Update: Following the November elections, Republicans will be in control of both houses of Congress come January.
Election Night 2024 hit sooner and harder than most people expected. Questions and concerns are being raised as a Republican-controlled Congress and a new, but all-too familiar President take over in January. How will people living with HIV be affected by a second Trump administration? What will happen to Medicare, the Affordable Care Act (ACA) and HIV programs such as Ryan White and the Ending the HIV Epidemic (EHE) initiative as Congress applies a conservative agenda?
“What are we as a community going to do to prepare for that, especially since all indications are that there probably won't be a lot of levelheaded folks invited into the administration, like we saw eight years ago?” asked Brandon Macsata, executive director of the ADAP Advocacy Association.
A week before election day, Mascata, along with Jen Laws, president and CEO of the Community Access National Network, organized members of several HIV advocacy and policy organizations from across the country for a virtual roundtable discussion over Zoom to address these questions and consider possible strategies. POSITIVELY AWARE was invited to attend the meeting on the condition that, other than Macsata and Laws, the names of the other attendees and their organizations would be kept private.
Laws pointed out that on the first day of Trump’s first administration on January 20, 2017, the website of the White House Office of National AIDS Policy (ONAP) went dark and the office was shut down. He voiced concerns over what would happen in the second Trump administration.
“I think that within the first 100 days, we’ll start to see pullback on rules that were in the middle of [being put into effect] or finalization,” he said, “and changes in direction of litigation, especially around the Americans with Disabilities Act and non-discrimination protections.”
The Affordable Care Act (“Obamacare”)
The advocates discussed how congressional Republicans will target the ACA, also known as “Obamacare.” The top leader of the House of Representatives is Speaker of the House Mike Johnson, a Republican from Louisiana. Just weeks before the November election, Johnson said that Republicans would repeal Obamacare, calling for “massive reform,” but without offering any details. During the previous Trump administration, House Republicans repeatedly tried to end the ACA but never had enough votes to do it. A new strategy, the advocates said, might be to “reform” the ACA, “nibbling at the edges,” and leaving implementation to the individual states, potentially gutting Obamacare.
But “gutting the ACA is political suicide, even for the Republicans,” another advocate said. More likely, he added, would be “message bills” meant to show some action was taken but without serious consequences like ending coverage for people with pre-existing conditions.
“I think that's what we're talking about, executive-level policy changes around the ACA, and what does that mean?” Laws said. ‘We've got Medicaid that supports 85% of people living with HIV in the United States, which we expect [will have new] restrictions. And we see the ACA on the other side, providing protections [for people with HIV], and Ryan White coming in between [providing HIV services]. Minor changes can have a big impact.”
Laws raised another scenario, speculating that the changes would be “just enough so that Trump can stamp his name on the ACA and move from there.”
Medicare
An advocate from Georgia raised his concern for Medicare. Under a provision of the Social Security Act, the secretary of the U.S. Department of Health and Human Services (HHS) can allow experimental or pilot projects that are aimed at saving money on Medicare. This has opened the door to states, mostly conservative or Republican-controlled, to create new work rules for eligibility, a move that has been praised by Trump. The advocate said some states that have already expanded Medicaid might want to “backtrack” and add their own work requirements.
In the House and Senate, congressional committees play a basic role, shaping proposed legislation before passing it on for a full vote, as well as reviewing the budget and operations of federal agencies. So, committee chairmanships are highly coveted, powerful positions. Traditionally, the most senior committee member from the majority party is named to head the committee. But recently, Macsata said, “there’s been under-the-radar chatter” that some House committee chairmanships might skip over the senior Republican, if that Republican is considered “too moderate” and handed to a more conservative, “MAGA Republican” instead. This could lead to pushing through conservative agenda items while stalling other measures.
Finding allies—or people we can work with
“What I'm doing is shoring up all of our allies in Congress who are sympathetic to our programs and trying to work with them to make sure that we have the strongest congressional stance possible to combat whatever may be coming down the pike,” said one D.C. advocate.
Laws mentioned Louisiana senator Bill Cassidy. Cassidy has helped get federal HIV grants to his home state, which has one of the highest rates of HIV in the country, and to other parts of the U.S. in need. Although a not a “champion,” Laws said Bennett “has been an astounding ally in very important spaces, including hepatitis C elimination plans.”
“If the Republicans take over the Senate, he's going to need our help—there's no two different ways about that,” Laws said. “Regardless of their rhetoric, I need [to find] policy-oriented Republicans who might be swayable or persuadable. Our programs get supported that way.”
Laws said he liked the idea of identifying the top 25 Republicans in the House and top five Republican senators who might be approachable and build allyship with them to have an impact on potential legislation or oversight activities.
“I also think that it's very likely that we see some industry allies maybe get named to cabinet position or sub-cabinet positions,” he added, citing Alex Azar, who was president of U.S. operations for pharmaceutical giant Eli Lilly & Co. when he became secretary of Health and Human Services in the first Trump administration.
“Azar [was] not necessarily the biggest friend of any kind, but far more predictable than some of these chaos agents [whose names have] been floated,” Laws said.
Naming names
Although the Trump transition team is already at work, vetting candidates to fill jobs in the new administration, the advocates discussed offering their own recommendations. Trump might decide to name his own ONAP director, replacing Francisco Ruiz, the current director of of the Office of National AIDS Policy, who was appointed by President Joe Biden.
“One of the things that we should be looking to do on a federal level, pretty much quickly, is identifying who might be folks that may be tenable to the administration and tenable to us and at least put the name forward,” one advocate said.
Strategic communications
“We've got to talk about strategic communications and what strategic presentation looks like [to achieving] our goal,” Laws said. This might mean sending an ally to do an advocate’s job if a better connection can be made with a lawmaker or other public official.
“Taking advantage of who are and taking advantage of who our allies are and how they represent us, is a really important strategic communication tool that we need to get comfortable with, because there's a level of violence in putting ourselves forward that I don't necessarily think we should encourage our most vulnerable members to expose themselves to,” he said.
Still, advocates living with HIV are situated to combine life experience and understanding of public policy to provide unique insight. This will apply to other federal programs threatened by a right-wing agenda. This includes the Ending the HIV Epidemic (EHE) initiative, Trump’s own HIV program, started in 2019. Republicans have proposed eliminating the EHE as part of a plan to slash funding for sexual and reproductive health programs.
Other issues are reauthorization of the Ryan White program and the Older Americans Act, which provides some protections for people aging with HIV and for older LGBTQ+ people. As Republican lawmakers push slash funding for programs and cut regulations on business, advocates will need to better understand public policy to collaborate with other advocacy organizations and to persuade public officials. It’s a continuation of the legacy of the HIV movement.
“We need to remember our history,” one advocate said. “We are a resilient community. We are multiple communities with multiple resiliencies. We have a history, specifically within the HIV/AIDS movement, going back four decades of being strategic, being tenacious and finding wins where no one thought wins were possible. We need to lean into that history and push forward.”