more than 90% of New York City AIDS funds are spent on inpatient hospital care, largely through the city government's 25% share of Medicaid expenditures, and direct subsidies to the NYCHHC and voluntary hospitals providing indigent care. 19 This results in sizable expenditures of local funds in New York because of the large number of AIDS patients who are enrolled in the Medicaid program. In comparison, in San Francisco only approximately 25% of municipal AIDS funds are spent on inpatient care. The large difference is due in part to San Francisco's local government not contributing to the Medicaid program. This reduces the cost of hospitalization to the city, while increasing the cost to the state of California.

These differences point out the importance of localstate relationships in responses to AIDS, especially in funding. In New York, the state health department has increased its influence vis-a-vis the New York City Health Department through its statutory responsibilities in Medicaid and in voluntary hospital financing in general. In addition, following the fiscal crisis of the 1970s, the state assumed other responsibilities that were formerly the province of city agencies. For example, administrative control over substance abuse programs was shifted to the state during the late 1970s, and it is these agencies that are trying to cope with the growing epidemic among IV drug users, 20

Both cities help pay for the costs of hospitalizing medically indigent patients who are not covered by any thirdparty payers. This has been an especially acute problem with AIDS patients, many of whom are treated with experimental drugs because no efficacious drug regimen is available. Third-party payers, both private and public, have been reluctant to pay for hospital care when experimental drugs are used in treatment. Thus, both local governments have been forced to subsidize treatment costs. Even more important for the cities' budgets is the fragmented mix of policies that have resulted in a large number of AIDS patients joining millions of other Americans who "fall through the cracks" and have inadequate health insurance coverage. It is estimated that more than 55 million people in this country have little or no health insurance at all. These patients, who are generally confined to municipal hospitals, are subsidized by local tax revenues in both cities.

The payer mix for AIDS patients in the municipal hospitals of each city is quite similar (Table IV). In the mu

nicipal hospitals, those patients not covered by private insurance, Medicaid, or Medicare usually have no other insurance coverage and are subsidized by local government. In San Francisco's nonmunicipal hospitals, Kaiser Permanente, a health maintenance organization, covers at least 50% of those patients in the "other" category, reducing the overall level of uncompensated care to approximately 13% of the total AIDS inpatient caseload in that city.

The budgets of the cities in the years preceding the epidemic also may have influenced the extent to which each committed financial resources to the epidemic. The ability of local government in San Francisco to respond to the AIDS crisis with substantial funds as early as 1983 was made easier by the existence of a budget surplus that existed during the early 1980s (but is now gone). In contrast, New York was just coming out of a protracted period of financial crisis and near bankruptcy in the late 1970s.

Another factor that existed before the epidemic and influenced local responses was the different roles of the local health departments. In San Francisco, the health department incorporated traditional public health functions. outpatient clinics, and San Francisco General Hospital under one bureaucracy. This strengthened local public health decision makers in their position that the health department should take the lead in responding to the AIDS epidemic through direct action and active coordination, funding, and support of other organizations. In New York, the health department's functions were separate from hospital services, which fell within the bureaucracy of the NYCHHC. Thus, the health department in general "should provide those services that others have not, will not, should not, or cannot provide," 22 ie, its role is to fill the gaps in the system. In an early response to the AIDS epidemic, the department called a meeting of all interested parties in the city and defined its role as "seeking not to direct, but to provide a neutral meeting ground." 22

A further difference lies in the difficulties of coordinating the diversity of services that can be used to address the AIDS epidemic. In New York, three large, separate city bureaucracies, the Health Department, the Health and Hospitals Corporation, and the Human Resources Administration, each developed programs to deal with AIDS, with little formalized central coordination. In San Francisco, these functions were under the authority of one agency, and this allowed extensive health department organizational resources to be used to encourage the integration of community-based, ambulatory, and institutional programs.

