[Senate Hearing 109-409]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-409

 FIGHTING THE AIDS EPIDEMIC OF TODAY: REVITALIZING THE RYAN WHITE CARE 
                                  ACT

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

   EXAMINING REAUTHORIZATION OF THE RYAN WHITE CARE ACT RELATING TO 
                  FIGHTING THE AIDS EPIDEMIC OF TODAY

                               __________

                             MARCH 1, 2006

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions



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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                  (ii)




                            C O N T E N T S

                               __________

                               STATEMENTS

                        WEDNESDAY, MARCH 1, 2006

                                                                   Page
Enzi, Hon. Michael B., Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Masachusetts, opening statement................................     4
Duke, Elizabeth, Administrator, Health Resources and Services 
  Administration, U.S. Department of Health and Human Services...     6
    Prepared statement...........................................     7
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina.......................................................    14
Clinton, Hon. Hillary Rodham, a U.S. Senator from the State of 
  New York.......................................................    16
Sessions, Hon. Jeff, a U.S. Senator from the State of New Mexico.    18

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response to questions of Senators Enzi, Kennedy, Burr, Hatch, 
      Dodd, Reed, and Clinton by the Department of Health and 
      Human Services.............................................
        Senator Enzi.............................................    21
        Senator Kennedy..........................................    25
        Senator Burr.............................................    54
        Senator Hatch............................................    56
        Senator Dodd.............................................    57
        Senator Reed.............................................    61
        Senator Clinton..........................................    64

                                 (iii)



 
 FIGHTING THE AIDS EPIDEMIC OF TODAY: REVITALIZING THE RYAN WHITE CARE 
                                  ACT

                              ----------                              


                        WEDNESDAY, MARCH 1, 2006

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 3:04 p.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Michael D. 
Enzi (chairman of the committee), presiding.
    Present: Senators Enzi, Burr, DeWine, Hatch, Sessions, 
Kennedy, Murray, and Clinton.

                   Opening Statement of Senator Enzi

    The Chairman. I call to order this hearing on ``Fighting 
the AIDS Epidemic of Today: Revitalizing the Ryan White CARE 
Act.''
    I want to welcome everyone to this hearing of the Committee 
on Health, Education, Labor, and Pensions. I definitely want to 
thank Senator Kennedy for his tremendous effort and cooperation 
in helping to come up with a solution that will make a 
difference to everyone and will allow us to fight this problem 
on today's terms, not yesterday's terms. There has been a real 
spirit of cooperation across the aisle. Senator Murray has 
played a tremendous role in all of this; Senator Burr--a number 
of people. I should not start enumerating them, because there 
is a tremendous interest in getting this done, and we have to 
get it done.
    I have mentioned that even rock star Bono, at the recent 
national prayer breakfast, while he had kind words for the 
United States and President Bush, emphasized a little bit our 
efforts to stop the global spread of AIDS. And today, the 
committee will be exploring a topic that is no less important, 
which is our fight against AIDS on the domestic front. We need 
to fight and win the battle here and abroad, so we have to 
ensure access to quality health care for all of those who have 
HIV and AIDS.
    In 2004, Dr. Frist, our Majority Leader, and I and some 
others traveled to Africa, where we witnessed firsthand the 
devastation that AIDS has brought to the families, to the 
employers, to the communities. In fact, we noticed in one of 
the countries that the teen generation is missing.
    While we have made significant progress throughout the 
world, there is much more to do to save lives through education 
and treatment, and domestically, our Federal safety net 
program, the Ryan White CARE Act, has provided a framework 
providing higher-quality care for every American with HIV.
    Ryan White, for whom the law was named, was a remarkable 
young man. He developed AIDS as a teenager, and even in the 
face of such a huge obstacle, he went on to become a 
spokesperson for all of those who are battling the disease. He 
never lost hope for his life. Unfortunately, every day was a 
battle against those who, for lack of understanding and 
education, hated what they could not understand.
    In response, Congress passed the Ryan White CARE Act to 
protect and support those battling HIV and AIDS so they could 
die with dignity and live normal lives without fear of 
discrimination, rejection, or abuse.
    If he were alive today, Ryan White would be a witness to 
the world that has changed a great deal in terms of those 
affected by HIV and AIDS and the treatment and care. He would 
celebrate the new, life-saving drugs, which have meant that the 
safety net program no longer just helps people die with grace 
and dignity, but it focuses each day on saving lives through 
treatment.
    However, to defeat this disease, we have to focus on the 
epidemic of today and not yesterday. In doing so, we 
acknowledge that the face of HIV and AIDS has changed, and all 
those living with HIV deserve quality care and equitable 
treatment. I think that is demonstrated by the work across the 
aisle, and we are also working across the building with the 
House folks already to be able to get this done expeditiously.
    Of course, one of the problems with any bill at this time 
of the year is how much time there is to debate something, so 
we have to be careful that any bill that we construct, we have 
people in cooperation to keep nonrelative amendments off of the 
bill, or we never have time to debate it. That is always a 
difficulty that we have.
    But through this hearing and the bipartisan work on it, I 
am sure that we will arrive at that.
    Now, until the ultimate cure, we do have to ensure that 
those infected with HIV receive our support and compassion. For 
instance, a mother in Wyoming recently shared with us the story 
of her HIV-infected daughter, who has benefited from the Ryan 
White CARE Act. Through the Wyoming AIDS Project, her teenage 
daughter was able to connect with others who have HIV and learn 
how to live with the disease. While she is currently enjoying 
her life as a normal college student, her mother continues to 
worry about how she will continue to receive her care once she 
leaves the university and seeks the normal life of having her 
own business, marrying, having children, buying a house.
    Her story is just one of many. Taken together, they do 
outline the struggle, and they help us see the impact that AIDS 
has had on too many lives.
    Here in the United States, this disease affects more women, 
more minorities, and more people in rural areas than ever 
before. According to the Kaiser Family Foundation, more 
African-Americans are affected and dying from HIV than any 
other ethnic or racial group in the United States. They 
represent half of all AIDS diagnoses in 2004, compared to only 
25 percent in 1986.
    In addition, early in the epidemic, HIV infection and AIDS 
were diagnosed in relatively few women. Today, according to the 
Centers for Disease Control and Prevention, the HIV/AIDS 
epidemic represents a growing and persistent health threat to 
women in the United States, especially young and minority 
women. African-American women account for two-thirds of the new 
AIDS cases among women.
    Finally, the epidemic is moving South. Seven of the States 
with the 10 highest AIDS case rates are located in the South. 
Our response must acknowledge these demographic shifts so that 
we can ensure equitable treatment for all Americans living with 
HIV.
    Our Federal resources for HIV, including those we provide 
through the Ryan White CARE Act, should go to where the 
epidemic is today and will be tomorrow--not necessarily where 
it was a decade ago. If we are to ensure equity, however, we 
have to first understand the current inequities within the 
system.
    Thankfully, in its June 2005 report, the GAO did highlight 
the funding inequities related to disparities in funding per 
AIDS case, the disproportionate effect of ``hold harmless'' 
provisions, and the inappropriate grandfathering of funded 
entities. Just yesterday, the GAO issued a new report that also 
noted that the Ryan White formulas currently allow for the 
counting of deceased cases of AIDS to determine the overall 
funding distribution.
    I want to commend GAO for its continued work to highlight 
these issues and to provide the important information on which 
we can base our legislative decisions.
    With us today is Dr. Elizabeth Duke, administrator of the 
Health Resources and Services Administration, to testify about 
the President's principles for the reauthorization of Ryan 
White. In addition, Dr. Duke, I hope you will further discuss 
the additional legislative and funding proposals which the 
President mentioned in his State of the Union Address and 
submitted in his fiscal year 2007 budget proposal.
    I commend you and your colleagues for discussing the tough 
issues related to those inequities and putting forward a 
legislative framework for dealing with those issues. Your work 
will help us focus our Ryan White efforts on saving lives 
through treatment.
    With respect to the committee's work to reauthorize this 
important program, I want to thank the many diverse 
organizations that have already provided their insights into 
critical issues facing the Ryan White CARE Act. We have met 
with over 50 different AIDS and minority organizations in the 
past few months, and we will continue to meet and discuss these 
critical issues. I look forward to that continued dialogue.
    People living with HIV/AIDS deserve quality care. At the 
end of 2003, the Centers for Disease Control and Prevention 
estimates that there are over 1 million Americans living with 
HIV/AIDS. Of those, one-quarter of them, which would be around 
250,000, are unaware of their HIV infection. In addition, each 
year, another 40,000 Americans become infected with HIV.
    Working together with my colleagues on this committee, we 
will act on our compassion for people living with HIV by 
strengthening our domestic response to this crisis by 
reauthorizing the Ryan White CARE Act this year. Ryan White and 
the legislation he inspired should become a symbol of hope and 
compassion for all Americans living with HIV and AIDS.
    Senator Kennedy.

                  Opening Statement of Senator Kennedy

    Senator Kennedy. Thank you very much, Chairman Enzi, and I 
want to thank you for all of your good assistance and help in 
bringing us to where we are today, and that is the strong 
commitment that we are going to get good legislation that will 
be bipartisan and bicameral. We are working with the 
Administration on this issue. It is the way to work.
    We were faced some 16 years ago with the real danger of 
having ideology override good science and a sense of humanity 
and decency, and in one of the important successes of the 
Senate at that particular time, members of both political 
parties put aside the ideology and really based the underlying 
legislation on sound science, and what a difference it has 
made. We are following in that tradition with bicameral 
legislation, working with the Administration. So I want to 
thank you very much for all of your good work and your 
cooperation and help and leadership, most importantly.
    Just briefly, Mr. Chairman, today is about one of the 
greatest public health investments that we have made in this 
country--the care and treatment of individuals with HIV and 
AIDS. As I mentioned, 16 years ago, the members of this 
committee demonstrated their commitment to the care and 
treatment of Americans living with AIDS by passing the Ryan 
White Act. Ryan White was a young boy, a hemophiliac, who 
acquired AIDS through a blood transfusion, was diagnosed when 
he was 13 years old and passed when he was 16 years old. But he 
was an extraordinary young person who was an inspiration to all 
of us, as was his family.
    This legislation has been a model of bipartisan cooperation 
and Federal leadership, and I am proud that this 
reauthorization process is continuing in that commitment.
    Sixteen years ago, Americans were struggling with the 
devastating effects of the virus, and by 1995, more than 1 
million citizens were infected with the AIDS virus, and AIDS 
itself had become the leading killer of young Americans age 25 
to 44. AIDS was killing brothers, sisters, children, parents, 
friends, loved ones, all in the prime of life.
    Since that time, community-based care has become more 
available; drug treatments have nearly doubled the life 
expectancy of HIV-positive individuals; public campaigns have 
increased awareness of the disease. And, while we still seek a 
cure for AIDS, the Ryan White funds have allowed us to help 
those infected by the virus to lead long and productive lives 
through the miracles of good care, treatment, and the 
availability of prescription drugs.
    This is evident in my own State of Massachusetts where, by 
the end of 2004, a little over 26,000 residents had been 
diagnosed and reported with HIV/AIDS. Of that number, 42 
percent have died, but 58 percent are living with HIV/AIDS; 
that was not the case 10 years ago.
    We in America know of the pain and loss that this disease 
cruelly inflicts. Millions of our fellow citizens, men, women, 
and children, are infected with HIV/AIDS, and far too many have 
lost their lives.
    As the challenge of HIV/AIDS continues year after year, it 
has become more difficult for anyone to claim that AIDS is 
someone else's problem. The epidemic has cost the Nation 
immeasurable talent and energy in young and promising lives 
struck down long before their time, and we must do a better job 
to provide care and treatment and support for those caught in 
the epidemic's path.
    As we approach this reauthorization, we should take a 
moment to understand the difference Ryan White has made in the 
lives of people living with HIV/AIDS. Because of life-saving 
resources, lives have been extended, and many have now been 
able to benefit from the Ryan White services needed to continue 
to live with HIV/AIDS.
    We cannot underestimate the importance of mental health 
services, nutritional services, and transitional housing 
support that make such a difference every day to those 
struggling with the disease.
    It will be important to ensure that in this authorization, 
we continue to affirm the structure of the CARE Act, which 
continues to provide a sound and solid backbone for HIV/AIDS 
care across the Nation. As we increase our efforts to provide 
better care and treatment and drugs in rural areas that have 
seen an increase in the AIDS epidemic, we must ensure that more 
State flexibility does not cause the collapse of existing 
structures of care under Ryan White. The establishment of these 
structures has been enormously powerful and important and 
valuable in terms of making this program a success.
    The Ryan White CARE Act is about more than just funds and 
health care services; it is about caring and the American 
tradition of reaching out to people who are suffering and in 
need of help.
    I look forward to the Administration's testimony on the 
impact that the Ryan White CARE Act has made over 16 years and 
their thoughts on where we need to go in the future.
    I want to acknowledge if I could, Mr. Chairman, the 
chairman of our committee 16 years ago. The Senator from Utah, 
Senator Hatch, was the chairman of this committee, led by a 
Republican. We let that happen from time to time around here. 
He was able to marshal and bring this committee together and 
also the Senate in, as I mentioned before he came in, one of 
the really important health achievements of recent times.
    So I want the record of our hearing today to acknowledge 
that leadership.
    Senator Hatch. Thank you, Senator. I appreciate that.
    The Chairman. Thank you.
    We will now move to our panel. We have one panel today. I 
will introduce the witness, and following her testimony, we 
will move to questions.
    Our first and only witness today is Dr. Elizabeth Duke. 
Since 2002, Dr. Duke has been the Administrator of the Health 
Resources and Services Administration, where she has improved 
and streamlined many of HRSA's processes and programs.
    Dr. Duke will discuss the current initiatives in place to 
combat HIV and AIDS in America, as well as next steps in 
fighting today's epidemic more effectively.
    We welcome you and will now hear from you. Thank you.

 STATEMENT OF ELIZABETH DUKE, ADMINISTRATOR, HEALTH RESOURCES 
  AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Ms. Duke. Thank you, Mr. Chairman, members of the 
committee.
    I am thankful for this opportunity to have this time with 
you to talk about the reauthorization of the Ryan White CARE 
Act. It is a comprehensive approach to the provision of medical 
care, treatment and support services to individuals living with 
HIV/AIDS who have no other means to obtain such care.
    As you know, it was enacted in 1990, amended and 
reauthorized in 1996 and in 2000. The authorization of 
appropriation expired on September 30, 2005.
    President Bush in his State of the Union Message stressed 
the importance of the program and asked the Congress ``to 
reform and reauthorize the Ryan White CARE Act and provide new 
funding to States so we end the waiting list for AIDS medicines 
in America.''
    Since its last reauthorization, we have been able to 
provide antiretroviral treatment, primary care, and support 
services to over half a million people annually living in the 
United States, Puerto Rico, Guam, the U.S. Virgin Islands, and 
the Territories. In 2004, an estimated 65 percent of the 
individuals were racial minorities, 33 percent were women, and 
87 percent were either uninsured or received public health 
benefits.
    The Ryan White CARE Act programs have provided important 
benefits to this population. Overall, AIDS mortality is down, 
and lives have been extended with HIV/AIDS medications 
purchased through the AIDS Drug Assistance Program, ADAP. 
Pregnant women have been provided with care that has allowed 
them to give birth to children free from HIV infection, and 
thousands have received support services that have allowed them 
to access and remain in health care.
    The structure of the Act allows for local flexibility and 
responsiveness in meeting diverse needs in different regions. 
It fosters collaboration among Federal, State and local 
governments, and public and private entities to create a 
continuum of care for people living with HIV/AIDS.
    Last July, the Administration emphasized five key 
principles for reauthorization of the Ryan White CARE Act: (1) 
to serve the neediest first; (2) to focus on life-saving and 
life-extending services; (3) to increase prevention efforts; 
(4) to increase accountability, and (5) to increase 
flexibility.
    The President has made fighting the spread of HIV/AIDS a 
top priority of his Administration, and he will continue to 
work with the Congress to encourage prevention and the 
provision of appropriate care and treatment for those suffering 
from the disease.
    The President requested $2.08 billion in 2006, and the 
Congress provided us with $2.06 billion. The President's 2007 
request for the CARE Act activities is $2.16 billion, an 
increase of $95 million, for several elements of a new domestic 
AIDS initiative. Further elements of that initiative focus on 
testing and other areas, and they are requested outside the 
CARE Act.
    The request will support a comprehensive approach to 
address the health needs of persons living with HIV/AIDS, 
consistent with the reauthorization principles. The budget also 
includes a new authority to increase program flexibility by 
allowing the Secretary to transfer up to 5 percent of funding 
provided for each Part of the Ryan White CARE Act to any other 
Part of the Act.
    Of the $95 million requested, $70 million will address the 
ongoing problem of State waiting lists and provide care and 
life-saving medicines to those newly-diagnosed as a result of 
increased testing efforts. The remaining $25 million will be 
used to expand outreach efforts by providing new HIV community 
action grants to intermediaries, including faith and community-
based organizations, and to provide technical assistance and 
sub-awards to grassroots organizations.
    In order to serve the neediest first, objective indicators 
must be established to determine the severity of need for 
funding core medical services. The Secretary of Health and 
Human Services would develop a Severity of Need for Core 
Services Index. This index will be based on objective criteria 
and will focus on core services. It would take into account 
variables such as HIV incidence and prevalence, levels of 
poverty, and availability of other resources.
    The Administration proposes focusing on life-saving and 
life-extending services by establishing a core set of medical 
services and requiring that 75 percent of funds in Title I 
through IV be spent on these core services, and maintaining a 
Federal list of core medications.
    It is my pleasure to be with you this afternoon, and I am 
ready to address questions from you.
    Thank you very much for allowing me to be here.
    [The prepared statement of Ms. Duke follows:]
             Prepared Statement of Elizabeth M. Duke, Ph.D.
                                summary
    The Ryan White CARE Act is a comprehensive approach to the 
provision of medical care, treatment, and support services to 
individuals living with HIV/AIDS who have no other means with which to 
obtain such care. The authorization of appropriations expired on 
September 30, 2005. President Bush in his 2006 State of the Union 
Address stressed the importance of this program and asked Congress to, 
``reform and reauthorize the Ryan White Act and provide new funding to 
States so we end the waiting lists for AIDS medicines in America.''
    Since its last reauthorization, we have been able to provide 
antiretroviral treatment, primary care, and support services to over 
half a million people annually in the United States, Puerto Rico, Guam, 
the U.S. Virgin Islands, and eligible U.S. territories. In 2004, an 
estimated 65 percent of these individuals were racial minorities, 33 
percent were women, and 87 percent were either uninsured or received 
public health benefits. Overall, AIDS mortality is down and lives have 
been extended with HIV/AIDS medications purchased through the AIDS Drug 
Assistance Program (ADAP). Pregnant women have been provided with care 
that has allowed them to give birth to children free from HIV 
infection, and thousands have received support services that have 
allowed them to access and remain in health care.
    The structure of the Ryan White CARE Act allows for local 
flexibility and responsiveness in meeting diverse needs in different 
regions. It fosters collaboration among Federal, State, and local 
governments, and public and private entities to create a continuum of 
care for people living with HIV/AIDS.
    The Ryan White CARE Act is organized into distinct program 
components.

