[Testimony before the U.S. House of Representatives Subcommittee on Health and the Environment on the AIDS epidemic and Medicaid
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1990-02-27 (February 27, 1990)
Koop, C. Everett
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Medical Subject Headings (MeSH):
Acquired Immunodeficiency Syndrome
Legislation as Topic
AIDS, the Surgeon General, and the Politics of Public Health
Testimony before the U.S. House of Representatives Subcommittee on Health and the Environment on the AIDS epidemic and Medicaid
(H.R. 4080)[Reminiscence] (2003)
Box Number: 9
Folder Number: 1990 Feb 27
[TRANSCRIBER'S NOTE: Pages 1-4 of the document were typewritten]
Date And Time: Tuesday, February 27, 1990 at 9:45 am
Place: 2123 Rayburn House Office Building
Subject: The AIDS Epidemic and Medicaid
C. Everett Koop, M.D.
Former Surgeon General
United States Public Health Service
Barbara King Loyd
South Florida AIDS Network
Jackson Memorial Medical Center
University of Miami
P.O. Box 016960 (R 60 A)
Miami, FL 33136
Robert L. Parrish
Grady Memorial Hospital
80 Butler Street, S.E.
Atlanta, GA 30335
Richard Conviser, PH.D.
Children's Hospital of New Jersey
15 South Ninth Street
Newark, New Jersey 07107
Kenneth E. Thrope
Harvard School of Public Health
Health Policy and Management
677 Huntington Avenue
Boston, MA 02115
Scott D. Merwin
Insurance Assistance Program
P.O. Box 30037
Lansing, MI 48909
David J. Baird
Insurance Coordination Program
HIV/AIDS and Infectious Disease
Department of Health
Mail Stop LJ 17
Olympia, MA 98504
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[BEGIN PAGE TWO]
To Dr. Koop, Mary Lee (202-939-4993; FAX 202-939-4838)
From Tim Westmoreland (202-225-4952; FAX 202-225-7090)
Re: February 27th hearing on AIDS
February 13, 1990
Henry has asked me to contact you regarding the hearing two weeks from today. Please feel free to contact me if you have any
questions or need any assistance.
This hearing is intended to be the opening of attempts to improve AIDS health care services. Although bills will be introduced
by that time, the hearing will not be limited to specific legislative provisions, although some may be discussed: instead
we hope to remind Members and the press that the epidemic is not over and that problems in health care are going to get a
The tentative plan for witnesses is:
2) Representatives of Grady Memorial Hospital, Newark Children's Hospital, and Jackson Memorial Hospital
3) Representatives of Medicaid authorities from Michigan, and Washington (state)
4) A health economist on financing trends
We would hope that you would address the ongoing seriousness of the epidemic. Henry is especially interested in pressing for
Federal Legislation to get prophylactic and early intervention drugs to people in an attempt to forestall the development
of disease and the need for hospital and institutional care: he would welcome any comments you might have on this point.
Waxman will have two major bills for this legislative year referred to as the AIDS Prevention Act and one that is made up
of Medicaid improvements. I have attached more detailed descriptions but this is a brief summary.
AIDS Prevention Legislation
This bill would provide Federal funds to States and primary care clinics (e.g. TB, STD, Family Planning, Drug, Homeless, etc.).
Grantees would agree to provide pre-test counseling, testing, post-test counseling, diagnostic services for those infected
(e.g., T-cell), and early intervention drugs as indicated (e.g., aerosol pentamidine).
[END PAGE TWO]
[BEGIN PAGE THREE]
In addition, the bill would make low-income people who are HIV-positive and severely immune-compromised eligible for ambulatory
care coverage under Medicaid (i.e., prescription drugs and related outpatient services, such as physician, lab, and clinical
The goal of such legislation is to prevent infections among the uninfected and to prevent disease in the infected. It is to
do so by giving people access to counseling, testing, and early intervention drugs. Patients in a variety of settings would
be encouraged to be counseled and tested. Those testing positive would be encouraged to have diagnostics. Those who have severe
immune deficiencies would be able to get early intervention drugs paid for by Medicaid (if they are poor) or on a sliding
scale by the grantees (if they are not poor enough to qualify for Medicaid).
