If you’ve been reading or listening to the news, you’ve been hearing a lot about the “fiscal cliff.” You might be asking yourself: What is the fiscal cliff, and why might it matter to healthcare, HIV and housing … or even me? Here are brief answers to those questions.
What is the fiscal cliff?
The term refers to more than $500 billion in tax increases and across-the-board spending cuts scheduled to take effect after Jan. 1 — for fiscal year 2013 alone — unless President Obama and Republicans reach an alternative deficit-reduction deal. The Chairman of the Federal Reserve coined the metaphor “fiscal cliff” last year to warn of a dangerous, yet avoidable, drop-off ahead in the nation’s fiscal path.
The budget deficit that the United States faces means that we are currently bringing in less revenue (through taxes and economic stimulus) than we are spending (federal programs). The deficit cannot rise faster than the economy indefinitely without causing economic and financial problems. On the other hand, trying to eliminate the deficit too soon could derail our country’s precarious economic recovery.
Certain laws were put in place over the years to spark the economy. Letting current laws continue past 2012 would significantly reduce future budget deficits. For example, the Bush Tax Cuts of 2001 and 2003 (extended by President Obama in 2010) are scheduled to expire at the end of 2012. This means people would pay more in taxes, and tax revenues can be helpful to reduce the deficit.
Other deficit reduction initiatives include allowing the automatic spending cuts mandated in a law called the Budget Control Act of 2011 to take effect. This is also referred to as sequestration, and it was never really designed to be enacted. It was viewed as an incentive to avoid a bad situation. Sequestration would result in dramatic, across-the-board cuts to both defense and non-defense discretionarily funded programs.
Republicans generally want reductions in spending on federal programs and Democrats generally want to increase taxes and tax rates for the wealthiest Americans.
If we go over the cliff, what happens?
If we go over the fiscal cliff all of this would happen at once. This would not be good news for Harlem United and the people we serve. For example, the HIV and AIDS program portfolio is entirely funded through discretionary federal funding. Discretionary funding levels are established annually by Congress, as opposed to mandatory spending that is required by laws that span multiple years, such as Social Security or Medicare. The cuts proposed to discretionary budgets would automatically impact all program line items threatening to oust thousands of people living with HIV and AIDS from many of our most important and effective programs like the AIDS Drug Assistance Program (ADAP), housing assistance, and medical care through Ryan White. HIV prevention programs at the U.S. Centers for Disease Control & Prevention and thousands of research projects at the National Institutes of Health also face cuts or elimination.
Uninsured and underinsured people who rely on federal programs to address their health care and support-service needs would risk losing access to services that they consider essential to their health, well-being, and quality of life.
We know that Medicare and Medicaid are essential to people living with HIV/AIDS, the elderly, the low-income, and individuals with disabilities and chronic diseases. They are truly the lifeline for millions of Americans and must not be undermined, but strengthened, at a time when the aging population in the U.S. is increasing. Further, the cuts would also most certainly mean deep cuts to federal housing programs as well.
Here are just a few examples of the many potential cuts and taxes that could be enacted:
Funding for HIV prevention at the Centers for Disease Control would be cut by $64 million;
The Ryan White HIV/AIDS Program, which provides care to low income people with the disease, would be cut by $196 million, including $77 million in cuts from the AIDS Drug Assistance Program
AIDS research at the National Institutes of Health would be cut by $251 million;
The Housing Opportunities for People with AIDS, or HOPWA, program would be cut by $5 million.
Medicare costs would be reduced by reducing payments to providers and eligibility aged raised to 67.
Taxes would increase. Revenues would increase, but some economists predict these drastic changes could contribute to another recession.
The US Department of Housing and Urban Development’s HOME program will take an $82 million cut in 2013, $8.3 million of which would come from New York programs.
Proposals to restructure the Medicaid program have been part of the budget negotiations, as well. This could mean changes like block granting and changes to Medicaid’s payment and reimbursement systems.
Funding for Community Health Centers could be cut $167 million this fiscal year.
