Bush Offers Vision for U.S. AIDS Care

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Breakin’ it Down: The President’s AIDS Plan

By Kai Wright

There it was, wedged into an otherwise unsurprising litany of Bush administration priorities in this year’s State of the Union: the President’s wholly unexpected acknowledgement of the epidemic raging among African Americans. “Because HIV/AIDS brings suffering and fear into so many lives,” President Bush told Congress, “I ask you to reauthorize the Ryan White Act…. And as we update this important law, we must focus our efforts on fellow citizens with the highest rates of new cases, African American men and women.”

Since then, the AIDS world has waited on edge to hear what exactly the Bush administration would recommend doing to “update” the feds’ primary AIDS funding vehicle. On July 27, the administration finally released those much awaited recommendations. [See document on Housing Works AIDS Issues Update.] The list of reforms is packed with explosive ideas that have quickly turned up the heat on an already boiling pot of controversy surrounding this fall’s reauthorization.

First passed by Congress in 1990, the Ryan White CARE Act is a complex web of regulations governing the national network of programs that serve poor people living with HIV/AIDS. State and local governments directly oversee the programs, working in conjunction with a legally-mandated board of community members to decide how the money Washington allocates each year gets spent. Since the CARE Act is not an “entitlement” program like Medicaid or Social Security, Congress must reauthorize it every five years.

The act’s third renewal is due in September, and its passage is a foregone conclusion. But for the first time in its history Ryan White is likely to undergo significant changes this time around.

Southern states, which now boast six of the ten highest AIDS case rates, are clamoring for reforms. They argue the current structure leaves them unable to compete for resources with large northeastern and western cities. As a result, southern advocates conclude, their overburdened network of programs is unable to deal with the South’s exploding epidemic and is rapidly collapsing.

Meanwhile, large cities long seen AIDS’ ground zero complain that Washington’s commitment has waned during the war years, leaving them struggling as well. They warn that help for the South can’t come at the expense of now-struggling urban centers.

Both sides agree that the main problem is there’s not enough money to go around. Since 2001, Ryan White funding has remained all but level, even as the Centers for Disease Control and Prevention has reported the epidemic’s steady growth. In June, CDC announced that more people are living with the virus today than ever before — more than a million, half of whom are Black.

If Congress accepts the CARE Act funding proposal for next year that the White House submitted this winter, spending on the $2.1 billion program will have gone up just $276 million since 2001. The gulf between that number and what advocates say Ryan White actually needs is awe inspiring: another $513 million this year alone.

With these disputes as backdrop, here’s a primer on the administration’s most controversial reform ideas – and how AIDS activists above and below the Mason Dixon line are likely to react to them.

Drugs come first. The recommendation that will likely draw the most universal disdain calls for a new rule mandating that 75% of Ryan White dollars be spent on “core medical services.” What’s a core medical service? The recommendations are vague on that point, noting only that “some [services] are clearly life prolonging and essential to maintaining physical and mental health; others are not,” and suggesting that a definitive list of each be drawn up –- presumably by Washington.

The rumor mill’s been abuzz with anticipation of this idea for months, and care providers have uniformly cringed at it. They fear services like transportation assistance, food banks and support groups won’t make the “essential” list. But doctors treating the sorts of low-income patients who depend upon CARE Act programs note that these things, more than the meds themselves, make the difference between sick and well.

“The irony is, yeah, we’ve got your $10,000 worth of drugs for the year, but we can’t help you with the $15 cab fee to help you get here and pick ‘em up,” says Dr. Laurie Dill, who treats patients at Montgomery AIDS Outreach in southeast Alabama. “And I have patients that literally don’t have food in the house and can’t take their medicines on an empty stomach. The food bank helps fill in those gaps.… It’s real clear to me that the people who are least adherent [to their treatment plans] are the people who are least able to be adherent, because of all these other problems.”

Send the money south. The most controversial recommendations undoubtedly are those that pit North and West vs. South in the scramble for scare resources.

Ryan White hands out money to every state and territory based on the size of its statewide epidemic. But it then gives additional money to states that are home to one of 51 metropolitan areas deemed to be in a state of “emergency” due to the size of their localized epidemics.

Southern and rural activists complain that this formula ignores the emerging reality of today’s epidemic, where in many places AIDS is no longer concentrated in one urban area but rather is dispersed in pockets all over the state. Moreover, they argue, the states with one of the 51 “emergency” cities are double-dipping, because the AIDS cases in those cities are included in the state’s overall count as well. The administration agrees, though its recommendations do not spell out exactly what a new formula would look like.

Of course, the cities deemed in crisis argue that, well…they’re in crisis. Cutting off their funding may marginally help states with more dispersed epidemics, they point out, but it will come at the cost of retarding decades of progress in urban centers. “Our nation’s AIDS budget cannot be balanced on the back of poor people of color — whether in urban or rural America,” said Alandra Mitchell, an HIV-positive New Yorker, in a Housing Works statement reacting to the Bush proposals.

Be the last to pay. The CARE Act, like Medicaid and other social safety net programs, was conceived as a “payer of last resort” – meaning it’s only supposed to be for people who can’t get care through any other route, be it public or private sector insurance. Keeping with conservative politicos’ focus on eliminating fraud in social programs as a path to efficiency, the administration is convinced Ryan White programs have been too ready to care for people who have other options. So it recommends tougher auditing and reporting requirements to ensure the money’s being spent appropriately.

Free government from the community. Currently, law requires that states and cities maintain community boards that work in conjunction with health departments to spend the money feds give them. The administration is convinced this communal input has unnecessarily limited the “flexibility” of all-knowing bureaucrats who, freed from the pesky requirement, could efficiently end AIDS – or something like that. In any case, one recommendation sure to spark universal anger would allow state and local officials to cut the community boards out of the planning process and relegate them to a purely advisory role.

Kai Wright is editor of BlackAIDS.org

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