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Health - Summary of Issues
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Global HIV/AIDS Pandemic
Sub-Saharan Africa has been more severely affected by AIDS than any other world region. In 2006, the United Nations reports, there were in the range of 24.7 million HIV-positive persons in Africa, which has just over 11% of the world's population but about 63% of the worldwide total of infected persons. The adult rate of infection in Africa in late 2005 was 6.1%, compared with 1% worldwide, but had dropped to 5.9% by late 2006. Nine southern African countries have infection rates above 10%. Ten African countries with the largest infected populations account for over 50% of infected adults worldwide. By late 2005, an estimated 28.9 million or more Africans had died of AIDS since 1982, including 2.1 million in 2006. These comprised about 72% of global AIDS death in 2006. AIDS has surpassed malaria as the leading cause of death in Africa, and it kills many more Africans than does war. In Africa, about 61% of infected adults are women.
Experts attribute the severity of Africa's AIDS epidemic to Africa's poverty, women's frequent lack of empowerment, high rates of male worker migration, and other factors. Many national health systems are ill-equipped for prevention, diagnosis, and treatment. AIDS causes severe social and economic consequences, such as declines in economic productivity due to sharp life expectancy reductions, the loss of skilled workers, and other factors. There are an estimated 12.3 million African AIDS orphans. They face increased risks of malnutrition and often lack access to education. AIDS is blamed for declines in farm production in some countries and is seen as a major contributor to hunger and famine.
Private organizations and the governments of donor and African nations have responded by supporting diverse efforts to prevent and reduce the rate of new infections and by trying to abate damage done by AIDS to families, societies, and economies. The adequacy of this response is much debated. An estimated 810,000 Africa AIDS patients were being treated with antiretroviral drugs in late-2005, up from 150,000 in mid-2004. An estimated total of 4.7 million persons were in need of such therapy. U.S. and other initiatives are expected to sharply expand access to treatment in the near future. Advocates see this goal as an affordable means of reducing the impact of the pandemic. Skeptics question whether drugs can be made widely accessible without costly health infrastructure improvements.
S. 805 introduced by Senator Durbin (D-IL), the African Health Capacity Investment Act of 2007, would authorize the President to provide assistance, including through international or nongovernmental organizations, for programs to improve human health care capacity in sub-Saharan Africa. It would direct the President to develop and transmit to Congress a strategy for coordinating, implementing, and monitoring assistance programs for human health care capacity in sub-Saharan Africa.
Disparities in Health Care for African Americans and Latinos
In the United States today, African Americans suffer from chronic diseases at a much higher rate than their white counterparts. Infant mortality rates are twice as high for African Americans than white Americans. The prevalence of diabetes, survival rate for cancer, HIV infection – all are in stark contrast to whites in this country. There are several explanations for this unfortunate reality. Latinos are the most likely to lack health insurance, with African Americans close behind. In addition, African Americans and Latinos are more likely to experience food insecurity, less likely to find affordable housing, more likely to suffer the effects of environmental pollution, and less likely to be educated and have access to reliable health information.
Uninsured Americans
Despite the multiple private and public sources of health insurance, millions of Americans are without health coverage. In 2005, more than 46 million people were without health insurance coverage for the entire year. For the vast majority of the uninsured, they lack coverage because they cannot access coverage (e.g., their employer does not offer health insurance as an employment benefit) or they cannot afford it.
Uninsurance is characterized as a problem of the under-65 population, given the near-universal coverage of seniors through Medicare. The nonelderly uninsured population differs from the insured population on a number of key demographic factors. One of the most striking characteristics of persons who lack coverage is that a significant proportion are in low-income families. For instance, among all uninsured persons under age 65, more than half were in poor or near poor families in 2005. Moreover, among nonelderly persons who are poor, 34% lacked health coverage. This contrasts with nonelderly individuals with moderate or high incomes. For these persons, only 12% had no health insurance.
