Viagra Goes Political

Last week, political leaders in both Sacramento and Washington pushed back against insurers that opted not to cover the new anti-impotence drug Viagra. The Clinton administration told state officials they must include Viagra in their Medicaid programs, and California legislators threatened legal reprisals against private insurers and HMOs that failed to cover the drug, which costs $8 to $10 per pill. “I think it’s hypocritical and inhumane for any insurance company not to recognize the need [for such a treatment],” said state Sen. Diane E. Watson (D-Los Angeles).

The intensity of the legislators’ attack was not surprising, for political leaders in both parties made health care reform their banner issue for the November elections and, despite its dangers for some men with heart disease, Viagra was the big medical good-news story of the moment. The political heat has not generated much light, though, because legislators are studiously avoiding the underlying problem of the Viagra controversy: a lack of consensus among health care consumers and providers over which treatments should be covered because they are “medically necessary” and which ones are merely “lifestyle enhancing.”

In an ideal world, insurers would be able to offer all treatments. But in the real world, in which promising and pricey new drugs arrive on the market almost daily, insurers ration care to keep costs under control.

By imposing particular coverage mandates, political leaders only make the problem worse, either leading insurers to drop some kinds of coverage or motivating them to opt out of a given health care market altogether. Over the last year, nearly a dozen major managed care providers, citing economic losses and cutbacks in government payments, stopped providing health care to low-income Medicaid recipients. The Clinton administration’s demand that Medicaid cover Viagra is likely to lead many more insurers to opt out of the program. The National Governors Assn. argues that the mandate would impose an undue burden on the cash-strapped Medicaid program by necessitating $100 million a year more in federal and state co-payments. Federal officials are also being troublingly inconsistent, requiring states to funnel scarce resources into Viagra at the same time that they are allowing cutbacks on basic Medicaid services for people with severe disabilities.

California legislators have threatened to prosecute insurers who don’t cover Viagra under the state’s Knox-Keene Act, which holds that “medical decisions must be independent of fiscal and administrative concerns.” But soaring medical costs have given insurers no choice but to act to reduce costs. While it may be premature to revise the Knox-Keene Act, it’s clearly time for state officials to encourage broad debate about which drugs--for impotence, for infertility, for mood alteration, for birth control and so on--are medically necessary.

Medical necessity should not be determined by insurers alone, for the concept is more subjective than scientific, and the process of defining it should be open to public scrutiny. But before imposing sweeping coverage mandates, legislators should involve both insurers and the public in a thoughtful discussion of how the health providers can best use their limited resources to offer the broadest range of basic, medically necessary care.