Many Working Families Struggle To Get Needed Care And Pay Medical Bills

Three-Quarters of the Currently or Recently Uninsured Are in Working Families

Nearly Half of Uninsured Adults in Working Families Have Access or Bill Problems

Embargoed for release until: 10:00 a.m., EST, Monday, December 8, 1997

For further Information contact: Chris Ferris (202)347-5270 or Mary Mahon (212)606-3853

Washington, D.C.– Three in four American adults who do not have health insurance or who have experienced a recent gap in coverage are part of working families — they are either full- or part-time workers or the spouse of a worker — according to a new survey released by the Kaiser Family Foundation and The Commonwealth Fund. The Kaiser/Commonwealth 1997 National Survey of Health Insurance also finds that as a result of being currently or recently uninsured, many working-age adults and their families face barriers to getting or paying for needed health care.

“This survey serves as a reminder that the problems of the working uninsured are still with us,” said Drew Altman, President of the Kaiser Family Foundation. “The low-wage working uninsured deserve special attention when the country considers the next incremental step in expanding health insurance coverage.”

Going without health coverage is not a matter of choice for most of the uninsured. About half (51%) of all uninsured adults report that they do not have insurance because they cannot afford it. Another quarter (25%) say they do not have health insurance because they lost their job or their employer does not offer benefits. Only 4% are uninsured because they have poor health or were denied health benefits.

Families with incomes below the median U.S. family income of $35,000 are most affected by lack of insurance. Three in five (59%) adults in families who earned less than $20,000 annually were uninsured or had a recent gap (sometime in the past two years) in health coverage. One-third (31%) who earned between $20,000 and $35,000 annually also were currently or recently uninsured.

The survey also finds that low-wage working families are at high risk overall. Two in five (41%) adults in working families said they had problems paying medical bills or went without needed care in the past year. More than half (56%) of adults in low-wage working families who are uninsured, and 50% of those with a recent gap in coverage, had problems with access to care or paying medical bills in the last year.

“This survey shows us that people are not uninsured because of preexisting conditions or because they opted out of coverage,” explained Karen Davis, President of The Commonwealth Fund. “Many working families simply cannot afford the high cost of health insurance premiums.”

Insurance Matters

Lack of health insurance leads directly to barriers to health care and problems paying medical bills. Nearly half of the working uninsured (48%) report difficulties with access or costs, while only 15 percent of people who had continuous coverage report these problems. The survey also finds that nearly one-quarter (24%) of uninsured adults say they had not filled a prescription they needed in the past year. One in six (17%) report that they had to change their families’ way of life significantly to pay medical bills.

“Many uninsured working families incur unmanageable financial burdens due to medical emergencies or serious illness, or even worse, go without health care at all,” noted Davis.

Survey respondents who had temporary gaps in health coverage and were uninsured at some point in the past two years face problems similar to those of the currently uninsured. One in five (21%) did not fill a prescription in the past year, and two in five (40%) postponed care in the past year due to costs. By comparison, about one in four of the uninsured (24%) did not fill a prescription; about half (55%) had delayed care.

Medicare Scores Highly Compared to Insurance of Working Families

In marked contrast to the situation of working families, the elderly ages 65 and over covered by Medicare are much more satisfied with their health insurance coverage. Medicare, which provides coverage for the elderly ages 65 and older, results in beneficiaries having greater access to health care and better financial protections than most low- and moderate-income working families. Despite more serious health problems, for example, only 7 percent of the elderly report problems getting health care in the past year, compared with 20 percent of all adults under age 65, and 42 percent of uninsured working-age adults. Medicare beneficiaries are also much more likely to be very satisfied with their health insurance (64%) and choice of doctors (74%) than are adults with job-based health coverage or Medicaid beneficiaries.

Methodology:

The Kaiser/Commonwealth 1997 National Survey of Health Insurance, which was conducted between November 1996 and March 1997 by Louis Harris and Associates, Inc., was designed and analyzed by staff at the Kaiser Family Foundation and The Commonwealth Fund. The survey sample consisted of 4,001 adults ages 18 and older, including 3,761 adults surveyed by telephone and 240 in-person interviews of people without telephones in their homes. The data were weighted to the March 1996 Current Population Survey for accurate representation of Americans by sex, race, age, education, and health insurance status.

The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. The Foundation’s work is focused on four main areas: health policy, reproductive health, and HIV policy in the United States, and health and development in South Africa.

The Commonwealth Fund, a New York City-based national foundation, undertakes independent research on health and social issues. Its mission is to enhance the common good by looking for new opportunities to help Americans live healthy and productive lives, and to assist specific groups with serious and neglected problems.

This press release is also available on the World Wide Web at www.kff.org or www.cmwf.org. Copies of the release and the accompanying chart pack can be ordered from the Kaiser Foundation’s toll-free publications request line (800/656-4533). Ask for document #1347.

1997 National Survey of Americans on AIDS/HIV

Public Knowledge And Attitudes About AIDS/HIV : Survey II

Princeton Survey Research Associates For The Kaiser Family Foundation

Questionnaire and National Toplines

December 4, 1997

Methodology

The 1997 National Survey of Americans on AIDS/HIV was designed by staff of the Kaiser Family Foundation and conducted for the Family Foundation by Princeton Survey Research Associates. The survey was conducted by telephone with 1,205 adults (age 18 or older) nationwide between September 17-October 19, 1997. The margin of sampling error is plus or minus 3 percentage points.

The Foundation last surveyed Americans on AIDS/HIV in December 1995. Where available trend data or information are noted. Some select questions also provide further trend information from other sources, each source is noted by an appropriate footnote reference.

Select questions were asked of a random half of the respondents. These questions are identified by “Form 1” or “Form 2,” indicating which half answered that particular question. There were 598 respondents in the “Form 1” group and 607 respondents in the “Form 2” group. The margin of error for this split sample is plus or minus 4 percentage points.

