The independent source for health policy research, polling, and news.
This comprehensive survey of people on Medicare, conducted in June and July 2004, assesses their attitudes toward the new Medicare drug law. This chartpack, issued in September 2004, presents additional analysis on the survey data, focusing on the views of people under age 65 with physical and/or mental disabilities.
Supplemental Chartpack (.pdf)
Assessing Public Education Programming on HIV/AIDS: A National Survey of African Americans
A new national survey of African Americans reviews aspects of the Rap It Up and KNOW HIV/AIDS campaigns, which are ongoing HIV/AIDS public education partnerships conducted by the Kaiser Family Foundation with Black Entertainment Television (BET) and Viacom, Inc., respectively. The survey seeks to look at the reach and impact of the campaigns. Rap It Up is the single largest public education effort on HIV/AIDS and related issues directed toward the African American community.
Survey (.pdf)
The Kaiser Family Foundation has put together a short Public Opinion Data Note analyzing recent polling about the importance of health care as an issue in the swing states for the upcoming November 2, 2004 elections.
Public Opinion Data Note (.pdf)
A new national survey of African Americans reviews aspects of the Rap It Up and KNOW HIV/AIDS campaigns, which are ongoing HIV/AIDS public education partnerships conducted by the Kaiser Family Foundation with Black Entertainment Television (BET) and Viacom, Inc., respectively. The survey seeks to look at the reach and impact of the campaigns. Rap It Up is the single largest public education effort on HIV/AIDS and related issues directed toward the African American community.
Assessing Public Education Programming on HIV/AIDS: A National Survey of African Americans
Race, Ethnicity and Health Care
Download a printable .pdf of Health Care and the 2004 Elections: Race, Ethnicity and Health Care.
IssueBackgroundRaising Public and Provider Awareness Expanding Health CoverageImproving the Number and Capacity of Providers in Underserved CommunitiesIncreasing the Knowledge BaseAssessing Candidate PositionsIssue
Racial and ethnic disparities in health care – whether in insurance coverage, access, or quality of care – are one of many factors producing inequalities in health status in the United States.1 Eliminating these disparities is politically sensitive and challenging in part because their causes are intertwined with a contentious history of race relations in America. Nonetheless, assuring greater equity and accountability of the health care system is important to a growing constituency base, including health plan purchasers, payers, and providers of care. To the extent that inequities in the health care system result in lost productivity or use of services at a later stage of illness, there are health and social costs beyond the individual or specific population group.
About 1 in 3 residents of the United States self-identify as either African American, American Indian/Alaska Native, Asian/Pacific American, or Latino. Few would disagree that for most of this nation’s history, race was a major factor in determining if you got care, where that care was obtained, and the quality of medical care. However, the influence of race today is more subtle. Public policy efforts, most notably the enactment of Medicaid and Medicare in 1965, along with enforcement of the 1964 Civil Rights Act, have made an enormous difference in reducing the health care divides in the U.S. So much progress has been achieved that many think that the disparities that remain are inconsequential, but they are not.
The Institute of Medicine (IOM) landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Care provides compelling evidence that racial/ethnic disparities persist in medical care for a number of health conditions and services.2 These disparities exist even when comparing individuals of similar income and insurance. Evidence of racial/ethnic disparities among patients with comparable insurance and the same illness has been the most troubling since health insurance coverage is widely considered the “great equalizer” in the health system.
The momentum to address health care disparities has grown largely in response to the step taken by the U.S. Department of Health and Human Services (DHHS) in 1999, establishing a national goal of eliminating health disparities by the end of this decade. Disparities between racial/ethnic groups and geographic areas were of major concern.3 The decision for the U.S. to have one set of goals for all Americans, rather than separate goals for the health of whites and minority populations, has helped to focus public and private sector attention on racial/ethnic disparities in the nation’s health and thus, health care system.
Policy Challenges in Addressing Health Care Disparities
Although attention to racial/ethnic disparities in care has increased among policymakers, there is little consensus on what can or should be done to reduce these disparities. The U.S. Congress provided early leadership on the issue by legislatively mandating the IOM study on health care disparities and creating in statute, the National Center on Minority Health and Health Disparities at the National Institutes of Health. Congress also required DHHS to produce an annual report, starting in 2003, on the nation’s progress in reducing health care disparities.4 These efforts have provided an important foundation for addressing health and health care disparities.