     Title I provides emergency assistance to Eligible 
Metropolitan Areas (EMAs) that are most severely affected by the HIV/
AIDS epidemic.
     Title II of the CARE Act provides grants to all 50 States, 
the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, 
and eligible U.S. territories to support a wide range of care and 
support services and grants to States for Emerging Communities.
     Title III, Early Intervention Services (EIS), supports 
comprehensive primary health care and certain services for individuals 
who have been diagnosed with HIV.
     Title IV provides community-based, family-centered 
services to women, children, and youth living with HIV and their 
families.
     Part F of the CARE Act includes--the Special Projects of 
National Significance (SPNS), the AIDS Education and Training Centers 
(AETCs), and the HIV/AIDS Dental Reimbursement Program--to support 
innovative programs that hold promise for improving health outcomes.
Principles of Reauthorization
    Last July, the Administration emphasized five key principles for 
reauthorization of the Ryan White CARE Act: (1) serve the neediest 
first; (2) focus on life-saving and life-extending services; (3) 
increase prevention efforts; (4) increase accountability; and (5) 
increase flexibility. The President has made fighting the spread of 
HIV/AIDS a top priority of his Administration, and he will continue to 
work with Congress to encourage prevention, and the provision of 
appropriate care and treatment to those suffering from the disease.
Budget Request
    Fiscal year 2006--request $2.08 billion; appropriation of $2.06 
billion.
    Fiscal year 2007--request $2.16 billion, increase of $95 million 
for several elements of a new Domestic HIV/AIDS initiative (further 
elements of that initiative, focusing on testing in the areas of 
greatest need, are requested outside the CARE Act).
    The request will support a comprehensive approach to address the 
health needs of persons living with HIV/AIDS, consistent with the 
reauthorization principles. The budget also includes a new authority to 
increase program flexibility by allowing the Secretary to transfer up 
to 5 percent of funding provided for each Part of the Ryan White CARE 
Act to any other Part. Of the new $95 million requested, $70 million 
will address the on-going problem of State waiting lists and provide 
care and life-saving medications to those newly diagnosed as a result 
of increased testing efforts. The remaining $25 million will be used to 
expand outreach efforts by providing new HIV community action grants to 
intermediaries including faith and community-based organizations, and 
to provide technical assistance and sub-awards to grassroots 
organizations.
                                 ______
                                 
    Mr. Chairman, members of the committee, I am thankful for the 
opportunity to meet with you today on behalf of the Department of 
Health and Human Services (HHS) to discuss the reauthorization of the 
Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.
Background
    The Ryan White CARE Act is a comprehensive approach to the 
provision of medical care, treatment, and support services to 
individuals living with HIV/AIDS who have no other means with which to 
obtain such care. The program is administered through the HIV/AIDS 
Bureau of the Health Resources and Services Administration (HRSA) 
within the Department of Health and Human Services (HHS). The Federal 
Ryan White CARE Act was enacted in 1990; it was amended and 
reauthorized in 1996 and again in 2000. The authorization of 
appropriations expired on September 30, 2005. President Bush in his 
2006 State of the Union Address stressed the importance of this program 
and asked Congress to, ``reform and reauthorize the Ryan White Act and 
provide new funding to States so we end the waiting lists for AIDS 
medicines in America.''
    Since its last reauthorization, we have been able to provide 
antiretroviral treatment, primary care, and support services to over 
half a million people annually in the United States, Puerto Rico, Guam, 
the U.S. Virgin Islands, and eligible U.S. territories. In 2004, an 
estimated 65 percent of these individuals were racial minorities, 33 
percent were women, and 87 percent were either uninsured or received 
public health benefits. The Ryan White CARE Act programs have provided 
important benefits to these populations. Overall, AIDS mortality is 
down and lives have been extended with HIV/AIDS medications purchased 
through the AIDS Drug Assistance Program (ADAP). Pregnant women have 
been provided with care that has allowed them to give birth to children 
free from HIV infection, and thousands have received support services 
that have allowed them to access and remain in health care.
    The structure of the Ryan White CARE Act allows for local 
flexibility and responsiveness in meeting diverse needs in different 
regions. It fosters collaboration among Federal, State, and local 
governments, and public and private entities to create a continuum of 
care for people living with HIV/AIDS.
    The Ryan White CARE Act is organized into distinct program 
components. Title I provides emergency assistance to Eligible 
Metropolitan Areas (EMAs) that are most severely affected by the HIV/
AIDS epidemic. To be eligible for title I funding, an area must have 
reported at least 2,000 AIDS cases during the previous 5 years and have 
a population of at least 500,000.
    Title II of the CARE Act provides grants to all 50 States, the 
District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and 
eligible U.S. territories. Title II grants support a wide range of care 
and support services. Title II also provides grants to States for 
Emerging Communities--that is, localities reporting between 500 and 
1,999 AIDS cases over the most recent 5 years. Additionally, title II 
funds the AIDS Drug Assistance Program (ADAP), which provides 
medications for the treatment of HIV disease.
    Title III, Early Intervention Services (EIS), supports 
comprehensive primary health care and certain services for individuals 
who have been diagnosed with HIV. Services include education to prevent 
transmission of HIV and case management to assure continuity of care. 
Title III grants expand the capacity of organizations providing primary 
care to indigent HIV-positive individuals. One third of all title III 
grantees are community health centers.
    Title IV provides community-based, family-centered services to 
women, children, and youth living with HIV and their families. Services 
include: primary and specialty medical care, psychosocial services, 
logistical support, outreach and case management.
    The Ryan White CARE Act includes Part F--the Special Projects of 
National Significance (SPNS), the AIDS Education and Training Centers 
(AETCs), and the HIV/AIDS Dental Reimbursement Program. SPNS grants 
support innovative programs that hold promise for improving health 
outcomes. The AETCs provide education and training on a variety of 
topics for clinicians who treat people living with HIV/AIDS, with a 
focus on primary HIV care for underserved populations. The Dental 
Reimbursement Program assists accredited dental schools and 
postdoctoral programs with uncompensated costs incurred in providing 
dental treatment to patients with HIV infection. The Community Based 
Dental Partnership Program funds eligible entities in their efforts to 
increase access to oral health care and to support oral health service 
delivery and provider training in community settings.
Principles of Reauthorization
    Last July, the Administration emphasized five key principles for 
reauthorization of the Ryan White CARE Act: (1) serve the neediest 
first; (2) focus on life-saving and life-extending services; (3) 
increase prevention efforts; (4) increase accountability; and (5) 
increase flexibility. The President has made fighting the spread of 
HIV/AIDS a top priority of his Administration, and he will continue to 
work with Congress to encourage prevention, and the provision of 
appropriate care and treatment to those suffering from the disease. The 
President requested $2.08 billion for fiscal year 2006 and Congress 
appropriated $2.06 billion for the program. The President's fiscal year 
2007 budget request for the CARE Act HIV/AIDS activities is $2.16 
billion, an increase of $95 million for several elements of a new 
Domestic HIV/AIDS initiative (further elements of that initiative, 
focusing on testing in the areas of greatest need, are requested 
outside the CARE Act). The request will support a comprehensive 
approach to address the health needs of persons living with HIV/AIDS, 
consistent with the reauthorization principles. The budget also 
includes a new authority to increase program flexibility by allowing 
the Secretary to transfer up to 5 percent of funding provided for each 
Part of the Ryan White CARE Act to any other Part. Of the new $95 
million requested, $70 million will address the on-going problem of 
State waiting lists and provide care and life-saving medications to 
those newly diagnosed as a result of increased testing efforts. The 
remaining $25 million will be used to expand outreach efforts by 
providing new HIV community action grants to intermediaries including 
faith and community-based organizations, and to provide technical 
assistance and sub-awards to grassroots organizations.
    In order to serve the neediest first, objective indicators must be 
established to determine the severity of need for funding core medical 
services. The Secretary of Health and Human Services (HHS) would 
develop a severity of need for core services index (SNCSI). This index 
would be based upon objective criteria and be focused on core services. 
It would take into account variables such as HIV incidence and 
prevalence, levels of poverty, and availability of other resources.
    The Administration proposes focusing on life-saving and life-
extending services by: establishing a set of core medical services; 
requiring that 75 percent of funds for titles I, II, III and IV be 
spent on these core services; and maintaining a Federal list of core 
medications for the AIDS Drug Assistance Program (ADAP).
    Requiring States to implement routine voluntary HIV testing in 
public facilities and working with private health care providers to 
implement testing will increase disease detection and further 
prevention efforts. With an estimated 250,000 HIV-positive individuals 
unaware of their HIV-positive status, testing is a key element in the 
Administration's prevention efforts. States will be encouraged to adopt 
important prevention strategies upon receipt of their Ryan White 
allocations.
    Grantees are more likely to be held accountable if: States are 
required to submit HIV data; grantees are required to report on system- 
and client-level data and progress; the payor-of-last-resort provision 
is strengthened; States coordinate HIV care and treatment with other 
federally funded programs to maximize efficiency and effectiveness; 
double counting of AIDS cases between eligible metropolitan areas 
(EMAs) and States is eliminated; and the ``hold harmless'' provisions 
are deleted.
    Today, because of the way AIDS cases are counted, that is by 
including cases spanning the last 10 years, metropolitan areas with 
newer epidemics receive disproportionately less than those with more 
longstanding problems. In order to more accurately reflect the current 
status of the epidemic, the provisions that entitle cities to be ``held 
harmless'' from funding reductions should be eliminated.
    Allowing the Secretary of HHS to redistribute unallocated balances 
based on the severity of need and allowing planning councils to serve 
as voluntary and advisory bodies to Mayors will increase flexibility in 
the program. To maximize all CARE Act funding, unspent funds from 
titles I and II would revert to the Secretary of HHS and the Secretary 
would extend those funds to ADAP programs or areas with the greatest 
need.
    We can all be proud of the accomplishments of the Ryan White CARE 
Act and the dedicated people who make it work. The program has reached 
over 571,000 uninsured or underinsured persons affected by HIV/AIDS 
annually. Medication was provided to an estimated 138,834 persons 
living with HIV/AIDS in 2004. The program strives to reach those 
individuals who are the most in need of its services. Today, people 
with HIV/AIDS are living longer and healthier lives in part because of 
this act. In order to make the legislation more responsive in the 
future, the Administration urges Congress to take into account the 
above stated principles in the reauthorization of the Ryan White CARE 
Act.
    Thank you for the opportunity to discuss the Administration's 
principles for the reauthorization of the Ryan White CARE Act. We look 
forward to working with the committee throughout the reauthorization 
process.