National Topline

1. My first question is… What do you think is the most urgent health problem facing this nation today? (Open-end. Do not read answer categories. Wait for reply before probe) Is there another health problem you think is almost as urgent?

Current 12/95 1/90¹ 38 AIDS 44 49 38 Cancer 27 31 21 Health insurance/access/cost 25 13 16 Heart 11 na² 5 Drugs 4 17 3 Smoking/Cigarettes na na 2 Elderly 4 12 2 Excess weight/Obesity na na 2 Diabetes *³ na 14 Other 15 na 8 Don’t know/Refused 8 9

Total exceeds 100% due to multiple responses.

2. Now I’d like you to think about the way the problem of AIDS is affecting this country today. Do you think the problem of AIDS is about the same as it has been, that the country is making progress in this area, or that the country is losing ground?

Based on form 1 respondents.

Current 12/95 3/94⁴ 14 About the same 15 22 52 Country making progress 32 23 27 Country losing ground 48 49 7 Don’t know/Refused 5 6 100 100 100

3. Thinking about the way AIDS is affecting your local community today, is the problem of AIDS about the same as it has been, is your community making progress, is your community losing ground, or has AIDS never been a problem in your community?

Based on form 1 respondents.

Current 12/95 19 About the same 23 14 Community making progress 11 11 Community losing ground 18 41 Never been a problem 38 15 Don’t know/Refused 10 100 100

4. Now I’d like you to think about the way the problem of AIDS is affecting this country today. Do you think AIDS is a more urgent problem for the country than it was a few years ago, is it a less urgent problem, or is it about as urgent as it was?

Based on form 2 respondents.

48 More urgent 12 Less urgent 38 About as urgent 2 Don’t know/Refused 100

5. Thinking about the way the problem of AIDS is affecting your local community today, do you think AIDS is a more urgent problem for your community than it was a few years ago, is it a less urgent problem, is it about as urgent as it was, or has AIDS never been a problem in your community?

Based on form 2 respondents.

25 More urgent 9 Less urgent 28 About as urgent 25 Never been a problem 13 Don’t know/Refused 100

6. How serious a problem do you think AIDS is for people you know? For people you know, do you think AIDS is…(read)

Current 12/95 34 A very serious problem 43 19 A somewhat serious problem 17 17 Not too serious a problem, or 15 25 Not a serious problem at all? 22 5 Don’t know/Refused 3 100 100

7. Bearing in mind the different ways people can be infected with H-I-V, the virus that causes AIDS–how concerned are you, personally, about becoming infected with HIV? Are you…(read)

Current 12/95 5/91⁵ 24 Very concerned 22 27 17 Somewhat concerned 18 21 21 Not too concerned, or 22 22 38 Not at all concerned? 38 30 * Don’t know/Refused * * 100 100 100

8. Are you more concerned about becoming infected with HIV than you were a few years ago, less concerned, or about as concerned?

27 More concerned 24 Less concerned 47 About as concerned 2 Don’t know/Refused 100

9. Do you, yourself, have any sons or daughters aged 21 years or younger?

43 Yes 57 No * Don’t know/Refused 100

10. How concerned are you about a son or daughter becoming infected with HIV? Are you…(read)

Based on parents of children aged 21 or younger.

Current 12/95 52 Very concerned 53 21 Somewhat concerned 24 16 Not too concerned, or 10 11 Not at all concerned 11 * Don’t know/Refused 2 100 100 (n=541) (n=666)

11. Are you more concerned about a son or daughter becoming infected with HIV than you were a few years ago, less concerned, or about as concerned?

Based on parents of children aged 21 or younger.

46 More concerned 9 Less concerned 44 About as concerned 1 Don’t know/Refused 100 (n=541)

12. Do you think AIDS is a major threat to public health in this country today, or is not a major threat to public health?

83 Major threat 14 Not a major threat 3 Don’t know/Refused 100

13. I’m going to read a list of groups in your local community. For each one, please tell me how much you think they are doing to help fight against AIDS. As far as you know, how much are (insert first item — rotate) doing to help fight against AIDS? Is this group doing a lot, some, only a little or nothing at all? How much do you think (insert next item — rotate) are doing?

Based on form 1 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Local church or religious leaders 18 29 24 12 17 =100 b. Local government and political leaders 11 34 30 13 12 =100 c. Local public schools 23 34 20 6 17 =100 d. Local health care providers, such as doctors, health clinics and hospitals 38 32 12 4 14 =100

14. And how about those outside of your local community . . . As far as you know, how much is (insert items in order) doing to help fight against AIDS– a lot, some, only a little or nothing at all?

Based on Form 1 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Your state government 15 43 24 6 12 =100 b. President Clinton 21 39 21 8 11 =100 c. The federal government 20 42 23 6 9 =100

15. I’m going to read a list of groups in your local community. For each one, please tell me your impression of how much this group cares about the fight against AIDS and makes it a priority. First, what about… (insert first item — rotate)–is it your impression that they care a lot about the fight against AIDS, some, only a little or not at all? How much do you think (insert next item — rotate) care?

Based on form 2 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Local church or religious leaders 39 34 15 5 7 =100 b. Local government and political leaders 17 42 27 8 6 =100 c. Local public schools 44 31 12 4 9 =100 d. Local health care providers, such as doctors, health clinics and hospitals 59 25 7 3 6 =100

16. And what is your impression of how much those outside of your local community care about the fight against AIDS and make it a priority . . . (First/Next) (insert items in order)–do you think (it/he) cares a lot about the fight against AIDS, some, only a little, or not at all?

