that the recommendations were developed within the broader context of the American health care system. It is, perhaps, instructive that in other developed countries with significant HIV-infected populations—such as the United Kingdom and Canada—national health insurance programs pay for most or all necessary medical care for residents, and do not require disease-specific programs. In those countries, the Committee is not aware of—and there would be little need for—large HIV-specific care programs that seek to “fill the gaps” in existing insurance systems.

In this country, different segments of the population obtain health insurance through a variety of public and private programs. Private health insurance is provided primarily through employers. Medicare, Medicaid, and the Department of Veterans Affairs (VA) fill significant (but not all) gaps in coverage for the elderly and poor. Many workers lack coverage, and the number of uninsured continues to grow. Even in this context, however, the political consensus necessary to create more comprehensive health insurance solutions has not emerged. Given these circumstances, it is a subpopulation of the uninsured and underinsured—those who are HIV infected—who are the intended beneficiaries of the CARE Act and the focus of the Committee’s charge. The Committee accepted the earlier decision by Congress to create and sustain HIV-specific programs as the starting point and framework for its work.

There are both humanitarian and public health reasons for a program targeted to help those infected with HIV. First, the human tragedy of people in large numbers unable to work, impoverished by the disease, and dying painfully and rapidly led Congress originally to pass and fund the CARE Act. Second, because HIV is a transmissible illness, providing care also provides opportunities to arrest the spread of the virus at the population level. In this way, a narrowly targeted program serves the interest of the public at large and justifies the dedication of public money to that purpose, a decision made by Congress in 1990.

The conclusions and recommendations presented in this report represent the Committee’s effort to develop a comprehensive vision of a system of care that will improve the quality and duration of life for those with HIV and promote effective management of the epidemic by providing access to comprehensive care to the greatest number of low-income individuals with HIV infection. Throughout its deliberations, the Committee sought the strongest evidence available for its conclusions and carefully weighed the feasibility of its recommendations.

The Committee gathered and analyzed information from a variety of sources. During public meetings, it heard testimony from many individuals, including advocates, policy makers, federal and state officials, and people living with HIV/AIDS. In addition, the Committee solicited the input and advice from a liaison panel made up of representatives of the HIV/AIDS



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