    The Chairman. Thank you for your testimony and the 
expertise you bring. I know that we do have questions, and I'll 
begin by asking you to explain a little bit further how the 
President's principles will ensure that the Ryan White formulas 
more appropriately target the growing number of HIV-infected 
minorities, women, and people in rural areas. How will the 
President's new domestic initiative further target these 
underserved populations?
    Ms. Duke. The principles that the President enunciated 
basically try to address the epidemic as it is today and 
address the need to make the provision of funding equitable 
across the country so that we address those in need first.
    Part of it is to address core services, those services 
which everyone needs, and to ensure that the funds in this act 
go to support those services. And the key to this is 
identifying the severity of need.
    Right now, we do not have an indicator which is objective, 
which is nationwide, which people can agree upon as a solid 
foundation for the awarding of funds. Do we have that now? No, 
we do not. Do we say that we have the answers 100 percent? No, 
we do not. We say that together, we can bring in the experts, 
that we can work with the grantees and with the communities to 
find ways to provide a standard that people will see as just 
and fair and that will address the needs of the population 
which is now facing such tremendous challenges with this 
disease.
    The Chairman. Thank you.
    We were pleased when the President announced in his State 
of the Union speech that we need to do more to address those 
who are on waiting lists for life-saving drugs, and the 
President did provide, I think, an additional $70 million to 
deal with those issues. How are you going to structure that 
program? Are we going to focus on other cost containment 
measures such as lowering eligibility requirements or 
restricting formularies to determine which States need more 
assistance to buy the medications?
    Ms. Duke. In the process of reorganization, we will be 
working with the committee and all of its members to try to 
find ways to allocate funds for drugs for people whose lives 
are actually maintained and sustained by these drugs.
    In the course of the working out of the new $70 million 
request, we are looking at the unique issue of waiting lists, 
and also, services for people newly identified as suffering 
from the disease who will need treatment. So the purpose of the 
$70 million is to address both the provision of treatments and 
also these waiting lists.
    Now, waiting lists vary from State to State. Some States 
have no waiting list. Other States have waiting lists of over 
300. So one of the issues is how do you get money to waiting 
lists, which are made up of the folks who need to get drug 
treatments today.
    So on the $70 million, we are in the process of trying to 
sort through how to propose to use that money so that we can 
get through to those who need it. If we put the $70 million 
through the formulas in the current act, we may give funds to 
States who cannot use them and not be able to get them to 
cities and States that desperately need them to give money to 
the waiting lists.
    So we will be working with the committee to try to find a 
way to get those funds to the people who need them.
    The Chairman. Several of the President's principles focus 
on creating equity within the formulas by eliminating ``hold 
harmless,'' grandfathering, and double counting. Can you tell 
us a little about how these current provisions are creating 
inequities in the formulas?
    Ms. Duke. Recent studies by GAO and others have shown that 
the availability of funds for people suffering from AIDS on a 
per-case basis varies from region to region. Part of it is the 
interaction among the provisions of the different titles of the 
act and some of the very well-intentioned protections that 
exist in this act. This act has so much heart in it, and it 
reflects, I think, very much the spirit that you talked about 
at the beginning, trying to make sure that we are providing the 
very best care across this Nation.
    But as the act has come into fruition, one of the 
challenges that we have is that different adjustments that have 
been made in different places now come into interactions with 
each other that have some perverse results. So for example, 
double-counting--it is really not double-counting; it is 
partial double-counting--but the effect of it is that the 
arithmetic playing out of a formula really gets fouled up in 
implementation, so that if you look just at Title II, Title II 
has an adjustment that was made in 1996, which was a very 
charitable and good thing to do, which was an 80/20 provision--
and I will not go into the details of the provision, but the 
net effect of it is that if you look at the difference in two 
States--a State that has a metropolitan area on the list and 
one that does not--you will find that there are different 
levels of funding available. I can provide more on the that for 
the record if you would like.
    The Chairman. I would appreciate that.
    My time has expired.
    Senator Kennedy.
    Senator Kennedy. Thank you very much, Dr. Duke, and thank 
you for, really, a long career of public service.
    Ms. Duke. Thank you.
    Senator Kennedy. You have been a very dedicated employee 
who has worked in the Department for years, under a number of 
administrations, and we are very fortunate to have that kind of 
dedication and commitment, and we thank you.
    Ms. Duke. Thank you very much.
    Senator Kennedy. Now, we have a short period of time here, 
and if you would, in your testimony, you referred to the 
importance of ``serving the neediest first'' and developing a 
new medical index that would drive funding. Every State and EMA 
is capable of demonstrating unmet needs, I think, in each area, 
but they suffer shortfalls in Federal support for medications. 
I think the Part D Medicare has been complex and difficult, 
even under Medicaid, with the variations and other support 
services.
    So do you interpret ``serving the neediest first'' to mean 
the neediest individuals nationwide, or do you mean the 
neediest jurisdictions, because they are not necessarily the 
same?
    Ms. Duke. Ultimately, in the case of health, I think health 
comes down to individuals. Individuals are the people who 
contract the disease, who live with the challenges of the 
disease, and who ultimately die of the disease. So we really 
want to find a way to use the jurisdictions and to use the 
available funds that have so much heart behind them to really 
provide life-saving, life-extending care for individuals. But 
we recognize that we have to have jurisdictions that share the 
concern for these individuals to work and implement a very 
complex law.
    Senator Kennedy. Just continuing, in assessing the 
jurisdiction need for funding, you also have a reference to 
taking account of other existing resources. Would you agree 
that it is shortsighted to consider the resources that States 
and locals have committed to supplement the CARE Act--for 
example, through a strong Medicaid program--in assessing the 
need for Ryan White funds?
    Many States, like my own, have made a huge commitment in 
health care for the poor and the disabled. Do you think it is 
really fair to use that investment against them in allocating 
the Ryan White funds?
    Ms. Duke. I think one of the challenges that we will all 
face in working together is exactly that challenge. One of the 
things that we believe in trying to work toward a newly-
authorized act is that we need to find a way to identify 
severity of need that takes into account the poverty of an 
area, the prevalence and incidence of the disease, and also 
does address other funds available, other sources of funding. 
But we have linked that to the continuation of commitments made 
by resources--State, local, and others.
    But we believe that we need to fight through this together 
so that we do not punish the communities that have provided so 
well for their citizens, nor do we advantage those who have not 
provided well. I think that this is one of those Solomonesque 
situations in which we are all going to have to work together 
to find that line where we take care of individuals in the very 
best way possible, and yet we recognize the superb performance 
of some areas of this country.
    Senator Kennedy. Well, I appreciate it, and we want to work 
with you, because I think you are going to find in a number of 
areas, particularly in States where there has been the highest 
incidence, there has been a strong commitment to try to look 
after the range of different services, and it seems to me it 
would be unfair to penalize them if they have demonstrated that 
kind of strong commitment.
    Let me move on to the code-based system, which you are 
familiar with.
    Ms. Duke. Yes.
    Senator Kennedy. Massachusetts uses a code-based system to 
identify HIV cases. They have had good feedback from CDC on the 
validity and reliability of this code-based system. And in the 
2000 reauthorization of Ryan White, it was mandated that by 
2004, the Secretary would begin to correct accurate and 
reliable HIV--and in deciding what is accurate and reliable, 
consideration should be given to the IOM study that was 
commissioned. And the IOM study clearly states that both name-
based and code-based would be acceptable if it was reliable.
    So, why is CDC demanding that Massachusetts collect names 
when it has never been established that their code-based system 
did not work, and that system, if it is a credible system under 
the Institute of Medicine, is indicated to be acceptable?
    Ms. Duke. My understanding--and I am not at CDC--but my 
understanding is that the interpretation of the laws that exist 
is that CDC must certify that the systems meet the standards of 
the law and that they have said that they cannot certify code-
based or name/code-based systems.
    We have about 13 or 14 States that have some situations--
and I believe my colleagues at CDC can work with you on that--
where they are having problems with compliance with what they 
view as the intent of the law.
    Senator Kennedy. It seems to me it ought to be an authentic 
system, but Massachusetts was a very early State, and we also 
take great pride particularly in the research that was done 
with mothers and babies at the Boston City Hospital Pediatric 
Center, which is really one of the great, great national 
treasures, doing an enormous amount of research with incredible 
productivity. But we have had great success with the code-based 
system. We do not have the time, because my time is up, to 
explain the reasons for it, and I do not want to be supporting 
that kind of concept if it does not meet the kind of strict 
requirements on reliability. But my information is that it 
does, and also that the Institute of Medicine recognized that 
if you have a creditable code-based system that it meets the 
other kinds of requirements. So we will have a chance to visit 
and talk with the Administration and others on this issue.
    My time is up, Mr. Chairman. I thank you.
    Ms. Duke. I will take your concern back and get back to you 
on that.
    Senator Kennedy. Thank you.
    The Chairman. Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Duke, welcome.
    Ms. Duke. Thank you.
    Senator Burr. Thank you so much, and I reiterate what 
Senator Kennedy said; thank you for your many years of service.
    Dr. Duke, if the unobligated funds within the CARE Act are 
not spent before the end of March, what happens to that money?
    Ms. Duke. Under the law, the unobligated balances 
ultimately get returned to Treasury.
    Senator Burr. Is there any way for us to recapture that 
money and have it redistributed via ADAP?
    Ms. Duke. I can absolutely tell you that I have spent hours 
and days pondering that very question and working with our 
lawyers, and we ended up with the realization that we did not 
have the authority to do so--furthermore, it is rather complex 
the way the interaction of various provisions works--but that 
we did not have the authority now to be able to bring those 
funds back in and reallocate them. And that is one of the 
things that we are asking for, is more flexibility in this law 
so that perhaps we could do that.
    Senator Burr. And were we to follow the guidelines set by 
the President, would we in fact accomplish that? Would you have 
the flexibility to recapture and redistribute within ADAP, or 
do you need additional authority from Congress?
    Ms. Duke. We believe that in this reauthorization, we would 
have to address this question directly.
    Senator Burr. I hope you will work with us to try to 
address that. As one who has an ADAP program that consistently 
has a waiting list, I would desperately like to see unobligated 
funds used, and I cannot think of a better way than for them to 
be used for those HIV and AIDS patients.
    Ms. Duke. As in all provisions of this law, we will be 
happy to work with this committee to try to see what we can do 
together.
    Senator Burr. Dr. Duke, could you help me to try to 
understand or explain to me why, when we combine the money that 
is going to each State under Title I and Title II funding, a 
State like California would receive $5,200-plus per AIDS case, 
while North Carolina would receive $3,700, Mississippi, $3,400, 
and Iowa, $3,300?
    Ms. Duke. This is a complex interaction of the multiple 
titles and the very well-intentioned adjustments that have been 
made within those titles.
    For example, the interaction between Title I and Title II--
some States do not have an Eligible Metropolitan Area, an EMA, 
and the impact of having an EMA is that funds get allocated to 
that State based on the supplemental funding in Title I that 
recognizes need, but they also get funding from a formula that 
recognizes their share of the AIDS cases.
    So if you have an EMA in your State, you get funding under 
Title I; then, you get Title II funding, and Title II funding 
comes to the State again in two pots of money. One pot, about 
97 percent of the money, comes through a formula, and then 
there is 3 percent set aside for severity of need.
    When those funds get allocated, that 97 percent gets 
allocated, again, we have issues about how you allocate. If you 
have an EMA in your State, 80 percent of the funds get 
allocated across the entire State, including the EMA, which has 
already been counted in Title I. So then, when you go to Title 
II, they get counted again in 80 percent of the allocation; but 
in 20 percent, according to the----
    Senator Burr. And that would be the double-counting?
    Ms. Duke. Yes, it's what you call double-counting, yes, 
sir--partial double-counting.
    Senator Burr. OK. I just wanted to make sure that I 
understood it.
    So, we created the CARE Act for what reason?
    Ms. Duke. I think that the opening statements reflected 
very much the heart of the U.S. Congress in recognizing that we 
wanted to take care of folks who were facing a horrible 
disease.
    Senator Burr. Haven't we made this way too complicated?
    Ms. Duke. This is an extraordinarily complex statute.
    Senator Burr. You just went through a very detailed answer 
to what I knew was not a simple question, but you did it 
without notes; you did it because you have spent time in it, 
and you have been asked the question before. And I am not 
exactly sure how I can go back and explain to a population, 
many of whom do not have available funds because we have a 
significant increase in the population, that the increase in 
population does not necessarily trigger proportionately what we 
should get as it relates to this very limited pot of money. And 
I am desperately trying as we have an opportunity to 
reauthorize to be able to go home and say, ``Once again, we 
were not perfect, but we got it better,'' and I have every hope 
that I can look at Senator Kennedy and say we made it less 
complicated than to make it more complicated.
    But I am fairly confident today that if we cannot get rid 
of certain things like double-counting, I am not sure that your 
explanation can ever be less than what it was, which is very 
difficult to follow, although I have every confidence in the 
world that you know exactly what you are talking about. If Part 
D is confusing to seniors, I can imagine what this is to those 
people who use the money to assist an HIV population in my 
State.
    Ms. Duke. It is a very complex law, and its complexity 
comes out of the fact that this is a complex epidemic. But our 
hope is that all of us working together can produce something 
that is fair and equitable and understandable.
    Senator Burr. I look forward to that.
    Mr. Chairman, I would ask unanimous consent that we be 
allowed to send Dr. Duke some additional questions. I think we 
will need it in this process.
    The Chairman. Absolutely. You do not even need to ask 
permission for it. Actually, we will allow any member's written 
statement to be entered into the record. If a member would like 
to submit additional questions for the record, we will ask Dr. 
Duke to answer those additional questions. Given the technical 
nature of this program, we may not want to ask here--we do not 
want the audience going to sleep--but it is information that we 
need that will be helpful for us as we re-examine this program.
    The Chairman. Senator Clinton.
    Senator Clinton. Thank you very much, Mr. Chairman.
    Welcome, Dr. Duke. We are delighted to have you here, and 
thanks also for your years of service.
    Ms. Duke. Thank you so much.
    Senator Clinton. I think we are all committed to ensuring 
that this program remains strong and viable and able to help as 
many people living with HIV and AIDS in our country as 
possible. I hope, too, that we do not try to expand the reach 
of the CARE Act by removing resources from areas which have 
historically been hardest hit by the domestic AIDS epidemic.
    For example, the need is greater than ever in my State of 
New York. Although New York only has 7 percent of the Nation's 
population, it has 17 percent of the Nation's AIDS cases. Over 
100,000 people living with HIV and AIDS reside in New York--
more than any other State in the Nation. And the epidemic 
unfortunately shows no signs of abating--more than 7,000 new 
cases of AIDS were reported in New York in 2004, again, more 
than any other State in the Nation.
    In response to a letter that I sent to you in October, with 
my colleagues in the New York delegation, outlining our 
concerns over the President's principles, you stated that ``The 
principles are proposing to target Federal funds to the most 
heavily impacted communities and to serve the neediest first.''
    Such a statement would seem to indicate strong 
administration support for a State like mine, which has borne 
the brunt of the epidemic. Yet, if the Administration's 
principles were implemented, as I understand them at this 
point, New York would experience decreases in funding that 
would terribly impact our ability to provide care and treatment 
to the 100,000 people we have living with HIV.
    Specifically, the principles would require 75 percent of 
the funds to be spent on a yet-to-be-defined list of medical 
services, establish a severity of need index that would take 
into account State spending, and make changes in the Title II 
formula that would shift funding away from areas with Title I 
Eligible Metropolitan Areas.
    Could you explain--because it is obviously important to me, 
to Senator Kennedy, to California, and to other States with 
large populations--how the President's proposal for 
reauthorization would help and not hurt heavily-impacted 
communities with demonstrated need, like New York?
    Ms. Duke. I think that the word ``principles'' is the key 
here. We have principles that we put forth, and what we have 
done is we have laid out some of what we see as problems with 
the equity of the statute as it exists.
    We are very aware of the tremendous job that New York has 
done and of the tremendous burden that New York bears in this 
epidemic. The reason we are working with principles rather than 
with some kind of assertion that we have truth, beauty, 
justice, and light on our side here, rather, what we are saying 
is here are some principles and here are some things that we 
see that are problems in the statute as it now exists.
    So what we have tried to do is say, for example, on the 75 
percent, of course, when I got your letter, I asked what's 
going on with this, what are we doing now--and then, of course, 
I was inundated with statistics. It basically boiled down to 
that we are already doing more than 75 percent.
    Now, what are core services and so forth? Everybody has a 
list of core services, and what I wanted to know is is there 
any commonality. There is a lot of commonality about what core 
services are.
    So what we are trying to find and what we are trying to put 
forth in these principles is can we, working together, find a 
way to address the reality that a big State like New York, with 
a big EMA like New York City, needs recognition and funding to 
deal with the epidemic as it appears in that jurisdiction, but 
that at the same time, we need to have some equity for the 
States that do not have an EMA and where we get this tremendous 
difference in per-case funding.
    And I honestly believe that all of us working together can 
sort our way through this to get a precise and manageable way 
of doing it that does not reward bad behavior or punish good 
behavior. That is what we are seeking here, and we do not 
pretend to have all the answers, but I believe we can do it 
together.
    Senator Clinton. Well, I certainly welcome your offer to 
work with you, because I think that is what all of us are 
striving for. And I could second Senator Burr's request that we 
look for a way to recapture funds that are not used. We did 
work that out in the Children's Health Insurance Program, the 
S-CHIP program, so maybe that is one of the models we can look 
at, because we had the situation there where some States were 
utilizing those funds, and others were returning them to the 
Treasury, and we were able to transfer those.
    Now, when we look at the severity of need index, we have to 
also take into account the effort that State and local 
governments have made, which I do not think we want to 
discourage or disincentivize. I think we also have to take into 
account the impact on Medicaid--because certainly the bulk of 
the medical costs in New York are paid for by Medicaid, not by 
the Ryan White CARE Act--with the cutbacks in Medicaid, how 
that is going to impact the caseloads that are already on the 
rolls for HIV/AIDS. And again, I would just raise these as 
cautionary notes.
    I also hope that we could study carefully the support 
services. I know there are some who think that the medical 
services and the access to medications are really the end-all 
and be-all, but we have found in New York, from a lot of trial 
and error and now some very good programs, that nutrition 
services, case management services, and emergency housing 
assistance are really medically-related and necessary services.
    So if we take the 75 percent CARE Act funding and direct it 
to the as-yet-undefined set of core medical services, how will 
we deal with case management and some of these supplemental 
services that we at least have found were necessary to keep 
people alive and to keep them able to go on with their daily 
lives when they were under tremendous health pressures?
    Ms. Duke. One of the things we did in trying to look at 
where we are now in terms of where we are going to perhaps go--
we tried to look at what are we spending money on now. What we 
found was that about 29 percent of the money gets spent on 
health care; about 42 percent of it gets spent on pharmacy. And 
we included in that definition case management services.
    So when we look at this definition of what is a core 
service, as you look across the definitions, and you sort of 
play almost those children games, where you tried to make 
things line up, one of the things that happens when you line up 
these various lists is that you find that there are 
commonalities--the idea of having outpatient services, having 
x-ray, having access to oral health care, mental health care, 
behavioral and substance abuse care--when you put all of those 
in, one thing that you also find is that case management comes 
up on most of those lists.
    Senator Clinton. Thank you very much, Dr. Duke.
    Ms. Duke. Thank you.
    The Chairman. Thank you.
    Senator Sessions.
    Senator Sessions. Thank you, Mr. Chairman.
    Dr. Duke, I want to ask just a question or two that relate 
to a matter that has come to my attention that concerns me. I 
know that Alabama's AIDS program is working hard; they have 
some very fine people involved in it. My daughter served on the 
board in Mobile, and they raised money and had auctions and 
things that people do.
    Then, I have come to be aware that the larger cities, the 
larger metropolitan areas, receive more money per patient--
substantially more, apparently--than the smaller areas. I do 
not think Birmingham, for example, is close to three-quarters 
of a million people, so they do not qualify as a larger area. 
So we have no area in the State that qualifies.
    I recently heard about people who had to leave New Orleans 
and go to other parts of Louisiana to live, and they had been 
receiving about $1,200 per month in assistance for drugs for 
treatment and so forth, and upon leaving New Orleans, their 
amount changed to $1,200 per year. To me, that seems 
unconscionable, that a single mother with AIDS in Alabama or in 
rural Louisiana is going to get substantially less than 
somebody who lives in New Orleans.
    Rural health care is already facing many adverse funding 
formulas. For example, a doctor in Alabama who does a gall 
bladder operation is paid a lot less than a doctor in a big 
urban area, for the very same procedure.
    So we have a problem here if those numbers are somewhat 
correct, and the State people tell me that they are. Dr. 
Williamson, the State health officer and a fine professional, 
says it is a real problem for them, that there are 300 on the 
waiting list right now that they do not have funding to take 
care of. I think our AIDS problem in Alabama is growing at 
least on par with other areas of the country and perhaps 
faster.
    So I guess I would ask you if you are aware that there is a 
funding disparity here, and do you have any plans to fix it.
    Ms. Duke. Yes, sir, we are very aware of the funding 
disparities as you go across the country. If you look at the 
funding in a State that has an Eligible Metropolitan Area 
versus a State that does not, then, the reality of 
differentials affecting the amount of money available per case 
becomes quite visible.
    One of the things that we hope----
    Senator Sessions. Of most Eligible Metropolitan Areas, 
which would have the most capability to support locally, if 
need be, AIDS patients--the larger areas or the smaller ones? I 
mean, why would we give more to the larger areas?
    Ms. Duke. One of the things that we have proposed here is 
trying to work through this dilemma, because we know that the 
formulas as they now exist produce this result, which was 
really not an intended result, that someone living in a rural 
area--the case--would get less funding.
    So we believe that working together, we can plow through 
this really complex law with these different formulas and try 
to deal with this equity issue, and that is an important piece 
of it. And the President in his State of the Union talked about 
trying to reform this act to address some of these issues. And 
also, in the budget for 2007, the President talked about trying 
to find a way to address the waiting list issues and has asked 
for funding that would allow us to get money to States that 
have waiting lists.
    So just to sum up, we are very concerned with these issues, 
and we believe that, working together----
    Senator Sessions. How do you propose fixing it? Is there 
anything in the fiscal year 2007 budget that would fix this?
    Ms. Duke. On the waiting list, yes, sir, the $70 million.
    Senator Sessions. Well, let's put that aside. I am not sure 
that that deals with the allocation disparity. What about the 
allocation disparity? Why don't you look at this and propose a 
fix?
    Ms. Duke. As I said earlier, that is of grave concern to 
us, and we do believe that, working together and using the 
principles that we have laid out, we can together find a way to 
deal with that problem of allocation, which is an interaction 
of these various titles as they have developed over the last 16 
years. Some of the well-intentioned changes that got made in 
titles have had some rather challenging implementation issues, 
and those are the issues that you have brought up, and we hope 
to work with this committee to see if we cannot find a way 
through this.
    Senator Sessions. Well, sometimes inequities occur because 
of unintended consequences; sometimes because of clever 
legislators. I do not know how this occurred, but if the 
numbers are anything like the numbers that I am hearing from my 
State and what I have heard about Louisiana, wouldn't you agree 
that that is inequitable?
    Ms. Duke. We have said that we do not have the same 
standard of funding of cases as we go about the country. We 
agree that we have equity problems in the law. The question is 
how can we work through those inequities in a way that 
together, we can find something that we believe is fair and 
just for the American people. And I think that is our challenge 
over the coming months.
    Senator Sessions. Will you help us?
    Ms. Duke. Absolutely. It is my pleasure to help you all.
    Senator Sessions. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. I believe that Senator Burr had one quick 
dollar-specific question.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Duke, I am curious--with the emergence of Part D 
Medicare, we have now provided an avenue for those individuals 
who had been classified as disabled from an affliction of AIDS. 
We have now opened an avenue for them to get their medication.
    Do you know, or do we have numbers on what the size of that 
population may be that this year has access to medications 
under that program that did not prior to Part D?
    Ms. Duke. I will have to get that for you for the records, 
sir, but I will.
    Senator Burr. Would you be kind enough? I think, Dr. Duke, 
that what you have heard from everybody is that our goal as we 
change these programs, as we reauthorize them, as we reshape 
them, whatever the final determination is, is that the focus 
needs to go on how we get the medications to those individuals 
who need it. I have dealt with this for long enough that I know 
it is impossible to do without ruffled feathers, without 
winners and losers, and as long as in the loser category, it is 
not a person with HIV or AIDS, then we have to be bold enough 
to complete this process. We need to make sure that more have 
an opportunity to be in the ``winner'' column regardless of 
where they are geographically.
    I thank you once again.
    Dr. Duke. Thank you, sir.
    The Chairman. Dr. Duke, I want to thank you for your 
testimony and your answers.
    I want to thank my colleagues for their attendance and 
interest, and I know there are people who want to submit some 
additional questions. We will not have any further questions at 
this time. This hearing has raised a lot of critical issues 
highlighting the need to retool our efforts to fight the AIDS 
epidemic of today, and we will be working on that. Senators 
will have an opportunity to submit additional questions. The 
record will remain open for 10 days for those questions to be 
answered.
    I thank everybody for their attendance and participation. 
The hearing is now adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

  Response to Questions of Senators Enzi, Kennedy, Burr, Hatch, Dodd, 
    Reed, and Clinton by the Department of Health and Human Services
                       questions of senator enzi

Rural Areas

    Question 1. Dr. Duke, one of the Ryan White CARE Act White House 
principles was the inclusion of a severity of need process in 
determining the Ryan White funding formula allocations. One of the key 
debates that we have on the Hill is one regarding the cost of health 
care in rural versus urban areas. That debate maintains itself in Ryan 
White because States who have no cases in metropolitan areas receive 
more than \1/4\ less funding per case. According to the GAO, States 
without separate funding for metropolitan areas received $3,592 per 
estimated living AIDS case, while States with a bulk of cases in 
metropolitan areas received $4,955 per case. Although I won't recreate 
the full debate here, I do want your thoughts on how rural States 
should deal with the increased number of cases in their areas, given 
their general lack of large health care infrastructure. For instance, 
in my own State of Wyoming, we only have two infectious disease doctors 
in the whole State to treat over 200 HIV-infected individuals. In 
addition, can you help outline specific issues with rural areas scaling 
up to provide their care?
    Answer 1. As small towns and cities experience a rise in the number 
of HIV/AIDS cases, patients may face obstacles to effective care. In 
addition, rural residents who have or are at risk for HIV infection may 
also need support services. Some of the barriers to care in rural areas 
exist for individuals seeking any type of medical treatment and support 
services in these areas. Some of the unique issues include having HIV/
AIDS; less access to intervention and prevention efforts; fewer 
resources and information about HIV/AIDS; long distances between homes 
and medical facilities; shortages of clinicians (doctors, nurses, 
psychologists, counselors, and social workers) able to diagnose and 
treat HIV infection and comorbidities; and fewer people with health 
care coverage. Transportation continues to be a barrier. For patients 
who have cars or can borrow cars to make frequent trips to distant 
clinics, the high cost of fuel can be prohibitive. Care in rural areas 
is particularly challenging for HIV-positive caregivers, such as HIV-
infected mothers who find it difficult to care for children and spend 
full days traveling to and from medical appointments.
    Recommendations for improving the quality of life for persons with 
HIV/AIDS in rural areas include conducting support sessions by 
telephone, helping patients identify support services in their area, 
using telecommunications to provide rural patients with information 
about contemporary treatment regimens, and assisting them in developing 
and maintaining strong social support networks.
    Some examples of how rural States have dealt with increased cases 
in their areas:

     In Vermont, the University of Vermont provides care 
throughout the State by providing care in three small cities, in which 
persons can travel within a 2-hour radius to get to these clinics. The 
clinics are run by a nurse practitioner with supervision from 
University Infectious Disease physicians, who travel monthly to the 
outlying sites. The key to high quality HIV care, particularly 
prescribing of Highly Active Antiretroviral Therapy, is consultation 
with experts. The CARE Act funds the University of California--San 
Francisco Warm line--through which clinicians may consult with HIV care 
specialists. This service is used most frequently by rural clinicians.
     Because of stigma, it's often effective to have services 
placed in small cities, i.e., cities with populations of less than 
30,000. In Pennsylvania, clinicians from the Hershey Medical Center 
travel to several areas within a 2- to 3-hour radius to provide medical 
care. Clinicians can often work in consultation with community 
physicians who may have limited experience in HIV care. In frontier 
States, this model is more challenging because the distances are 
farther. In these States, expert HIV physicians often fly to other 
cities within the State to provide services.
     In Maryland, Johns Hopkins University provides care in 
local health departments in several adjacent rural counties. HIV-
positive patients without complicated medical needs are served in their 
own locales by Hopkins' physicians.