Based on form 2 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Your state government 22 53 19 3 3 =100 b. President Clinton 31 39 16 7 7 =100 c. The federal government 21 47 22 5 5 =100

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1997 National Survey of Americans on AIDS/HIV:Press Release Survey Part One Part Two Part Three Part Four Part Five Chart Pack

Overview of Medicaid Managed Care Provisions in the Balanced Budget Act of 1997

Prepared by Andy SchneiderThe Center on Budget and Policy Priorities

for The Kaiser Commission on the Future of Medicaid

December 1997

This paper was prepared for The Kaiser Commission on the Future of Medicaid with support from The Henry J. Kaiser Family Foundation. The views represented in this report are those of the author and do not necessarily represent the views of The Kaiser Commission on the Future of Medicaid.

Contents

Overview

1. Summary
2. Medicaid Managed Care: An Overview
3. Statutory Pathways to Mandatory Medicaid Managed Care
4. Standards for State Contracting with Medicaid MCOs
5. Payment Rates for Medicaid MCOs
6. Organizational Qualifications for Medicaid MCOs
7. Access and Quality Standards for Medicaid MCOs
8. Beneficiary Protections
9. Accountability of Medicaid MCOs for Compliance with State and Federal Standards
10. Primary Care Case Management Option and Rural Beneficiaries
11. Implications for Safety Net Providers

Conclusion

Appendices:

A. Standards for State Contracts with Medicaid MCOs

B. Index to Statutory Provisions Relating to Medicaid Managed Care

Overview of Medicaid Managed Care Provisions in the Balanced Budget Act of 1997

The Balanced Budget Act of 1997 (P.L. 105-33) dramatically expands the authority of state Medicaid agencies to provide covered health care services through managed care organizations (MCOs). The Act enables states, without obtaining waivers from the Secretary of Health and Human Services, to require most Medicaid beneficiaries to enroll in MCOs that do business only with the Medicaid program. It also allows states, again without obtaining waivers, to limit the number of participating Medicaid MCOs. These provisions are likely to have a major effect on access to covered hospital and physician services by low-income women and children and other Medicaid beneficiary populations.¹ The implications of these provisions for beneficiaries, for states, for “safety net” hospitals and clinics, and for MCOs are the focus of this analysis. The budgetary and policy context in which these changes were enacted is discussed elsewhere.²

1. Summary

The Balanced Budget Act did not launch the shift of Medicaid from fee-for-service to managed care. That transition has been under way for several years, prompted largely by state efforts to restrain Medicaid expenditure growth and nurtured by federal waivers.³ A recent Urban Institute analysis finds that between 1991 and 1996, enrollment of Medicaid beneficiaries in managed care nationally grew from 9.5 percent to 40.1 percent of total Medicaid enrollment.⁴ Even before passage of the Balanced Budget Act, CBO projected that, between fiscal years 1996 and 2002, federal matching payments to Medicaid MCOs would increase, on average, more than 15 percent annually, from $7 billion, or 11 percent of federal spending on Medicaid benefits, to $17 billion, or 14 percent.⁵

What the Balanced Budget Act has done is to alter fundamentally the managed care policy options available to states under the federal Medicaid statute. In the past, states that wanted to require Medicaid beneficiaries to enroll in MCOs that do business mainly or exclusively with Medicaid had to obtain a waiver from the Secretary of Health and Human Services (HHS). Under the Balanced Budget Act, they will now be able to do so without seeking a waiver. State managed care initiatives currently rely heavily on the use of mostly Medicaid MCOs. In 1996, for instance, 7.7 million Medicaid beneficiaries were enrolled in 355 fully capitated managed care plans in 35 states, according to a recent analysis by Mathematica Policy Research. Of these, 3.6 million, or 48 percent, were in 156 managed care plans in which Medicaid beneficiaries accounted for more than 75 percent of total enrollment.⁶ The Balanced Budget Act gives states the flexibility to rely more heavily on MCOs that primarily or exclusively enroll Medicaid beneficiaries. These could include MCOs that are for-profit, MCOs that are owned by non-profit or public “safety net” providers, as well as MCOs specializing in particular services like mental health.

Under the Act, states that want to limit Medicaid beneficiaries living in urban areas to a choice between two MCOs can do so without seeking a waiver from the Secretary of HHS. States can also restrict beneficiaries living in rural areas to a single MCO. In either case, all the MCOs that a state allows to participate may do business primarily or exclusively with Medicaid. For this purpose, the managed care plans with which the state contracts can be fully capitated – that is, at financial risk for providing hospital, physician, and other covered services to Medicaid beneficiaries – or a primary care case manager (PCCM), which does not assume financial risk for the provision of covered hospital services.

This new authority translates into additional bargaining power for state Medicaid programs vis-a-vis managed care plans. States can use this leverage to obtain more favorable rates from participating plans and to limit participants to those that demonstrate the highest levels of quality in services provided. However, this bargaining power can also raise the financial rewards to winning MCOs substantially, by limiting competition, thus giving each MCO a far larger market share and a heftier revenue stream. The Medicaid managed care business can be extremely lucrative.⁷ The potential for favorable results in the Medicaid market has attracted venture capital firms, where, as a rule of thumb, the expected rate of return is roughly one and one-half to three times the normal market rate of return.⁸ This venture capital will help finance new entrants into the Medicaid managed care market as well as the expansion of firms already participating.

One attraction of Medicaid managed care as an investment opportunity is that the conversion of Medicaid beneficiaries into mandatory MCO enrollees creates large monthly flows of capitation payments. An MCO with a mandatory enrollment of, say, 30,000 Medicaid-eligible women and children at an average capitation rate of $90 per month will realize a monthly cash flow of $2.7 million and annual revenues of $32.4 million without accounting for interest. The prospect of such large revenue streams — and the potential returns to be realized in the Medicaid managed care business — are likely to prove highly attractive in many states. As new entrants seek to acquire market share and incumbent plans attempt to protect or expand their existing positions by bringing financial and other resources to bear, the state Medicaid contracting process requires careful monitoring to assure its integrity.

