The Once and Future Payers of Last Resort: The States and AIDS
Daniel M. Fox
Financing health care for persons with HIV infection and related diseases became a significant burden on the states and the taxpayers in the late 1980s. A number of states tried to meet this burden in ways that were innovative within the constraints imposed on state policymaking over many years by the United States Congress and regulators in the Health Care Financing Administration. By the end of 1990, this period of modest innovation was overtaken by events in the economy and in the public (and therefore the political) perception of AIDS. As one senior legislator put it, concern about AIDS in his state, even among liberals had been replaced by "massive apathy." A more scholarly assessment appeared in The New England Journal of Medicine in May 1991, where an article by Ronald Bayer, an expert on policy for AIDS, declared "An End to HIV Exceptionalism."
This chapter tells the story of that brief period of state innovation in financing for AIDS, the years between 1986 and 1990. In those years, the epidemic spread to every state and the federal government refused to make more than token gestures toward financing treatment. Estimates of the number of cases that would occur in the 1990s and of the cost per case caused great alarm in state capitols. The AIDS epidemic compounded the standard problems of financing health care for the poor and for everyone with chronic degenerative diseases.