146 OFFICE OF TECHNOLOGY ASSESSMENT the relationship between the level or type of individuals' health insurance coverage (or the lack of insurance coverage) and the individuals' health status, health outcomes for specific medical conditions, and the timing, nature, and location of health technologies used. The relationship between health insurance status (financial access), health outcomes, and use of health technology is critical because there are more than 31 million uninsured people (nonelderly) and perhaps 20 million to 60 million additional people with inadequate health insurance coverage in the United States (refers to those whose coverage does not protect them from health care expenses that equal or exceed 10 percent of their income). Insurance status and ability to pay for health care may not only affect the timing but even whether someone seeks care at all; and there is growing evidence that, in many instances, the eventual effects may be unnecessary deaths, more serious illness, and higher costs of health care. Thus, financial coverage (including public and private sources) affects not only access but also the quality and costs of health care. The goal of this OTA assessment is to provide an objective, rigorously critiqued analysis of the often complex, sometimes disputed, network of relationships between health insurance status (either lack of insurance coverage or having inadequate coverage) and negative health outcomes, poor health status, and the timing, location, and nature of health technologies and services delivered. It is the intent of OTA to provide Congress with a clear picture of these important relationships in the context of the U.S. health care system and its financing so that Congress can take them into account as it considers substantial changes in national health policy. Possible Impact on Legislation: H.R.144: A bill to reform the health care system by restoring the full tax deductibility of medical expenses; eliminating incentives for abusive litigation against hospitals, doctors, nurses, and health care providers; abolishing noneconomic damages in medical care liability actions; and redirecting punitive damages to community hospitals that care for the indigent. H.R.191: A bill to reform the United States health care delivery and financing system, to increase access to health care and affordable health insurance, to contain costs of health care in a manner that improves health care, and for other purposes. H.R.200: A bill to establish the framework for a health care system that will bring about universal access to affordable, quality health care by containing the growth in health care costs through a national health budget, managed competition, and other means, by improving access to and simplifying the administration of health insurance, by deterring and prosecuting health care fraud and abuse, by expanding benefits under the Medicare program, by expanding eligibility and increasing payment levels under the Medicaid program, and by making health insurance available to all children. H.R.834: A bill to provide for comprehensive health care access expansion and cost control through reform and simplification of private health care insurance and other means. H.R.1563: A bill to establish a comprehensive policy with respect to the provision of health care coverage and services to individuals with severe mental illnesses, and for other purposes. H.R.1691: A bill to provide universal access for all Americans to basic health care services and OFFICE OF TECHNOLOGY ASSESSMENT 147 H.R.1976: A bill to guarantee access to affordable health care coverage, to provide for equality with respect to the provision of service in rural areas, and for other purposes. H.R.2624: A bill to provide for comprehensive health care and health care cost containment. H.R.3075: A bill to promote greater equity in the delivery of health care services to American women through expanded research on women's health issues and through improved access to health care services, including preventive health services. H.R.3080: A bill to improve access to health insurance and contain health care costs, and for other purposes. S.18: A bill to provide improved access to health care, enhance informed individual choice regarding health care services, lower health care costs through the use of appropriate providers, improve the quality of health care, improve access to long-term care, and for other purposes. S.223: A bill to contain health care costs and increase access to affordable health care, and for other purposes. S.325: A bill to provide for comprehensive health care access expansion and cost control through reform and simplification of private health care insurance and other means. S.631: A bill to contain health care costs and increase access to affordable health care, and for other purposes. S.671: A bill to establish a comprehensive policy with respect to the provision of health care coverage and services to individuals with severe mental illnesses, and for other purposes. S.684: A bill to establish a national health plan, and for other purposes. S.728: A