As many of my colleagues have expressed in their blog posts over the past week, there is a great deal of uncertainty about what a Trump administration will ultimately mean for health. Perhaps nowhere is this uncertainty more acute than in the realm of U.S. foreign aid and health.
What hangs in the balance has enormous consequences globally. Nearly 40% of the budgets for the World Food Programme and the United Nations High Commissioner for Refugees, comes from the United States. These agencies are responsible for feeding and assisting millions of the most vulnerable people in the world and are already significantly underfunded for the scope of the issues that they are trying to address. The U.S. is also the biggest donor of emergency aid and conventional foreign aid- two areas where funding has direct links to individual, population and global health outcomes.
No one knows what the Trump administration will do with existing foreign aid programs and other international initiatives targeted towards promoting health around the globe. Mr. Trump himself chose not to speak much about foreign aid on the campaign trail and with no public service record to examine, we are left with only a few sound bites to guide expectations about what might eventuate. We do not yet know who will fill critical leadership jobs such as Secretary of State, head of USAID or PEPFAR- choices that will be critical in setting the tone of the administration towards global development and health, particularly after several top Republicans in the foreign intelligence space vowed not to work under a Trump administration.
We know that Mr. Trump’s campaign was built on an ‘America first’ principle and so it is highly likely that he would not see foreign aid as an issue of global cooperation and interconnected outcomes, but instead through a nationalist lense that would be based more on what kind of ‘deal’ he saw for the U.S. He has said that he was in favor of providing aid, based on how friendly the particular country was to the U.S. and how much of security risk to the U.S. failure to provide the aid would become. The obvious problem with looking at foreign assistance and development for health through this frame is that it ignores the interconnectedness of global health outcomes. Diseases do not stop at borders and are not held back by walls. Nor does it take into account the deep value that foreign aid provides in building successful partnerships between nations.
With generally bipartisan Congressional support for foreign aid and the relatively small percentage of the overall budget that foreign aid makes up, it is possible that funding amounts will not shift a great deal. However, Trump and the Republican Congress he will be working with, have said that they want to increase military spending without increasing the overall budget which means that cuts have to come from somewhere. Even if the funding does not shift significantly, the values and tone with which it is provided will be important. Aid for health and development agencies is critical and and failure to recognize the responsibility that the U.S. holds as a leader in setting the agenda for global health and development would be a detriment to us all.
Posted in Global Health;
Respect for equal human dignity, the rule of law, and health in all sectors – these are three preconditions of realizing the right to health. Respect for equal human dignity is the core principle of the right to health and all human rights. Respect for the rule of law is an underlying requirement for the right to health and all other human rights to have meaning. Without the rule of law, governments will do as they wish, too often to benefit the interests of those in power. Any nominal commitment to human rights would then mean little. And for the right to health to be realized, it must be respected across all sectors. Whatever level of health care is available, if people do not have clean water and sanitation, safe housing, education, employment, and so forth, their ability to achieve the highest attainable standard of physical and mental health will suffer enormously.
That these elements are foundational to the right to health gives considerable cause for concern about the right to health in the coming four years under the incoming U.S. President and his Administration. On this blog, my colleagues provide their perspectives about particular areas of concern, and there are many – how U.S. policy could affect reproductive rights both at home and abroad, implications for foreign assistance for health, whether years of expanding access to health services will go into reverse. Here, I reflect briefly on the implications of how the overall tone and policy approach of the incoming Administration may affect the right to health.
First, respect for equal dignity. Non-discrimination and equal treatment, with an emphasis on ending inequities (unfair inequalities), is an overarching principle of all human rights. Entire human rights treaties (such as those on race and women) have been developed around precisely this principle. Yet in his statements during the campaign, as well as his early post-election appointment of a Chief White House Strategist “who has either ridiculed or demonized women, LGBT people, Muslims, Jews and others,” the President-elect has failed to respect this principle. This attitude appears to have unleashed a kind of license to disrespect, with the Southern Poverty Law Center collected more than 400 reports of incidents of hate and harassment in the first 6 days after the election, with the largest number focusing on immigrants, blacks, LGBT people, and Muslims. (A difficult, painful to watch, graphic video of some of the images and words of this hatred can be found here.) Read More
The U.S. election results evoke concern, anxiety, and fear among many Americans, and throughout the world. Public health advocates are concerned about the future of the Affordable Care Act, fearful of restrictions on women’s reproductive rights, and anxious to strengthen efforts to reduce smoking, obesity, and other risk factors for non-communicable diseases (NCDs).
