The President’s Budget Versus the President’s Plan to End AIDS

In his fiscal 2020 Budget Request released last Monday, the President recommended that we reduce national spending by $2.7 trillion. This would be, according to PoliticoPro, “the largest cut by any administration in American history.” While proposing to reduce the Department of Health and Human Services (DHHS) funding by 12%, the budget’sdeepest cuts (31% each) were assigned to the Environmental Protection Agency and the Army Corps of Engineers, one of  “the world’s largest public engineering, design, and construction management agencies”.

The document lists DHHS’ most serious public health priorities as the opioid epidemic, serious mental illness, and “preparing for public health threats.” It promises (among other things) to reduce drug costs and protect Medicare. It also flaunts “Ending the AIDS Epidemic, unveiled last month, as “an ambitious, yet necessary effort to eliminate a disease that has plagued the Nation for more than three decades.” How these priorities work together is unclear until one considers that the President’s proposal is only the beginning of the FY 2020 budget process and is not expected to be viewed as a final outcome.

During the FY 2019 budget process, for example, the President proposed to cut Ryan White Program funds by $58 million, HIV prevention (handled by CDC) by $40 million and HOPWA (HIV housing assistance) by $26 million. None of these cuts withstood Congress’ subsequent deliberation. In the final FY 2019 budget, Congress boosted Ryan White funding from $2.319 billion in FY2018 to $2.465 billion in FY2019. HIV housing assistance funding rose from $375 million to $393 billion and HIV prevention held steady at $7.887 million.

As we begin the FY2020 budget debates, about one quarter of Americans living with HIV are enrolled in Medicare and over 40% are enrolled in Medicaid. Two-thirds of our population living with HIV rely on these programs now and more are expected to enroll when the President’s $291 million plan for “Ending the AIDS Epidemic” swings into action in 2020. The goal of that plan, as presented, is to lower HIV transmission dramatically by getting untreated people living with HIV into treatment on ARVs so they don’t transmit the virus and those at risk of HIV onto PrEP. Both sectors need ongoing care which, presumably, requires insurance.

The CDC fully recognizes that “socio-economic factors” can increase HIV risk, and that a substantial percentage of the people entering care as a result of this plan will need Medicare and Medicaid. But the President’s FY2020 budget proposes, according to CNBC, to “shave an estimated $800 billion or more off Medicare” over the coming decade and to “cut spending on Medicaid…by more than $200 billion while setting up block grants to states.”

One can only assume that the sharp contradiction between these two scenarios is something that Congress is expected to resolve.