JANUARY 2007 HOT TOPICS

Disparities in Care for HIV Patients

Congress has played an ongoing, instrumental role in providing funding for the treatment of and research to prevent HIV/AIDS. HIV treatments introduced in the 1990s have extended the lives of HIV-positive people and have improved their quality of life. For example, most HIV-positive people benefit from receiving a cocktail of drugs known as highly active antiretroviral therapy (HAART), along with needed support services. However, this treatment can benefit only patients with access to it. RAND's HIV Costs and Services Utilization Study (HCSUS) is the first comprehensive U.S. survey of health care use among a nationally representative sample of HIV-positive people currently undergoing treatment for HIV. As part of HCSUS, a team of analysts examined access to HIV treatment and services as well as disparities in access across different socioeconomic groups. The results identified six factors that influenced access among HIV-positive people. Specifically, they were less likely to receive HAART when it was initially introduced if (1) they were African American or Hispanic; (2) lacked health insurance or had public insurance; (3) were exposed to HIV through intravenous drug use; (4) had less than a college education; (5) faced competing demands on their time, attention, or resources; or (6) received their care from non-specialists. Individuals who need other supportive services, such as substance abuse treatment, were also less likely to receive HAART. In addition, some groups of HIV-positive patients, including African-American or Hispanic persons, were less likely to receive other needed care, such as prophylactic antibiotics and routine preventive care. Disparities in access to HAART among various groups are narrowing. However, the study recommended that an increased use of case management to help HIV-positive patients coordinate their care would help eliminate those disparities.

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Modest Amount of Public Funding Goes to Health Care for Undocumented Immigrants

Part of the debate over U.S. immigration policy in Congress centers on the cost of health care for immigrants, especially for the undocumented. Although advocates on both sides dispute the extent to which immigrants burden the health care system, to date there has been little evidence about the extent to which immigrants use publicly funded health services. A study by demographer James Smith and health economists Dana Goldman and Neeraj Sood has provided some of the first empirical data on health care use and costs among immigrants. Working within Los Angeles County, which has the largest concentration of immigrants in the nation, researchers analyzed information from the Los Angeles Family Neighborhood Survey, which interviewed non-elderly participants in 2000 and 2001 about their health, medical insurance, the type and amount of care they used, and their immigration status. After deriving estimates for the county, researchers used statistical techniques to extrapolate the estimates to the national level. The study found that foreign-born residents spend less on health care than do native-born Americans. Of the $430 billion in national medical spending in 2000, native-born residents accounted for 87 percent of the population but for 91.5 percent of the spending. Foreign-born residents, including undocumented immigrants, accounted for 13 percent of the population but only 8.5 percent of spending. The study also found that relatively modest amounts of government funds are spent for health care on undocumented immigrants: about $1.1 billion annually. In contrast, a total of $88 billion in government funds were spent on health care for all non-elderly adults in 2000. The differences in spending were driven primarily by immigrants' lower use of medical services and relatively better health.

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Solitary Use of Alcohol, Cigarettes, or Marijuana Puts Youths at Higher Risk for Problems as Adults

Prior research has shown that adolescents who use alcohol, cigarettes, or marijuana increase their risk of health problems in later life. A recent RAND study has found that teens who engage in such behavior while alone are at even greater risk than their peers who use substances only in social settings. The study involved long-term tracking of 6,000 students from California and Oregon who were enrolled in Project ALERT, a drug use prevention program developed by RAND for middle school children. Participants were interviewed during middle school and high school and again at age 23. Results showed that solitary users of alcohol, cigarettes, and marijuana are less likely to graduate from college, more likely to have substance use problems as young adults, and tend to report poorer physical health by age 23 than their peers who were social substance users. In addition, solitary users reported higher frequency and quantity of substance use than their peers. The study was the first of its kind to track solitary teen substance users and suggests the importance of better understanding and addressing the needs of this high-risk group.

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