- Email: [email protected]
Up, up and away
POLICY WATCH
Stein believe that the latter risk is overstated and that women should be advised to use spermicide as a protection against HIV disease. Cates, S t e w a r t , and Trussell believe that the risk is real and that the protective value of spermicides is overstated, especially in comparison to condom use. All agree that further research is n e e d e d on b o t h the benefits and comparative risks of all forms of female-controlled protection against STDs, especially HIV. U n f o r t u n a t e l y , women with AIDS are dying now, and the health professions cannot sit in silence awaiting the outcome of more and better-designed studies. Granting that abstinence and high selectivity in choice of partners are unlikely, Stein's message to women is: "first, do your absolute best to persuade your male sex partner to use a condom. If you do not succeed but nonetheless and for whatever reason still have sex with him, then use a spermicide." It is the second part of this message that is in disp u t e - - t h e part of the message entirely under the control of women themselves. One would hope, a decade into the AIDS crisis, that the health sciences would have already resolved this dispute, but Stein states that "neither the National Institutes of Health nor the Centers for Disease Control have shown the energy or commitment to face this issue, critical as it seems to women the world o v e r . " In t h e m e a n t i m e , the AIDS toll among young women in t h e U.S. a l o n e is more t h a n 12,000 and increasing. Are there not a few million dollars present somewhere in the vast research budgets of the National Institutes of Health and the CDC that would definitively settle these q u e s t i o n s so t h a t a b s t i n e n c e aside, women have other options that they know will protect them from contracting H I V ? - - J D W ||
up, up, ano away r a m , . _
[Burner ST, Waldo DR, McKusick DR. National health expenditures projections through 2030. Health Care Financing Review 1992; 14:
1-39.]
requent reference is made to the ticking fiscal time bomb within the present health services system. The latest and most authoritative projections for the Health Care Financing Administration should convince all but the most incorrigible skeptic that talk of an impending crisis is more than just political hubris employed to foist upon us a reform agenda, ready or not. Given a continuation of the system's current practices, we will reach an annual expenditure of $1.7 trillion by the year 2000 (and by the year 2030 we'll top $16 trillion per year, accounting for 32% of the gross domestic product!). Compare the total health expenditure of $666 billion in 1990 with the $1.7 trillion estimated for the year 2000. What accounts for the additional billion dollars a year by that time? Some are exogenous factors such as population growth, demographic shifts, and inflation; but three factors are endogenous--dare we call them endemic? These are prices of services relative to the general economic price index, volume of care per capita, and intensity, all of which reflect changes in technology and number and composition of services during each unit of service. All knowledgeable observers are aware that the pressures in all these parameters are moving steadily upwards. The major factor will be health care price inflation, averaging 5.2% per year from 1990 to 2030. Per capita expenditures will grow an average of 2.3% a year. These and all other factors will lead to an average annual growth rate of 10.0%.
F
THE AMERICAN JOURNAL OFSURGERY
VOLUME 165
JUNE 1993
These projections show an especially rapid growth in public spending (Medicare and Medicaid) over this period, attributable to baby boomers entering Medicare and to a dramatic increase in Medicaid's share, from about 10% of total outlays to nearly 21% by the turn of the century. President Clinton was correct in coupling these increases in public spending with the yearly federal budget deficit problem. It is sobering to realize that if the additional trillion dollars a year that will be pumped into health services could be diverted instead to the federal debt, it would be paid off within less than 5 years, yet federal policymakers must struggle to reduce the yearly deficit by much more than $100 billion a year, while the debt will continue to rise. Overall, these figures (with detailed tables to which the reader interested in specific sectors such as physicians' services, inpatient and o u t p a t i e n t care, nursing homes, drugs, and so forth, may wish to refer) are meant to convey a sense of the momentum within the present system, a "base case" against which reform proposals can be measured.--WFB
Doctors, Doctors Everywhere: The Movie [Shi L. The relationship between primary care and life chances. J Health Care Poor Underserved 1992; 3: 321-35.] e a l t h c a r e r e f o r m has emerged as the primary domestic policy issue for the Clinton Administration, in large measure because of the impact of escalating health care costs on the federal deficit. Additionally, it is assumed that improving access to health care services for the uninsured and underinsured will improve the health status of large
