New Congress poses challenges for advocates

Key changes in Congress could have impact

No one is worried that a financially strapped federal government might kill Ryan White Care Act funding, but AIDS advocates say they are concerned about what will happen with the bill in a slightly different political environment this year.

"The bill has always enjoyed bipartisan support," says Ernest Hopkins, director of federal affairs for the San Francisco AIDS Foundation. "But the election has certainly had an impact on some of the dynamics that will play out in reauthorization."

Reauthorization of the bill, which expires Sept. 30, 2005, takes place in the context of an enormously challenging funding environment, says Mark Del Monte, JD, director of policy and government affairs with the AIDS Alliance for Children, Youth & Families in Washington, DC.

"So I think the difficulty is going to be how do we preserve the Care Act to meet the needs of HIV-positive people," he says. "The risk is that the appropriations environment will be so difficult that it will intrude on the legitimate policy discussions."

President George W. Bush and his administration are expected to produce a position paper for the Ryan White Care Act reauthorization, and that’s something that AIDS advocates will follow closely, Del Monte says. "They will have an administrative position on which they’d like to see it reauthorized, and that’s a new dynamic."

It’s also possible that AIDS advocates will have to spend some time educating new senators and representatives about the Ryan White Care Act, and they may have to fight potentially negative amendments that could be added to the act, says Greg Smiley, MPH, public policy director of the American Academy of HIV Medicine in Washington, DC.

Plus, the Ryan White Care Act is only one part of the overall health care picture that will affect the HIV community, he says.

"It’s all about interdependence, protecting Medicare and Medicaid as you protect Ryan White funding," Smiley explains. "If you protect Ryan White funds, but let Medicaid drop, you’ve kept your eye off the ball because Medicaid and Medicare are larger expenditures than the AIDS Drug Assistance Program (ADAP)."

Cost-effectiveness is a major factor

One possible scenario is that Congress and the administration will focus on a cost-benefit analysis, he says. "Health care costs across the board are busting everyone’s budget, so they’re going to look at not only how to cut costs, but also the cost-benefit analysis: Can you prove this is efficient, this is effective, and will this save us money down the road?" Smiley explains. "So a lot of our talks over reauthorization for the next year will be talking about strategies that are cost-effective."

No one holds out much hope that the Care Act will be expanded and improved, as recommended in May, 2004, by the Institute of Medicine of the National Academies (IOM) of Washington, DC. The IOM report recommends expanding the Ryan White Care Act to ensure that thousands of HIV-infected people who receive no or inadequate care will gain access to the services they need.

This should be accomplished through turning the Ryan White Care Act into an entitlement program in which the federal government would assume all costs related to providing HIV/AIDS services to the poor and relieving state Medicaid programs of the burden of paying for HIV/AIDS patients, the IOM report says. If this measure were adopted, it would increase federal spending on HIV/AIDS care for low-income people by about $5.6 billion over 10 years, the report notes.

However, AIDS advocates say they have little hope in convincing Congress to appropriate significant additional money for AIDS treatment when there is an expected additional $75 billion needed for the war in Iraq and when key leaders in Washington, DC, are calling for cutting the federal budget deficit in half within the next four years. "And you’ve got the Medicare drug benefit that’s more expensive than anyone expected," Smiley says.

Another possibility is Congress will use the reauthorization as a platform for passing ideological-based amendments. For instance, newly elected senators Tom Coburn (R-OK) and Jim DeMint (R-SC), who have expressed interest in being on the Senate Health, Education, Labor, and Pensions Committee, have made negative public comments about gays, Hopkins and Smiley say.

At the very least, AIDS advocates will have to deal with a new chairman on the health committee. Sen. Judd Gregg (R-NH) will leave that position, and Sen. Mike Enzi (R-WY) will take the chair position, Hopkins notes.

"So that’s a change that will require our getting acquainted with his staff and bringing them up to speed with a variety of things," he says.

Still, the biggest changes might involve an ideological shift toward abstinence-only education and other issues important to certain religious conservatives, AIDS advocates say.

"Coburn is a person who challenges the efficacy of condoms, is a strong advocate for abstinence-only education with regard to HIV, a strong proponent of criminalization of HIV transmission, and mandatory testing of newborns and pregnant women," Hopkins says. "He has made many anti-gay statements during the coarse of his tenure in Congress and during his recent election to the senate; and from our perspective, he may cause the greatest challenges for some folks in the AIDS community."

And Coburn has taken a personal interest in the Ryan White Care Act in the past, he adds.

"Even if Senator Coburn is not put on the health committee, which he might be, we suspect he would have a strong role to play in the coming reauthorization," Hopkins says.

DeMint, who has said gay people and unmarried mothers should not be teachers in schools, is another new senator to watch, according to Smiley.

"We’re going to have a hard time coming up with strategies to fight the measures they’ll want us to include in the reauthorization that we might not like," he notes. "There’s a potential for anything, and we don’t know what we’re going to be facing."

Although the Ryan White Care Act is supposed to be about services, it’s possible Congress will try to legislate prevention priorities in the act’s reauthorization, Smiley adds.

"Having said that, once again, the bill still enjoys broad bipartisan support with resources that flow to every state in the nation, and everyone has a stake in ensuring these resources are maintained, because in many instances, they represent the lion’s share of resources available to provide HIV care and services," he says.

"So while the process may be a bit more challenging, I think the outcome still is expected to be positive," he adds.