CHAPTER 7 OF BOOK “HOW I WOULD RUN THE COUNTRY IF I WERE DICTATOR” by Argus C. Zall
Chapter 7 “Health Care”
In this chapter I describe how I would reform the health care system
(Copyright July 31 2006)
The health-care system of the United States is a national disgrace. Over the last quarter century, it has risen in cost at twice the rate of inflation, and in 1999 amounted to an astonishing 13.5% of GDP (SATUS 1995-2000, Table 159, plus SATUS 2000, Table 459 for determination of GDP). It combines the highest-tech care in the world for the rich with an infant mortality rate for the poor that a third-world country would be ashamed of. It combines a surplus of specialists in urban areas with a shortage of primary care physicians in most of the country. It leaves one third of the population unable to afford to get sick, while the rich can buy a replacement part for any organ except the one they need the most, the brain.
It acquires all these characteristics in part as a result of an unholy alliance among the fee-for-service medical establishment, the malpractice lawyers, and the medical/medical-liability insurance industry. Based on what these three groups have to say about each other, it would seem nonsensical to claim that they are allies in the rape of the public. Nevertheless, if not in outright alliance, they at the very least live in a strong symbiotic relationship, to the mutual enrichment and profit of all three.
The threat of suits incited by the malpractice lawyers makes the physicians practice “defensive medicine”, ordering expensive tests of marginal utility in diagnosis. The tests themselves are covered by insurance, for those who have it. “I recommend a CAT scan to confirm that you don’t have a bullet in your brain, although your headaches appear to be from simple eyestrain; after all, it won’t cost you anything, because it is covered by your insurance”. The tests themselves, of course, are extremely profitable to perform; there is a multi-billion dollar industry furnishing equipment and consumable supplies for these tests.
Malpractice lawyers profit from suing the medical practitioners every time there is a less-than-perfect outcome to a medical situation. Most of the cases are settled out of court, because both sides know that if it gets to a jury, the patient will most likely win big bucks. The settlement is paid by the malpractice insurance company, with typically one-third going to the lawyer, and the cost distributed through premiums for malpractice insurance. Neither the lawyer nor the malpractice insurer have any interest whatsoever in eliminating less-competent physicians from the field; most settlements absolutely prohibit any disclosure. Since the lawyer makes profit from suing, and the malpractice insurance company makes profit from selling insurance, the more malpractice there is, the better is business for both of them.
Physicians and hospitals and diagnostic laboratories don’t pay these costs; they simply add their mark-ups to them and incorporate them into their fees. These fees are paid by the patient, or on the patient’s behalf by another party. For two-thirds of Americans, the third party is a medical insurer, who incorporates these costs into the premiums charged. For the remainder of our citizens, the third party is the taxpayer.
Again, the medical insurers have no incentive to reduce the costs; the more medical costs, the more insurance to sell and the bigger the profit. The patient and the patient’s family certainly have no incentive: “How can you talk about money at a time like this?”. Moreover, most of us do not directly pay the medical insurance premium; it is paid for by an employer. American industry and the American economy pays the cost, at the rate of thousands of dollars per car, for example. Meanwhile, Americans buy Japanese cars in record numbers! Their cost is not saddled with this burden.
The lawyers insist that the ever-present threat of malpractice improves the performance of the health-care system by pricing incompetent practitioners out of the market. Their malpractice insurance premiums will be so high if they can get insurance at all, the story goes, that they cannot make a profit at a competitive fee. That may be, but the side effect is worse. It drives practitioners out of more-risky specialties into safer ones. Try to find an obstetrician in a poor community. He/she would treat high-risk cases, unable to afford proper prenatal care. Many of the patients would be uninsured, so his fee income would be attenuated. The malpractice insurance premiums would be sky high, because the probability of unfortunate outcomes to the pregnancies would be high. He/she is much better off as a skin specialist, or dentist, or ophthalmologist, or any one of a number of specialties in which the patients are not at risk of dying or of life-long disabilities.
