Thank you, ACS!

Breathable indoor air has become so commonplace in the United States (and, increasingly, worldwide) that many forget that it has been less than a quarter century since the major push to limit indoor smoking really began to have an impact. Long before the Master Settlement on Tobacco (see http://www.naag.org/tobacco.php) was negotiated by the attorneys general of 46 states, local activists began pushing to make public places and workplaces free of "used smoke" from those who continued to smoke. What may also be forgotten is the powerful alliance of 3 major disease-oriented advocacy organizations that provided important energy and information. Working together, the American Cancer Society (ACS), the American Heart Association (AHA), and the American Lung Association were substantial contributors to the shift in public opinion and public readiness to add regulatory force to the growing concern about the relationship between tobacco products and poor health.

The ACS is at it again: It has joined forces with AARP, the Alzheimer's Association, the American Diabetes Association, and the AHA to push for comprehensive health insurance coverage. This includes the decision to invest precious advertising dollars that might otherwise have been spent on cancer-specific issues, such as education for early screening for breast, cervical, or colon cancer in the health coverage campaign. Why? Because the leaders of the ACS and the other involved organizations have realized that meeting their goals to alleviate particular conditions is severely hampered when a substantial portion of the public lacks a reasonable way to pay for any needed diagnosis, treatment, or prevention.

It is extremely easy to become trapped in the minutia of specific potential proposals, rather like having a major family fight on the eventual color of the living room carpet before agreeing that a new house must be built. The ACS's Cancer Action Network (CAN) is going about this the right way: begin with basic principles and then move on to making them a reality. The ACS-CAN has identified the basic tenents for health care coverage in the United States as follows:

• Adequate. People must have timely access to the full range of health care, including prevention and early detection.
• Affordable. Health care costs should be based on the patient's ability to pay.
• Available. People need to have coverage no matter what their health status is or what treatments they have had in the past.
• Administratively simple. Health care processes should be easy to understand and navigate.

It would have been even better if one or more of the AIDS activist groups had been listed as cofounders of this effort and cofunders of the advertising campaign. The Web site of AIDS Action continues to list this organization's policy priorities through 2010 as "work to develop a comprehensive national plan that includes HIV prevention, treatment, and care and research" and the "impact of HIV/AIDS on communities of color and sexual minorities nationwide." There is nothing wrong with this goal: our lack of a comprehensive national plan, which would be used as a basis for action for all national policymakers, is an embarrassment, and the continuing disproportionate impact of HIV on minorities should be stopped. And it is good that the CDC has begun consultation on an updated National HIV Prevention Plan. [See Holtgrave DR, McGuire JF, Milan J Jr. The magnitude of key HIV prevention challenges in the United States: implications for a new national HIV prevention plan. Am J Public Health. 2007;97:1163-1167.] However, as identified in this column before, in the absence of universal access to care and payment for care, any disease-specific plan is crippled before it begins.

People are not single-disease creatures. Even while managing the impact of a chronic condition such as HIV infection, people will have comorbidities and will need routine preventive services, such as screening for other treatable conditions. And having one member of a family eligible for services (no matter how that family is constituted) by virtue of a specific diagnosis while others are left struggling, even for emergency services, is a sure invitation to family tension, dissension, or disintegration. The basic principle in the ACS-CAN statement designated "Available" incorporates a key issue for those concerned about HIV infection; that is, a specific diagnosis or specific prior treatments should not be a barrier to continued access to services that are needed.

If all of the disease-specific advocacy groups in the country made the same decision that ACS has made, what a difference it would make! Right now, policymakers are able to use conflicting advocacy priorities to excuse their lack of action. Each group that approaches a member of Congress wants something different and specific to one population or one disease. It is easier-if the policymaker is inclined to do anything at all-to make small, specific responses to very specific requests and ignore the larger question. There is no question that the difficulties are huge. Witness the recent opposition from the White House to improvements in the State Children's Health Insurance Program despite nearly universal support, even from such potential opponents as the health insurance industry.

Without a doubt, we benefit from disease-specific advocacy in the policy arena, and the AIDS activist community should continue to monitor and support policies on medication access, comprehensive prevention education, and nondiscrimination. But when multiple groups tackle a common problem, each voicing the same disease-specific reasons for a single, common solution, their collective voice is louder, and change becomes more likely.

We desperately need a commitment to comprehensive access to affordable health and illness services. Thank you, ACS, for your leadership!