    Question 2. How is HRSA working with the CDC to help low-incidence 
States prevent new infections and reduce incidence rates, given the 
changing HIV epidemic? What specific programs does HRSA have to help 
low-incidence States serve the needs of newly detected individuals?
    Answer 2. The CDC Advancing HIV Prevention Initiative aims to 
reduce HIV transmission by encouraging people to learn their HIV 
status; to provide referrals to care, treatment, and prevention 
services; and to prioritize prevention services for persons with HIV. 
All of the CDC initiative's main precepts directly affect HIV care and 
the Health Resources and Services Administration (HRSA) HIV/AIDS 
Bureau's (HAB) programs: to make HIV testing a routine part of medical 
care; to prevent new infections by working with persons diagnosed with 
HIV and their partners; and to further decrease perinatal transmission 
by screening all pregnant women for HIV. HAB is working closely with 
the CDC to collaborate on projects that support the initiative, as well 
as working to promote HIV prevention, counseling, and testing in HRSA 
programs. Activities that support the CDC's initiative currently 
include: training providers on HIV counseling and testing, use of the 
Rapid test and integrating HIV prevention into clinical care through 
our AIDS Education and Training Centers (AETC) programs; testing models 
that integrate prevention activities into clinical care settings; 
collaboration with CDC and CMS to identify methods to streamline and 
integrate case management services; and ways to promote perinatal 
counseling and testing activities. In addition, CDC and HAB worked 
together in an effort to quantify the impact of this initiative on HIV 
care and treatment programs.
    In November 2002, in order to promote better coordination of 
prevention and care resources, the Health Resources and Services 
Administration AIDS Advisory Committee (HAAC) and the Centers for 
Disease Control and Prevention Advisory Committee on HIV and STD 
Prevention (ACHSP) were combined into one entity.
    The resulting body, the CDC/HRSA Advisory Committee on HIV and STD 
Prevention and Treatment (CHAC), helps CDC, HRSA, and HHS determine how 
best to identify and respond to the prevention and health care service 
needs of communities and individuals affected by HIV and AIDS and other 
STDs. CHAC offers recommendations on strategic, programmatic, and 
policy issues, and provides general support to the agencies as they 
respond to emerging HIV or STD-related health needs.

Code-Based Systems

    Question 3. Can you clarify something for me? How long has CDC been 
stating that names-based reporting is an accurate and reliable method 
for HIV reporting? How many times and in what way has CDC made this 
information available to the States? What documentation has CDC 
provided about the issues of having code-based systems? What are the 
major barriers for those code-based systems, keeping CDC from accepting 
them as ``accurate and reliable?'' What data do you have about the cost 
of code-based systems as they relate to name-based systems?
    Answer 3. At the beginning of the HIV epidemic, before the 
discovery of the etiologic virus, surveillance of this public health 
problem could only be conducted by tracking AIDS cases. In the early 
1980s when all States implemented mandatory reporting for this 
condition, they used the name of the affected person as the patient 
identifier. All other reportable diseases in all States are and have 
been monitored using this method except for diagnosed HIV infections 
that have not progressed to AIDS.
    Currently, seven States and the District of Columbia use a code 
rather than name as the patient identifier for non-AIDS HIV. In 1985, 
when the first diagnostic test for HIV became available, Minnesota and 
Colorado were the first States to begin conducting surveillance for 
persons diagnosed with non-AIDS HIV. These States used name-based 
reporting for this condition as well. By the beginning of 1994, when 
CDC began to support national aggregation of surveillance data on non-
AIDS HIV, 25 States collecting this information were using name-based 
systems. Two other States (Connecticut, and Oregon) were using codes.
    Numerous formal evaluations of name-based reporting for AIDS were 
executed during the late 1980s and early 1990s. The evaluations 
demonstrated that this was a highly accurate and reliable method for 
conducting surveillance for AIDS. Because the vast majority of States 
were using name-based systems for non-AIDS HIV, name-based AIDS 
surveillance had been shown to be highly accurate and reliable, and no 
formal evaluations of code-based systems had been conducted, CDC 
determined that only name-based reports would be accepted into the data 
collection system for the national database. During 1994, two other 
States (Maryland and Texas) implemented code-based reporting systems.
    In 1995, CDC convened a meeting of States conducting non-AIDS HIV 
surveillance (code and name-based) to review the operational, 
technical, and scientific challenges associated with surveillance using 
coded identifiers. The States recommended that CDC evaluate additional 
coded identifiers and assist them in documenting and disseminating the 
results of their findings. With CDC collaboration and support, Texas 
and Maryland conducted an evaluation of their code-based systems based 
on reports submitted during 1994-96. This research documented nearly 50 
percent incomplete reporting and other deficiencies in the accuracy and 
reliability of these systems. Texas subsequently switched to name-based 
reporting whereas Maryland continued to execute and evaluate their 
code-based system.
    In 1997, the Council of State and Territorial Epidemiologists 
promulgated a position statement recommending the addition of non-AIDS 
HIV to the national public health surveillance system. In 1999, CDC 
published formal guidelines for the conduct of non-AIDS HIV 
surveillance. These recommendations provided performance standards for 
evaluating HIV surveillance systems (name or code), reviewed the 
existing evidence for the reliability and accuracy of varying methods 
for reporting this condition, and based on the existing evidence at 
that time, ``advised'' that States use name-based systems. However, CDC 
also stated that it would continue to work with States to develop and 
implement standardized methods for evaluating surveillance systems 
using name and code-based data. Throughout all subsequent national 
meetings, as well as discussions with States, CDC reiterated that it 
``advised'' States to use name-based reporting, and the agency 
commitment to develop standardized evaluation methods.
    In 2001, CDC funded 10 States (3 code and 7 name) to pilot methods 
for evaluating these systems. (Two of these code-based States--Illinois 
and Washington--that participated in this pilot, have subsequently 
switched to name-based reporting.) Also, because it was clear that due 
to the growing availability of Highly Active Anti-Retroviral Therapy, 
persons with HIV and AIDS were living longer, healthier lives, and were 
more likely to move across and within States. CDC launched a national 
evaluation of interstate duplicate reports (i.e., multiple reports from 
multiple States that provide information about one person). From the 
outset of this latter evaluation, it was clear that technical problems 
made it impossible to efficiently include code-based reports. These 
problems included: (1) the variety of codes used by different States 
conducting this type of surveillance, (2) the lack of a central, 
standardized, national database with code-based reports, and (3) the 
inability of States using codes to adequately communicate with States 
using names regarding potential duplicate records. Therefore, only 
name-based reports could be included. The results of this assessment 
indicated that the number of duplicate reports for non-AIDS HIV cases 
varied a great deal from state-to-state, and exceeded the proportion of 
duplicate case reports for AIDS cases.
    After the interstate duplication study was completed, and the 
results were presented at the national meeting of the Council of State 
and Territorial Epidemiologists, CDC did three things: (1) identified 
and eliminated all identified records attributable to duplicate 
reporting from the national database; (2) implemented a formal system 
for coordinating the ongoing identification and removal of duplicate 
reports from the national database; (3) in July of 2005 published and 
disseminated a ``Dear Colleague'' letter signed by the director of CDC 
stating that the agency was upgrading the guidance for States to 
implement name-based HIV reporting from ``advising'' to 
``recommending.'' The letter also indicated that CDC would focus 
technical assistance on assisting States transitioning from code- to 
name-based systems to assure that their data could be integrated into 
the national HIV (non-AIDS and AIDS) data system as quickly as 
possible. However, the implementation and dissemination of the methods 
for conducting evaluations of the accuracy and reliability of reporting 
systems within States, regardless of reporting method, would continue.
    CDC's policy is to report HIV infection and AIDS case surveillance 
data only from areas conducting confidential name-based reporting 
because this reporting has been shown to routinely achieve high levels 
of accuracy and reliability. Personal identifiers are removed before 
data are provided to CDC. HIV surveillance that is conducted using 
coded patient identifiers has not been shown to routinely produce 
equally accurate, timely, or complete data to that conducted using 
confidential, name-based surveillance methods. Code-based and name-to-
code systems are also more expensive to implement than name-based 
systems. Currently, only confidential, name-based HIV reporting, 
integrated with AIDS surveillance data, can be used by States to 
identify and remove cases that are counted in more than one State 
before they are reported to CDC's national surveillance database.
References
CDC. Guidelines for National Human Immunodeficiency Virus Case 
Surveillance, Including Monitoring for Human Immunodeficiency Virus 
Infection and Acquired Immunodeficiency Syndrome. MMWR 1999; 
48(RR13);1-28.
CDC. Evaluation of HIV case surveillance through the use of non-name 
unique identifiers--Maryland and Texas, 1994-1996. MMWR 1998;46:1254-
8,1271.
Council of State and Territorial Epidemiologists. CSTE: position 
statement ID-4. National HIV surveillance: addition to the National 
Public Health Surveillance System. Atlanta, Georgia: Council of State 
and Territorial Epidemiologists, 1997.
    Dear Colleague Letter from Julie Louise Gerberding, Director of 
CDC, July 5, 2005.

Grandfathering

    Question 4. Dr. Duke, although I agree that the currently funded 
title 1 cities have been providing key infrastructure for AIDS care for 
some time, one of the key White House principles for the 
reauthorization of Ryan White is to eliminate the grandfathered EMAs. 
Currently, metropolitan areas continue to receive funding in 
perpetuity, regardless of whether those metropolitan areas would still 
be eligible for funding. According to the GAO, in 2004, 57 percent of 
the current metropolitan areas would not be eligible under current 
eligibility requirements. These areas received over $116 M in funding 
in 1 year alone! Obviously, the Administration has acknowledged issues 
in this area, given your desire to eliminate those who would no longer 
be eligible. Can you further describe how you would envision doing 
this? What sort of transition seems appropriate to you?
    Answer 4. Under Title I of the 1990 Ryan White CARE Act, 
metropolitan areas eligible for funding had to meet one of two 
criteria: (1) 2000 AIDS cases; or (2) a per capita incidence of 
cumulative cases not less than 0.0025. The per capita incidence 
criteria, removed in 1996, established many of the smaller EMAs funded 
in 1990. The 1996 CARE Act Amendments attempted to further target 
funding to larger EMAs by replacing the per capita incidence criteria 
with language limiting funding to areas with a population of at least 
500,000 and limiting the threshold of 2,000 cases to the most recent 
period of 5 calendar years. At the same time, however, a 
``grandfather'' clause was established in the CARE Act Amendments of 
1996 which allowed metropolitan areas eligible for funding in fiscal 
year 1996 to remain eligible even if their reported number of AIDS 
cases dropped below the case threshold. There are currently 29 EMAs 
that are no longer meeting the current eligibility criteria and are 
protected by the grandfather clause. The number of reported AIDS cases 
for the most recent 5-year period in these 29 EMAs ranged from 223 to 
1,941 cases.

Testing

    Question 5. Some have suggested that the Administration only 
focuses on testing, given the new Domestic HIV/AIDS initiative. 
However, CDC spends quite a bit of money outside that initiative for 
HIV prevention. Can you discuss what other things are funded by CDC 
each year in these activities to give a better context as to why the 
current new proposal focuses on testing?
    Answer 5. To have the largest impact on the HIV epidemic, CDC 
utilizes a comprehensive approach to HIV prevention. Comprehensive HIV 
prevention is a broad term that incorporates surveillance, research, 
prevention interventions and evaluation. CDC's surveillance and 
research activities help to better define and understand the HIV/AIDS 
epidemic across the Nation. CDC's prevention interventions and capacity 
building efforts are based on behavioral, laboratory and medical 
science and work to contain the spread of HIV and AIDS. Program 
evaluation and policy research and development assess intervention 
effectiveness and refine prevention approaches. Additional information 
about CDC's comprehensive approach to HIV prevention is contained in 
the attached fact sheet, ``Comprehensive HIV Prevention.''
    In fiscal year 2006, CDC received $651.1 million for domestic HIV/
AIDS prevention activities conducted by the National Center for HIV, 
STD, and TB Prevention. It is estimated that 14 percent of this total 
will be spent on surveillance activities; 9 percent on prevention 
research; 9 percent on capacity building/technical assistance efforts; 
63 percent on intervention activities including testing programs and 
other prevention activities carried out by State, local and community-
based organizations (CBOs); and 5 percent on program evaluation and 
policy development. An additional $68.6 million will be spent CDC-wide 
on efforts such as HIV school health education, safe motherhood, 
hemophilia programs, and preventing nosocomial transmission. The vast 
majority of CDC's domestic HIV/AIDS funding is spent extramurally 
through cooperative agreements to private-sector, State and local 
health departments, education agencies, non-governmental organizations, 
and CBOs.
    For fiscal year 2007, we have proposed expanding our HIV testing 
efforts. HIV testing is an integral part of CDC's HIV prevention 
strategy, as knowledge of one's HIV infection can help prevent spread 
of the infection to others. Studies have shown that when people know 
that they are infected with HIV, they are significantly more likely to 
protect their partners from infection than when they were unaware of 
their infection. We think that this initiative will identify a large 
number of previously undiagnosed cases, and help link those persons to 
care, treatment and counseling, and avoid transmitting HIV to others.

Core Medical Services

    Question 6. Dr. Duke, I find it rather appalling that some States 
spend less than 25 percent of their Ryan White dollars on ``core 
medical services,'' while other States are struggling to provide key 
medical care to individuals. In addition, only seven metropolitan areas 
receiving special Ryan White funds spent 75 percent or more on health 
care services. The rest may be spent on support services, such as 
buddy/companion services. Meanwhile 1,043 individuals with HIV/AIDS are 
awaiting life-saving prescription drugs. I applaud you for your efforts 
to focus Ryan White on providing care that will save lives. Can you 
outline how you would generally want to implement the requirement for 
75 percent of funds to be spent on these services? Would this 
implementation be difficult, given HRSA's current accounting process?
    Answer 6. Both title I and title II program guidance describe the 
elements of a continuum of care and utilize the term ``core services.'' 
In the 2005 title I guidance, grantees were asked to prioritize 
essential core services, describe the priority setting and allocations 
processes and how data were used in this process to increase access to 
core services. Grantees were also asked to justify other sources of 
core services if funds are not allocated to these services. For the top 
services they identified, including core services, grantees were asked 
to develop one or more service goals for each priority with time--
limited and measurable program objectives.
    Title III utilizes the terminology primary care services, which is 
essentially equivalent to core services. At the present time, 82 
percent of title III dollars are spent on these ``core services.'' 
Title IV grantees are aware of the proposed changes, both through HRSA 
efforts as well as through the efforts of the national constituency 
organizations. HRSA will continue to promote the anticipated 
implementation of these changes.

Double Counting

    Question 7. Dr. Duke, I applaud the Administration's proposal to 
more fairly count the HIV cases by eliminating ``double counting.'' As 
you are aware, the current Ryan White formulas allow a person living in 
certain metropolitan areas to be counted twice--one as part of the 
title 1 funds and partially counted as part of the title 2 funds. Do 
you see the elimination of double counting as a mechanism to provide 
more fairness to the Ryan White formulas? Can you highlight some of the 
disparities in funding now due to this requirement?
    Answer 7. We see the elimination of double counting as a mechanism 
to provide more equitable distribution of CARE Act Funds. The recent 
GAO report, ``Changes Needed to Improve the Distribution of Ryan White 
CARE Act and Housing Funds,'' illustrated the effect of counting EMA 
cases twice by comparing the relationship between the percentage of a 
States' estimated living cases that are within EMAs and the amount of 
total title I and title II funding they receive per ELC. The Table 
presented below shows that as the percentage of a State's or Puerto 
Rico's ELCs within EMAs increases, the total title I and II funding per 
ELC also increases. For example, States with no ELCs in EMAs received 
on average $3,592 per ELC. States with 75 percent or more of their 
cases in EMAs and Puerto Rico received on average $4,995 per ELC, or 38 
percent more funding than States with no EMA. If the total title I and 
title II funding had been distributed proportionally per ELC among all 
States and Puerto Rico, each grantee would have received $4,782 per 
ELC.

   Relationship Between ELCs in EMAs and Total CARE Act Title I and II
                    Funding per ELC, Fiscal Year 2004
------------------------------------------------------------------------
                                                        Average funding
 Percentage of States' and Puerto Rico's ELCs in EMAs       per ELC
------------------------------------------------------------------------
None.................................................             $3,592
Less than 50 percent.................................             $3,954
50 to 75 percent.....................................             $4,717
More than 75 percent.................................             $4,955
------------------------------------------------------------------------
Source: GAO analysis of HRSA data.

                      questions of senator kennedy
    Question 1. I am looking for some information on what was done with 
HRSA funding in fiscal year 2005. Specifically, I am looking for a 
state-by-state breakdown for fiscal year 2005 health professions 
grants--a cumulative total, as well as Bureau of Primary Health Care 
grants (including migrant health centers, community health centers, 
school-based health, and integrated services development initiative 
among others). This information is not yet posted on the HRSA Web site. 
In past years I believe it has been table 9E of the Uniform Data 
System. Can you provide this to my office in a timely manner?
    Answer 1. Spreadsheets are attached.

