Thursday, March 20, 2014

President Obama's FY15 Budget Offers Promise & Dismay

By Anna Meghan Nunn

With the implementation of the Affordable Care Act (ACA), Rep. Paul Ryan's recent House Budget Committee Report, and the reemergence of previously eliminated AIDS Drug Assistant Program (ADAP) waiting lists, President Obama’s Fiscal Year (FY) 2015 budget proposal has been highly anticipated by those in the HIV/AIDS community. So how does the President’s budget stack up with respect to the Ryan White CARE Act, in general, and ADAP, specifically? To put it in perspective, it is important to revisit the President’s previous commitments.

On World AIDS Day 2011, President Obama took to the stage of George Washington University and spoke to a packed house about his commitment to ending AIDS, saying:

We just have to keep at it, steady, persistent, today, tomorrow and every day until we get to zero. And as long as I have the honor of being your president, that’s what this administration is going to do. That’s my pledge — my commitment — to you. And that has to be our promise to each other — because we have come so far; we have saved so many lives. We might as well finish the fight.”

Months later, President Obama unveiled his FY13 budget proposal with a $47 million increase in ADAP funding, or a total of $943 million. The final budget passed by Congress did not include the proposed increase, and ADAP received $886.3 million. In March 2013, the President laid out his FY14 budget, which again requested a $47 million increase in funding for ADAPs. The final funding passed at $900 million later that year. Fast forward...

Earlier this month the President released his FY15 budget proposal. The budget proposal calls for a $4 million increase in Ryan White Care program funding for a total of $2.3 billion. It also proposes flat-funding for ADAP programs at a continued $900 million level. The flat-funding is viewed by some to be a demonstration of the President’s ongoing commitment to the fight against HIV/AIDS in a time of federal budgetary austerity; others view it as falling short because the need is much higher. Some advocacy groups suggest that the proposed budget is $189 million short of the need. 

President Barack Obama signs copies of the FY 2015 Budget as Sylvia Mathews Burwell, Director, Office of Management and Budget, and OMB staff look on in the Oval Office, March 4, 2014. (Official White House Photo by Pete Souza)
President Barack Obama signs copies of the FY 2015 Budget as Sylvia Mathews Burwell, Director, Office of Management and Budget, and OMB staff look on in the Oval Office, March 4, 2014. (Official White House Photo by Pete Souza)

Most notably however, it is a testament to the cost-effectiveness of Ryan White programs and ADAPs. Just as Rep. Ryan’s House Budget Committee Report found Ryan White programs to be sustainable, President Obama’s budget proposal also seems to demonstrate an understanding of the success of these programs. 

William Arnold, President & CEO of the Community Access National Network (CANN), and the ADAP Advocacy Association's board co-chair argues that:

The country is in a state of austerity with many federal programs coming under fire in an attempt to reduce the budget deficit. The fact that Ryan White and ADAPs have fared so well under these circumstances authenticates the proven Return on Investment that these programs have demonstrated.” 

ADAP Education Initiative Director Eddie Hamilton had this to say about the recent budget proposal:

The President’s proposal to basically flat fund the ADAP Program is a positive step in the right direction even though there is more that needs to be done for the program. With improved testing and the new treatment guidelines that are adding new patients, the Program will begin to struggle yet again after a very brief hiatus from growing nationwide waiting lists.”

Hamilton is echoing a growing number of responses to the proposed budget. While many advocates are pleased that Ryan White and ADAPs are continuing to be funded at a significant level, there are concerns about the future of ADAP programs including the following:
  • Uncertainty of Medicaid Eligibility Expansion Among States
  • Affordable Care Act (ACA)
  • Waiting Lists & Reduced Formularies
According to the Henry J. Kaiser Family Foundation, 26 states (including the District of Columbia) have opted to accept the federal funding for expanding Medicaid eligibility offered by the ACA (as of January 28, 2014). Nineteen states have announced that they will not move forward with the expansion at this time and 6 states are still openly debating the decision. Because there is uncertainty in how many clients will transfer over to Medicaid programs, ADAPs must be flexible and reactive in how they will best disseminate funds and what needs they will have. Further, some states that have chosen not to expand Medicaid eligibility have also announced that they will cut state ADAP funding.

For example, according to Disability Rights North Carolina, Governor Pat McCrory has proposed a budget calling for an $8 million cut to the state’s ADAPs in his FY14-15 budget. Some argue that what is unfolding in North Carolina provides further evidence of why there is a need of additional federal funding of ADAPs is still necessary.

