While President Trump was facing a joint Congress session for his State of the Union address in February called on Republicans and Democrats alike to support the bold goal of to stop the spread of HIV within a decade. "Together, we will defeat AIDS in America and elsewhere," he said.
The White House 2020 budget request, published this week, proposes an additional 291 million dollars as a down payment for a new initiative on HIV. Yet the $ 4.7 billion budget also requires large spending reductions for Medicaid, the public insurance program for the poor on which more than 2 in 5 Americans depend on the virus.
This contradiction – giving while one is taking – crosses the arithmetic of the budget for many of the priorities of the Trump administration's health care. In addition to fighting HIV, the president has targeted childhood cancer and the opioid crisis, but his budget would jeopardize all those efforts by reducing the health infrastructure that people on those issues rely on while the national costs for cancer research are being squashed – even when it offers discreet vessels of money for those causes, politicians say.
"If you're cutting Medicaid, you're taking the legs from under the aid system for people with the AIDS virus," said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation.
On the fight against the opioid crisis – another promise mentioned in the speech on the state of the Trump Union – Keith Humphreys, professor of psychiatry at Stanford University, called the budget "very negligent on a large scale. "The budget would allocate $ 4.8 billion to the Department of Health and Human Services to help stem the epidemic. But as with HIV, Medicaid is the main contributor for addiction treatment, paying $ 1 billion a year, and cuts in that program – as well as in Medicare – flood anything else the government says it is doing.
"If you cut Medicaid and Medicare, you're taking a lot more out of the pool than what you're doing," said Humphreys. And he criticized the budget's recommendation to eliminate most of the funding for the White House National Drug Policy Office – an idea that Trump has woven into all three of his budgets.
"You have an office in the White House uniquely positioned to do politics on the epidemic," said Humphreys, "and now you will cut it."
To combat childhood cancer, the White House tax plan would increase research funding by $ 50 million next year – another priority in the president's State of the Union address – but would reduce the overall funding for the National Cancer Institute by $ 897 million, about 18 times.
And despite the president's promises of not harming Medicare, his budget includes changes that will reduce spending on the popular $ 845 billion program over the next decade – with the biggest savings on supplier payment reductions and new efforts to combat fraud and abuse.
Some gods are unlikely that the boldest budgetary ideas to redefine health policies pass by the page, having been rejected during Trump's tenure even when Congress was in full Republican control – with less momentum now than the Democrats hold # 39; Assembly. The main of these is a call to convert Medicaid from its history for half a century as a rights program, in which the government pays a certain fee for those entitled, to state subsidies or to strict limits per person who are not affected by the changes economic.
On Capitol Hill, it appears that bipartisan support is emerging for the financing of HIV and pediatric cancer. Republicans and Democrats rejected this week against reductions in the National Institutes of Health and its oncology institute.
"I was alarmed to see" the cut for NIH cancer research, Rep. Fred Upton (R-Mich.), A former chairman of the Chamber's Energy and Trade Committee, said Tuesday to secretary of health and human services Alex Azar in a budget subcommittee hearing.
"I understand the pain," replied Azar, saying that the cut was proportional to an overall reduction of 12 percent of the HHS budget. "It's a difficult budget environment."
The Democrats were even more vehement about the nation's main source of insurance for the poor. "If this administration is serious about granting a blockade or a different redefinition of Medicaid as we know it," Rep. G.K. Butterfield (NC) warned Azar, "we will have a real firestorm, not only from Congress, but from the American people."
Charles N. "Chip" Kahn III, president of the Federation of American hospitals, Having said this, although "for almost every president, there is this notion of a dead balance on arrival, and in general it's true, "the political priorities enumerated in Trump's budget should be taken seriously.
"Budgets have a lot to do – set priorities and make political statements," Kahn said, so the proposals "give a certain credibility. It gives people coverage for change." Well, it was in the president's budget, so it's good. ""
Previous presidents, including Barack Obama, tried to slow down Medicare spending, partly to extend the life of a financially fragile trust fund for a section of the program that covers hospital stays. But the budget of this year "is at a different level and has wider implications", proposing to slow down funding for medical education and reduce reimbursements to doctors and hospitals that take care of a large portion of patients who cannot afford to pay their bills. .
Medicare changes would not directly affect patient benefits, although their care could be compromised if doctors left the program because they opposed reducing payments.
The proposed changes to Medicaid, however, could have profound effects for people with HIV, as well as those who combat addiction. Medicaid is the largest single source of health insurance for drug addicts and HIV-positive people, as Kaiser's figures show.
In particular, the goal of the budget to end the expansion of Medicaid under the Affordable Care Act "will damage our efforts towards the end of HIV," said Carl Schmid, deputy director executive of the Washington AIDS Institute. The expansion in about three dozen states "was of paramount importance for HIV," he said, because it allowed for the first time individual infected men and women to get coverage even if they did not have the 39; full-blown AIDS, which has long been considered a disability that qualifies people for the program.
Supporters say the financing of the budget for the HIV initiative, although well received, is not up to what it would take to reach the president's goal of stopping the spread of the virus within a decade. Of the $ 291 million, Schmid said, nearly $ 60 million consists of money already spent on health centers and other purposes.
And a central strategy: identifying people in the community who are "hot spots" for the disease and giving uninfected people a protective drug known as PrEP – costs about $ 20,000 a year per person, experts say. The Centers for Disease Control and Prevention estimate that 1.1 million people should be in treatment – far more than the budget could cover.
"It's great to have this problem on the radar and it's good to finally see new money," said Rochelle Walensky, an infectious disease specialist at Massachusetts General Hospital. "But those numbers give you an idea of how we'll think about this."