                              BHPr State by State Grant Report for Fiscal Year 2005
----------------------------------------------------------------------------------------------------------------
                                                                                        # of       Total # of
                     State                                  Program Name               Grants        Dollars
----------------------------------------------------------------------------------------------------------------
Alabama........................................  Advanced Education Nursing Grants.          2     $1,748,891.00
                                                 Advanced Education Nursing                  6        546,285.00
                                                  Traineeship.                               1      2,547,562.00
                                                 Centers of Excellence.............          1        206,905.00
                                                 Graduate Geropsychology Education           1         47,102.00
                                                  Program.                                   3      1,690,850.00
                                                 Health Administration Traineeships          1         45,099.00
                                                  and Special Projects.                      3        828,840.00
                                                 Health Careers Opportunity Program          1        562,826.00
                                                 Nurse Anesthetist Traineeships....          1        284,556.00
                                                 Nurse Education Practice and                1        199,325.00
                                                  Retention.                                 1        133,278.00
                                                 Nurse Education, Practice and               1         60,455.00
                                                  Retention: Career Ladder.                  1        165,598.00
                                                 Nursing Workforce Diversity.......          1        163,713.00
                                                 Physician Assistant Training in             6        562,893.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Public Health Traineeship.........
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for AL..................................................................         31     $9,794,178.00
----------------------------------------------------------------------------------------------------------------
Alaska.........................................  Advanced Education Nursing                  1        $36,192.00
                                                  Traineeship.
                                                 Basic/Core Area Health Education            1        763,713.00
                                                  Centers.
                                                 Geriatric Education Centers.......          1        412,037.00
                                                 Health Careers Opportunity Program          1        149,063.00
                                                 Nurse Education, Practice, and              1        156,206.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Quentin N. Burdick Program For              1        267,417.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           1        209,012.00
                                                  Pediatric Dentistry.
----------------------------------------------------------------------------------------------------------------
    Totals for AK..................................................................          7     $1,993,640.00
----------------------------------------------------------------------------------------------------------------
Arizona........................................  Academic Administrative Units in            1       $201,293.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          2      2,114,188.00
                                                 Advanced Education Nursing                  3        162,033.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        151,227.00
                                                 Centers of Excellence.............          1        500,000.00
                                                 Faculty Development in Primary              1        187,137.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        399,350.00
                                                 Grants to States for Loan                   1         40,194.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         11,387.00
                                                  and Special Projects.
                                                 Health Education and Training               1        166,558.00
                                                  Centers.
                                                 Model State-Supported Area Health           1        412,940.00
                                                  Education Centers.
                                                 Nurse Education, Practice and               1        190,845.00
                                                  Retention: Career Ladder.
                                                 Nursing Workforce Diversity.......          2        505,465.00
                                                 Pathways to Health Professions....          1        107,645.00
                                                 Pre-Doctoral Training in Primary            2        340,924.00
                                                  Care.
                                                 Quentin N. Burdick Program For              1        266,355.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care          1        124,200.00
                                                 Scholarships for Disadvantaged              3        330,316.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for AZ..................................................................         25     $6,212,057.00
----------------------------------------------------------------------------------------------------------------
Arkansas.......................................  Advanced Education Nursing Grants.          1       $212,299.00
                                                 Advanced Education Nursing                  3        116,018.00
                                                  Traineeship.                               1        133,301.00
                                                 Faculty Development in Primary              1        424,380.00
                                                  Care.                                      1         21,739.00
                                                 Geriatric Education Centers.......          1        419,278.00
                                                 Health Administration Traineeships          1        315,471.00
                                                  and Special Projects.                      1        495,528.00
                                                 Health Careers Opportunity Program          1          6,769.00
                                                 Health Education Training Centers.          1        108,000.00
                                                 Model State-Supported Area Health           1        271,852.00
                                                  Education Centers.                         1        160,043.00
                                                 Nurse Anesthetist Traineeships....          1        261,138.00
                                                 Nurse Education, Practice and               1        216,849.00
                                                  Retention: Career Ladder.                  4        142,461.00
                                                 Nursing Workforce Diversity.......
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for AR..................................................................         20     $3,305,126.00
----------------------------------------------------------------------------------------------------------------
California.....................................  Academic Administrative Units in            4       $988,253.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          3     $1,875,254.00
                                                 Advanced Education Nursing                 17      1,370,794.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        175,924.00
                                                 Bioterriorism Training and                  2      1,599,970.00
                                                  Curriculum Development Program.
                                                 Center for Health Workforce.......          1        250,000.00
                                                 Centers for Excellence............          4      3,059,127.00
                                                 Dental Public Health Residency              1         99,622.00
                                                  Training Grants.
                                                 Faculty Development in Primary              5      2,178,239.00
                                                  Care.
                                                 Geriatric Education Centers.......          3      1,069,588.00
                                                 Geriatric Training Program for              2      1,431,130.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Psychology Education               1        103,702.00
                                                  Programs.
                                                 Grants to States for Loan                   1        452,098.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         40,425.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          4      2,964,305.00
                                                 Health Education Training Centers.          1        503,312.00
                                                 Model State-Supported Area Health           1        908,457.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          2        884,968.00
                                                 Nurse Anesthetist Traineeships....          3         49,779.00
                                                 Nurse Education Practice and                1        669,579.00
                                                  Retention.
                                                 Nurse Education, Practice and               5      1,551,221.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        274,655.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               4        885,122.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          3        968,699.00
                                                 Other Health Professions Programs           4      1,415,816.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             5        921,468.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            6        983,305.00
                                                  Care.
                                                 Preventive Medicine Residencies...          1        157,191.00
                                                 Public Health Traineeship.........          3         92,194.00
                                                 Public Health Training Centers....          1        366,315.00
                                                 Residency Training in General and           1        435,689.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care         11      2,761,417.00
                                                 Scholarships for Disadvantaged             17      5,919,468.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for CA..................................................................        120    $37,407,086.00
----------------------------------------------------------------------------------------------------------------
Colorado.......................................  Academic Administrative Units in            1       $257,234.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1        203,582.00
                                                 Advanced Education Nursing                  3        346,999.00
                                                  Traineeship.
                                                 Bioterrorism Training and                   1        684,510.00
                                                  Curriculum Development Program.
                                                 Faculty Development in Primary              1        600,235.00
                                                  Care.
                                                 Graduate Psychology Education               1        161,106.00
                                                  Programs.
                                                 Grants to States for Loan                   1         46,668.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         61,595.00
                                                  and Special Projects.
                                                 Model State-Supported Area Health           1        412,940.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        291,688.00
                                                 Nurse Education, Practice and               1        301,298.00
                                                  Retention.
                                                 Nurse Education, Practice and               1        190,601.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Physician Assistant Training in             1        190,685.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            2        429,334.00
                                                  Care.
                                                 Preventive Medicine Residencies...          1        164,509.00
                                                 Public Health Traineeship.........          1          9,236.00
                                                 Residency Training in Primary Care          2        497,662.00
                                                 Scholarships for Disadvantaged              2        380,062.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for CO..................................................................
----------------------------------------------------------------------------------------------------------------
Connecticut....................................  Advanced Education Nursing Grants.          1       $215,799.00
                                                 Advanced Education Nursing                  5        242,170.00
                                                  Traineeship.                               2      1,577,130.00
                                                 Bioterrorism Training and                   1         96,859.00
                                                  Curriculum Development Program.            1        148,232.00
                                                 Faculty Development in Primary              1          5,000.00
                                                  Care.                                      1         75,000.00
                                                 Graduate Psychology Education               1        673,795.00
                                                  Programs.                                  1        330,352.00
                                                 Grants to States for Loan                   1          9,044.00
                                                  Repayment.                                 1        158,463.00
                                                 Grow Your Own FQHC Nurse..........          1        191,244.00
                                                 Health Careers Opportunity Program          1        133,739.00
                                                 Model State-Supported Area Health           1         38,288.00
                                                  Education Centers.                         1        298,794.00
                                                 Nurse Anesthetist Traineeships....          1        150,377.00
                                                 Physician Assistant Training in             1         97,105.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Preventive Medicine Residencies...
                                                 Public Health Traineeship.........
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for CT..................................................................         22     $4,441,391.00
----------------------------------------------------------------------------------------------------------------
Delaware.......................................  Advanced Education Nursing                  3       $122,430.00
                                                  Traineeship.                               1        299,898.00
                                                 Faculty Development in Primary              1        138,086.00
                                                  Care.                                      1         32,413.00
                                                 Graduate Psychology Education               1        188,932.00
                                                  Programs.
                                                 Grants to States for Loan
                                                  Repayment.
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for DE..................................................................          7       $781,759.00
----------------------------------------------------------------------------------------------------------------
District of Columbia...........................  Academic Administrative Units in            1       $310,226.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1        764,557.00
                                                 Advanced Education Nursing                  1         93,844.00
                                                  Traineeship.
                                                 ASPH Cooperative Agreement........          1        343,694.00
                                                 Basic/Core Area Health Education            1        456,156.00
                                                  Centers.
                                                 Centers of Excellence.............          1        582,433.00
                                                 Faculty Development in Primary              1        607,791.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        310,879.00
                                                 Graduate Psychology Education               1        157,845.00
                                                  Programs.
                                                 Health Careers Opportunity Program          1        875,810.00
                                                 Minority Faculty Fellowships......          1         54,604.00
                                                 Nurse Anesthetist Traineeships....          1         32,243.00
                                                 Nurse Education, Practice and               1        157,124.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        309,395.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nursing Workforce Diversity.......          1      1,068,870.00
                                                 Other Health Professions Programs           1        496,000.00
                                                  (Earmarks).
                                                 Pre-Doctoral Training in Primary            1        162,000.00
                                                  Care.
                                                 Public Health Training Centers....          1        926,864.00
                                                 Residency Training in General and           1        619,937.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          1        202,657.00
                                                 Scholarships for Disadvantaged              1        470,989.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for DC..................................................................         21     $9,003,918.00
----------------------------------------------------------------------------------------------------------------
Florida........................................  Academic Administrative Units in            1       $190,633.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          5      1,284,847.00
                                                 Advanced Education Nursing                 11        771,866.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        140,722.00
                                                 Bioterrorism Training and                   2      1,724,076.00
                                                  Curriculum Development Program.
                                                 Comprehensive Geriatric Education           1         50,000.00
                                                  Program.
                                                 Dental Public Health Residency              1         92,457.00
                                                  Training Grants.
                                                 Geriatric Education Centers.......          3        926,329.00
                                                 Graduate Geropsychology Education           1        220,643.00
                                                  Program.
                                                 Graduate Psychology Education               1        167,341.00
                                                  Programs.
                                                 Health Administration Traineeships          1         16,512.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          5      1,718,926.00
                                                 Health Education Training Centers.          1        556,010.00
                                                 Model State-Supported Area Health           4        879,070.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          4         63,590.00
                                                 Nurse Education Practice and                1        222,196.00
                                                  Retention.
                                                 Nurse Education, Practice and               2        515,555.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        129,775.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          1        282,726.00
                                                 Pathways to Health Professions....          1         94,752.00
                                                 Physician Assistant Training in             1        162,918.00
                                                  Primary Care.
                                                 Podiatric Residency Training in             1        200,876.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            2        305,640.00
                                                  Care.
                                                 Public Health Traineeship.........          2         36,776.00
                                                 Residency Training in General and           1        236,278.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          3        408,240.00
                                                 Scholarships for Disadvantaged             11      2,527,180.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for FL..................................................................         69    $13,925,934.00
----------------------------------------------------------------------------------------------------------------
Georgia........................................  Academic Administrative Units in            1       $221,288.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          5      2,222,989.00
                                                 Advanced Education Nursing                 10        357,941.00
                                                  Traineeship.
                                                 Bioterriorism Training and                  1      1,499,269.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        586,479.00
                                                 Faculty Development in Primary              2        608,417.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        341,665.00
                                                 Graduate Psychology Education               1        131,905.00
                                                  Programs.
                                                 Grants to States for Loan                   1         75,625.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          3      1,124,581.00
                                                 Health Education and Training               1        315,000.00
                                                  Centers.
                                                 Model State-Supported Area Health           2        578,113.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          1         12,152.00
                                                 Nurse Education, Practice and               1        252,041.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          1        192,208.00
                                                 Pathways to Health Professions....          1         50,424.00
                                                 Physician Assistant Training in             1         62,861.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            2        615,703.00
                                                  Care.
                                                 Preventive Medicine Residencies...          1        187,201.00
                                                 Public Health Traineeship.........          1         30,059.00
                                                 Quentin N. Burdick Program for              1        348,692.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care          3        580,793.00
                                                 Scholarships for Disadvantaged              4      1,274,718.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for GA..................................................................         46    $11,670,124.00
----------------------------------------------------------------------------------------------------------------
Hawaii.........................................  Advanced Education Nursing Grants.          1       $691,777.00
                                                 Advanced Education Nursing                  2         77,400.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        181,130.00
                                                 Basic/Core Area Health Education            1      1,240,774.00
                                                  Centers.
                                                 Bioterrorism Training and                   1      1,648,271.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        741,029.00
                                                 Comprehensive Geriatric Education           1        120,840.00
                                                  Program.
                                                 Cooperative Agreement to Plan,              1        385,179.00
                                                  Develop & Operate a Continuing
                                                  Clinical Education Program in
                                                  Pacific Basin.
                                                 Faculty Development in Primary              1        378,252.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        431,280.00
                                                 Health Education Training Centers.          1        239,508.00
                                                 Nurse Education, Practice and               1        208,494.00
                                                  Retention.
                                                 Pre-Doctoral Training in Primary            1        149,242.00
                                                  Care.
                                                 Quentin N. Burdick Program for              1        336,227.00
                                                  Rural Interdisciplinary Training.
                                                 Scholarships for Disadvantaged              1         59,085.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for HI..................................................................         16     $6,888,488.00
----------------------------------------------------------------------------------------------------------------
Idaho..........................................  Advanced Education Nursing                  1        $27,051.00
                                                  Traineeship.
                                                 Bioterrorism Training and                   1      1,287,901.00
                                                  Curriculum Development Program.
                                                 Nurse Education Practice and                1        234,582.00
                                                  Retention.
                                                 Other Health Professions Programs           1        245,516.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             1        150,206.00
                                                  Primary Care.
                                                 Quentin N. Burdick Program for              1        277,668.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           1        369,197.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          2        415,651.00
                                                 Scholarships for Disadvantaged              2        348,481.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for ID..................................................................         11     $3,356,253.00
----------------------------------------------------------------------------------------------------------------
Illinois.......................................  Academic Administrative Units in            1       $187,920.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          4      2,549,587.00
                                                 Advanced Education Nursing                 10        604,921.00
                                                  Traineeship.
                                                 Allied Health Projects............          2        246,566.00
                                                 Bioterrorism Training and                   3      2,396,412.00
                                                  Curriculum Development Program.
                                                 Center for Health Workforce.......          1        250,000.00
                                                 Centers of Excellence.............          1        570,841.00
                                                 Comprehensive Geriatric Education           2        264,109.00
                                                  Program.
                                                 Faculty Development in Primary              1        817,697.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        214,347.00
                                                 Graduate Geropsychology Education           2       170, 326.00
                                                  Program.
                                                 Grants to States for Loan                   1        149,323.00
                                                  Repayment.
                                                 Health Administration Traineeships          2         75,053.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          1        661,745.00
                                                 Model State-Supported Area Health           1        330,352.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          4         70,302.00
                                                 Nurse Education Practice and                2        474,191.00
                                                  Retention.
                                                 Nurse Education, Practice and               2        555,790.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               2        666,170.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               2        354,754.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          2        482,151.00
                                                 Physician Assistant Training in             2        349,980.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            2        454,254.00
                                                  Care.
                                                 Public Health Traineeship.........          1         71,370.00
                                                 Public Health Training Centers....          1        270,507.00
                                                 Residency Training in General and           1        306,189.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          3        864,788.00
                                                 Scholarships for Disadvantaged              7        984,821.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for IL..................................................................         64    $15,394,466.00
----------------------------------------------------------------------------------------------------------------
Indiana........................................  Advanced Education Nursing Grants.          2       $347,638.00
                                                 Advanced Education Nursing                  7        354,094.00
                                                  Traineeship.                               1      1,215,105.00
                                                 Basic/Core Area Health Education            1         59,306.00
                                                  Centers.                                   2        279,080.00
                                                 Grants to States for Loan                   1        216,000.00
                                                  Repayment.                                 5        693,823.00
                                                 Nurse Education, Practice and
                                                  Retention: Career Ladder.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for IN..................................................................         19     $3,165,046.00
----------------------------------------------------------------------------------------------------------------
Iowa...........................................  Advanced Education Nursing                  3       $119,872.00
                                                  Traineeship.
                                                 Center for Health Workforce.......          1        457,780.00
                                                 Chiropractic Demonstration                  1        369,572.00
                                                  Projects.
                                                 Dental Public Health Residency              1        159,714.00
                                                  Training Grants.
                                                 Faculty Development in Primary              1        157,428.00
                                                  Care.
                                                 Geriatric Education Centers.......          2        694,761.00
                                                 Geriatric Training Program for              1        483,507.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Grants to States for Loan                   1        138,050.00
                                                  Repayment.
                                                 Nurse Anesthetist Traineeships....          1          8,707.00
                                                 Nurse Education, Practice and               1        230,592.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Other Health Professions Programs           2      1,671,498.00
                                                  (Earmark).
                                                 Pre-Doctoral Training in Primary            1        138,172.00
                                                  Care.
                                                 Public Health Traineeship.........          1         22,838.00
                                                 Public Health Training Centers....          1        421,704.00
                                                 Scholarships for Disadvantaged              3        421,193.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for IA..................................................................         21     $5,495,388.00
----------------------------------------------------------------------------------------------------------------
Kansas.........................................  Academic Administrative Units in            2       $314,650.00
                                                  Primary Care.                              4        166,368.00
                                                 Advanced Education Nursing                  1      1,427,903.00
                                                  Traineeship.                               1      1,274,870.00
                                                 Bioterrorism Training and                   1        192,161.00
                                                  Curriculum Development Program.            1        544,911.00
                                                 Centers for Excellence............          1        396,363.00
                                                 Comprehensive Geriatric Education           1          5,000.00
                                                  Program.                                   1         28,986.00
                                                 Faculty Development in Primary              1        819,412.00
                                                  Care.                                      2         23,874.00
                                                 Geriatric Education Centers.......          1        227,134.00
                                                 Grants to States for Loan                   1        220,329.00
                                                  Repayment.                                 1        368,264.00
                                                 Health Administration Traineeships          1        325,960.00
                                                  and Special Projects.                      1        248,350.00
                                                 Health Careers Opportunity Program          1         75,533.00
                                                 Nurse Anesthetist Traineeships....
                                                 Nurse Education, Practice and
                                                  Retention: Career Ladder.
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for KS..................................................................         22     $6,660,068.00
----------------------------------------------------------------------------------------------------------------
Kentucky.......................................  Academic Administrative Units in            1       $205,200.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          2        552,709.00
                                                 Advanced Education Nursing                  7        423,268.00
                                                  Traineeship.
                                                 Allied Health Projects............          2        482,037.00
                                                 Bioterrorism Training and                   1      1,078,164.00
                                                  Curriculum Development Program.
                                                 Faculty Development in Primary              1        413,767.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        414,560.00
                                                 Graduate Psychology Education               1        156,600.00
                                                  Programs.
                                                 Grants to States for Loan                   1          5,000.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         15,011.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          2        677,319.00
                                                 Health Education Training Centers.          1        347,864.00
                                                 Model State-Supported Area Health           1        660,704.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          1          4,091.00
