By Dawn Wolfe Gutterman
WASHINGTON – The Bush Administration's proposals for reauthorizing the Ryan White CARE Act could "set HIV prevention and care work back at least 10 years," create "enormous steps backward" in cities, including Detroit, that have been dealing with the epidemic for years, and result in "about a $40,000 reduction [in Ryan White funding] for Michigan." At least, those are the opinions of some of Michigan's leaders in the fight against AIDS.
On July 27, the Department of Health and Human Services issued a press release detailing the "Ryan White Care Act Reauthorization Principles" that the department plans to push for in Congressional hearings set to begin this month. While calling for a less than one percent increase in Ryan White funding, the administration is also pushing for a massive reallocation of funds and greater restrictions on how those funds can be used. Other controversial aspects of the administration's Reauthorization Principles are calls to use Ryan White dollars to adopt a Centers for Disease Control initiative which has been questioned by experts in the field and to gut the authority of local planning councils which currently set priorities for AIDS spending.
The great fund migration
One of the Principles for Reauthorization that has AIDS service experts concerned is the proposal to establish a "severity of need" for core services index, which "would take into account not only HIV incidence, but levels of poverty, availability of other resources including local, state, and federal programs of support, and private resources," according to the July 27 Health Resources and Services Administration statement.
Rather than implementing "Greater Flexibility To Serve Those Most In Need," as the HRSA statement claims, AIDS service experts and organizations are claiming that this Principle ought to be called "robbing Peter to pay Paul."
"The Bush proposal would transfer tens of millions (perhaps hundreds of millions) of dollars from urban areas, who are currently spending them on essential services, to other areas," said Terje Anderson, the executive director of the National Association of People with AIDS, in an Aug. 1 statement.
Loretta Davis-Satterla, head of the State AIDS Office of the Michigan Department of Community Health, agreed.
"If the President's Principals on Reauthorization do go through, there would be some funding shifts from certain states, particularly those states that were hardest or moderately hit at the beginning of the epidemic," she said. "It would put the current states in a very difficult situation."
While Davis-Satterla agreed with the goal of the Principle – to get needed funding to Southern states that have seen a surge in the AIDS epidemic – she said that the Bush proposal is not the answer.
"It's true that the funding [Southern states have] been receiving is not adequate to the epidemic that they're seeing today," she said. "Of course the solution to that – it would be detrimental for states to lose the funding that they have, so the answer to that truly is to try to seek new money – which is a hard message to get across at this time, but it's one that we need to say because these other states are experiencing a growth in their epidemic, but it hasn't abated in other states [that are currently receiving the bulk of Ryan White funding]." Davis-Satterla said that, if enacted, this Principle could result in Michigan losing $40,000 in Ryan White money.
According to both NAPWA and the National Association of State AIDS Directors, this aspect of the Bush proposal is shortsighted.
"[W]hat the Bush proposal doesn't do is discuss what the impact of these massive funding shifts would be on the communities that lose money. Huge cuts in health care and essential support and care services will take place in these communities, and the impact will be catastrophic for many people living with HIV/AIDS," said NAPWA's Anderson.
The National Association of State AIDS Directors expressed alarm over this aspect of the Bush Administration's AIDS agenda in a recent letter to HRSA.
"The focus on redistribution of funds seemingly stems from a perception that the epidemic has shifted," the letter said. "This is not the case. While the epidemic has expanded, there is no state in which the epidemic has stabilized or diminished."
"This [Principle] suggests that CARE Act funding provisions, particularly related to Title I and Title II, are responsible for service variations between states," the letter continues. "This is not true. These variances are largely attributable to differences in the resources that the state itself provides for the care and treatment of persons with HIV/AIDS as well as the services available through Medicaid. … In addition, the principle serves as a powerful disincentive for jurisdictions to allocate local resources to meet the needs of their residents with HIV/AIDS."
Core medical services?
Another highly contested Reauthorization Principle touted by HRSA would require "that 75 Percent of Ryan White Funds in Titles I-IV Be Used For Core Medical Services."
"The devil is in the details because we don't know what the definition of 'core medical services' will be," said Davis-Satterla. "Depending on what those core medical services turned out to be, it could cause a dramatic shift away from those services provided by community based organizations" that help people living with HIV/AIDS access and adhere to their medical care.
Cindy Bolden-Calhoun, executive director of Detroit's Community Health Awareness Group, said that if this Principle is enacted, "I think that they're going to set HIV prevention and care work back at least 10 years. … Once you eliminate [the support services] piece you're going to have a whole segment of people who are living with HIV who won't be getting care. I think we have to look for ways to support the services that have been designed and are tried and true over the past 15 years; if you step back from continuum, that's a mistake that's going to cost lives."
The proposed shifting of Ryan White funds to medical services is something HRSA has been working on for several years. So far, according to Davis-Satterla, "We were still able to fund important support services as long as we could justify that those services were necessary."
"If [the Reauthorization Principle] follows what HRSA is moving us toward now, with the flexibility to continue providing other services, then we won't feel such a dramatic negative impact," she added. "If it turns out to be something different we could have more difficulty."
Jimena Loveluck, executive director of the HIV/AIDS Resource Center in Ypsilanti, said that her organization, which receives Title II funds, is already feeling squeezed.