bill to provide for a comprehensive health care plan for all Americans, and for other purposes. S.1057: A bill to provide for the establishment of a nationwide, universal access health coverage program, and for other purposes. Project Director: Denise Dougherty Estimated publication date: Associated publications: "Does Health Insurance Make a Difference (BP), published September 1992. "Health Insurance: The Hawaiian Experience" (BP), published June 1993. "An Inconsistent Picture: A Compilation of Analyses of Economic Impacts of Competing Approaches to Health Care Reform by Experts and Stakeholders" published June 1993. "Benefit Design in Health Care Reform: Clinical Preventive Services" published September 1993. "Benefit Design in Health Care Reform: Mental Health Services and Substance Abuse Treatment" Winter 1993-94. "Benefit Design in Health Care Reform: Patient-Cost Sharing” (BP), published September 1993. "Benefit Design in Health Care Reform: General Policy Issues for Health Care Reform" Winter 1993-94. "Insurance Status of Health Care Utilization: Analysis of Four Data Bases and Cost Implications of Universal Coverage" (BP), Winter 1993-94. "Nonfinancial Barriers to Access in Health Care" (BP), Winter 1993-94. 148 OFFICE OF TECHNOLOGY ASSESSMENT Issues Related to AIDS Technologies The growing impact of AIDS on the Nation's health continues unabated, despite the optimism generated by the discovery and rapid approval of the first palliative drug against the AIDS virus and preliminary testing of possible vaccines. Preventing the spread of the AIDS virus is the primary strategy that is available, but is dependent on as yet unresolved differences on when testing for infection is appropriate and on how to alter the behavior of high-risk groups. The Nation's and even many other countries' social, economic, legal, and political systems have all been affected to some degree by the appearance of AIDS, and controversies over AIDS have even begun to affect international relations and comity among nations. Congress has responded with rapid increases in Federal funds for scientific and medical research and for research and services in preventive education, and has begun to grapple with the difficult issues involved in financing AIDS-related health care. These diverse issues warrant a different approach from the usual OTA assessment, so this project is oriented toward a monitoring and advisory capability within OTA to assist the increasing number of congressional committees that have AIDS on their agendas. Possible Impact on Legislation: H.CON.RES.155: A concurrent resolution expressing the sense of the Congress that a comprehensive program be developed and implemented by the federal government to deal with the Human Immuno-Deficiency Virus (HIV) and Acquired Immuno Deficiency Syndrome (AIDS). H.R.1022: A bill to establish a program to provide grants to improve the quality and availability of comprehensive education, health and social services for at-risk youth and their families, and for other purposes. H.R.1326: A bill to suspend temporarily the duty on rifabutin (dosage form). H.R.1538: A bill to amend the Public Health Service Act to promote activities for the prevention of additional cases of infection with the virus commonly known as HIV. H.R.2394: A bill to amend the Public Health Service Act to establish programs of research with respect to women and cases of infection with the human immunodeficiency virus. S.59: A bill to control the spread of AIDS, and for other purposes. S.312: A bill to suspend temporarily the duty on rifabutin (dosage form). S.1428: A bill to amend the Public Health Service Act to provide for programs regarding women and the human immunodeficiency virus, and for other purposes. Project Director: Michael Gluck Estimated publication date: Associated publications: "Do Insects Transmit AIDS?" (Staff Paper), published September 1987 "AIDS and Health Insurance: An OTA Survey" (Staff Paper), published February 1988 "How Effective Is AIDS Education?" (Staff Paper), published June 1988 "Impact of AIDS on the Northern California Region of Kaiser Permanente" (Staff Paper), published July 1988. "How Has Federal Research on AIDS/HIV Disease Contributed to Other Fields?" (Staff Paper), published April 1990. "The Effectiveness of Treating Drug Addiction and The Spread of AIDS Virus" (Staff Paper), published OFFICE OF TECHNOLOGY ASSESSMENT 149 "HIV in the Health Care Workplace” (BP), published October 1991. "The CDC's Case Definition of AIDS: Implications of Proposed Revisions" (BP), published June 1992. "Difficult-to-Reuse Needles for the Prevention of HIV Among Injecting Drug Users" (BP), published September 1992. "Issues Related to Development of AIDS Vaccine" (BP), Fall 1993. Requested by: Technology Assessment Board, with encouragement from the House Committee on Appropriations Policy Issues in the Prevention and Treatment of Osteoporosis It is estimated that 15 to 24 million Americans have osteoporosis a condition in which bone mass, density, and quality are diminished, causing a person's bones to be fragile and highly susceptible to