Do you perhaps see a connection between the unholy symbiosis of fee-for-service practitioners/malpractice lawyers/insurers and the shockingly high infant mortality of poorer inner-city neighborhoods? I do. The system drives obstetricians out of the places they are needed the most.
Meanwhile, the existence of this spiral jack under the health-care industry pushes up the cost of health-care delivery to rich and poor alike. The Medicare-Medicaid system under which one-third of the nation’s population receives its health care threatens to bankrupt the nation. Between 2000 and 2005, the expenditures for Health and Human Services (mostly Medicare and Medicaid) rose from $383 billion to $586 billion , (SATUS 2000, Table 462) 53% in five years. The total increase in the Consumer Price Index over that period was 9.6% (SATUS 2000, Table 706). Moreover, these billions are just the Federal component of the financing; the states contribute comparable amounts.
Part of the reason for the outlandish costs is the incredibly complex system of billing and payment. I had last year a pelvic CAT scan at a local hospital to test for kidney and prostate problems. This generated 9 separate and distinct billing documents. For use of the equipment, from the hospital first to Medicare, then to supplemental insurance, then to me, 3 documents; From the radiologist who supervised the tests, and “read” the resulting images, bills to all the same payors, 3 more documents. From the referring physician who interpreted the results, 3 more bills to the same payors. The procedure took place on 12/27/05, and the last bill was not paid until 6/6/06.
A simple flu shot, administered by the town nurse, took two Medicare billings and payments:; one to the town for administering the shot, one to the state for providing the vaccine. And, of course, each of the entities involved in all of these transactions has to add a markup to cover the allocation of fixed costs, plus a profit. It reminds me of the line in the play “The Madwoman of Chaillot” where one of the characters is complaining about the high cost of everything, created by all the “pimps” in the process: “Ten percent for the glass pimp, ten percent for the beer pimp, twenty percent for the glass-of-beer pimp!” (Those markups, by the way, are early twentieth century; they are all much bigger nowadays).
All in all, this is a system only a bookkeeper could love.
Worse still, the hardest hit by the entire system are the working poor. Honest, hard-working people, working in jobs at the fringes of the economy, trying to improve their lives, and raise their children to be responsible citizens, are outrageously penalized. The employers they work for are usually too marginal to be able to provide medical insurance as a fringe benefit, and the wages received by the working poor barely cover food, shelter, clothing, and transportation. These people will usually have no medical insurance at all. However, if they get sick, they are not covered by the Medicaid system because they are not on welfare. A one-week illness of a child in the family can bankrupt them.
It is positively not in the interest of a family in this situation to work for a living. They are better off on welfare, where at least they will have public-funded medical insurance. Meanwhile, the Medicare system provides publicly-funded medical insurance to well-to-do pensioners who can perfectly well afford to pay for their own. I don’t think this system is fair at all.
Moreover, the vast expansion of medical technology in the area of replacement organs appears to be largely reserved for those who can afford it. Heart bypasses and organ transplants seem to be outside the scope of Medicaid and Medicare and many private insurance coverages, although kidney dialysis is covered in many jurisdictions. Thus the papers are full of heart-rending efforts by middle class Americans trying to raise money for bone-marrow transplants for leukemic children. The poor merely have to get a few hundred bucks together for a decent funeral. Then, of course, politicians keep passing laws requiring insurers to pay for this that and the other expensive procedure; the insurers must necessarily jack up the premiums paid by everybody to cover these costs. The politicians can then proudly congratulate themselves on having mandated a benefit for their constituents “without raising taxes”, while another clutch of middle-class citizens have to drop insurance coverage because it has become too expensive.
To cut costs, the Medicaid system tries to mandate hospital treatment protocols that kick patients out of hospital beds after an arbitrary bureaucratically-determined stay; whether the particular patient is ready or not seems to be irrelevant. At the same time, Medicaid and Medicare will pay for extended hospitalizations for patients who cannot be cared for at home, but will not pay for extended nursing home care. Thus we have patients who could be cared for in nursing homes occupying hospital beds at far greater cost.
