PEPFAR is the federal government's anti–HIV/AIDS foreign aid program, established by the Global AIDS Act of 2003 and renewed in 2008 and 2013. It is the single largest global health initiative targeting a single disease in history.
PEPFAR is an accomplishment that deserves to stand alongside the Affordable Care Act, Medicare, the Marshall Plan, and Social Security as one of the greatest spending programs the federal government ever enacted.
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Who isn't great at spending other people's surplus?
A modestly good president could have done that while still leaving the country a surplus.