Remarks at a Meeting With the President's Advisory Council on HIV/AIDS

[Office of National AIDS Policy Director Sandra Thurman made brief opening remarks and introduced the President.]

The President. Thank you very much. I want to get right to the subject of listening to all of you, but I would like to say that, as all of you know, we had a very good couple of days when we finally made the budget last year. We've had a lot of good increases, a lot of things that I know you care so much about, but we've got a lot of work to do, especially in prevention and in the vaccine development. I think we're going to—[inaudible]—pretty soon.

I would prefer, I think, because we've met before and I try to stay familiar with our concerns—I think we've done a good job of getting the money into the programs this time, but there's a lot more we can do—[inaudible]. However, you organized this. [Laughter].

[At this point, Council Chair Dr. H. Scott Hitt introduced the cochair of the Council's Racial Ethnic Populations Subcommittee, Rev. Altagracia Perez, who led the participants in a prayer. Dr. Hitt then commended the President for his commitment to AIDS research.]

The President. Thank you.

[Dr. Hitt emphasized the need for better AIDS awareness efforts in ethnic communities, noting that many Americans infected with HIV were unaware of it. He stated that thousands of HIV infected people could not get the Public Health Service recommended early treatment, but instead had to wait until they became disabled from the disease to become eligible. Council member Rabbi Joseph Edelheit remarked that the Council's duty was to ensure that help and treatment, such as needle-exchange programs and drug therapies, for those living with HIV/ AIDS continued into the next century. He presented the President with a dreidel, the traditional Hanukkah toy, and said the Council's hope was to revive the President's vision of a zero rate of transmission and equitable access to care. Council member B. Thomas Henderson, a person living with HIV, noted the progress made under the President's leadership, but pointed out the need for reform in Medicaid coverage for HIV/AIDS to enable patients to receive early treatment prior to disability. Citing a Health Care Financing Administration evaluation which concluded that could not be done in a budget-neutral manner, Mr. Henderson suggested that the administration needed to look for offset cost savings beyond Medicaid and consider a budget window longer than 5 years, rather than relying solely on demonstration-program legislation introduced by Senators Jeffords and Kennedy. He concluded that drug cost issues needed to be addressed at the same time.]

The President. Well, I'll see what I can do about that. You know, generally, this whole medical coverage problem is getting worse in America. It reminds me of that old joke that the Republicans used to tell on us; they told me, if I voted for Barry Goldwater, we'd get involved in Vietnam too much. And I did, and sure enough, it happened. [Laughter] And they said, when they attacked Hillary and me for our health care plan, they said that, if people supported it, things would get worse. And sure enough, they did. [Laughter]

We've had—these coverage problems have gotten quite profound, and as a consequence, with fewer and fewer people getting medical coverage at work, what you've got is more and more people trying to find a way to get into Medicare.

One of the things, for example, that I want to look at, as a result of this, is something we're doing with disabled people who get back into the workplace. I just started an initiative, not very long ago, to try and have people who have disabilities, which include some people with HIV and AIDS, and they get better—if you have disabilities and you go back to work, it used to be automatically you lose your Medicaid. And now, more and more people are working in small businesses where they don't have employer-based health insurance or they have small pools and they can't afford to take somebody with a preexisting condition. So we're trying to modify the rules so that when people are on disability, then they get off of it and they go back into the work force, they can keep their Medicaid for some period of time. And I want to go back and look and see exactly how we did that and what else we can do here.

Tom, I want to make sure what you said. You believe that there are savings in non-Medicaid areas that would come from keeping people off—help give people the drugs before they get sick in the first place.

Mr. Henderson. As you know, the process right now is for States to seek 1115 waivers. We've been working closely with a number of States who have been working on those waivers for submission at the present time. They believe that there are significant savings in SSI and SSDI, in other areas, that would result——

The President. [Inaudible]—all would be counted.

Mr. Henderson. Yes, sir. And current rules don't allow that.

