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HIV disease, poverty, and youth
POLICY WATCH
differential in the U.S. and Cana- huge U.S. pharmaceutical indusda for the drugs listed on the for- try is a world leader, whose innomulary is a whooping 49%, where- vative R & D makes a major conas for those not on the formulary, tribution to fundamental medical scientific knowledge. The the difference is 10%! A surprising finding is the im- "health" of this industry is very pact on the market prices of in- important to the U.S. economy. t r o d u c i n g c o m p e t i n g generic The major companies not only d r u g p r o d u c t s . R a t h e r t h a n spend large amounts of money on equalizing out the U.S.-Canadian research, they also take substanprices, drugs that have lost pat- tial financial risks during the deent p r o t e c t i o n show an even velopment of new products and greater price differential in the agents, many of which may fail. two countries. It would appear Perhaps there should be a way to that in the U.S., the major phar- prevent companies from making maceutical companies meet com- excess profits on p r o d u c t i o n petition from the generics by items, but this must be carefully standing firm with their estab- balanced with their major loss lished market and promise of items. This topic is certain to be quality. In Canada, the provincial debated in the months ahead as g o v e r n m e n t a l f o r m u l a r y and the Clinton proposal makes its buying policy makes it almost way through the congressional mandatory that prices of the pri- committee hearings.--CKO mary brand names adjust downwards to meet the more cheaply produced generic competitors. The fact that virtually all manufactured goods cost more in HIV Disease, Poverty, and Canada than in the U.S. has been Youth attributed to the larger U.S. market, bigger sales volumes, and [Conway GA, Epstein MR, Hayrnan greater productivity. The smaller OR, et al. Trends in HIV prevalence among disadvantaged Canadian companies cannot pro- youth. JAMA 1993; 269: 2887-9.] duce items at competitive costs. Why, then, does this business axince March 1987, the Naiom so completely break down tional Job Corps Training when one deals with items related P r o g r a m has r o u t i n e l y to the U.S. health care system? Why do larger production vol- screened applicants for HIV seroumes in the health care system positivity; complete HIV data on not bring prices down? Costs Job Corps applicants have been seem to progressively rise with available beginning in January greater utilization, behaving like 1988. Job Corps applicants are a commodity in short supply, go- e c o n o m i c a l l y d i s a d v a n t a g e d ing up in price as the demand in- youth (ages 16 to 21) who have creases. The prices often seem to either dropped out of high school be what the traffic will bear. Is or, if high school graduates, rethis what one of the "problems" quire additional training to sewith the U.S. health costs is really cure meaningful employment. all about--health care is a busi- The Job Corps data thus provide ness rather t h a n an excepted a unique opportunity to examine the prevalence and trends in HIV right of citizenship? Before becoming enamored of infection among the impoverthe Canadian way of constraining ished young. Indeed, the only drug prices, some words of cau- other national data on HIV infection should be interjected. The tion among youth are those ob-
S
mined through screening applic a n t s for t h e U.S. m i l i t a r y service. Over the 5 years between January 1988 and December 1992, about 270,000 disadvantaged youths applied to the Job Corps; 812 of them (0.3%) tested positive for HIV-1 antibodies. The gross rate of HIV infection among this population is, therefore, on the order of 3 per 1,000, high given the youth of this population but consistent with other research. HIV seroprevalance among men showed some decline over the 5 years (from 3.6 to 2.2 per 1,000), whereas the rate for women increased (from 2.1 to 4.2 per 1,000). For both men and women, rates were higher among blacks than among whites. Among African-American women, the rate of infection increased from 3.2 to 6.6 cases per 1,000. The Job Corps screening data are not ideal for estimating HIV seroprevalance among economically disadvantaged youth because persons actively using illicit drugs (and those who require ongoing medical care) are excluded from Job Corps eligibility. There has been a marked decrease in male applicants over time, especially in African-American male applicants. Therefore, African-American males at highest risk of HIV might be excluded from the data (if they are actively using drugs), or they might have selected themselves out of the applicant pool. It is likely, although not certain, that changes in the applicant pool over time account for the apparent decreases in seropositivity among male applicants. However, applications by females, in general, have shown comparatively little change, and so the trend observed among female applicants is probably real. Taking the results at face value, by 1992, HIV seropositivity was higher among young, disadvan-
