What is the Coburn Bill?
Ironically entitled the "HIV Prevention Act of 1997" the bill (S. 503/HR. 1062) was introduced by Tom Coburn, Republican Congressman from Oklahoma. (Coburn achieved notoriety last year by denouncing the network broadcast of Schindler's List _as indecent.)
The bill requires that States do the following:
- Mandate the NAMES reporting of all positive HIV test results to public health authorities. (Anonymous testing would end.)
- Cooperate with other states in developing a national partner notification program, to trace and notify the partners of anyone who tests HIV positive.
- Test people accused of sexual offenses whenever the victim or alleged victim requests it, and permit the defendant's HIV test results to be used in court.
- Authorize health care workers to refuse to perform any invasive medical procedure until the patient has been tested for HIV.
- Authorize funeral homes to refuse to perform funeral procedures unless the body is tested for HIV.
- Disclose a child's HIV status to adoptive parents.
The bill withholds federal Medicaid funds to any state that does not comply with these mandates.
It also includes a "sense of the Congress" resolution urging states to criminalize the intentional transmission of HIV.
It provides no new money to finance any of these initiatives. It has only a nonbinding resolution to protect the confidentiality of test results. It provides no non-punitive HIV prevention measures, such as prevention campaigns directed to gay men. It makes no provision for following testing and notification with health care. It provides no money, for example, to make protease inhibitors available to those who test positive. (Protease inhibitors are still unaffordable and inaccessible for the majority of those with HIV.)
Early '98 update...
The bill has YET to be heard in committee. The senate counterpart version of his bill, sponsored by Sen. Nickles, has also not yet been heard in committee. But it's time will come....
>The first hearings on the 2000 reauthorization of the Ryan White CARE Act
>were held March 2, 2000 by the Senate Committee on Labor, Health, Education
>and Pensions. Statements presented by several witnesses and by Senators
>Jeffords and Harkin are now posted on the LHEP webpage. This is the site
>where future postings of the Senate activity on the CARE Act can be found.
> Witnesses include Sandy Thurman and Ryan White's mother. This page also
>leads directly to key information about the committee, its jurisdiction and
>functions, and members of the committee.
Rep. Coburn's testimony in support of mandatory partner notification is especially interesting. Coburn simply states, with absolutely no scientific basis (because there is none) that partner notification is an effective means of reducing the transmission of HIV, then continues with an emotional appeal about monogamous women and their babies (i.e. the "innocent" victims). It's clear what his goal is: not stopping the AIDS epidemic, but a moralization of AIDS. But since doctors' and public health officials' authority is rooted in the supposedly "scientific" nature of their claims, I find it useful when discussing these superficially convincing arguments with others to challenge the science. In other words, instead of saying, "But don't you see his political agenda?" I say, "But there are no scientific studies showing partner notification actually works, or that mandatory partner notification is better than voluntary," etc. In fact a recent study showed that partner notification did not increase in with HIV names reporting, as opposed to anonymous testing. Of course, these are arguments I make for potential allies. I don't waste my breath arguing with those health bureaucrats and politicians like Coburn, whose agenda has nothing to do with finding an effective end to the AIDS epidemic.
Richard Jackman, RESIST THE LIST, Seattle, WA USA
March 23, 2000
POLITICS & POLICY
RYAN WHITE CARE ACT: COBURN CITES DISADVANTAGES FOR BLACKS, HISPANICS AND WOMEN
In announcing his plans to revamp the Ryan White CARE Act, Rep. Tom Coburn (R-Okla.) yesterday released a General Accounting Office report and said that rural areas, women and minorities are shortchanged in the amount of CARE Act funding they receive (Myers, Tulsa World, 3/23). According to the report, three- quarters of those who benefit from the CARE Act are men, while women and minorities, who account for an increasing number of AIDS cases, "generally receive less appropriate health care for their disease when assessed in terms of physical visits, emergency room visits, hospitalizations and antiretroviral and prophylactic drug therapies." Additionally, when compared to whites, African Americans and Hispanics received "less appropriate care." Urban areas also received higher funding per AIDS case than did rural areas, which therefore "may offer more limited medical and social services" (Coburn summary, 3/23). Phoenix, for example, received $3,133 for each of 1,670 AIDS patients in 1997, while areas around the city received $1,000 less per patient for 760 AIDS patients. Detroit received $3,296 for each of 2,765 AIDS patients, compared to $2,170 each for 1,285 patients in the rest of Michigan.
Although the government provides more funding for AIDS cases in urban areas, the number of rural AIDS cases is on the rise; rural AIDS cases accounted for 7.2% of all AIDS cases, a 5.4% increase since 1993 (Gullo, Associated Press, 3/23). Coburn said, "Because of the built-in funding disparities, those living with HIV/AIDS in rural America have limited medical and social services and often times may have to travel to urban areas to receive proper care. ... Geography should not determine a patient's fate" (Coburn release, 3/23).
