Some gains seen in ADAP access, but big problems remain

The National Alliance of State and Territorial AIDS Directors (NASTAD) and the AIDS Treatment Data Service compiled a study on how States implement and manage AIDS Drug Assistance Programs (ADAPs). The study shows a wide disparity in access from State to State, and shows that States with weak Medicaid programs tend to have higher expenses in their ADAP programs. The national survey found that more than 43,000 people relied on ADAPs. A table details the program funding in each State.     

Most States moving toward HIV reporting, but methods vary

Thirty States require adult HIV reporting to public health departments, and more are considering doing so, as the Centers for Disease Control and Prevention (CDC) prepares to publish new guidelines for tracking infection. A recent National Alliance of State and Territorial AIDS Directors (NASTAD) survey found wide support for HIV reporting by name. State-by-State case surveillance information is provided.     

States' responses to Title II of the Ryan White CARE Act.

Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 provides formula-based grants to States to help them improve the quality, availability, and organization of health care and support services for people with human immunodeficiency virus (HIV) infection. This article reviews State expenditures during the first year of CARE Act funding (April 1991-March 1992) within the context of Title II guidelines and the federally funded grant programs that preceded and helped shape Title II. The authors also discuss future challenges that require development of resources, the assessment of program impact, and the evaluation of the quality and appropriateness of HIV-related services. Ninety-one percent of the $77.5 million awarded to States during fiscal year 1991 went for the provision of medical and support services through HIV care consortia, drug reimbursement programs, home and community-based care programs, and health insurance initiatives. The remaining monies were used for planning, evaluation, and program administration. Forty States allocated $38.9 million for the establishment of HIV care consortia to assess service needs and to develop comprehensive continuums of health and support services in the areas most affected by HIV disease. Fifty States allocated an additional $28.3 million for the continuation or expansion of FDA-approved drug therapies for low-income people with HIV infection. Twenty-five States allocated $2.2 million for the provision of home- and community-based health services, and 16 States allocated $1.3 million for programs that help low-income people with HIV infection to purchase or maintain health insurance coverage.     

State epidemiology programs and state epidemiologists: results of a national survey

In 1983, the State Epidemiologists in 46 States completed a survey questionnaire describing the professional qualifications, training, and experience of State health department epidemiologists and the scope of participation by the State Epidemiologists and their staffs in public health programs. The survey identified 224 State health department epidemiologists (estimated U.S. ratio 1.1 per million population). A State health department epidemiologist was most often male (80 percent), frequently (57 percent) was a physician, had an average age of 41 years, and had worked as an epidemiologist for 9 years. Participation in public health programs (either by supervising or providing consultation) by the State Epidemiologists and their staffs focused mainly on general epidemiology and communicable disease programs; fewer than half had participated in programs relating to the health of women and children, chronic diseases, injuries, or in other programs directed towards preventing premature mortality. Recently, the State Epidemiologists have been trying to broaden their activities into these areas; however, the demands created by the acquired immunodeficiency syndrome (AIDS) will mostly likely slow this process. Based on the overall findings and collective experience, it was concluded that State health departments have too few epidemiologists to address the wide variety of important public health problems facing our communities. It was proposed that each State health department have at least four epidemiologists (including one or more physician epidemiologists) and at least one master's level biostatistician and that the epidemiologists-per-population ratio not be less than 1 per million.     

Using Medicaid/SCHIP to insure working families: the Massachusetts experience

Massachusetts was the first State to implement a premium subsidy program for employer-sponsored health insurance, using both Medicaid and State Children's Health Insurance Program (SCHIP) funding. The Insurance Partnership (IP) provides subsidies directly to small employers, and the Premium Assistance Program provides subsidies to their low-income employees. Approximately 3,500 small firms currently participate, most of them offering health insurance coverage for the first time. Approximately 10,000 adults and children are covered through the program, the majority of whom had been uninsured prior to enrolling. Massachusetts' successful experience with premium subsidies offers important lessons for other States wishing to implement similar programs.     