                                                 Nurse Education, Practice and               2        428,527.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice, and              1        205,978.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nursing Workforce Diversity.......          2        579,751.00
                                                 Physician Assistant Training in             1        179,038.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        352,391.00
                                                  Care.
                                                 Quentin N. Burdick Program for              1        348,035.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           1        495,795.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          2        513,472.00
                                                 Scholarships for Disadvantaged              3        138,656.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for KY..................................................................         37     $8,677,937.00
----------------------------------------------------------------------------------------------------------------
Louisiana......................................  Advanced Education Nursing Grants.          1       $179,541.00
                                                 Advanced Education Nursing                  7        316,796.00
                                                  Traineeship.                               1        105,403.00
                                                 Allied Health Projects............          1      2,280,000.00
                                                 Center of Excellence..............          2        553,022.00
                                                 Faculty Development in Primary              1        275,000.00
                                                  Care.                                      1        486,974.00
                                                 Grants to States for Loan                   2        330,352.00
                                                  Repayment.                                 1         38,057.00
                                                 Health Careers Opportunity Program          2        563,618.00
                                                 Model State-Supported Area Health           1         97,315.00
                                                  Education Centers.                         1        178,425.00
                                                 Nurse Anesthetist Traineeships....          1        114,360.00
                                                 Nursing Workforce Diversity.......          1        381,308.00
                                                 Pathways to Health Professions....          1        386,573.00
                                                 Pre-Doctoral Training in Primary            1         48,183.00
                                                  Care.                                      5      1,286,012.00
                                                 Public Health Traineeship.........
                                                 Public Health Training Centers....
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for LA..................................................................         30     $7,620,939.00
----------------------------------------------------------------------------------------------------------------
Maine..........................................  Advanced Education Nursing                  3       $107,350.00
                                                  Traineeship.                               1        198,628.00
                                                 Geriatric Education Centers.......          1         89,375.00
                                                 Grants to State for Loan Repayment          1        247,764.00
                                                 Model State-Supported Area Health           1          7,752.00
                                                  Education Centers.                         1        257,000.00
                                                 Nurse Anesthetist Traineeships....          1         89,119.00
                                                 Nurse Education Practice and                1          6,748.00
                                                  Retention.
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Scholarships for Disadvantaged
                                                  Student.
----------------------------------------------------------------------------------------------------------------
    Totals for ME..................................................................         10     $1,003,736.00
----------------------------------------------------------------------------------------------------------------
Maryland.......................................  Advanced Education Nursing Grants.          1       $598,579.00
                                                 Advanced Education Nursing                  3        322,336.00
                                                  Traineeship.
                                                 Allied Health Projects............          3        469,331.00
                                                 Comprehensive Geriatric Education           1        174,216.00
                                                  Program.
                                                 Faculty Development in Primary              1      1,676,458.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        162,000.00
                                                 Geriatric Training Program for              1        326,846.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Grants to States for Loan                   1        200,000.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          1        499,524.00
                                                 Model State-Supported Area Health           1        247,761.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        633,140.00
                                                 Nurse Anesthetist Traineeships....          1            431.00
                                                 Nurse Education, Practice and               1        265,224.00
                                                  Retention: Career Ladder.
                                                 Nursing Workforce Diversity.......          1        396,876.00
                                                 Other Health Professions Programs           2        540,134.00
                                                  (Earmarks).
                                                 Preventive Medicine Residencies...          1        523,943.00
                                                 Public Health Traineeship.........          1        126,619.00
                                                 Public Health Training Centers....          1        295,906.00
                                                 Quentin N. Burdick Program for              1        243,729.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care          1        208,209.00
                                                 Scholarships for Disadvantaged              3        676,259.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MD..................................................................         28     $8,587,521.00
----------------------------------------------------------------------------------------------------------------
Massachusetts..................................  Academic Administrative Units in            2       $829,520.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          2        889,640.00
                                                 Advanced Education Nursing                  7        563,244.00
                                                  Traineeships.
                                                 Dental Public Health Residency              1        133,299.00
                                                  Training Grants.
                                                 Faculty Development in Primary              2      1,184,454.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        397,949.00
                                                 Geriatric Training Program for              1      1,174,994.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Psychology Education               1        243,251.00
                                                  Programs.
                                                 Grants to States for Loan                   1        140,220.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         35,715.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          2        608,509.00
                                                 Model State-Supported Area Health           1        495,528.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          2      2,074,241.00
                                                 Nurse Anesthetist Traineeships....          2         23,844.00
                                                 Nurse Education, Practice and               1        180,587.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        270,000.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nurse Workforce Diversity.........          3        750,863.00
                                                 Pre-Doctoral Training in Primary            2        520,846.00
                                                  Care.
                                                 Public Health Traineeship.........          3        143,917.00
                                                 Public Health Training Centers....          1        331,450.00
                                                 Residency Training in General and           3        507,356.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          1        358,057.00
                                                 Scholarships for Disadvantaged              5        840,379.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
Totals for MA......................................................................         46    $12,697,863.00
----------------------------------------------------------------------------------------------------------------
Michigan.......................................  Academic Administrative Units in            3     $1,019,822.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1        246,468.00
                                                 Advanced Education Nursing                  7        366,576.00
                                                  Traineeship.
                                                 Basic/Core Area Health Education            1      1,187,445.00
                                                  Centers.
                                                 Bioterrorism Training and                   1        100,000.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        801,812.00
                                                 Comprehensive Geriatric Education           2        206,343.00
                                                  Program.
                                                 Faculty Development in Primary              1        534,556.00
                                                  Care.
                                                 Geriatric Education Centers.......          1       $323,798.00
                                                 Grants to States for Loan                   1        620,822.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          3      2,513,183.00
                                                 Nurse Anesthetist Traineeship.....          3         83,745.00
                                                 Nurse Education Practice and                2        352,530.00
                                                  Retention.
                                                 Nurse Education Practice and                1        241,479.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        239,569.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nursing Workforce Diversity.......          3        618,800.00
                                                 Pre-Doctoral Training in Primary            1        434,375.00
                                                  Care.
                                                 Public Health Traineeship.........          1        122,421.00
                                                 Public Health Training Centers....          1        403,161.00
                                                 Scholarships for Disadvantaged              6        729,886.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MI..................................................................         41    $11,146,791.00
----------------------------------------------------------------------------------------------------------------
Minnesota......................................    ................................          2       $637,167.00
                                                 Advanced Education Nursing Grants.          2        562,131.00
                                                 Advanced Education Nursing                  5        252,744.00
                                                  Traineeship.
                                                 Basic/Core Area Health Education            1        700,767.00
                                                  Centers.
                                                 Bioterrorism Training and                   1        878,251.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        492,077.00
                                                 Chiropractic Demonstration                  1        938,256.00
                                                  Projects.
                                                 Faculty Development in Primary              1        742,300.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        360,000.00
                                                 Grants to States for Loan                   1         82,500.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         27,951.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          1        358,294.00
                                                 Nurse Anesthetist Traineeships....          2         34,670.00
                                                 Nurse Education Practice and                1        143,357.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        174,488.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Other Health Professions Programs           2        437,020.00
                                                  (Earmarks).
                                                 Pre-Doctoral Training in Primary            1         97,200.00
                                                  Care.
                                                 Public Health Traineeship.........          1         54,409.00
                                                 Public Health Training Centers....          1        353,111.00
                                                 Scholarships for Disadvantaged              1         64,210.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MN..................................................................         28     $7,390,903.00
----------------------------------------------------------------------------------------------------------------
Mississippi....................................  Advanced Education Nursing                  5       $214,871.00
                                                  Traineeship.
                                                 Basic/Core Area Health Education            1        884,095.00
                                                  Centers.
                                                 Nurse Education, Practice and               1        232,056.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Pre-Doctoral Training in Primary            1        147,333.00
                                                  Care.
                                                 Public Health Traineeship.........          1          9,572.00
                                                 Residency Training in General and           1        110,569.00
                                                  Pediatric Dentistry.
                                                 Scholarships for Disadvantaged              3      1,398,847.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MS..................................................................         13     $2,997,343.00
----------------------------------------------------------------------------------------------------------------
Missouri.......................................  Academic Administrative Units in            2       $340,582.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          2        407,317.00
                                                 Advanced Education Nursing                  8        401,062.00
                                                  Traineeship.
                                                 Basic/Core Area Health Education            1        122,863.00
                                                  Centers.
                                                 Bioterrorism Training and                   1        193,181.00
                                                  Curriculum Development Program.
                                                 Comprehensive Geriatric Education           1         50,000.00
                                                  Program.
                                                 Faculty Development in Primary              1        475,125.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        432,000.00
                                                 Graduate Psychology Education               2        326,125.00
                                                  Programs.
                                                 Grants to States for Loan                   1        149,105.00
                                                  Repayment.
                                                 Health Administration Traineeships          2         51,243.00
                                                  and Special Projects.
                                                 Model State-Supported Area Health           2        541,441.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          2         28,367.00
                                                 Nurse Education Practice and                1        250,442.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        191,052.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nursing Workforce Diversity.......          2        399,943.00
                                                 Physician Assistant Training in             1        191,041.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        135,000.00
                                                  Care.
                                                 Public Health Traineeship.........          1         11,419.00
                                                 Public Health Training Centers....          1        232,284.00
                                                 Residency Training in Primary Care          3        475,176.00
                                                 Scholarships for Disadvantaged              3        252,532.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MO..................................................................         40     $5,657,300.00
----------------------------------------------------------------------------------------------------------------
Montana........................................  Advanced Education Nursing Grants.          1       $280,129.00
                                                 Advanced Education Nursing                  1         27,152.00
                                                  Traineeship.                               1      1,447,404.00
                                                 Bioterrorism Training and                   1         50,632.00
                                                  Curriculum Development Program.            1        344,017.00
                                                 Centers of Excellence.............          1        983,517.00
                                                 Geriatric Education Centers.......          1        296,470.00
                                                 Health Careers Opportunity Program          1         56,700.00
                                                 Nursing Workforce Diversity.......          3        595,238.00
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for MT..................................................................         11     $4,081,259.00
----------------------------------------------------------------------------------------------------------------
Nebraska.......................................  Academic Administrative Units in            1        $74,414.00
                                                  Primary Care.                              1       $262,792.00
                                                 Advanced Education Nursing Grants.          1        143,890.00
                                                 Advanced Education Nursing                  1        308,582.00
                                                  Traineeship.                               1      1,965,151.00
                                                 Allied Health Projects............          1        200,000.00
                                                 Basic/Core Area Health Education            1        530,014.00
                                                  Centers.                                   1        428,090.00
                                                 Bioterrorism Training and                   1        160,316.00
                                                  Curriculum Development Program.            1        482,478.00
                                                 Centers of Excellence.............          1          9,784.00
                                                 Geriatric Education Centers.......          1        388,052.00
                                                 Graduate Psychology Education               1        225,978.00
                                                  Programs.                                  1         77,812.00
                                                 Health Careers Opportunity Program          1        203,298.00
                                                 Nurse Anesthetist Traineeships....          1         74,785.00
                                                 Nurse Education Practice and
                                                  Retention.
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care
----------------------------------------------------------------------------------------------------------------
    Totals for NE..................................................................         16     $5,535,436.00
----------------------------------------------------------------------------------------------------------------
Nevada.........................................  Advanced Education Nursing Grants.          1        $79,105.00
                                                 Advanced Education Nursing                  2         51,884.00
                                                  Traineeship.                               1        871,128.00
                                                 Bioterrorism Training and                   1        216,000.00
                                                  Curriculum Development Program.            1          5,000.00
                                                 Geriatric Education Centers.......          1        165,174.00
                                                 Grants to States for Loan                   1        982,065.00
                                                  Repayment.                                 1        270,000.00
                                                 Model State-Supported Area Health           2         76,649.00
                                                  Education Centers.
                                                 Other Health Professions Programs
                                                  (Earmarks).
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for NV..................................................................  .........     $2,717,005.00
----------------------------------------------------------------------------------------------------------------
New Hampshire..................................  Academic Administrative Units in            1       $272,941.00
                                                  Primary Care.
                                                 Advanced Education Nursing                  1         54,443.00
                                                  Traineeship.
                                                 Faculty Development in Primary              2        127,715.00
                                                  Care.
                                                 Grants to States for Loan                   1          5,000.00
                                                  Repayment.
                                                 Model State-Supported Area Health           1        165,176.00
                                                  Education Centers.
                                                 Nurse Education, Practice and               1        132,458.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Pre-Doctoral Training in Primary            1        276,754.00
                                                  Care.
                                                 Residency Training in Primary Care          1        179,280.00
----------------------------------------------------------------------------------------------------------------
    Totals for NH..................................................................  .........     $1,213,767.00
----------------------------------------------------------------------------------------------------------------
New Jersey.....................................  Academic Administrative Units in            3       $782,052.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          4      1,272,337.00
                                                 Advanced Education Nursing                  9        359,848.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        218,172.00
                                                 Bioterrorism Training and                   1      1,428,590.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        608,065.00
                                                 Comprehensive Geriatric Education           1         49,990.00
                                                  Program.
                                                 Faculty Development in Primary              1        348,019.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        431,805.00
                                                 Geriatric Training Program for              1        371,737.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Psychology Education               1         96,615.00
                                                  Programs.
                                                 Grants to States for Loan                   1         33,247.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          3      1,092,069.00
                                                 Model State-Supported Area Health           1        247,761.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        269,927.00
                                                 Nurse Anesthetist Traineeships....          1         22,984.00
                                                 Nurse Education Practice and                1        199,367.00
                                                  Retention.
                                                 Nurse Education Practice and                2        757,609.00
                                                  Retention: Career Ladder.
                                                 Other Health Professions Programs           1         73,655.00
                                                  (Earmarks).
                                                 Pre-Doctoral Training in Primary            3        687,374.00
                                                  Care.
                                                 Public Health Traineeship.........          1         16,793.00
                                                 Residency Training in Primary Care          2        554,800.00
                                                 Scholarships for Disadvantaged              4      1,301,854.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for NJ..................................................................  .........    $11,219,670.00
----------------------------------------------------------------------------------------------------------------
New Mexico.....................................  Academic Administrative Units in            1       $266,673.00
                                                  Primary Care.                              1        362,504.00
                                                 Advanced Education Nursing Grants.          2         91,727.00
                                                 Advanced Education Nursing                  1      1,491,550.00
                                                  Traineeship.                               1        632,987.00
                                                 Bioterrorism Training and                   1        323,917.00
                                                  Curriculum Development Program.            1        140,775.00
                                                 Centers of Excellence.............          1         87,044.00
                                                 Geriatric Education Centers.......          1        484,573.00
                                                 Graduate Psychology Education               1        100,000.00
                                                  Programs.                                  1        165,174.00
                                                 Grants to States for Loan                   1        193,176.00
                                                  Repayment.                                 1        342,746.00
                                                 Health Careers Opportunity Program          1        151,661.00
                                                 Health Education Training Centers.          1        205,988.00
                                                 Model State-Supported Area Health           1        339,742.00
                                                  Education Center.                          1        243,102.00
                                                 Nurse Education Practice and                1        181,354.00
                                                  Retention.                                 2        989,635.00
                                                 Nurse Education Practice and
                                                  Retention: Career Ladder.
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for NM..................................................................  .........     $6,796,328.00
----------------------------------------------------------------------------------------------------------------
New York.......................................  Academic Administrative Units in            5     $1,318,963.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          4      2,201,758.00
                                                 Advanced Education Nursing                 19      1,304,242.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        153,062.00
                                                 Basic/Core Area Health Education            1      2,582,605.00
                                                  Centers.
                                                 Bioterrorism Training and                   1      1,245,076.00
                                                  Curriculum Development Program.
                                                 Centers for Health Workforce......          1        250,000.00
                                                 Centers of Excellence.............          1        562,902.00
                                                 Comprehensive Geriatric Education           3        268,698.00
                                                  Program.
                                                 Dental Public Health Residency              1         59,665.00
                                                  Training Grants.
                                                 Faculty Development in Primary              4      2,957,147.00
                                                  Care.
                                                 Geriatric Education Centers.......          3      1,050,936.00
                                                 Geriatric Training Program for              2        888,539.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Geropsychology Education           2       418, 586.00
                                                  Program.
                                                 Graduate Psychology Education               1        237,375.00
                                                  Programs.
                                                 Health Administration Traineeships          2        124,950.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          5      1,863,134.00
                                                 NRSA for Primary Medical Care.....          2        464,078.00
                                                 Nurse Anesthetist Traineeships....          3         49,808.00
                                                 Nurse Education Practice and                3      1,573,304.00
                                                  Retention.
                                                 Nurse Education Practice and                1        297,161.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        500,712.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               1        610,322.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          3      1,311,236.00
                                                 Other Health Professions Programs           3        534,243.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             3        778,929.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            4        961,643.00
                                                  Care.
                                                 Preventive Medicine Residencies...          1        266,049.00
                                                 Public Health Traineeship.........          2        119,231.00
                                                 Public Health Training Centers....          1        355,935.00
                                                 Quentin N. Burdick Program for              1        313,528.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           5      1,644,383.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          8      2,021,474.00
                                                 Scholarships for Disadvantaged             12      4,365,152.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for NY...................................................................  .........    $33,654,853.00
----------------------------------------------------------------------------------------------------------------
North Carolina.................................  Academic Administrative Units in            2       $519,052.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          4      1,405,683.00
                                                 Advanced Education Nursing                  6        447,223.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        124,145.00
                                                 Bioterrorism Training and                   1        197,334.00
                                                  Curriculum Development Program.
                                                 Centers for Health Workforce......          1        250,000.00
                                                 Comprehensive Geriatric Education           3        610,750.00
                                                  Program.
                                                 Dental Public Health Residency              1              1.00
                                                  Training Grants.
                                                 Faculty Development in Primary              1        502,421.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        148,310.00
                                                 Geriatric Training Program for              1        541,559.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Health Careers Opportunity Program          4      1,714,486.00
                                                 Model State-Supported Area Health           1        743,292.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        357,042.00
                                                 Nurse Anesthetist Traineeships....          4         63,561.00
                                                 Nurse Education Practice and                2        513,026.00
                                                  Retention.
                                                 Nurse Education Practice and                2        598,192.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nursing Workforce Diversity.......          3        578,692.00
                                                 Other Health Professions Programs           1        343,723.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             2        422,615.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            3        498,903.00
                                                  Care.
                                                 Public Health Traineeship.........          1        129,474.00
                                                 Public Health Training Centers....          1        381,832.00
                                                 Quentin N. Burdick Program for              1        419,937.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           1        133,826.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          3        420,477.00
                                                 Scholarships for Disadvantaged              5      1,204,263.00
                                                  Students.
                                                 Technical and Non Financial                 1        190,750.00
                                                  Assistance.
----------------------------------------------------------------------------------------------------------------
    Total for NC...................................................................  .........    $13,460,569.00
----------------------------------------------------------------------------------------------------------------
North Dakota...................................  Advanced Education Nursing Grants.          1       $462,209.00
                                                 Advanced Education Nursing                  2         54,342.00
                                                  Traineeship.                               1        427,695.00
                                                 Geriatric Education Centers.......          1        224,344.00
                                                 Graduate Psychology Education               1         20,000.00
                                                  Programs.                                  2        898,134.00
                                                 Grants to States for Loan                   1          9,138.00
                                                  Repayment.                                 1        239,760.00
                                                 Health Careers Opportunity Program          1        132,952.00
                                                 Nurse Anesthetist Traineeships....          1        106,880.00
                                                 Nursing Workforce Diversity.......          1         48,553.00
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for ND...................................................................  .........     $2,624,007.00
----------------------------------------------------------------------------------------------------------------
Ohio...........................................  Academic Administrative Units in            5     $1,351,061.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          4      1,159,267.00
                                                 Advanced Education Nursing                 10        624,990.00
                                                  Traineeship.
                                                 Allied Health Projects............          2        229,416.00
                                                 Centers of Excellence.............          1        533,684.00
                                                 Comprehensive Geriatric Education           1        197,315.00
