'The need for modernization and improvement of the Ryan White CARE Act is more evident than ever,' Health and Human Services Secretary Michael Leavitt said July 27 in releasing the Bush administration's guidelines for reauthorization of the Act.
Their release had been delayed for months; doing so during the chaos of marathon congressional sessions as it raced to a summer recess likely was no accident but was designed to minimize media coverage.
Many but not all AIDS advocates supported the principles, though each had their own often unstated goals as to how the details of each provision should take final shape. The greatest fear is that already inadequate federal funding will simply be redivided, with few new resources added, thus creating winners and losers.
The first principle articulated by Leavitt is to 'serve the neediest first,' based on a ''severity of need' for core services ... . It would take into account not only HIV incidence, but levels of poverty, availability of other resources including local, state, and federal programs and support, and private resources.'
Some observers fear that this might penalize jurisdictions that have added their own resources to AIDS programs, while rewarding areas that have shirked those responsibilities.
The second is to 'focus on live-saving and life-extending services' by prioritizing use of Ryan White funds for core medical services; requiring that a threshold of 75% be spent for those purposes. This is part of the administration's 'medicalized' approach to all HIV programs, to the detriment of supporting social services.
It threatens to pit those who provide such services against those who provide supportive social services such as case management, education/prevention services, transportation assistance, and housing.
The principle of increased prevention activity continues the medicalization strategy with an emphasis upon testing, to the detriment of community-based education and prevention activities. Some see this as a continued move to defund what have been among the most vocal AIDS advocacy groups, who have been critical of every administration.
Increased accountability often is a generic statement of good government, but this one has explicit pointed teeth to it. The elimination of double counting of HIV/AIDS cases, as outlined a General Accountability Office report ( www.gao.gov/new.items/d05841t.pdf ) , coupled with elimination of 'hold harmless' provisions and no significant increase in funding, would result in a shift of funds from states hit first by the epidemic to states that have seen more recent increase in caseloads; primarily in the South.
One consequence would be to penalize those areas that have been most effective at containing the spread of HIV, often by adding their own money, while rewarding those areas that have been less effective, often because of their unwillingness to spend local resources. San Francisco would be particularly hard hit.
The final principle of increased flexibility would give the Secretary greater authority in moving around unallocated funds.
REACTIONS
AIDS advocates based in Washington, D.C., were careful to publicly genuflect to an administration that does not take kindly to opposition. They emphasized the points upon which they agreed, even while redoubling their efforts on Capitol Hill to try and get the fine print written to their favor. Those outside the beltway spoke with a freer voice.
'Whether you get the treatment that can save your life shouldn't depend on where you live. We're glad that the administration understands that,' said Anita Vaughn, a member of the board of the HIV Medicine Association.
It looks forward to working with the administration and Congress to define a set of core medical services 'that reflects the complexity of HIV disease, including mental health, substance abuse, and nutrition counseling services.'
AIDS Healthcare Foundation president Michael Weinstein strongly supported 'the proposal to require local planning councils to direct up to 75% of Ryan White funding to medical care.' No surprise there, the Foundation's largest revenue stream is direct reimbursement for provision of medical services.
AIDS Project Los Angeles Executive Director Craig Thompson chided states that have not adequately contributed their own funds to the fight against AIDS, as California has done. They would benefit from the proposed changes. He said the feds must take state efforts into account, 'Otherwise, we'll have a race for the bottom' in the level of HIV services that are provided.
San Francisco AIDS Foundation Executive Director Mark Cloutier was gravely concerned with 'elimination of the hold-harmless provision' that has particularly benefited San Francisco. It stands to lose $7 million, about a quarter of current CARE Act funding, if the provision is eliminated. He said, 'The solution is to supply new federal dollars to keep pace with the epidemic.'
David Munar, policy director for the AIDS Foundation of Chicago, said the shift of dollars from hard-hit urban centers to rural parts of the country 'is the clearest indication yet' that the Bush administration does not intend to commit significant new discretionary funding to the epidemic.
'More than 70% of people with HIV/AIDS in the U.S. live in a metropolitan area served by Title I' that are likely to lose funds, he said. 'Expanding medical care should not come at the expense of enabling services that have proved effective in helping vulnerable populations gain access to and stay in care.'
'President Bush's principles are insufficient—and they may endanger the lives of people living with AIDS and HIV in the United States,' said Robert Cordero, director of federal advocacy for Housing Works, in New York City. He said the administration is trying 'to pit regions of the country against one another ... . It's rearranging the deck chairs on the Titanic' without providing significant new funding to meet the ever-increasing needs.
Cordero noted that the CARE Act essentially has been flat-funded for five straight years at about $2.1 billion. This is while the number of people living with HIV has grown by an estimated 125,000. Housing Works is calling for a $513 million increase, to $2.56 billion, in funding for the fiscal year that begins Oct. 1.
The organization is a leading supporter of the Campaign to End AIDS ( www.C2EA.org ) a nationwide effort to educate and empower local AIDS advocates.
A centerpiece of its organizing activity is a series of nine caravans from the corners of the U.S. that will culminate in Washington, D.C., in October on Columbus Day.
