The Uneasy Calm before the Budget Storm

Posted in: News 2005-Older

Column: The Politics of AIDS

By Kai Wright

AIDS politicos making the rounds on Capitol Hill this summer must feel like they’ve been transported into the climax of “The Good, the Bad and the Ugly”—that unnerving scene in which three gunslingers stand at the points of a triangle, weapons at the ready, trying to sort out who is friend and who is foe before someone else pulls the trigger.

Since Congress created the Ryan White CARE Act 15 years ago, its mandatory re-authorization every five years has been a largely perfunctory process. There was always the back and forth about needing more money—which it usually got—and maybe some nibbling around the edges of reform. But with all players feeling the crunch from recent years’ “war budgets,” and Southern states pushing hard for major reforms this time around, both the stakes and the tensions are running high in Washington.

Old alliances within the AIDS lobby are being strained. Activists pushing major reforms are finding key supporters among one-time enemies. And everybody’s waiting for the Bush Administration to make the opening move.

Conservative Republican gadfly Sen. Tom Coburn (Okla.) tried to jumpstart the process with a hearing in his Homeland Security & Governmental Affairs Subcommittee late last month. It was an odd setting for an AIDS budget hearing, but still more bizarre was Coburn’s uncharacteristically light hand in broaching the most controversial issue on the summer’s agenda: How to balance the need for a massive infusion of resources into Southern and rural states without stealing it from the big cities that have long been considered the AIDS frontline.

In strong but careful language, Coburn called for reforms that would gut two sacred cows in the federal AIDS budget process. Currently, Washington distributes money to states based on a complicated formula that favors 51 metropolitan areas deemed to be hotspots, a designation which is based on their number of AIDS cases rather than their tally of new HIV infections. That formula also includes a “hold harmless” clause that guarantees a certain percentage of the previous year’s funding will remain in place for each state and each of the hotspot cities.

Critics like Coburn argue that these aspects of the formula give places that were hit early by the epidemic new money every year to care for people who are long since dead, while those where the epidemic is just heating up today are left with crumbs. San Francisco is the primary beneficiary. According to a June 23 Government Accountability Office study, San Francisco collected 90 percent of the “hold harmless” funds doled out in fiscal year 2004.

Meanwhile in the South, which is home to seven of the 10 states with the nation’s highest HIV case rates today, service providers and AIDS Drug Assistance Programs face annual budget shortfalls. Four of the six states with the longest waiting lists for people to get meds from the AIDS Drug Assistance Program are in the South. This, while some states that have old hotspots end the year with unspent funds.

And so lobbyists for southern states with new epidemics have taken up their post at one of the points of the gunslinger triangle, while advocates for the old hot spots have staked out another.

Both have been leery of saying too much too early about what they will and will no support, but righting the funding scales will no doubt be complicated. Congress has flat-funded the CARE Act every year since 2001, and has actually cut the money going to the 51 hotspots. A number of those cities have found themselves slashing basic services like addiction treatment and support groups. So with a shrinking pool of money, even as the epidemic has expanded to a larger number than ever before, reforming the system necessarily means leaving somebody with inadequate resources.

One popular solution, floated by the Bush Administration earlier this year, would be to allow money not spent at the end of the year in one state to flow into the coffers of those that are dealing with budget shortfalls. Currently, states can’t even use their own unspent funds the next year.

Another solution would be to factor HIV cases into the existing funding formula. The GAO report found that, if that had happened last year, about half the states would have gotten more money—mostly in the South—and half would have gotten less. The problem with counting HIV cases, however, is that there is no uniform national system for monitoring HIV. Only 32 states use the name-based HIV tracking system that the Centers for Disease Control and Prevention has endorsed.

But the real fear is that the White House recommendations everyone now awaits will make the job still more difficult. Washington insiders worry those recommendations will include a push to focus CARE Act spending on “core” services—which means cutting funding for things like transportation assistance and case management, things that most AIDS service providers consider essential to successfully treating the people who are most severely impacted by the epidemic.

Whatever happens when the shooting starts in earnest, the process is certain to make previous reauthorization negotiations look like love fests.

Kai Wright, a writer in Brooklyn, New York, is editor of

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