AIDS Health Care Financing
This legislation provides for improvement of acute and long-term care services for people with AIDS. It would do so in three
1) It would require States to pay a higher rate to hospitals that care for a large number of Medicaid AIDS patients. (Such
an adjustment already exists in the law for hospitals that care for a large number of Medicaid or no-payment patients; this
AIDS adjustment would be in addition to this existing Disproportionate Share Adjustment.) Such a rate increase can be justified
by the resource requirements of treating AIDS patients (e.g., the above-average use of personnel and lab services, as well
as the above-average length of stay) as well as the shortfalls of current reimbursements under Medicaid.
2) It would allow States to use Federal Medicaid matching funds to pay for continuation of group insurance coverage for HIV-infected
persons who have left their jobs because of disability. This continuation coverage is already available by law, but is quite
expensive since the patient must pay both the employer and the employee share of the premium. This provision would help slow
the process of private insurers shifting the cost of AIDS care onto public programs.
3) It would allow States to use Federal Medicaid matching funds to provide home- and community-based care to children (i.e.,
under 18) with AIDS. This would allow States to create alternatives to hospital care and thus allow these kids to be treated
at home, in foster care, or in other community settings. States may now provide such services if they apply to HCFA for a
waiver to do so, but HCFA may only approve a waiver that is "budget neutral," i.e. that spends no more on home- and
community-based care than would be spent on institutional care. Because OMB has construed such budget neutrality to be a very
strict test, waivers have been very difficult to get. This legislation would eliminate the "budget neutrality" requirement
for these services to
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[BEGIN PAGE FOUR]
children with AIDS.
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[BEGIN PAGE FIVE]
Sub Committee on Health
Henry Waxman, Chair.
C. Everett Koop, M.D.
February 27, 1990
[END PAGE FIVE]
[BEGIN PAGE SIX]
Mr. Chairman, I appreciate this opportunity to address the committee on certain aspects of the Aids [sic] epidemic. I am also
grateful that you maintain a forum for continuing the discussion of the AIDS epidemic
First may I remind the committee that there are still several aspects of aids [sic] that color everything we say and do about
the disease and raise barriers to dealing with the epidemic comfortably. -- AIDS is still somewhat of a mystery, it is fatal,
and people get Aids [sic] by doing things the majority of people dont [sic] do and dont [sic] approve of
[END PAGE SIX]
[BEGIN PAGE SEVEN]
These factors still keep many from addressing the issues that might contain the epidemic and provide necessary care for those
afflicted. Instead our attention is frequently turned toward more volatile issues of Law -- Ethics -- Economics -- Morality
-- and Social Cohesion.
The close of 1989 saw 117000 diagnoses of AIDs [sic], with 35000 new cases in 1989 and 40000 new cases predicted for this
The media has done a creditable job
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[BEGIN PAGE EIGHT]
of informing the public of a most complicated disease and of keeping the epidemic before them. I have been surprised that
the public's attention could be held so long.
Mr. Chairman, since leaving public office I have continued to travel about the country and indeed may, in some circumstances,
have better access to parts of the health care system than I did previously. I have become convinced that the figures I quoted
for you are under reported. I also am discomforted[?] to sense
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[BEGIN PAGE NINE]
a kind of complacency about the AIDS epidemic for at least three reasons: First, There are those who interpret the slightly
reduced projection for new cases this year as evidence that the epidemic is over. Secondly, there are others who view the
disease as "NOT THEIR PROBLEM" -- after all aren't new cases turning up in predominantly in black and hispanic
IV drug abusers? They say
[END PAGE NINE]
[BEGIN PAGE TEN]
Third, there are many, misled by innaccurate [sic] assessments in books and magazines that are convinced AIDS is not spread
heterosexually. The truth is that it is passed heterosexually male to female and female to male -- and dont [sic] forget:
My final concerns, Mr. Chairman, have to do with health care for persons with AIDS. When I released the
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[BEGIN PAGE ELEVEN]
Surgeon General's report on AIDS in October 1986, a report, incidentally, which is still accurate -- I said that the epidemic
of AIDS would impact everyone. It already has in many subtle ways but let me speak about the care of patients.