What can I do?
If you believe federal government programs ADAP and HOPWA provide a critical safety net to homeless people, people living with HIV and others, are important, please contact your congressional leadership in the House and Senate to let them know that you care about these programs and do not want them cut.
What is the most important message for members of Congress to hear?
Over the last 20 years, Congress has funded the Ryan White CARE Act. It is the largest single disease discretionary program and is a model for comprehensive, community-based medical care and supportive services. As we integrate people living with HIV into the broader framework established under the Affordable Care Act, we will need resources to transition and coordinate seamless access to care for people living with HIV, and Ryan White can provide those resources.
For people at risk for HIV, new research reinforces the critical importance of routine testing and early access to treatment. Early HIV treatment improves the health of the individual and also dramatically reduces the viral burden in communities. That, in turn, reduces the likelihood of new infections. Early investments in preventive health services ultimately reduce overall health care costs on federal, state, and local systems.
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As you may have seen in the news a week or so ago, AIDS Activists took over the office of Speaker John Boehner in Washington DC, and exposed themselves in order to expose the “naked truth” about AIDS budget cuts. You don’t have to get naked, but here’s what you can do:
*Call our New York Congressional leaders: Representative Charles Rangel (202) 225 -4365 and/or Senators Kirsten Gillibrand at (202) 224-4451 and Charles Schumer at (202)224-6542.
*Call Majority Leader Senator Harry Reid (D-NV) at (202) 224‐3542.
*Call House Minority Leader Nancy Pelosi (D-CA) at (202) 225‐4965.
Here's a sample call in script to use when you're making calls:
Hello my name is [ ], and I'm calling on behalf of people living with HIV and the service organizations that support them. Please inform [insert Congress person’s name here] that I strongly oppose any budget cuts to HIV, community health centers and housing programs and expect that --HE/SHE-- will renew --HIS/HER-- commitment to fully funding these life-saving programs.
Earlier this month, the head of New York State’s Department of Health, Commissioner Nirav Shah, MD, MPH, visited Harlem United to speak with members of the executive team and tour Willis Green Jr. ADHC medical and dental clinics and Foundation House West. His visit reflected an appreciation of the important model of care developed and practiced at Harlem United.
As New York State continues to revamp its Medicaid program, the commissioner and his staff are seeking out innovative models of care to achieve the Triple Aim of New York State’s Medicaid Redesign; improving the quality of care, improving health outcomes and reducing Medicaid costs. The Commissioner wanted to get a close look at an agency that is successfully improving care, while at the same time, doing it more efficiently. Harlem United’s model of stably housing many of it patients and integrating a wide variety of services around a convenient clinical space has drawn the attention of the state. These models will likely be replicated throughout New York and the nation in the coming years.
For many years, the practice of integrating housing supports into health care services has shown promise in lowering health care and shelter costs. Stably housed Medicaid patients visit the emergency room less often and are less frequently admitted for costly in-patient hospital stays. Commissioner Shah hopes to dedicate $750 million over five years in funding for supportive housing programs that successfully integrate health and home.
The supportive housing model used by Harlem United is a terrific example of the type of program that Dr. Shah hopes to promote. During his site visit, Dr. Shah greatly enjoyed touring the medical and dental clinics at the ADHC West. The proximity of Foundation House West to the clinics was a point of pride for Harlem United. By keeping health care and housing services close to one another, Harlem United improves the health of its patients by ensuring they have unblocked access to care – a point Dr. Shah was sure to remember.
Coordination of Care and Health Homes
New York State sees a lot of promise for improving health care and lowering costs by creating a continuum of care that follows patients throughout the healthy and ill periods of their lives. Dr. Shah hopes to create a health care environment where people do not simply seek health care services when they are sick; rather, they access prevention services when they are healthy through high quality primary care. Often times, when people lack insurance or access to care, they will obtain health care services in costly hospital setting only once health issues reach emergency status.