The President. I've got to go back and look at that. Part of it is the way the law disaggregates money into mandatory and nonmandatory spending. I'll look at it and see if we can do something about that. I know it's very important.

[At this point, Council member Bob Hattoy entered the meeting.]

The President. I presume you still—hello, Bob.

Mr. Hattoy. Hello, Mr. President. [Laughter] Sorry I'm late.

The President. I'm glad you're here. [Laughter]

Mr. Hattoy. I'm glad you're here. [Laughter]

The President. [Inaudible]—notwithstanding what you said, you still think we ought to pass the Kennedy-Jeffords bill? They tell me it's a good bill.

Mr. Henderson. Yes, sir. Absolutely. We just think that there are some things that can be done in the near term, though, within the administration, that do not require legislation, that they would move this problem forward.

The President. I'll do some work on it—what you said.

[H. Alexander Robinson, cochair of the Council's Prevention Subcommittee, said that prevention of new infections remained a problem. He proposed Federal funding for needle-exchange programs and a bold national media campaign by the White House Office of National AIDS Policy to promote voluntary HIV testing, which would be modeled on the national youth antidrug media campaign.]

The President. It sounds like a good idea. I think Sandy is going to come up with a proposal, I think, about what we should do, but I think it's a good idea.

Ms. Thurman. We'll work with you and get one done.

The President. And it offers the promise of sort of getting by the divisive arguments of the past and actually doing something. I like it.

Participant. Proactive.

[Council member Helen M. Miramontes stressed the need for continuing research both in vaccines and therapeutics. Praising the establishment of a 10-year goal for finding a vaccine, she pointed out the urgency of appointing a director for the vaccine center at the National Institutes of Health; following up on the preliminary vaccine meeting; placing a council-recommended vaccine effort coordinator within the Office of National AIDS Policy; and developing and implementing a comprehensive plan.]

The President. Well, let me make a couple comments. First of all, I think the vaccine director is about to be appointed. I've been as impatient about that as you have. I've been—[inaudible].

Secondly, I do think Dr. Neal Nathanson, the new Director of the Office of AIDS Research, has been doing quite a good job. We got about a 33 percent increase in funds for vaccine research in the last budget, so that's good. And we're going to try to—I just had a brief meeting, before I came in here, with our folks, talking about how we can expand Sandy's office over here and introduce this kind of work and kind of ride her on this thing. I think that's important. It does make a difference just to have a sort of sustained White House involvement on any kind of project to keep cutting through the resistance.

[Council member Regina Aragon addressed the need for meaningful and substantial increases in HIV funding in the fiscal year 2000 budget. She thanked the President for his efforts in securing $156 million in funding for a Congressional Black Caucus initiative to address the AIDS crisis in the African-American and Latino communities but noted that conditions required a sustained and expanded Federal response. Ms. Aragon also underscored the importance of funding for a national testing awareness media campaign. Michael T. Isbell, cochair of the Council's Prevention Subcommittee, noted that more than 90 percent of HIV infections occur in the developing world. He commended the President for a $10 million program addressing the needs of AIDS-affected women and orphans and suggested making that funding a permanent part of the U.S. Agency for International Development. Saying that U.S. funding for global AIDS activities had declined in real dollars since 1993, he urged more funding in the upcoming budget and improved coordination of Federal international AIDS efforts.]

The President. Well, in general, let me say I think the budget should reflect better attention both to prevention at home and to the communities of color. And I've been trying to get more money for the USAID mission, and we'll put some more money in there. I think I'd like to make two points.

One is that this budget year will be more difficult than the last one because we got such big increases in everything last time. And because of the global economy kind of slowing down, we don't expect the same amount of revenues to come in this time, and we have to fund all the big increases we got last time again. But we'll do the best we can.

The second thing I would like to say is I think that it would be very helpful to have all of you using your—whatever influence you have with Members of Congress in both parties to support more global efforts, because eventually all this is going to be a menace to the United States. So it's not only a moral imperative, it's also very practical over the long run.

