AIDS service providers fret about pending reform.

Critical issues on care not addressed by Clinton plan

Even though Clinton's health care reform proposal would increase AIDS patients' access to care, local AIDS activists said they still have reservations about the Clinton package.

They applauded the notion that people who have lost their jobs and insurance as a result of getting AIDS will no longer be left out of the health care system.

But, they said, some issues -- like quality of care and access to certain types of specialized care for patients with Acquired Immune Deficiency Syndrome (AIDS) -- are still up in the air in Clinton's plan, formally known as the American Health Security Act of 1993.

The eventual outcome of how AIDS patients are treated under reform holds great significance for Los Angeles County, where AIDS is a growing health peril that is severely straining public resources. (See accompanying table.)

"If health care reform does what it should do, there won't be a need for AIDS service providers," said Phill Wilson, director of public policy for AIDS Project Los Angeles, one of the largest AIDS service organizations in the state. "We exist because the health care system is not functioning."

John Schunhoff, director of the AIDS program for the L.A. County Department of Health Services, said an estimated 45,000 people in L.A. County have tested positive for the Human Immunodeficiency Virus (HIV) -- the virus that could lead to the deadly AIDS disease. Without a cure, he said, at least 60 percent of those people will contract AIDS with 10 years. He said the county currently has 6,000 to 7,000 diagnosed cases of full-blown AIDS.

AIDS experts in L.A. County said it is too early to tell how AIDS patients would be treated under health care reform, especially since Congress could totally rework the plan. But some unanswered questions that are causing them concern include:

* Would people infected with the HIV virus be considered disabled and eligible for long-term care?

* With the zeal for cost cutting at managed care companies, would AIDS patients be denied experimental treatments and access to HIV specialists?

Under Clinton's plan, people would be allowed to choose from among three options, each of which would carry a different co-payment requirement. Joining a health maintenance organization, which provides health care for a set monthly fee, would be the cheapest. But few HMOs today offer HIV specialists. Kaiser Permanente is one of the only HMOs, in fact, to have an HIV unit.

Rising toll of AIDS on Los Angeles County

Year of
diagnosis          Cases          Deaths

1980                   3               3
1981                  20              19
1982                  81              73
1983                 273             256
1984                 494             463
1985                 958             902
1986               1,505           1,428
1987               2,023           1,845
1988               2,307           1,977
1989               2,699           2,082
1990               3,128           2,111
1991               3,675           1,936
1992(*)            3,465           1,101
1993(**)           1,690             291

Total             22,322          14,487

* Data are not all in because of the time lag in reporting AIDS
cases.

** Cases diagnosed this year and reported by Sept. 30, 1993.
John Schunhoff, director of the AIDS program for the L.A.
County Department of Health Services, said the number of AIDS
cases are increasing every year, but at a declining rate.
Although the number of AIDS cases appears low, Schunhoff said
he expects more AIDS cases in 1993 than 1992 and more in 1992
than in 1991.

Source: Los Angeles County Department of Health Services AIDS
Programs

* What would happen to the AIDS services currently being funded through the federal government's Ryan White Care Act, named after the Indiana teenager who died of AIDS.

Schunhoff said the act, which! provided $19 million in AIDS services for Los Angeles County in 1993 and is expected to provide $26 million in 1994, funds services that aren't covered under typical insurance policies. Those services include attendant care, housing assistance, transportation and substance abuse counseling. Most of those services would not be covered under Clinton's plan.

What would happen if the act is not renewed? Would the costs of providing non-medical AIDS services be included in some other federal entitlements?

* How would undocumented workers with HIV receive care? Under the American Health Security Act, undocumented workers would be excluded from guaranteed coverage. They either have to receive care at county-owned facilities or rely on their employers to purchase insurance for them. (Insurance companies would be prohibited from passing along information obtained from such employer purchases to the Immigration and Naturalization Service.)

A study released by AIDS Project Los Angeles on how health care reform would affect its clients concluded that APLA clients with neither private insurance nor Medi-Cal would benefit the most from Clinton reforms. Medi-Cal is government subsidized insurance for the poor and indigent. Such uncovered patients make up 13 percent of APLA's clients.

APLA noted that employed people without health insurance would receive health care benefits through their employers and unemployed people who do not qualify for Medi-Cal would be able to receive federal subsidies for the purchase of health insurance.

APLA officials also said that, although universal access is the best feature of Clinton's plan, "it is just one component in the fight against AIDS," according to an issue paper by the AIDS group.

"We must ensure that the benefits packages provide adequate and quality care, prescription drugs are available and affordable and the care environments are free of discrimination," the paper concluded.

Schunhoff said one indication of how AIDS patients would likely be treated under health care reform can be ascertained by observing the way in which L.A. County and the state are handling the transfer of Medi-Cal patients into managed care.

Under managed care, patients are provided health care for a set monthly fee. Such systems have been criticized by some health care officials because these systems attempt to minimize access to medical specialists to keep costs down. Primary care doctors are the gatekeepers of a managed care system and make the decisions on whether patient needs to see a specialist.

Schunhoff said he would support a system under which AIDS patients would be able to choose their doctors. But as to whether or not AIDS patients would be allowed that freedom has not yet been decided, he said. That issue and other details of the plan are still being negotiated.

Many AIDS experts said they hope the current matrix of AIDS care providers would be allowed to serve as vendors to the proposed regional health care alliances.