A researcher in the University of Iowa College of Medicine says the funding provided by the federal and state governments to help pay for increasingly expensive treatment for AIDS is a fragile, short-term solution that may not provide a stable, long-term way to improve access to health care.
The article, "Have We Treated AIDS Too Well? Rationing and the Future of AIDS Exceptionalism," written by Dr. David Casarett, a fellow in the UI Department of Internal Medicine, and Dr. John Lantos of the University of Chicago, both of whom are physician-ethicists, appears in the May 1 issue of the Annals of Internal Medicine. In it, the authors say the funding mechanism developed in 1987 to help low-income and uninsured people with AIDS pay for drugs is being threatened by the development of expensive new treatments for the disease.
"We are allocating funds for medications for AIDS, but not for other diseases," Casarett says. "A person with AIDS will have access to drugs, while another person of the same socioeconomic status who has Hepatitis C or schizophrenia will have to do without."
Casarett warns this difference, described as "exceptionalism," will widen the gap between the treatment of AIDS and the treatment of other serious diseases.
"If we have a moral imperative to provide AIDS patients with treatment, then we must provide the same assistance to people with other serious conditions," he says.
Casarett says AIDS has always been treated differently than other diseases, both in terms of rules regarding testing and in funding for health care. In 1987, the federal government implemented the AIDS Drug Assistance Program (ADAP) which provided a then-new drug, azuvudine (AZT), to persons with AIDS. In the years since, funding has grown and each state has created its own ADAP to comply with federal mandates.
In 1995, a class of drugs called protease inhibitors was introduced. The new treatments created enormous demands on the ADAPs, in some cases quadrupling the costs of the programs. Casarett says the dramatic rise in the cost of the programs came in part because many patients who were able to pay for cheaper drugs found the new treatments too expensive.
"As the cost of the programs rose, federal and state funding could not keep up, and states have been forced to cut costs," Casarett says. "They have done this by limiting enrollment, by putting 'caps' on allotments for each person, and by refusing to pay for some expensive medications."
The AIDS community has lobbied aggressively for better funding and they have been quite successful. However, Casarett says, lobbying and political power offer only a short-term solution. He says that what has developed is a system of health care "driven by political power that is uneven.
"If society allocates resources to people with AIDS that it does not allocate to persons with other diseases, this system will be increasingly vulnerable to accusations of unfairness." he says. "These accusations will threaten the ADAPs, no matter how much political power they have behind them."
Casarett and Lantos warn, however, that to cut funding for AIDS programs in the name of fairness would be a grave mistake.
"Bringing AIDS programs back down to the level of care for other diseases would be like breaking a patient's other leg for the sake of symmetry and would be equally shortsided," Casarett argues. "The problem is not that we have treated AIDS too well but that we have not treated other diseases well enough.
"AIDS programs like ADAPs have achieved remarkable successes in health care delivery and we should think twice before giving up those victories. If we must close the gap between the treatment of AIDS and our treatment of other diseases, we should do so by making the innovations of AIDS care more widely available."