One of the things that has kind of bothered me is that, in the aftermath of the cold war, we were able for several years to reduce our defense budget, and that was a good thing, and everyone—and even the Pentagon wanted to do it. There was just like about 300,000—the number of civilian employees—and they plan for further reductions there. But during that time, we actually needed to make a larger commitment on the diplomatic front or in the nondefense security areas, if you will. And with the exception of the special efforts we made in the former Soviet Union to dismantle and destroy nuclear weapons, basically there's been a wholesale effort to cut back on our diplomatic budget even though, contrary to popular wisdom, the United States spends a smaller percentage of our income on international affairs than any other major country.

And one of the things that I have seen— almost no one knows this, but it's true—one of the things I have—now, to be fair, we also spend more on defense, and a lot of our defense goes to protect other countries, as you see in the last couple of days. But still, for—the numbers are so much more modest, not only for 8 years; let's look at the USAID program, the health programs, the empowerment of women and children, especially young girls, initiatives, the small scale microeconomic development, all that stuff that doesn't cost much money and it has a huge impact, and especially a lot of the things we can do in public health—and, interestingly enough, a lot of the preventive activities that we would engage in with regard to AIDS, for example, would go quite well with other things we need to be doing out there with these large populations anyway in a lot of countries that have severe public health problems.

So we've been sitting here meeting in our— I've been having, each of the last 3 or 4 days, rather long, detailed budget sessions, trying to figure out how to get more blood out of that turnip. And one of the things that I'm trying to do is to figure out how to make the case to the Congress, in an effective way, that the United States has enormous interests, as well as obligations, in making these kinds of investments beyond our borders.

And I think anything you can do to help that, I would appreciate it. I mean, there is this sort of general awareness in Congress that the world is becoming more interdependent. There's a much more sophisticated understanding of the economics, for example. But it's not just economics. It's the environment; it's the public health; it's all these other things where we are becoming more and more caught up with each other.

Our major military mission in the last 6 months, before the operation in Iraq, has been to send several thousand of our uniformed personnel to Central America to help them rebuild after Hurricane Mitch. It's not only the right thing to do from a humanitarian point of view, it is in our national interest. Because if those countries don't rebuild, they will become highly vulnerable to all the drug traffickers. And if they don't rebuild, then all their people will have to come here and, if they can't get here legally, they will try to become illegal immigrants. So there's all these things that we need to begin to see our relationships beyond our borders as more of an extension of our relationships with one another rather than as something totally different and apart from our relations with one another.

And anyway, I don't mean to give you a speech on that; I know you believe that. But the point I want to make is most people who run for Congress never have to think about these things unless they have a large immigrant population within their district from a particular place. So it doesn't—this kind of discussion we're having, because you understand the HIV/ AIDS issue—I'm preaching to the choir here. But anything you can do to sort of just sit down and walk through this with congressional delegations or their chiefs of staff or whoever the appropriate people are from around the country, I would really appreciate, because I think there is a lot of support. For example, you can always get good support in Congress, bipartisan, for a big increase in the Ryan White Act. And now we've finally got pretty good support in Congress, this whopping increase we had to help people purchase the drugs, the medicines. But it drops off markedly when you try to talk about the connection between what we're doing here at home and beyond our borders. And I really think you could help, because this is one example of a more general challenge the country will have to face more every year for the next 20 years, maybe forever, but certainly for the next 20 years.

Dr. Hitt. Mr. President, we really have made—probably hundreds of recommendations in the past few years, I mean—[laughter]. We've tried our best to narrow down——

The President. This is the most energetic— [laughter].

Dr. Hitt. But we have narrowed down a few specific initiatives we brought to your attention today. And the reason is clear, that we've talked to many administration officials and this is where we feel that there's a logjam that you can really help and get involved in and take it to heart.

The President. I will.

Dr. Hitt. And thank you again for meeting with us.

The President. Thank you for the dreidel, the book, the letters. I came away so well, I might have to make the room again. [Laughter] Thank you very much.