                                                  Program.
                                                 Faculty Development in Primary              3        660,179.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        421,488.00
                                                 Grants to States for Loan                   1          5,000.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         31,315.00
                                                  and Special Projects.
                                                 Model State-Supported Area Health           1        660,696.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          2        389,854.00
                                                 Nurse Anesthetist Traineeships....          2         43,226.00
                                                 Nurse Education Practice and                3        533,505.00
                                                  Retention.
                                                 Nurse Education Practice and                1        845,810.00
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and               1        293,835.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          1        341,990.00
                                                 Other Health Professions Programs           1         98,206.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             5        119,303.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        834,427.00
                                                  Care.
                                                 Public Health Traineeship.........          1         10,748.00
                                                 Quentin N. Burdick Program for              1        195,277.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           3        495,223.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          3        630,971.00
                                                 Scholarships for Disadvantaged              9      1,761,118.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for OH...................................................................  .........    $13,221,091.00
----------------------------------------------------------------------------------------------------------------
Oklahoma.......................................  Academic Administrative Units in            1       $473,128.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1        242,901.00
                                                 Advanced Education Nursing                  1         79,687.00
                                                  Traineeship.
                                                 Centers of Excellence.............          1        520,170.00
                                                 Geriatric Education Centers.......          1        244,194.00
                                                 Grants to States for Loan                   1                 -
                                                  Repayment.
                                                 Health Careers Opportunity Program          1        482,170.00
                                                 Model State-Supported Area Health           1        330,348.00
                                                  Education Centers.
                                                 Nurse Education Practice and                2        468,603.00
                                                  Retention.
                                                 Nurse Education Practice and                2        388,498.00
                                                  Retention: Career Ladder.
                                                 Nursing Workforce Diversity.......          2        490,176.00
                                                 Public Health Traineeship.........          1         38,624.00
                                                 Residency Training in Primary Care          1        215,367.00
                                                 Scholarships for Disadvantaged              5      1,184,251.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for OK..................................................................  .........     $5,158,117.00
----------------------------------------------------------------------------------------------------------------
Oregon.........................................  Academic Administrative Units in            1       $147,464.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1      1,209,024.00
                                                 Advanced Education Nursing                  1        117,723.00
                                                  Traineeship.
                                                 Faculty Development in Primary              1        154,585.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        412,564.00
                                                 Health Careers Opportunity Program          2        684,540.00
                                                 Model State-Supported Area Health           1        412,935.00
                                                  Education Centers.
                                                 Nurse Education Practice and                1        192,207.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        269,207.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               1        210,568.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          2        412,043.00
                                                 Pre-Doctoral Training in Primary            1        121,495.00
                                                  Care.
                                                 Residency Training in Primary Care          1        376,544.00
                                                 Scholarships for Disadvantaged              1        123,833.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for OR..................................................................  .........     $4,845,441.00
----------------------------------------------------------------------------------------------------------------
Pennsylvania...................................  Academic Administrative Units in            1       $172,800.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          5      1,560,248.00
                                                 Advanced Education Nursing                 15        846,782.00
                                                  Traineeship.
                                                 Allied Health Projects............          2       349, 885.00
                                                 Bioterrorism Training and                   1        135,119.00
                                                  Curriculum Development Program.
                                                 Centers of Excellence.............          1        877,217.00
                                                 Comprehensive Geriatric Education           2        207,563.00
                                                  Program.
                                                 Faculty Development in Primary              3      1,684,192.00
                                                  Care.
                                                 Geriatric Education Centers.......          2      1,091,624.00
                                                 Geriatric Training Program for              1       418, 070.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Psychology Education               1        124,788.00
                                                  Programs.
                                                 Grants to States for Loan                   1        121,384.00
                                                  Repayment.
                                                 Health Administration Traineeships          4        151,090.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          2        555,529.00
                                                 Model State-Supported Area Health           1        660,696.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        426,441.00
                                                 Nurse Anesthetist Traineeships....          6        187,179.00
                                                 Nursing Workforce Diversity.......          1        193,947.00
                                                 Other Health Professions Programs           2         73,657.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             1        128,248.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            3        882,254.00
                                                  Care.
                                                 Public Health Traineeship.........          1         17,297.00
                                                 Public Health Training Centers....          1        301,375.00
                                                 Residency Training in General and           1         75,748.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          4        534,541.00
                                                 Scholarships for Disadvantaged              5      2,456,271.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for PA..................................................................  .........    $14,233,946.00
----------------------------------------------------------------------------------------------------------------
Puerto Rico....................................  Advanced Education Nursing Grants.          1       $307,120.00
                                                 Advanced Education Nursing                  4        105,816.00
                                                  Traineeship.                               1      1,281,731.00
                                                 Centers of Excellence.............          1        157,529.00
                                                 Faculty Development in Primary              1        180,000.00
                                                  Care.                                      2         48,551.00
                                                 Geriatric Education Centers.......          1        242,118.00
                                                 Nurse Anesthetist Traineeships....          1        343,723.00
                                                 Nursing Workforce Diversity.......          1        200,619.00
                                                 Other Health Professions Programs           1         28,716.00
                                                  (Earmarks).                                1        464,770.00
                                                 Pre-Doctoral Training in Primary            1        129,600.00
                                                  Care.                                      7      4,034,604.00
                                                 Public Health Traineeship.........
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for PR...................................................................  .........     $7,524,897.00
----------------------------------------------------------------------------------------------------------------
Rhode Island...................................  Academic Administrative Units in            1       $169,582.00
                                                  Primary Care.                              1        249,878.00
                                                 Advanced Education Nursing Grants.          1         53,249.00
                                                 Advanced Education Nursing                  1        747,768.00
                                                  Traineeship.                               1        198,222.00
                                                 Basic/Core Area Health Education            1        431,998.00
                                                  Centers.                                   1         31,075.00
                                                 Faculty Development in Primary              1        132,579.00
                                                  Care.                                      1        191,488.00
                                                 Geriatric Education Centers.......          2        248,400.00
                                                 Grants to States for Loan                   1        142,421.00
                                                  Repayment.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Residency Training in General and
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for RI...................................................................  .........     $2,596,660.00
----------------------------------------------------------------------------------------------------------------
South Carolina.................................  Academic Administrative Units in            1       $427,262.00
                                                  Primary Care.                              1        211,955.00
                                                 Advanced Education Nursing Grants.          3        164,732.00
                                                 Advanced Education Nursing                  1        214,390.00
                                                  Traineeship.                               1      1,331,869.00
                                                 Allied Health Projects............          1         50,000.00
                                                 Bioterrorism Training and                   1        599,640.00
                                                  Curriculum Development Program.            1        303,188.00
                                                 Comprehensive Geriatric Education           1        140,673.00
                                                  Program.                                   1          5,000.00
                                                 Faculty Development in Primary              1         36,232.00
                                                  Care.                                      1        330,352.00
                                                 Geriatric Education Centers.......          2         33,349.00
                                                 Graduate Psychology Education               2        836,031.00
                                                  Programs.                                  2        673,063.00
                                                 Grants to States for Loan                   1        161,973.00
                                                  Repayment.                                 1        176,267.00
                                                 Health Administration Traineeships          1         37,784.00
                                                  and Special Projects.                      1        358,396.00
                                                 Model State-Supported Area Health           1        177,150.00
                                                  Education Centers.                         2         42,089.00
                                                 Nurse Anesthetist Traineeships....
                                                 Nurse Education Practice and
                                                  Retention.
                                                 Nursing Workforce Diversity.......
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Public Health Traineeship.........
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for SC..................................................................  .........     $6,311,395.00
----------------------------------------------------------------------------------------------------------------
South Dakota...................................  Advanced Education Nursing Grants.          1       $266,972.00
                                                 Advanced Education Nursing                  1         37,626.00
                                                  Traineeship.                               1        117,675.00
                                                 Allied Health Projects............          1        269,997.00
                                                 Graduate Geropsychology Education           1         20,000.00
                                                  Program.                                   2        388,716.00
                                                 Grants to States for Loan                   1        137,262.00
                                                  Repayment.                                 1        336,138.00
                                                 Nurse Education Practice and                4        399,133.00
                                                  Retention: Career Ladder.
                                                 Physician Assistant Training in
                                                  Primary Care.
                                                 Quentin N. Burdick Program for
                                                  Rural Interdisciplinary Training.
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for SD...................................................................  .........     $1,973,513.00
----------------------------------------------------------------------------------------------------------------
Tennessee......................................  Academic Administrative Units in            2       $499,010.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          3      2,058,123.00
                                                 Advanced Education Nursing                  7        481,091.00
                                                  Traineeship.
                                                 Centers of Excellence.............          2      8,148,777.00
                                                 Faculty Development in Primary              1        112,687.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        423,968.00
                                                 Health Careers Opportunity Program          3      2,004,969.00
                                                 Minority Faculty Fellowships......          1         53,313.00
                                                 Model State-Supported Area Health           1        165,176.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          4         68,823.00
                                                 Nurse Education Practice and                2        627,557.00
                                                  Retention.
                                                 Nurse Education Practice and                1        230,518.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Other Health Professions Programs           1        147,310.00
                                                  (Earmarks).
                                                 Quentin N. Burdick Program for              1        242,895.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in Primary Care          3        781,175.00
                                                 Scholarships for Disadvantaged              4      1,969,514.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for TN..................................................................  .........    $18,014,906.00
----------------------------------------------------------------------------------------------------------------
Texas..........................................  Academic Administrative Units in            3       $545,729.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          3      1,172,657.00
                                                 Advanced Education Nursing                 16      1,031,130.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        167,824.00
                                                 ASPH Cooperative Agreement........          1         60,000.00
                                                 Basic/Core Area Health Education            1        807,596.00
                                                  Centers.
                                                 Bioterrorism Training and                   1      1,500,000.00
                                                  Curriculum Development Program.
                                                 Center for Health Workforce.......          1        250,000.00
                                                 Centers of Excellence.............          5      4,194,324.00
                                                 Comprehensive Geriatric Education           2        362,914.00
                                                  Program.
                                                 Dental Public Health Residency              1        101,292.00
                                                  Training Grants.
                                                 Faculty Development in Primary              3      1,200,020.00
                                                  Care.
                                                 Geriatric Education Centers.......          3        860,762.00
                                                 Geriatric Training Program for              1        650,544.00
                                                  Physicians, Dentists, and
                                                  Behavioral and Mental Health
                                                  Professions.
                                                 Graduate Psychology Education               1        213,515.00
                                                  Programs.
                                                 Grants to States for Loan                   1        213,600.00
                                                  Repayment.
                                                 Health Administration Traineeships          4        188,823.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          3     1,104,719.000
                                                 Health Education and Training               1         456,671.0
                                                  Centers.
                                                 Model State-Supported Area Health           2      1,156,218.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        462,116.00
                                                 Nurse Anesthetist Traineeships....          2        103,766.00
                                                 Nurse Education Practice and                5      1,611,725.00
                                                  Retention.
                                                 Nurse Education Practice and                4        904,986.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                4        942,720.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               2        312,250.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          6      1,605,710.00
                                                 Other Health Professions Programs           2        294,621.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             4        643,693.00
                                                  Primary Care.
                                                 Podiatric Residency Training in             1        280,314.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            4        635,732.00
                                                  Care.
                                                 Public Health Traineeship.........          3         94,545.00
                                                 Public Health Training Centers....          1        313,213.00
                                                 Residency Training in Primary Care          5      1,251,632.00
                                                 Scholarships for Disadvantaged             12      2,446,879.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for TX..................................................................  .........    $28,145,240.00
----------------------------------------------------------------------------------------------------------------
US Virgin Islands..............................  Health Careers Opportunity Program          1       $314,347.00
                                                 Nursing Workforce Diversity.......          1        186,657.00
                                                 Scholarships for Disadvantaged              1         72,874.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for VI..................................................................  .........       $573,878.00
----------------------------------------------------------------------------------------------------------------
Utah...........................................  Academic Administrative Units in            1       $247,320.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1        264,483.00
                                                 Advanced Education Nursing                  1        111,413.00
                                                  Traineeship.
                                                 Comprehensive Geriatric Education           1        152,065.00
                                                  Program.
                                                 Faculty Development in Primary              1        415,995.00
                                                  Care.
                                                 Grants to States for Loan                   1          5,000.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          1        276,374.00
                                                 Model State-Supported Area Health           1        247,761.00
                                                  Education Centers.
                                                 Nurse Education, Practice and               1        194,047.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          1        267,904.00
                                                 Physician Assistant Training in             1        162,379.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        119,988.00
                                                  Care.
----------------------------------------------------------------------------------------------------------------
    Totals for UT..................................................................  .........     $2,464,729.00
----------------------------------------------------------------------------------------------------------------
Vermont........................................  Academic Administrative Units in            1       $199,800.00
                                                  Primary Care.
                                                 Advanced Education Nursing                  1         13,475.00
                                                  Traineeship.
                                                 Model State-Supported Area Health           1        247,761.00
                                                  Education Centers.
                                                 Nurse Education Practice and                1        202,790.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1         77,601.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               1        219,812.00
                                                  Retention: Internship and
                                                  Residency Program.
                                                 Pre-Doctoral Training in Primary            1        111,255.00
                                                  Care.
                                                 Residency Training in Primary Care          1        149,938.00
----------------------------------------------------------------------------------------------------------------
    Totals for VT..................................................................  .........     $1,222,432.00
----------------------------------------------------------------------------------------------------------------
Virginia.......................................  Academic Administrative Units in            2       $468,062.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          5      2,330,788.00
                                                 Advanced Education Nursing                  9        522,847.00
                                                  Traineeship.
                                                 Allied Health Projects............          1        146,900.00
                                                 Comprehensive Geriatric Education           2        267,296.00
                                                  Program.
                                                 Faculty Development in Primary              1        425,766.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        414,851.00
                                                 Grants to States for Loan                   1         60,624.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         55,229.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          1        343,718.00
                                                 Model State-Supported Area Health           1        660,696.00
                                                  Education Centers.
                                                 Nurse Anesthetist Traineeships....          2         41,934.00
                                                 Nurse Education Practice and                2        638,856.00
                                                  Retention.
                                                 Nurse Education Practice and                3        619,151.00
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        138,780.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Physician Assistant Training in             3        337,864.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            3        541,827.00
                                                  Care.
                                                 Residency Training in General and           1        251,937.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          1        147,961.00
                                                 Scholarships for Disadvantaged              4        737,836.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for VA..................................................................  .........     $9,230,683.00
----------------------------------------------------------------------------------------------------------------
Washington.....................................  Academic Administrative Units in            1       $154,152.00
                                                  Primary Care.
                                                 Advanced Education Nursing Grants.          1      1,927,303.00
                                                 Advanced Education Nursing                  4        325,887.00
                                                  Traineeship.
                                                 Bioterrorism Training and                   1        197,473.00
                                                  Curriculum Development Program.
                                                 Center for Health Workforce.......          1        250,000.00
                                                 Centers of Excellence.............          1        484,509.00
                                                 Faculty Development in Primary              1        178,556.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        215,998.00
                                                 Grants to States for Loan                   2        290,330.00
                                                  Repayment.
                                                 Health Administration Traineeships          1         14,286.00
                                                  and Special Projects.
                                                 Health Careers Opportunity Program          2        835,839.00
                                                 Health Education and Training               1        300,087.00
                                                  Centers.
                                                 Model State-Supported Area Health           1        495,522.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          1        467,252.00
                                                 Nurse Anesthetist Traineeships....          1          3,015.00
                                                 Nurse Education Practice and                2      1,106,008.00
                                                  Retention.
                                                 Nurse Education Practice and                1        189,813.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               2        423,232.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          2        489,873.00
                                                 Other Health Professions Programs           1        294,619.00
                                                  (Earmarks).
                                                 Pathways To Health Professions....          1         43,824.00
                                                 Physician Assistant Training in             1        357,422.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        170,439.00
                                                  Care.
                                                 Public Health Traineeship.........          1         46,013.00
                                                 Public Health Training Centers....          1        433,353.00
                                                 Quentin N. Burdick Program for              1        312,429.00
                                                  Rural Interdisciplinary Training.
                                                 Residency Training in General and           2        432,492.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          1        107,829.00
                                                 Scholarships for Disadvantaged              3        288,495.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Total for WA...................................................................  .........    $10,836,050.00
----------------------------------------------------------------------------------------------------------------
West Virginia..................................  Academic Administrative Units in            1       $218,803.00
                                                  Primary Care.                              2         50,590.00
                                                 Advanced Education Nursing                  1        153,622.00
                                                  Traineeship.                               1        972,532.00
                                                 Allied Health Projects............          1        431,997.00
                                                 Basic/Core Area Health Education            1         76,121.00
                                                  Centers.                                   1        557,042.00
                                                 Geriatric Education Centers.......          1         15,382.00
                                                 Grants to States for Loan                   2        453,714.00
                                                  Repayment.                                 1        163,285.00
                                                 Health Careers Opportunity Program          1        313,000.00
                                                 Nurse Anesthetist Traineeships....          3         63,427.00
                                                 Nurse Education Practice and
                                                  Retention: Career Ladder.
                                                 Pre-Doctoral Training in Primary
                                                  Care.
                                                 Residency Training in Primary Care
                                                 Scholarships for Disadvantaged
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for WV..................................................................  .........     $3,469,515.00
----------------------------------------------------------------------------------------------------------------
Wisconsin......................................  Advanced Education Nursing Grants.          2       $742,759.00
                                                 Advanced Education Nursing                  8        349,691.00
                                                  Traineeship.
                                                 Comprehensive Geriatric Education           1         47,747.00
                                                  Program.
                                                 Faculty Development in Primary              2        780,677.00
                                                  Care.
                                                 Geriatric Education Centers.......          1        429,107.00
                                                 Grants to States for Loan                   1        149,602.00
                                                  Repayment.
                                                 Health Careers Opportunity Program          1      1,008,872.00
                                                 Health Education and Training               1        326,615.00
                                                  Centers.
                                                 Model State-Supported Area Health           1        330,615.00
                                                  Education Centers.
                                                 NRSA for Primary Medical Care.....          2        894,253.00
                                                 Nurse Anesthetist Traineeships....          1          6,984.00
                                                 Nurse Education Practice and                1                 -
                                                  Retention: Career Ladder.
                                                 Nurse Education Practice and                1        171,817.00
                                                  Retention: Enhancing Patient Care
                                                  Delivery Systems.
                                                 Nurse Education, Practice and               1        298,743.00
                                                  Retention: Internship and
                                                  Residency Programs.
                                                 Nursing Workforce Diversity.......          2        499,573.00
                                                 Other Health Professions Programs           1        441,929.00
                                                  (Earmarks).
                                                 Physician Assistant Training in             2        375,731.00
                                                  Primary Care.
                                                 Pre-Doctoral Training in Primary            1        129,104.00
                                                  Care.
                                                 Residency Training in General and           1          6,107.00
                                                  Pediatric Dentistry.
                                                 Residency Training in Primary Care          2        290,626.00
                                                 Scholarships for Disadvantaged              4        597,939.00
                                                  Students.
----------------------------------------------------------------------------------------------------------------
    Totals for WI..................................................................  .........      7,878,224.00
----------------------------------------------------------------------------------------------------------------
Wyoming........................................  Advanced Education Nursing Grants.          1       $190,232.00
                                                 Advanced Education Nursing                  1         42,503.00
                                                  Traineeship.                               1        113,514.00
                                                 Faculty Development in Primary              1        188,646.00
                                                  Care.                                      1        104,691.00
                                                 Nurse Education Practice and
                                                  Retention: Career Ladder.
                                                 Nurse Education, Practice and
                                                  Retention: Internship and
                                                  Residency Programs.
----------------------------------------------------------------------------------------------------------------
    Totals for WY..................................................................  .........       $639,586.00
----------------------------------------------------------------------------------------------------------------


