President’s budget concerns advocates

Prevention money cuts are dark omen

President George W. Bush expressed support for the reauthorization of the Ryan White Care Act in his State of the Union address, but his budget for the 2006 fiscal year provided mostly flat funding. AIDS advocates say cuts in prevention activities are a sign that trouble is ahead for state budgets and AIDS service organizations struggling to provide prevention, care, and other services to growing HIV populations.

"The president talked about the Ryan White Care Act and the need to attend to the HIV epidemic among African Americans in the State of the Union address. Less than a week later, he launches a budget with not one dollar more for minority AIDS initiative prevention," says Paul Feldman, public affairs director of the National Association of People with AIDS (NAPWA).

"Given his rhetoric around the need to attend to the AIDS epidemic among African Americans, the fact that he didn’t fund the instrument designed expressly for that purpose makes the point that talk is cheap," he adds.

It hasn’t escaped Feldman’s and other AIDS advocates’ notice that while the overall HIV spending picture is bleak, the president did find money to increase abstinence-only education, which recently was criticized for inaccurate curriculum.

"It bugs me a lot that we’re letting politics a nd ideology get in the way of public health and attending to the most vulnerable among us," Feldman says. "AIDS is a disease of poverty, and most people living with AIDS in this country are poor. They need help to get care and treatment and prevention services."

Flat funding through 2006

HIV/AIDS spending for the fiscal year 2005 was cut across-the-board because of a 0.80% rescission included in the Omnibus Appropriations bill. While the percentage is small, it came on the heels of several years of flat funding, and the president’s FY 2006 budget makes it clear that next year’s funding will be as bleak, AIDS advocates note.

"The Ryan White Care Act has been flat funded another year, except for a small increase to the AIDS Drug Assistance Program (ADAP)," says Carl Schmid, director of federal affairs for The AIDS Institute in Washington, DC.

"So it’s disappointing we’re not getting higher increases. We’re going to have to take our arguments to Congress to get increased numbers, and we haven’t been that successful in current years," he adds.

Meantime, HIV caseloads are on the rise because of new infections and people living longer with HIV, Schmid says.

ADAP funding was offered by the president’s proposal of a $10 million increase, which is a small fraction of the $250 million increase requested by ADAP advocates and the AIDS Budget and Appropriations Coalition, which would like to bring total ADAP spending for FY 2006 to $1.037 billion to meet the funding challenges of a program now burdened heavily by waiting lists and growing need. (See AIDS Budget Coalition's chart of HIV funding for FY 2005 and what's needed for 2006.)

CDC prevention activities were cut by $4.6 million, 0.05%, and the housing budget for people with AIDS was cut $13.7 million in the president’s proposed budget, says Mark Del Monte, JD, director of policy and government affairs at the AIDS Alliance for Children, Youth & Families.

"The housing cuts come on the heels of a cut last year for that program of $13.1 million," he adds.

"I think, generally, the president’s commitment to reauthorization of the Ryan White Care Act and increased support for ADAP in this budget environment are positive things," Del Monte says.

"On the other hand, we’re faced with a situation of overwhelming need, and we’ve got to find a way even in tough budget times to meet our basic obligations to people with HIV or who are at risk for HIV infection," he explains.

Cuts to Medicaid?

AIDS advocates say they fear an even bigger problem if the signs coming from the Bush administration about Medicaid changes are followed through.

Mike Leavitt, the new secretary of Health and Human Services (HHS), spoke to the World Health Care Congress Feb. 1, 2005, about Medicaid, in a speech, "Medicaid, A Time to Act."

"The most important signal, the secretary said, was the Bush administration’s interest in blowing out guaranteed entitlement to needed medical service," says Michael Kink, legislative counsel for Housing Works Inc., based in New York City. Housing Works relies heavily on Medicaid and private donations to provide medical care and other services to HIV patients.

Housing Works, HIV Medicine Association of Alexandria, VA, and NAPWA were among about 300 organizations that sent President Bush a letter, dated Jan. 26, 2005, requesting he not propose cuts in Medicaid funding or make any changes in the program’s structure that would alter the open-ended financing for states.

"Medicaid works so well for HIV/AIDS because it covers necessary benefits and services for people who qualify," Kink says. "The Bush administration would like the states and private companies like HMOs to decide how much and what kind of medical treatment folks would get."

This practice would lead to HMOs deciding which antiretroviral drugs and high-cost interventions they would cover or not cover, he notes.

"Right now Medicaid is an entitlement, and in most states if it’s needed and you’re covered, you can get it. What we’re looking at [with the Bush plan] is not just the creation of 50 different Medicaid programs, but probably thousands of different Medicaid benefits, depending on how much a state is willing to give power to private companies and depending on how much private companies are willing to spend on beneficiaries," Kink explains.

Leavitt suggested the change would enable Medicaid to expand to more people who need some help, while reducing costs by eliminating some high-cost care. In his speech, Leavitt said, "Wouldn’t it be better to provide health insurance to more people, rather than comprehensive care to a smaller group? Wouldn’t it be better to give Chevies to everyone rather than Cadillacs to a few?"

Leavitt’s words and other signs coming from the Bush administration have led to a belief among AIDS advocates and others that there soon will be a dramatic Medicaid restructuring proposal with the primary aim of limiting federal Medicaid expenditures, says Christine Lubinski, executive director of the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA).

"He forwarded such a program two years ago, and it didn’t take off," she points out. "But he has strengthened his support in Congress, and the concern is that with resources needed to continue the war and make tax cuts permanent and revamp Social Security that Medicaid is one of the places where he’s looking to get some of those resources."

Medicaid expert Jeffrey Crowley, MPH, project director at Georgetown University’s Health Policy Institute in Washington, DC, says the gist of Leavitt’s speech is that the government needs to protect critical services for children, the elderly, and people with disabilities — the mandatory populations — while not providing comprehensive coverage to optional populations.

The problem with that logic is there is no distinction with regard to disability or medical needs between the mandatory and optional populations, he says.

"The distinction is income," Crowley explains.

People who live on disability income are subsisting on money that still puts them below the federal poverty level, but if their low income is $5 more than the Medicaid cutoff for mandatory populations, then it would mean their benefits are cut off, he notes.

"The vast majority of adults with AIDS qualify because they are disabled, so we’re not talking about people who are healthier and need coverage less than others," he adds. "We’re talking about people who are severely disabled by AIDS and have $5 more in disability payments than others."

What would happen on the proposal that Leavitt discussed is that the people administering Medicaid funds could make arbitrary decisions about whether to cover new medications for HIV treatment or whether to provide coverage for other medical care to some disabled people, Crowley says.

"The [Bush administration] is saying that states should be able to say to optional coverage people that they’ll give them fewer benefits than other people," he notes.

"They start going down this road and pick winners and losers, and it’s all based on politics and the budget — a very dangerous road to travel," Crowley adds.