In New York City it is estimated that a quarter of the hospital beds are occupied by AIDS patients. And the problem of babies
with AIDS is growing by the day. There is ample anecdotul [sic] evidence of the anger and frustration [ . . . ]
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[BEGIN PAGE TWELVE]
families who cannot get a hospital bed for a loved one because it is occupied by an AIDS patient. I think it was before this
committee, Mr [sic] Chairmen that I predicted this situation and urged that it be prevented.
Babies born HIV positive, who eventually develop AIDS, are frequently addicted to the drug their mothers were addicted to
at the time of delivery. In a city I visited just recently, an addicted mother, her baby less than a day old, walked out of
the hospital with
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[BEGIN PAGE THIRTEEN]
an intravenous still attached to her arm -- either forgetting or not caring that she left her child behind to the abandoned
state so many of these youngsters inherit.
Mr. Chairman, public health and governmental goals in this epidemic remain the same -- even as the situation worsens and will
continue to do so. We need to keep the infected from infecting others, and where possible we must postpone the onset of opportunistic
disease and [ . . . ]
[END PAGE THIRTEEN]
[BEGIN PAGE FOURTEEN]
other than acute care hospitals.
Persons with Aids [sic] need help, physically, financially[?].
Hospitals that have a disproportionate case load of AIDS patients need help.
An alternate to hospital care for AIDS babies -- especially those abandoned -- must be found.
Much of what I have said this morning Mr. Chairmen I have said over and over again for the last five years. My concerns expressed
this morning have yet to be addressed at a National level. Unless there is congressional[?] intervention the situation can
only get worse. Indeed it is of [ . . . ]
[END PAGE FOURTEEN]
[BEGIN PAGE FIFTEEN]
[TRANSCRIBER'S NOTE: Pages 15-19 of the document were typewritten]
II. Although AIDS has receded from newspaper headlines for the moment the epidemic is far from over.
A. There have been about 120,000 cases of AIDS in total over the last eight years. There are about 50,000 Americans living
with AIDS now. We can expect that many people to be diagnosed this year alone.
B. There are an estimated one million people in the U.S. infected with HIV. 51% of these people have T-cells below 500 and
are thus on the verge of being sick. 20% of these people have T-cells below 200 and are at very high risk of pneumonia and
other serious AIDS-related illnesses.
C. As far as health care spending goes the epidemic is just building up force. People who are recently infected are relatively
inexpensive to care for because their illnesses are mild. But the 20% of the infected who have low T-Cell counts have been
getting progressively more sick and progressively more expensive to care for.
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[BEGIN PAGE SIXTEEN]
III. The best response is, of course, prevention.
A. We should take all necessary courses to prevent infection among the uninfected.
a. Of high risk groups
b. Of young people
2. Risk reduction
a. Abstinence and safer sex
b. Treatment of drug abusers
c. Abstinence and safer drug use
3. Counseling and testing of people at high risk
[END PAGE SIXTEEN]
[BEGIN PAGE SEVENTEEN]
B. We should also expand the prevention agenda to include prevention of AIDS among the infected.
1. A lot has changed over the past year in this area of prevention.
a. Development of aerosol pentamidine and other prevention drugs means that pneumonia -- the leading cause of hospitalization
and of death among people with AIDS -- is not inevitable any more.
b. Trials of early intervention use of AZT mean that immune system collapse can be postponed.
c. Trials of lower dosages of AZT mean that more people can take this drug with fewer side effects.
d. Other drugs to prevent illness are being developed and still more research should be undertaken.
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[BEGIN PAGE EIGHTEEN]
2. But this research must be gotten to people who need it.
a. If we are to prevent AIDS effectively and limit the need for expensive hospital care, we must get such early intervention
to the people who need it.
b. Everyone -- NIH, CDC, FDA -- all agree that such treatment is State-of-the-Art Medicine.
c. It is wrong to structure our whole health care system on treating acute AIDS when we could prevent much of the illness.
Prevention is cheaper and better for everyone.
d. It is wrong to bring people in for testing and then deprive them of the treatments they need.
e. It is especially wrong to make the poor get sick while providing prevention only to those who can afford it.
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[BEGIN PAGE NINETEEN]
A. We've come a long way since the early days of AIDS.
1. In understanding AIDS
2. In learning to deal with it without fear
3. In learning how to prevent it
4. In learning how to care for those who have it.
B. We should not rest, however, until we take what we've learned and gotten it to the Nation.