Sen. Bernie Sanders of Vermont shares with former vice president Joe Biden the distinction of being one of only two candidates in the Democratic nominating contest whose political career spans the entire course of the HIV epidemic. Yet, among all the candidates running to be president, Sen. Sanders alone is the one most likely to use his administration to end the epidemic.
Sanders is an unwavering advocate for universal access to high-quality, affordable medical care, ready to deploy government resources without stigma, and willing to respond to pressure from activists and experts in an iterative approach to policy-making. To push the current public health response to the point where we can eradicate the virus as a continued global threat will require a president who can demonstrate these attributes.
Since he was first elected mayor of Burlington, Vermont, in 1981, Sanders has shown his commitment to people-centered policies and governance. At a time when Ronald Reagan used the Oval Office to push market-oriented economic policies that promised tax cuts and deregulation, Sanders fought developers in favor of affordable housing, cooperative food markets, and public access to the city’s waterfront. As Reagan ignored the unfolding AIDS crisis (he wouldn’t formally address it until 1985, when 12,529 Americans had already died of the disease), Sanders signed a city ordinance banning housing discrimination against LGBTQ people and supported Burlington’s first Pride celebration. As the conservative movement built a society in which the private sector was deemed to be the antidote to the “problem” of government, Sanders used his powers as mayor of Burlington to create a progressive society in which the government played a critical role in creating a dignified life for its residents.
The delivery of funds and services to address the HIV epidemic still bears the philosophical imprint of Ronald Reagan. The federal government disburses funds to a national patchwork of state agencies, local nonprofits, and service organizations that cycle the money to private insurers, medical providers, and pharmaceutical companies at the center of our current system of health care delivery.
At the federal level, Sen. Sanders has advocated for a single-payer, government-managed health care system in the United states since at least 1993. He likes to remind voters that he wrote the damned bill on Medicare for All—without such a system, there’s simply no way to end the epidemic.
Under a system of universal health care paid for by the government, no person would find themselves in the situation where an HIV diagnosis is also an introduction to the complexities of finding and sustaining ongoing medical care. Science has made HIV a disease manageable with effective treatment, but only for those who have the capacity to access it consistently. Every year, 7,000 people die of causes attributable to HIV, and a contributing factor to these deaths is the difficulty of navigating the system—from testing to the corollary mental health and social services—following a diagnosis that makes it easier to maintain an effective treatment regime.
Any system of care that puts the burden of accessing it on the person who needs it, whether filing claims with an insurer or managing the paperwork necessary to be offered services under the AIDS Drug Assistance Program (ADAP), is going to be less effective in ending the epidemic.
But it isn’t simply a matter of testing and treatment for HIV. For the populations most at risk of being exposed to the virus, the current system is ineffective at meeting their needs. In 2017, 70% of new HIV diagnoses occurred among gay and bisexual men. As of 2014, the Kaiser Family Foundation reported that just over a quarter of gay men felt uncomfortable discussing their sexual health with their doctors. In the same year, 83% of the cases of primary and secondary syphilis involved men who have sex with men, and syphilis is one of many sexually transmitted infections that increase the likelihood of HIV infection.
Under a system of Medicare for All, the sole purpose of the health care system would be to provide the best health outcome for the people in the system. Yet, that objective exists at the opposite end of the spectrum from a system of predominantly private health care industry—one that is sustained nonetheless by public support via research grants, tax incentives, and direct payments. Drug manufacturers, medical device companies, and their distributors make money treating chronic diseases, not curing them. The income of private insurers is derived by limiting the costs they must cover; and individuals who access the health care system most frequently—those with the greatest need for care—are the most costly for insurers. The existing system is a battle among providers of health services, those who produce drugs and equipment, and those facilitating the payments for the largest share of the total income of the system.
As a result, most policy considerations regarding health care are related to who has the most economic and political power within this framework. Until policy exists only to eliminate barriers between a patient and her doctor, the system of health care in this country will be incapable of ending the epidemic. More importantly, a health care system that is not centered on the doctor-patient relationship and achieving the best health outcomes for the patient, is one in which all areas of public health policy will be inherently politicized.
Nowhere are the politics of public health more apparent than in the fight to end the HIV epidemic. Since the earliest days of the AIDS crisis, stigma and bias attached to populations most at risk for exposure to HIV have defined the politics of the disease. Racism, homophobia, and a disregard for the root causes of addiction have created a cultural adhesion to the idea that HIV is not a problem of sufficient concern for those who find themselves at very low risk. A system of universal health care, if managed in a way that makes it genuinely accessible to all, will exist beyond the reach of the bigotry now used to ration care. The politics of who gets funding for HIV-related services, how much, and where will disappear.
Despite these benefits, a system of universal health care won’t matter if it can’t be fully implemented. Over the course of the Democratic primary contest, Sanders’ opponents have indicated that getting to such a system is an unlikely possibility with a Republican-controlled Senate. As mayor of Burlington, Sanders worked creatively to implement his agenda for the city. As The Nation described it, “He encouraged grassroots organizing, adopted local laws to protect the vulnerable, challenged the city’s business power brokers, and worked collaboratively with other politicians to create a more livable city.” It’s a strategy he intends to replicate on a larger scale as president.
It’s conceivable that Sanders would use his authority as commander-in-chief to open Veterans Administration (VA) hospitals to the general public for medical care. If Trump can use military funds to build the wall he promised Mexico would pay for, Sanders can use VA hospitals to deploy a system of universally accessible health care to the American people. And given his record of opposition to the extension of Gilead’s patent for Descovy (emtricitabine/tenofovir alafenamide), there’s little doubt that he would use his administrative authority to enable the immediate production of generic drugs necessary for pre-exposure prophylaxis (PrEP). Without a doubt, he would use his budgetary authority to increase research funding to the National Institutes of Health, Centers for Disease Control and Prevention, and other agencies in order to find a cure for HIV.
But neither the realization of single-payer universal health care nor an aggressive push for its implementation will matter if the system is not responsive to those it is intended to serve. Without input from experts and activists to highlight ongoing needs and emerging issues, it will be susceptible to existing bigotries within the general population and political pressure to maintain the status quo of HIV among the priorities of the current health care system.
In 2016, following a comment from former secretary of state Hillary Clinton about Nancy Reagan’s response to the AIDS crisis, activists pushed to meet with both her and Sanders to discuss the ongoing HIV crisis. Sanders cancelled his meeting, and after public pressure forced him to reschedule, he handled the entire episode in a way that is still disconcerting. However, his subsequent actions regarding Gilead’s patent and his support among members of the LGBTQ+ community, as noted in Super Tuesday exit polls, seem to indicate he’s learned from his past approach.
If elected, he’ll need to respond more appropriately to the concerns of HIV experts in order for a single-payer system to evolve at the same pace as the constantly changing science related to HIV. As an example, if his desire to pursue a cure for HIV becomes a policy goal to the exclusion of improving the quality of life for those in treatment on existing drug combinations, the system cannot be said to work for those it is meant to serve. Making drugs more effective and removing obstacles to adherence with treatment regimens or PrEP protocols will remain an important part of ending the epidemic.
A Sanders nomination would create unique struggles in the general election. Republicans have made it clear that they will attack the senator’s positions on economic justice, including access to higher education and health care, as “socialism.” Their hope is that the loaded context of the word will sink his campaign. But if what they describe as socialism is the best path to achieve the end of the HIV epidemic, then we ourselves cannot dismiss the Sanders campaign with the same zeal that’s been expressed by Republicans.
Electing Bernie Sanders president is the best hope we now have of ending the epidemic over the course of the next decade. Or we can choose to perpetuate the legacy of Reagan.