For Kenyon Farrow and Jeremiah Johnson of PrEP4All— and the hundreds of thousands of Americans who rely on the HIV prevention pill—decision last week by a Texas federal judge that employers are not required to provide health insurance plans that cover preventive services like PrEP was appalling, but not entirely surprising.
Since the nonprofit was founded in 2018, PrEP4All has been advocating for increased access to pre-exposure prophylaxis drugs that can reduce the risk of HIV infection by 99%. Johnson, the organization’s PrEP program manager, and Kenyon, its chief advocacy and organizing officer, say they anticipated Judge Reed O’Conner’s decision with what Johnson described as a “resignation depressed”.
On September 7, Judge O’Connor of the United States District Court for the Northern District of Texas ruled in favor from a group of Christian business owners that the Affordable Care Act (ACA) requirement that health insurance plans cover PrEP, free of charge, because preventative care violates their constitutional right to liberty religious. One of the plaintiffs in the case, Dr. Steven Hotze, said in the complaint that providing an employee health insurance plan that covers PrEP goes against his sincere religious beliefs because it would “encourage the behaviors homosexuals”.
“Unfortunately, I’ve been following the case for some time and this particular judge is known to be quite an aberrant on all things, certainly ACA,” Johnson says. More recently, in 2018, he ruled that by striking down the 2010 Act’s individual warrant penalty, lawmakers had rendered the ACA unconstitutional, a decision which the Supreme Court later reversed.
Its latest advisory also takes aim at the ACA’s process for determining what types of preventive care should be fully covered by private health insurance, ruling that the US Task Force on Preventive Services violates the appointment clause of the US Constitution.
Last week, White House press secretary Karine Jean-Pierre tweeted that the Biden administration is reconsidering O’Connor’s decision and that legal experts expect the administration to challenge it.
“[O’Connor is] also an outlier in terms of approaching HIV as a nation, in terms of efforts to expand access to PrEP,” Johnson says. “It’s a bipartisan issue in America.” He quotes 2019 from former President Donald Trump “Initiative to End the HIV Epidemic”, which included increased access to PrEP and support from Rick Scott for the “PrEP Availability Act Ryan White.”
And, as Farrow and Johnson note, providing health plans that cover preventative care like PrEP is also a cost-saving measure for employers. With the introduction of generic alternatives to brand name drugs like Truvada and Descovy last year, the cost of PrEP can be as low as $20 per month, according to Johnson. Compare that with the CDC’s estimate for lifetime costs associated with new HIV infections: over $500,000.
“We’re pouring a lot of money into the United States into our health care system to have poorer health care outcomes compared to comparable countries around the world,” he explains. “It will ultimately be so much better for all of us if people [can] prevent health care outcomes before they become more costly and costly to the system as a whole.
Farrow and Johnson were reluctant to speculate on how employers would react to O’Connor’s decision. “There’s really no argument for cost savings by not providing health plans that cover PrEP,” Farrow says. “But people sometimes don’t make decisions based on their pocketbook, they sometimes make decisions, even if it costs them, based on their bigotry and their personal biases. So it remains to be seen how this will play out with employers and their health plans. »
But Johnson notes that providing less comprehensive health care plans goes against the trend of employers investing in the general well-being of workers.
“We see it in terms of mental health issues, we see it in terms of providing more flexibility for individuals in the work environment. Certainly in the time of COVID-19 we have become more aware of employee health and its importance,” says Johnson. “It certainly seems to be going in the opposite direction to where we are heading as a nation in terms of talking about employee safety and making sure they have reasonable accommodations to avoid any complicated outcomes with their health. .”
But the current situation shows the problem of relying so heavily on employer-provided health insurance, he says.
“This is literally a case where a small subset of individuals say we shouldn’t cover a cost-saving intervention and society should pick up the excess cost through the system of healthcare, because they have a very confused belief about what PrEP means in terms of what they cover,” says Johnson. “Really, we shouldn’t allow individual employers, based on perhaps arbitrary beliefs , to make that judgment for the whole company and for their employees. It’s just too much power to give to those individuals.
Following O’Connor’s decision, PrEP4All will continue to advocate for a national PrEP delivery program for uninsured Americans. In its budget proposal for the 2023 financial year, President Biden pledged $9.8 billion to establish such a program.
“We’re really stepping up our efforts,” Johnson said in an email, “to address these types of disruptions in PrEP service and to continue to build broad bipartisan support for scaling up PrEP as a economic intervention for the American healthcare system.”