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The American Public Health Association (APHA) has long advocated the development of a system of universal health care for all US residents. APHA has adopted several policies on this topic that stress the financing of the system of universal health care under a single-payer mechanism. However, this approach has never been adopted by US policymakers. The need for universal health coverage in the United States is growing more acute, and failure to provide such coverage threatens the health status of the public. I propose an alternative approach to the single-payer system that is based on incremental extension of existing coverage mechanisms, accompanied by fundamental reform of the health care delivery system. This approach is in keeping with the traditional methods of policy development in the United States, and I urge APHA to assume leadership in advocating it.

The Washington, DC, City Council authorized a pilot syringe exchange program to operate for only 60 days at a single drug abuse treatment facility in the District. Only adults on the waiting list for treatment were eligible (n = 467). Of the 33 who enrolled, median duration of drug injection was 18 years. Twenty-seven participants denied needle sharing. Of 209 needles distributed, 69% were returned. Low enrollment might have been due to restrictive entry criteria, inconvenient location, incorrect syringe size, and attitudes of treatment staff. For future efforts to have a public health impact, wider accessibility will be needed. (Am J Public Health. 1994;84:303-304), Convenient location, correct equipment and non-restrictive entry criteria appear to be necessary for a successful needle exchange program. The case of a limited needle exchange program in Washington, DC, is discussed. The program was chartered to last for only 60 days. Entry was restricted to adults on a waiting list for drug abuse treatment. The needle exchange program had only one location. A total of 33 intravenous drug abusers were enrolled in the program. Participants were provided with up to three needles, bleach, alcohol swabs, cotton, condoms and information on preventing HIV infection. There were 97 visits by the 33 participants but 18 participants returned to the center once. Of the 209 needles distributed, 144 were returned. Participants commented that the needles were too large. Staff members in the methadone program in the same building as the needle exchange program were opposed to needle exchanges. Community outreach coupled with less restrictive entry criteria as found in Tacoma, WA, and New Haven, CT, appears to be more successful in encouraging needle exchanges.