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amsterdam Controversy leads to new Netherlands HIV-test guidelines
DISPATCHES
WASHINGTON
Clinton’s swan-song appeal for health-care reform
S President Bill Clinton was still preaching health-care reform last week in his seventh and final State of the Union address, urging Congress to extend coverage to more of the nation’s medically uninsured and underinsured millions. As usual, there is humanitarian disbelief that neglect on that scale can go on indefinitely amid the riches of America in the new millennium. Strong pressures from the politically potent lobbies of the elderly may force enactment of insurance coverage for the fast-rising costs of prescription drugs. But beyond that change, the political calendar may impose a hold on health-care reform, at least for the year 2000, and maybe beyond. After some quiescence in the clamour of politics, the insurance issue has been revived by rapid increases in drug costs, for which little if any coverage is available, and a continuing rise in the ranks of the uninsured, despite various piecemeal efforts to bring them into the system. Creeping progress has been made since the collapse of the big-bang reform proposed in 1993 and 1994, at the outset of Clinton’s presidency. For example, employees who leave a job that provided health insurance can continue their coverage, although at their own expense. And the Children’s Health Insurance Program, enacted in 1997, has enrolled 2 million children, and is aiming for another 3 million. But, as the president noted in what could serve as an epitaph for health politics of recent times, “there are still more than 40 million of our
U
AMSTERDAM
fellow Americans without health insurance—more than there were in 1993”. In fact, there are at least 4 million more. The President’s proposals for extending insurance coverage would bring in additional millions by providing tax subsidies for whole families enrolling in the children’s programme and by open-
“there are still more than 40 million of our fellow Americans without health insurance—more than there were in 1993” ing the Medicare programme, now limited to people aged 65 and older, to those aged 55 to 65 on a “buy-in” basis, assisted by tax credits. As alternatives to politically unattainable comprehensive reform, these proposed smaller changes are the best that can make it to a realistic political agenda. Anything on a larger scale draws denunciations such as “socialised medicine”, illustrated with horror tales from Canada and the UK, with particular emphasis on patients fleeing queues in those lands to obtain medical care in the USA. The deprivations of the domestic uninsured and at least as many poorly insured are on a par with those of the medical refugees streaming from abroad into American clinics, but there is less drama in familiar homegrown misfortune. The short-term prospects for health-care reform are not glowing.
With the presidential and congressional elections just 9 months away, the Republican majorities on Capitol Hill are not disposed to accommodate the president they tried to evict just a year ago, or to enhance the stature of his preferred successor, Vice President Al Gore. While the Congressional Democrats cheered the President’s State of the Union health-care proposals, the Republicans sat impassively. The main opportunities for legislative collaboration are on drug insurance coverage, a high priority among senior citizens, and a “patients bill of rights” in dealings with health-maintenance organisations (HMOs). Tales of high-handed, neglectful treatment by HMOs easily make it into press and television coverage, and into Congressional hearing rooms. Films, political cartoons, and late-night television humour demonise HMOs as vultures feasting on hapless patients. Presenting the Republican response to the President’s address, Senator Bill Frist, of Tennessee, a cardiac transplant surgeon in former days, endorsed the patients’ bill of rights and prescription drug coverage for the elderly. Regarding other matters, the Senator questioned the President’s intentions, recalling the failed attempt at the beginning of the Clinton presidency to make over the nation’s whole system in one grand legislative act. There is no attempt in sight for another try on that scale. Daniel S Greenberg
Controversy leads to new Netherlands HIV-test guidelines
L
ast week, the Dutch Minister of Health, Els Borst-Eilers, responded to mounting criticism of new guidelines on testing for HIV, promising to alter legislation on the treatment of women who are illegal immigrants or asylum seekers from AIDS-endemic countries. The controversy was sparked at the end of last year when the Dutch Health Care Inspector issued new guidelines on serological testing for HIV in pregnant women. Until then, testing for HIV (unlike for syphilis and hepatitis B) had been discouraged, with the argument that women who tested positive could be offered little in the way of therapy. But, with the advent of successful therapeutic regimens,
THE LANCET • Vol 355 • February 5, 2000
the Health Care Inspector recommended that the test should be offered to pregnant women in highrisk groups. However, the guidelines also put specific restrictions on offering the test to women who are asylum seekers or illegal immigrants, which provoked a furious reaction from doctors. The contentious guideline states: “In women from AIDS-endemic areas, who are not certain to stay in the Netherlands (asylum seekers and illegal immigrants), the chance of extradition must be taken into account when deciding on ordering an HIV test.” The Inspector argued that this restriction was reasonable, pointing out that extradited women who are known to be infected with
HIV, would face social isolation on return to their country of origin. Critics responded that cooperation with the extradition of HIV-positive people to an area where the infection is not treatable is, in fact, complying with a death sentence. In response to the criticism, Borst-Eilers ordered an investigation into the number of HIVpositive illegal immigrants in the Netherlands. The government has also stated that all pregnant HIVpositive illegal immigrants and asylum seekers are entitled to medical treatment, while acknowledging that this policy might lead to increased “medical tourism”. Wim Weber
