“Don't expatriate,” David Poole said, when asked about GOP control of the White House, Congress, and, the Supreme Court. Poole serves as the Director of Legislative Affairs for the AIDS Healthcare Foundation (AHF). He deals with Florida’s Legislature, bureaucracy, and Congressional Delegation. Somehow, he remains optimistic.
While Trump’s tweets and appointments do concern Poole, he feels “the future under President-Elect Trump is a big unknown.” Two areas worry him: Medicaid, and the impact of the promised repeal of the Affordable Care Act (ACA) on Ryan White Care (RWC). Repeal would strongly affect the AIDS Drug Assistance Program (ADAP), which pays for HIV medications.
According to the National Association of State and Territorial AIDS Directors (NASTAD), 11.8 percent of all US ADAP clients rely on the ACA to pay for their care. Among Florida ADAP clients, 7.9 percent do.
Poole thinks it unlikely that Congress could fully repeal and replace the ACA in 2017. While Congress could change parts, it is just too complex and too linked with other programs. A smooth transition from the ACA to some replacement will take time. Even after Congress acts, the federal bureaucracy would have to implement it. The glacial pace of bureaucratic change might be beneficial, if Congress enacts a bad replacement, a rough transition, or no replacement.
According to Poole, the health care industry has yet to reach a consensus on what to do. This lack of consensus worries him. “If you can't build that consensus, then you end up with people coming to the conclusion, that it's best just to throw out as much of it as you can, and start to rebuild.” Poole continued, “I'm not convinced that that can be done without severe consequences.”
Insurance costs less than direct purchase of HIV medications. Consequently, RWC officials have urged RWC clients to enroll in the ACA to cut costs. This cost transfer has allowed ADAP to serve more clients.
Poole said that if Congress “makes abrupt changes to the ACA without any kind of contingency plans, then you would end up dumping a great deal of people into our RWC safety net.” In that case Poole continued, “We will go back once again to advocating substantial increases in appropriations to RWC.” If that fails then RWC may have to reduce “services to core clinic and medical services and some priority support services”. ADAP wait lists might even return.
Three other factors could add to Poole’s fears about RWC’s ability to re-absorb former ACA clients. First, the newly HIV-diagnosed will still enter RWC. Second, RWC has to re-engage those RWC clients who have dropped out of RWC. Third, the ACA also allowed states to expand Medicaid. If Congress repeals the ACA abruptly, these clients could be expelled from Medicaid. RWC will then have to re-absorb those clients. As Florida refused to expand Medicaid, the third point will not affect Florida, but it will affect national RWC.
The authorization for RWC ran out in September 2013. Since then Congress has funded RWC at the same levels through Continuing Resolutions. Any funding increase to RWC would require re-authorization.
Instability in health care could increase the risk of people dropping out of treatment. “If enough change occurs over a short period of time,” said Poole, “the fear is that you will lose [clients] altogether.” HIV treatment dropouts will end up in the Emergency Room. They also become more capable of infecting others. “We have excellent data in research to show that treatment is prevention,” Poole said, but that could be lost with an abrupt repeal of the ACA.
Before ACA/Medicaid expansion, Medicaid paid for medical care for people under 65 with very low incomes. According to NASTAD, Medicaid pays for the care of 6.6 percent of U.S. ADAP clients. It pays for about 0.1 percent of Florida ADAP clients. This drastic difference results from Florida’s strict, if not stingy, Medicaid eligibility rules.
Poole reported that Medicaid is facing serious danger. Paul Ryan, Speaker of the House, wants to change Medicaid from an “entitlement” program to block grants to the states. The House has passed bills in 2013, 2014, and 2015 to do just that. Poole felt that Medicaid block grants have become more likely with GOP control of Congress and the White House.
According to a Congressional Research Service Report, block grants differ from categorical grants in less federal control. This allows states to differ in the services they provide. While categorical “entitlement” grants grow with economic and demographic changes, block grants have set funding amounts. Several studies have found that block grants fail to adjust for inflation.
David Poole remains optimistic despite his concerns. “Many people are fearing many things, but, until those things present themselves, I think we need to remain optimistic. If some of those horrible things occur,” Poole continued, “We have to fight the good fight. We got to rally. We can't sit back and be apathetic. I think that's what makes America great.” The word “again” was conspicuously absent.
Unless explicitly stated otherwise, Poole’s responses in this interview reflect his personal views and not necessarily those of AHF.
To read the Congressional Research Service report, please visit, https://fas.org/sgp/crs/misc/R40486.pdf
To read the NASTAD 2016 ADAP report, please visit, https://www.nastad.org/resource/national-adap-monitoring-project-2016-annual-report