Policies, Public Health Care, and the AIDS Epidemic
REPOhistory members Carin Kuoni and Brian Goldfarb used nineteenth century history to raise their contemporary concerns about public health care and policies, particularly as they related to the AIDS epidemic in New York City, to create Sign 17- Who Owns Your Life: Insurance and National Health Care and Sign 27- Epidemics, respectively.
From the Great Depression until the 1980s, employers increasingly covered the costs of their employees’ medical care. Between 1972 and 1985, the cost more than doubled from $46 billion to $105 billion. Before the AIDS epidemic, many employers were already beginning to search for ways to reduce their role in paying for employees’ health care. Some experts believed this shift would also help with the rising costs of health by making patients more mindful with their medical spending. However, others expressed concern that people who really needed health care would not get it if they had to pay for it themselves. Other cost-shifting methods included increasing deductibles and co-insurance provisions, and requiring employees to pay a portion of the health insurance premium (Lewin 1987).
Around the same time, insurance companies also began to refuse coverage of some advanced and expensive drug treatments in another move to attempt to reduce rising medical costs. The expensive treatments for cancer and AIDS, along with related expenses such as hospital stays, professional fees, and others are among those being challenged (Leary 1989). Sign 17- Who Owns Your Life: Insurance and National Health Care criticizes this system claiming “insurance companies can more or less choose whom to insure.” In the situation above, insurance companies are trying to reduce health costs by attempting to deny coverage of more expensive treatments (Leary 1989). As Kuoni questions “Who Owns Your Life?,” the health and lives of some patients are dependent on what and how much is covered by insurance or if they can even afford medical insurance or health care at all. This is also evident from The New York Times article cited on Sign 17- Who Owns Your Life: Insurance and National Health Care, which reported patients without medical insurance died at a higher rate than those with insurance (Associated Press 1991).
While these struggles over medical care costs were happening, New York City saw the spread of tuberculosis and HIV/AID. Municipal, state, and federal policy, budget, and tax decisions contributed to the spread of these diseases in the city. After the city’s fiscal crisis in the 1970s, the city was unprepared to handle the two epidemics. During this fiscal crisis, the Department of Health’s budget was cut by 20%, cutting staff, closing health centers and stations, and reducing programs. This left fewer facilities, less staff, and overburdened hospitals to control the epidemics (Freudenberg et al. 2006, 424-428). While other places places across the country had a surplus of beds, hospitals in New York City were overcrowded causing ambulances to be turned away and leaving patients waiting hours or days for beds to open up (Pabst 1988). Goldfarb notes many people with AIDS were among those who had long waits in the first comparison on Sign 27- Epidemics.
In addition to closing health centers and clinics, in the 1970s, the city’s Department of Health also laid off most of its health educators and reduced health services to schools. This later inhibited the Department’s ability to communicate health information on HIV/AIDS effectively and delayed the establishment of HIV programs in city schools. One of the agencies that was eliminated was the Addiction Services Agency, which was responsible for substance abuse treatments. As the number of New Yorkers with drug addiction in the city grew, fewer were able to get treatment after treatment was transferred to state-funded programs. Though there were eventually increases in treatments, these increases were not enough for the influx in drug abusers who needed to receive treatment (Freudenberg et al. 2006, 427-428).
As the city struggled, the federal government turned down the mayor’s request for help. From the mid-1970s to the early 1980s, the federal government also made policy decisions and budget cuts which affected New York City. This included reductions in funding for urban development and public programs and reductions in federal support for low-income housing, forcing some people into homelessness. Homeless people were particularly vulnerable to tuberculosis and HIV/AIDS (Freudenberg et al. 2006, 431). Sign 27- Epidemics recognizes this connection and shares the fact that over 13,000 New Yorkers with AIDS were among the homeless.
In an effort to restore its tax base after the fiscal crisis, the city offered developers tax incentives to convert single-occupancy hotels that once housed mentally ill patients into luxury condominiums and apartments. The AIDS Coalition To Unleash Power (ACT UP), a prominent AIDS activism group, and its Housing Committee planned protests at sites that benefited from these and other business developments. They also set themselves up outside the Department of Housing Preservation and Development and demanded to meet with a commissioner. This eventually pressured both the city and state governments to dedicate more funding for housing specifically for homeless people with AIDS (Carroll 2016). Like ACT UP, Goldfarb is critical of the tax abatements for corporations, which he expresses in the second comparison on the reverse side of Sign 27- Epidemics.
