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Ask a Policy Wonk: At Stake for People with HIV in the 2012 Election?

, by Reilly O'Neal

On November 6, U.S. voters will choose the person we want to lead our country for the next four years: incumbent President Barack Obama, or former Massachusetts Governor Mitt Romney. Among those voters will be people living with HIV, as well as their families, friends, care providers, and others working to end HIV/AIDS.

What’s at stake for them in the 2012 election?

BETA put this question to San Francisco AIDS Foundation’s Director of Legislative Affairs, Ernest Hopkins, and Courtney Mulhern-Pearson, Director of State and Local Affairs. Hopkins and Mulhern-Pearson lead our legislative advocacy efforts at the national, state, and local levels, working with elected officials toward policy that supports HIV prevention and care and preserves funding for vital HIV programs and services across the country.

. . .

BETA: How will the results of the 2012 presidential election affect people with HIV?

Ernest Hopkins: The most important outcome from the election is whether the Affordable Care Act [ACA] designed by President Obama will be maintained or repealed. Health care access for 30 million uninsured Americans is at stake, and the myriad changes to health systems that are underway at the federal and state levels could be undermined by any decisions by a new presidential administration that opposes the legislation.

Courtney Mulhern-Pearson: Currently, too many people with HIV can’t purchase insurance—either because their HIV is considered a pre-existing condition or because it’s simply too expensive to purchase insurance. So the ACA’s removal of the pre-existing condition barrier is hugely important for people with HIV and would mean many people have access to health insurance for the first time ever.

If Governor Romney becomes president, he has said he will repeal part, if not all, of the ACA. In the first presidential debate last week, he talked about keeping the pre-existing condition change but getting rid of the individual mandate. The individual mandate means everyone has to buy insurance, which ultimately helps finance the other changes in the ACA. Without the individual mandate, you end up with only sicker people in the insurance pool, and that makes health insurance prohibitively expensive. I’m not sure how Romney would be able to make insurance attainable for people with pre-existing conditions without the individual mandate in place.

BETA: Another important part of the ACA is the expansion of Medicaid, right? That’s the program run jointly by the federal and state governments that offers health care to low-income people with disabilities, among others. If that part of the ACA were dismantled, what would it mean for people with HIV?

Courtney Mulhern-Pearson: Medicaid is already the largest payer for medical care for people living with HIV. As it stands now, the expansion would make even more people eligible for health care coverage under Medicaid; in California we are estimating that as up to 70% of currently uninsured people with HIV would be eligible for the expanded Medicaid if Obama wins and the ACA is implemented.

Under the ACA, the federal government matches 100% of the funds put in by the states for the first two years, and then gradually it drops down to a 90% federal match. Romney has talked about block-granting Medicaid instead, which means the federal government would give grants of fixed amounts to the states and have them run their own Medicaid programs. That’s potentially problematic for people with high-cost medical conditions like HIV disease, because then you have less guarantee that the proposed per-capita cap in the Medicaid program would be sufficient to meet the costs associated with your annual medical needs.

You also have states with a really low commitment to their Medicaid program. Currently, the program has a “maintenance of effort” requirement—the states have to put in a certain amount of money and run their program according to a set of basic standards in order to qualify for the federal matching funds. I don’t know what that would look like in states that refuse the matching funds and refuse to expand their Medicaid programs—what their commitments to Medicaid would be if they didn’t have those requirements from the federal government.

Ernest Hopkins: For a state like California, which decided to implement health care reforms early—well in advance of many important federal regulations and rules being finalized—any retrenchment in the federal commitment to widespread coverage would harm our progress immeasurably. The state gambled that if it acted proactively, it would not be cut off if it went out on a limb. Many California citizens are out on that limb and vulnerable to any federal change that would hamper full implementation of the ACA.

Courtney Mulhern-Pearson: If the election favors Obama, we move even more full-force forward with health care reform implementation.

BETA: What other aspects of the two candidate’s plans should voters be paying attention to?

Courtney Mulhern-Pearson: I would encourage people to understand the candidates’ commitment to maintaining the “safety net” of supportive programs for people with HIV and public health programs that work toward preventing new HIV infections.

If all the talk is of reducing the deficit without any mention of revenue, then you have to look at Medicaid, Medicare, the Ryan White HIV/AIDS Program, HIV and sexually transmitted infections prevention programs at the Centers for Disease Control and Prevention [CDC], and the National Institutes of Health [NIH]—all of those programs become a lot more vulnerable to some pretty serious cuts.

Ernest Hopkins: Programs like Ryan White, which enjoys broad bipartisan support, and others like HIV prevention at the CDC—which is a perennial target as a surrogate for anti-gay attacks—are all under review in the context of the next federal budget and health care reform.

In a new administration, I’d say the prioritizing of HIV/AIDS both domestically and globally is at risk and the likelihood of sustained commitment to the National HIV/AIDS Strategy is minimal.

BETA: Ernest, can you explain what “sequestration” is, and how it might affect HIV prevention programs and services for people with HIV?

Ernest Hopkins: The Joint Budget Committee established by Congress could not agree on a bill to reduce the federal deficit, which resulted in something called “sequestration,” where federal money that would ordinarily have been allocated to various agencies is essentially locked up and spending cuts are triggered. If the Congress is unable to agree to an explicit  fix that ends the sequestration, those “sequester cuts” will be enacted automatically in January 2013.

So what would be the direct impact of the sequester cuts on HIV/AIDS programs? Medicare and Medicaid are largely protected, but they would receive a 2% cut—or an $11 billion reduction, largely targeted to payments to care providers. Also, the program-management lines at the Center for Medicare and Medicaid Services, which administers both programs, would be subject to $63 million in cuts that would undermine effective implementation of the ACA.

Funding for the Health Resources and Services Administration would be cut by $605 million, which would mean 12,900 people lose access to lifesaving medications through the AIDS Drug Assistance Program (ADAP).

The Department of Housing and Urban Development’s Section 8 vouchers would be cut by at least 8.2%, as would Housing Opportunities for People With AIDS (HOPWA). An estimated 5,000 people with HIV would lose housing support through HOPWA alone.

CDC funding would be cut by $490 million, of which $64.5 million would come from HIV/AIDS prevention services. The NIH budget would be reduced by $2.5 billion, resulting in the immediate elimination of 2,500 grants—517 of them directly related to HIV/AIDS. The Substance Abuse and Mental Health Services Administration would also lose $275 million.

BETA: How does the outcome of the presidential election change that budget scenario?

Ernest Hopkins: If Romney wins and the Congress enacts the budget proposed by his running mate, Representative Paul Ryan, there would be minimum cuts of 22% per year for HIV programs, including HOPWA, Ryan White, and HIV prevention at the CDC. That’s on top of the 8.2% cuts required by sequestration!

If President Obama wins a second term, there are indications that the Congress will quickly cut a deal that alters the sequestration to avoid those budget cuts. But regardless of who wins the presidency, if the Congress is unable to come to agreement before the end of the calendar year, sequestration cuts will automatically enact and the U.S. will go over the fiscal cliff.

These cuts must not be enacted and we are doing what we can to ensure that this level of budget cut is not considered.

. . .

Editor’s note: Just as other BETA articles do not endorse a particular drug or prevention strategy, this column is not intended to endorse a presidential candidate.

What BETA does endorse is informed decisions about the leaders and policies that affect our health and our communities. Whichever way you cast your vote on November 6, make sure it’s an educated choice.

Reilly O’Neal is a freelance writer and former editor of BETA.



3 Responses to Ask a Policy Wonk: At Stake for People with HIV in the 2012 Election?

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