The federal COVID-19 public health emergency officially ends next week on May 11. We’ll be rounding up some papers highlighting the most interesting lessons learned from this period of unprecedented flexibility in our federal health policies.

Send your favorite PHE studies my way! You can find me on Twitter @Soleil_Shah or on email at sshah@tradeoffs.org.

What we’ve learned from federal efforts to fight HIV/AIDS​

Last week, the U.S. Department of Health and Human Services awarded nearly $140 million in new federal funding to states and cities to reduce HIV infections. And in March, President Biden’s $6.8 trillion budget proposal designated billions for other diseases, like cancer and hepatitis C. 

Having cared for patients with these conditions, I have no question they are worthy targets of public health campaigns. But are disease-specific federal dollars the best way to fund progress on these problems?

I came across a working paper by Marcus Dillender that uses a creative study design to shed light on this question. 

Dillender’s paper evaluated the impact of the past two decades of federal funding for HIV/AIDS. This terrifying and deadly epidemic also gave rise to a unique piece of federal policy: the Ryan White CARE Act.

Extra federal funds to cities helped avert infection and death

Since 1990, the Ryan White Act has granted more than $19 billion in federal dollars directly to cities — but, in the law’s early days, only if the city had at least 2,000 AIDS cases.

This funding model gave Dillender a unique setup for the research question: How many lives and dollars has this disease-focused approach saved? He could compare 25 cities with just over 2,000 AIDS cases that did receive funding to 25 other cities with just under 2,000 AIDS cases that did not.

Taking advantage of a few additional policy quirks, Dillender was able to isolate the impact of Ryan White funding on HIV/AIDS outcomes, not just over years, but decades.

Controlling for factors like variations in local laws, Dillender estimated that, compared to the cities in the U.S. without Ryan White funding, cities with Ryan White funding had:

• 324,000 to 378,000 fewer total HIV transmissions from 1995 to 2008.
• 57,000 fewer total deaths from HIV/AIDS from 1988 to 2018.

Dillender went further and compared the cost of saving and extending lives through the Ryan White Act to a couple of other policy approaches. He found that the Ryan White approach — funneling federal money to local governments to fight a specific disease — was: 

• As much as 40 times more efficient than funding Medicaid expansion.

• Between 5 and 14 times more efficient than spending on the Medicare program.

Targeted federal funding also has drawbacks

Dillender’s study shows that giving federal funds to cities to provide HIV/AIDS-related services has been a cost-effective, life-saving response to this particular public health crisis. 

But it’s also had some downsides. As this study found, cost-effective public health campaigns can fall short on other important outcomes, like equity. 

Dillender notes the place-based nature of Ryan White funding and its arbitrary cutoff of 2,000 cases have combined to worsen geographic and racial disparities in HIV/AIDS outcomes.

Although this more targeted approach appears highly cost-effective relative to broader federal programs like Medicare and Medicaid, each has its own role to play in improving public health.