Omnibus Appropriations: The power of the purse

By: Marcus Hopkins, HEAL blogger

Once again, the U.S. government was on the verge of being shut down over disagreements on federal funding levels.  “Nothin’ new,” one might say – we haven’t had a functional legislative branch with much in the way of bipartisanship for close to five years (or some might argue even longer), outside of major legislation that is often passed out of the fear of voter retribution that rarely comes as a result of gerrymandered districting on both sides of the aisle.  In an act of self-preservation, the Republican-led Congress passed a three-day spending bill so that the details could be hammered out on the $1.012-trillion Omnibus spending bill.

For those of you unfamiliar with the term, an Omnibus bill is a large bill that covers a variety of diverse or entirely unrelated topics.  This current bill covers the entire discretionary budget and is comprised of no fewer than 1,582 pages, and largely follows the same conservative trend in government spending that has, in the past, spelled trouble for healthcare and public health initiatives.

Sign from Congressional Appropriations Committee,

Appropriations

The fifteen-day government shutdown that ended on October 16th, 2013, was largely the result of the Tea Party elements within the Congressional Republican Caucus attempting to defund or repeal the Affordable Care Act (better known as “Obamacare”).  When the inaction of our elected officials came to a head and the voters responded with both exasperation and outrage, legislators on both sides of the aisle brought their toys back to the playground and began playing with them, again, in their own separate corners.

Republican appropriators touted their “win” of no new funding for the ACA, and made certain to note that $1 billion was cut from the Independent Payment Advisory Board (once famously referred to by ½-term Alaskan Governor Sarah Palin as the “Death Panel”).  The latter was done to prevent the Secretary of Health and Human Services (currently Kathleen Sebelius) from “raiding” these funds to for the Health Care Insurance Exchanges.

Additional cuts include $10 million from Title X Family Planning funding, which funds many women’s health clinics that provide vital testing services for STDs/STIs, including HIV and HCV.  These clinics primarily serve people with no or low income, two of the highest non-race-related risk groups in the country for contracting both HIV and HCV.

Democratic representatives will be quick to point out that we saw an increase in funding for Alzheimer’s research, as well as a $1 billion increase in funding for the National Institutes for Health (NIH), both of which are fantastic.  But, with every quid, there comes a pro quo, and the cost, in this case, may be higher than we should be expected to pay.

A couple of things should be noted about the current omnibus:

1.)   There are no real serious attacks against programs that are a priority for access to care, and by “real,” I mean, “No funding has been substantially cut that will negatively impact more than a handful of people.”

2.)   While we avoided additional sequestration with this bill, and in fact it was slightly scaled back, it must be noted that this could prove to be problematic, still, for the Ryan White Care Act and the AIDS Drugs Assistance Program (ADAP) – programs upon which co-infected HIV/HCV patients are very likely to depend.

As I’ve noted in previous blogs, RWCA and ADAP are already problematic, as they are not nationally implemented with any consistency from state to state.  The popular saying in the HIV/AIDS community is, “When you’ve seen one ADAP, you’ve seen one ADAP.”

One of the primary issues I have with ADAP is that the money is allocated at the Federal level, is disbursed at the state level, and it’s basically a free-for-all from there.  Each state then has virtual carte blanche to appropriate those funds however they see fit, resulting in a hodgepodge of programs that may meet certain needs, but not others. Fortunately for patients seeking HCV treatment, about ½ of the ADAPs cover some level of access to care and treatment for the disease.

That said, with funding levels largely stagnant and the patient base increasing, it’s difficult to say whether or not state ADAPs will be able to cope, should an influx of new patients occur, particularly states that have not opted in to the Medicaid expansion (most notably in the American South).  The staff at HEAL Blog (myself included) don’t foresee the return of ADAP waiting lists, at the present time, but with every state healthcare agency working overtime to ensure that new regulations are met and coverage is provided under the ACA, we likely won’t know for certain until someone realizes (often too late) that there’s a problem.

The continuing funding issue with Ryan White and ADAP is something that will very likely lead to a lot of vociferous infighting within the HIV/AIDS policy community, as reauthorization of the Ryan White Act is due at any time…which may or may not even be necessary, as there is no sunset provision attached to the law (meaning that no new legislation is required to keep the funding active through the annual congressional appropriations process.  At this time, it’s fair to say that not many people can provide definitive answers about the fate of the RWAC/ADAP programs under the ACA, myself included.

So, where does this leave us as health educators and healthcare providers?  In the same position we’ve been in for several years, now – being asked to provide more services to a growing number of patients with fewer resources.

There are many within the healthcare community who take a look at these numbers and attempt to figure out how we can fit all that we need to accomplish into the ever tightening noose that is the funding game – the Pollyannas of the group who insist that, when handed fewer lemons, we make more watery lemonade.

I am not one of those people.   I am a realist, and the reality is that, if the current trend funding trends continue, as they are likely to do if Congressional seats do not flip one way or the other, we will eventually be asked to do with so little that any efforts will be both negligible and fruitless.

There comes a point when we must begin advocating not only for ourselves, but for those whose voices cannot reach the ears of Congressional leaders more concerned about retaining their seats than they are about doing what is best for everyone in the country.  If we intend to increase awareness and testing within the HCV community, it would behoove us to better leverage ourselves in a manner that will influence the Congressional purse strings.

Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates.

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