As President Trump stood before a joint session of Congress for his State of the Union address in February, he urged Republicans and Democrats alike to support the audacious goal of stopping the spread of HIV within a decade. “Together, we will defeat AIDS in America and beyond,” he declared.
The White House’s 2020 budget request, issued this week, does propose an additional $291 million as a down payment for a new HIV initiative. Yet the $4.7 trillion budget also calls for sharp spending reductions to Medicaid, the public insurance program for the poor on which more than 2 in 5 Americans with the virus depend.
Such a contradiction — giving while also taking away — runs through the budget arithmetic for many of the Trump administration’s health-care priorities. In addition to combating HIV, the president has taken aim at childhood cancer and the opioid crisis, but his budget would undermine all those efforts by shrinking the health infrastructure that people struggling with those issues rely on while throttling back national cancer research spending — even as it offers discrete pots of money for those causes, policymakers say.
“If you’re cutting Medicaid, you’re taking the legs out from underneath the system” of help for people with the AIDS virus, said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation.
On combating the opioid crisis — another promise mentioned in Trump’s State of the Union speech — Keith Humphreys, a psychiatry professor at Stanford University, called the budget “really negligent on a grand scale.” The budget would devote $4.8 billion at the Department of Health and Human Services to help stem the epidemic. But like with HIV, Medicaid is the top payer for addiction treatment, paying $1 billion a year, and cuts in that program — as well as in Medicare — swamp anything else the government says it is doing.
“If you slash Medicaid and Medicare, you are taking far more out of the pool than you are putting in,” Humphreys said. And he criticized the budget’s recommendation to eliminate most of the funding for the White House’s Office of National Drug Control Policy — an idea Trump has woven into all three of his budgets.
“You have an office in the White House uniquely positioned to do policy on the epidemic,” Humphreys said, “and now you are going to cut it.”
To fight childhood cancer, the White House’s fiscal blueprint would increase funding for research by $50 million next year — another priority in the president’s State of the Union speech — but would reduce overall funding for the National Cancer Institute by $897 million, nearly 18 times that amount.
And despite the president’s promises not to harm Medicare, his budget envisions changes that would reduce spending on the popular program by $845 billion over the next decade — with the largest savings related to payment reductions to providers and new efforts to combat fraud and abuse.
Some of the budget’s boldest ideas for redefining health-care policies are unlikely to move off the page, having been rejected during Trump’s tenure even when Congress was in full Republican control — with less momentum now that Democrats hold the House. Chief among these is a call to convert Medicaid from its history for half a century as an entitlement program, in which the government pays a certain share for those eligible, to state block grants or strict per-person limits that are not affected by economic changes.
On Capitol Hill, early bipartisan support appears to be emerging for the HIV and pediatric cancer funding. Republicans as well as Democrats pushed back this week against reductions to the National Institutes of Health and its cancer institute.
“I was alarmed to see” the cut for NIH’s cancer research, Rep. Fred Upton (R-Mich.), a former chairman of the House Energy and Commerce Committee, told Health and Human Services Secretary Alex Azar at a subcommittee hearing on the budget.
“I understand the pain,” Azar replied, saying the cut was in proportion to an overall 12 percent reduction in the HHS budget. “It’s a tough budget environment.”
Democrats were even more vehement about the nation’s main source of insurance for the poor. “If this administration is serious about block granting or otherwise redefining Medicaid as we know it,” Rep. G.K. Butterfield (N.C.) warned Azar, “we are going to be in for a real firestorm, not just from Congress but from the American people.”
Charles N. “Chip” Kahn III, president of the Federation of American Hospitals, said that, even though “for every president almost, there is this notion of a budget being dead on arrival, and that generally is true,” the policy priorities enumerated in Trump’s budget should be taken seriously.
“Budgets have a lot of purposes — setting priorities and making political statements,” Kahn said, so the proposals “give a certain credibility. It gives people cover for changes. ‘Well, it was in the president’s budget, so it must be okay.’ ”
Previous presidents, including Barack Obama, sought to slow spending on Medicare, in part to lengthen the life of a financially fragile trust fund for a section of the program that covers hospital stays. But this year’s budget “is at a different level and has broader implications,” proposing to slow funding for medical education, and reduce reimbursements to physicians and hospitals that care for a large share of patients who cannot afford to pay for their bills, Kahn said.
The Medicare changes would not directly affect benefits for patients, although their care could be affected if physicians leave the program because they object to lower payments.
The proposed changes to Medicaid, however, could have profound effects for people with HIV, as well as those battling addiction. Medicaid is the largest single source of health insurance for drug-addicted and HIV-positive people, Kaiser figures show.
In particular, the budget’s goal of ending the expansion of Medicaid under the Affordable Care Act “will harm our efforts toward ending HIV,” said Carl Schmid, deputy executive director of the AIDS Institute in Washington. The expansion in about three dozen states “has been critically important for HIV,” he said, because it has, for the first time, allowed single men and women who are infected to get coverage even if they do not have full-blown AIDS, which has long been considered a disability that qualifies people for the program.
Advocates say that the budget’s funding for the HIV initiative, although welcome, falls short of what would be needed to meet the president’s goal of stopping the virus’s spread within a decade. Of the $291 million, Schmid said, close to $60 million consists of money already being spent for community health centers and other purposes.
And a central strategy — identifying people in communities that are “hot spots” for the disease and giving uninfected people a protective medication known as PrEP — costs about $20,000 a year per person, experts say. The Centers for Disease Control and Prevention estimates that 1.1 million people should be on the medication — many more than the budget could cover.
“It’s great to have this issue on the radar, and it’s great to finally see new money,” said Rochelle Walensky, an infectious-disease specialist at Massachusetts General Hospital. “But those numbers give you a sense of how we are going to think about this.”