The IOM study committee for Unequal Treatment recommended the use of a comprehensive multi-level strategy to address potential causes of racial/ethnic disparities in care that arise from circumstances or interactions at the level of the patient, provider, and health care system. The recommendations point to four broad areas of policy challenges:
Raising Public and Provider Awareness
Misperceptions about the nature and extent of racial/ethnic disparities in care add a level of complexity to efforts to address the problem. The public has a marginal, at best, awareness of racial/ethnic disparities in the U.S. health system. Over two-thirds (67%) of whites say they believe African Americans get the same quality of care as they do, and over half (59%) of whites say they believe Latinos get the same quality of care as they do.5 Not surprisingly, some of the misperceptions of the public are also found among physicians. The vast majority (69%) of physicians say that the health care system “rarely or never” treats people unfairly based on an individual’s racial/ethnic background.6 Among those who believe disparities exist, the most common perception is that they are largely a result of differences in patient characteristics – especially insurance, education, and personal preferences. This perception persists despite an abundance of studies that control for these patient level characteristics. Perceptions of a problem often influence the actions taken (or not taken) to change policy and practices. If the public or providers are unaware that a problem exist or misunderstands the nature of the problem, it is difficult to direct resources to address that problem.
Race clearly matters in the U.S. health system, but so do many other factors – especially insurance coverage. Racial/ethnic minority Americans make up about a third of the U.S. population, but disproportionately comprise 52% of the uninsured – 23 million of the 45 million uninsured in 2003. When compared with the insured, the uninsured are less likely to have a regular doctor or to get timely and routine care, and are more likely to be hospitalized for preventable conditions. Differences in health insurance coverage across racial/ethnic groups are partially explained by differences in types of employment and eligibility for public programs. Like the general population under age 65, employers are a major source of coverage for racial/ethnic minority groups. However, Medicaid, a source of coverage for many of the nation’s poor and disabled, is an important safety net for about 1 in 5 nonelderly African Americans, American Indians/Alaska Natives, and Latinos and about 1 in 10 Asian/Pacific Americans and whites. Efforts are needed, therefore, to assure that existing sources of coverage, such as Medicaid, are not undermined while also working to expand sources of coverage for those who are uninsured.
Improving the Number and Capacity of Providers in Underserved Communities
Access to a racially and ethnically diverse mix of high-quality sources of medical care also affects disparities in care. Despite efforts to increase the number of health professionals in medically underserved areas, people of color are still more likely than whites to live in neighborhoods that lack adequate health resources. For example, 28% of Latinos and 22% of African Americans report having little or no choice in where to seek care, while only 15% of whites report this difficulty.7 Even among the insured, African Americans and Latinos are twice as likely as whites to rely upon a hospital clinic or outpatient department as their regular source of care, rather than on a private physician or other office-based provider.8
When health providers are geographically accessible, language and cultural barriers are sometimes a problem. About three in ten Latinos say they have had a problem communicating with health providers over the past year, and half of Latinos whose primary language is Spanish report language barriers.9 Medical interpretation services are among the strategies recommended by the IOM to reduce these barriers. To strengthen patient-provider communication and relationships, the IOM committee also recommended expanding the racial/ethnic diversity of the health professions workforce and developing provider training programs and tools in cross-cultural education. These recommendations are rooted in evidence that minority providers are more likely than whites to practice in minority and medically underserved areas, and that when patient and providers are of the same race there is greater satisfaction and adherence to treatment.10
Although evidence of racial/ethnic health care disparities is substantial, the evidence-base for developing interventions to eliminate these disparities is limited. For example, one of the most controversial conclusions of the IOM report Unequal Treatment was that provider bias and stereotypical beliefs may play a role in clinical decisionmaking. More precise information about the role of bias and other potential causes of disparities will help when making decisions about how to allocate resources to eliminate disparities. Increasing the knowledge base will require routinely collecting and analyzing data on health care use across racial/ethnic groups. Data from national surveys, health insurers, and different health settings is needed to better understand the problems and impact of interventions. The lack of data on racial/ethnic minority groups other than African Americans is a major cause for concern. One reason we know so little about patterns of health care use of American Indians/Alaska Natives, Asian /Pacific Islanders, and Latinos is that we have not collected the data or have insufficient sample sizes in available data sources. Baseline and follow-up data across racial/ethnic groups is essential for monitoring purposes.
