it was requiring all HIV / AIDS patients they insure to obtain their drugs through a mandatory Mail Order program. Buy from one supplier, get the maximum price discount, make sure the prescription never runs out. Seemed like a good idea when it was thought up in a cost containment meeting. But, before I could Blog away Anthem allowed for an opt out for it's insureds and life returned back to "normal".

In our country there are 1.1 million people, just slightly less than the population of Dallas, with HIV. Many of these people do not get regular care, get medicine, have regular access to doctors. The Affordable Care Act and Medicaid expansion is supposed to close this gap. Not every state opted to expand Medicaid, removing the requirement of total disability to qualify for benefits. For an HIV patient, total disability means waiting until the illness progresses to AIDS. Not a good option.

The Affordable Care Act mandates a certain level of benefits. Now every insurer can only offer four Metallic Plan choices (think Henry Ford and black cars). The only cost containment options are to limit the network of Doctors and Hospitals and the Prescription Drug choices. In order to protect themselves from the high cost of these drugs, insurers limited drug choices and assigned high Co-Pay's for the treatment of HIV /AIDS.

Drug companies have been able to combine multiple HIV / AIDS drugs into a single tablet under the thought that it's easier to remember to take a single pill. A one month supply runs over $2,000 (Stribild, Atripla, Complera), far above the premium the insurer will be able to charge. Multiply this over many, many newly insured HIV / AIDS patients and you get the picture. Antacid dispenser in the Actuaries lounge.

Which brings me to the news this week when Blue Cross and Blue Shield of Louisiana announced it would reject checks from a Federal Program (known as the Ryan White HIV AIDS Program) designed to pay premiums for HIV /AIDS patients to enroll in the Affordable Care Act. The concern they have stems from statements from the Centers for Medicare and Medicaid Services (CMS) that it had significant concerns about this, citing the risk of fraud. 

AIDS advocates in Louisiana "were enrolling anyone and everyone" in the state exchange. The folks at Blue Cross and Blue Shield no doubt are pretty nervous about all of this and the CMS provided them a four lane highway to escape the potential of huge adverse selection (think stacked deck). The CMS is now doing a massive back pedal to cover it's rear end and allow these checks to be used. 

Maybe it was just wishful thinking by the artist, there is no true "Normal" for someone diagnosed with HIV /AIDS. 

What Don Draper knew 50 years before CVS

It had been so long since I had seen one of these machines that I had to photograph it. I was in Atlanta for the NAHU convention last summer at a restaurant and right after I took the photo someone asked me why I took it. "These are almost extinct", I said, thankfully.

I remeber a time when these were everywhere, living in California, where you can't smoke anywhere, this is a thing of the past. When the MadMen episode where Don Draper writes his fictional "Why I'm Quitting Tobacco" advertisement he states the obvious, "people can't stop themselves from buying it". It was the convenient placement of these machines that acted as a reminder to all of those smokers to keep on puffing.

So yesterday, when CVS Pharmacy announced they were going to stop selling cigarettes in their pharmacies, it was if another of these machines just disappeared. The familiar Ka-Chung sound of the lever followed by regular or menthol, soft pack or box, right there at the fingertips.

Reports estimate that CVS will loose about $2 Billion in revenue from this decision from the loss of tobacco sales, but the goodwill is just overwhelming. They changed the profile picture on all of their social media sights to this no smoking avatar just to drill their corporate goodness home.

In a real world application this is not completely earth shattering, there are still many, many places to purchase cigarettes, but at least now you won't be able to stop and pick them up along with your lung cancer medication.

There are roughly 480,000 people who die each year in the US from tobacco, roughly the population of Fresno or Sacramento. It's $132 Billion in medical care cost (think about that next time your health insurance premium comes due). That a national pharmacy believes that the goodwill will out weigh the lost revenue is pretty significant.

In 1965 when the fictional Don Draper penned his missive saying, "We knew it wasn't good for us but we couldn't stop", he was on to something. In the 50 years since, smoking rates have dropped from 42% to 18% of the population.

We all know that smoking has become less socially acceptable. The kids of smokers are smarter than their parents in many cases and have resisted the urge to light up. Like many great changes in our world it just gets pushed along slowly over time. You did a good thing yesterday CVS, I hope their decision helps someone you love let go of cigarettes and maybe our children won't see cigarette machines anywhere in their lifetime.