Contrary to Rhetoric, Trump Budget Cuts Access to Care for HIV, Substance Use Disorders

Just weeks after promising in the State of the Union to expand funding to substantially reduce new HIV infections over the next ten years and combat the opioid epidemic, President Trump unveiled a budget today that deeply cuts Medicaid, the core program providing access to health care for people with these conditions. Even with its limited new funds for programs that address HIV and substance use disorders (SUDs), the budget on the whole would make it less likely that people get needed care and would undermine the President’s stated goals.

Medicaid is the single largest source of coverage for people with HIV. Many parents and other adults with HIV have received coverage thanks to the Affordable Care Act’s (ACA) Medicaid expansion. Access to treatment for people with HIV is important both to maintaining health and to preventing the spread of disease: people receiving regular HIV treatment are much less likely to transmit the disease to others.

Medicaid is also essential for people with SUDs, such as opioid use disorders. Nearly 12 percent of adults in Medicaid have an SUD, and Medicaid is the nation’s largest payer for behavioral health services. Medicaid provides a range of services to meet the needs of people with SUDs, including detox, recovery supports, and prescriptions for use in medically assisted treatment.

Although the President’s goals of reducing HIV infection and combatting the opioid epidemic are laudable, his 2020 budget would dramatically cut the programs that people with these conditions need to get care. For example, it would:

• Eliminate the ACA’s Medicaid expansion, which has extended coverage to 12 million low-income adults — many with HIV or substance use disorders. Congress rejected this idea in 2017, but the budget nevertheless proposes it again.
• Replace both the Medicaid expansion and the ACA subsidies, which help millions of people afford private coverage, with a vastly inadequate block grant. Block grant funding would fall far below current-law funding, since the block grant would grow only with general inflation and wouldn’t adjust for population growth or health care costs. Nor would it adjust for unexpected costs, so states would be entirely on the hook for all costs from public health emergencies (such as another sudden increase in SUDs like those involving opioids, or a new outbreak of HIV), recessions, natural disasters, or prescription drug price spikes.
• Convert the rest of Medicaid, including coverage for children and people with disabilities, to a per capita cap that limits federal funding per enrollee regardless of need. The cap would grow each year only with general inflation, so it would fall further and further below the cost of providing health care.
• Take Medicaid coverage away from adults if they don’t meet a work requirement. Arkansas is the first state in the nation to take coverage away from people who don’t meet a work requirement. In the first seven months of implementation, more than 1 in 5 people subject to the policy lost their coverage. Applying this policy nationally, as the budget proposal would do, would have devastating effects on coverage — particularly for people with complex health care needs, and likely many people with HIV and SUDs.

The budget overall would cut funding for Medicaid and ACA subsidies by $777 billion over ten years, compared to current law.

These proposals come on top of other Administration actions that make it harder for people with serious health needs to get coverage and care. The Administration has offered unprecedented approval for state proposals restricting Medicaid coverage, such as by taking coverage away from people who don’t meet work requirements, pay unaffordable premiums, or submit paperwork on time. It has also expanded two kinds of private health plans that don’t have to meet the ACA’s protections for people with pre-existing conditions: short-term health plans, which typically exclude coverage of pre-existing conditions and often don’t cover treatment for substance use disorders (among other things), and association health plans, which also don’t have to provide the ACA’s “essential health benefits” and can set premiums in ways that penalize small groups and individuals who are costlier to insure.