However, results from four down-ballot measures offer a glimmer of hope: voters in four cities approved taxes on sugary drinks. This small step forward in tackling epidemics of obesity and type 2 diabetes reconfirms that local governments can take meaningful action to promote public health. More than ever, strong leadership is required at local and state levels, and among advocates, researchers, and communities. Read More
The 2016 presidential election ended in a result that few who are passionate about public health, human rights, and race, gender and sexual orientation equality could have ever wanted. However, as we face the reality of this reality, we who work to improve health outcomes must steel our resolve and continue to address the critical needs of public health and human rights domestically and abroad, and ponder strategies to still champion our causes in the face of potentially increased adversity.
I find some comfort in thinking that health is one of those few issues that can be easily agreed upon by those of otherwise starkly differing political and ideological views. It is in this mindset that I would like the incoming administration to think when considering health and policy changes that affect the health of Americans. Here are some of the most significant threats to the access to health care for Hepatitis C patients posed by the changes proffered by Republicans and the President-elect.
Hepatitis C and ACA repeal
In the Hepatitis C realm, the threat of repeal or major curtailment of the Affordable Care Act could have catastrophic consequences to those infected with virus and dealing with the associated health issues. The pre-existing condition clause of the ACA, which bans insurers from barring coverage to persons because of an existing health condition, is a key element of the law that allowed may with Hepatitis C to secure health coverage since it was passed. The popularity of this clause is likely to allow it to survive ACA modifications, or to have it emerge in some form in whatever ACA alternative proposed by legislators.
Medicaid expansion is unpopular in Republican states, and many have declined undertaking expansion. Many of these same states, however, house the exact types of Americans that this provision was created to cover. Low-income workers and agricultural/seasonal workers are those who benefit from this extension of coverage. In states that have tried to take steps to reverse their initial support of ACA provisions such as the expansion have found themselves in a moral and political impasse of trying to justify taking health coverage from hundreds of thousands of their citizens. Kentucky is one of these states. Their current governor successfully ran on a campaign that promised to curtail the state’s participation in the ACA, including the Medicaid expansion. This promise has proven to be less likely to come to fruition as he faces the reality of cutting coverage to 400,00 of his citizens if he sees it through. It should be noted that Kentucky is a state that saw a huge Hepatitis C outbreak in recent years, and many of those affected by this outbreak are the very same low-income citizens covered by the state’s Medicaid expansion. Drastic changes to the ACA and Medicaid funding generally could mean the loss of coverage to theses existing patients, and no recourse for obtaining coverage for newly-identified patients. The real-world challenges of attempting a state-level repeal in Kentucky offer some hope that Medicaid expansion can survive in some form, even after an ACA overhaul. However, public awareness and continued pressure on legislature to present comparable alternatives are essential to maintaining access to health care for the millions that could be affected by these changes.
Block Granting Medicaid: Reducing funding to an already cash-strapped program
One of the leading threats to health care coverage for the poor in this country is the Republican push to change Medicaid to a block grant program. This means that states would get a set amount of money to run their program each year, rather than the current process of the federal government providing 60 percent of the funding, and requiring states to cover certain groups of people, such as pregnant women and children. Currently, Medicaid is an entitlement program, which means all who qualify for it must receive coverage. A block grant system would allow states to cap the number of persons it enrolls, and to cut the covered services that the states provide. Block grants would give states more control over how they run their programs and who are covered, but that also means that there is no guarantee that those currently covered will retain their health care. Analysts project that such a plan would leave millions of Americans uninsured.
One of the bigger costs to states under Medicaid is pharmaceutical expenses. I have already droned on ad nauseum in previous blog posts about the cost of Hepatitis C drug treatments. Drug costs will be one of the biggest expenses on the chopping block under the block grant scheme, and Hepatitis C patients, who are already facing hardships getting their drugs covered through Medicaid under its current funding system, will likely face an even greater challenge to getting the drug and clinical care they need to survive.
