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Who pays for AZT?

In October 1987 the U.S. Congress appropriated $30 million to subsidize the purchase of AZT by individuals who do not have insurance coverage for the drug or who are not eligible for Medicaid. Congress provided the finding on an emergency basis for one year only, with the expectation that the states would act to continue the subsidization program under local auspices. Congress has since extended the federal program twice with an additional $20 million appropriation), to give the states additional time to devise programs of their own. State legislatures are beginning to consider local funding of such programs. Congress approved the AZT subsidy program because of the efficacy of the drug and its prohibitive cost. AZT is the only drug approved for use in the United States that has been shown to be effective in ameliorating the effects of AIDS. Although there are no complete studies on the effects of AZT, interim improvements in the health of many patients with symptomatic HIV infection have been significant. AZT both prolongs and improves the quality of the lives of persons with AIDS- AZT reduces the number of opportunistic infections and the rate of replication of the HIV virus in the patient's system. it also increases the number of healthy helper cells. As a result of taking AZT, some patients either remain healthy enough to continue to work or regain their health sufficiently enough to return to work.

Despite its helpful properties, AZT is highly toxic. Some patients cannot tolerate the drug at all; others can tolerate it only for a short while (less than one year). In addition, if taken off the drug, patients who had been helped by AZT experience a rapid decline in their health.

Moreover, AZT is not curative. Thus, despite AZT's availability, AIDS remains a fatal disease.

Although it is the only AIDS drug approved for use, AZT is prohibitively expensive. The purchase price of AZT is approximately $650 per month, or $7,900 per year at full dose. Although Medicaid eligibiiity standards differ from state to state, each has categorical (e.g., blind, aged, permanently and totally disabled) and financial (i.e., income and assets) tests that applicants must meet. The federal AZT program has no categorical requirement, and it leaves financial standards up to each individual state. In each state, it is easier to qualify for the AZT program than it is to qualify for Medicaid.

Many persons with AIDS work in service industries where their income keeps them at or just above poverty level. But many patients taking AZT are not eligible for Medicaid: even if they meet Medicaid's financial status requirements even one month's bill for AZT can devastate a patient's resources), AZT keeps them healthy enough not to be permanently and tot% disabled, and they generally ally do not meet the other Medicaid categories (blind, aged, AFDC recipient).

A proposal to find the subsidization of AZT purchase is now up for debate before one state legislature. How should it decide? The prohibitive cost of AZT clearly calls for some kind of government assistance. Arguments in support of state aid can be based on four principles: equitability, humanitarianism, financial savings, and precedent.

The principle of equity unquestionably demands a governmentsupported AZT purchase program. AZT is an FDA-approved drug that is available to persons with the financial means to purchase it, with medical insurance or who are on Medicaid; it is also the only FDA approved drug currently available to help persons with AIDS. The only legal therapy for AIDS is therefore available to the wealthy and the disabled, but not to persons in financial need. In fact, the purchase of AZT may be what makes the program's participants financially needy. It would be fundamentally unjust to deny access to AZT to persons who cannot afford to purchase the drug, but do not qualify for Medicaid.

An argument based on humanitarian principles is equally compelling. One immediate justification for continuing the AZT program is a moral imperative to help sufferers of this devastating disease in all ways possible. To respond that AZT does not cure but merely prolongs life or alleviates suffering, and that we should therefore not interfere with the inevitable, would be callous and unbefitting civilized society. Second, all persons deserve to live in dignity, one element of which is the opportunity to continue to carry out a productive life for as long as possible. Quite apart from any cost savings realized by keeping persons out of the welfare system, humanitarian considerations weigh heavily in favor of doing what we can to allow everyone to participate as fully as possible in society. For many AIDS patients, AZT presents the only means that enables them to participate in society.

Fiscal considerations on two levels support government assistance for persons who are medically and financially needy, but do not qualify for Medicaid. On the first level, use of AZT prolongs patients' ability to continue to work and thus reduces their need for reliance on Medicaid and other government programs such as food stamps, disability, AFDC, and subsidized housing. Such persons remain productive members of the economy and society in general, producing goods and services and paying taxes.

On the second level, the use of AZT may reduce the cost of delivering care to AIDS patients because they appear to suffer fewer opportunistic infections and thus require less hospital care. It has been estimated that the use of AZT reduces the direct costs of treating AIDS by $1 1,000 per patient year, and reduces the costs of treating AIDS-Related Complex by $25,000 per patient year.1 The combined savings amounts to $386 million on the national level for the first year's use of AZT. Thus, once patients who have been taking AZT do become eligible for Medicaid, it may well be that Medicaid will pay out less in claims. Even for those patients who do not go on Medicaid, fewer medical resources are directed toward the care of AIDS sufferers and can be used for other needs, at least in the short run. Thus, the direct outlay of funds for the AZT program may well be offset by cost savings in other state- and federally-funded programs. The uncertainties of the financial implications of a state-level AZT program are not so great as to justify a refusal to continue assisting those in need.

Finally, the role of precedent in devising new medical programs is worth noting. By providing emergency funding, the federal government made clear that an important element of fighting AIDS is assisting persons in purchasing AZT Furthermore, programs already exist in many states to help patients with such diseases as hemophilia, sickle cell anemia, and renal disease who are in need but are not eligible for Medicaid. Some states have also provided special assistance for the purchase of extraordinarily expensive prescription drugs in at least one other setting: organ transplants. Medicaid in those states will pay for the costs associated with a transplant including the continued purchase of immunosuppressive drug therapy. It is unquestionably an appropriate response, well within the scheme of government medical assistance programs, to make AZT available to persons who are medically needy but do not qualify for Medicaid.

A nagging background question remains: With most other illnesses, patients must use up their own financial resources and be permanently disabled before they can obtain government assistance; why should AIDS be any different? It is possible, however, to distinguish AIDS from other diseases. First of all, AIDS is an illness unlike any other illness: At present no other communicable diseases hold such a destructive potential for our entire populace. It is true that AZT does not cure AIDS, but the longer patients survive, the greater the possibility that other, curative, drugs or treatments will be developed.

Another criticism of giving AZT programs priority is that in many states a whole array of health care programs is also in desperate need of support. Nonetheless, the severe and devastating nature of AIDS, together with the relatively low cost of and potential savings generated by the program should give AZT funding the highest priority in state public health expenditures.

A related issue is whether, within the framework of caring for persons with AIDS, an AZT program is the best way to spend scarce health care funds. Are there other programs on which funds would be better spent, such as making twenty-four hour home nursing care or hospice facilities available? States are attempting to develop comprehensive schemes to ensure adequate delivery of care to persons with AIDS; the resources they have to work with are not unlimited. Until policy makers can see where the AZT program fits in a comprehensive plan, funding should continue.
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Title Annotation:case study and commentary
Author:Penslar, Robin Levin
Publication:The Hastings Center Report
Date:Sep 1, 1989
Previous Article:Four-one-four.
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