!! THE AMERICANJOURNAL OF SURGERY VOLUME166 NOVEMBER1993
POLICY WATCH
taged women than among young disadvantaged men, a pattern that likely results from the greater efficiency of male-to-female than female-to-male transmission of the virus. The Job Corps data thus provide further evidence in a mounting body of evidence that poverty itself is a risk factor for HIV infection. Efforts to prevent the spread of HIV infection among youth must, therefore, target this very hard-to-reach group of outof-school, impoverished, largely minority youth. Not incidentally, these data also add weight to the recent recommendation of the Public Health Task Force on Minority Health Data that direct indicators of socioeconomic status be routinely included in disease surveillance efforts.--JDW
AccessDoes Not Equal Improved Outcomes [Haas J, Udvarhelyi S, Morris C, Epstein A. The effect of providing health coverage to poor uninsured pregnant women in Massachusetts. JAMA 1993; 269: 87-91.] ne of the major objectives of the Clinton administration's Health Care Reform Plan is to provide health care coverage for all Americ~n~. However, as this timely article indicates, extending insurance coverage will n o t a u t o m a t i c a l l y translate to the provision of needed and appropriate services, particularly for certain vulnerable population groups such as poor pregnant women. This article reports on a study that examines whether the extension of health care coverage through Healthy Start, a statefunded program designed to cover low-income women not eligible for Medicaid, was associated with
O
an improvement in access to prenatal care and newborn health outcomes. The program targeted teenage pregnant woman and minorities, two groups at partic~flar risk for inadequate access to good prenatal care. Healthy Start, begun in 1985, provided a comprehensive set of benefits including home visits for high-risk pregnancies, care for any condition complicating pregnancy, as well as one postpartum visit. Compensation to physicians and hospitals was comparable with that provided by Medicaid in Massachusetts. Community outreach was emphasized. Study results indicate that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987, due to change, the authors speculate, in the demographic characteristics of the population. In the context of this statewide decline in access, Healthy Start was not associated with improved satisfactory prenatal care in women who initiated care before the third trimester. There was also no improvement in birth outcomes. Although the program was moderately successful in achieving enrollment of teenagers a n d m i n o r i t i e s , t h e s e changes were not associated with improvements in care or outcomes for these groups. This well-conducted study and analysis suggest that expanded health insurance alone may not result in improved health outcomes, particularly for high-risk populations. A number of reasons can be given, many of them supported by other findings. Nonfinancial barriers--demographic, language, cultural, racial, geographic, and organizational-have been shown to represent impediments to health care for isolated and disadvantaged populations. Access to medical care implies access to physicians. However, the paucity of provid-
ers willing to set up practice in minority neighborhoods or to care for Medicaid patients has been amply documented. Socioeconomic status is a major determinant of health and strongly influences mortality and morbidity. Even in countries with long traditions of universal access like the United Kingdom, there continue to be disparities in health among socioeconomic classes. As our nation begins an historic debate on health care reform, it is important to remember that the laudable goal of universal insurance may not result in adequate access for all of our citizens. Special attention will also have to be paid to making the delivery system more responsive and appropriate for vulnerable populations and those outside the mRinstreAm of care.--MEL
Health Insurance Redux [Cooper P, Johnson A. Employment related health insurance in I987. National Medical Expenditure Research Survey Findings 17. Agency for Health Care Policy and Research, April 1993.] or the last two generations, national health policy hRs been predicted on employment-based health insurance. If you worked, you got health insurance. However, public policy has remained behind the curve of the changes in the health insurance industry. Escalating health care costs have precluded many employers from offering insurance to their employees. Although the majority of Americans obtain their health insurance through the workplace, the results of this most recent national survey of insurance plans show the wide variability in coverage.