A defining characteristic of the nonelderly uninsured population is that over 80% are persons with ties to the paid labor force, or dependents of such persons. Even more surprising is that nearly 56% of the nonelderly uninsured were workers with full-time, full-year status, or the dependents of those workers. While such findings may be counter-intuitive, there are multiple reasons why employed persons and their families may lack health coverage. For example, a worker may be offered health insurance by his/her employer, but declines it because he/she thinks it is too expensive. An employee may work for a small firm which is less likely than a large firm to offer health insurance as a benefit. A low-wage employee, even working full time, is less likely to be offered health insurance at work and less likely to be able to afford it than higher-wage workers in the same firm. Finally, a healthy worker may be willing to take on the risk of being uninsured and choose not to purchase insurance at all. So despite the dominance of employer-sponsored health insurance, the dynamics of work, insurance risk, and financial resources intersect to impede the coverage of all workers and their families.
The problem of the uninsured is a paramount health care concern to many policymakers and legislators. One of the topics of ongoing debate is the overall number of uninsured and the direction of the uninsurance rate. These issues have generated some controversy over dueling analyses which show slightly different (and sometimes, moderately different) findings. But despite the forceful discussions regarding trends in uninsurance, the year-to-year changes in the uninsurance rate actually are small. For example, from 1987 to 2005, the change in the uninsurance rate from year to year has been less than 1%. Nonetheless, tens of millions of Americans were without coverage during that time period. Such circumstances beg the questions: why does pervasive uninsurance persist (even during the robust economy of the mid-1990s), and what are the implications for legislation and public policies to expand health coverage?
In 2005, 46.6 million people in the United States had no health insurance -- an increase of approximately 1.3 million people, compared to 2004. The percentage of people covered by job-based coverage has dropped annually since 2000. Whether the uninsurance rate rose in response depended on how much of the decrease in job-based coverage was offset by increases in public coverage. Unlike some previous years, public coverage rates did not increase significantly between 2004 and 2005, and the uninsurance rate rose significantly, to 15.9% in 2005 from 15.6% in 2004. Mostly because of Medicare, 1% of those 65 and older were uninsured in 2005; among the nonelderly, 17.9% were uninsured. More than half of the nonelderly uninsured were full-time, full-year workers or their family. Young adults were more likely to be uninsured than any other age group. More than one of three of those who claimed Hispanic ethnicity were uninsured, the highest of the racial/ethnic categories. In March of 2007, the Census Bureau reported that it had lowered its estimate of the number of uninsured from 15.9% to 15.3% of the population, or to about 44.8 million people.
To address many of these issues, Congressman John Conyers (D-MI) has introduced HR 676, the United States National Health Insurance Act which is currently being considered by the House Committees on Energy and Commerce, Ways and Means and Natural Resources. The bill establishes free health insurance for all Americans.
Prescription Drug Benefit in Medicare
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA, P.L. 108-173) established a new voluntary prescription drug benefit under a new Part D, effective January 1, 2006. Medicare beneficiaries are able to purchase drug coverage through private plans offered by prescription drug plan (PDP) sponsors or managed care organizations offering Medicare Advantage prescription drug (MA-PD) plans. These private plans bear some of the financial risk for drug costs. Federal subsidies covering the bulk of the risk are provided to encourage participation in these private plans.
MMA required PDP sponsors and MA-PDP plans to offer a minimum set of benefits, referred to as "qualified coverage." "Qualified coverage" is defined as either "standard prescription drug coverage" or "alternative prescription drug coverage" with actuarially equivalent benefits (i.e., having at least equivalent dollar value). In both cases, access must be provided to negotiated prices for drugs. Beneficiaries are required to pay a monthly premium for program coverage as well as certain cost-sharing charges when they obtain benefits.
