If it wasn't clear after President's Trump's bare-bones budget request last year, his fiscal 2019 budget request has left no doubt that people living with or affected by HIV are not a priority for his administration. In fact, most of the Trump budget for 2019 calls for cuts in federal programs that serve people living with HIV.
Released on Monday, the request largely ignores the recent budget deal struck by Congress to raise non-defense domestic discretionary spending by $131 billion over the next two years, and it seeks instead to slash health care spending and pump more and more money into the nation's military.
Like most presidential budgets, President Trump's fiscal 2019 budget is less a serious attempt to provide an overarching blueprint for funding the federal government and more an executive wish list that gives members of Congress some insight into the White House's budgetary priorities. The future envisioned by the Trump administration in its latest budget is much more fantasy than reality as it assumes a number of things about the viability of the Affordable Care Act (ACA) that are extremely unlikely to happen in the near future.
Related: HIV Activists Prepare for What Lies Ahead in 2018
At the heart of the administration's budgetary health care vision is a plan that looks similar in design to the ACA "repeal-and-replace" plan put forward by senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) last year. The fiscal 2019 budget assumes the termination of the tremendously successful Medicaid expansion program that has been adopted by 33 states and serves roughly 15 million people, while also assuming that Medicaid will cease being an entitlement program and will switch to a restrictive block grant or per-capita cap system, leading to massive cuts in spending. The president's budget also embraces the recent trend towards allowing work requirements for Medicaid eligibility, further impeding access to health care for those who need it most.
When it comes to the Ryan White program funding, the president's new budget calls for cuts to at least two programs funded by Ryan White. Overall, the White House's fiscal 2019 budget funds the Ryan White Program at $2.26 billion, which is $43 million less than its current level of funding. The bulk of that funding decrease is due to the Trump administration's zeroing out of the AIDS Education Training Centers, which educate health care providers on the latest in HIV/AIDS prevention, treatment, and care, as well as its elimination the Special Projects of National Significance (SPNS) program, which serves as an incubator for new and innovative models of HIV care. Specifics around spending for the Secretary's Minority AIDS Initiative Fund (SMAIF) were not included in this initial budget, but given the fact that SMAIF was eliminated in last year's budget, it's reasonable to assume major cuts might be sought this year, as well.
The Centers for Disease Control and Prevention (CDC) also didn't fare well under the administration's budget, seeing an overall cut of 12% from its 2017 funding level. The CDC's domestic HIV/AIDS research and prevention efforts would be reduced by $35 million from its current funding level. For its part, the Housing Opportunities for People With AIDS program would see its funding cut by $26 million compared with current spending.
One area where the president's budget actually would add funding is around the federal government's response to the opioid epidemic, an area in which the Trump administration had engaged in a lot of talk, but very limited action. President Trump's budget would provide the Department of Health and Human Services with $10 billion in discretionary spending for opioid prevention and treatment efforts in fiscal 2019. Of that $10 billion, $5 billion would come from cuts to mandatory spending on similar programs, meaning it would have to be renewed each year by Congress. However, before you get too excited over the prospect of new opioid disorder prevention and treatment funding, it is worth noting that this increase is coupled with a request for $18 billion for border wall, $400 million in addition funds to the Drug Enforcement Agency, and $50 million for a "just say no"-style anti-drug media campaign.
It remains to be seen how much of an effect President Trump's budget will have on HIV-related spending, but based on Congress's response to his first budget and the increased budgetary caps that were just put in place, there is reason to believe that it won't be significant. That being said, it remains vital for HIV advocates to continue reaching out to their elected officials, as they did in 2017, to demand that vital HIV programs in the Trump administration's crosshairs are not cut, but are instead sustained and raised.