Immunizations

Immunization is considered a safe, effective and cost-effective method of controlling many communicable diseases. 33 However, it is not without risk. Yearly, a small number of people suffer serious injury or death from reactions to vaccines. 34 When an entire population is at risk of harm from a disease, risk from the preventive measure seems minimal. Thus, all children are immunized against the childhood diseases. However, when the risk of disease is very low, risk of injury from vaccine assumes a greater importance. Selecting the population appropriate to receive the preventive measure helps to balance the risks. Thus, influenza vaccine is targeted to the medically high risk population for whom a mild case of flu can be life-threatening. When it is difficult to estimate which carries the greater risk, the intervention or the disease, decisions to promote, provide, or accept a vaccine may be made on the basis of personal values.

Children in the U.S. are routinely immunized against diphtheria, tetanus, pertussis (whooping cough), poliomyelitis, measles, mumps and rubella (German measles), and recently, haemophilus influenzae b (Hib). Vaccines against diphtheria, tetanus, and pertussis are administered in a single shot (DTP). Similarly, vaccines against measles, mumps and rubella are administered as the single MMR. Polio vaccinations are administered orally and are commonly referred to as OPV. The relatively new Hib protects against the Hib infection which is the leading cause of bacterial meningitis. The vaccines provide both health benefits and cost savings. 35, 36

For adults, the Centers for Disease Control, the American College of Physicians and the USPSTF recommend pneumococcal and influenza vaccines for persons over age 65. Hepatitis B vaccine is recommended by CDC and the USPSTF for intravenous drug users and others at special risk. Tetanus-diphtheria boosters are recommended for all adults every 10 years.

33 U.S. Department of Health and Human Services, Fiscal Year 1990 Justification of Appropriation Estimates for Committee on Appropriations, (2) (Washington, D.C.: 1989), 61. (Hereafter cited as U.S. Department of Health and Human Services, Appropriation Estimates.)

34 U.S. Congress, House Committee on Energy and Commerce, National Childhood Vaccine Injury Act of 1986, House Report No. 99-908, 99th Cong., 2d sess., part 1 (Washington, D.C.: Government Printing Office, 1986).

35 U.S. Congress, Office of Technology Assessment, Healthy Children: Investing in the Future (Washington, D.C.: Government Printing Office, 1988), 135.

36 U.S. Department of Health and Human Services, Appropriation Estimates, (2): 60-61.

Screening

If a screening procedure is to result in an improved outcome relative to conventional diagnosis after symptoms are present, the procedure should accurately detect an early stage of disease sooner than it could be detected without the screening examination and there should be an effective therapy available for treating the condition. The benefits of early detection are questionable if the condition that is the target of the screening is not treatable.

The ultimate benefits of early detection depend not only on the availability of treatment, but also on the patient's willingness to enter into and maintain the course of treatment which may entail substantial changes to lifestyle. An individual who, before screening, had no signs or symptoms of illness, may be reluctant to adhere to a difficult and costly regimen that offers the uncertain possibility of avoiding illness many years in the future.

There are some screening procedures which authorities agree should be performed on everyone even though they may not agree on the target population, the frequency with which the procedure should be performed or on the threshold for initiating treatment. There is general agreement on screening for hypertension or high blood pressure, for high blood cholesterol, and on performing Pap smears, clinical breast examinations and mammograms. Some tests not recommended for the general population may be recommended for persons who have no symptoms but who have been determined to be at high risk for the target condition because of medical history or some other reason. As these cases are generally left to the physician's discretion, the following discussions refer to persons at average risk.

Routine newborn screenings include those for phenylketonuria (PKU) and hypothyroidism, problems which can cause irreversible severe mental retardation if they are not treated or not treated early enough in an infant's development. Some States require screening for other metabolic diseases which have serious adverse consequences. While early diagnosis may be useful to some infants and their families, in some cases, there is no treatment for the target condition, or the benefits of early treatment are not known. When tests are performed for PKU and hypothyroidism only, savings amount to about $93,000 for each case found and treated. 37 Additional tests may require collecting additional specimens at substantially higher cost.

37 Office of Technology Assessment, Healthy Children, 106.

Hypertension, a leading factor in coronary artery disease, congestive heart failure and stroke, may affect as many as 58 million Americans. 38 The benefits of controlling hypertension have been well established with the greatest effects seen in reductions of cerebrovascular disease and deaths due to stroke. The American Academy of Pediatrics and the National Heart, Lung and Blood Institute recommend annual testing for persons 3 to 20 years old; they recommend tests every 2 years for adults not previously identified as having high blood pressure. Because the procedure can be performed simply during the course of a medical visit, it is reasonable to expect that no additional charge would be incurred.

High blood cholesterol is a major risk factor in coronary heart disease in men. The benefit of lowering cholesterol in women and the elderly has not been established. However, these groups account for a large portion of the population where a small benefit to large numbers may have a significant public health impact. The National Heart, Lung and Blood Institute recommends measurement of blood cholesterol in all adults at least every 5 years although the USPSTF leaves testing to the physician's discretion.

Pap smear is the principal screening test for cancer of the cervix. Each year, there are about 13,000 new cases and 7,000 deaths from cervical cancer in the U.S. Both figures represent decreases due in part to early detection and treatment. The appropriate frequency and ages for Pap test screening are controversial. With frequent testing, lesions that could be precancerous are less likely to escape detection. However, there may be a diminishing return with increasing frequency. The American Cancer Society, the National Cancer Institute, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Nurses Association, the American Academy of Family Physicians and the American Medical Women's Association recommend annual Pap smears for all women who are or have been sexually active or have reached age 18. After 3 normal annual smears, the recommendations allow for less frequent testing at the discretion of a physician. The National Institutes of Health recommends Pap testing be discontinued after age 60 if previous smears have been consistently negative. The USPSTF recommends Pap smears be repeated every 1 to 3 years at the physician's discretion and discontinued at age 65 if previous smears have been consistently normal.