The Ryan White CARE Act should be refocused to concentrate on prevention rather than treatment, Coburn also said yesterday, as he announced his intention to make "sweeping changes" in this year's CARE Act reauthorization, CongressDaily/A.M. reports. Coburn lamented that the federal government spends an estimated $10 billion annually to treat HIV/AIDS, but allocates only about 10% of that amount for prevention efforts. He said, "In any epidemic, the most important thing is to prevent the next person from getting it" (Rovner, CongressDaily/A.M., 3/24). Coburn added, "If the best care is prevention, our current federal prevention program is guilty of malpractice" (Tulsa World, 3/23). Coburn also criticized the CARE Act's funding method, which dole out monies based upon the number of AIDS cases, not HIV cases, which "tends to disadvantage women and minorities." He said, "If you base it just on AIDS, you're looking at the epidemic seven to 10 years ago." Because of that distribution method, Coburn asserted that in Oklahoma, "someone has to die before they can access lifesaving medications, while in New York City, federal funds are used for special services such as dog walking and art classes in addition to care" (CongressDaily/A.M., 3/24). Coburn added that because of the AIDS-only focus results, "states and cities with relatively new epidemics [do not receive] the federal support they need" (Health News Daily, 3/24). In the next several weeks, Coburn plans to make his proposals public, focusing on education and other prevention-related programs, as well as increased funding to provide AIDS drugs to those with HIV and for treating IV drug users (CongressDaily/A.M., 3/24). Coburn's legislation also would require all states to implement HIV surveillance and conduct partner notification by 2003 (Health News Daily, 3/24).
Coburn also had requested that the GAO investigate allegations of abuse and misuse of CARE Act funds, and the inquiry turned up three cases. In San Juan, Puerto Rico, 12 individuals were indicted for conspiring to commit fraud by transferring more than $2.2 million from the city to a private corporation. The Western North Carolina AIDS Project was found to have misappropriated a CARE Act-funded educational position and overstated reports of individuals receiving educational assistance. In Florida, a Central Florida AIDS Unified Resources Inc. bookkeeper was arrested for allegedly embezzling more than $200,000 in funds (GAO briefing paper).
Linda Brandt, executive director of the Rural AIDS Action Network in Minnesota, said, "The few of us who are spending 100% of our time on rural AIDS feel completely excluded." But Jeff Jacobs, an AIDS Action lobbyist, said rural funding should not come at the expense of urban programs and called for a "balancing act" between rural and urban needs (Associated Press, 3/23). For its part, AIDS Action said the GAO report confirmed the "effectiveness and efficiency of the Ryan White CARE Act in serving Americans with HIV and AIDS." Acting Executive Director at AIDS Action Claudia French pointed out that the report said that "CARE Act funds are reaching the people who are hardest hit by the epidemic, including people of color, women and the poor," and that "African Americans, Hispanics, and women are served by the CARE Act in higher proportions than their representation in the AIDS population." Noting that the CARE Act provides an "efficient, effective and powerful means of getting funds to the thousands of community-based organizations on the frontlines of the battle against HIV/AIDS," French said that the GAO study "demonstrates how vital the Ryan White CARE Act is, and emphasizes the need to reauthorize it this year" (AIDS Action release, 3/23).
The coded message (or one of them) in Coburn's report is mandatory HIV names reporting, mandatory testing and mandatory partner notification. The claim that using AIDS instead of HIV surveillance data to allocate funds ignores the fact that data from names reporting is inaccurate as well, undercounting those who avoid testing and treatment.
Of course another tactic here is pitting groups against each other: the old gay men v. women and people of color tactic, but also the urban v. rural tactic. The old wrong assumption continues to be: "the same amount of money needs to be reallocated." Instead we need to demand more money, because the epidemic continues to expand.
Richard Jackman, RESIST THE LIST Seattle, WASHINGTON
Roland Foster is the Health Legislative Aide to Congressman Tom Cobra (ROOK) who sits on the Health subcommittee of the House Commerce Committee. The Health Subcommittee, chaired by Michael Bilarakis (RIFLE) is technically where the CARE Act reauthorization process should start on the House side. Roland has been meeting with other committee staff and community folks for quite some time now--against many of our better judgments--in hopes that we could come to some agreement on the CARE Act that would not include heinous provisions that threatened the civil liberties and confidentiality of individuals living with and at risk for HIV infection.
