The election of George W. Bush to a second term as President of the United States, combined with an increase in the Republican majority in both houses of Congress and an increase in the conservative faction of the majority, is likely to continue ominous conditions for HIV/AIDS service organizations and for national HIV/AIDS public policy. While the specific details of any negative impact cannot be ascertained fully at this time, there is a nearly universal consensus within the HIV/AIDS community that the fight against AIDS will be threatened seriously, domestically and globally, by a second Bush term in office. The very real difficulties, attacks, and outright setbacks that were experienced in the first term give credence to the concerns over what will happen over the next 2 - 4 years.
Key factors affecting the overall impact of a Bush second term on HIV/AIDS will be the degree to which Mr. Bush's and his administration's tendency towards right-wing conservative ideological principles prevail and the degree to which a hard line, regressive approach on HIV/AIDS, especially the domestic HIV agenda, is promulgated to reward social conservatives and Christian fundamentalists for their support in the 2004 elections and appease those constituencies for their continued support. Again, the first term and some post-election actions suggest that conservative ideology and social conservative and religious viewpoints will continue to have a heavy influence on how the administration and Congress responds to the HIV/AIDS pandemic, here and abroad.
The impact on national HIV/AIDS public policy of a second term likely will be across the board and emerge over time. The impact on three areas, however, likely will be more immediate and very negative. These areas are Federal appropriations for HIV/AIDS, reauthorization of the Ryan White CARE Act, and health care access, specifically Medicare.
Mr. Bush's first term saw a marked reversal of the fairly steady increases (albeit at times incremental) in discretionary Federal funding for HIV/AIDS. For the past few fiscal years, Mr. Bush's Budget Requests basically have called for flat-funding for domestic HIV/AIDS programs and funding for global AIDS programs well below needed levels. Overall, Congress has adhered closely to the President's requests in passing the actual appropriations. When inflation and rising caseloads are taken into account, there has been an effective cutback in funding for domestic HIV/AIDS programs. The recently enacted omnibus appropriations bill for FY 2005 exemplifies this trend.
Nearly all Federal budget experts agree that the administration's FY 2006 Budget Request will call for an overall cut, for some individual programs deep cuts, in non-defense discretionary funding. With a strengthened Republican majority, Congress likely will continue to adhere closely to the administration's budget as it enacts appropriation legislation. The reduction in non-defense discretionary funding will be driven by the impact of the already enacted tax cuts, Mr. Bush's stated intent to make permanent many of the tax cuts, the record level deficit, the continuing and growing costs of the military campaign in Afghanistan and the war in Iraq, and the costs of homeland security. This reduction trend likely will continue in the out-years (FY 2007 and thereafter). According to a paper published by GalleryWatch and Federal BudgetObserver, the Federal Office of Management and Budget itself projects that over the next four years non-defense discretionary funding will be cut by $11.6 billion. If Mr. Bush is successful in achieving his goals of overhauling the Federal income tax and restructuring Social Security, the need for further cuts in non-defense discretionary funding may well exceed the OMB's $11.6 billion projection.
Given this context, Federal spending for domestic HIV/AIDS programs will be at best flat-funded and may well experience actual reductions (the Federal HOPWA program already has experienced a nearly $13 million reduction in funding, after the across-the-board recision, in the FY 2005 omnibus spending bill). Actual or effective reduced funding for the CARE Act and for domestic HIV prevention can be expected under the Bush second term.
Reauthorization of the Ryan White CARE Act
The current authorization of the Ryan White CARE Act expires on September 30, 2005.
While work on reauthorizing the Act has been underway, especially among HIV/AIDS public policy advocates, for the past 18 months, actual proposals from the administration were not expected until after the 2004 elections. Likewise, Congressional action was not expected until the new 109th Congress convenes in January.
With a second Bush term now a reality, the administration's thinking will have a major, if not overwhelming, influence on reauthorization. The most salient likely influence will be a further move towards the "medicalization" of CARE Act services, especially under Title I. If this trend is realized, then the result could be to render ineligible many or all of the mental health and social supportive services now funded under Title I. This would have a drastic, negative impact on the funding to AIDS service organizations, and other community-based organizations.
The administration, with the support of the majority in Congress, is also expected to call for changes in the funding formulas for Titles I and II. The stated intent of the administration's proposed formula changes will be to achieve greater funding equity among Title I jurisdictions and among the states, the District of Columbia, and the territories funded under Title II. A revision or outright elimination of current hold harmless provisions is expected to be proposed or at least supported by the administration and the Congressional leadership. If such proposals are enacted, and when applied to the above described funding scenarios, then the effect of the formula changes could be a major reduction in Title I and Title II funding to Northeast and West Coast jurisdictions, smaller reductions to Mid-West jurisdictions, and significant funding gains for Southern jurisdictions.
A further potentially negative factor for reauthorization is the election of Tom Coburn to the Senate. Mr. Coburn is a hard-core political and social conservative. As a U.S. Representative from Oklahoma, Mr. Coburn was a key player during the previous reauthorization of the Act. He is expected to try to play a similar leadership role even as a freshman senator. Mr. Coburn can be expected to propose changes and amendments to the Act that would promote abstinence-only programs, enhanced partner notification and contact tracing efforts, and the "medicalization" of HIV/AIDS services.
Health Care Access: Medicaid
Medicaid is the largest source of health coverage for people living with HIV/AIDS. In 2003, President Bush proposed to change the financing of Medicaid to a block grant, which would have eliminated the entitlement nature of the program in exchange for states receiving lump sums of Federal dollars. A block grant approach effectively would cap Federal Medicaid spending. A capped Medicaid program would essentially leave states "holding the bag" for increases in their Medicaid costs, especially during economic downturns or disasters/emergency situations. It is widely held by advocates that a capped Medicaid program would lead to capped enrollment, reductions in benefits, increased cost-sharing and increased numbers of the uninsured. Through tireless advocacy, consumer groups, including strong support from the HIV/AIDS community, across the country working closely with Congressional allies helped stop the President's proposal in 2003.