Harlem United’s care coordination programs are just the sort of health support services that the Commissioner is hoping to implement across the state. The Access to Care team and case management services keep Harlem United patients connected to care in all stages of their experience with the agency. By ensuring that patients adhere to their medications and keep in regular contact with their primary care provider, Harlem United’s dedicated staff keeps people healthier and reduces the overall cost of Medicaid in New York State. Dr. Shah pushed the agency to provide stories and data that would show the success of the agencies coordination efforts and allow him to convince state officials that these are effective, helpful strategies.
Integration of Services
Part of the continuum of care idea involves the integration of additional health care services into primary care. Specialty care such as HIV care, mental illness services, substance use and harm reduction counseling work better and produce improved health outcomes when they are coupled with strong primary care services. The Department of Health sees the integration of these services into mainstream health care provision as essential to achieving the goals of the Medicaid Redesign Team.
Harlem United, being a one stop shop providing services from housing to health care and every support service in between, has become a recognized leader in care integration strategies. By providing these services in coordination with one another in a centralized area, Harlem United ensures that patients can easily attain primary care, behavioral health and HIV specialty care in a convenient manner.
In the coming months and years, New York State and the federal government will be guiding health care patients and providers through a number of health care developments aimed at improving care and lowering costs. As they do so, policy makers and health care stakeholders will be looking for proof of success for these new models. Senior Vice President of Policy Doug Berman noted, “Harlem United has proven itself to be a leader and an innovative creator of new care models. I think Dr. Shah saw that first hand today.” The care models advanced by Harlem United have been pointed to by many as the type of programs and models needed to positively transform the health care environment in the United States and here in New York.
Lorenzo Penn of New York City is 50 years old and HIV positive, and he came to the AIDS Conference in Washington, D.C., this week, ready to tell his story.
He knows he owes his life to the rabble-rousing protesters I met as a reporter in Washington more than 25 years ago.
I remember them as young, beautiful and angry. Looking back, I also see them as heroes. Though many of the ones I interviewed knew they were infected and might not live to benefit from their actions, they traveled to Washington from across the country to show their faces and make scientists and political leaders listen to what they had to say.
They fought successfully for the political will to fund the research that now keeps alive Penn and millions of other HIV-positive people worldwide.
A diagnosis of infection with HIV no longer has to lead to the outcomes described in terrible detail in a government report I covered for The San Francisco Chronicle in 1988, when only 10 percent of people diagnosed with AIDS were expected to live more than five years.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told reporters this week that he and his colleagues have "a scientific basis for being optimistic." Recent research shows that treatment can prevent transmission, and the government last week approved the use of Truvada, a combination of antiretrovirals sold in a single pill (for about $1,000 a month), to protect people who are at risk but not infected with the disease.
Yet Fauci and other scientific leaders at the conference acknowledge that biomedical solutions are not enough in battling the global epidemic. Research suggests that in the United States, 20 percent of the 1.2 million people who are infected with HIV don't know they are. And a study published this week in the Journal of the American Medical Association reports that 70 percent of the 426,000 people on antiretrovirals in the United States have suppressed viral loads, which means that 30 percent are at risk of transmitting the disease and of developing drug resistance.
It's clear that the challenge is to identify and get people into treatment early, but also to keep them there. Worldwide, behavior change is vital not only in preventing HIV, but in ensuring that people take their medication, and remain tied into the systems that can save their lives and move the world closer to eliminating the epidemic. And that is the new front line.
Penn says people will adhere to treatment. But they need to see it as part of a strategy that will help them transform their lives for the better.
Gay and African American, Penn was living in Omaha, Neb., when he was diagnosed in 1992, and he feared the prejudice he had seen chase Ryan White's family out of their community in Indiana in the 1980s. "I was scared to death," he says. "And I thought I had five years to live."
So, in 1994, he moved to San Francisco, where he was put on newly approved life-saving drugs. His life got better, but he began to take "drug holidays," which affected his physical and emotional health. After two years in San Francisco, he moved to Los Angeles and from there to New York.