The Medicaid managed care business is not always financially rewarding. There is considerable variation from state to state in the Medicaid payment and regulatory policies toward MCOs. This in turn produces variations in the attraction of Medicaid as a business proposition for managed care plans. A recent review of Medicaid managed care in the trade press indicates that some investor-owned MCOs have either halted new Medicaid enrollment or withdrawn from the Medicaid market altogether in a number of states, including Arizona, Illinois, New York, Ohio, Oregon, and Tennessee. The article attributes this trend primarily to low Medicaid payment rates.⁹

The Balanced Budget Act alters the statutory options available to states with respect to Medicaid managed care, but it does not change the sometimes conflicting interests of states in pursuing this policy path. On the one hand, states have an interest in ensuring that their low-income families have access to basic health care services. Medicaid managed care, when properly implemented, can improve both the accessibility and quality of basic health care services for Medicaid beneficiaries, particularly in those communities in which the quality and continuity of fee-for-service care are substandard.

On the other hand, states want to limit their Medicaid expenditures. The shift from fee-for-service to managed care enables them to curb Medicaid spending on a per beneficiary basis without formally and publicly narrowing the benefits package that they offer under their Medicaid programs. States also have an interest in limiting per beneficiary payments to MCOs and allowing the MCOs to narrow the covered services enrollees actually get. How these sometimes conflicting interests are resolved will vary from state to state.

This analysis describes the new legal and policy framework within which the shift of state Medicaid programs from fee-for-service to managed care will take place over the next few years. The analysis does not duplicate section-by-section summaries of the Balanced Budget Act’s Medicaid managed care provisions.¹⁰ Instead, it focuses on those provisions that are likely to have the most influence in shaping the transition to managed care and its impact on Medicaid beneficiaries:

• standards relating to state procedures for contracting with MCOs,
• standards for MCO organizational qualifications,
• standards relating to Medicaid payment rates for MCOs,
• standards relating to accessibility and quality of care in MCOs,
• beneficiary protections,
• accountability of MCOs for compliance with these standards, and
• provisions affecting safety net providers.

The interpretation of many of these provisions here is necessarily preliminary, since as of December 19, 1997, the Health Care Financing Administration (HCFA) has issued administrative guidance to the states or to MCOs with respect to only some of these amendments.¹¹

Endnotes

1. CBO, Budgetary Implications of the Balanced Budget Act of 1997, August 12, 1997. CBO does not attribute any federal savings to these provisions. In CBO’s view, the only budget effect of the legislation’s Medicaid managed care provisions is to increase federal spending somewhat ($0.1 billion over five years and $0.3 billion over ten) due to the requirement that Medicaid MCOs pay for hospital emergency visits whenever a “prudent layperson” would seek emergency care. 2. Andy Schneider, Overview of Medicaid Provisions in the Balanced Budget Act of 1997, P.L. 105-33, Center on Budget and Policy Priorities, Revised, September 8, 1997. www.cbpp.org/908mcaid.cfm. 3. For a detailed state-by-state survey of the scope of Medicaid managed care, see Jane Horvath et al., Medicaid Managed Care: A Guide for States, 3rd Edition, National Academy for State Health Policy, January 1997 4. Stephen Zuckerman, Alison Evans, and John Holahan, Questions for States as They Turn to Medicaid Managed Care, Urban Institute, August, 1997. 5. CBO Memorandum, Behind the Numbers: An Explanation of CBO’s January 1997 Medicaid Baseline, April 1997, p. 9. 6. Suzanne Felt-Lisk and Sara Yang, “Changes in Health Plans Serving Medicaid, 1993-1996,” Health Affairs, September/October 1997, at 127. 7. A recent report on a Medicaid-only MCO operating in Philadelphia found that between 1989 and 1996, the organization had generated pretax profits of $119 million (a return of 7,600 percent on a $200,000 investment, according to a 1994 audit), and had paid its four founders a total of $26.8 million in bonuses. Craig McCoy and Karl Stark, “An HMO Finds Lots of Money in Poverty,” Philadelphia Inquirer, August 3, 1997. A recent review of a Medicaid MCO contract by the HHS Inspector General found that one contractor realized a profit of $22.9 million over a three-year period, exceeding the IG’s “benchmark for reasonableness” by $4 million. Office of Inspector General, Department of Health and Human Services, State of Wisconsin’s Medicaid Managed Care Program Financial Safeguards, February 1997, p. 3. 8. For example, venture capital firms have invested $38 million in Americaid Community Care, which targets the Medicaid market in large urban areas like Houston and Chicago. A managing partner of Acacia Venture Partners of San Francisco, which has invested $5.5 million in Americaid, believes that Medicaid is “an exciting market, one largely ignored by the large, commercial HMOs.” Debra Gordon, “Virginia Beach-based HMO Takes the Medicaid Gamble,” The Virginian-Pilot, July 26, 1997. 9. The article quotes a health stock analyst as follows: “States have gotten reckless in cutting rates because they couldn’t care less about the Medicaid population. Only the worst HMOs, those that desperately need Medicaid will stay in.” Harris Meyer, “Medicaid: States Serve Up a Real Turkey,” Hospitals and Health Networks, November 20, 1997, p. 22. 10. For a summary section-by-section overview, see Sara Rosenbaum and Julie Darnell, A Comparison of the Medicaid Provisions in the Balanced Budget Act of 1996 (P.L. 105-33) With Prior Law, Kaiser Commission on the Future of Medicaid, September 1997. For a detailed section-by-section analysis, see National Health Law Program, National Center for Youth Law, National Senior Citizens Law Center, and Center for Medicare Advocacy, The Balanced Budget Act of 1997 – Reshaping the Health Safety Net for America’s Poor, October 1997 at www.healthlaw.org. 11. This guidance currently takes the form of letters to state Medicaid Directors. Copies are available on the HCFA Website, www.hcfa.gov/medicaid/bbahmpg.cfm.