The year the Lower Manhattan Sign Project went up, 1992, HIV/AIDS became the number one cause of death for U.S. men between the ages of 25 and 44, and was the fourth leading cause of death for women (Center for Disease Control 1993). By 1994, it was the leading cause of death for all Americans between the ages 25 and 44. A few years earlier, in 1990, U.S. Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act to provide federal grant funding for HIV community-based care (U.S. Department of Health and Human Services 2016). In 1994, the Health Commissioner secured funding from the Ryan White CARE Act (The New York City Department of Health and Mental Hygiene, 60 and 63). By the late 1990s, deaths caused by HIV/AIDS were declining (Altman 1997). Sadly, in 1997, REPOhistory lost Ed Eisenberg, one of its founding members, to AIDS (Visual AIDS 2017). Eisenberg designed Sign 15- False Democracy.
Altman, Lawerence K. 1997. “Deaths from AIDS Decline Sharply in New York City.” The New York Times, January 25. http://www.nytimes.com/1997/01/25/nyregion/deaths-from-aids-decline-sharply-in-new-york-city.html.
Associated Press (AP). 1991. “Uninsured Hospital Patients Found Far More Likely to Die.” The New York Times, January 16. http://www.nytimes.com/1991/01/16/us/uninsured-hospital-patients-found-far-more-likely-to-die.html.
Carroll, Tamar W. 2016. “The majority of people dying of AIDS were people of color: Activism & Rising Inequality.” Gotham: A Blog for Scholars of New York City History, February 16. Accessed April 13, 2017. https://www.gothamcenter.org/blog/the-majority-of-people-dying-of-aids-were-people-of-color-aids-activism-amp-rising-inequality.
Center for Disease Control. 1993. “Update: Mortality Attributable to HIV Infection Among Persons Aged 25-44 Years -- United States, 1991 and 1992.” Morbidity and Morality Weekly Report 42, no. 45 (November 19): 869-872. https://www.cdc.gov/mmwr/preview/mmwrhtml/00022174.htm.
Freudenberg, Nicholas, Marianne Fahs, Sandro Galea, and Andrew Greenberg. 2006. “The Impact of New York City’s 1975 Fiscal Crisis on the Tuberculosis, HIV, and Homicide Syndemic.” American Journal of Public Health 96, no. 3 (March 2006): 424-434. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470515/pdf/0960424.pdf.
Leary, Warren E. 1989. “Health: Insurance Coverage; Payment Policy on New Treatments Draws Fire.” The New York Times, March 2. Accessed April 11, 2017. http://www.nytimes.com/1989/03/02/us/health-insurance-coverage-payment-policy-on-new-treatments-draws-fire.html.
Lewin, Tamar. 1987. “Business and Health: Shifting Costs to Employees.” The New York Times, June 9. Accessed April 11, 2017. http://www.nytimes.com/1987/06/09/business/business-and-health-shifting-costs-to-employees.html.
The New York City Department of Health and Mental Hygiene. Protecting Public Health in New York City: 200 Years of Leadership, 1805-2005. http://www1.nyc.gov/assets/doh/downloads/pdf/bicentennial/historical-booklet.pdf.
Pabst, Diana. 1988. “New York Facing A Shortage of Hospital Beds.” Washington Post, January 19. Access April 14, 2017. https://www.washingtonpost.com/archive/lifestyle/wellness/1988/01/19/new-york-facing-a-shortage-of-hospital-beds/611931c2-65c8-4919-b596-f9fa5288cd08/?utm_term=.359c03e80e99.
U.S. Department of Health and Human Services. 2016. “A Timeline of HIV/AIDS.” Updated 2016. Accessed April 13, 2017. https://www.aids.gov/hiv-aids-basics/hiv-aids-101/aids-timeline/.
Visual AIDS. 2017. “Ed Eisenberg, 1951-1997.” Accessed April 13, 2017. https://www.visualaids.org/artists/detail/ed-eisenberg.