475
WASHINGTON
Clinton’s swan-song appeal for health-care reform
S President Bill Clinton was still preaching health-care reform last week in his seventh and final State of the Union address, urging Congress to extend coverage to more of the nation’s medically uninsured and underinsured millions. As usual, there is humanitarian disbelief that neglect on that scale can go on indefinitely amid the riches of America in the new millennium. Strong pressures from the politically potent lobbies of the elderly may force enactment of insurance coverage for the fast-rising costs of prescription drugs. But beyond that change, the political calendar may impose a hold on health-care reform, at least for the year 2000, and maybe beyond. After some quiescence in the clamour of politics, the insurance issue has been revived by rapid increases in drug costs, for which little if any coverage is available, and a continuing rise in the ranks of the uninsured, despite various piecemeal efforts to bring them into the system. Creeping progress has been made since the collapse of the big-bang reform proposed in 1993 and 1994, at the outset of Clinton’s presidency. For example, employees who leave a job that provided health insurance can continue their coverage, although at their own expense. And the Children’s Health Insurance Program, enacted in 1997, has enrolled 2 million children, and is aiming for another 3 million. But, as the president noted in what could serve as an epitaph for health politics of recent times, “there are still more than 40 million of our
U
AMSTERDAM
fellow Americans without health insurance—more than there were in 1993”. In fact, there are at least 4 million more. The President’s proposals for extending insurance coverage would bring in additional millions by providing tax subsidies for whole families enrolling in the children’s programme and by open-
“there are still more than 40 million of our fellow Americans without health insurance—more than there were in 1993” ing the Medicare programme, now limited to people aged 65 and older, to those aged 55 to 65 on a “buy-in” basis, assisted by tax credits. As alternatives to politically unattainable comprehensive reform, these proposed smaller changes are the best that can make it to a realistic political agenda. Anything on a larger scale draws denunciations such as “socialised medicine”, illustrated with horror tales from Canada and the UK, with particular emphasis on patients fleeing queues in those lands to obtain medical care in the USA. The deprivations of the domestic uninsured and at least as many poorly insured are on a par with those of the medical refugees streaming from abroad into American clinics, but there is less drama in familiar homegrown misfortune. The short-term prospects for health-care reform are not glowing.
With the presidential and congressional elections just 9 months away, the Republican majorities on Capitol Hill are not disposed to accommodate the president they tried to evict just a year ago, or to enhance the stature of his preferred successor, Vice President Al Gore. While the Congressional Democrats cheered the President’s State of the Union health-care proposals, the Republicans sat impassively. The main opportunities for legislative collaboration are on drug insurance coverage, a high priority among senior citizens, and a “patients bill of rights” in dealings with health-maintenance organisations (HMOs). Tales of high-handed, neglectful treatment by HMOs easily make it into press and television coverage, and into Congressional hearing rooms. Films, political cartoons, and late-night television humour demonise HMOs as vultures feasting on hapless patients. Presenting the Republican response to the President’s address, Senator Bill Frist, of Tennessee, a cardiac transplant surgeon in former days, endorsed the patients’ bill of rights and prescription drug coverage for the elderly. Regarding other matters, the Senator questioned the President’s intentions, recalling the failed attempt at the beginning of the Clinton presidency to make over the nation’s whole system in one grand legislative act. There is no attempt in sight for another try on that scale. Daniel S Greenberg
Controversy leads to new Netherlands HIV-test guidelines
L
ast week, the Dutch Minister of Health, Els Borst-Eilers, responded to mounting criticism of new guidelines on testing for HIV, promising to alter legislation on the treatment of women who are illegal immigrants or asylum seekers from AIDS-endemic countries. The controversy was sparked at the end of last year when the Dutch Health Care Inspector issued new guidelines on serological testing for HIV in pregnant women. Until then, testing for HIV (unlike for syphilis and hepatitis B) had been discouraged, with the argument that women who tested positive could be offered little in the way of therapy. But, with the advent of successful therapeutic regimens,
THE LANCET • Vol 355 • February 5, 2000
the Health Care Inspector recommended that the test should be offered to pregnant women in highrisk groups. However, the guidelines also put specific restrictions on offering the test to women who are asylum seekers or illegal immigrants, which provoked a furious reaction from doctors. The contentious guideline states: “In women from AIDS-endemic areas, who are not certain to stay in the Netherlands (asylum seekers and illegal immigrants), the chance of extradition must be taken into account when deciding on ordering an HIV test.” The Inspector argued that this restriction was reasonable, pointing out that extradited women who are known to be infected with
HIV, would face social isolation on return to their country of origin. Critics responded that cooperation with the extradition of HIV-positive people to an area where the infection is not treatable is, in fact, complying with a death sentence. In response to the criticism, Borst-Eilers ordered an investigation into the number of HIVpositive illegal immigrants in the Netherlands. The government has also stated that all pregnant HIVpositive illegal immigrants and asylum seekers are entitled to medical treatment, while acknowledging that this policy might lead to increased “medical tourism”. Wim Weber
475