The preexisting social and political structures of persons in the major risk groups are a second component that helps explain the differences in the two cities. In San Francisco, AIDS has predominantly affected white, middle-class, homosexual men. In New York, at least half the cases are reported among minorities, and almost a third are known IV drug users-an impoverished, highly stigmatized, and politically powerless stratum of society. In a 1984 survey, the number of openly homosexual or bisexual men in San Francisco was estimated to be approximately 69,000, or 24% of all men aged 15 years and older. The homosexual community was also found to be relatively affluent and well-educated, with 44% having

pre-tax carnings of $25,000 or more, 57% having college degrees, and 21% having postgraduate degrees. A preliminary survey in New York indicates a similar socioeconomic background for homosexual men.24 However, given the distribution of cases in other patient groups (eg, IV drug users) and by race, AIDS has afflicted a poorer and less educated population in New York.

The roles of the risk groups in the economic and political life of these communities are markedly different. The homosexual community is a well-organized, visible, and powerful political force in San Francisco, with openly gay representatives holding elective office in local government since the late 1970s. There is no comparable group of gay political power in New York. Thus, in San Francisco, the major identified risk group has been represented by organized spokesmen who were an integral component of the local political establishment even before the AIDS epidemic began.

Such visibility and political power for the major risk group in San Francisco is probably reflected in the differences in newspaper coverage of AIDS by The New York Times and The San Francisco Chronicle. Although these two papers play somewhat different roles, in that the Chronicle is viewed as more locally oriented than the Times (and therefore would be expected to put more emphasis on a locally important issue), the more extensive AIDS coverage by the Chronicle is still noteworthy. Between June 1982 and June 1985, 442 articles about AIDS appeared in the Chronicle, of which 67 were front-page stories. This compares to 226 articles published in the Times, of which seven were page-one news. The extensive nature of coverage by the Chronicle, aside from providing a degree of health education not found in New York, helped to sustain a level of political pressure on local government and health officials to respond to the AIDS crisis. The difference in coverage is also probably a reflection of the relative importance of the AIDS epidemic among other local issues. In San Francisco, AIDS was clearly a top issue, in New York, it had to compete for attention with a multitude of other issues.

Thus, the preexisting social and political structures of the institutions and major risk groups reinforced the differences in the epidemiology of AIDS in the two cities. In New York, the complexity of coping with AIDS was heightened by the heterogeneity of the risk groups and their diffuse political and social organization, by the number and diversity of organizational actors in the health and human services sector, by the roles of public agencies in financing health care and in responding to the epidemic, and by the relative importance of AIDS as a local policy issue. In San Francisco, on the other hand, both the epidemiology and the social and political factors put fewer constraints on those agencies that responded to the epidemic. Indeed, the conditions were that a well-educated, highly organized, and politically active group of citizens were at risk of AIDS in a city with relatively well-coordinated relationships among the major public health care institutions. The epidemiology and the social and political factors contributed, directly and indirectly, to some of the differences between the two cities through their influence on the cities' policy responses.

Policy Responses in New York and San Francisco. In

both cities, the AIDS epidemic has generated a largely unanticipated need for a variety of medical, public health, social, and educational resources. For example, active disease surveillance and epidemiologic investigations have been necessary to track the epidemic, to establish routes of transmission, and to plan for future health care resources to service the needs of those afflicted. AIDS patients require hospital care, outpatient services, social support and, in many cases, housing and food. Members of highrisk groups need public health education, counseling, and specific guidelines regarding behavior to prevent transmission of the disease. The population outside the main risk groups needs education to understand the risks and how the disease is transmitted in order to reduce unwarranted fears, to promote support for effective programs, and to prevent further spread of the epidemic. The policy responses in the two cities, as reflected in agency behavior, followed paths that were consistent with the differences in epidemiologic factors and social and political structures. In 1982, the San Francisco Department of Public Health (SFDPH), through its Office of Lesbian and Gay Health, began to coordinate efforts to plan and develop services to deal with AIDS. By 1983, in efforts to avoid duplication of services by a growing number of organizations and to coordinate the city and county's responses, a separate AIDS Activity Office was established within the SFDPH with the following specific purposes: to better coordinate and link the continuum of services related to the AIDS epidemic; to identify service gaps and develop plans for addressing these needs; to oversee, monitor, and support AIDS-related contract services; to anticipate funding requirements and justify new funding requests; and to develop and maintain the department's liaison with certain external funding and service agencies, community groups, and education programs. However, significant local funding for AIDS programs in San Francisco did not begin until FY 1984, when expenditures increased to $4.3 million from $180,000 the previous year."