Texas addresses HIV job bias and end-of-life issues

Governor George W. Bush of Texas signed four HIV-related bills at the closing of the 1997-98 legislative session. The State employment discrimination law was amended to include people with HIV and AIDS. House Bill 1865 enhances options that group or individual life insurance policy holders have in obtaining accelerated health benefits. The bill removes a $25,000 cap on accelerated benefits available to those with terminal or long-term illnesses. House Bill 163 removes a prohibition on State employees selling their group life insurance policy in the State Employees Retirement System to a viatical settlement corporation. House Bill 710 provides a funding mechanism for the State health insurance risk pool.     

Chances dim for fiscal '97 boost in AIDS drug funds

Congressional leaders rejected a proposal to supplement Federal funding for State-run AIDS drug assistance programs (ADAP), and President Clinton refused to intervene. A proposal by Rep. Nancy Pelosi (D-CA) that included $68 million in additional ADAP funding was part of a supplemental appropriations bill aimed largely at paying for flood relief. Some State ADAP programs remain financially sound following the latest round of Ryan White CARE Act grant allocations. Several States have curtailed new enrollments or adopted other cost-saving measures. Almost all of the States' budgets are being rapidly depleted as more people demand access to expensive medicines. The worst problem is in Mississippi, where State funds are not used to cover AIDS programs. AIDS policy advocates and State public health officials were disappointed that President Clinton declined to support Rep. Pelosi's request. The President's AIDS policy director, Sandra Thurman, explained that the funding request could not be developed without taking into account two factors. First, the Department of Health and Human Services is seeking ways to extend Medicaid eligibility to more low-income people living with HIV, reducing the ADAP budget. Second, upcoming treatment guidelines could affect the amount of funding needed to adequately fund the ADAPs. The guidelines are expected to recommend combination drug therapy using a protease inhibitor.     

Role of state health agencies in responding to AIDS

State health agencies have assumed a leadership role in responding to the major public health issues raised by the AIDS epidemic. Directors of State health agencies (State health officers) have asserted their influence at the national level as well as at the State level. The Association of State and Territorial Health Officials (ASTHO), and especially ASTHO'S AIDS Committee, has served as the primary vehicle through which State health officers communicate their views to the Federal Government and vice versa. To date, ASTHO has held four national conferences on AIDS. Each one has brought together Federal, State, and local officials, advocacy groups, and other public health experts, and each has resulted in practical recommendations to public health departments on how to implement their AIDS programs most effectively. Although State health agencies have responded differently to the epidemic, many have adopted innovative, and sometimes unpopular, approaches. State health agencies' responses to the AIDS epidemic are governed partly by environmental factors, including the views of political leaders in the State, the strength of concerned advocacy groups, and the number of AIDS cases in the State. Despite their different approaches, State health officers have agreed that education is the most important tool in their programs to prevent human immunodeficiency virus (HIV) infections. The rapidly changing AIDS epidemic has required State health agencies to be flexible in their approaches to controlling the epidemic. State health officers' evolving views about HIV testing and partner notification are two examples of how new information about the epidemic has affected States' HIV control programs.     

Medicaid disproportionate share and other special financing programs

Medicaid disproportionate share hospital (DSH) and related programs, such as provider-specific taxes or intergovernmental transfers (IGTs), help support uncompensated care and effectively reduce State Medicaid expenditures by increasing Federal matching funds. We analyze the uses of these funds, based on a survey completed by 39 States and case studies of 6 States. We find that only a small share of these funds were available to cover the costs of uncompensated care. One method to ensure that funds are used for health care would be to reprogram funds into health insurance subsidies. An alternative to improve equity of funding across the Nation would be to create a substitute Federal grant program to directly support uncompensated care.     