Breast self-examination (BSE) along with clinical breast examination and mammography are the three

38 U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, Prepublication copy (May 1989). (Hereafter cited as U.S. Preventive Services, Clinical Preventive Services.)

screening techniques used to detect breast cancer, the leading cause of cancer deaths among women. Breast cancer accounts for over 140,000 new cases and over 40,000 deaths in the U.S. each year. The effectiveness of self-examination on mortality is not clear; the effectiveness of clinical breast exams and mammography has been demonstrated in reducing mortality among women age 50 and over. 39, 40 However, there is uncertainty about the benefits of mammographies for women ages 40 to 49.41 Most authorities recommend or support monthly BSE, regular clinical examination, baseline mammography between ages 35 and 40 followed by annual or biennial mammograms from ages 40 to 49, and annual mammograms beginning at age 50. The American College of Physicians recommends annual clinical breast examinations starting at age 40 and annual mammograms beginning at age 50. The USPSTF limits recommendations for mammography to every 1 to 2 years for women ages 50 to 75.

Fecal occult blood testing (FOBT) and sigmoidoscopy are used to screen for colorectal cancer, the second most common form of cancer in the U.S. With the 'second highest mortality rate from cancer, colorectal cancer accounts for 150,000 new cases and 61,000 deaths per year. In addition, the condition and treatment can produce considerable discomfort and suffering.

Sigmoidoscopic tests use rigid or flexible instruments that enable the examiner to look into the rectum. These examinations may detect polyps, 5 to 40 percent of which may become cancerous over a period of 10 to 15 years. In persons with no symptoms, 1 to 4 cancers may be detected for every 1,000 sigmoidoscopic examinations. At $100 to $200, the sigmoidoscopic examination is relatively expensive, with the cost of screening all adults over age 50 estimated at $1 billion per year. Risks include possible perforation of the bowel in addition to the danger of false-positives.

While some studies in which screening was a factor show reduced mortality from colorectal cancer, firm evidence that screening prevents morbidity and mortality from colorectal cancer is not available. The American Cancer Society, the National Cancer Institute, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy recommend annual FOBT and sigmoidoscopy

39 Makuc, American Journal, 21-26.

40 David M. Eddy, et al., "The Value of Mammography Screening in Women Under Age 50 Years," Journal of the American Medical Association, 259 (10) (March 11, 1988): 1512-1519.

41 David Eddy, et al., reviewed several studies and concluded that annual screening for 25 percent of the women in this age group would reduce deaths from breast cancer in the U.S. from 10,700 to 10,327 in the year 2000 at a cost of over $400 million.

In response to your request, we have prepared the following memorandum on the design of a benefit package for substance abuse and mental health treatment services. The paper begins with background information on the populations at risk, with estimates of the numbers of persons abusing alcohol and illegal drugs and the numbers of persons with mental illness as reported by the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) of the Department of Health and Human Services (HHS). The opening section also includes estimates of the costs to society of substance abuse and mental illness, as reported by ADAMHA. The second section of the report describes the types of treatment modalities for substance abuse and mental illness currently in use, as well as the results of research into the effectiveness and cost-effectiveness of the various treatment modalities. The third section of the paper describes Federal programs for substance abuse and mental health treatment services, under the Alcohol, Drug Abuse, and Mental Health Block Grant, and the Department of Veterans Affairs (VA). The fourth section describes existing public and private insurance coverage for substance abuse and mental health treatment. This part includes information on Medicare and Medicaid coverage for substance abuse and mental health treatment services, as well as State laws mandating health insurance coverage for such treatment, and employerbased health insurance coverage, including coverage under the Federal Employee Health Benefits Program (FEHB). The final part of the paper discusses issues in considering a benefits package for substance abuse and mental health treatment.

• Memorandum prepared by Edward Klebe, Specialist in Social Legislation, Education and Public Welfare Division, Congressional Research Service, January 26, 1990.

BACKGROUND

The Population at Risk

Substance Abuse Population-Estimates of the extent of drug and alcohol abuse in the United States vary, but it seems clear that millions of persons in this country abuse such substances each year to varying degrees. In addition, although substance abuse trends in recent years appear to be on the decline, the fact remains that a significant proportion of our population are using illicit drugs and alcohol to excess and make up a substantial population at risk for treatment and rehabilitation services.

ADAMHA finances and publishes several national surveys that measure the extent of substance abuse in the United States. The 1988 National Household Survey on Drug Abuse, for instance, is the ninth in a series of national surveys first carried out in 1971 to measure the prevalence of drug use among the American household population aged 12 and over. The 1988 National Household Survey found that 7.3 percent of the household population age 12 and over (14.5 million persons) were "current" users of such illicit drugs as marijuana, cocaine, and others, i.e., they admitted to using such drugs in the 30 days before the survey was conducted. This was a decrease in 37 percent from the 23 million current users in the 1985 study. Users of any illicit drug "within the last year" declined from 37 million in 1985 to 28 million in 1988 (14.1 percent of the population group), a drop of almost 25 percent. The number of "current" users of cocaine fell by 50 percent, from 5.8 million in 1985 to 2.9 million (1.5 percent of the population group) in 1988, and those who used cocaine "within the past year" fell by a third, from 12 million to 8 million (4.1) percent of the population group).