The San Francisco Examiner - Wednesday, Sept. 24, 1997
Lisa M. Krieger of the Examiner Staff

"The populations affected by HIV are increasingly poor, heterosexual minorities, intravenous drug users, and women, most of whom are not been able to obtain private insurance coverage to pay for their expensive anti-viral therapy and monitoring," lead investigator Dr. Allyn K. Nakashima of the federal Centers for Disease Control and Prevention told The Examiner.

"These populations are likely to rely on public insurers: Medicaid, Ryan White CARE Act funds, the AIDS Drug Assistance Programs and state-subsidized programs," she said.

"The private role is growing less and less, over time."

The growing number of underinsured HIV patients means that "the currently recommended HIV therapy for infected persons will be accessible only if public insurance coverage - such as Medicaid - is expanded," she said. "Clinton has talked about expanding Medicaid, but whether that will actually happen or not is up to policy makers. Our job is to bring attention to the problem."

The cost of a year's supply of anti-viral drugs, plus tests to monitor the virus and immune system, can surpass $14,000.

Nakashima and her CDC team conducted interviews with 17,089 patients at state and city health departments around the nation and found that 16.9 percent were covered by private health insurance and 40.5 percent were on Medicaid. About 13 percent relied on some other form of public medical assistance and 29.2 percent had no insurance coverage.

Heterosexual men were more likely than women or gay men to be without any form of insurance. Women were more likely than men to be covered by Medicaid, particularly if they had children. Gay men were more likely than either women or heterosexual men to have private health insurance.

The typical uninsured HIV patient was male, non-white, and under the age of 35 years, the study found.

The problem grows

In all groups surveyed, private insurance coverage was found to be a dwindling phenomenon. In 1997, the proportion of gay men with private insurance was 20 percent, down from 25 percent in 1991. Among intravenous drug users, the proportion dropped to 10 percent from 18 percent in the same years. Among men and women heterosexuals, the proportion dropped to 6 percent from 9 percent.

Of those who had worked and been insured, many had quit their jobs and spent their savings to qualify for the expensive life-prolonging drugs, she said.

"The numbers suggest that, over time, a growing percentage of HIV / AIDS cases will be uninsured or require public assistance," said Nakashima. Her study was released at the annual meeting of the Infectious Disease Society of America in San Francisco.

The CDC research team interviewed patients in state health departments in Arizona, New Mexico, South Carolina, Delaware, Florida, New Jersey and Connecticut and local health departments in Detroit, Denver, Atlanta, Los Angeles County, and Washington, D.C.

Study participants were 40 percent white, 43 percent black, and 16 percent Latino. About 46 percent had acquired the AIDS virus through male-to-male sex, 33 percent through sharing intravenous drug syringes, and 14 percent through heterosexual sex with men or women with high-risk behaviors for acquiring HIV.

Fifty-four percent of patients interviewed earned less than $10,000 a year. Three-quarters were unemployed.

The high cost of AIDS

The numbers are sad but not surprising, said Dr. Mitch Katz, acting director of the San Francisco Health Department.

Such is the toll of AIDS that even the affluent can find themselves quickly impoverished. Once a job is lost, people who once lived the good life are forced onto public assistance, he said.

"Because in this country we have employer-based insurance, when people develop a serious illness such as AIDS, they risk losing their health insurance because they are unable to pay their premiums once they are no longer working," he said. "This results in a large proportion of people losing their private insurance and relying on government programs instead.

"Innovative programs are being developed by the state of California which would enable the state to pay private insurance premiums for people who are employed, so they can maintain their insurance once they are not working," he added.

The trend also is driven by the changing patient population, he said.

"The high number of people without insurance reflects the increasing poverty of the epidemic," said Katz. "Increasingly, the epidemic is comprised of women, people of color, and intravenous drug users - people with little in the way of economic resources."

It is increasingly difficult to deliver - and pay for - the provision of ever-more-complex medical care to this sick and socially disconnected patient population, doctors say.

. . . . . .Date

. . . . . .reported. . Cases. . . Deaths

S.F.. . . .9/1 . . . . 24,611 . . 16,878

Calif.. . .9/1 . . . .102,574 . . 65,463

U.S.. . . .9/1 . . . .581,429 . .362,004

WHO(rprtd) 9/1 . . .8,400,000 . 6,400,000

Figures are cumulative since June 1981. Government officials now compile and release statistics quarterly, not monthly.

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