During the early years of the epidemic in New York (1981-1984), there was no centralized governmental response. Although an Office of Gay and Lesbian Health existed within the Department of Health since 1982, it was an advisory body with no policy-making authority. More importantly, it had less political power than the comparable office in San Francisco due to its location within the health department and its inability to influence other city bureaucracies that deal with AIDS in New York.

In November 1984, at the direction of the mayor, an AIDS Policy and Planning Committee was formed. Its first order of business was to send a fact-finding delegation to San Francisco (January 1985) to study that city's response and to make recommendations for improving New York's services to AIDS patients.

The delegation's foremost recommendation was to improve administrative coordination among all city agencies dealing with the AIDS crisis through the Policy and Planning Committee. This body was formalized in March 1985, and its charge was to oversee planning, coordination, monitoring, and evaluation of all the AIDS services provided by the city directly or by contract. Other recommendations called for increased resources for the surveil

lance efforts of the health department, and enhancement of acute and chronic medical services (including outpatient services), the provision of housing and social services, and educational programs. Most of these recommendations and other AIDS programs were implemented by the beginning of 1986, with a large increase in city appropriations during FY 1986.9

In San Francisco, the existence of an office within the health department devoted to gay and lesbian health issues provided a natural organizational focus for AIDS issues as the epidemic developed. The relatively small scale of the city, the recognized importance of homosexuals in local politics, the relatively high educational and income levels of the gay community, and its social organization all contributed to the development of an integrated system of outpatient and community-based services for AIDS patients. These services not only provide an important part of the care for AIDS patients, they have a financial impact on the local health care system by allowing many patients to remain outside the hospital for longer periods and, once admitted, to be discharged earlier. The range of community services available include outpatient clinics, public health education, hospice care, legal services and entitlements advocacy, psychosocial counseling, substance abuse services, and practical support and housing for AIDS patients.

While these services now exist in each city, the timing of their development and sources of funding differed. For example, outpatient clinical services for AIDS patients have been available at SFGH since September 1981. In the fall of 1982, SFGH established a special multidisciplinary clinic (infectious diseases, oncology, psychiatry, psychology, nursing, dermatology, and social work). At the University of California in San Francisco (UCSF), another outpatient clinic for AIDS patients opened in August 1984. During 1985, the clinics at SFGH and UCSF averaged approximately 1,000 patient visits per month.

In New York City, the first outpatient clinic for AIDS patients was opened at Kings County Hospital in early 1984. During 1985, it was open two afternoons per week and handled between 120 and 175 patient visits per month. The first full-time AIDS ambulatory care clinic was opened in Manhattan in the spring of 1985. Slowness in providing comprehensive AIDS outpatient services in New York has probably increased the level and expense of hospitalization there.

The diversity of AIDS patients in New York makes the process of developing a useful range of services far more difficult. Developing services appropriate for both IV drug users and children with AIDS has obviously been much more of a problem for New York than for San Francisco. On the other hand, the highly successful, specialized inpatient AIDS ward at San Francisco General Hospital, where most patients are middle class gay men, has benefited from the homogeneity of its patients and extensive support from the gay community. Attempts to develop such a ward in a setting where the majority of patients are substance abusers would obviously entail difficulties. Other community-based programs in San Francisco, such as the Shanti AIDS Residence Program, which provides longterm housing for AIDS patients (and thereby helps keep patients out of the hospital), are not designed to accom

modate patients with substance abuse problems, and, in fact, Shanti does not accept such patients into its program. Thus, the ability of San Francisco to develop a range of successful community-based services is due not only to good planning and a commitment of local resources, it is a reflection of the strength and importance of the gay community, whose members comprise the majority of patients and those at risk.