I sometimes think that the only cure is to socialize the whole system, and get it out of the fee-for-service mode entirely. Where this has been done, most notably in England, it results in a two-tier system. The vast majority of the population is served by a publicly-funded health-care system widely perceived to be second rate. Those who can afford it are served by a fee-for-service system partly defrayed by private insurance. At least, this system does not suffer as badly from the infant mortality syndrome that we do.
As Dictator, I would abolish this entire payment system and replace it by the following. Abolish the entire present system of medical insurance, including employer-paid insurance. Raise everybody’s salary and wage by 15%. Apply a new withholding tax of 15% to all salaries, wages, and other income, to go into individually-owned Health-Management Accounts (HMA) managed by the government. Require that all persons use these funds to purchase a standard family medical insurance policy, covering emergency-room services, hospitalizations, and a limited number of physician visits. The policies will be at group rates, with all persons residing in a particular zip code constituting a group. Persons living in unhealthy zip-codes will necessarily pay higher premiums. For persons below a certain family income level, this withholding will not suffice to pay the insurance premium. The balance of the premium for the standard policy will be taxpayer-subsidized, but these persons will be treated only in a pro-bono-publico system of health care that I will describe below.
Retirees having only social security income will be treated in the pro bono public system as well, with Medicare defraying a portion of the costs. Retirees with income in addition to social security will be assessed a 15% tax on that income to pay premiums for the standard medical insurance policy, as a supplement to Medicare. If the tax was insufficient to cover the premium, the balance would be covered from general funds as a subsidy.
All bills from providers must be itemized in plain English (no arcane code numbers) and sent directly to the person treated, who will verify that the services billed were in fact provided, and then forward them to the insurer for payment. For every procedure taking place in a hospital, all providers involved will be legally-considered to be employees of the hospital; their fees will be paid by the hospital and incorporated in its bill. Only one final bill will be sent to the person treated. As employer, the hospital will be accountable for the quality of the services rendered by every provider involved. Services not covered by insurance will remain the responsibility of the person treated. The hospital will be required at the time to inform the patient or health-care proxy whether any service or procedure recommended is covered under the patient’s insurance, and what the cost to the patient will be if it is not.
Nothing in this system will prevent those who can afford it from purchasing additional medical insurance covering a much wider range of services, to cover expenses for which they are responsible not paid for under the standard policy.
This streamlined system of payment will save enormous sums by reducing the present incredible paperwork, and the extremely long lag times in obtaining final payment. It will remove from American manufacturers the burden of medical insurance premiums which now increase the costs of every single article manufactured in the United States. It will save billions in carrying costs by the medical industry which now has to finance enormous sums in accounts receivable while waiting for payment. But it is only a partial solution to the problem. The other half, of course, is to reduce the costs of providing medical care.
As Dictator, I would recognize that the American medical care system exhibits most of the characteristics of a monopoly. Entrance to the practice of medicine is severely limited: first by the availability of medical training, and second by the high cost of a medical education. Consequently, the number of physicians is limited far below optimum levels. This permits them to charge outrageous fees.
Some years ago, the major full-service hospital in my vicinity systematically drove all the community hospitals in surrounding communities out of business. It did so by requiring all physicians on its staff to send their patients only to it, or lose their staff privileges. Since all of them had some patients who required treatment available only in a full-service hospital, they had to remain on the staff of the full-service hospital in order to continue to serve these patients. Therefore, they had to send all of their patients to the full-service hospital, even though 90% of them could have been treated in a local community hospital at half the cost. One by one, the patient censuses in the surrounding local community hospitals fell below the minimum level capable of covering the fixed costs, and one by one they closed. Consequently, for the ninety percent of patients who could have received entirely satisfactory surgical and medical treatment in a community hospital, medical costs were doubled.
In any other business, this would have been illegal restraint of trade, and would have been prosecuted under anti-trust statutes. In my dictatorship, this nonsense will be reversed.
