With the popularity of the impotence-treatment drug Viagra continuing its surge, the next battlefield over the nation's trendiest drug is likely to be among the poor.
Medicaid offices in several states are deciding whether the government health insurance program for the poor, blind and disabled will pay for Viagra prescriptions for impotent male patients among their 36 million beneficiaries.
Across the nation, the emerging debate already has proven an incendiary mix of sex, poverty and politics. On the "Larry King" show Thursday night, former presidential candidate Bob Dole, 74, disclosed that he was in the clinical tests for the drug.
In Little Rock, Ark., on Friday morning, one caller blasted the proposed Medicaid coverage of Viagra. Tax dollars, he told a talk-radio audience, should not go to "help poor people make more poor people."
Clinton administration officials said the federal government, which oversees and provides most of the funding for state Medicaid programs, has not issued official guidance on Viagra coverage. But state officials, including those from California's $18.7-billion Medi-Cal program, said that they believe state Medicaid agencies will be required to cover Viagra prescriptions in cases of "medical necessity."
At the same time, most expect to impose significant restrictions on their coverage of Viagra, a product of Pfizer Inc. In Arkansas, for instance, Medicaid beneficiaries will be limited each month to no more than six of the little blue pills that many report improve erections and enhance the sexual experience.
But while states ponder their obligations under federal law, the issue has sparked debate over whether the rich are the only ones who should be allowed to enjoy the nation's new fascination with a vibrant sex life. At a time when many private insurers are refusing to foot the bill for Viagra, others are questioning whether taxpayers should pay to give Medicaid recipients the drug.
The debate is made more difficult by the burgeoning market in pharmaceuticals designed largely to improve patients' quality of life--drugs that are blurring the line between medical necessity and emotional well-being. While impotence frequently stems from underlying medical conditions like heart disease, prostate cancer and diabetes, few believe it is a medical necessity to treat a man's inability to achieve an erection.
But in a society obsessed with sex and sexual performance, sexual dysfunction is seen by many as a debilitating disease that can cause heartache and even shorten life spans. And if those who can afford private insurance deserve access to the $10-a-pop pill, many reason, so do the poor, blind and disabled.
Add to this dilemma the strained politics of poverty and the debate becomes ever more tangled. Only two years ago, Congress adopted a sweeping welfare reform law that many called punitive toward poor Americans. Although many state officials have hailed welfare reform for getting recipients back to work, others fear that the stigma against public aid recipients will likewise influence the debate over Viagra.
Thirty years ago, distrust of the poor prompted lawmakers to ban the use of food stamps for imported foods, then considered a luxury. Today, experts say that lingering suspicion of poor people has prompted many changes in welfare policy that restrict public aid recipients' freedom to use public funds on goods and services that might be deemed "luxuries."
"And when it's about sex, it's like, whoa!" said Linda Wolf, deputy director of the American Public Welfare Assn., an organization of state welfare officials. "It just becomes a heck of a lot more complicated."
Indeed, many state Medicaid directors worry that, if the federal government directs them to cover Viagra, they soon will have to cover a host of "quality of life" drugs that are not now covered. Current law allows state Medicaid agencies to refuse coverage of diet and anorexia drugs, smoking cessation aids, drugs to enhance fertility or counteract baldness, and barbiturates.
Beyond those exceptions, however, a 1990 law required state Medicaid agencies to cover any drug approved by the Food and Drug Administration and prescribed by a physician in cases of "medical necessity." The law, however, allows states to place a wide range of restrictions on their coverage. Birth-control medication is widely covered by Medicaid with few restrictions. Antidepressant drugs like Prozac also must be covered by all states' Medicaid agencies. But many states strictly limit the length of time or the circumstances under which a patient can stay on the medication.
"The drug itself raises serious medical necessity questions for a program like ours," said Bruce Bullen, Massachusetts' commissioner of medical assistance and chairman of the National Assn. of Medicaid Directors. "A lot of Medicaid directors' health care dollars are limited. To require spending in areas that may be of questionable necessity may be a diversion of funds."
In early discussions among state and federal Medicaid officials, several states' directors have signaled their strong opposition to covering the new impotency drug. Several have argued that Viagra should be considered a fertility drug--a decision that would allow states to deny coverage under the 1990 law.
Many Medicaid directors assert that they are considering only their legal obligations to Medicaid recipients--not the potentially explosive political debate into which they have been thrust.
"This obviously is a complicated issue. This is not an antibiotic," said Raymond Hanley, who heads the Arkansas Medicaid program.