F
THE AMERICANJOURNALOF SURGERY VOLUME166 NOVEMBER1993 II!
differential in the U.S. and Cana- huge U.S. pharmaceutical indusda for the drugs listed on the for- try is a world leader, whose innomulary is a whooping 49%, where- vative R & D makes a major conas for those not on the formulary, tribution to fundamental medical scientific knowledge. The the difference is 10%! A surprising finding is the im- "health" of this industry is very pact on the market prices of in- important to the U.S. economy. t r o d u c i n g c o m p e t i n g generic The major companies not only d r u g p r o d u c t s . R a t h e r t h a n spend large amounts of money on equalizing out the U.S.-Canadian research, they also take substanprices, drugs that have lost pat- tial financial risks during the deent p r o t e c t i o n show an even velopment of new products and greater price differential in the agents, many of which may fail. two countries. It would appear Perhaps there should be a way to that in the U.S., the major phar- prevent companies from making maceutical companies meet com- excess profits on p r o d u c t i o n petition from the generics by items, but this must be carefully standing firm with their estab- balanced with their major loss lished market and promise of items. This topic is certain to be quality. In Canada, the provincial debated in the months ahead as g o v e r n m e n t a l f o r m u l a r y and the Clinton proposal makes its buying policy makes it almost way through the congressional mandatory that prices of the pri- committee hearings.--CKO mary brand names adjust downwards to meet the more cheaply produced generic competitors. The fact that virtually all manufactured goods cost more in HIV Disease, Poverty, and Canada than in the U.S. has been Youth attributed to the larger U.S. market, bigger sales volumes, and [Conway GA, Epstein MR, Hayrnan greater productivity. The smaller OR, et al. Trends in HIV prevalence among disadvantaged Canadian companies cannot pro- youth. JAMA 1993; 269: 2887-9.] duce items at competitive costs. Why, then, does this business axince March 1987, the Naiom so completely break down tional Job Corps Training when one deals with items related P r o g r a m has r o u t i n e l y to the U.S. health care system? Why do larger production vol- screened applicants for HIV seroumes in the health care system positivity; complete HIV data on not bring prices down? Costs Job Corps applicants have been seem to progressively rise with available beginning in January greater utilization, behaving like 1988. Job Corps applicants are a commodity in short supply, go- e c o n o m i c a l l y d i s a d v a n t a g e d ing up in price as the demand in- youth (ages 16 to 21) who have creases. The prices often seem to either dropped out of high school be what the traffic will bear. Is or, if high school graduates, rethis what one of the "problems" quire additional training to sewith the U.S. health costs is really cure meaningful employment. all about--health care is a busi- The Job Corps data thus provide ness rather t h a n an excepted a unique opportunity to examine the prevalence and trends in HIV right of citizenship? Before becoming enamored of infection among the impoverthe Canadian way of constraining ished young. Indeed, the only drug prices, some words of cau- other national data on HIV infection should be interjected. The tion among youth are those ob-
S
mined through screening applic a n t s for t h e U.S. m i l i t a r y service. Over the 5 years between January 1988 and December 1992, about 270,000 disadvantaged youths applied to the Job Corps; 812 of them (0.3%) tested positive for HIV-1 antibodies. The gross rate of HIV infection among this population is, therefore, on the order of 3 per 1,000, high given the youth of this population but consistent with other research. HIV seroprevalance among men showed some decline over the 5 years (from 3.6 to 2.2 per 1,000), whereas the rate for women increased (from 2.1 to 4.2 per 1,000). For both men and women, rates were higher among blacks than among whites. Among African-American women, the rate of infection increased from 3.2 to 6.6 cases per 1,000. The Job Corps screening data are not ideal for estimating HIV seroprevalance among economically disadvantaged youth because persons actively using illicit drugs (and those who require ongoing medical care) are excluded from Job Corps eligibility. There has been a marked decrease in male applicants over time, especially in African-American male applicants. Therefore, African-American males at highest risk of HIV might be excluded from the data (if they are actively using drugs), or they might have selected themselves out of the applicant pool. It is likely, although not certain, that changes in the applicant pool over time account for the apparent decreases in seropositivity among male applicants. However, applications by females, in general, have shown comparatively little change, and so the trend observed among female applicants is probably real. Taking the results at face value, by 1992, HIV seropositivity was higher among young, disadvan-