ADAP funding seen as insufficient; increases sought

Federal and State lawmakers are being asked to appropriate an additional $244.9 million this fiscal year and next to meet the growing demand for medicine through AIDS drug assistance programs (ADAPs). The ADAP Working Group revealed preliminary data indicating a widening gap between existing funding and projected needs of people with HIV who lack private insurance. A $66.9 million shortfall is expected in the current fiscal year. The projected spending needs for 1997 and 1998 are based on a survey of a pharmacoeconomic model that includes the rate of growth in applications to State ADAPs. The model takes into account future prescribing practices, assuming greater use of combination therapy using two nucleoside analogues and a protease inhibitor. Four States do not currently cover protease inhibitors and ten have capped access to new drugs. Despite rising costs for ADAPs, expenses could become even greater if people are denied access to medication.     

Expanding health insurance for children

This issue of States of Health provides information that advocates, consumers, legislators, and other policymakers can use in crafting effective state health insurance programs for children. It looks at states' options under the rules and funding of the State Children's Health Insurance Program, the 10-year, $50-billion federal package enacted in 1997 as Title XXI, highlighting the critical program design issues that may mean the difference between healthy children and wasted opportunity.     

Reproductive and sexual health benefits in private health insurance plans in Washington State

CONTEXT: Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems. METHODS: A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations. RESULTS: Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally. CONCLUSIONS: A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.     

ADAPs remain in crisis as demand grows for new drugs

Many State-run AIDS drug assistance programs (ADAPs) remain in perilous financial situations despite an infusion of government funds. Between 1996 and 1997 the amount of money that Federal and State governments spent on the programs rose 85 percent, yet 35 States have had to enact emergency measures within that time frame. Fifteen States capped or restricted access to protease inhibitors, 16 States instituted waiting lists, 11 States reduced the number of drugs that they will cover, 13 States capped the number of people served, and 7 restricted eligibility by lowering the income levels covered.     

Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87

Since 1981, the Centers for Disease Control has collaborated with State health departments and the District of Columbia to conduct random digit-dialed telephone surveys of adults concerning their health practices and behaviors. This State-based surveillance system, which yields data needed in planning, initiating, and supporting health promotion and disease prevention programs, is described in this paper. Standard methods and questionnaires were used to assess the prevalence of personal health practices and behaviors related to the leading causes of death, including seatbelt use, high blood pressure control, physical activity, weight control, cigarette smoking, alcohol use, drinking and driving, and preventive health practices. Between 1981 and 1983, 29 States (includes the District of Columbia) conducted one-time telephone surveys. Beginning in 1984, most States began collecting data continuously throughout the year, completing approximately 100 interviews per month (range 50-250), with an average of 1,200 completed interviews per year (range 600-3,000). The raw data were weighted to the age, race, and sex distribution for each State from the 1980 census data. This weighting accounts for the underrepresentation of men, whites, and younger persons (18-24 years) in the telephone surveys and, for many health practices, provides prevalence estimates comparable with estimates obtained from household surveys. Nearly all (86 percent) of the States distributed selected survey results to other State agencies, local health departments, voluntary organizations, hospitals, universities, State legislators, and the press. The majority (60 percent) of States used information from the surveys to set State health objectives, prepare State health planning documents, and plan a variety of programs concerning antismoking, the prevention of chronic diseases, and health promotion. Further, nearly two-thirds (65 percent) used results to support legislation, primarily related to the use of tobacco and seatbelts. Most of the States (84 percent) reported that alternative sources for such data (prevalence of behavioral risk factors) were unavailable. Currently in 1988, over 40 State health departments are conducting telephone surveys as part of the Behavioral Risk Factor Surveillance System. This system has proved to be (a) flexible--it provides data on emerging public health problems, such as smokeless tobacco use and AIDS, (b) timely--it provides results within a few months after the data are collected, and (c) affordable--it operates at a fraction of the cost of comparable statewide in-person surveys.(ABSTRACT TRUNCATED AT 400 WORDS)     

Sexually transmitted diseases: a neglected public health priority.

