POLICY WATCH

terns have not been developed ex- tensively, usable data are not al- ways available to both plan and evaluate services. However, high- lighting some preliminary data that have become available, he argues that physicians are in fact appropriately triaging patients, selecting those cases most in need of immediate attention and that less than 1% of patients died be- fore receiving their CABS or per- cutaneous transluminal coronary angioplasty. We are not told how these figures compare with those in other jurisdictions.

From a policymaking point of view, Naylor’s concluding com- ments are key-queuing should not be taken as a given in medical systems with universal access. Rather, a question should be asked: what are the respective burdens of delay versus denial? This dichotomy is often present- ed as the essence of the Canada versus U.S. health insurance de- bate: delay versus denial, when in reality neither may be appropri- ate or necessary.-WDD

Squeezing the Drug Balloon

[Soumerai SB, Ross-Degnan D, Avorn J, McLaughlin TJ, Choodovskiy I. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med 1991; 325: 1072-7.1

T he effects of imposing a three-medication cap on Medicaid patients in New

Hampshire were compared with a parallel experience in New Jer- sey, where no tampering with medication coverage under Med- icaid was attempted. There was an increase in the rate of admis- sions to nursing homes during the period when the cap was imple- mented. There was an insignifiz cant increase in hospital .admis- sions as well. The effects were

most marked among those receiv- ing multiple medications for clin- ically relevant problems.

Once again, an effort to save money in one sector may wind up costing more money overall. Just as changing the payment for hos- pital care bred a new wave of out- patient activity that may ulti- mately increase the amount of care delivered, so here too does limiting access to one mode of payment prompt changes in pat- terns of care. Ironically, since that approach was repealed, new rules have been promulgated lim- iting the use of certain types of psychoactive medications in nursing homes, with evidence of concomitant increased use of nonprohibited drugs.

Interestingly, in the present case, there is no ready explana- tion for the increased use of nurs- ing homes, especially in the ab- sence of increased hospital use. One could speculate that persons were admitted to nursing homes in order to avoid the limit on drugs imposed on ambulatory pa- tients or that lack of drugs led to clinical complications necessi- tating admission, but then why wouldn’t hospital admissions in- crease also? Perhaps the drug factor was simply diluted in the press of other reasons to admit older patients but not to dis- charge them to nursing homes.

These parables of balloon squeezing, with expansions in other places to compensate for the efforts to compress the pri- mary targets, are discouraging lessons for the health reformer who favors creeping incremental- ism. Health care does not seem amenable to segmented solu- tions. The results of this study, especially in the context of other similar experiences, argue that we may be better off taking a big bite than trying to nibble away at the problem. Broad capitation, as part of universally provided care under a single auspice, may be

the most efficient way to control costs in the end.-RLK

Race, Genocide, and Public Health

[Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 1972: implib&ions for HIV education and AIDS risk education programs in the black community. Am J Public Health 1991 NOD; 81: 1498-l 505.1

R elations between the health care system and the black community have always

been strained, but never more so than in the era of AIDS. Current- ly fashionable conspiracy theo- ries “range from the belief that the government promotes drug abuse in black communities to the belief that HIV is a manmade weapon of racial warfare.” As evi- dence that the white public health establishment would will- ingly inflict suffering and death on blacks, reference is frequently made to the “Tuskegee Syphilis Study.” The mythology that has come to surround the Tuskegee study is said to serve as a barrier to modern day public health ef- forts to reduce HIV risk behavior in the black community. But that was then and this is now. The fact of the matter is that our response to the devastating threat of AIDS is still woefully inadequate for all groups engaged in risky sexual behavior.

In its most extreme manifesta- tion, the mythology has it ‘that the Tuskegee study began with a sample of black men, randomly assigned them to treatment and control groups, infected the “treatment” group with syphilis, and then sat back for 40 years to observe the results. Although the reality of the study is bad enough, it is not nearly so bad as this ideo- logic reconstruction suggests. No

II March 1992 The American Journal of Medicine Volume 92