!! THE AMERICANJOURNAL OF SURGERY VOLUME166 NOVEMBER1993
POLICY WATCH
taged women than among young disadvantaged men, a pattern that likely results from the greater efficiency of male-to-female than female-to-male transmission of the virus. The Job Corps data thus provide further evidence in a mounting body of evidence that poverty itself is a risk factor for HIV infection. Efforts to prevent the spread of HIV infection among youth must, therefore, target this very hard-to-reach group of outof-school, impoverished, largely minority youth. Not incidentally, these data also add weight to the recent recommendation of the Public Health Task Force on Minority Health Data that direct indicators of socioeconomic status be routinely included in disease surveillance efforts.--JDW
AccessDoes Not Equal Improved Outcomes [Haas J, Udvarhelyi S, Morris C, Epstein A. The effect of providing health coverage to poor uninsured pregnant women in Massachusetts. JAMA 1993; 269: 87-91.] ne of the major objectives of the Clinton administration's Health Care Reform Plan is to provide health care coverage for all Americ~n~. However, as this timely article indicates, extending insurance coverage will n o t a u t o m a t i c a l l y translate to the provision of needed and appropriate services, particularly for certain vulnerable population groups such as poor pregnant women. This article reports on a study that examines whether the extension of health care coverage through Healthy Start, a statefunded program designed to cover low-income women not eligible for Medicaid, was associated with
O
an improvement in access to prenatal care and newborn health outcomes. The program targeted teenage pregnant woman and minorities, two groups at partic~flar risk for inadequate access to good prenatal care. Healthy Start, begun in 1985, provided a comprehensive set of benefits including home visits for high-risk pregnancies, care for any condition complicating pregnancy, as well as one postpartum visit. Compensation to physicians and hospitals was comparable with that provided by Medicaid in Massachusetts. Community outreach was emphasized. Study results indicate that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987, due to change, the authors speculate, in the demographic characteristics of the population. In the context of this statewide decline in access, Healthy Start was not associated with improved satisfactory prenatal care in women who initiated care before the third trimester. There was also no improvement in birth outcomes. Although the program was moderately successful in achieving enrollment of teenagers a n d m i n o r i t i e s , t h e s e changes were not associated with improvements in care or outcomes for these groups. This well-conducted study and analysis suggest that expanded health insurance alone may not result in improved health outcomes, particularly for high-risk populations. A number of reasons can be given, many of them supported by other findings. Nonfinancial barriers--demographic, language, cultural, racial, geographic, and organizational-have been shown to represent impediments to health care for isolated and disadvantaged populations. Access to medical care implies access to physicians. However, the paucity of provid-
ers willing to set up practice in minority neighborhoods or to care for Medicaid patients has been amply documented. Socioeconomic status is a major determinant of health and strongly influences mortality and morbidity. Even in countries with long traditions of universal access like the United Kingdom, there continue to be disparities in health among socioeconomic classes. As our nation begins an historic debate on health care reform, it is important to remember that the laudable goal of universal insurance may not result in adequate access for all of our citizens. Special attention will also have to be paid to making the delivery system more responsive and appropriate for vulnerable populations and those outside the mRinstreAm of care.--MEL
Health Insurance Redux [Cooper P, Johnson A. Employment related health insurance in I987. National Medical Expenditure Research Survey Findings 17. Agency for Health Care Policy and Research, April 1993.] or the last two generations, national health policy hRs been predicted on employment-based health insurance. If you worked, you got health insurance. However, public policy has remained behind the curve of the changes in the health insurance industry. Escalating health care costs have precluded many employers from offering insurance to their employees. Although the majority of Americans obtain their health insurance through the workplace, the results of this most recent national survey of insurance plans show the wide variability in coverage.
F
THE AMERICANJOURNALOF SURGERY VOLUME166 NOVEMBER1993 II!