He arrived homeless and sick, and he had given up hope. He found it in a community-based group named Harlem United. Plugged into programs that provided him with food, medical care, mental health services and shelter, Penn went back to school and studied medical billing. He is now in a program at New York University that he hopes will lead to a career at the university.
Penn's story says that hopelessness is the real disease, and he wants that message heard.
And in allowing me to identify him as HIV positive - though still frightened of the prejudice that led him to leave Omaha 20 years ago - Penn takes up the mantle of the fiery advocates whose spirits walk the halls of the Washington Convention Center this week.
Coimbra Sirica is a science writer who helps nonprofit organizations draw attention to evidence-based solutions to problems of disease, hunger and poverty in the developing world.
The FDA’s Antiviral Drugs Advisory Committeerecommended Truvada be used as PrEP in May, but the FDA’s final decision wasn’t expected until September.
Truvada as PrEP is based on the landmark iPrex clinical trial, which showed an average of 44% reduction in HIV infections among study participants when combined with risk reduction counseling and condom usage. Protection from HIV infection became even stronger (90% efficacy) for those who consistently took the pill every day.
While many believe PrEP holds a great deal of promise, there are many implications to consider in administering PrEP to individuals and communities like those whom we serve. Harlem United has convened an internal PrEP Working Group, which is planning staff and provider education among other things. Similarly, the Policy Team will be prioritizing the subsequent policy and advocacy issues, such as ensuring access and insurance coverage. The estimated cost of PrEP is $8,000 – $9,000 per person, per year.
More details on the programmatic and policy implications of PrEP coming to your inbox soon.
Please contact Kimberleigh J. Smith at email@example.com with questions or requests for more information.
F.D.A. Advisory Panel Backs Preventive Use of H.I.V. Drug
SILVER SPRING, Md. — A drug already used to treat H.I.V. infection should also be approved to prevent it, an advisory panel to the Food and Drug Administration said on Thursday. The recommendation is the first time that government advisers have advocated giving antiviral medicine to healthy people who might be exposed through sexual activity to the virus that causes AIDS.
One panelist called approving the drug “an amazing opportunity to turn the tide on this epidemic.”
Studies have shown that people who take the medicine, Truvada, every day have a greatly reduced risk of infection.
The F.D.A. usually accepts the advice of its advisory panels, which are made up of outside medical experts.
On Thursday, after evaluating studies of the once-a-day pill and hearing scientific presentations, the panel recommended that Truvada be prescribed for people at high risk of infection, like gay men who have multiple sex partners, especially those who do not always use condoms, and people in relationships with someone who is H.I.V.-positive. Young black men who have sex with other men are at highest risk. The drug would also be recommended for other high-risk people, like prostitutes.
AVAC Urges FDA Approval of PrEP Following Positive Advisory Committee Recommendation; Lays out Priorities to Ensure Access
New York, NY — AVAC hails the recommendation by an FDA Advisory Committee that emtricitabine/tenofovir disoproxil fumarate (TDF/FTC or Truvada) be approved for use as pre-exposure prophylaxis (PrEP) among sexually active adult men and women. Citing the urgent need for new HIV prevention options to stem HIV infections, AVAC urges the FDA to issue an approval for all men and women at risk, and is calling on public health agencies, governments, advocates and funders to take action to ensure access to TDF/FTC as PrEP.
The first of a two-part series examining what can be done to reverse the high rates of new HIV infection among Black gay and bisexual men.
The number of new HIV cases in the United States has remained fairly stable at about 50,000 per year between 2006 and 2009, according to data from the Centers for Disease Control and Prevention (CDC) that was published in early August in the online scientific journal PLoS ONE.
Many of these men aren't aware they're infected. Guest host Tony Cox discusses the study with the director of the CDC's National Center for HIV and AIDS Prevention, and the Harlem United Community AIDS Center's Senior Director of Federal Policy.
In the new study, the authors -- from New York University, CDC, and Harlem United Community AIDS Center -- said black MSM accounted for 38 percent of new HIV diagnoses in New York City. The team used data from the New York City setting of a multi-site ...