Sexually transmitted diseases remain uncontrolled although millions of cases occur annually in the United States. The advent of acquired immunodeficiency syndrome (AIDS), which is also a sexually transmitted disease, has not altered this situation. The major portion of federal funding for sexually transmitted diseases is allocated to a search for an AIDS vaccine or cure. State health department funding for sexually transmitted diseases, although only a small fraction of the $1.3 billion AIDS research budget of the National Institutes of Health, is largely consumed by AIDS. A single adequately funded sexually transmitted disease control program that applies well-established public health principles for the control of communicable diseases would make sense. However, a consensus to develop and support such a program does not exist in the United States.     

The family of HIV seroprevalence surveys: objectives, methods, and uses of sentinel surveillance for HIV in the United States

During 1987-89, the Centers for Disease Control (CDC), in collaboration with State and local health departments, other Federal agencies, blood collection agencies, and medical research institutions, implemented a national sentinel surveillance system for human immunodeficiency virus (HIV) infection. This ongoing surveillance system, known as the CDC family of HIV seroprevalence surveys, uses standardized survey and HIV serologic testing procedures in a group of sentinel populations from geographically diverse metropolitan areas, States, and Territories of the United States. As of September 1989, sentinel surveillance for HIV infection was being conducted in 41 States, Puerto Rico, and 39 metropolitan areas, including the District of Columbia. Information from this system complements AIDS surveillance data to assist health officials to direct resources and develop strategies for HIV prevention and health-care programs.     

U.S. Public School Enrollment-Based Health Insurance Initiatives and America's Uninsured

ABSTRACT: This article reviews current literature on school enrollment-based health insurance programs underway or pending in the United States. This model of affordable family health insurance delivery was first proposed in a 1988 New England Journal of Medicine Sounding Board article, but only a few states - Arkansas, Florida, New Hampshire, and Texas - have begun public sector-driven programs in the 1990s that use school enrollment as a pooling mechanism to purchase group insurance policies from the private sector. Public support of this model is strong, interest is currently growing, and other states, including North Carolina and Iowa, are exploring or have enacted legislation that supports establishment of school enrollment-based health insurance programs. After summarizing these public-sector initiatives, additional information is presented on uninsuredness in America; risk factors for uninsuredness among children; and national public and private initiatives in child health insurance using eligibility criteria other than or including school enrollment that were examined by the GAO in 1994/95.     

Fate of Medicaid remains uncertain as showdown nears

A Republican plan to renovate the Medicaid program has been proposed in Congress as one component of an overall budget reconciliation act. President Bill Clinton is expected to veto this proposal. The Republicans combined the budget reconciliation with an increase in the Federal debt ceiling. A showdown between Congress and the President is expected by November 6, 1995. If no agreement is reached at that time, the U.S. Government will shut down or default on financial obligations. AIDS activists and health care providers are striving to ensure that the Congressional Medicaid proposal does not pass, as it would devastate health care protection for the indigent, the elderly, and many AIDS patients. Medicaid is the single largest federally-funded health care program for people with AIDS, with over forty percent of people with AIDS relying on Medicaid for their health insurance. Under the Republican plan, Federal funding for State-run Medicaid programs would be at least nineteen percent lower than the amount necessary to cover medical costs; the shortfall ranges from thirty percent in Washington to two percent in Kansas. States would be able to choose the number of beneficiaries that would be covered, the types of services offered, and the source of health care providers. The President's counter-proposal would eliminate projected spending through increased use of managed choice health-care. His plan retains Medicaid as a means-tested entitlement program.     

Sources of health insurance in the U.S.: analysis of state-level data and implications for public health programs.

Lack of health insurance coverage is associated with lack of accessibility to preventive health care services such as mammography screening, clinical breast examination, Papanicolaou smear test, digital rectal examination, proctoscopy examination, and cholesterol screening. State and federal public health agencies must have an understanding of insurance coverage of the population to plan intervention programs aimed at early detection of medical conditions. Using data from the March Supplement of the Current Population Survey for the years 1994, 1995, and 1996, this study examines the sources of health insurance coverage in the U.S. The implications of the findings for public health programs are discussed.