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At What Price is there U. S. Global Leadership in Health

November 4, 2011

On October 11, CSIS hosted a Dialogue on “U. S. Leadership in Global Health”. It was chaired by Bob Schieffer, chief Washington Correspondent for CBS News; accompanied by a panel composed of Stephen Morrison, Senior Vice President and Director, CSIS Global Health Policy Center; Thomas Frieden, Director, U. S. Center for Disease Control and Prevention; Representative Kay Granger (R-TX).

Bob Schieffer initiated the Dialogue by stating some global health statistics directly related to or heavily supported by U. S. funding, e.g.: specifically  it was $1.7 billion in 2003, rising to $8.7 billion in 2010; and, GAVI has immunized 285 million children since its beginning. He concluded by saying ‘this is in our national interests and we need to sustain these achievements and improve on number of those receiving these services’.

Steve Morrison then commented that global AIDS has to be seen in perspective. That is, in 2003, it was commonly thought that it was too expensive to offer treatment, and that even though South Africa was initially “hostile to AIDS”, it is now the leading program for PEPFAR, which has expended $3.1 billion there. He went on to say that partnerships with industry have made this possible. Tom Frieden stated that “treatment is prevention”, meaning that the earlier one can be put on ARVs, the chances of that person passing on the virus decreases dramatically. He went on to comment that PEPFAR alone now has 4 million patients under ARV treatment [out of 7 million globally].

In an earlier post by Steve Morrison, he expressed concern that even before the Super Committee was to deliver its recommendations on budget cuts, the House Foreign Operations Appropriations Subcommittee had reduced the foreign operations budget for “2012 by 9% in global health and 18% in overall foreign aid”.

Given these concerns about future budget cuts, it is reasonable to inquire about the “mortgage liabilities” that the U. S. has on sustaining 4 million AIDS patients on ARV treatment for the remainder of their natural life spans, in addition to millions of others who are receiving some kind of health assistance from PEPFAR.

In July 2010, PEPFAR released a report to Congress on the Costs of Treatment for a program funded at $48 billion over six years.  At that time, there were only 3.2 million under ARV therapies. It was perhaps the most detailed analysis yet on the costs and number of people that were beneficiaries of PEPFAR. For the 4 million now on ARV therapies, the costs for lst, 2nd line and pediatric patients is $3.2 billion per annum. The report went beyond the 4 million under direct ARV treatment. It also included the number of “Women of all Ages and Children Aged 0-14”. That came to 2.3 million additional patients, or a grand total of 6.3 million under ARV treatment. In addition, the Report also list several categories of patients receiving various forms of assistance from PEPFAR: the number of those Tested and Counseling Results at 32.9 million; Pregnant Women with know HIV status tested, 8.4 million; Orphans & Vulnerable Children, 3.8 million; Direct Care & Support, 11.4 million. This sub-total of 56.5 million can be added to the 6.3 million receiving direct ARV are for a grand total of 62.8 million patients.

Since South Africa is the epicenter of global AIDS, and the signature country for PEPFAR programming, it would be worthwhile to review current tensions between that government and the U. S. Again, these have been described recently by Stephen Morrison in a post.

South Africa has 1.7 million patients under ARV treatment, with PEPFAR having been a major financier. The U. S. share of total funding has dropped from 65% to 35%, with the South African government picking up the majority as of 2010.  However, the U. S. now wants to transition from an emergency mode to a long-term sustainable approach by strengthening the government’s human and management capacity. The fundamental intervention that the U. S. now wants to foster is to elevate prevention as a strategic priority.  One reason for the tension: South Africa feels it followed PEPFAR’s lead in placing treatment as the priority but now that it is becoming too expensive, the U. S. wants to switch to prevention as a least cost alternative. South Africa is bearing the major portion of costs from a burden levied on them by a previous U. S. priority.

A proxy for weighing the U. S. global AIDS cost is to lay it against national costs.  At present, in the largest states with the highest number of AIDS patients, e.g., New York, California, etc., AIDS expenditures consume the second largest line item in Medicaid budgets after Long Term Care. And there are less than 500,000 AIDS patients in the U. S. It is also has been treating AIDS patients over an extended period of time—since 1988, and understands that costs only increase with age and the onset of co-morbidities.

In June 2011, the Washington Post carried an OpEd article on the fiscal difficulties being experienced by AIDS patients in Washington D. C. It has the highest incidence rate in the U. S. Yet, “the AIDS Drug Assistance Program which provides drugs to patients, has a waiting list that has balloon from 99 in June 2009 to 2,939 in September 2010 … additionally, thousands have been kicked out of the program because of restrictions”.

The U. S. has signed on with the WHO goal of having 15 million patients on ARV therapies by 2015.  Since PEPAR has been diligent in reporting all costs to the Congress, does it understand that in supporting 62.8 million AIDS patients with various forms of assistance, this burden is a future unfunded liability greater than the total number of people now receiving healthcare assistance under Medicaid, the differences in service composition notwithstanding? These are human beings in 35 different countries that are dependent upon U. S. health assistance, including 1+ million in China, the world’s 2nd largest economy.

Perhaps the pause which might ensure from the Super Committee’s decision on global health funding can serve to refocus our efforts and help us to determine the price on future unfunded health liabilities that the U. S. can reasonably carry into the future.

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