AIDS’ New Cruelty: Impoverishment : Patients Without Jobs, Insurance Fall Through the Health Net

The files of the Gay Men’s Health Crisis in New York include the case of a 29-year-old AIDS patient from Paterson, N.J., which warns of an AIDS crisis yet to come.

The man lost his job and shortly thereafter his medical insurance. Having little savings, he applied for Social Security disability payments. But the $480 a month he started receiving five months later, while enough to pay most living expenses, was not enough to finance his chemotherapy treatments and hospital stays.

So he skipped some treatments. He also looked at other government programs. He discovered that Medicare offers a program for the disabled but with a rather macabre catch-22: You have to wait two years before becoming eligible, longer than most AIDS patients have to live. Medicaid, the medical assistance program for the poor, required no such wait. But his $480 disability payment made him too wealthy to be eligible in New Jersey. So he moved to New York City, where he was eligible but where the local hospitals, not the federal government, paid most of the bill.

This case shows our health-care system straining to meet the needs of one individual. It doesn’t show that when there are 250,000 of these individuals--or 500,000, as has been projected--the health-care systems of a few states will be stretching to the point of rupture. AIDS will foist an estimated $8 billion to $16 billion in new costs on the health-care system in 1991.

The factors that make AIDS a cruel killer also make it an especially expensive disease to treat--about $70,000 per patient. When the immune system collapses on the battlefield early on, medicine must pick up where the body’s natural defenses fail. Complications are the norm and patients often need constant monitoring.

But because the U.S. health-care system resembles more a mis-designed jigsaw puzzle than a coherent network, this disease will take a tremendous toll.

Consider the options open to patients of AIDS (or any other expensive terminal disease, for that matter). First, the individual is supposed to contribute to his or her own treatment. Given the exorbitant cost of AIDS, few can bear that cost alone. For those who aren’t wealthy, the first line of protection is supposed to be private insurance, usually provided by an employer. Yet it is difficult for AIDS patients to hold their jobs because of frequent hospitalizations and decaying health. On average, AIDS patients are unemployed 10 months before their deaths. And most lose their insurance when they lose their jobs.

Ironically, community and government efforts to isolate AIDS patients in the name of protecting the public health will likely make this cost crisis worse. The Justice Department ruling allowing employers to fire AIDS-infected workers--even if they are capable of performing their jobs--will most likely hasten the transformation of the afflicted from self-supporting patient to ward of the state.

Meanwhile, insurance companies, by using antibody tests or by searching for “life-style” clues, have tried to reduce the number of risky policies they issue. They are near panic worrying how they will satisfy the claims of tens, even hundreds, of thousands of young working men who were supposed to be subsidizing the health care of older beneficiaries. According to the logic of insurance mathematics, the industry’s retreat makes sense. But if the insurance industry flinches from paying for AIDS, who will?

The government should. But on the federal level, as the man from Paterson discovered, Medicaid, the only major medical assistance program, requires recipients to be poor or to “spend down” into poverty. This system prevents the wealthy from using illness to chisel the government. But it also forces some AIDS victims in the last months of their lives to leave their homes and sell their possessions, or forgo needed treatments.

In addition, Medicaid will not pay for experimental treatment, a particularly troubling provision since many of the drugs used for AIDS are experimental. Nor will it pay for AIDS-related complex, a condition that does not cripple the immune system but partially weakens it.

Although a huge chunk of AIDS treatment costs cannot be avoided, there are steps that can be taken to reduce costs and spread the burden more evenly. But the Reagan Administration has done virtually nothing to alleviate the crisis. In fact it tried to cancel $16 million that Congress appropriated last year to set up less-costly model treatment programs.

In addition to expanding that program, Congress should approve legislation offered by Rep. Henry Waxman (D-Los Angeles) allowing Medicaid to pay for less expensive home care for AIDS patients. Congress also could allow Medicaid to pay for experimental treatments. And it could force insurance companies to set up high-risk pools open to AIDS patients.