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Overview of Medicaid Managed Care Provisions in the Balanced Budget Act of 1997

Report Part One Part Two Part Three Part Four Part Five Part Six Part Seven Part Eight

Do Americans Think The AIDS Epidemic Is “Over”?

Many See Progress In Fight Against The Disease, Yet Support Still Strong For Spending On Prevention And Treatment

Though Still Number One, AIDS Now Tied with CancerAs Nation’s Most Urgent Health Problem

Embargoed For Release Until:10:00 am, ET, Thursday, December 4, 1997

Washington, DC — As new drugs have become available to help people with AIDS/HIV livelonger, advocates have worried that the public will perceive the epidemicas “over,” while others have questioned whether AIDS should receive specialstatus among the nation’s health concerns. Sixteen years since thebeginning of the epidemic, a new survey finds that while Americans seegrowing progress in the fight against the disease, they also continue toview AIDS as an urgent health problem for the nation and still stronglysupport spending on prevention, research, and treatment.

According to a Kaiser Family Foundation survey released today, the publicis far from thinking the AIDS epidemic is “over:” the vast majority — 88percent — give an emphatic no. But, a majority of Americans (52%) now dosee the country making progress in addressing the problems of AIDS. Only athird (32%) were as optimistic in 1995, when the Foundation surveyedAmericans on AIDS/HIV. And, in 1994, it was just a quarter (23%),according to a Times Mirror survey. Even so, the public continues to rankAIDS among the most serious health concerns facing the nation; although, itis now seen as more comparable with other diseases. Today, the samepercentages of Americans name AIDS (38%) as name cancer (38%) when askedwhat is the most urgent health problem facing the nation. Two years ago,AIDS was ranked first by 44 percent of the public, followed by cancer with27 percent. In 1990, 49 percent of the public said AIDS, and 31 percent,cancer, according to a Los Angeles Times poll.

“After more than a decade of fighting this deadly disease, Americans arelearning to live with AIDS. While the public continues to see AIDS as anurgent issue, it is no longer a viewed as an emergent one,” said SophiaChang, MD, MPH, Director of HIV Programs, Kaiser Family Foundation.

Support for government spending to help pay for drug therapies forlow-income people with AIDS is especially strong. Three quarters (73%) ofAmericans say the government should help pay for new AIDS treatmentsregardless of income-level; 20 percent say the responsibility should beleft to individuals and their families. Two thirds (64%) support spendingeven when told it would result in higher costs to the government; 29percent say the government cannot afford it.

Overall, a majority (51%) of the American people say the government spendstoo little money on AIDS (32% say “about the right amount;” 8% say “toomuch”). Forty percent (40%) say federal spending on AIDS is too low, ascompared to what is spent on other health problems such as cancer and heartdisease (35% say “about the right amount;” 11% say “too high”). This isdown from 1995, when 50 percent of Americans said not enough was spent onfighting the disease as compared to what is spent on other health concerns(31% said “about the right amount;” 12% said “too high”). Still, thereremain high levels of support today for spending in all areas of AIDSeducation, prevention, and treatment. When asked to choose a “toppriority” for HIV spending, the public favors devoting resources toresearch to find an AIDS vaccine (47%), followed by HIV/AIDS education andother prevention efforts (32%).

The survey also finds that most people — 89 percent — think that by nowall adults should know how to protect themselves from HIV infection, and 71percent think those who become infected today are more responsible fortheir circumstances than those infected earlier. While public sentimentleans toward greater personal responsibility, the public’s attitude towardpeople with AIDS is not punitive: a majority — 54 percent — do not thinkthat adults with AIDS/HIV should have to pay more of their medical billsthemselves than those infected years ago; 42 percent say should have topay more today.

Trends in AIDS/HIV.

For the first time this decade, in February of 1997,the Centers for Disease Control and Prevention (CDC) announced a decline inAIDS deaths in the United States. Deaths from AIDS among Americans, ages13 and older, declined 23 percent between 1995 and 1996. Declines werereported in all geographic areas, among men and women, among all racial andethnic groups, and in all risk and exposure categories. The number ofAmericans living with AIDS — almost a quarter of a million today –increased by 11 percent over the same time period. This increase in peopleliving with AIDS comes at a time when new drug therapies are available tohelp treat the disease and lengthen life. Protease inhibitors, a class ofdrug commonly used in combination therapies to treat people with HIV/AIDS,was approved by the Food and Drug Administration for use in this country inDecember 1995. The use of zidovudine (AZT) to prevent the transmission ofHIV from mother to child also appears to be having an impact. New AIDScases as a result of mother to child transmissions were recently reportedto have decreased by 43 percent between 1992 and 1996.

New Drug Therapies.

More people today (86%) than two years ago (75%) knowthat drug therapies are available to help people with AIDS live longer.The public is also more aware today that certain drugs can be taken bypregnant women with HIV to help prevent transmission to their babies: 49percent today, as compared to 30 percent in 1995.

Awareness about the availability of new drugs may be one reason the publicsees progress in the fight against AIDS: 44 percent of Americans today say”a lot” of progress has been made in keeping people with AIDS alive longer,up from 24 percent in 1995. However, most people believe that the newdrugs do not benefit everyone with AIDS/HIV: 79 percent say most peoplewho want the treatments are not getting them, and 58 percent say they arenot effective for most people who are taking them. The public also appearsto have a realistic understanding of the high cost of the new drugs: 42percent know the average monthly expense can be as high as $1000; 30percent think it is closer to $500 per month.

