Important note: Information in this article was accurate in 1989. The state of the art may have changed since the publication date.
The real answer is equal health care
San Francisco Chronicle - Monday October 16, 1989
Randy Shilts
When Dr. Mark Smith talks about the future of AIDS policy in the 1990s, he recalls two patients he tended during his residency at San Francisco General Hospital. One was an 80-year-old man who had lived his entire life in San Francisco and was dying of a brutally disfiguring cancer. The man fell through the cracks of available social programs. There was no hospice program that would accept him; instead, he had to languish alone in his hospital bed. Next door was a young man who had lived in San Francisco for only five months. Because this patient had AIDS, he was served by a hospice program, tended by grief counseling volunteers, had access to home health care services, had meals delivered to his home and would even have his burial expenses paid for by a private group. "The point is not that the second gentleman shouldn't have had all that," says Smith, now the assistant director of AIDS services at Johns Hopkins University in Baltimore. "The point is that everybody should have that." When many of the nation's top AIDS experts gathered in San Francisco last week for a national conference that looked toward the future of the AIDS epidemic, many offered a similar analysis. The clear consensus among health policy thinkers was that what the nation does not need is new programs just for AIDS, but programs that can address the broader deficiencies in health care delivery in America. "In the years ahead," Smith admonished the audience, "we will be increasingly hard-pressed to justify the special nature of AIDS." Even as the experts spoke, the problems with the special-interest approach to AIDS policy were becoming apparent in Washington when Congress was voting on whether to extend the $30 million in federal subsidies to give life-saving AZT treatments to AIDS patients. The subsidies have routinely been passed by Congress in the three years since the expensive drug was first licensed. Although the subsidy passed, the appropriation faced tougher sledding last week as legislators wondered openly why the federal government should subsidize this drug for AIDS but not other drugs for other diseases. Such disease-specific programs are not unique to AIDS, of course. The federal government doles out hundreds of millions of dollars annually to provide kidney dialysis to people who would die of renal disease without such help. Still, similar programs are unlikely to be initiated at a time when federal budgets are shrinking. This is particularly the case with the recent calls for early-intervention programs to provide AZT and new treatments to HIV-infected people to prevent them from getting AIDS. Such programs undoubtedly will save money by keeping people out of expensive hospital beds, but so do lots of other health programs, such as pre-natal projects, that are not getting federal bucks. Moreover, health policy theoreticians say it will be harder in the years ahead to justify programs geared only to AIDS patients when an estimated 31 million Americans also do not have access to health care because they do not have private health insurance. "We cannot meet the needs of people with AIDS with another categorical program like we have with renal disease," says Dr. Phil Lee, director of the Institute of Health Policy Studies at the University of California in San Francisco. "I don't believe it will be politically feasible," he says. "We must develop a coalition to build bridges and make sure all people are covered" by health programs. Lee says AIDS groups will need to join with other constituencies who are underserved by the way America provides its health care, such as the elderly and, of course, the 31 million uninsured, most of whom are among the working poor. The goal, he says, should not be just to get AZT to AIDS sufferers but to make sure the elderly can afford their medications and ensure that expectant mothers in Harlem get pre-natal care. There's as much political wisdom as altruism in this proposal. Most polls show that upward of 80 percent of Americans agree that this country needs to change the way it finances health care so that everybody, not just the privileged, can have access to what is inarguably the greatest medical system in the world. In the short term, cities like San Francisco and New York can make convincing cases for some sort of disaster relief from Congress, given the huge share of the AIDS burden they bear. In the longer term, however, the experts in San Francisco last week were saying that AIDS should just be one wheel of a larger bandwagon that already is rolling over the political landscape. "The problems are generic to the health care system and we need generic solutions," said Dr. James Mason, who, as the assistant secretary for health, is the nation's top health official. "The whole system needs to be changed," Mason said last week. "It's going to happen. The only question is when."
Keywords: HEALTH INSURANCE; US; AIDS; MEDICINE; HEALTH; POLICY
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