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

Trump leaves AIDS advocates feeling anxious


AIDS advocates are concerned about what President-elect Donald Trump will do to health care programs. Photo: Courtesy ABC News
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The election of Donald Trump has left many people with HIV, their medical providers, and advocates feeling uncertain and anxious. Although Trump said little about HIV during the presidential campaign, his opposition to the Affordable Care Act and his conservative Cabinet picks suggest many of the advances of the Obama years may be rolled back. But all agreed that it is hard to predict specific details.

"There are serious threats to Medicaid, insurance marketplaces, and Medicare looming," said Anne Donnelly of Project Inform. "The plans are also an attack on entitlement programs, which, of course, means that when you most need them, there will not be enough money to cover people."

Tim Horn of Treatment Action Group listed other areas of concern including National Institutes of Health funding for HIV vaccine and cure research, looser Food and Drug Administration approval requirements, Centers for Disease Control and Prevention support for health departments and community-based organizations, the Ryan White HIV/AIDS program, the Housing Opportunities for People with AIDS program, the President's Emergency Plan for AIDS Relief, and even provisions of the Americans with Disabilities Act.

"What's really concerning is that we now have the most conservative and potentially dangerous federal government in U.S. history," Horn told the Bay Area Reporter. "Fortunately, there's a history of bipartisan support for federal programs addressing the prevention and care needs of people living with and vulnerable to HIV. We need activism now more than ever."

Advocates are equally wary of Vice President-elect Mike Pence, who was governor of Indiana during a 2015 HIV and hepatitis C outbreak traced to opioid injection. In Congress, Pence was among the first legislators to propose defunding Planned Parenthood, which provides HIV testing and other sexual health services in addition to reproductive health care.

"We now have a vice president who set the conditions for an HIV outbreak in his state by ignoring the signs of a potential epidemic," said Gregg Gonsalves of Yale's Global Health Justice Partnership. "After the epidemic started he refused to act and started praying. By the time his prayers were over and he decided to allow needle exchange, close to 200 people had gotten infected and his actions were too little too late. He cost his state millions of dollars by his willingness to let ideology trump public health."

This week Trump nominated Congressman Tom Price (R-Georgia), an orthopedic surgeon who has repeatedly attempted to repeal the ACA, as secretary of Health and Human Services – a position that oversees the Center for Medicare and Medicaid Services, the CDC, the FDA, the Health Resources and Services Administration, and the NIH.

Advocates are also worried about what a Republican Congress will do once it is free of President Barack Obama's veto power. For example, House Speaker Paul Ryan (R-Wisconsin) has expressed a desire to dramatically restructure the Medicare program for seniors, replacing it with tax credits to purchase private insurance.


Threats to the ACA

Throughout the campaign Trump promised to repeal and replace the ACA, though he offered little detail about what he planned to replace it with other than "something terrific." The Congressional Budget Office estimates that repealing the ACA could leave 22 million Americans without health coverage.

Trump and his allies in Congress have suggested that they wish to keep popular features of the ACA, such as allowing young people to remain on their parents' insurance until age 26 and banning exclusion of people with pre-existing conditions, while getting rid of less popular aspects like the insurance mandate. But most health policy experts think these cannot be separated.

"Because repealing Obamacare has been an ongoing Republican mantra and a focal point of Trump's campaign promises, it is hard to see how they could completely back off," said Donnelly. "And unfortunately there are a number of things that they can do that don't require a majority vote."

Republicans currently hold a majority in both the House and Senate, but not by a wide enough margin to pass most legislation on their own. However, they can use the reconciliation process – which requires only a simple majority – to quickly reverse aspects of the ACA that involve federal spending, such as the subsidies that enable many low- and middle-income people to afford insurance.

"In a climate of uncertainty, will insurance companies pull out? They're already leaving exchanges, but will that happen at a greater rate?" asked Wendy Armstrong, chair of the HIV Medicine Association. "There could be a collapse, even if the ACA is not fully repealed, before a replacement is sorted out."

One Trump proposal is to switch Medicaid (Medi-Cal in California) from an individual entitlement program to block grants to states.

Medicaid covers about 40 percent of people with HIV and is responsible for 30 percent of all federal funding for HIV care, according to the Kaiser Family Foundation. Before the ACA expanded Medicaid to cover people up to 138 percent of the federal poverty level – in states that opted to do so – HIV-positive people generally had to become sick enough to be considered disabled before they qualified.

States are allowed to use Ryan White funds to cover Medicaid or private insurance premiums, deductibles, and co-pays for people with HIV. But if Medicaid funding shrinks, that puts the onus back on the joint federal-state AIDS Drug Assistance Programs, or ADAPs, which pay for antiretroviral medications but not general health care.

"Ryan White has had great bipartisan support over the years and there hasn't been talk of dismantling it, but any cuts to the ACA or Medicaid will make Ryan White ever more important for HIV care and wrap-around services," Armstrong told the B.A.R.


Global funding and harm reduction

Some advocates predict that global HIV/AIDS funding, such as PEPFAR, could fare better than domestic programs.

"George Bush got PEPFAR started and it's always been considered a bipartisan thing," said Hilary McQuie of HealthGAP. "But Paul Ryan has proposed cutting billions from discretionary funds, and that covers global health funding. It seems very unlikely under Ryan's budgets that we'd get the $2 billion extra we need to ramp up the response to end AIDS by 2030."

McQuie also expressed concern about the return of restrictions in place during the Reagan and Bush years that hampered global AIDS prevention and care efforts.

"Abstinence-only, anti-gay policies, the anti-prostitution pledge, harm reduction not being funded – these threaten the ability to reach the key populations we need to reach most if we're going to end the epidemic," she told the B.A.R.

A Trump administration could undo some of the progress in harm reduction that has occurred under the Obama administration, including rescinding the ban on needle exchange funding and a shift toward treating drug addiction as a public health rather than a criminal justice issue. Efforts to go further – such as opening supervised injection facilities – appear even more remote.


A time for activism

Beyond dismantling specific health services, the communities at greatest risk for HIV also face further stigma and marginalization, including threats to same-sex marriage, denial of transition-related care for transgender people, criminalization of people who use drugs, and increased risk for undocumented immigrants.

"The kind of divisiveness we've seen during the campaign and in the weeks after the election makes me worry that more stigma and less acceptance will make our vulnerable patients less willing to access HIV prevention services and drive them away from pursuing care," said Armstrong.

Advocates stressed that proposed changes to the ACA and Medicaid are not yet in effect and may not be for quite some time. The annual ACA open enrollment period is underway now, until December 15.

"Sign up for health-care coverage – the more people who are receiving health care, the harder it becomes to dismantle it," Donnelly urged. "Start speaking up about your health care and why it matters to you and how the ACA and Medicaid expansion have helped you. Now is the time to be telling your story and organizing others to tell theirs."

Calling upon their experience during the worst of the AIDS years, people with HIV and their advocates are spearheading activism against Trump's agenda. In the days after the election HIV advocates launched an Activist-Led Emergency Response Team, and a Capitol Hill protest is planned for World AIDS Day.

"No one knows how bad the new administration could be in its intents or in its effects, but it could be very bad indeed," said Mark Harington of TAG. "We must forge ahead nonetheless in the face of these challenges and arm-in-arm with our allies and comrades who are facing essentially the same struggle. Too many lives are at stake, too much progress has already been achieved, and too many new discoveries are within our grasp to turn back now."


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