In spite of greater awareness about the drug therapies, the percentage ofAmericans who report having been tested for HIV has remained relativelyconstant over the last two years. Currently, two out of five people (38%)say they have ever been tested for HIV, including 16 percent in the lastyear; about the same percentages as reported being tested in 1995. Just 20percent of those surveyed say they have ever talked with a health careprovider about getting tested for HIV; two thirds (66%) of whom say theybrought the topic up themselves.

Needle Exchange.

Over the two years the Foundation has surveyed thepublic on needle exchange, Americans have remained supportive of these programs, which offer clean needles to IV drug users in exchange for usedneedles, as an AIDS prevention measure. As of the end of November, 64percent of the public favor needle exchange and 30 percent oppose. Earlierin the fall when the Foundation surveyed on needle exchange, 58 percentsupported and 38 percent opposed such programs. Two years earlier, 66percent supported needle exchange, and 30 percent opposed.

Public opinion on needle exchange, however, appears to be influenced byhow the issue is presented. When presented with the major arguments forand against needle exchange (including the criticism that needle exchangeprograms give tacit approval of illegal drug use) the differences levelout: in November, 48 percent support and 46 percent oppose. A few monthsearlier, 43 percent support and 53 percent oppose needle exchange whengiven these same arguments. Better knowledge of the scientific evidence onneedle exchange, on the other hand, appears to increase support. Afterhearing that organizations such as the National Academy of Sciences haveconcluded that needle exchange programs reduce HIV infection among IV drugusers without increasing their drug use, support for the programs in themost recent survey increases. Among the first group, those asked aboutneedle exchange without arguments, support increases from 64 percent to 73percent (20% still oppose); among those given both sides of the argument,support increases from 48 percent to 60 percent (32% still oppose). (Thisquestion was not asked in the earlier surveys.)

Today, a majority of Americans — 61 percent — think current law shouldbe changed to allow state and local governments to decide for themselveswhether federal funds should be used for needle exchange.

Other Prevention Efforts.

Americans support efforts to encourage condomuse to help stop the spread of HIV:

• 62 percent say the TV networks should accept condom advertising (33%say should not);
• 55 percent say when movies and TV shows deal with sexual relationshipsthere should be more references to condoms (32% say there are enoughreferences now); and
• 44 percent say condoms should be made available in high schools, andanother 52 percent say only information about AIDS prevention should beprovided (1% oppose both).

Parents, Kids, and AIDS

The theme for this year’s World AIDS Day, held on Monday, December 1, was”Give Children Hope in a World with AIDS.” According to the Kaiser FamilyFoundation survey, parents remain a worried group about AIDS, especiallywhen it comes to their children: 52 percent of those with children 21 andyounger say they are “very concerned” about their son or daughter becominginfected with HIV, and an additional 21 percent say they are “somewhatconcerned.” Close to half — 46 percent say their concerns have heightenedfrom just a few years ago. Most parents — 57 percent — say they needmore information about what to discuss with their children about AIDS.

When it comes to other AIDS prevention efforts, parents are among the mostsupportive: 47 percent favor providing condoms in high schools; 64 percentsay more references to condoms should be included in movies and televisionshows that deal with sexual relationships; and 66 percent think condom adsshould be aired on network television. In total, 97 percent think someinformation about AIDS and how it is spread should be provided to teens inhigh school.

Methodology

The Kaiser Family Foundation’s 1997 National Survey of Americans onAIDS/HIV is a random-sample survey of 1205 adults, 18 years and older. Itwas designed by staff at the Foundation and conducted by telephone byPrinceton Survey Research Associates (PSRA) between September 17 andOctober 19, 1997. Additional questions were asked as part of a nationalomnibus telephone survey of 1,009 adults conducted November 20-23, 1997.The margin of sampling error for both national samples are plus or minus 3percent. The margin of sampling error may be higher for some of thesub-sets in this analysis.

The Kaiser Family Foundation, based in Menlo Park, California, is anindependent national health care philanthropy and not associated withKaiser Permanente or Kaiser Industries. The Foundation’s work is focusedon four main areas: health policy, reproductive health, and HIV in theUnited States, and health and development in South Africa.

Copies of the questionnaire and top line data for the findings reported inthis release available by calling the Kaiser Family Foundation’spublication request line at 1-800-656-4533 (Ask for #1346). Also availableis the top line data from the Kaiser Family Foundation’s 1995 NationalSurvey of Americans on AIDS/HIV (Ask for #1118).

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1997 National Survey Of Americans on AIDS/HIV:Press Release Survey ChartPack Library Index

This report describes the new legal and policy framework within which the shift of state Medicaid programs from fee-for-service to managed care will take place over the next few years.

A national random-sample survey of 1205 adults, 18 years and older, that examines Americans views on AIDS. The findings show that although Americans see growing progress in the fight against the disease, AIDS is still viewed as an urgent health problem for the nation and spending on prevention, research, and treatment is strongly supported. The survey also looks at public support for AIDS prevention efforts, including condoms in schools and needle exchange. The survey was designed by staff at the Foundation and conducted by telephone by Princeton Survey Research Associates (PSRA) between September 17 and October 19, 1997. Additional questions, asked as part of a national omnibus telephone survey of 1,009 adults conducted November 20-23, 1997, are also reported on in the release.

1997 Kaiser Family Foundation Survey of Americans on Emergency Contraception

Conducted for the Henry J. Kaiser Family Foundation By Princeton Survey Research Associates

Topline For Men

May 13-May 26, 1997

Introduction:

Hello, my name is _____, and I’m calling from Princeton Survey Research of Princeton, New Jersey. We are conducting a confidential national opinion survey about some important health issues.

N = 300 men, age 18-44 Margin of error: plus or minus 5 percent * Men were asked a subset of the women’s questions.