fracture. Older people are far more likely than younger people to have osteoporosis, and women are more likely than men to have it, but 20 percent of people with osteoporosis are men. At least 1.3 million fractures attributable to osteoporosis occur each year. The cost of osteoporosis primarily the cost of medical and nursing care for people with hip fractures was estimated to be $6 to $10 billion in 1986. As the older population grows, so will the number of people who have it, the number of fractures, and the associated costs. Since there are no proven methods for revering osteoporosis, prevention is a primary objective. Many people already have osteoporosis by the time they are 65, so prevention generally must take place in younger age groups. Some methods of preventing osteoporosis are medical treatments, and other methods involve lifestyle changes, including diet and exercise. Anecdotal evidence suggests that some people are worried about osteoporosis but confused about how to prevent it. Osteoporosis often is not diagnosed in an individual until he or she has sustained a fracture, by which time, prevention may no longer be a possibility. The capacity of existing technologies to detect bone loss early in the disease process and the cost of the technologies are key questions in deciding what the role of screening should be in any initiative to prevent osteoporosis. Possible Impact on Legislation: H.R.694: A bill to amend the Public Health Service Act to expand and intensify programs of the National Institutes of Health with respect to research and related activities concerning osteoporosis, Paget's disease, and related bone disorders. H.R.954: A bill to amend title XVIII of the Social Security Act to provide for coverage of bone mass measurements for certain individuals under part B of the Medicare program. H.R.1844: A bill to amend the Public Health Service Act to expand and intensify programs of the National Institutes of Health with respect to research and related activities concerning osteoporosis and related bone disorders. H.R.3075: A bill to promote greater equity in the delivery of health care services to American women through expanded research on women's health issues and through improved access to health care services, including preventive health services. H.R.3203: A bill to amend title XVIII of the Social Security Act to provide for coverage of bone mass measurements and an annual screening mammography under part B of the Medicare program, 150 OFFICE OF TECHNOLOGY ASSESSMENT Project Director: Katie Maslow Estimated publication date: Fall 1993. Associated publication: "Cost Effectiveness of Screening for Osteoporosis" (BP), Winter 1993-94. "Hip Fracture Outcomes in People Age 50 and Over: Mortality, Service Use, Expenditures and Long-term Functional Impairment" (BP), published September 1993. Requested by: Senate Special Committee on Aging Senator Charles E. Grassley Senator John Glenn Representative Thomas J. Downey, Chairman, House Select Committee on Aging, Subcommittee on Representative Olympia J. Snowe, Ranking Minority Member, House Select Committee on Aging, Representative Benjamin A. Gilman Representative Patricia F. Saiki Monitoring of Mandated Veteran Studies Studies of possible long-term health effects stemming from aspects of military service in Vietnam were mandated in 1979 (Public Law 96-151) and 1981 (Public Law 97-72). Both laws require the approval of study protocols and monitoring of approved studies by OTA. The Centers for Disease Control were given responsibility for designing and carrying out these studies in 1983, and, with OTA approval, have been engaged in two studies the Vietnam Experience study and the Selected Cancers Study since then. CDC has stated and OTA concurred that a large-scale Agent Orange study is not feasible. OTA will continue to monitor the two ongoing studies. Public Law 99-272 contained a mandate for a study of women Vietnam veterans, and OTA is functioning similarly in regard to this study. Thus far, no protocol has been approved. Similar responsibilities have been mandated to OTA by legislation (Public Law 98-160) related to "atomic veterans," military personnel exposed to atomic weapons testing. Project Director: Hellen Gelband Estimated publication date: Ongoing. Associated publications: "Workshop on NAS Medical Follow-Up Agency," Fall 1988. "Review of a Protocol for a Study of Reproductive Health Outcomes Among Women Vietnam Veterans" (BP), published December 1991 Requested by: Mandated New Approaches to Environmental Regulation As U.S. environmental compliance costs have risen, Congress has come under increasing pressure to move away from traditional regulatory programs to newer and more economically efficient or effective approaches. These include: market-based mechanisms (such as the marketable permit program used to control acid rain) and information programs (such as the toxic release inventory under Superfund). This assessment would evaluate how well current command-and-control regulations have worked and the appropriateness of alternative policy instruments for the wide variety of |