Court ruling may change Medicaid disability policy
Court ruling may change Medicaid disability policy
Treatment should be covered, critics claim
A recent U.S. Supreme Court decision holding that HIV infection is protected under the Americans With Disabilities Act is a landmark ruling that will help combat discrimination, but also could provide the impetus to change the way Medicaid pays for treatment, according to several AIDS organizations.
"The Supreme Court handed people with HIV their greatest legal victory since the beginning of the epidemic," says Daniel Zingale, executive director for AIDS Action, a Washington, DC-based lobby. "The ground has shifted beneath us as a new standard has been set for federal treatment of people living with HIV."
In March 1997, the 1st U.S. Circuit Court of Appeals in Boston upheld a lower court's decision that Maine dentist Randon Bragdon violated the Americans with Disabilities Act by refusing to treat an HIV-infected yet symptomless woman in his office. Although 1,276 HIV-positive people have made claims of discrimination under the ADA since 1992, this is the first time a federal appeals court has ruled that the ADA applies to an HIV-positive person who has not developed AIDS.1
Sidney Abbott, the 34-year-old patient in the case, sued the Bangor dentist for discrimination after he refused to fill her cavity. Abbott had no symptoms of HIV, but confided on a patient information form that she was HIV-positive. After she confirmed that she was infected, Bragdon offered to treat her at a hospital - at her expense. Abbott refused the offer and filed an administrative complaint with the Maine Human Rights Commission. Although the commission decided in favor of Abbott, the commission was unable to resolve the case and Abbott filed suit in U.S. District Court. (See AIDS Alert, September 1995, p. 118.)
The Supreme Court ruled 5-4 that asymptomatic HIV infection qualifies for the legal definition of being physically impaired. People with full-blown AIDS have been protected by the ADA. As the court's first ruling on an HIV issue, the justices sent a message that HIV is a stigmatizing disease that has lead to widespread discrimination, says Beverly Saunders Biddle, executive director of the National Lesbian and Gay Health Association in Washington, DC.
"It is very refreshing to see that the court has a clear and concise clinical understanding of HIV disease," she says. "Every major association of medical and other health care professionals agrees that it is safe to treat patients who are HIV-positive so long as universal precautions are observed."
While the court refused to create a special standard for charging those who violate the ADA, Biddle notes that employers must rely on scientific evidence when taking action regarding HIV-infected people.
One of the ruling's implications is that the federal government may have a harder time justifying its Medicaid guidelines, which deny patients payment treatment until they are deemed disabled through a diagnosis of AIDS.
"The federal government's anachronistic treatment of asymptomatic HIV disease has threatened the lives of the most vulnerable HIV-positive Americans," Zingale says. "If the Supreme Court says people with HIV should be protected from discrimination, they should be protected from advancement to AIDS."
In a letter to the Health Care Financing Administration, AIDS Action calls for the "modernizing" of HCFA's Medicaid guidelines so they will reflect the standards of care as defined by the National Institutes of Health. The changes would make HIV-positive people eligible for Medicaid so long as they meet income eligibility requirements for the program.
"Reinventing Medicaid to cover healthy HIV-positive Americans would save lives and save money," Zingale argues. "Every major study of protease cocktails has proven that early treatment provides the best route for preventing the onset of illness. Moreover, the cost of providing drugs early would offset exorbitant hospitalizations and other medical costs associated with AIDS treatment."
AIDS Action's letter to HCFA notes that Medicaid paid out $1.8 billion for benefits to more than 100,000 people with AIDS. "Ironically, studies show that costs of caring for people with full-blown AIDS are nearly twice that of healthy HIV-positive individuals," the letter states. (See new cost analyses of protease cocktails, p. 105.)
Reference
1. Sydney Abbott, et al v. Randon Bragdon, No. 96-1643, Appeal from the United States District Court for the District of Maine (Mar. 5, 1997).
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