Health care experts widely expect Mr. Bush to revive his Medicaid capped entitlement and block grant proposal early in his second term. The common assumption is that the administration's Medicaid proposal will be entwined in the FY 2006 budget process. By "burying" Medicaid changes in the budget process and with a bigger Republican majority in Congress, the administration's Medicaid proposal will be much harder to defeat. In addition, the nationwide pressure on the states to cut their Medicaid costs may make many governors willing to support the administration in exchange for relief on their state budgets.
If Mr. Bush's proposals are enacted, then the impact on thousands of people living with HIV/AIDS likely will be negative to a significant, perhaps life-threatening, degree.
Impact on Other HIV/AIDS Public Policy Areas
Medicare is increasingly growing in importance to people living with HIV/AIDS, and is the second largest source of funding for HIV care. In late 2003, Congress passed the Medicare Modernization Act of 2003, which added a drug benefit (Part D) to Medicare. The law allows private drug plans to administer the drug benefit and create formularies and approval processes for accessing drugs. The most immediate concern to PWAs is the loss of Medicaid drug coverage on January 1, 2006 for dual eligibles (there are about 80,000 in the U.S. with HIV) without an immediate fall back for drug coverage in case they are not enrolled in a Part D plan. Other major concerns include the availability of antiretroviral and non-HIV prescriptions for PWAs, whether off-label use of medications will be covered, the appeals process for PWAs who are denied medications through their plans, and the ability of ADAP to wrap around Part D.
Prior to the 2004 elections, an advocacy hope was to influence the new administration's implementation of the Part D benefit and to work with Congress to make actual changes in the law that would mitigate negative impacts. The election results make changes in the law a dim prospect, at best. The administration's Mark McClellan seems amenable to addressing some of the concerns of the HIV community, but it is quite clear that implementing the benefit will take some time to work out, and PWAs run the risk of having their regimens interrupted while the problems in the system are fixed.
Prescription Drug Pricing
The increasing costs of prescription drugs is the biggest factor in keeping the increases in overall health care costs above the rate of inflation. The close relationship between the Bush administration and the pharmaceutical industry and the industry's strong lobbying efforts in Congress have blocked efforts to effect Federal drug price control policies. Again, the election results are not likely to change this situation. The lack of drug price controls is squeezing public programs and causing more and more employer-based plans to pass on costs their employees. States are forced to deal with the high price of prescription drugs in varying ways, some of which have the effect of limiting access to drug treatment. While New York State enjoys a relatively solid safety net to ensure access to needed medications, especially for people living with HIV/AIDS, New York is not immune to pressures to control rising drug costs. Attempts to enact a preferred drug list under Medicaid are an example.
Domestic HIV Prevention
Beyond the likely impact of flat or reduced funding for domestic HIV prevention programs, the second term of the Bush administration likely will continue the trend towards a more politically and socially conservative approach to HIV prevention that minimizes or even disregards sound public health science. The administration likely will continue to push for an increased emphasis on abstinence-only-to-marriage programs (which received a $30 million increase in the FY 2005 omnibus spending bill). The shift in priorities at the Federal Centers for Disease Control and Prevention away from primary prevention likely will continue. This will result in decreased funding support for efforts to reach and intervene with at-risk communities, especially among men who have sex with men, drug users, and women of color. Enactment of proposed guidelines for the review of HIV prevention materials, unless changed in light of comments from GMHC and others in the HIV/AIDS community, will also have a negative, chilling effect on the ability of community-based programs to produce materials that are appropriate for targeted audiences.
After a ten year period during which the NIH budget has doubled, a period of stagnant funding is likely with annual increases that are below the rate of biomedical inflation. For HIV/AIDS research, this likely will mean that little new research will be funded unless current projects are de-funded. An additional negative impact of a second Bush administration is the likely continuation of outright hostility towards the NIH's HIV/AIDS research program by the leadership at the Department of Health and Human Services and, some members of Congress.
A generally perceived impact of the last four years of the Bush administration has been an increase in the Federal government's attention to the global AIDS crisis. Mr. Bush's announcement of a major $15 billion initiative in his 2003 State of the Union Address and Congress's enactment of his proposed initiative underscored the administration's attention to the global AIDS pandemic. All too often, however, this has been more of a shift in attention from the domestic HIV/AIDS agenda to a focus on global AIDS. Moreover, the administration's approach to global AIDS has been characterized as being more unilateral than multilateral, as evidenced in the administration's stance towards generic antiretroviral drugs that have been approved by the World Health Organization. Also, funding for the President's global AIDS program has been well below expectations and even below the annualized amounts authorized by Congress. The administration has also allowed its approach to be guided by political and social ideologies over sound public health and the local needs of recipient countries.
These trends are very likely to be continued in the second term. An ominous indication of this was the recent strong opposition of the administration to the Global Fund's starting a fifth round of funding to initiate new programs.
A Bush second term and the results of the Congressional elections likely will stall any efforts to lift the immigration bar on entry to the United States by HIV-positive individuals. The administration is also expected to continue, and perhaps expand, the policy of discriminating against HIV-positive personnel in the military. Negative impact on HIV-positive immigrants was foreshadowed by the administration during its first term ending of PRUCOL, a previous option to petition the government for lawful stay used by many HIV-positive immigrants. Finally, the administration, in its first term, moved away from forceful Federal enforcement under the American with Disabilities Act (ADA) of disability discrimination laws, leaving enforcement to the states. Again, these trends are likely to continue, if not increase, in the second term.