1. My first question is, In general, how would you describe your own health? Is it excellent, good, only fair, or poor?

35Excellent55Good7Only fair3Poor*Don’t know0Refused100 2. These next few questions are about your own sexual behavior. Please keep in mind that all of your answers are confidential. First, have you had sexual intercourse within the last six months?

82Yes17No0Gay (Vol.)*Don’t know1Refused100 3. Have you ever had sexual intercourse?

Based on those who have not had sexual intercourse within the last six months (n=55)

76Yes24No0Gay (Vol.)0Don’t know0Refused100 4. Do you have a partner who is currently pregnant or trying to get pregnant?

Based on those who have had sexual intercourse within the last six months (n=245)

15Yes85No*Gay (Vol.)0Don’t know*Refused100 5. Have you or your partner, if you have one, been sterilized, or have any condition that makes it impossible for your partner to ever get pregnant? (Birth Control Devices Not Included)

Based on those who have had sexual intercourse within the last six months and whose partners are not pregnant or trying to get pregnant (n=210)

25Yes73No0Gay (Vol.)1Don’t know1Refused100 6. When you have sexual intercourse, how often do you and your partner use birth control or do anything else to try to prevent pregnancy? Would you say … (Read)

Based on those who have had sexual intercourse within the last six months, whose partners are not pregnant or trying to get pregnant, and who are able to conceive (n=166)

12Never8Only sometimes,19Most of the time, or59All of the time use birth control?0Don’t know (Do Not Read)2Refused (Do Not Read)100 7. I am going to read a list of birth control methods. We are interested in which of these methods you use most often. Please tell me which of these you or your most recent partner use by saying “yes” when I mention it. You can say “yes” to more than one type of birth control if you currently use more than one method at the same time. Here’s the list. (Read 1 – 10 In Order. Record Up To Three Mentions. If Respondent Has More Than One Current Partner, Ask About His Main Partner.)

Based on those who have had sexual intercourse within the last six months, whose partners are not pregnant or trying to get pregnant, who are able to conceive, and who use birth control at least sometimes (n=143)

71Condoms60Birth control pills4A diaphragm or cervical cap1An IUD, or intrauterine device7Depo-Provera, or contraceptive shots1Norplant, or contraceptive implants9Spermicides, or foams and suppositories with spermicides10The rhythm method, or having sex only during the safe time of the month18Withdrawal or “pulling out”2Refused (Do Not Read)1Some other method? (Specify)20Don’t know0Refused 8. If a woman has just had sex and thinks she might become pregnant, is there anything she can do in the next few days to prevent the pregnancy? (Accept Multiple “Yes” Responses)

21Yes, there is something (Unspecified)*Yes, there is something — RU-486/French abortion pill (Vol.)2Yes, there is something — birth control pills (Vol.)3Yes, there is something — morning-after pills (Vol.)1Yes, there is something — emergency contraceptive pills (Vol.)1Yes, there is something — other (Specify)34No, there is not anything1Too late to prevent pregnancy (Vol.)38Not sure/Don’t know*Refused9. What could she do in the next few days to prevent the pregnancy? (Do Not Read. Record Only One Response.)

Based on respondents who said yes to Q8 but did not specify a method (n=60)

19Take morning-after pills2Take emergency contraceptive pills15Take birth control pills11Take RU-486/French abortion pill0Insert an IUD6Get an abortion15Other32Not sure/Don’t know (Do Not Probe)0Refused100 10. Have you ever heard of emergency contraceptive pills? (Accept Multiple “Yes” Responses)

Based on those who did not mention emergency contraceptive pills for Q8 or Q9 (n=298)

19Yes, have heard of it (Unspecified)2Yes, is RU-486 (Vol.)2Yes, is birth control pills (Vol.)1Yes, it is the same thing as morning-after pills (Vol.)*Yes, is other (Specify)76No, have not heard of it*Not sure/Don’t know0Refused

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1997 Kaiser Family Foundation Survey of Americans on Emergency Contraception Survey Part Four Part One Part Two Part Three Part Five Press Release Report

This Fact Sheet summarizes eligibility, benefits and cost-sharing, and financing rules of the State Children’s Health Insurance Program as well as other child-related Medicaid provisions from the Balanced Budget Act of 1997.

• Fact Sheet
• Fact Sheet

New Survey Offers Insight Into Experiences of Managed Care Consumers

Majority of Sacramento Managed Care Consumers Report No Difficulty with Their Plan, But Over a Quarter Had Problems

For Immediate Release:Wednesday, November 19, 1997

Contacts:Heather Balas,Kaiser Family Foundation, (650) 854-9400

Katie Salvas,Sierra Health Foundation, (916) 922-4755

Magdalena Beltran-del Omo,The California Wellness Foundation, (818) 589-6600

Lauren Schaefer,Health Rights Hotline, (916) 551-2147

Medicaid Beneficiaries Report Highest Rate of Difficulty

Sacramento, California — Much national attention is currently focused on managed care issues, with a Presidential advisory commission considering a “bill of rights” for health care consumers and California policy-makers awaiting recommendations from a managed care task force. A new Survey of Consumer Experiences With Managed Care conducted in the Sacramento, California area – a region with one of the highest rates of managed care enrollment in the country – may help inform state and national debates about managed care regulation, offering new insight into difficulties people have with health plans and how they go about resolving them.

The survey finds that the majority of Sacramento managed care consumers cited no difficulties with their health insurance in the previous year, but that more than a quarter (27%) reported some problems. Of those managed care consumers experiencing problems, the most commonly reported difficulties included:

• Delay or denial of care or payment (42%), such as disputes over coverage, delays or denials in authorization for care, and disagreement over the scope of benefits covered by the plan.
• Limited access to physicians (32%), such as difficulty getting an appointment or limited access to specialists.
• Concerns about quality of care (11%), including perceived problems with inappropriate or inadequate treatment, facilities, or diagnoses, or with obtaining test results.