OK, let’s start with medical training. I would socialize medical training and the medical schools. I would give qualified students medical training absolutely free, and pay them a stipend for living expenses during their training. In exchange, they would be required to provide pro-bono-publico service to those members of society lacking the wherewithal to provide for their own health care. This would be an extension of their internship for a period of seven years, at a salary, working in clinics and hospitals serving the communities needing them, rural as well as urban. Having completed their pro bono service reimbursing society for the cost of their training, then and only then would they receive a license to engage in the private practice of medicine.
As long as I was running the medical-education system, and controlling the entry into the profession, I would open it up to a much larger number of entrants. At present, entry into the profession is limited by cost, and by the medical establishment itself in the number of educational openings provided. The limited number of entrants keeps the number of doctors down, which in turn limits the competition and keeps fees high. I would double the number of entrants as well as make the opportunity much more widely available to minority applicants. Pro bono service by the graduates would be performed wherever I decided there was need: inner-city neighborhoods, poor rural communities, and other places poorly served by the medical establishment at present. Because these places are relatively undesirable, most practitioners will leave them as soon as their pro bono service is complete. I will need a continuing flow of new graduates into them to insure that the medical needs of the entire population are met. The influx of this large number of qualified practitioners into the fee-for-service practice will have very salutary influence on the fees that can be commanded by the profession for its services.
There is nothing particularly new about the education/service idea. It has been used for decades to provide medical and dental personnel for the military. They get med school education under ROTC, then serve for four or five years as doctors in the military. I would simply extend it to the much larger civilian population and make it the only means of entry into the private practice of medicine. Paramedical personnel would be educated in similar fashion. Their training program would not be nearly as long, and their pro bono service requirement correspondingly shorter.
I have already described above who would be treated in the pro bono system: the unemployed, the working poor, and retirees with insufficient income to cover the cost of the minimum standard medical insurance policy. The vast majority of their inpatient and outpatient hospital care will be in the local community hospitals and clinics which I will re-establish. The cost of their hospitalizations will be covered by the standard policy; the hospital may not charge higher rates than the policy will pay.
All full-service hospitals will be required to establish and operate a network of satellite community hospitals capable of providing minor surgery, routine hospitalizations not requiring intensive care, and basic emergency service. This would be at much lower cost than required at the full-service hospital, because there would be much lower fixed costs. Patients needing intensive care, diagnostics provided by multi-million dollar machines or major surgery would be treated in the full-service hospitals. Moreover, no hospitals would be saddled with the cost of providing free emergency service to indigent patients, since everybody would have insurance.
All licensed physicians will automatically be on the staffs of every hospital within a fifty-mile radius of their offices. Hospitals will be required to publish a schedule of their rates for various services, as well as whatever amenities they offer. They will also be required to publish their success and failure rates for the various procedures. Patients needing hospital services may be able to compare and choose with their physician the hospital which offers the best combination of service, success, and cost. Motels compete for travelers by advertising “Free Internet and HBO”. Hospitals today saddle a patient already paying outrageous prices with additional charges for TV sets and for telephones. Under my system, hospitaals will have to compete for customers on service and price.
A final point about hospitals. It is reported that 2 million patients per year contract infections in hospitals, of whom 100,000 die! .(Center for Disease Control, reported in “Germ Warfare” Forbes Magazine, June 15 2006, p 62) Hospitals do their best to suppress information about infection rates, apparently for good reason. They presently have a financial incentive to infect their patients, and do not incur any penalty for doing so, If a patient becomes infected in the hospital, the hospital gets to keep a bed full for longer, and charge huge sums for antibiotic treatments that the patient, or patient’s insurance pays for. The information is suppressed so there is no adverse consequence to the hospital.
