This post originally appeared in Roll Call on February 5, 2019.
President Donald Trump’s plan to eliminate HIV transmission in the United States by 2030, which he announced Tuesday night, would be an ambitious goal that would require his administration to reverse course on a number of policies that potentially hinder access to HIV/AIDS care. “Together, we will defeat AIDS in America,” Trump said in his State of the Union address. He said that his budget will “ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.”
Trump is winning some praise for the goal, and most advocates say that, scientifically, it is achievable. However, the administration’s broader policies, such as liberalizing health insurance regulations and cutting discretionary spending, are at odds with increasing access to drugs and other steps that could end the spread of the high-profile disease.
“The Trump Administration has repeatedly undermined our progress in ending the epidemic — whether it’s proposing a Medicare Part D rule that would push lifesaving drugs out of reach for people living with HIV, redirecting critical funding away from Ryan White and other key programs, or pursuing discriminatory policies against the LGBTQ community,” said Rep. Barbara Lee, D-Calif., chairwoman of the Congressional HIV/AIDS Caucus. “If the administration is serious about addressing HIV, it should start with ending the counterproductive attacks on these crucial programs and fully funding them at home and abroad.”
A Trump administration proposal to change coverage in Medicare’s prescription drug benefit could result in older HIV/AIDS patients losing access to some types of treatment.
Currently, Medicare Part D drug plans must cover almost all medications in six categories of drugs. Those so-called “protected classes” are designed to ensure that vulnerable populations have access to certain drugs, including treatments for HIV/AIDS. Drugs that prevent transmission to people at risk of HIV are effective, as are AIDS treatment drugs that reduce the viral load to a level where the disease isn’t transmissible.
As part of its drug-pricing agenda, the administration proposed giving the private insurance plans that administer Medicare’s drug benefit the flexibility to exclude some of these drugs that they currently cover. The plans would continue to cover at least two types of treatment in each category.
By offering that flexibility, the plans could potentially extract better prices from drugmakers if they can stop covering some drugs in those categories.
If Medicare patients with HIV/AIDS who have lowered their viral loads with certain drugs are forced to switch to a new kind of treatment, advocates say their conditions could worsen and their risk of transmission could increase.
“President Trump has to understand that Medicare Part D is also a key component of access to care and his recent proposal to change protected class status for antiretrovirals will simply not help. It will set us back,” said Jesse Milan Jr., president of AIDS United, a policy and advocacy group.
The White House and Department of Health and Human Services declined to comment.
To be sure, advocates and Democrats praise the goal Trump is expected to propose and have confidence in his team. Centers for Disease Control and Prevention Director Robert Redfield has decades of experience treating HIV/AIDS patients. Longtime National Institutes of Health scientist Anthony Fauci is also a widely-respect expert. Surgeon General Jerome Adams helped contain an HIV outbreak when he was an Indiana health official, and advocates speak highly of Brett Giroir, the Health and Human Services official expected to lead the new initiative.
“We know what tools are needed. It’s really more on the implementation side, so I’m encouraged by that,” said Daniel Raymond, policy director of the Harm Reduction Coalition, a nonprofit that works on mitigating the consequences of drug use, such as infectious diseases like HIV/AIDS.
But, he noted: “This administration has had a rocky track record in terms of access to health care, which has to be part of the solution.”
The president’s proposed budget is one example.
For nearly three decades, the federal government’s signature domestic HIV/AIDS program, Ryan White, has provided billions in grants to states and local organizations to provide medication and other care. Trump’s fiscal 2019 budget proposed cutting the $2.3 billion program by $43 million. Most of those proposed cuts would have come by ending Ryan White’s education and training programs for health care providers who serve minority populations, the homeless and the incarcerated — populations more at risk of contracting HIV.
Lawmakers rejected the proposed cuts in the fiscal 2019 spending bill that included the Health and Human Services Department, and Ryan White programs received the same amount as they did in 2018.
If the Trump administration proposes funding increases to pay for its new HIV/AIDS plans, it can probably count on support in Congress. Rep. Rosa DeLauro, D-Conn., who oversees HHS funding on the House Appropriations Committee, said that for years, she has fought off attempts to shift money from HIV programs to other areas. She said the Trump proposal could mean more Republican support for HIV funding increases.
“It’s been a long time goal of so many of my colleagues, including myself, and I’ve had the opportunity to make sure that there has been funding for HIV, and I will continue to fight,” she said in an interview.
Other ways that the administration has proposed changing health care coverage also could limit access to care, say advocates.
Trump is cheerleading for the collapse of the 2010 health care law (PL 111-148, PL 111-152) as a lawsuit challenging its constitutionality makes its way through the courts. If a ruling in favor of Texas and other states opposing the law is upheld on appeal, it would put aspects of the law that helps HIV/AIDS patients at risk, including guaranteed coverage of pre-existing conditions. In addition to the lawsuit, congressional Republicans sought in 2017 to cut the growth of Medicaid and repeal parts of the law.
The 2010 law’s expansion of Medicaid to adults just over the poverty line was important in increasing the number of men who have sex with men — one of the groups most at-risk of HIV — who were eligible for Medicaid. In the early years of the health law, states that expanded Medicaid saw the uninsured rate among people with HIV drop from 13 percent to 7 percent, according to a Kaiser Family Foundation analysis.
The law also prevented insurers from denying coverage or charging more based on someone’s pre-existing health condition, including HIV. But the short-term, limited duration insurance plans promoted by the Trump administration as an affordable alternative for plans sold on state health exchanges don’t have to comply with coverage requirements in the 2010 health care law. That means they don’t have to cover people with pre-existing conditions or cover many drugs.
Last summer, researchers at the Kaiser Family Foundation attempted to apply for coverage in 38 short-term plans as someone with HIV, and were denied every time.
Milan said the changes were “a step backwards, because those plans do not provide the kind of protection and the kind of comprehensive coverage that people living with HIV actually need.”