A major focus of MMA is the enhanced coverage provided to low-income individuals who enroll in Part D. Low-income enrollees, including persons (known as "dual eligibles") who previously received drug benefits under Medicaid, have their prescription drug costs paid under the new Part D. Persons with incomes below 150% of poverty (and assets below specified levels) have assistance with some portion of the premium and cost-sharing charges. Persons with the lowest incomes have the highest level of assistance. MMA represents the first time that the level of Medicare benefits is tied to income.
Implementation of the new program, particularly for the low-income population, proved challenging. The main concern now is the fact that, despite extensive federal, state, and local outreach efforts, not all persons potentially eligible for a low-income subsidy (LIS) have enrolled in the program. As of January 2007, the Centers for Medicare and Medicaid Services (CMS) estimated that 3.3 million persons eligible for LIS had neither signed up for Part D nor had coverage through another source. It is not immediately clear why some individuals have failed to enroll, though several factors, including a lack of program awareness, the nature of the application process itself, and the assets limits presumably each play a role. It is hoped that the continued waiver of both the enrollment deadline and the delayed enrollment penalty for the low-income population in 2007 will encourage more persons to enroll during the remainder of the year.
Reproductive Rights
In 1973, the U.S. Supreme Court held that the U.S. Constitution protects a woman's decision whether to terminate her pregnancy, Roe v. Wade, and that a state may not unduly burden the exercise of that fundamental right by regulations that prohibit or substantially limit access to the means of effectuating that decision, Doe v. Bolton. Rather than settle the issue, the Court's rulings have kindled heated debate and precipitated a variety of governmental actions at the national, state, and local levels designed either to nullify the rulings or limit their effect. These governmental regulations have, in turn, spawned further litigation in which resulting judicial refinements in the law have been no more successful in dampening the controversy.
In recent years, the rights enumerated in Roe have been redefined by decisions such as Webster v. Reproductive Health Services, which gave greater leeway to the States to restrict abortion, and Rust v. Sullivan, which narrowed the scope of permissible abortion-related activities that are linked to federal funding. The decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, which established the "undue burden" standard for determining whether abortion restrictions are permissible, gave Congress additional impetus to move on statutory responses to the abortion issue, such as the Freedom of Choice Act.
In each Congress since 1973, constitutional amendments to prohibit abortion have been introduced. These measures have been considered in committee, but none has been passed by either the House or the Senate.
Legislation to prohibit a specific abortion procedure, the so-called "partial-birth" abortion procedure, was passed in the 108th Congress. The Partial-Birth Abortion Ban Act appears to be one of the only examples of Congress restricting the performance of a medical procedure. In the 109th Congress, H.R. 748, the Child Interstate Abortion Notification Act, incorporated the language of the Child Custody Protection Act, but also imposed a 24-hour parental notification requirement for abortions occurring outside a minor's state of residence. The Child Custody Protection Act was also introduced in the Senate as S. 403.
Since Roe, Congress has attached abortion funding restrictions to numerous appropriations measures. The greatest focus has been on restricting Medicaid abortions under the annual appropriations for the Department of Health and Human Services. This series of restrictions is popularly known as the "Hyde Amendments." Restrictions on the use of appropriated funds affect numerous federal entities, including the Department of Justice, where federal funds may not be used to perform abortions in the federal prison system except in cases of rape or endangerment of the mother. Such restrictions also impact the District of Columbia, where both federal and local funds may not be used to perform abortions except in cases of rape, incest or endangerment of the mother, and affect international organizations like the United Nations Population Fund, which receives funds through the annual Foreign Operations appropriations measure.
On November 6, 2006, the U.S. Supreme Court heard oral arguments in Gonzales v. Carhart and Gonzales v. Planned Parenthood, two cases involving the constitutionality of the Partial-Birth Abortion Ban Act. Carhart and Gonzales provide the Court with the opportunity to evaluate all of the legal theories asserted against the validity of the act. Apart from the usual interest in abortion cases before the Court, the two cases have attracted additional attention because of Justice O'Connor's retirement and the appointment of Justice Alito.
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