There is also a great deal of uncertainty associated with the intersection of the ACA and ADAPs. Whereas there is some uncertainty about the enrollment numbers, state ADAPs are also unsure how many clients will be transferred into Marketplace insurance plans. Clients moving into these plans may require additional ADAP funds to assist with co-payments, laboratory tests, and other out of pocket expenses. There is now an emerging question surrounding whether these types of wrap-around services will even be covered, thus potentially leaving patients in a bind.

Without additional federal funds ADAPs fear that they may once again become cash strapped and fall short of meeting these needs. In the past when this has happened states have been forced to take drastic measures, creating waiting lists and reducing formularies. A recent press release from The AIDS Institute makes the point that states have struggled in the past to keep up with low-income clients living with HIV/AIDS. They contend that enrollment in ADAP grew by 8 percent in 2013. 

Earlier this year also brought the return of ADAP waiting lists, a problem that had been eradicated in late 2013. The latest ADAP Watch, published by the National Alliance of State & Territorial AIDS Directors (NASTAD), noted these concerns:
  • Utah established a new waiting list on February 19, 2014.
  • Ten ADAPs have had cost-containment measures in place since April 1, 2013 (reported as of February 4, 2014).
  • Louisiana reports considering implementing new or additional cost-containment measures by the end of ADAP’s current fiscal year (March 31, 2014).
  • Seven ADAPs reported modifying or eliminating existing cost-containment measures since April 1, 2013 (reported as of February 4, 2014).
  • Wyoming eliminated their enrollment cap on November 21, 2013.
Further federal funding would assist with thwarting these anxieties.

The other concern with the President’s budget proposal is the issue surrounding Part D of Ryan White. Part D is devoted solely to “providing family-centered care involving outpatient or ambulatory care for women, infants, children, and youth with HIV/AIDS” (U.S. Department of Health and Human Services). Grantees use this funding to help pay for costs associated with services including:
  • Lab, x-ray, and other diagnostic tests.
  • Pharmaceutical assistance for HIV-related medications, and vaccines.
  • Oral health-care services.
  • Mental health services.
  • Substance abuse outpatient care.
  • Medical nutrition therapy.
  • Transportation for clinical care providers to provide care.
Just like the other Parts of Ryan White, funds are used as a cost-effective way to assist low-income individuals. However, unlike other Parts of Ryan White, Part D is aimed directly at assisting women, children, infants, youth, and families affected by HIV/AIDS.  The President’s budget proposes to combine Part D with Part C. The argument for the consolidation, which will administered through the same division under the Health Services & Resources Administration (HRSA), is to achieve "savings" through increased efficiencies and decreased overlap.  Many advocates are concerned that the proposed consolidation will leave these vulnerable groups without the important care they need. This translates into a coverage gap for many low-income families; families that will fall through the cracks of healthcare.

A recent press release from the AIDS Alliance for Women, Infants, Children, Youth & Families raised these concerns last week. Deputy Executive Director Dr. Ivy Turnbull had this to say:

Ryan White Part D is the lifeline for women, infants, children and youth living with HIV/AIDS. The Part D programs are instrumental in preventing mother-to-child transmission of HIV and for ensuring that women and youth have access to quality HIV care.  Since the program’s inception in 1988, the Part D programs have been and continue to be the entry point into medical care for women and youth and, in many communities or regions, Part D programs are the only perinatal clinical service available to serve HIV-positive pregnant women and youth.  Removing Part D from the federal budget would eliminate a strong safety net for our most vulnerable populations and weaken the system of care these programs have created and invested in for more than 25 years.”

The same press release quoted HIV advocate Janet Kitchen as saying:

I am shocked that this is happening when the services for women and children are so important and the President has invested so much in promoting health care access in this country.  I believe everyone in the HIV community should be concerned about this and the community should be involved with the administration and congress to discuss and create a system that serves the people in need.”

Although there is concern over Ryan White Part D, Hamilton makes an important distinction saying, “It appears that the reconfiguration of Part D Services will not play any detrimental role to the ADAP Program at this time.” 

This is good news for ADAP recipients who are seeing growing apprehension from the healthcare community with regard to Part D.

The overarching reaction from the public health community and HIV/AIDS advocates is that the President’s budget is congruent with his promised commitment to continue funding programs like Ryan White in an effort to eradicate HIV/AIDS in the U.S. That being said, there is a fear that the lack of additional funding for ADAPs may cause unintended consequences for states programs that are already cash-strapped and will see growing financial needs due to the transferring of clients into Marketplace plans and the uncertainty of how the Medicaid expansion will effect ADAPs. The HIV/AIDS community will continue to closely monitor the budget proposal as it moves through congress and the ADAP Advocacy Association will continue to update its followers with regard to this issue.

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