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.
If there is anything that we have learned from the Ebola crisis and the Zika outbreak in the Americas is that public health surveillance and response systems are critical to ensuring health security at the national and global levels. Health systems that ensure strong surveillance and rapid response to disease threats are the key to minimizing the impact of epidemics. A country, and the world for that matter, can incur significant social and economic costs during an epidemic and its aftermath. The 2014 Ebola outbreak in West Africa decimated what were already fragile health systems, killing an estimated 11,000 people in the region—half of all those infected. This experience was what framed the Global Health Security Agenda (GHSA) as we know it today. For these reasons, the incoming administration under President-Elect Donald Trump would be well advised to think carefully as it decides whether to support global health security efforts, which include the implementation of the GHSA and other legal and policy frameworks for pandemic preparedness and response like the World Health Organization’s International Health Regulations (IHR) (2005) and the Pandemic Influenza Preparedness (PIP) Framework.
It all boils down to the fact that viruses do not obey borders or politics. Viruses will continue to emerge and re-emerge regardless of whether the new administration makes global health security a priority or not. The GHSA and other frameworks reflect the lessons learned. Granted, there is still a substantial need to invest further in fighting Zika and building preparedness in the U.S. and abroad, but we have made great strides in the last few years. Turning a blind eye or actively undermining efforts to ensure global health security can be catastrophic not only to U.S. national security but also to the new administration’s agenda. As the Commission on a Global Health Risk Framework (CGHRF) (one of four global commissions created following the Ebola epidemic) concluded in its report, a pandemic is costly. It estimated that losses from pandemics figure approximately $60 billion per year. It also emphasized that an annual incremental investment of $4.5 billion (or 65 cents per person) for increasing global preparedness could significantly reduce costs, both social and economic.
On November 4th, during a Bill Maher interview with President Obama, Obama acknowledged that federal prohibition could begin to crumble if the five states voting on cannabis legalization for personal use approved the initiatives. In his words “The good news is that after this referenda, to some degree it’s going to call the question. Because if in fact it passed in all these states, you’ll now have a fifth of the country that’s operating under one set of laws and four-fifths in another. The Justice Department, DEA, FBI, for them to try to straddle and figure out how they’re supposed to enforce laws in some places and not in others, they’re going to guard against transporting these drugs across state lines – you’ve got the entire Pacific Corridor where this is legal. That is not going to be tenable.”
Now, although Arizona’s initiative failed to pass by a small margin, the other four states—California, Maine, Massachusetts and Nevada—approved ballot initiatives legalizing and regulating cannabis for adult use. With these four states added to the existing four plus the District of Colombia, there are now approximately 69 million Americans that are residents of jurisdictions where recreational cannabis is legal; that’s 1 in 5 Americans. This is a significant rise from the 18 million who had access before the November 8th vote.
Additionally, another three states—Arkansas, Florida and North Dakota—voted to approve the use of cannabis for medical purposes, while Montana voters approved an initiative to broaden access under their state’s existing medical marijuana law. As seen in the map above, there are now 28 states (and the District of Colombia) that have legalized medical cannabis, making them the majority. Read More
People from all walks of life who believe in human rights and social justice woke up with great fear on November 9. For the U.S. President-elect had, during a bitter campaign, expressed grave disrespect towards large segments of our society, and views and promises deeply at odds with equal human dignity.
What are we to do now? Here are eight ideas, beginning with the political, moving to ways to support social justice where government policy may denigrate it, and concluding with the more personal.
1. Become part of a social justice movement. Social justice movements are alive and as insistent in their demands for justice as ever. They’re already planning to how respond to new political realities. Choose the issues that most stir your passions for justice. Is it the rights of immigrants? Nuclear disarmament? Criminal justice reform? Climate change? Health care? Workers’ rights? Women’s rights? Global development? Refugees? There are movements around all these areas, and more. Find them. Support them. Join them.
Participate in marches, rallies, calls to action. Help to create new political space in the months ahead, and prepare the ground for candidates committed to the rights of all in the next elections. As President Obama has so often has reminded us, the arc of history is long, but it bends towards justice. We need to keep it that way.
This post was written by Hayley Scheer. Hayley is an LL.M. candidate in Global Health Law and International Institutions at Georgetown University Law Center. She is currently an extern at the Joint United Nations Programme on HIV/AIDS (UNAIDS). Any questions or comments about this post can be directed to [email protected]
The Ohio Supreme Court recently made a move in a positive direction for rights of individuals living with HIV when it announced that it would review the state’s HIV criminal exposure law for its constitutionality.
Ohio currently has a specific HIV exposure law that carries a felony conviction if found guilty. Ohio’s state laws provide that failure to disclose one’s HIV status to his or her partner is a felony, punishable up to eight years imprisonment. While proof of disclosure prior to sexual conduct is considered an affirmative defense to such a charge, use of condoms or other use of protection is not recognized in the state’s jurisdiction. However, case precedent has shown that proof of disclosure is extremely difficult to prove in court when an individual is charged under this statute.
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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.