Assessing Candidate Positions
Attracting the votes of people of color has been a goal of both candidates in the closely contested 2004 election. Recent surveys show that communities of color place considerable importance on health care issues when casting their votes. African Americans are about twice as likely as whites to say that health care issues are important in deciding their vote, and about half of registered Latinos say that the cost of heath care and insurance will be extremely important to their vote.11 Views also differ by race on government’s role in eliminating health care disparities. The vast majority (90%) of African Americans, as compared to 55% of whites, say the “federal government should be responsible for ensuring that minorities have equality with whites in health care services, even if it means raising taxes.” 12 Such contrasting views contribute to the lack of consensus on how to address disparities in care.
The following questions will help you evaluate the candidates’ proposals for addressing racial/ethnic health care disparities:
1 Disparities in “health care” and in “health” are often discussed as if they are one in the same. A health care disparity refers to differences in, for example, coverage, access, or quality of care that is not due to health needs. A health disparity refers to a higher burden of illness, injury, disability, or mortality experienced by one population group in relation to another. The two concepts are related in that disparities in health care can contribute to health disparities, and the goal of the use of health services is to maintain and improve a population’s health. However, other factors (e.g., genetics, personal behavior, and socio-economic factors) also are major determinants of a population’s health.2 Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002. 3 U.S. Department of Health and Human Services, Healthy People 2010. pp:11-16. 4 U.S. Department of Health and Human Services, 2003 National Healthcare Disparities Report, 2003. 5 Kaiser Family Foundation, Race Ethnicity & Medical Care: Survey of Public Perceptions and Expectations, 1999. 6 Kaiser Family Foundation, National Survey of Physicians, Part 1: Doctors on Disparities in Medical Care, 2002; 7 The Commonwealth Fund Health Care Quality Survey, 2001 8 Lillie-Blanton et al. Site of Medical Care: Do Racial and Ethnic Differences Persist? Yale Journal of Health Policy, Law, and Ethics, 2001. 9 Kaiser Family Foundation/Pew Hispanic Center, Health Care Experiences, Survey Brief, 2004. 10 Komaromy et al. The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations. NEJM. 1996; Cooper-Patrick et al. Race, Gender, and Partnership in the Patient -Physician Relationship. JAMA. 1999. 11 Talylor-Clark, K. et al. African Americans’ Views on Health Policy: Implications for The 2004 Elections. Health Affairs, 2003; Kaiser Family Foundation/Pew Hispanic Center, Health Care Experiences, Survey Brief, 2004. 12 Talylor-Clark, K., et al. African Americans’ Views on Health Policy: Implications for The 2004 Elections. Health Affairs, 2003.
A new national survey of African Americans reviews aspects of the Rap It Up and KNOW HIV/AIDS campaigns, which are ongoing HIV/AIDS public education partnerships conducted by the Kaiser Family Foundation with Black Entertainment Television (BET) and Viacom, Inc., respectively. The survey seeks to look at the reach and impact of the campaigns. Rap It Up is the single largest public education effort on HIV/AIDS and related issues directed toward the African American community.
Toplines (.pdf)
This issue brief prepared by researchers at the University of California at San Francisco and the Kaiser Family Foundation, analyzes changes in racial/ethnic and socioeconomic disparities in maternal and infant health in California in 1994/1995 and 1999/2001. The issue brief also reviews the policy implications of these differences and offers general recommendations for health care policymakers to consider in addressing health disparities.
Issue Brief (.pdf)
Medical Liability Reforms: Comparison of Candidate’s Proposals
Bush-Cheney1
Kerry-Edwards2
1http://www.georgewbush.com.2http://www.johnkerry.com.
HIV/AIDS
Download a printable .pdf of Health Care and the 2004 Elections: HIV/AIDS.
IssueBackgroundPolicy Challenges Facing the Response to HIV/AIDSAssessing Candidate Positions
HIV/AIDS is a critical issue to many who may have questions for candidates concerning their positions on the U.S. response to the epidemic at home and abroad. The U.S. is faced with numerous challenges in addressing the epidemic, including: funding levels for global and domestic HIV/AIDS efforts; differing approaches to prevention, care, treatment, and research; and questions about the role of the U.S. as a leader in the global fight against the epidemic.
