America Living With AIDS

AM E R ICA Living Wit

vention will continue to be missed,
and individuals whose HIV disease
requires acute care will turn increasingly to the already overburdened
public hospital system.*
THE PARTICULAR CHALLENGES
OF HIV DISEASE
Original estimates of the costs of caring for people with AIDS were quite
high. The first and most widely cited
estimate, made in the mid-1980s, was
$147,000 for each patient for the
direct medical costs of AIDS care from
AIDS diagnosis to death. This figure
has been revised substantially downward in several subsequent studies, as
ambulatory care has supplanted
expensive hospitalizations and as costs
for many of the drugs needed to treat
manifestations of AIDS have declined.
Although caring for people with HIV
disease is still quite expensive, in the
aggregate, costs for HIV care presently
and in the foreseeable future probably
total no more than 2 percent of total
U.S. health expenditures. In this context, therefore, it is probably more
accurate to think of HIV disease as
posing "financing," rather than "cost"
problems.
The financing problems are severe.
They arise in part because much of the
SMaterial in this chapter is drawn from a technical
report prepared for the National Commission on
AIDS (Davis et al., 1991). All cost estimates and
projected savings cited in this chapter are based on
information submitted by consultants from The
Johns Hopkins University School of Hygiene and
Public Health and The Actuarial Research Corporation to the National Commission on AIDS. Further information regarding these calculations is
available from the Commission.

need for HIV care is concentrated in
particular cities and among people
whose care is not covered by private
insurers. Moreover, both private and
public third-party payers often fail to
cover the full range of services needed.
Exclusion from private coverage has
resulted from a combination of factors
such as the clinical nature of HIV disease, the demographic characteristics
of people with AIDS, and the employer-centered nature of health insurance.
HIV disease is disproportionately represented among the poor and people
of color, who are at greater risk of
being uninsured. Even those with HIV
disease who have private health insurance often find coverage wanting.
Employment-based private health
insurance frequently fails to provide
comprehensive coverage of preventive
care, outpatient care, long-term care,
and prescription drugs, all of which are
key elements of care for HIV disease.
A substantial portion of the costs of
caring for people with HIV disease is
being shifted from private insurers to
public-sector programs. State, county,
and municipal governments are experiencing enormous financial and political difficulties as they are pressed into
service as providers of last resort in
rendering uncompensated care. Those
who are impoverished by the disease
and "spend down" to meet eligibility
for public programs will find that
Medicaid coverage varies widely from
state to state, often leaving people with
HIV disease without effective entitle
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