As Dictator, I will decree that the total cost of treating any hospital-acquired infection (including any rehabilitation or relapses) is borne by the hospital, and the patient receive a stipend of $1000/day for pain and suffering during the treatment. Upon admission to the hospital, a blood sample will be withdrawn from the patient and forwarded to an independent laboratory. If the patient becomes infected in the hospital, a second blood sample will be sent to the same laboratory to determine whether the patient entered the hospital with the infection. If not, all the above elements will apply. Hospitals will be required to publish infection rates along with the success/failure rates and costs noted above, for informed patient judgments. The financial burdens of treating infections will force hospitals to take serious steps to prevent infections, and will result in great reductions in rates of infection and death. This will force hospitals to be built with the idea of preventing or disinfecting bacterial and viral contamination in the first place. Any doctor who practiced medicine in the 1930’s, before penicillin, would be absolutely horrified at hospital rooms with drop ceilings that are ideal dust collectors and bacterial farms!!! They can’t even be adequately fumigated.
A particularly egregious one-hand-washing-the-other arrangement that I will abolish is the present practice of ownership or financial interest in hospitals (particularly specialty hospitals), clinics, and laboratories by physicians, surgeons, and their families. This is clearly a conflict of interest, since the physician will always steer the patient to the facility in which he has a financial interest, whether or not it offers the patient the best combination of favorable outcome and lowest cost. In recommending a facility for any patient, the physician must always be acting in the best interests of the patient, not himself.
More than ten percent of medical costs are for prescription drugs . (SATUS 1995-2000, Tables 159, 160). Americans pay two or three times as much for the same prescription drugs as do citizens of almost any foreign country. The pharmaceutical industry justifies these costs as necessary to support the enormous expense of searching for and developing new medications. If that is true, Americans are subsidizing the discovery and development for the whole world. Moreover, it is believed that Big Pharma spends as much on advertising and merchandising as it does on research and development.
The reason for this disparity is that in nearly every other country than the US, the purchaser from the pharmaceutical company is the government. which negotiates volume discounts. Such government intrusion into the marketing process is forbidden by law in the US, an accomplishment of which drug-industry lobbyists are justifiably proud. As Dictator, I will throw a giant monkey-wrench into this happy grinding of the profit machinery.
First of all, I would drastically reduce their marketing costs by forbidding direct advertising of prescription medications to the public. The public has inadequate medical background knowledge to evaluate the multifarious claims and teeny-weeny fine-print disclaimers (which flash by so fast that you need a stop-motion TIVO to even realize they are there). All these ads accomplish is the patient placing pressure on the physician to prescribe the latest and most expensive nostrum seen on TV. The physician fears losing the patient or a malpractice suit if the prescription is not provided.
Second, the government will be the only purchaser of prescription medications, at a (deeply-discounted) negotiated price. The negotiators will be former buyers from Walmart. The government will then distribute these medications at cost directly to pharmacies in a secure manner. The pharmacies will buy their prescription medications only from the government, and not through third-party concerns, eliminating a present opportunity for slipping counterfeits into the channel. The government will not bother to buy me-too drugs of marginal benefit over what is already available. With these changes, I will reduce the cost of prescription medications (perhaps by as much as a factor two), and the foreigners will pay a bigger share of the R&D costs. Big Pharma will have to cut them smaller discounts to make up for the money they don’t get from us.
None of my proposals directly reduce costs for upper-middle-class or wealthy Americans. They will benefit indirectly, however, because the system will incorporate much more competition, will be much more efficient, and will not be forced to saddle on them the costs of treating uninsured patients who cannot pay.
Having totally reformed the financing and delivery of medical care for rich and poor alike, I will then convert the malpractice system to a no-fault mechanism. Any individual suffering an unfortunate outcome in a medical situation will be compensated for actual loss plus pain and suffering without having to claim and prove negligence on the part of the practitioners; no punitive damages will be permitted. Every such instance will, however, be reviewed by a medical panel to determine whether practitioner negligence was a contributing factor. Any practitioner found to be negligent three times will be barred from practice anywhere in the US for the rest of his life. Hospitals having larger rates of unfavorable outcomes than the 90th percentile will be barred from performing the service in question for ten years. This method of dealing with malpractice will greatly speed up the compensation of victims for their losses, effectively weed out incompetent practitioners and hospitals, and eliminate the additional cost of the skimming by lawyers. For their part, the practitioners will have the security of knowing that the evaluation of negligence will be made by a jury of peers knowledgeable in the limitations of medical practice as well as of its capabilities. Malpractice insurance will become “Unfavorable-outcome” insurance; it will become much cheaper because negligent practitioners and hospitals will be driven from the field, and because punitive damages and lawyer-skimming are eliminated.