H
Stein believe that the latter risk is overstated and that women should be advised to use spermicide as a protection against HIV disease. Cates, S t e w a r t , and Trussell believe that the risk is real and that the protective value of spermicides is overstated, especially in comparison to condom use. All agree that further research is n e e d e d on b o t h the benefits and comparative risks of all forms of female-controlled protection against STDs, especially HIV. U n f o r t u n a t e l y , women with AIDS are dying now, and the health professions cannot sit in silence awaiting the outcome of more and better-designed studies. Granting that abstinence and high selectivity in choice of partners are unlikely, Stein's message to women is: "first, do your absolute best to persuade your male sex partner to use a condom. If you do not succeed but nonetheless and for whatever reason still have sex with him, then use a spermicide." It is the second part of this message that is in disp u t e - - t h e part of the message entirely under the control of women themselves. One would hope, a decade into the AIDS crisis, that the health sciences would have already resolved this dispute, but Stein states that "neither the National Institutes of Health nor the Centers for Disease Control have shown the energy or commitment to face this issue, critical as it seems to women the world o v e r . " In t h e m e a n t i m e , the AIDS toll among young women in t h e U.S. a l o n e is more t h a n 12,000 and increasing. Are there not a few million dollars present somewhere in the vast research budgets of the National Institutes of Health and the CDC that would definitively settle these q u e s t i o n s so t h a t a b s t i n e n c e aside, women have other options that they know will protect them from contracting H I V ? - - J D W ||
up, up, ano away r a m , . _
[Burner ST, Waldo DR, McKusick DR. National health expenditures projections through 2030. Health Care Financing Review 1992; 14:
1-39.]
requent reference is made to the ticking fiscal time bomb within the present health services system. The latest and most authoritative projections for the Health Care Financing Administration should convince all but the most incorrigible skeptic that talk of an impending crisis is more than just political hubris employed to foist upon us a reform agenda, ready or not. Given a continuation of the system's current practices, we will reach an annual expenditure of $1.7 trillion by the year 2000 (and by the year 2030 we'll top $16 trillion per year, accounting for 32% of the gross domestic product!). Compare the total health expenditure of $666 billion in 1990 with the $1.7 trillion estimated for the year 2000. What accounts for the additional billion dollars a year by that time? Some are exogenous factors such as population growth, demographic shifts, and inflation; but three factors are endogenous--dare we call them endemic? These are prices of services relative to the general economic price index, volume of care per capita, and intensity, all of which reflect changes in technology and number and composition of services during each unit of service. All knowledgeable observers are aware that the pressures in all these parameters are moving steadily upwards. The major factor will be health care price inflation, averaging 5.2% per year from 1990 to 2030. Per capita expenditures will grow an average of 2.3% a year. These and all other factors will lead to an average annual growth rate of 10.0%.
F
THE AMERICAN JOURNAL OFSURGERY
VOLUME 165
JUNE 1993
These projections show an especially rapid growth in public spending (Medicare and Medicaid) over this period, attributable to baby boomers entering Medicare and to a dramatic increase in Medicaid's share, from about 10% of total outlays to nearly 21% by the turn of the century. President Clinton was correct in coupling these increases in public spending with the yearly federal budget deficit problem. It is sobering to realize that if the additional trillion dollars a year that will be pumped into health services could be diverted instead to the federal debt, it would be paid off within less than 5 years, yet federal policymakers must struggle to reduce the yearly deficit by much more than $100 billion a year, while the debt will continue to rise. Overall, these figures (with detailed tables to which the reader interested in specific sectors such as physicians' services, inpatient and o u t p a t i e n t care, nursing homes, drugs, and so forth, may wish to refer) are meant to convey a sense of the momentum within the present system, a "base case" against which reform proposals can be measured.--WFB
Doctors, Doctors Everywhere: The Movie [Shi L. The relationship between primary care and life chances. J Health Care Poor Underserved 1992; 3: 321-35.] e a l t h c a r e r e f o r m has emerged as the primary domestic policy issue for the Clinton Administration, in large measure because of the impact of escalating health care costs on the federal deficit. Additionally, it is assumed that improving access to health care services for the uninsured and underinsured will improve the health status of large
H