Trump Budget Worries HIV, Hepatitis Advocates

President Donald Trump's 2018 budget proposal released this week includes major cuts to medical research and health services for low-income people that would have a devastating impact on people living with HIV, advocates said.

Medicaid, disability insurance, food stamps, and children's health coverage are all on the chopping block, while the $4.1 trillion budget would beef up spending for the military and immigration and border control.

"The Trump administration's FY 2018 budget is the first one since the president took office and as such it reflect his priorities for our nation," Ernest Hopkins, director of legislative affairs at the San Francisco AIDS Foundation, told the Bay Area Reporter. "It is a messaging document, and the message is that President Trump is willing to gut essential health and social service programs for our most vulnerable citizens in exchange for missiles and bombs."

The new budget would slash Medicaid (known as Medi-Cal in California), which provides health care for low-income people, by $610 billion over the next decade. This comes on top of the $800 billion reduction achieved by repealing the Affordable Care Act and replacing it with something like the American Health Care Act, as the House voted to do earlier this month. The Congressional Budget Office estimated that the change could mean 24 million people will lose their health coverage over the next 10 years.

Cuts would be especially burdensome for the 31 states - including California - that have expanded their Medicaid programs to include low-income adults up to 133 percent of the federal poverty level. Medicaid provides health coverage for more than 40 percent of people living with HIV, according to the Kaiser Family Foundation.

White House Office of Management and Budget director Mick Mulvaney denied that the budget proposal involves actual cuts to Medicaid in any given year, saying it will instead make the program grow more slowly over 10 years.

The proposal does not include substantial cuts to Medicare, the federal health coverage program for seniors of all income levels, in keeping with Trump's campaign promises. It also does not cut the broad Social Security program for retirees. However, it does reduce Social Security Disability Insurance and Supplemental Security Income, which many people with HIV and other chronic health conditions rely on.

The budget proposal also lists $1.2 billion in cuts for the Centers for Disease Control and Prevention, including a 17 percent decrease for its National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. The Housing Opportunities for People with AIDS program would also see a large cut. Planned Parenthood, a major provider of HIV testing and prevention services in many communities, is barred from receiving federal funding.

The National Institutes of Health would lose $5.8 billion, or 18 percent, including a $1 billion cut for the National Cancer Institute and an $838 million cut for the National Institute of Allergy and Infectious Diseases, which oversees HIV treatment and cure research. The budget proposes to eliminate the NIH's Fogarty International Center, which helps build local capacity to respond to outbreaks of infectious diseases like Ebola and the Zika virus.

"Cutting programs that support HIV care and treatment that prevents illness, saves lives, and reduces transmission risks to near zero will negatively impact public health, leading to greater health expenditures and rising HIV infections and deaths," HIV Medical Association Chair Dr. Wendy Armstrong said in a statement. "The proposal to slash funding for the [CDC] including $183 million from HIV, viral hepatitis and sexually transmitted disease programs, will reverse important gains made in reducing new HIV infections and leave us even further behind in responding to alarming increases in hepatitis B and C infections in addition to increases in new cases of chlamydia, gonorrhea, and syphilis."

The fate of the budget remains unknown, as numerous congressional leaders from both parties have said they do not agree with some of Trump's priorities. Many experts think the budget's assumption that the U.S. economy will grow by 3 percent is unrealistic. Senate leaders have also said they will not adopt the House version of the AHCA - which the budget proposal is built upon - and a CBO analysis due this week could send that legislation back to the House for another vote.

Advocates take stock
The budget was a major theme of a May 22 forum sponsored by Project Inform that looked at the first 100-plus days of the Trump administration.

"I don't want to be a downer, but I am scared to death," said Project Inform Executive Director Dana Van Gorder. "We already know that the ACA is under attack and there's a decent likelihood that it will be destroyed as we know it, which will have a profound impact on the work that we do and the people we care about. But the [proposed] federal budget is truly horrifying. We have a lot of fighting to do."

Forum speakers addressed the health needs of people living with HIV and viral hepatitis, efforts to expand access to PrEP, and the health of people who use drugs - a group disproportionately affected by both diseases.

The U.S. is in the midst of an opioid epidemic that has led to a dramatic increase in prescription painkiller and heroin overdoses, as well as outbreaks of HIV and hepatitis C. There were around 52,000 overdose deaths in 2015 - one every 10 minutes - exceeding deaths due to motor vehicle accidents and gun homicides combined, according to Monique Tula, executive director of the Harm Reduction Coalition.

Contrary to an earlier proposal, Trump's budget largely preserves the Office of National Drug Control Policy, home of the national "drug czar." The office plays a key role in the federal government's efforts to combat the opioid epidemic, but it has also been involved in federal crackdowns on medical cannabis in states where it has been legalized, including California.

"The office has some baggage, but it has also worked with recovery and harm reduction advocates, and has stated that the opioid epidemic is a high priority. But priorities are illustrated through budgets," Tula said.

Emalie Huriaux from Project Inform reminded attendees that cities and states have the potential to hold the line in the face of federal cutbacks. California has patient protection regulations, anti-discrimination provisions, and caps on prescription drug costs that will remain in effect even if the ACA goes away, and legislators are now having conversations about universal coverage for everyone in the state.

California also protects the health of people who use drugs, and has gotten further along than any other state with legislation to enable safer consumption spaces where people can inject drugs under medical supervision. Several forum speakers and attendees had earlier attended a City Hall rally the same day in support of supervised consumption spaces. A full Assembly vote on that legislation, known as Assembly Bill 186, is scheduled for next week.

"California is really a success story about expanding Medicaid. Medi-Cal has covered a lot of people at risk for and living with HIV and hepatitis C," Huriaux said. "California is showing what's possible. It shows you can be a successful, economically well-developed state and have regulations that protect poor people."

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