Government has a DUTY to preserve the health of the people
As the new administration and Congress takes control, I urge them to remember the tenet that they have a responsibility to make laws and policies in the best interest of ALL AMERICANS. Health care is chief on that list, because the government is charged to provide care to those least equipped to afford it, such as the poor, disabled, and elderly through programs like Medicaid. The new administration and the Congress MUST transcend political discourse when considering changes to the public health schemes, and focus on implementing common sense policies that will protect access to health for the most vulnerable.
The election of Donald Trump as the next President of the United States has sent shockwaves throughout the country and across the globe. While the President-elect’s policy agenda was often sparse with details during his campaign, his election will no doubt have a profound impact on a number of major issues, such as healthcare, immigration, gun control, and women’s rights.
At this point, little is known about exactly what a Trump presidency means for HIV. On the one hand, the focal point of his health care policy is the repeal of the Affordable Care Act (ACA), which would have negative consequences for people living with and affected by HIV in the United States. Trump’s early decisions during his presidential transition also do not bode well for HIV policy. Most notable are the announcement of Vice President-elect Mike Pence, who cut Indiana’s HIV spending during his governorship and has a record of undermining the rights of LGBT people, as chairman of the presidential transition effort, and the appointments of Reince Priebus as White House chief of staff, Steve Bannon as White House chief strategist, and Jeff Sessions as Attorney General.
On the other hand, the few things that Trump has said specifically about HIV, while non-committal, suggest some support. When asked at a campaign event in 2015 whether he would commit to doubling the number of people on HIV treatment globally to 30 million people by 2020, Trump said, “Well, I like committing to all of those things. Those are great things. Alzheimer’s, AIDS, so many different – you know, we are close on some of them. On some of them, honestly, with all of the work that’s been done – which hasn’t been enough, we are not very close. But the answer is yes. I believe so strongly in that. And we’re going to lead the way.”
It is important that we in the HIV community adapt our advocacy and policy efforts to these circumstances. First and foremost, this means making Medicaid a top priority and aligning with broader efforts to ensure that the program continues to provide health insurance coverage and access to care for millions of Americans. Medicaid is the largest source of insurance coverage for people living with HIV and covers more than 40% of people with HIV in care. Because Medicaid is an entitlement program, everyone who is eligible is guaranteed coverage, but Trump’s plans for Medicaid could include turning it into a block grant program, which would provide states with annual lump sums and effectively end the open-ended entitlement approach by capping federal matching payments. The result would likely be loss of coverage for some people, a reduction in Medicaid benefits, or both.
Second, we must educate federal and state politicians and their staff about the importance of Medicaid expansion and other features of the ACA for low-income people living with HIV. By expanding the Medicaid program to nearly all non-elderly adults with incomes at or below 138% of the federal poverty level in states that choose to participate, the ACA removed the categorical eligibility requirement, such as disability, which had been a barrier to many people with HIV. The ACA also provides states with an enhanced federal mating rate for the Medicaid expansion population and includes a number of other key previsions, including the elimination of pre-existing condition exclusions and of annual and lifetime caps on coverage as well as expanded options for pushing coverage through Health Insurance Marketplaces.
Third, it is important to state clearly that we have an unprecedented opportunity to move closer to the end of the domestic HIV epidemic, but that the United States must take appropriate steps to achieve this goal. Research has confirmed that people with HIV have better health outcomes when they begin antiretroviral treatment (ART) as soon as possible after diagnosis. Studies have also shown that ART can dramatically reduce the likelihood of HIV transmission. Moreover, studies have demonstrated that pre-exposure prophylaxis (PrEP), a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day, is an extraordinarily effective HIV prevention strategy. The Ryan White Program and the Affordable Care Act play critical roles in ending the HIV epidemic because they foster access to HIV treatment and prevention services, better engagement in care, and enhanced viral suppression.
While it is not possible to say with certainty how HIV issues will fare under a Trump Presidency, there is plenty of reason for concern. As more details come out in the coming months, we must be prepared to: (1) respond to efforts to repeal the ACA and change the fundamental structure and financing of Medicaid, (2) engage in strategic activism around cabinet and other high-level appointments (especially within the Department of Health and Human Services), and (3) increase our efforts to make the case for HIV funding and programs.
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.