AN especially odd, ethically loathsome feature of health insurance coverage in America is the emerging practice of setting a monetary cap on the amount of coverage if you get sick.
More and more insurance companies and private insurance plans are setting caps on what they will pay hospitals and nursing homes for treating particular diseases. The insurance plans are saying, in effect, that some diseases are worth paying more for than others.
Allowing insurance plans to decide which diseases are worthy of care is about as absurd a place to put moral responsibility as can be imagined. But that is the way the world of insurance currently stands.
Mark Kadinger found out about this the hard way. When the St. Paul man contracted AIDS, he learned that his union medical insurance plan would pay only $50,000 to cover the costs of AIDS-related care. His bills were higher than that.
If Kadinger had been hit by a car or struck by lightning, his insurance would have covered up to $500,000 in medical bills. But because he had AIDS, he faced going bankrupt -- thanks to the cap that his insurance plan had imposed on payments to treat his disease.
The practice of limiting payments according to the type of disease someone has is inherently unfair. Why should those facing huge medical bills have to worry that their insurance will RTC run out depending on the nature of their illness? Are those with AIDS somehow less worthy of the same degree of coverage as someone who has Alzheimer's, tuberculosis, food poisoning or a spinal cord injury? Mark Kadinger did not think so.
Before he died last Nov. 20, Kadinger asked his physician, Dr. Frank Rhame of the University of Minnesota, and the Minnesota AIDS Project to take legal action to challenge this patently immoral insurance practice.
That is why on March 17 the University of Minnesota and the estate of Mark Kadinger filed suit in U.S. District Court in Minneapolis alleging that the health plan operated by the International Brotherhood of Electrical Workers, of which Kadinger was a member, discriminated against him by capping the amount of money he could receive to pay his AIDS-related medical bills.
The legal basis for the suit is the Americans with Disabilities Act, which was enacted by Congress last year to prevent discrimination against those with disabilities.
Since AIDS is recognized as a disability under this law, the hope -- according to Gayle Dixon, legal program coordinator for the Minnesota AIDS Project -- is that this most unusual lawsuit will put "employers on notice that they cannot cap specific diseases."
While the practice of putting caps on insurance payouts by disease would seem to be inherently discriminatory and unfair, some experts doubt that the lawsuit will succeed. George Annas, a professor of law, ethics and public health at Boston University, believes that the court will rule in favor of the right of the union to use disease-specific caps in its health plan.
"It is terrible that they can do this," Annas says, "but the Americans with Disabilities Act only protects individuals against discrimination, not groups. If everyone who has AIDS or any another disease has a cap placed on what they can receive in terms of health benefits, the court is not likely to find that discriminatory."
Mr. Annas' discouraging prediction about the fate of the lawsuit is echoed by his colleague at Boston University, Wendy Mariner. Ms. Mariner notes in a recent New England Journal of Medicine article that health plans that self-insure are turning more and more to disease exclusions and caps as a way to contain costs. At least 18 plans have reduced or eliminated health insurance benefits for those with AIDS.
There is a chance that the Kadinger case will be lost. Perhaps telling people with AIDS or Parkinson's or Alzheimer's that they cannot get the same degree of medical coverage as others whose bills are the same -- but whose diseases are different -- does not violate the Americans with Disabilities Act.
But it surely ought to offend every American's sense of decency and fairness to permit a health-care insurance system in which a faceless, bureaucratic bean-counter with an eye on the bottom line gets to decide whether treatment of your disease is deemed worthy of payment in full.
Arthur Caplan is director of the Center for Biomedical Ethics at the University of Minnesota.