By Cleo Manago On Tuesday, July 13th 2010, president Obama presented the National HIV/AIDS Strategy (NHAS) for the United States. According to his administration, the NHAS is a concise plan for moving the country forward in the fight against HIV and AIDS with three primary goals: reducing HIV incidence, increasing access to care and optimizing health outcomes, and reducing HIV-related health disparities.

The NHAS is a good first start for America. What I appreciate about the strategy is its’ unprecedented existence. No other administration has created a White House Office of National HIV/AIDS Policy, or has had so many progressive people in its midst. (The NHAS is now available to the public: http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf)

Theoretically, this is a history making initiative. However, upon close review, NHAS content features elements that are not necessarily signs of innovation or a framework shift in terms of how HIV services may roll out or be resourced. It appears that the strong [white] gay identity bias (to be explained in more detail later) will continue to skew attempts at culturally diversifying how HIV services are framed, funded and prioritized.

Though diverse groups in America are impacted by HIV/AIDS, blacks, by a large percentage, are more impacted than all other groups in the country. Yet, deciphering this could be a challenge as presented in this NHAS excerpt, “While anyone can become infected with HIV, some Americans are at greater risk than others. This includes gay and bisexual men of all races and ethnicities, black men and women, Latinos and Latinas, people struggling with addiction, including injection drug users, and people in geographic hot spots, including the United States South and Northeast, as well as Puerto Rico and the U.S. Virgin Islands. By focusing our efforts in communities where HIV is concentrated, we can have the biggest impact in lowering all communities’ collective risk of acquiring HIV.”

This NHAS passage also abstracts the disproportionate depth of HIV in black communities by bundling everyone as “Communities where HIV is concentrated.” This passage, “While anyone can become infected with HIV, some Americans are at greater risk than others. This includes gay and bisexual men of all races and ethnicities…” muddles the fact that – by leaps and bounds – black men, specifically, are the most HIV impacted group in the United States. Yet, what is not abstract is how much the NHSA affirms gay identity, despite that many homosexual and bisexual men of color don’t identify with or as gay. Over the last 30 years, this gay identity bias and barrier has been a contributing factor to diverse black men at HIV sexual risk not seeking HIV services or internalizing prevention messages.

While Obama’s White House is committing resources and efforts to initiatives like HIV/AIDS and healthcare, the explicit context of race and culture continues to be overlooked.

The first HIV/AIDS services paradigm in America was designed by white gay men, and ultimately was very effective for that community. Despite the relative success of the white gay community at saving itself from HIV/AIDS, a once frequently deadly disease, the disease has since gotten blacker and blacker. To date, there are no published examples of similar HIV success among African Americans. Even after three decades. Not to mention, gay identified men – black and white – have controlled and directed this epidemic, and blamed its failure to blacks simply on “homophobia.”

The organization identified as the Black AIDS Institute once featured an article stating, “Homophobia Causes AIDS (http://www.blackaids.org/ShowArticle.aspx?articletype=NEWS&articleid=168&pagenumber=1).” Yet, if this was true, given the still very present existence of the rabidly anti-homosexual white right-wing – Pat Roberson, Rush Limbaugh, the legacy of Jerry Falwell and most republicans – the white gay community should still have an HIV problem – equal if not similar to African Americans. But they don’t.

Frequently, within the black HIV industry, while black gay identity and “pride” (in being gay identified) are often encouraged, engagement of the symptoms of social injustice toward black communities and self-concept, cultural affirmation, repair and restoration are very rarely included as HIV problem-solving strategies. The white gay community understood one thing: in order to eradicate the numbers of new HIV cases they had to empower their community, while at the same time address the self-esteem damage done by homophobia, discrimination, hatred and oppression. Their primary HIV prevention strategy was (because, ultimately, most finally knew how HIV was transmitted) to publicly and actively resist social injustice toward their community, and affirm [white] gay identity. As a result, it has been comparatively (to all others) very successful at managing HIV/AIDS.

Unfortunately and concurrently, the white gay community has had little interest in resisting [white] racism within its community or society as a whole, just homophobia. And the black gay-identifying movement and approach (including within HIV services) has taken on that same paradigm; not an approach that is directly relevant to black culture, history, circumstance, problem-solving, diversity, process and under-engagement of relevant black issues. “Gay” acceptance is often more important than issues directly relevant to diverse black life, culture, history and healing. As a result, many black gay identified HIV leaders have become ill-equipped to address black community issues, to counter the risk behavior inducing impact of internalized racism, institutionalized racism, black male or female trauma and white biases internalized by [black] America.

Essentially identity politics have superseded capacity to effectively engage diverse black subgroups and communities facing disproportionate HIV threats. The NHAS, while strong on affirming gay identity, fails to affirm black specific culture, diversity and relevance.

The gay paradigm creates little to no encouragement for same-gender loving (SGL) and bisexual African American healing and cultural affirmation. Being limited to “gay” has created HIV issue disenchantment among Black men who have sex with men (MSM). As a result, black homosexual subgroups have emerged in an attempt to connect more with the rhythms of black life and culture. Many black homosexual and bisexual males do not have an affinity with gay identity and culture, seeing it as white or culturally unrelated. There are “homo-thugs,” men on the “down-low,” and more in the affirmative men who identify as same-gender-loving (SGL) or bisexual. If more space was created for homosexual and bisexual black males to be fluid and “black” regarding their identity, more would likely self-identify.