To support its community-based services, New York City has relied more on state and private funding and less on local funds compared to San Francisco. This may be due to the transfer of responsibility for various services from New York City to New York State government after the fiscal crisis of the 1970s, or it may be due to a paucity of local political power among the groups at risk. It may also reflect the enormous management and planning difficulties rooted in the complexity of the epidemic in New York of local government officials as they attempted to develop programs. For example, a city-funded program for home attendant services to persons with AIDS provided care to only a fraction of those in need. An audit of this program found that from its inception in December 1983 through February 1985 a total of only 80 clients had received service, although it was designed to serve a 200client caseload.25 The report elaborated a series of reasons for the program's failure to meet its goals, including poor contract planning, lack of needs assessment, enrollment limited to those who were eligible for Medicaid, excessive processing time, lack of housing, and poor community outreach.

Nevertheless, community-based AIDS organizations have played a key role in responding to the epidemic in both cities. They have provided an important and otherwise missing dimension to patient care and have been instrumental in developing and disseminating risk reduction strategies. At the same time, they have had an important financial impact on the local health care systems by keeping patients out of the hospital.

One reason government support for community-based organizations is a cost effective strategy is the heavy reliance on volunteer labor in these groups, which allows for a greater production of services per dollar expended than would be possible if government provided these services directly. However, a significant level of financial support is still necessary to develop administrative structures and to pay staff who can recruit, train, supervise, and support volunteers. According to one national survey,26 nearly 80% of services provided by community-based AIDS groups around the country were performed by volunteers. In New York and San Francisco, the magnitude of donated labor is enormous, conservatively estimated at more than 100,000 hours in each city (Table V). The amount of donated labor at the Gay Men's Health Crisis in New York is similar to the combined total of the Shanti Project and the San Francisco AIDS Foundation. However, the ratio of unpaid staff hours to paid staff hours is twice as large in New York, indicating a greater reliance on volunteers and lesser funding by local government there.

CONCLUSIONS

The large number of AIDS cases in New York and San Francisco has had a significant impact on the local health

270 NEW YORK STATE JOURNAL OF MEDICINE/MAY 1987

care systems. It is likely that as the epidemic spreads it will place increasingly greater strains on other health care systems in cities and counties with growing numbers of cases, as well as on public and private sources of health care financing. While the absolute number of AIDS cases continues to grow in metropolitan areas, there is convincing evidence that the disease is spreading across the country. According to the Centers for Disease Control, the four cities with the largest number of AIDS cases-New York, San Francisco, Los Angeles, and Miami-accounted for 73% of all reported cases in September 1982. This figure declined to 65% by September 1983, and, by February 1987, their proportion of the nation's total had fallen to 50%. In other words, the proportion of total AIDS cases not based in these four metropolitan areas has increased by more than 85% during this time period.

The availability of outpatient and community-based care facilities and programs and the relatively low charges per AIDS admission in San Francisco may give an important clue to the direction other communities should follow in a rational planning policy for the treatment of AIDS patients. The average length of hospitalization for AIDS patients in San Francisco is far shorter than in New York and in most other cities. This is due in part to the variations in patient groups, case mix, and practice patterns that are found in different regions of the country. However, an integrated system of health care delivery which is subsidized by local government in San Francisco and includes outpatient clinics, home health and hospice care, housing, and other social support services, allows patients to be discharged from the hospital earlier than in other cities where such services are not as readily available. The success of San Francisco's response to the epidemic does not, however, mean that other cities should attempt to respond in exactly the same way. New York's example illustrates how one city, confronted with complex problems, considered a variety of local conditions rather than merely adopting another city's model. Each community should develop its own response in light of its own epidemiologic circumstances and social and political structures, learning from the experiences of San Francisco and New York City.

