In the past year, health advocacy in the U.S. was a real stressor. President Donald Trump (along with the GOP-led houses of Congress) came into office fully focused on dismantling the Affordable Care Act (ACA) and reforming taxes to benefit the wealthy. This move could have taken us back to the days of AIDS Drug Assistance Program (ADAP) waiting lists, people with HIV being denied coverage, and people being refused coverage for pre-exposure prophylaxis (PrEP). A lot was at stake, the community sprung into action, and it was at least successful in stopping the outright repeal of the ACA. But advocates working in Washington, D.C., haven't rested on their laurels. They're continuing to plan for what Congress and the administration have in store for the upcoming year.
Health Care and the Tax Bill Threatening the Individual Mandate
The Republican leadership made it clear that they intended to repeal the ACA and most of its components, including cutting Medicaid spending. GOP leaders such as Paul Ryan have longed to end the Medicaid entitlement and turn into a block-grant system, which would designate a fixed amount of money to each state to run its own Medicaid program. This idea is not new or strictly Republican. President Bill Clinton proposed a similar reform in 1997. Advocates for block grants claim that they would save money and give states flexibility, but medical costs are already very high, and if a state exceeded its allocated amount, it would have to dig in its own pockets to make up the difference. Even worse, a block-grant system would allow states to outright cut programs and use Medicaid money to fill other budget holes, leaving fewer people with health coverage.
Further damaging the ACA, the individual mandate is about to be eliminated via the tax bill President Trump signed into law just before the 2017 holidays. Withdrawing the mandate could result in as many as 13 million people without health insurance, leaving fewer incentives for insurers to stay in the ACA marketplace and making it even more difficult for people who need or want to be insured to obtain private insurance coverage. It's hard to retain people living with HIV in care when they don't have health insurance.
"With the passing of the tax bill, [Congress] is gonna have to start chipping away at non-defense discretionary funding to pay for [the tax cuts]," said Kathie Hiers, chief executive officer of AIDS Alabama:
That includes all of our programs: Ryan White, housing subsidies, CDC [Centers for Disease Control and Prevention] funding for HIV prevention, [and] testing and screening funds. I'm extremely worried about all of those portfolios. We are at a very unique time in the epidemic cause we're actually seeing stats go down. All of these states are working on plans to end the epidemic. Right now is not a good time to pull out of funding it.
Related: Looking Back on 2017 in HIV/AIDS, and What's in Store for 2018
ADAP Waiting List Return?
Will the lack of Medicaid expansion lead to less funding for AIDS drugs? It's certainly something to watch in 2018. With the ACA being chipped away and without Medicaid expansion, we could possibly see the resurgence of ADAP waiting lists. It's a scenario that could literally be a matter if life and death. Brandon Macsata, chief executive officer of ADAP Advocacy Association says that troubled ACA waters could be disastrous for ADAP:
There is an ongoing assault by the Trump administration on the social fabric that holds our nation's public health system together, which links people to the needed care and treatment. We're holding on by a thread, and the thread is about to break. This administration's attempt to undermine the ACA marketplace is causing many people living with HIV/AIDS to lose their coverage, and we're likely looking at a tsunami hitting the state AIDS Drug Assistance Programs.
Midterm Elections in Congress
U.S. congressional elections will occur on Nov. 6, 2018. Thirty-three of the 100 Senate seats will be up for regular election. The Republican Party holds the majority in this chamber, and the Democrats will have to defend 25 seats. Among those Democratic seats, ten are in states that chose Donald Trump over Hillary Clinton in the 2016 presidential election, including Florida, Wisconsin, Michigan, and Pennsylvania. However, recent Democratic wins in places such as Alabama and Virginia show that even Republican incumbents in conservative states may face difficult re-elections due to an energized Democratic electorate.
In the House of Representatives, all 435 seats are up for election this year. Republicans currently control the House, but that could change depending on voters' actions at the polls. Many of the candidates are vying for seats in states where HIV is stigma interrupts progress. Bob Poe, in Florida, could be the first openly HIV-positive person elected to Congress. There are four open seats in the House from the state of Texas, where funding for HIV was moved to abstinence education and where the HIV prevention services provided by Planned Parenthood's Houston affiliate, whose contract was terminated a year ago, [[have yet to be fully replaced.
The South has been a concern for AIDS activists for quite some time now, as 45% of all Americans with HIV reside in southern states, most of which haven't expanded Medicaid. The recent upset in the Senate election in Alabama placed long-shot candidate Democrat Doug Jones in the seat. It offered a glimmer of hope, particularly for Hiers, who met with Jones. She noted: "He is very open minded and a smart individual. He's been around Alabama for a long time. He has an openly gay son. He's quite familiar with a lot of our issues. So, I feel pretty darn sure that we're going to be able to work with him."
Hiers isn't the only one seeing some bright spots in such a difficult time. Jeffrey Crowley, former director of the Office of National AIDS Policy and program director for Infectious Disease Initiatives at Georgetown's O'Neill Institute for National and Global Health Law in Washington, D.C., acknowledges the struggle but remains optimistic about what's to come:
Many of our community's biggest threats are not directly about HIV, but we are under threat as long as trans people are being attacked, immigrants are being harassed, blatant sexism and other threats to women increase, and on and on. Now, we are hearing of plans to renew efforts to gut Medicaid and Medicare and cut welfare before the tax giveaway to the rich has even happened. What keeps me going is knowing how resilient our community is, as well as my belief that on issue after issue, most Americans want what we want. Still, we have to stay focused and strong.