In the late 1980s, the Centers for Disease Control and Prevention (CDC) discovered that the term or label “gay” was a barrier in getting black and Latino men to identify as men who had sex with men, and disclose HIV risk factors. As a result, the now widely used term MSM, or men-who-have-sex with men was derived. Initially, white gays and black homosexuals who internalized the gay politic balked at the term, claiming it was homophobic. The fact of the matter was the term MSM was more neutral in terms of identity, inclusive and culturally responsive to the diverse ways of being among homosexual and bisexual black men.

A footnote excerpt from the NHAS states: “Throughout this document we use the terms “gay and bisexual men” and “gay men” interchangeably, and we intend these terms to be inclusive of all men who have sex with men (MSM); even those who do not identify as gay or bisexual.” In other words, even if you are not gay, or don’t identify as gay, or don’t want to, we are referring to all homosexual and bisexual men as gay regardless. This is not helpful to African Americans and is an example of an institutionally racist barrier to life and ways of being very present within black communities.

Sure, many of us are used to simply calling all homosexuals gay. In the black community this is not the result of an identify poll taken in the community, but because SGL black people have rarely been rationally engaged in a Black community context. While the powerful white gay community vigilantly profiles its gay idenity politics and ideas, this does not necessarily represent all homosexual and bisexual Black people.

Without these considerations or an examination of the relationship cultural barriers have to HIV risks among Black women and men, the NHAS will likely have limited impact on advancing the Black HIV landscape. As a result it may be discreetly shelved by many Black organizations.

While the National HIV/AIDS Strategy (NHAS) for the United States does represent a potentially progressive step forward, its’ lack of specific strategies for African Americans has resulted in some response. National organizations are in the process of generating recommendations to the president as an addendum to the historic NHAS. All African Americans interested in getting involved or contributing somehow to this effort are earnestly invited to do so. If interested in contributing call The National Black Leadership Commission on AIDS (NBLCA) at 800-992-6531, or the Black Men’s Xchange National at 888-472-2837.

What Conservatives Are Winning
Conservatives are out of sorts these days about the direction in which health care is headed. They think the new health reform law expands the role of government too much and spends too much at a time when they believe deficit reduction should be a higher priority. The claims about death panels and a government takeover of the health system aside, these are principled positions for conservatives to take – they are supposed to be for smaller government and less public spending. But for all of the frustration and even anger within the conservative movement about where health care is headed, the fact of the matter is that they are winning more than even they may realize in the current health care equation. That's because the nature of health insurance itself is being redefined and moving gradually but seemingly inexorably in the direction conservatives have long advocated: more consumer "skin in the game" through higher patient deductibles.

Item: In our recent survey of people in the non-group insurance market, we found that the average deductible for an individual policy is now $2,498, and for families it's $5,149. These are very high thresholds by any standard. Consider, for example, that a family with median income facing such a deductible would be spending almost 10% of their annual income just for their deductible before their insurance kicked in.

Item: The percentage of workers facing high deductibles -- $1,000 or more for single coverage --  has been growing rapidly. It doubled from 10 percent to 22 percent between 2006 and 2009, and increased from 16 percent to 40 percent in small firms.

Item: Indications are that the share of workers with high deductibles is continuing to grow, a trend I expect our 2010 employer survey to confirm when we release it in September as we have every year for more than a decade now. And a substantial number of these high deductible plans are paired with tax-advantaged savings accounts, which conservatives have long advocated. Facing cost pressures without alternative answers, employers are moving to plans with less comprehensive coverage to reduce their expenses for employee benefits.

Item: Health reform is unlikely to reverse these trends. Large employers will continue to look for ways to address the rising cost of health care. And, for the basic "bronze" insurance plan that people will be required to buy, deductibles could run several thousand dollars for individuals and double that for families. To be sure, other aspects of health reform cut the other way. For example, there will be no cost sharing for preventive services in newly-purchased plans, and insurers will be required to cap consumer out-of-pocket costs at defined levels. And, of course, there are substantial subsidies to reduce premium and out-of-pocket costs for lower-income people. But, for the first time, the government will be defining the threshold that decent insurance must meet, and that minimum coverage will have the kind of high deductibles that conservatives favor.

Given the drift towards less comprehensive coverage in the marketplace, it is perhaps no surprise that two seemingly contradictory things are happening at the same time. For several years we have seen moderate increases in premiums for employment-based health insurance. I suspect that rising deductibles and other out-of-pocket costs are one explanation for this. It's simple arithmetic that employers can buy down premium increases by switching to less comprehensive coverage and shifting more costs to workers. Plus, these higher out-of-pocket costs exert downward pressure on utilization – in some cases for the better, in some cases for the worse -- and thus on premiums as well. At the same time, people have never been more upset about their own rising health care costs, as the coverage they get offers less and less financial protection. This seeming contradiction underscores the fundamental difference between how people and experts look at health care costs: To experts, who focus on the rate of increase in aggregate numbers such as the annual increase in health insurance premiums, costs look like they have been moderating. But to people, who focus only on what they themselves are paying, expenses out of their own pockets are rising far faster than they can afford, especially in a bad economy.

If you look at what is happening in health insurance from a policy perspective, the big challenge will be to find the right balance between appropriate cost sharing and cost sharing that is so high that it poses barriers to care and a threat to people's economic security, especially for people who are chronically ill or have lower or moderate incomes. Deductibles are just one part of this picture. Looked at through a political lens, liberals have gained through passage of major health reform legislation, including expanded coverage and increased government oversight of the health insurance system. But increasingly, the insurance itself is looking more and more like the vision advanced by conservatives – less comprehensive with more skin in the game. That's where conservatives may be winning more than they realize in the ongoing battle over the future of health care.
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