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.