The report found that consumers did not appear to know of the availability of existing resources, particularly from state agencies. Of the 1,014 managed care consumers in the survey who reported difficulties – of whom many had major problems unresolved after over two months – only four individuals reported calling either the California Departments of Corporations or Insurance for assistance or to complain. A total of 2% of consumers with difficulties contacted any state or local agency.

Thirty-eight percent contacted their health plan and 37% contacted their doctor, while a quarter took no action. (32% used two or more resources.) Of those who took no action, 26% didn’t think it would do any good, 24% thought it was not worth the time, and 14% did not know what to do.

About the same number of consumers resolved their difficulty relatively quickly as those whose problem took two months or longer to settle. Over a third of consumers (36%) resolved their difficulty in less than a month, while 13% achieved resolution in one to two months. Another 13% took two months or longer to resolve their problem, and 35% had not resolved their problem at the time of the interviews. (Almost three-fourths of unresolved problems were at least two months old.)

The survey was conducted to provide baseline information for a multi-year evaluation of a pilot consumer assistance program, the Health Rights Hotline, funded by the Kaiser Family Foundation, Sierra Health Foundation, and The California Wellness Foundation with initial support of $1.6 million for the first two years of the project. The program is the largest test of an independent assistance program for consumers in managed care in the nation. Over the next three years, additional data on cases handled by the Health Rights Hotline and a full-scale evaluation of its effectiveness will be conducted.

Len McCandliss, president of Sierra Health Foundation, said, “With over 90% of privately insured Sacramentans enrolled in managed care, the community has long been considered an HMO ‘laboratory.’ We believe that very soon practically every community in the nation will resemble Sacramento in terms of managed care prevalence.”

Medicaid and Medicare

Low-income people enrolled in managed care through Medicaid (called Medi-Cal in California) experienced the highest rate of difficulty (42%). People insured through Medicare managed care (who account for 45% of all elderly and disabled Medicare beneficiaries in Sacramento county) experienced the lowest rate of difficulty (17%).

Reported Consequences of Difficulties

To provide information about the severity of the difficulties consumers experienced, the survey asked people several questions about the consequences they attributed to their difficulties (as opposed to the consequences of any underlying health condition). Of the 27% of people who reported a difficulty with their health plans:

• 30% attributed a personal financial loss to the difficulty, including 12% who reported a financial loss of greater than $200.
• 31% attributed time lost from work, school, or other major activity to the difficulty, including 16% who reported losing two days or more.
• About one in ten (11%) reported experiencing a worsening of a health condition or developing a new condition as a result of the difficulty.

“Quality health care has to work for patients,” said Gary Yates, president and CEO of The California Wellness Foundation. “These results show that while the majority of consumers reported no problems with their care, we must strive to make the system work for everyone. We see that even consumers with long-term continuity and familiarity with managed care have experienced difficulties.”

Consumer services

Most consumers said they would have used the services of an independent group to resolve their difficulty, had the option been available. The most popular requests were: a mechanism for lodging a complaint to prevent future problems for others (66%); information about consumer rights (62%); referral to other resources (60%); and assistance in understanding their health plan’s policies and procedures (54%).

“At a time when people across the country are complaining about managed care, this project is trying to find solutions,” said Drew Altman, president of the Kaiser Family Foundation, referring to the Health Rights Hotline. “It is the leading community-based effort in the nation giving people concrete help for their health plan problems.”

Methodology

The Survey of Consumer Experiences in Managed Care was developed and analyzed by the Lewin Group of Fairfax, Virginia. The survey was administered by Survey Methods Group, Inc., of San Francisco, California. Screening interviews were conducted in June and August, 1997 with representatives from 4,419 Sacramento households contacted at random by phone. Of these 3,768 were managed care consumers, upon whom survey results were based. For Medicare and Medicaid beneficiaries, managed care enrolles were identified based on the names of their plans. Since traditional fee-for-service coverage is virtually non-existent in the Sacramento area, all privately insured people were categorized as being in managed care. The margin of error is +/- 3% for most questions. These findings are preliminary; a final report will be released at a later date.

Additional information, including a complete copy of this preliminary report, can be obtained by calling the Kaiser Family Foundation’s toll-free publication request line at 800-656-4533 and requesting document #1344.

The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. Sierra Health Foundation, located in Sacramento, supports health and health-related activities in Northern California. Based in Woodland Hills, The California Wellness Foundation’s mission is to improve the health and wellness of the people of California.

Health Rights Hotline

The Survey of Consumer Experiences in Managed Care was conducted as part of a broader program to support and evaluate the Health Rights Hotline, a free, independent source of information and assistance for health care consumers in California’s El Dorado, Placer, Sacramento, and Yolo counties. The Health Rights Hotline, which began providing services in June 1997, is the first program of its kind in the nation to assist consumers regardless of the type of health plan they have and regardless who pays for care – whether an employer, individual, Medicare, Medi-Cal, or CHAMPUS. The Health Rights Hotline – a program of the Center for Health Care Rights in Los Angeles – is funded for a four-year pilot period to:

• improve consumers’ access to health care by educating and assisting them to be responsible, informed, and empowered;
• improve the health care system in the four-county Sacramento area by collecting and analyzing information on the types of issues consumers face, and providing feedback to health plans, health care providers, purchasers, regulators, and the public regarding consumers’ experiences; and
• test this program as a model for other consumer-oriented programs in California and the nation.

“The survey results point to the role that independent consumer assistance organizations like the Health Rights Hotline can play in helping consumers navigate an often confusing system,” noted Peter Lee, Health Rights Hotline Project Director.

The Health Rights Hotline is open 9 a.m. to 6 p.m., and can be reached toll-free by consumers in the four-county service area at (888) 354-4474 or (916) 551-2100.