PROVINCETOWN — When Jeff Schaffer learned in January that the Supreme Court would hear a case that threatened coverage of lifesaving HIV-prevention medications, he was not surprised.
Schaffer, a registered nurse who founded and manages the testNtreat sexual health program at Outer Cape Health Services, said he and his colleagues are used to navigating obstacles to get their patients access to care. “There are already so many challenges,” he said.
“Nurses in general — it’s in their DNA to find solutions and remove barriers to care,” he said. That’s why he started the program. “I saw barriers in my community and thought, how can we remove those barriers?”
HIV-prevention medications — including a daily pill marketed as Truvada, an equivalent generic pill, and a newer injectable drug — must be covered for free by all private insurance plans sold in state and federal marketplaces and by all 40 states that have expanded their Medicaid programs under the Affordable Care Act.
That requirement took effect in 2019, when a task force in the Dept. of Health and Human Services officially listed pre-exposure prophylaxis, or PrEP, drugs as “essential preventive medications.”
The case the Supreme Court will decide in June, Becerra v. Braidwood, could erase that requirement.
In 2023, a federal district court in Texas ruled in favor of a group of plaintiffs who argued that the task force’s requirements for preventive health care were unconstitutional. The plaintiffs — a group of insurance providers and “Christian” advocacy groups — objected specifically to the requirement to cover HIV prevention. They argued that the medication “facilitates homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman.”
Schaffer is confident that, no matter what the court decides, his program will continue. “We were here in 2019,” Schaffer said — referring to the time before the task force required free coverage of PrEP. And should that coverage go away, he said, “We’ll be here to help you afterwards.”
Looking to the State
Leaders and health officials on the Outer Cape have been monitoring the Braidwood case for years. In 2023, state Sen. Julian Cyr called the district court ruling “an explicit attack on the life-saving HIV-prevention medication, which has dramatically reduced HIV infections in Massachusetts and across the world.”
A Supreme Court ruling that strikes down preventive care mandates “would put us back into a place where important public health interventions would now be potentially subject to high costs for the consumer,” Robert Goldstein, commissioner of the Mass. Dept. of Public Health, told the Independent.
Truvada, the brand-name pill that was approved for HIV prevention in 2012, costs almost $2,000 per month without insurance.
“For something like PrEP access, that court case would be detrimental just as far as cost to the average individual,” said Dan Gates, director of the AIDS Support Group of Cape Cod. The cost barrier could weaken the effect of preventive care, Gates said, citing a 2022 Yale School of Public Health study estimating that the removal of coverage requirements could result in an additional 2,000 preventable HIV infections a year.
Goldstein said lab tests are required for patients to begin and remain on PrEP, and those costs could run into the thousands of dollars as well.
If the Supreme Court were to strike down the coverage requirement, “in Massachusetts, we have some inoculation,” Cyr told the Independent last week. “We’re going to watch this case closely and make sure that Massachusetts law is responsive to whatever outcome occurs.”
After the Texas court’s ruling in 2023, Cyr worked with a group of other senators to replicate federal requirements for preventive care in the state budget. “Massachusetts has the ability to guarantee coverage in our Medicaid program as well as commercial insurance that is regulated by the state,” Cyr said. The state has less leverage over Medicare and certain retirement plans, which are governed by federal standards, he said.
“This isn’t our first rodeo,” Gates said. “AIDS Support Group in particular was born of a time when there were not federal resources to support the need for these services. We built our system around responding to a crisis and using your own community’s resources to navigate that.”
Gates said a lot of people don’t realize how much of what his organization does isn’t dependent on federal funding, thanks to donor support.
Goldstein said the state spends about $1.2 million on its PrEP Drug Assistance Program, which offers full financial assistance to cover PrEP costs, including co-pays, for residents who are uninsured and earn less than five times the federal poverty rate. The PrEP DAP covered medication for 229 Massachusetts residents in the previous fiscal year, according to the DPH. “If somebody had an insurance plan that was not on the marketplace and therefore not subject to the Affordable Care Act,” Goldstein said, “the state has available resources to pay for that medication.”
“The state is pretty invested in Provincetown having this program,” Schaffer said. Provincetown has the highest percentage of residents living with HIV in Massachusetts. As of 2022, nearly 12 percent of the town’s residents were living with HIV, according to the DPH’s latest statewide epidemiological report.
“What Outer Cape Health Services and the AIDS Support Group have been able to do is pretty innovative in bringing a public health lens to the delivery of health care,” Goldstein said.
Outer Cape Health Services received $228,758 in grants last year from the DPH to support the testNtreat program and an additional $176,500 for HIV case management, according to CEO Damian Archer. “There are no other direct funding sources for these programs,” he said.
The DPH itself depends on federal grants for nearly half of its $2 billion budget, but Goldstein said that the grants come from over 150 different sources and agencies. With a diverse portfolio and a temporary restraining order on the Trump administration’s funds freeze, “we are operating with federal funds flowing and making sure that we’re doing the work that we promised we would do with those federal funds,” Goldstein said.
TestNtreat routinely sees patients with varied insurance coverage, including people who are underinsured, uninsured, or not U.S. citizens, Schaffer said. When he started testNtreat, “I looked at it as: we do have access to testing. What about treatment and other services? People think testNtreat is so progressive, but the system is so conservative, with its roots in the eighties. Maybe we can land somewhere in the middle.”