The Global EpidemicIn the more than two decades since the beginning of the HIV/AIDS epidemic, over 60 million people worldwide have become infected, including more than 20 million who have already died. 1 The number of people living with HIV/AIDS has grown significantly over time, with an estimated 37.8 million living with HIV/AIDS today (see Figure). Women now comprise almost half of adults living with HIV/AIDS and young people continue to bear the brunt of the epidemic, especially young women. Sub-Saharan Africa has been particularly affected, accounting for two-thirds of all people living with HIV/AIDS. 1 There are also growing concerns about “next wave” countries, those on the verge of major epidemics, particularly Russia, India, and China. Complicating the response worldwide is that most people with HIV/AIDS do not know they are infected. In addition, only eight percent of those in need of antiretroviral therapy are estimated to have access 2 and fewer than one in five are reached by prevention programs. 1 Finally, global funding for HIV/AIDS from governments and other donors falls far short of projected need. 1
The U.S. Epidemic
Almost one million people are estimated to be living with HIV/AIDS in the U.S. A significant proportion is not receiving regular HIV care, including medications for HIV, and an estimated one in four people with HIV do not know they are infected.3 Minority communities, young people, women, and men who have sex with men have been particularly hard hit. African Americans, for example, represent a growing proportion of new HIV infections and AIDS diagnoses, accounting for half of AIDS cases diagnosed in 2002. Women also represent an increasing proportion of AIDS diagnoses, accounting for about one quarter of new diagnoses in 2002 (see Figure). The number of new HIV infections each year – about 40,000 – has remained constant for more than a decade, but there are troubling signs that the incidence of HIV may be on the rise. 4,5 In addition, many of the critical programs that provide care, treatment, support, and prevention to people at risk for and living with HIV in the U.S. are facing resource constraints and, because of funding shortages, there are waiting lists for AIDS medications in several states.
Policy Challenges Facing the Response to HIV/AIDS
Among the major policy challenges facing U.S. policymakers in addressing the epidemic are:
Global HIV/AIDSU.S. Global HIV/AIDS Leadership. In 2003, the Administration announced the President’s Emergency Plan for AIDS Relief (PEPFAR), a new 5-year, $15 billion global HIV/AIDS initiative later enacted into law, which includes almost $10 billion in new funding. The bulk of the new funds ($9 billion) is targeted to 15 hard hit “priority” countries; up to $1 billion would be contributed to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), an international partnership of governments and private organizations created to help finance the response to HIV/AIDS, TB, and malaria. The remaining $5 billion will go to continuing U.S. efforts in other countries.6
Global AIDS legislation and Administration policy include requirements for where and how the money gets spent, including targeting a subset of countries, limiting Global Fund contributions, and allocating specific funding percentages to prevention, including abstinence-only prevention, care, and treatment. Many have called for increased funding for global AIDS, and some policymakers support doubling U.S. assistance to $30 billion over five years and allocating a greater share to the Global Fund. Much of this discussion has centered on what should be the U.S. government’s “fair share” in the fight against the global epidemic. There have also been calls to expand beyond the 15 PEPFAR priority countries to include large, next wave countries, where more resources now could help prevent millions of infections. Other concerns have been raised about the need to get money to the front lines as quickly as possible and the importance of coordinating with other governments and donors and those in affected countries themselves.
Affordable Access to Treatment and Role of Generic Drugs. The high cost and complexity of combination antiretroviral therapy is an obstacle to HIV/AIDS treatment, particularly in poor countries but also within the U.S. Fixed-dose combination and co-packaged antiretroviral drugs, including those with generics, are seen as one way to expand access to treatment in highly affected countries because they are often more affordable and are easier for patients because they require fewer pills. The Administration has decided to allow PEPFAR funds to be used to purchase such medications for international use, but only if these drugs receive approval from the U.S. Food and Drug Administration (FDA) through an expedited process , stating that this is the only way to ensure that they are safe and effective. Critics of this approach argue that an existing World Health Organization (WHO) pre-qualification process is sufficient to ensure drug safety and quality, and is already used by other countries.
Immigration and Travel Ban. Longstanding U.S. policy prohibits people with HIV from immigrating to the U.S., as well as traveling to the U.S. (with limited exceptions). Some want the ban to be lifted, arguing that this policy is not based on public health principles but is instead a form of discrimination.
