WASHINGTON – As President Donald Trump stood before a joint session of Congress for his State of the Union address, he urged Republicans and Democrats alike to support the audacious goal of halting the spread of HIV within a decade. “Together, we will defeat AIDS in America and beyond,” he declared that February night.
The White House budget, issued this week, does propose an additional $291 million next year as a down payment for a new HIV initiative. Yet the $4.7 trillion budget also calls for sharp spending reductions on Medicaid, the public insurance program for the poor on which more than two in five Americans infected with the virus depend.
Such a contradiction – giving while also making major cuts – runs through the budget arithmetic for many of the Trump administration’s health-care priorities. In addition to combating HIV, the president has taken aim at childhood cancer and the opioid crisis, but his budget would undermine all those efforts by shrinking the health infrastructure that people struggling with those issues rely upon while throttling back national cancer research spending – even as it offers discrete pots of money for those causes, say policymakers.
“If you’re cutting Medicaid, you’re taking the legs out from underneath the system” of help for people infected with the AIDS virus, said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation.
On combating the opioid crisis – another promise mentioned in Trump’s State of the Union speech – Keith Humphreys, professor of psychiatry at Stanford University, called the budget “really negligent on a grand scale.” Like HIV, Medicaid is the top payer for addiction treatment, paying $1 billion a year, and cuts in that program – as well as in Medicare – swamp anything else the government says it’s doing.
“If you slash Medicaid and Medicare, you are taking far more out of the pool than you are putting in,” Humphreys said. And he criticized the budget’s recommendation to eliminate most of the funding for the White House’s Office of National Drug Control Policy – an idea Trump has woven into all three of his budgets.
“You have an office in the White House uniquely positioned to do policy on the epidemic,” Humphreys said, “and now you are going to cut it.”
On childhood cancers, the White House’s fiscal blueprint would increase funds for research by $50 million next year – another priority in the president’s State of the Union speech – but would reduce overall funding of the National Cancer Institute by $897 million, nearly 18 times that amount. The budget also would devote $4.8 billion at the Department of Health and Human Services to stem the opioid epidemic, while eliminating almost all the funding from a White House office in charge of curbing illicit drug use.
And despite the president’s promises not to harm Medicare, his budget envisions a constellation of changes that would decelerate spending on the popular program by $845 billion over the next decade – with the largest savings related to payment reductions to providers and new efforts to combat fraud and abuse.
Some of the budget’s boldest ideas for redefining health-care policies are unlikely to move off the page, having been rejected during Trump’s tenure even when Congress was in full Republican control – with less momentum now that Democrats hold the House. Chief among these is the call to convert Medicaid from its half-century history as an entitlement program, in which the government pays a certain share for anyone eligible, to state block grants or per-person caps that impose a strict pending ceiling regardless of what happens to the economy.
On Capitol Hill, early bipartisan support appears to be emerging for the HIV and pediatric cancer funds. Republicans as well as Democrats pushed back this week against reductions for the National Institutes of Health and its cancer institute.
“I was alarmed to see” the cut for NIH’s cancer research, Rep. Fred Upton, R-Mich., a former House Energy and Commerce Committee chairman, told Health and Human Services Secretary Alex Azar at a subcommittee’s hearing Tuesday on the budget.
“I understand the pain,” Azar replied, saying the cut was in proportion to an overall 12 percent reduction in HHS’s budget. “It’s a tough budget environment.”
Democrats were even more vehement about the nation’s main source of insurance for the poor. “If this administration is serious about block granting or otherwise redefining Medicaid as we know it,” Rep. G.K. Butterfield, D-N.C., warned Azar, “we are going to be in for a real firestorm, not just from Congress but from the American people.”
Charles “Chip” Kahn, president of the Federation of American Hospitals, said that, even though “for every president almost, there is this notion of a budget being dead on arrival, and that generally is true,” the policy priorities enumerated in Trump’s budget should be taken seriously.
“Budgets have a lot of purposes – setting priorities and making political statements,” Kahn said, so the proposals “give a certain credibility. It gives people cover for changes. ‘Well, it was in the president’s budget, so it must be okay.’ ”
Previous presidents, including Barack Obama, sought to slow spending on Medicare, in part to lengthen the life of a financially fragile trust fund for a section of the program that covers hospital stays. But this year’s budget “is at a different level and has broader implications,” proposing to slow funding for medical education, and reduce reimbursements to physicians and hospitals that care for a large share of patients who cannot afford to pay for their bills themselves, Kahn said.
The Medicare changes would not directly affect benefits for patients, although their care could be affected if physicians leave the program because they object to lower payments.
The proposed changes to Medicaid, however, could have profound effects for people with HIV infection, as well as those battling addiction. Medicaid is the largest single source of health insurance for both drug-addicted and HIV-positive people, Kaiser figures show.
In particular, the budget’s goal of ending the expansion of Medicaid under the Affordable Care Act “will harm our efforts toward ending HIV,” said Carl Schmid, deputy executive director of the AIDS Institute. The expansion in about three dozen states “has been critically important for HIV,” Schmid said, because it has, for the first time, allowed single men and women who are infected to get coverage even if they don’t have full-blown AIDS, which has long been considered a disability that makes people eligible for the program.
Advocates say that the budget’s funding for the HIV initiative, while welcome, falls short of what would be needed to meet the president’s goal of stopping the virus’s spread within a decade. Of the $291 million, Schmid said, close to $60 million consists of funds already being spent for community health centers and other purposes.
And a central strategy – identifying people in communities that are “hot spots” for the disease and giving uninfected people a protective pill known as PrEP – costs about $20,000 a year per person, experts say. The Centers for Disease Control and Prevention estimates that 1.1 million people should be on the medication – many more than the money in the budget could cover.
“It’s great to have this issue on the radar, and it’s great to finally see new money,” said Rochelle Walensky, an infectious disease specialist at Massachusetts General Hospital. “But those numbers give you a sense of how we are going to think about this.”
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