The investment of public funds in community-based services affords better quality care for AIDS patients. It is also a rational fiscal response that helps reduce the economic impact of the epidemic by reducing the need for inpatient care. This lowers private health insurance expenditures, Medicaid outlays, and local tax revenues that

must be spent when Medicaid or other third-party reimbursement is unavailable or below costs.

Aside from financial support from the public sector, the viability of community-based AIDS organizations depends on a large, steady stream of unpaid labor. If the patient mix shifts further away from homosexual men towards IV drug users, as it slowly appears to be doing, it is unclear whether the level of voluntarism can be maintained. In low incidence regions, there may not be an identified at-risk population from which to draw volunteers. Thus, unless further financial support is forthcoming, gaps in services to AIDS patients, already experienced by many of these communities, may become more severe as the epidemic continues to spread geographically.

New York City and San Francisco illustrate that the AIDS epidemic may manifest itself quite differently in various cities and can trigger diverse responses based on local conditions. With the likely prospect of other cities facing large increases in the number of those afflicted with AIDS, the experiences of New York and San Francisco may prove useful. They indicate that each community's response to AIDS will probably reflect the underlying social, economic, and political characteristics of AIDS victims and the existing structure and organizational roles of traditional health care and community-based service providers. They also indicate the intrinsic limits to the current dependency on unpaid labor and the contributions from private charity and local government, increasing the pressure for additional state and federal support for community-based services and the care of AIDS patients.

Acknowledgment. The authors thank the many people in New York City and San Francisco who generously provided their time and expertise in helping to gather and interpret the data from each community.

8

San Francisco Department of Public Health: San Francisco's Response to AIDS Status Update. October 8, 1985.

9. Sencer DJ. Botnick VE Report to the Mayor: New York City's Response to the AIDS Crisis. Office of the Mayor, City of New York, December 1985. 10. West Bay Hospital Conference. Quarterly AIDS Utilization Report, San Matco, California. March 5, 1986

11. Scitovsky AA, Cline M. Lee PR: Medical care costs of patients with AIDS in San Francisco. JAMA 1986, 256:3103-3106

12 Knickman J, Foltz AM Regional differences in hospital utilization. How much can be traced to population differences? Med Care 1984; 22.971-986. 13 Gay Men's Health Crisis: 1984 Annual Report, New York, 1985. 14. Arno PS: The nonprofit sector's response to the AIDS epidemic. Community-based services in San Francisco. Am J Public Health 1986, 76:1325 1330. 15. Centers for Disease Control: AIDS Weekly Surveillance Report. US AIDS Program, Center for Infectious Diseases, Atlanta, Georgia, January 5, 1987. 16 New York City Department of Health AIDS Surveillance Update. Office of Epidemiologic Surveillance and Statistics, January 1987

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18 Boufford JI Statement before Subcommittee on Health and Environment, Committee on Energy and Commerce, US House of Representatives, November 1. 1985

19. New York State Comptroller. Review of New York City's Proposed Financial Plan for Fiscal Years 1986 through 1989. Report No. 30-86, December 11, 1985

20. Imperato PJ: The Administration of a Public Health Agency. New York, Human Sciences Press, 1983, pp 100 105.

21 Farley PJ Who are the underinsured? Milbank Memorial Fund Quarterly/Health and Society 1985; 63:476-503.

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23. Research and Decisions Corporation: Designing an Effective AIDS Prevention Strategy for San Francisco, Results from the First Probability Sample of an Urban Gay Male Community Prepared for the San Francisco AIDS Foundation, December 3, 1984.

24 Martin JL: The Impact of AIDS on New York City Gay Men Develop ment of a Community Sample. Presented at the Annual Meetings of the American Public Health Association, Washington, DC, November 21, 1985.

25 New York City Comptroller Report on the New York City Human Resources Administration of the American Red Cross AIDS Home Attendant Program, ML 85-504, April 15, 1985.

26. US Conference of Mayors: Local Responses to AIDS A Report of $5 Cities. Washington, DC, November 1984