AIDS policy: Two divisive issues

AIDS policy: Two divisive issues

POLICY WATCH by an advisory board with undefined power. Dr. Relman makes a strong case for a physician majority on the board with extensive clout to ...

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POLICY WATCH

by an advisory board with undefined power. Dr. Relman makes a strong case for a physician majority on the board with extensive clout to impact the plan’s policies and internal utilization review activities. He further emphasizes the need to relax antitrust regulation to allow physicians to collectively bargain with health care plans. This would help to prevent the domination of business versus health care decisions. Dr. Relman believes that health care plans should be physicianowned not-for-profit oganizations, which have been encouraged to develop through federal grants for start-up costs and personal indemnification if the plan does not succeed. Furthermore, these plans should be prevented form providing physician incentives to underserve their patients. He makes an appeal for physicians everywhere to get involved in such efforts and not to become the pawns of big business. In a companion editorial, Dr. Angel1 evaluates the Clinton Health Care Reform Plan. She rates the Plan high on its effort to provide universal, comprehensive care; medium for its ability to contain costs and for placing the burden on employees to pay for it; and low for its lack of coherence and its inability to maintain or strengthen morale of physicians and patients. Dr. Angel1 also expresses serious concern about the takeover by big business with the resultant decrease in the medical profession’s role. She speaks out for a single-payor (Medicare-like) system with second preference given to not-for-profit plans which are funded by fured premiums. Both of these writers are complimentary of President Clinton for bringing health care reform to the political forefront, but rightfully critical of issues which are key to physicians and their patients. It is gratifying to see col-

leagues of this stature speaking

out in such clear and direct terms! More physicians need to be following their example. Even organized medicine, and particularly the American Medical Association, has learned that it is unwise to ignore or attempt to stonewall important national policy decisions, especially when they have reached the level of interest that health care reform has. Medicine has already lost much of the control of the health care policy decision-making process, and any success at fulf?lling Dr. Relman’s recommendations will require a strong grass-roots effort. I’here will most likely be some Formof enacted reform by the fall Df 1994 (before the November Elections), so there is less than 3 year to make a difference. Physicians need to keep well inFormed, to educate their elected representatives, and to encourage their colleagues, to do the same. 3rd~ then will this process be renectiveof the patients’ best interest.

HIV Prevention: Respect for Self and Others ‘RogersDE, Osborn JE, AIDS Poliw: Two 3ivisive Is.sues.JAMA 27O(4):494-495.1 ogers and Osbom, member

of the National Commission on AIDS, speak to mismterpretation and controversy surroundingthe release of the National Research Council’s February 1993 report entitled, The Social Impact of AIDS in the United States. The two most contentious debates center around whether HIV prevention programs should be broadly or narrowly targeted and whether syringe exchange programs should be a significant part of new prevention efforts. These may be smoke screens for major issues of whether the Centers for Disease Control and Prevention and those accountable for the health of the nation should R

be exempt from political control and whether large-domain issues such as poverty and social inequality are to be publicly acknowledged as legitimate predictors or determinants of HIV infection. If they are, whose mandate will it be to tackle these endemic problems in the name of HIV and TB prevention? Concerning the first point, if the highest-placed health officials in the nation are to have the authority and wherewithal to control disease, then the objectives of HIV prevention programs must include access to sterile Gection equipment as well as to condoms and drug treatment programs. Does prevention need to be widely targeted? Researchers in Britain constructed a general-population infection-exposure risk index and found that, according to self-reported sexual behavior, roughly 85% of the adult population aged 18 to 50 were estimated to be at some risk for behavioral exposure to HIV. Clearly, “deemphasizing a national prevention strategy in favor sf prevention efforts targeted at a relative handful of identifiable neighborhoods or behavior groups” would be disastrous. People need to be in control of their lives. Access to uncontaminated syringes would hardly seem to be a debatable issue at this point; more debatable would be how to add effective access to counselling and treatment, to legal substitutes for illegal drugs, to health care services, to support and encouragement from community, family and friends, to employment, and to a future. The expertise exists to put these preventive measures into place; what is needed is the political will and the consolidation of services and agencies that will facilitate achievement of these goals and objectives in the most efficient and least costly manner.-LWG

THE AMERICAN JOURNAL OF SURGERY

VOLUME 167 MARCH 1994

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