On May 11th, the other shoe finally dropped on Cobra's true intentions related toHIV legislation this session when he co-authored a baby testing bill. While this bill is free standing legislation from the CARE Act reauthorization it would preclude states from receiving state-based CARE Act Title II grants if they did not adhere the provisions of this proposed law. The text of the legislation follows:
Women and Children's HIV Protection Act of 2000 (Introduced in the House) HR 4426 IH 106th CONGRESS 2d Session
H. R. 4426
To amend the Public Health Service Act with respect to testing pregnant women and newborn infants for infection with the human immunodeficiency virus.
IN THE HOUSE OF REPRESENTATIVES
May 11, 2000
Mr. ACKERMAN (for himself and Mr. COBURN) introduced the following bill; which was referred to the Committee on Commerce
To amend the Public Health Service Act with respect to testing pregnant women and newborn infants for infection with the human immunodeficiency virus.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Women and Children's HIV Protection Act of 2000'.
SEC. 2. FINDINGS.
The Congress finds as follows:
(1) Perinatal transmission is the leading cause of pediatric cases of acquired immune deficiency syndrome (commonly known as AIDS).
(2) The Centers for Disease Control and Prevention (CDC) estimates that nearly 7,000 HIV-infected women give birth in the United States each year and as many as 400 babies continue to be born with HIV infection each year.
(3) Medical advances have made it possible to nearly eliminate perinatal HIV transmission.
(4) Research studies have demonstrated that the administration of antiviral medication during pregnancy, during labor, and immediately following birth can significantly reduce the transmission of the human immunodeficiency virus (commonly known as HIV) from an infected mother to her baby. Cesarean section further reduces the risk of transmission.
(5) Even if treatment begins shortly after birth, antiretroviral therapy can substantially reduce the chance that an HIV-exposed child will become infected.
(6) Breastfeeding by HIV-infected mothers poses additional significant risk of infection to babies.
(7) The Institute of Medicine (IOM) has recommended the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care. However, 15 percent of HIV-infected pregnant women receive no prenatal care according to the IOM.
(8) The American Medical Association recommends mandatory HIV testing of all pregnant women and newborns with counseling and recommendations for appropriate treatment.
(9) Testing newborns whose mothers' status is unknown ensures that every child at risk for HIV is identified.
(10) The provision of testing of pregnant women and newborns with appropriate counseling and treatment can significantly reduce the number of pediatric cases of acquired immune deficiency syndrome, can improve access to and medical care for the woman and children, and can provide opportunities to further reduce transmission among adults.
(11) The provision of such testing, counseling, and treatment can reduce the overall cost of pediatric cases of AIDS.
(12) For the reasons specified in paragraphs (1) through (7)--
(A) universal routine HIV testing of pregnant women and newborns should be the standard of care; and
(B) the relevant medical organizations, as well as public health officials, should issue guidelines making such testing, counseling, and treatment the standard of care.
CARE ACT RESTRICTIONS SECTION (emphasis my own)
SEC. 3. ADDITIONAL REQUIREMENT FOR CERTAIN GRANTS.
Subpart I of part B of title XXVI of the Public Health Service Act (42 U.S.C. 300ff-21 et seq.) is amended by inserting after section 2616 the following section:
`SEC. 2616A. ADDITIONAL REQUIREMENT FOR CERTAIN GRANTS.
`For fiscal year 2002 and subsequent fiscal years, the Secretary shall not make a grant to a State under this part unless the State demonstrates that the law or regulations of the State are in accordance with the following:
`(1) That all pregnant women receiving prenatal care in the State be offered counseling and testing regarding HIV disease.
`(2) In the case of prenatal testing for such disease that is conducted in the State, that the results of such testing be promptly disclosed to the pregnant woman involved.
`(3) In the case of newborn infants who are born in the State and whose biological mothers have not undergone prenatal testing for HIV disease, that each such infant undergo testing for such disease.
`(4) That the results of such testing of a newborn infant be promptly disclosed in accordance with the following, as applicable to the infant involved:
`(A) To the biological mother of the infant (without regard to whether she is the legal guardian of the infant).
`(B) If the State is the legal guardian of the infant:
`(i) To the appropriate official of the State agency with responsibility for the care of the infant.
`(ii) To the appropriate official of each authorized agency providing assistance in the placement of the infant.
`(iii) If the authorized agency is giving significant consideration to approving an individual as a foster parent of the infant, to the prospective foster parent.
`(iv) If the authorized agency is giving significant consideration to approving an individual as an adoptive parent of the infant, to the prospective adoptive parent.
`(C) If neither the biological mother nor the State is the legal guardian of the infant, to another legal guardian of the infant.
`(D) To the child's health care provider.
`(5) That, in disclosing the test results to an individual under paragraph (2) or (4), appropriate counseling on HIV disease and appropriate referrals for health care be offered to the individual (except in the case of a disclosure to an official of a State or an authorized agency, or to a health care provider).'.
Ernest C. Hopkins
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