Measuring What Matters Allocation, Planning, and Quality Assessment for the Ryan White CARE Act (2004) / Chapter Skim
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2 Overview of the HIV/AIDS Epidemic and the Ryan White CARE Act
2 Overview of the HIV/AIDS Epidemic and the Ryan White CARE Act
Pages 41-72
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Act (RWCA) in the context of other federal spending programs for HIV/AIDS care, and the history and current structure of the CARE Act and its allocation formulas.
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. To date, no cure or vaccine has been developed for HIV disease, although recent treatment advances in combination antiretroviral therapy have resulted in slowing of the progression of the disease, and often temporary restoration of immune functioning, in infected individuals.
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. HIV disease is also increasingly affecting people who are poor, unemployed, and confront a variety of barriers to care (Bozzette et al., 1998; Kaiser Family Foundation, 2000)
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These sources of coverage are poorly coordinated and constitute a substantial barrier for people with HIV/AIDS to obtaining appropriate care (Kaiser Family Foundation, 2000)
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. Since the initial authorization, the bill has been reauthorized and amended in 1996 (Ryan White CARE Act Amendments of 1996.
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. The purpose of the Act is "to provide emergency assistance to localities disproportionately affected by the HIV epidemic and to make financial assistance to States and other public and private nonprofit entities to provide for the development, organization, coordination, and operations of more effective and cost-efficient systems for the delivery of essential services to individuals and families with HIV disease" (Ryan White CARE Act of 1990.
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Congress provided the Secretary of HHS, through the supplemental award process, the authority to direct one-half of the total appropriation to eligible Title I grantees based on the following: the number of persons with AIDS who needed care, demographic data such as poverty levels, the average cost of providing each category of services and the extent to which third-party payer coverage is available, and the aggregate amounts expended on services (Ryan White CARE Act 1990.
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This included the Demonstration Grants for Research and Services for Pediatric Patients with AIDS (Ryan White CARE Act 1990.
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The Secretary of HHS was directed to consider the ability of the qualified applicant to expend funds efficiently, and the effect on the cost and complexity of delivering health care and support to individuals with HIV disease in the eligible areas (Ryan White CARE Act Amendments of 1996.
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, that wide disparities continued to exist in the per-case funding levels between Title grantees. GAO explained this was most likely occurring because of two factors: a lack of appropriate data, specifically HIV surveillance data, to estimate numbers of HIVinfected persons in eligible areas, and the application of the hold-harmless provisions to EMA grant awards.
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The aim of these provisions was to develop a comprehensive plan for all HIV-infected persons in the local community. Congress also intended to enhance the ability of the existing local planning process to establish and support services for newly infected persons and persons from historically underserved communities (Ryan White CARE Act Amendments of 2000.
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Fiscal Year FIGURE 2-2 Ryan White CARE Act funding FY1991 to FY2003.
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. Congress intends to incorporate data on HIV cases into the formula for awarding these grants as early as FY2005 but no later than FY2007, provided that the Secretary of HHS determines that such data are "sufficiently accurate" and reliable for use in the formulas (Ryan White CARE Act.
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awards Title I grants to the chief elected official of the city or county that provides services to the greatest number of people living with AIDS in the EMA. A 5These numbers reflect funding available for distribution rather than the appropriations.
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. Planning Councils are also responsible for developing a comprehensive plan that includes strategies for identifying HIV-positive persons not in care and strategies for coordinating services to be funded with existing prevention and substance abuse treatment services (Ryan White CARE Act.
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. Title II funds may be used for a number of services including ambulatory and home-based health care, purchase of insurance coverage, medications, support services, early intervention services, and outreach services to people who know their status (HRSA, 2002f)
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71% FIGURE 2-5 Ryan White CARE Act Title II resource allocations by service category in 54 states and territories, FY2000 (Total: $751,079,694)
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Title II also includes $7 million for the MAI to increase participation of minorities in ADAPs. Figure 2-6 shows the breakdown of Title II allocations by the base award, ADAP award, MAI, and EC award.8 7The ADAP budget includes funding from the Ryan White CARE Act (ADAP earmark, Title I, Title II, ADAP supplemental)
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SOURCE: HRSA, 2002k. Title III -- Early Intervention Services, and Planning and Capacity Grants Title III of the CARE Act funds early intervention HIV services provided by public and nonprofit groups.9 Early intervention services include counseling, testing, medical evaluation, primary care, antiretroviral therapies, medical and mental health care, case management, and other services.
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, AIDS Education and Training Centers, and the Dental Reimbursement Program. Special Projects of National Significance The SPNS program was established to advance the knowledge and skills needed to deliver health and support services to underserved populations with HIV infection.
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Base Award An EMA's base award is determined by a formula based on its proportion of the total number of ELCs in all EMAs. The formula also includes a hold-harmless provision that limits the amount an EMA's funding can fall from year to year, according to a schedule specified in the legislation.11 San Francisco is the only EMA that now benefits from the hold-harmless provision (HRSA, 2002j)
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Although they vary widely among programs, most formulas combine two or more of these elements of need, cost, fiscal capacity, and effort. The NRC panel provides examples of how various measures are combined and discusses how errors Supplemental Award12 Supplemental awards are determined by a competitive application process, rather than by a formula.
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. Title I Minority AIDS Initiative Award MAI grant awards are divided among all EMAs according to a formula based on their proportion of racial and ethnic minorities AIDS
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There is no 80-20 split like base award. Title II AIDS Drug ADAP supplemental award is divided 10 most recent years Assistance among qualifying*
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OVERVIEW 65 Minimum Threshold Award Hold-Harmless Match Requirement MSAs with a No Base year is No population 500,000 FY2000 and with 2000 appropriation. reported AIDS cases FY2001 = 98%; in most recent 5 years FY2002 = 95%; FY2003 = 92%; FY2004 = 89%; FY2005+ = 85% For jurisdictions No No No with >0 reported AIDS cases among racial and ethnic minorities No $200,000 for Base year is For states2 with >1% of states with FY2000 national total reported AIDS <90 cases; appropriation.
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Title II Minority MAI award is divided among all Cumulative reported AIDS states based on the state's proportion nonwhite AIDS Initiative of reported AIDS cases in the most cases for most recent (MAI) recent 2 year period among racial and 2 years (adjusted for ethnic minorities.
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< 10 medications to treat opportunistic infections. SOURCE: National Alliance of State and Territorial AIDS Directories, Kaiser Family Foundation, AIDS Treatment Data Network (2003)
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. AIDS Drug Assistance Program Award The ADAP award is based on a state's proportion of the total ELCs in all states and territories.
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Kaiser Family Foundation. Gallo RC, Salahuddin SZ, Popovic M, Shearer GM, Kaplan M, Haynes BF, Palker TJ, Redfield R, Oleske J, Safai B, et al.
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2002j. FY2002 Ryan White CARE Act Title I Emergency Relief Grants.
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2000. Report on Ryan White CARE Act Amendments of 2000 (106-788)
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1995. Report on Ryan White CARE Reauthorization Act of 1995 (104-25)
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