"What is particularly challenging … is that all of the support services we provide – housing to food to transportation – those kind of services are coming under greater scrutiny because HRSA is telling us that unless a service is directly related to somebody's medical care [they] are not going to fund them."
Barbara Murray, executive director of AIDS Partnership Michigan in Detroit, put the problem in Biblical terms.
"Because we have not looked at our health care system as a whole, and decided that all deserve care regardless of economic status … you end up with what will happen now with Care Act renewal … you pit primary medical care against social support services. I believe Solomon had the same problem with a baby. The fact is you need both."
"There seems to be this mindset at this point inside the Beltway that people need to pull themselves up by their bootstraps," Murray said. "Not all of us in this country have bootstraps to pull ourselves up with."
An ounce of prevention?
Without adding a significant increase in Ryan White funding, the Bush Administration, in its Reauthorization Principles, seems to be adding yet another task to the agencies receiving that funding – prevention. According to the Principles, "States will be encouraged, upon receipt of their Ryan White allocations, to adopt various important HIV prevention strategies, such as routing opt out HIV testing, contact tracing, and the recommendations of the CDC Advancing HIV Prevention Initiative."
Not only does this Principle create an unfunded mandate, but the CDC Advancing HIV Prevention Initiative's Four Strategies have come under fire as ineffective. The Four Strategies are: Incorporate HIV testing as a routine part of care in traditional medical settings; Implement new models for diagnosing HIV infections outside medical settings; Prevent new infections by working with people diagnosed with HIV and their partners; and Further decrease mother-to-child HIV transmission. While these Strategies may sound good at first glance, a July report by the Rand Corporation seems to indicate that the Four Strategies, used alone, are ineffective.
According to the Rand report, titled "Cost-Effective Allocation of Government Funds To Prevent HIV Infection," "To prevent 20,000 infections using only these four strategies, the federal HIV prevention budget would have to be increased from $400 million to $1.7 billion." An estimated 40,000 new HIV infections are diagnosed in the U.S. each year, according to the Rand report. And while the CDC initiative was launched in 2003 with a goal of preventing half of these new infections, the Rand report estimated that potentially only 7,300 infections are prevented annually using the CDC's four strategies.
NAPWA's Anderson questions the Bush Administration's motives in seeking to shift CARE Act funds to prevention.
"By proposing to refocus the CARE Act on prevention activities, the Bush Administration seeks to make it one more battlefield in the cultural wars over HIV prevention issues that they have been fighting since they came into office. Such a proposal ignores the original intent of the CARE Act and threatens to drag it into the ugliest of ideological battles about sex and drugs."
Davis-Satterla was concerned with the lack of detail about how exactly the CDC Prevention Initiatives might be linked to CARE fund dollars. "We've been operating under CDC's initiative since April of 2003," she said. "There's mixed emotions about it because certainly there's some proposals in there that make a lot of sense – routinized testing, linking people to early care – but there's some other things that we believe that the CDC has been a little short-sighted on. … There are some natural links to the CARE Act because of the fact of trying to get [clients] into early treatment and early care, but again, the devil is in the details because we don't know how these things are going to be linked."
"It looks like some prevention dollars are going to be taken from care dollars – and you don't rob Peter to pay Paul," said Jake Distel, executive director of the Lansing Area AIDS Network.
And while his agency doesn't receive Ryan White funding, Craig Covey, CEO of the Midwest AIDS Prevention Project, did have an opinion about the latest Bush proposals.
"Just as I think the President's policies can't get any worse, Bush continues to amaze me by his muddled thinking and his disingenuous policies in every aspect of this administration," Covey said. "His record on HIV/AIDS will be just one more tombstone in the graveyard that will be his legacy."
Eliminating community control
Currently, community planning councils set the priorities for how Ryan White dollars are allocated. The councils allow ordinary citizens, including people living with AIDS, to have input in how the funds are spent. Under the HRSA Reauthorization Principles, these councils "would no longer be required to set priorities for spending," and "would be structured at the discretion of the mayor."
"In short, they propose taking decision-making over from participatory community [bodies] and putting it into the hands of local bureaucrats," said Anderson.
Bush Administration: 'No comment'
BTL's efforts to communicate with HRSA officials on the Principles were unproductive. When asked for a copy of the Principles and any specific dollar amounts the administration is planning on submitting to Congress, David Bowman, a HRSA spokesman, said, "It is not our policy to comment on our budget before it's finalized." He added that the administration's proposals were not public information but "internal information."
HRSA's Ryan White CARE Act Reauthorization Principles will first be heard by the Energy and Commerce Committee in the U.S. House of Representatives. Hearings should begin "sometime after the Sept. 15," according to a Democratic committee staffer.
Contact the Michigan representatives on the committee and share your opinion of the Bush Administration's Ryan White proposals. To find out if any of the Michigan representatives on the committee is your U.S. Representative call the U.S. Congressional Switchboard at 202-224-3121 or visit Project Vote Smart at http://www.vote-smart.org.
The Michigan members of the Energy and Commerce Committee are:
John D. Dingell 202-225-4071
Fred Upton 202-225-3761
Bart Stupak 202-225-4735
Mike Rogers 202-225-4872