Here in Washington, the professional policy warriors fighting on HIV's federal battlefield are worrying about what, come November's first Tuesday, a President Dole would mean for AIDS.
The closest thing we have to a crystal ball involves looking to the past: Bob Dole's Senate voting record. Even that, though, leaves much room for debate: The Kansan's recent conversion to right-wing ideology -- the now-you-see-it-now-you-don't dance of a one-time political centrist-conservative -- is an object of great skepticism among real conservatives. Would Dole's jig to the Right end as soon as he's ensconced in the Oval Office, or does it signal a permanent change of heart?
Perhaps to be on the safe side, almost everyone working on AIDS interests on the federal level quietly makes quite clear their support for Clinton. Christine Lubinski, deputy executive director of AIDS Action Council, is "very frightened by the prospect of President Dole in the context of AIDS policy." Jim Graham, executive director of Washington, D.C.'s Whitman-Walker Clinic, concurs: "The indicators are few but convincing. I think the message is pretty clear it would be a step backwards on AIDS issues."
Winnie Stachelberg, deputy political director for legislation of the Human Rights Campaign (HRC) -- which has endorsed Clinton -- states flatly: "Senator Dole has not been a friend to the AIDS community. He has not been a huge obstacle, but in no way has he been proactive or actively supportive. To get him where he is now has taken great effort. Take Ryan White [CARE Act] reauthorization."
Stachelberg recalls that the 1995 reauthorization for the bill -- the mammoth AIDS-funding mandate first introduced in 1990 by, among others, Sen. Orrin Hatch (R-Utah) -- enjoyed broad bipartisan support. Sens. Nancy Kassebaum (R-KS) and Ted Kennedy (D-MA) were shepherding the bill toward passage, there were no amendments proposed, and it was approved unanimously in committee -- yet, each time Kennedy or Kassebaum went to then-Majority Leader Dole for floor time (the first step to debate and a vote), Dole said no.
When, months later, Dole finally announced he would give floor time, Sen. Jesse Helms put a hold on the bill. Dole did not ask Helms to back off. When debate finally began, Helms offered several amendments, one of which would have specifically denied funds to organizations that served the gay and lesbian community. Dole voted for that amendment along with 54 other Senators, but Hatch, Kassebaum, Alan Simpson (R-WY) and Al D'Amato (R-NY) voted against it. "[That vote] illustrated that Dole was willing to go along with whatever the extremists come up with," says HRC Political Director Daniel Zingale.
For the record, Dole did not vote for other Helms amendments, such as one to forbid greater expenditure on AIDS than on cancer.
Given Ryan White's reauthorization, everyone's primary policy concern in the '96 election is not, in fact, AIDS-specific. It is Medicaid. Ryan White funnels around $800 million to AIDS; Medicaid lumbers in at well over $3 billion. Ninety percent of children with AIDS receive some services through Medicaid, and 50 percent or more of people with AIDS depend on Medicaid for health care. And, of course, Medicaid is caught up in both the mandate to balance the budget by 2002 and the political ideology of the GOP.
Nailing down any accurate figures on who is proposing how much in cuts is made difficult by political jockeying and constantly changing information. The conservative group Americans for a Sound AIDS Policy maintains that both Clinton and Dole have proposed basically the same reductions in growth for Medicaid, respectively a 7.8 percent and 7.1 percent cut in the growth rate up to 2002; only a 0.7 percentage-point difference. Richard Sorian in the White House AIDS Policy Office puts Clinton's savings at $54 billion and the Republicans' at $72 billion over six years -- definitely not a gap of 0.7 percent.
Sorian further points out that the Republican proposal allows states to reduce Medicaid spending by 20 percent, which means they could cut another $185 billion on top of the $72 billion. At worst, that makes a total of $257 billion in growth reduction. And Sorian adds, very dryly: "When given the power to reduce Medicaid spending yet receive the same dollars from the federal government, the assumption is that [states] would take the opportunity."
But what is acknowledged -- surprising, given the above battle over figures -- is that the real war is not over the amount of money. The Republican proposal on Medicaid, consistent with its States' Rights agenda, is to "block grant" it, give each state a certain hunk of money and let them decide, alone, what to do with it.
Block granting -- supported by Dole and opposed by Clinton -- horrifies most AIDS activists because it could create huge nationwide disparaties in the care PWAs receive. Mike Isbell of Gay Men's Health Crisis (GMHC) and a recent appointee to Clinton's Advisory Council on HIV/AIDS says, "Bob Dole has endorsed providing a substantially reduced lump sum to the states and saying, 'Fine, dispose of this money as you see fit.' We are concerned that if the federal government doesn't require certain spending on AIDS, the services won't be there, and sick people will be the first to suffer. This would be a catastrophe." Adds HRC's Stachelberg, "States will not cover people with AIDS, particularly the more expensive care."
One AIDS lobbyist who disagrees is conservative Shepherd Smith, executive director of Americans for a Sound AIDS Policy. "I think a Dole Presidency would more rapidly limit the spread of the disease and thus limit suffering more than [the Clinton] administration," says Smith. "The anti-block grant response is knee-jerk liberalism responding to the idea. God forbid they should say anything good about a Republican idea."
Smith's analysis is interesting. "If people are concerned about what a Dole administration might do, they should know they'd be better off because...on the local level, they can spend the money more efficiently than can bureaucrats back in Washington."
Of course, everyone observes that Clinton has himself fallen short of the mark on AIDS. Two lesser-known examples: When campaigning in 1992, he promised a "Manhattan Project" to find a cure. He has not followed through, and both Clinton and Dole refuse to support the AIDS Cure Act, a detailed plan for such a project cosponsored by 20 members of Congress. And candidate Clinton promised to support needle exchange; President Clinton's administration remains categorically opposed, as does Dole.
But Clinton held the first White House conference on AIDS and made both Ryan White and AIDS research "investment priorities," meaning he would never issue a budget without increases in these areas. Stachelberg and others would like him to do the same for prevention, "which he hasn't done so far," she says. "Prevention is a place where people feel he could be better." But what prevention policies would Bob Dole support? He has voted for Senate attempts to restrict schools from using materials that "promote homosexuality" (and HIV prevention materials that target gay men are always considered such by right-wingers), to require written parental consent for minors to obtain condoms, to prohibit use of federal funds for needle exchange or the distribution of bleach to drug users, to criminalize donation of blood by people with HIV, to criminalize health care workers with HIV who perform invasive medical procedures on patients without notifying them, to allow medical professionals to manditorily test patients for HIV prior to invasive procedures and women during pregnancy.
"Listen, President Clinton has supported a balanced budet, so we're going to have fights there even if he wins," Christine Lubinski says. "I don't mean to suggest that if Clinton wins again, we ride off happily into the sunset. But we who advocate for people with AIDS will be at a distinct disadvantage if this whole town is run by Republicans."
What if Dole does win? "I think that were Dole to be elected, we would do our best to educate his administration and work with it," Mike Isbell says cautiously. But he adds immediately: "I think that the prospect of a return to a Republican White House, however, certainly causes some concern and alarm. Under Reagan and Bush, the White House was not friendly terrain." And Dole would love to be the next Ronald Reagan.