So far, I have knocked down two of the major factors driving up the unfairness and the cost of health care: providing for the care of the one third of the nation that is unable in the present system to care for itself; and the reducing the tax imposed by the legal tort method of compensating victims of malpractice. The third, the proliferation of extremely expensive spare-parts replacement treatments, and how to ration them, is more difficult.
We cannot afford to provide these treatments to our entire population. Therefore, they must be rationed. We ration them now, to those who can afford to pay for them, either outright or through private insurance coverage. I think there must be a better way.
I would require the practitioners performing these very expensive procedures to perform one procedure for free in the pro bono system for every one they performed for a fee in the private system. This will undoubtedly result in higher costs charged to the fee-paying patients and their insurers, because they are in effect paying for two procedures instead of one. For many, it will still be a bargain. For others, it will shift a procedure with a marginal benefit/cost ratio into the unfavorable category.
This ukase will still not result in the medical resources to furnish such services to every person in the US who needs them or can afford them. Rationing will still be necessary, euphemistically called “prioritizing”. If this were to be done by a rational selection process, the first component of establishing priorities (for both fee-paying and pro bono patients) could be the quality and quantity of new life conferred. Why waste a kidney transplant on a seventy-year old in poor health with only a few years to live, when a teen-ager injured in a car wreck could be given a normal life span that he otherwise would not have? The second component might be determined by what the prospective patient proposes to do with the new life he is given. Why waste a liver transplant on a forty-year old confirmed alcoholic, when you can give a young mother ravaged by hepatitis a new lease on life to rear her children?
Although this all sounds very logical and straightforward, this dimension of the problem would involve some extremely difficult value judgments if you really get down to priority rank-ordering the cases. Is a banker more worthy than a lawyer? Is a homemaker more worthy than a politician? More importantly, who would decide? Oregon recently held a referendum to try to decide this type of question, and came up with a formula such that everybody’s second or third choice won the sweepstakes, and they went back to the drawing board.
No, such a system would be far too prone to manipulation by whoever ran the decision-making process, and it would be perceived as being manipulated by everyone ruled out, even if it were run by God himself. I would say, instead, set up a few obvious categories to rule out, and select priority ranking for the rest by lottery. At the beginning of the year, randomly pick all three hundred sixty-five dates of the year in sequence to establish the priority order. Match patients needing a particular treatment to the priority listing according to their birth dates. Perform all the procedures for all patients having birthdate corresponding to the number one priority date, then go on to the number two priority date, and so on. Some patients would not survive until their birthdate came up; c’est la vie. Others might survive the entire year and still be around to participate in next year’s lottery; viva la vie.
It seems heartless; it seems cruel, to make life depend on the roll of the dice. But remember, every last one of the treatments we are referring to has been developed only within the last half century, many of them within the last quarter century. And in many cases, the limiting factor is not the availability of medical service, but the availability of organs to transplant. So, none of us are worse off by being denied access to these treatments than we would have been a few years ago. All we are doing is taking them away from being the exclusive province of the well-to-do, and making them available to a wider fraction of the population in as scrupulously fair a manner as possible.
It would take some very sharp figuring to determine whether all my changes would save any money. Medical service to a substantial part of the population would be expanded, albeit at lower cost per unit of service. Expanding medical school places would certainly entail investment cost. I think that the introduction of competition, and the placing of the decision-making with respect to cost in the same locus as the decision-making with respect to benefit (the patient) will help to limit future growth of costs to no more than that of inflation. Elimination of the lawyers from the practice of medicine will certainly help to hold costs down. And finally the restriction of subsidies to those who really need them will improve the fairness of the whole process.
