The International Association of Physicians in AIDS Care (IAPAC), which represents approximately 4,000 HIV-treating clinicians in the United States [out of a global membership of over 13,000], today released results of a nationwide survey indicating that while supportive of ongoing health care reform efforts, a significant percentage of its U.S. membership is concerned about issues ranging from increased patient caseloads to the possibility of rationing HIV care.
The survey results come on the heels of President Barack Obama's recent national address underscoring the importance of health care reform. With mounting pressure from the White House, Congress is currently working to pass health care reform legislation that would create a more affordable and efficiently run health care system, as well as expanding coverage to the estimated 45-50 million Americans that are either uninsured or underinsured, among them people living with HIV/AIDS.
"Our clinician-members recognize HIV/AIDS is but one of the myriad health challenges posed in reforming the U.S. health care system so that it delivers care at a cost that is affordable, but in a manner that does not sacrifice quality or jeopardize access," said Jose M. Zuniga, Ph.D., IAPAC's President/CEO. "Their concerns, however, must be addressed in the health care reform legislation eventually enacted because the health and well-being of over 1 million Americans living with HIV/AIDS and those as yet undiagnosed are at stake."
HIV-Specific Views Related to Health Care Reform
Fifty-seven percent of respondents favored the inclusion of HIV-specific provisions in health care reform legislation citing the special needs of people living with HIV/AIDS. Forty-three percent disagreed, favoring an approach that would mainstream HIV and thus avoid "HIV exceptionalism."
Among those who disagree with the inclusion of HIV-specific provisions is Neal Rzepkowski, MD, an HIV-treating physician from Cassadaga, New York, who himself is HIV-positive. "HIV-specific implies 'special status,' 'special interest,' and by the same token, discrimination, or a tiered medical system," Rzepkowski wrote in response to the survey. "This type of 'special treatment' has backfired and hindered good HIV care."
When asked how health care reform would affect their practices, clinician-respondents claimed it would expand the numbers of HIV-positive patients they treat (23%), increase their paperwork (23%), decrease their reimbursement (13%), and require them to ration HIV care (10%). Positive affects included the integration of HIV care into primary care (17%), stabilizing their practices' finances (7%), and lowering drug and administrative costs (7%).
Health care reform "could potentially be better for those without insurance," wrote a Connecticut-based HIV-treating nurse who requested anonymity, "but personally, the elimination of choice for those insured and the possibility of the government telling those of us providing or receiving care what can and cannot be done is not right." For Barbara Yusko, RN, an HIV-treating nurse from Albany, New York, health care reform poses another challenge: "The health care environment is a busy one. Too many changes too quickly can create harm. I am opposed to sudden drastic changes that cannot be accommodated by an already overburdened system."
Still, for HIV-treating physicians such as J. Yusuf Erskine, DO, from Sebastapol, California, achieving health care reform "would deter the erosion of health care, and stabilize the health care financial situation so that I can afford to continue to provide HIV care." This sentiment is shared by Bary Siegel, MD, an HIV-treating physician from Sacramento, California, who added that with health care reform, "this would be the first time that all of my patients might be able to actually afford all of their medications, needed lab work, and follow-up care they need to manage their acute and chronic diseases."
Survey respondents were also asked to make specific recommendations related to health care reform legislation. Survey respondents prioritized incorporating prevention into HIV clinical management (21%), allowing for proper HIV clinician reimbursement (18%), prohibiting discrimination based upon HIV diagnosis (pre-existing condition) (14%), guaranteeing antiretroviral drug access (14%), and enhancing HIV treatment adherence (14%), among a series of other recommendations.
Views on Health Care Reform Overall
Sixty-three percent of respondents indicated they are "very informed" about current efforts to reform the U.S. health care system, while an equal percent (18%) said they are either "somewhat informed" or "somewhat uninformed."
When asked about the level of urgency to enact health care reform, 36% consider the matter "extremely urgent (reform legislation is needed immediately)," 31.8% "urgent (reform legislation is needed as soon as possible in 2009)," and 23% "somewhat urgent (reform is needed but can await further debate)." Seven percent said health care reform was "not urgent (reform legislation can wait, there are more pressing priorities)," and 2% were undecided.
With respect to a public health insurance option, the majority (73%) supported the option (which garnered more support from nurses than physicians, 83% to 72%, respectively), and 25% rejected the option. Two percent were undecided.
Among the specific positive factors that respondents said would influence their support of health care reform were: extending health care coverage (21%), eliminating pre-existing condition barriers to health care (7%), a focus on prevention (2%), and improved quality of care (2%). Sixty-five percent cited all four of these factors as influencing their decision-making on the matter. Two percent said none of these factors had an influence.
Three specific negative factors were cited by respondents as influencing their support of health care reform, including overall cost (15%), detrimental affect on medical practices (15%), and the possibility of rationing care (13%). Twenty-eight percent said these three factors influenced their support for health care reform, while 30% said none of these reasons bore any significant influence.
About the Survey
Potential respondents were invited to participate in the 10-question online survey via two IAPAC email invitations transmitted July 22, 2009, and July 24, 2009, to HIV-treating clinicians in the United States. Of the 400 respondents, 70% were physicians, 23% were nurses, 5% were pharmacists, and 2% were physician-assistants. Among physician-respondents, 74% reported that less than 50% of their patients were uninsured, and 26% reported that more than 50% were uninsured. Following is a geographic breakdown of respondents' home states (plus the District of Columbia): New York (24%); California, Illinois, and Massachusetts (10% each); Texas (8%); Maryland (7%); Louisiana (6%); Arizona, District of Columbia, Georgia, and Pennsylvania (4% each); Florida and New Jersey (3%); Arkansas, North Carolina, and Tennessee (1% each).
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