Uncertainty & havoc: Federal budget showdown impacts HIV services


By Ernest Hopkins, director of legislative affairs at San Francisco AIDS Foundation  

Many of the healthcare and housing services that cities and states provide to prevent and treat HIV are funded in total or in part by the federal government. This year, like many recent years, the process to finalize the federal budget has been delayed. This uncertainty creates havoc at the local and state levels for public health grantees and service providers who rely on grants and contracts to secure funding for the year.  

Ernest Hopkins

Ernest Hopkins

The fiscal year began on October 1, 2016. Currently, funding for federal programs has been provided through a stop gap measure called a continuing resolution (CR), that funds the government for a short period of time giving legislators time to work out differences in funding levels and policy. The current continuing resolution expires on February 8, 2018. Unless Congress passes another, the government will shut down again as it did on January 20, 2018.  

Discussions with congressional staff suggest that it is likely that at least one, if not two more CRs will be required to give Congress and the Trump Administration time to resolve many contentious issues.  

The Ryan White HIV Treatment Program, which provides essential HIV care and treatment funding to states and jurisdictions across the U.S., is funded annually through the appropriations process. Recently, the federal agency that administers Ryan White alerted local grant administrators that they would only receive 31% of their formula funding to start the program funding year that begins in April. Many organizations have difficulty, or find it impossible, to sign service contracts for less that the total amount of their grant, calling into question their ability to provide Ryan White-funded HIV services until the final budget is resolved.  

The Housing Opportunities for People with AIDS (HOPWA) program is also funding current services through the CR. Although the House has proposed flat funding for this housing program for people living with HIV, the Senate has proposed a $26 million cut, making it difficult for the Office of AIDS Housing at the Department of Housing and Urban Development (HUD) to plan and distribute resources to funded localities.  

In the midst of the federal opioid emergency, HIV-related substance use and mental health services targeted to minority populations were cut in the Trump Administration budget by $17 million. While the House didn't accept the cut, the Senate did. We won't know how much money the Minority AIDS Initiative at the Substance Abuse Mental Health Services Administration (SAMHSA) gets for these critical services until the final federal budget is decided.  

Medicaid, the largest single payer of HIV care, and Medicare (which is also a very significant funder of HIV services with more people living with HIV becoming seniors), were cut in the congressional budget that passed the tax legislation of 2018. Budget rules could require the federal government to cut the Medicare program by $500 million over the next 10 years. These pay-as-you-go rules can, and may, be waived by Congress, and it's hard to say how individual states will absorb their portion of the federal cut. But we know that cuts to safety net programs that support underserved individuals weaken the ability of states to respond effectively to the health care needs of the low-income, the disabled, and seniors.  

We all await the congressional action on February 8, when we will know whether we have budget, a government shutdown, or another CR and continued negotiation. Stay tuned.  

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