Unfortunately, this does not quite take care of the whole problem. Looming over the entire medical industry is the specter of AIDS, the Acquired Immune Deficiency Syndrome. AIDS is a contagious disease, and has no cure, although anti-retroviral drugs appear to drastically slow its progress. Before they were introduced, the disease was 100% fatal, but infected persons might live as long as ten years after diagnosis. The disease involved loss of immune-system function, leading to frequent opportunistic infections, increasing disability and eventual death from one or more of the infections. Some patients on anti-retroviral drug “cocktails” have now survived longer than ten years in otherwise good health with adequately-functioning immune systems. These treatments are quite expensive, of order $5000 per month. (These costs will go down under my prescriptions for reducing the cost of pharmaceuticals).
The disease is spread by “exchange of bodily fluids” between an infected person and an uninfected one, introducing the HIV virus into the latter’s bloodstream. There it invades immune system T-cells to replicate, killing them. As of 2005, there were reported to be 1.2 million HIV-infected persons in North America ,(Global Health Care Council Website) perhaps a million in the US. The modes of transmission are as follows (SATUS 2000, Table 217). Of 35000 new cases among men in 1999,half resulted from homosexual sex or drug use, with another 8% from heterosexual sex; among 10000 new cases among women, half resulted from heterosexual sex or drug use. For 25% of all cases, the mode of transmission was undetermined.
Interestingly enough, published statements by medical authorities have totally ruled out insects as possible vectors of transmission, even though mosquitoes are known to transmit many blood-borne infections, notably malaria and yellow fever, not to mention equine encephalitis and West Nile virus. Similarly, infection by flea bites has figured prominently in the transmission of bubonic plague to humans from rodents in the past. Deer ticks are the vector transmitting Lyme disease. The reasons advanced for the unique absence of such channels in the case of AIDS are not very convincing: that the viral concentration in the blood of an HIV-positive person is low enough that an insect cannot withdraw enough viruses with its typical blood dose to infect the next person it bites.
This is a “long-tail” statistical situation. While the probability of an infection transmission from one bite is very low, it is not zero. Because an HIV-infected person lives for ten years or more, and his blood contains active viruses the entire time, and in Africa at least may be bitten by insects tens of thousands of times, the cumulative probability of transmission may well approach one before the patient dies. In order for the epidemic to continue, all that is necessary is for an infected person to infect at least one person before he dies. I do not believe there is any epidemiological way of proving that a one-in-ten-thousand channel of insect transmission does not exist. Clearly, however, treatment with anti-retroviral drugs (drastically reducing the viral concentration of the blood stream) tips the odds in a much more favorable direction in the US.
However, these drugs do not cure the disease, and are only effective when they are taken continuously. Discontinuing treatment after suppression of viral concentrations and rebuilding immune-cell concentrations results in relapse and return of viral load to critical levels. Since the transmission by all routes is reduced by reduction in viral load of the infector, it is vital that infected persons be required to remain on their medications for the rest of their lives, regardless of the serious side effects that sometimes occur.
I will dictate persons infected with AIDS be required to wear a plainly visible badge, identifying them as HIV-positive, submit to a monthly blood test to determine their viral load and immune-system status, and must be provided with the necessary anti-retroviral drugs at no cost. The purpose of the badge is to inform non-infected persons to avoid homo- or hetero-sexual contact, to avoid sharing drug-needles, and to inform medical personnel, who may treat them in event of injury, of their status. Should HIV-positive persons fail in any of these requirements, they will be quarantined to remove them from contact with the public. All persons entering into the United States from abroad must prove HIV-negative status before receiving a visa.
With these procedures in place, HIV and AIDS can be stamped out in the US within a decade or two.
The high cost of anti-retroviral drugs and the inadequate public-health infrastructure in Africa and many parts of Asia make this prescription difficult if not impossible to implement there. It might be worthwhile for the US to provide the necessary medications to these areas free of charge, under the condition that the countries involved institute the other aspects of the program. Public-health measures to reduce the enormous insect-bite hazard would be an excellent contribution, not only to the AIDS problem, but to minimizing the transmission of other endemic diseases as well.