Issue:  Vol. 48 / No. 8 / 22 February 2018

The race to reauthorize Ryan White CARE Act


Representative Henry Waxman. Photo: Bob Roehr
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The Ryan White AIDS programs are set to expire on September 30 because of a sunset provision written into the last version of the law, unless Congress enacts a reauthorization of those vital services.

House Energy and Commerce Committee Chairman Henry Waxman (D-California) and health subcommittee chairman Frank Pallone (D-New Jersey) introduced a "discussion draft" for reauthorization of the Ryan White CARE Act a few days prior to a subcommittee hearing on September 9.

The draft was drawn from consensus recommendations signed on to by more than 300 community-based AIDS organizations, and comments from the Obama administration. It reflects only modest changes from the status quo.

AIDS advocates have been frustrated in trying to get anything more than vague principles out of the Obama administration. That was clear even at a special meeting between them held less than a week before the hearing, on September 3.

"They didn't offer any information on their position" on reauthorization, said Carl Schmid with the AIDS Institute. "We were disappointed that they hadn't been more forthcoming." Their position on some issues was still unclear at the hearing itself.

In his opening statement Waxman said, "Today some half million Americans rely on the program for basic care, treatment, and support services. It's hard to imagine how patients, their families, and our states would be able to deal with the epidemic without this program in place."

Pallone added that the proposal to extend the program for three years "is very much a draft and I am interested in having conversations with [Republicans] as well as with the Senate in an effort to come up with a strong piece of legislation that can be passed by both chambers and be signed into law by the president."

Republican members at the hearing echoed that sentiment and it appears that overall, bipartisan support for Ryan White remains strong.

One of the more contentious issues within the community and on Capitol Hill has been the "hold harmless" provision. Under the draft, it would protect areas first hit hard by the epidemic – cities like San Francisco, Los Angeles, and New York – by limiting any decrease in funding to no more than 5 percent the first year, and nothing in the next two years.

Areas where the epidemic has hit harder over the last decade, particularly the rural South where the caseload continues to grow most rapidly, have complained that they are getting only a fraction of the funds per patient that the "first wave" cities receive.

With only modest increases in funding for Ryan White there has not been adequate resources to both protect appropriations for the cities and bring other regions up to spending parity. Organizations in the South have pushed for a distribution of existing spending to be more equitable.

"From our perspective [the draft legislation] is a great starting point," said Bill McColl, political director of AIDS Action, which was initially formed by city-based AIDS organizations.

While the HIV caseload may be increasing faster in some areas than others, it is not going down in any part of the country. In San Francisco, rates are flat.

"You build up a certain level of infrastructure that you've got to maintain," McColl said. The solution is to find more money, which is difficult in the current "culture of deficit."

After the hearing Schmid was optimistic that reauthorization would move forward rapidly. A meeting of House and Senate staffers to work through details was scheduled for the next day. But when it was canceled at the last minute he said, "That is not good news, I'm not as optimistic now."

Behind the cancellation was the surprise naming of Tom Harkin (D-Iowa) to chair the Senate health committee, left vacant by the death of Ted Kennedy. Senator Christopher Dodd (D-Connecticut) had chaired the committee during Kennedy's prolonged absence but he will remain as head of the banking committee.

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