Trump promises to support health programs, but his budget does not stand up under the system.

The White House's 2020 budget request, issued this week, proposes an additional $ 291 million in down payment for a new HIV initiative. Yet the $ 4.7 trillion budget also calls for sharp cuts in spending on Medicaid, the public insurance program for the poor, on which more than 2 out of 5 Americans with HIV depend.

Such a contradiction – giving at the same time as withdrawing – is the budgetary arithmetic of many of the Trump administration's priorities in health care. In addition to fighting HIV, the President's goal is to fight childhood cancer and the opioid crisis, but his budget would undermine all of these efforts by reducing the health infrastructure on which People with these problems are at the root of the problem while slowing down national spending on cancer research, even though it offers discrete money for these causes, say policymakers.

"If you cut Medicaid, you separate yourself from the system of" helping people with the AIDS virus, "said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation.

On the fight against the opioid crisis – another promise mentioned in the State of the Trump Union speech – Keith Humphreys, professor of psychiatry at Stanford University, called the budget of "true gross negligence". The budget would allocate $ 4.8 billion to the Ministry of Health. and Human Services to help stop the epidemic. But like HIV, Medicaid is the biggest payer for drug treatment, paying $ 1 billion a year, and cutting this program – as well as Medicare – overwhelms everything the government says it's doing. to do.

"If you remove Medicaid and Medicare, you are removing a lot more resources than you are investing in," Humphreys said. And he criticized the budget's recommendation to eliminate most of the funding from the Office of the National Drug Control Policy of the White House – an idea that Trump has incorporated into his three budgets.

"You have a White House office that is particularly well placed to develop an epidemic policy," said Humphreys. "And now you will reduce it."

To fight cancer in children, the White House's financial plan would increase research funding by $ 50 million next year – another priority of the president's speech on the state of the United States. Union – but would reduce the overall funding of the National Cancer Institute by 897 million, or nearly 18 times more amount.

And despite the president's promises not to hurt Medicare, his budget is considering changes that would cut spending on the popular program by $ 845 billion over the next decade – with the biggest savings from reduced payments to suppliers and new efforts to combat fraud and abuse.

Some of the boldest ideas in the budget to redefine health policies are unlikely to come off the table, they were rejected during Trump's term even as Congress exercised total Republican control – with less momentum now than the Democrats hold the House. Of these, the most important is a call to convert Medicaid from its history for half a century as a rights granting program, in which the government pays a certain share for eligible people, to grants overall or strict limits per person unaffected by economic changes. .

At Capitol Hill, early bipartite support appears to be emerging for funding for HIV and pediatric cancer. Republicans and Democrats reacted this week against cuts to the National Institutes of Health and its institute against cancer.

Fred Upton (R-Mich.), Former Chair of the House Committee on Energy and Trade, told Alex Azar, Secretary of Health and Social Services, on Tuesday at a sub-committee hearing on the budget.

"I understand the pain," said Azar, saying the reduction was proportional to an overall 12 percent reduction in the HHS budget. "It's a difficult budget environment."

Democrats were even more vehement about the main source of insurance for the poor for the country. "If this administration wants to seriously block or redefine Medicaid in another way as we know it," Rep. G.K. Butterfield (CN) warned Azar, "We will expect a real firestorm, not just Congress, but the American people."

Charles N. "Chip" Kahn III, president of the Federation of American Hospitals, said that while "almost every president, there is this notion of a budget to death, and that's generally true" , the political priorities listed in Trump's budget should be taken seriously.

"Budgets have several purposes – prioritizing and making political statements," Kahn said. The proposals "confer some credibility. This allows people to protect themselves from changes. "Well, it was in the president's budget, so it must go."

Previous presidents, including Barack Obama, have sought to slow spending on Medicare, partly to extend the life of a financially fragile trust fund for part of the program that covers stays in the hospital. But this year's budget "is at a different level and has wider implications," proposing to slow funding for medical education and reduce reimbursements to doctors and hospitals that care for a large portion of patients who They can not afford to pay their bills, said Kahn. .

Changes to Medicare would not directly affect the benefits to patients, although their care could be affected if physicians left the program because they opposed a reduction in payments.

The proposed changes to Medicaid could, however, have profound effects on people living with HIV, as well as on those who struggle with addiction. Kaiser figures show that Medicaid is the single largest source of health insurance for drug addicts and HIV-positive people.

In particular, the budget's goal of ending the expansion of Medicaid under the Affordable Care Act "will hurt our efforts to end HIV," said Carl Schmid, deputy executive director of the AIDS Institute of Washington. Expansion in about three dozen states "has been crucial for HIV," he said, as it allowed infected men and women to be covered even for the first time if they do not have AIDS declared. , which has long been considered a handicap that qualifies people for the program.

Human rights activists say the budget for the HIV initiative, while welcome, is not up to what would be needed to meet the president's goal of curbing human rights. spread of the virus within a decade. According to Schmid, of the $ 291 million, nearly $ 60 million is money already spent on community health centers and for other purposes.

And a central strategy – identifying people in communities that are "hot spots" for the disease and giving uninfected people a protective drug called PrEP – costs around $ 20,000 a year per person, according to experts. The Centers for Disease Control and Prevention estimate that 1.1 million people should take this medicine – much more than the budget could cover.

"It's great to have this problem on the radar and finally see new money," said Rochelle Walensky, an infectious disease specialist at Massachusetts General Hospital. "But these numbers give you an idea of ​​how we are going to think about this."

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