U.S. Epidemic
Care, Treatment, and Waiting Lists for Medications. Even in the U.S., not everyone with HIV/AIDS who needs medications can get them, and access to care and treatment varies significantly across the country – what you get depends on where you live. The Ryan White CARE Act, the nation’s largest program designed for people with HIV/AIDS, faces funding constraints in many parts of the country. The AIDS Drug Assistance Program (ADAP) of the Ryan White CARE Act in particular, which funds states to provide HIV medications to those who cannot get them elsewhere, faces continual funding shortages resulting in waiting lists for medications – as of August 2004, 9 state ADAPs had waiting lists, totaling more than 1,500 people. 7 ADAP funding constraints also lead to significant disparities in access to different HIV medications across states. 8 Medicaid and Medicare also play a critical role for people with HIV/AIDS, providing insurance coverage to about half of those receiving care.9 As people live longer with HIV/AIDS these programs will become even more important, raising important issues concerning the rising cost of prescription drugs, current eligibility rules for these programs, and state and federal funding constraints.10,11
Preventing New Infections. Because HIV incidence in the U.S. has remained steady for so long, current policy and program debates center on how to expand access to HIV testing, the role of community-based organizations vs. government in designing HIV prevention interventions, and how to balance prevention efforts between those who are at risk and those who are already HIV-positive. In both global and domestic HIV/AIDS debates, there are differing opinions about approaches to HIV prevention. The Administration, while endorsing an “ABC” approach (“Abstinence, Be faithful and when appropriate, use Condoms”), emphasizes abstinence as the only sure way to prevent sexual transmission of HIV and other sexually transmitted diseases. Others say that a comprehensive approach, one that includes but does not prioritize abstinence over condoms, is needed. U.S. global AIDS legislation requires a certain amount of funding to go to abstinence-only programs. For the U.S., President Bush has called for doubling funding for abstinence-only programs, which affects HIV prevention activities.
Minorities and Other Hard-Hit Populations. Specific challenges face policymakers in addressing the epidemic’s growing impact on minority populations, including how best to support existing efforts focused on minorities, such as the Minority AIDS Initiative 12 , as well as strengthen other programs that also serve minorities at risk for and living with HIV, and whether new approaches are also needed. There are also challenges about how best to address the U.S. epidemic’s impact on women and other vulnerable groups.
Assessing Candidate Positions
The following questions are intended to help evaluate candidate positions on HIV/AIDS:
Prepared by Health Policy Alternatives, Inc
1 UNAIDS, 2004 Report on the Global AIDS Epidemic, July 2004.2 World Health Organization, “Coverage of Adults in Developing Countries on Antiretroviral Treatment, by WHO Region, Situation as of June 2004”.3 Fleming, P., et al., “HIV Prevalence in the United States 2000”, 9th Conference on Retroviruses and Opportunistic Infections, 2002.4 Centers for Disease Control and Prevention, MMWR, “Advancing HIV Prevention: New Strategies for a Changing Epidemic – United States, 2003”, Vol. 52, No. 47, November 2003.5 Centers for Disease Control and Prevention, MMWR, “Increases in HIV Diagnoses – 29 States, 1999 – 2002”, Vol. 52, No. 15, April 2003.6 State Department, Fact Sheet: The President’s Emergency Plan for AIDS Relief Five-Year Strategy, September 2004.7 National Alliance of State and Territorial AIDS Directors, The ADAP Watch, August 2004.8 National Alliance of State and Territorial AIDS Directors, Kaiser Family Foundation, AIDS Treatment Data Network, National ADAP Monitoring Project – Annual Report, May 2004.9 Bozzette, et al., “The Care of HIV-Infected Adults in the United States.” NEJM, Vol. 339, No. 26. December, 1998.10 Kaiser Family Foundation, Fact Sheet: Medicaid and HIV/AIDS, September 2004.11 Kaiser Family Foundation, Fact Sheet: Medicare and HIV/AIDS, September 2004.12 Kaiser Family Foundation, Policy Brief: The Minority AIDS Initiative, June 2004.
This fact sheet explores the history of teen magazines that generally focus on 12-19 year olds, as well as trends affecting the genre, including advertising, readership, content, the role the magazines play in the lives of their readers, the effect of the web, and magazines for teen boys.
This is the eleventh in a series of reports and fact sheets on topics related to children, media and health that pull together the most relevant research on such issues as the digital divide, TV violence, teens online, media ratings, and children and video games.
Key Facts (.pdf)