                                       HRSA/Bureau of Primary Health Care
                              Grant Programs Totals by State for Fiscal Year 2005*
----------------------------------------------------------------------------------------------------------------
                                                                                         Financial     Number of
                     State                                  Program Name                Assistance       Grants
----------------------------------------------------------------------------------------------------------------
Alabama........................................  Community Health Center Program...       $30,799,978         14
Alabama........................................  Health Care for the Homeless......         1,772,088          2
Alabama........................................  Migrant Health Center and Migrant          1,273,815          3
                                                  Health Programs.
Alabama........................................  Public Housing Primary Care.......         1,324,707          3
Alabama........................................  Black Lung/Coal Miner Clinics                181,829          1
                                                  Program.
----------------------------------------------------------------------------------------------------------------
    Alabama Total..................................................................       $35,352,417         23
----------------------------------------------------------------------------------------------------------------
Alaska.........................................  Community Health Center Program...       $23,685,612         24
Alaska.........................................  Health Care for the Homeless......           904,779          2
----------------------------------------------------------------------------------------------------------------
    Alaska Total...................................................................       $24,590,391         26
----------------------------------------------------------------------------------------------------------------
American Samoa.................................  Community Health Center Program...          $493,210          1
----------------------------------------------------------------------------------------------------------------
    American Samoa Total...........................................................          $493,210          1
----------------------------------------------------------------------------------------------------------------
Arizona........................................  Community Health Center Program...       $26,419,514         13
Arizona........................................  Health Care for the Homeless......         3,115,376          2
Arizona........................................  Migrant Health Center and Migrant          1,939,524          3
                                                  Health Programs.
Arizona........................................  Healthy Communities Access Program           884,767          2
Arizona........................................  Integrated Services Development               99,200          1
                                                  Initiative.
Arizona........................................  Radiation Exposure Screening and             194,773          1
                                                  Education Program.
----------------------------------------------------------------------------------------------------------------
    Arizona Total..................................................................       $32,653,154         22
----------------------------------------------------------------------------------------------------------------
Arkansas.......................................  Community Health Center Program...       $21,866,808         12
Arkansas.......................................  Health Care for the Homeless......           263,126          1
----------------------------------------------------------------------------------------------------------------
    Arkansas Total.................................................................       $22,129,934         13
----------------------------------------------------------------------------------------------------------------
California.....................................  Community Health Center Program...      $109,136,136         82
California.....................................  Health Care for the Homeless......        23,018,935         24
California.....................................  Migrant Health Center and Migrant         27,811,485         21
                                                  Health Programs.
California.....................................  Public Housing Primary Care.......         3,337,576          7
California.....................................  Healthy Communities Access Program         9,239,206         13
California.....................................  Integrated Services Development              917,572          5
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    California Total...............................................................      $173,460,910        152
----------------------------------------------------------------------------------------------------------------
Colorado.......................................  Community Health Center Program...       $39,408,822         14
Colorado.......................................  Health Care for the Homeless......         3,744,450          4
Colorado.......................................  Migrant Health Center and Migrant          4,645,041          5
                                                  Health Programs.
Colorado.......................................  Public Housing Primary Care.......           568,038          1
Colorado.......................................  Black Lung/Coal Miner Clinics                392,993          1
                                                  Program.
Colorado.......................................  Healthy Communities Access Program         1,820,371          2
Colorado.......................................  Integrated Services Development              350,766          2
                                                  Initiative.
Colorado.......................................  Radiation Exposure Screening and             282,368          1
                                                  Education Program.
----------------------------------------------------------------------------------------------------------------
    Colorado Total.................................................................       $51,212,849         30
----------------------------------------------------------------------------------------------------------------
Connecticut....................................  Community Health Center Program...       $14,693,205         10
Connecticut....................................  Health Care for the Homeless......         2,617,700          6
Connecticut....................................  Public Housing Primary Care.......           630,643          2
Connecticut....................................  Healthy Communities Access Program         2,654,337          4
----------------------------------------------------------------------------------------------------------------
    Connecticut Total..............................................................       $20,595,885         22
----------------------------------------------------------------------------------------------------------------
Delaware.......................................  Community Health Center Program...        $3,486,614          3
Delaware.......................................  Health Care for the Homeless......           265,682          1
Delaware.......................................  Migrant Health Center and Migrant            529,133          1
                                                  Health Programs.
----------------------------------------------------------------------------------------------------------------
    Delaware Total.................................................................        $4,281,429          5
----------------------------------------------------------------------------------------------------------------
District of Columbia...........................  Community Health Center Program...        $4,792,720          3
District of Columbia...........................  Health Care for the Homeless......         2,877,226          1
District of Columbia...........................  Healthy Communities Access Program           474,347          1
----------------------------------------------------------------------------------------------------------------
    District of Columbia Total.....................................................        $8,144,293          5
----------------------------------------------------------------------------------------------------------------
Fed. States of Micronesia......................  Community Health Center Program...          $190,943          1
----------------------------------------------------------------------------------------------------------------
    Fed. States of Micronesia Total................................................          $190,943          1
----------------------------------------------------------------------------------------------------------------
Florida........................................  Community Health Center Program...       $57,339,148         33
Florida........................................  Health Care for the Homeless......         6,772,688          8
Florida........................................  Migrant Health Center and Migrant         12,545,368         12
                                                  Health Programs.
Florida........................................  Emergency Supplement for Florida           1,287,918          5
                                                  Hurricane Relief.
Florida........................................  Healthy Communities Access Program         6,118,649          7
Florida........................................  Integrated Services Development            1,529,797          3
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Florida Total..................................................................       $85,593,568         68
----------------------------------------------------------------------------------------------------------------
Georgia........................................  Community Health Center Program...       $27,173,453         21
Georgia........................................  Health Care for the Homeless......         2,131,145          2
Georgia........................................  Migrant Health Center and Migrant          2,222,309          1
                                                  Health Programs.
Georgia........................................  Public Housing Primary Care.......         1,189,337          2
Georgia........................................  Healthy Communities Access Program         2,883,106          4
----------------------------------------------------------------------------------------------------------------
    Georgia Total..................................................................       $35,599,350         30
----------------------------------------------------------------------------------------------------------------
Guam...........................................  Community Health Center Program...          $987,461          1
----------------------------------------------------------------------------------------------------------------
    Guam Total.....................................................................          $987,461          1
----------------------------------------------------------------------------------------------------------------
Hawaii.........................................  Community Health Center Program...        $8,765,592         10
Hawaii.........................................  Health Care for the Homeless......           488,678          1
Hawaii.........................................  Public Housing Primary Care.......           482,645          1
Hawaii.........................................  Native Hawaiian Health Care.......        12,738,145          8
----------------------------------------------------------------------------------------------------------------
    Hawaii Total...................................................................       $22,475,060         20
----------------------------------------------------------------------------------------------------------------
Idaho..........................................  Community Health Center Program...       $10,701,827          9
Idaho..........................................  Health Care for the Homeless......           617,453          1
Idaho..........................................  Migrant Health Center and Migrant          4,009,208          7
                                                  Health Programs.
Idaho..........................................  Healthy Communities Access Program           644,169          1
----------------------------------------------------------------------------------------------------------------
    Idaho Total....................................................................       $15,972,657         18
----------------------------------------------------------------------------------------------------------------
Illinois.......................................  Community Health Center Program...       $58,333,162         31
Illinois.......................................  Health Care for the Homeless......         4,810,089          3
Illinois.......................................  Migrant Health Center and Migrant          1,997,454          3
                                                  Health Programs.
Illinois.......................................  Public Housing Primary Care.......         1,704,311          3
Illinois.......................................  Black Lung/Coal Miner Clinics                973,531          2
                                                  Program.
Illinois.......................................  Healthy Communities Access Program         3,537,443          5
Illinois.......................................  Integrated Services Development            1,117,000          2
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Illinois Total.................................................................       $72,472,990         49
----------------------------------------------------------------------------------------------------------------
Indiana........................................  Community Health Center Program...       $12,765,336         13
Indiana........................................  Health Care for the Homeless......         1,556,938          3
Indiana........................................  Migrant Health Center and Migrant            870,011          1
                                                  Health Programs.
Indiana........................................  Public Housing Primary Care.......           415,555          1
Indiana........................................  Integrated Services Development              119,040          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Indiana Total..................................................................       $15,726,880         19
----------------------------------------------------------------------------------------------------------------
Iowa...........................................  Community Health Center Program...       $11,409,883          8
Iowa...........................................  Health Care for the Homeless......           902,648          3
Iowa...........................................  Migrant Health Center and Migrant            398,620          1
                                                  Health Programs.
Iowa...........................................  Integrated Services Development              106,640          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Iowa Total.....................................................................       $12,817,791         13
----------------------------------------------------------------------------------------------------------------
Kansas.........................................  Community Health Center Program...        $5,780,911          8
Kansas.........................................  Health Care for the Homeless......           521,859          1
Kansas.........................................  Migrant Health Center and Migrant            658,498          1
                                                  Health Programs.
Kansas.........................................  Healthy Communities Access Program           829,060          2
----------------------------------------------------------------------------------------------------------------
    Kansas Total...................................................................        $7,790,328         12
----------------------------------------------------------------------------------------------------------------
Kentucky.......................................  Community Health Center Program...       $17,765,545         11
Kentucky.......................................  Health Care for the Homeless......         2,420,468          4
Kentucky.......................................  Migrant Health Center and Migrant            923,154          1
                                                  Health Programs.
Kentucky.......................................  Black Lung/Coal Miner Clinics                776,034          2
                                                  Program.
Kentucky.......................................  Healthy Communities Access Program           975,841          1
----------------------------------------------------------------------------------------------------------------
    Kentucky Total.................................................................       $22,861,042         19
----------------------------------------------------------------------------------------------------------------
Louisiana......................................  Community Health Center Program...       $17,275,973         19
Louisiana......................................  Health Care for the Homeless......         1,719,774          2
Louisiana......................................  Public Housing Primary Care.......           485,090          1
Louisiana......................................  Healthy Communities Access Program         2,292,358          4
Louisiana......................................  Integrated Services Development              124,000          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Louisiana Total................................................................       $21,897,175         27
----------------------------------------------------------------------------------------------------------------
Maine..........................................  Community Health Center Program...        $9,598,807         13
Maine..........................................  Health Care for the Homeless......           723,656          2
Maine..........................................  Migrant Health Center and Migrant            464,887          1
                                                  Health Programs.
Maine..........................................  Public Housing Primary Care.......           155,000          1
Maine..........................................  Healthy Communities Access Program         1,553,369          2
Maine..........................................  Integrated Services Development              743,720          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Maine Total....................................................................       $13,239,439         20
----------------------------------------------------------------------------------------------------------------
Marshall Islands...............................  Community Health Center Program...          $483,977          1
----------------------------------------------------------------------------------------------------------------
    Marshall Islands Total.........................................................          $483,977          1
----------------------------------------------------------------------------------------------------------------
Maryland.......................................  Community Health Center Program...       $17,710,043         12
Maryland.......................................  Health Care for the Homeless......         1,625,446          1
Maryland.......................................  Migrant Health Center and Migrant            421,528          3
                                                  Health Programs.
Maryland.......................................  Healthy Communities Access Program           730,333          1
----------------------------------------------------------------------------------------------------------------
    Maryland Total.................................................................       $20,487,350         17
----------------------------------------------------------------------------------------------------------------
Massachusetts..................................  Community Health Center Program...       $36,878,460         28
Massachusetts..................................  Health Care for the Homeless......         4,144,181          5
Massachusetts..................................  Migrant Health Center and Migrant            399,512          1
                                                  Health Programs.
Massachusetts..................................  Public Housing Primary Care.......           992,839          2
Massachusetts..................................  Healthy Communities Access Program         1,925,882          3
Massachusetts..................................  Integrated Services Development              148,800          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Massachusetts Total............................................................       $44,489,674         40
----------------------------------------------------------------------------------------------------------------
Michigan.......................................  Community Health Center Program...       $30,192,857         22
Michigan.......................................  Health Care for the Homeless......         3,010,124          7
Michigan.......................................  Migrant Health Center and Migrant          5,122,167          4
                                                  Health Programs.
Michigan.......................................  Healthy Communities Access Program         3,796,124          6
----------------------------------------------------------------------------------------------------------------
    Michigan Total.................................................................       $42,121,272         39
----------------------------------------------------------------------------------------------------------------
Minnesota......................................  Community Health Center Program...       $10,327,731         10
Minnesota......................................  Health Care for the Homeless......         2,059,487          2
Minnesota......................................  Migrant Health Center and Migrant          1,954,526          1
                                                  Health Programs.
Minnesota......................................  Public Housing Primary Care.......           509,245          1
Minnesota......................................  Healthy Communities Access Program           659,680          1
Minnesota......................................  Integrated Services Development              404,736          2
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Minnesota Total................................................................       $15,915,405         17
----------------------------------------------------------------------------------------------------------------
Mississippi....................................  Community Health Center Program...       $35,063,785         22
Mississippi....................................  Health Care for the Homeless......           515,319          2
Mississippi....................................  Integrated Services Development               99,200          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Mississippi Total..............................................................       $35,678,304         25
----------------------------------------------------------------------------------------------------------------
Missouri.......................................  Community Health Center Program...       $31,793,163         17
Missouri.......................................  Health Care for the Homeless......         3,263,958          2
Missouri.......................................  Migrant Health Center and Migrant            353,687          1
                                                  Health Programs.
Missouri.......................................  Public Housing Primary Care.......           771,594          1
Missouri.......................................  Integrated Services Development              142,500          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Missouri Total.................................................................       $36,324,902         22
----------------------------------------------------------------------------------------------------------------
Montana........................................  Community Health Center Program...        $9,889,782         11
Montana........................................  Health Care for the Homeless......         1,538,295          1
Montana........................................  Migrant Health Center and Migrant          1,270,569          1
                                                  Health Programs.
Montana........................................  Healthy Communities Access Program         1,967,129          2
----------------------------------------------------------------------------------------------------------------
    Montana Total..................................................................       $14,665,775         15
----------------------------------------------------------------------------------------------------------------
Nebraska.......................................  Community Health Center Program...        $3,907,730          5
Nebraska.......................................  Health Care for the Homeless......           238,231          1
Nebraska.......................................  Migrant Health Center and Migrant            501,299          1
                                                  Health Programs.
Nebraska.......................................  Integrated Services Development              148,800          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Nebraska Total.................................................................        $4,796,060          8
----------------------------------------------------------------------------------------------------------------
Nevada.........................................  Community Health Center Program...        $6,605,030          2
Nevada.........................................  Health Care for the Homeless......         1,230,525          2
Nevada.........................................  Healthy Communities Access Program           745,395          1
Nevada.........................................  Radiation Exposure Screening and             220,000          1
                                                  Education Program.
----------------------------------------------------------------------------------------------------------------
    Nevada Total...................................................................        $8,800,950          6
----------------------------------------------------------------------------------------------------------------
New Hampshire..................................  Community Health Center Program...        $5,138,842          6
New Hampshire..................................  Health Care for the Homeless......           558,963          2
New Hampshire..................................  Healthy Communities Access Program           566,127          1
New Hampshire..................................  Integrated Services Development              237,894          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    New Hampshire Total............................................................        $6,501,826         10
----------------------------------------------------------------------------------------------------------------
New Jersey.....................................  Community Health Center Program...       $24,371,832         14
New Jersey.....................................  Health Care for the Homeless......         3,455,382          5
New Jersey.....................................  Migrant Health Center and Migrant            626,023          2
                                                  Health Programs.
----------------------------------------------------------------------------------------------------------------
    New Jersey Total...............................................................       $28,453,237         21
----------------------------------------------------------------------------------------------------------------
New Mexico.....................................  Community Health Center Program...       $28,073,870         13
New Mexico.....................................  Health Care for the Homeless......         2,387,301          2
New Mexico.....................................  Migrant Health Center and Migrant          1,786,503          2
                                                  Health Programs.
New Mexico.....................................  Black Lung/Coal Miner Clinics                270,936          1
                                                  Program.
New Mexico.....................................  Healthy Communities Access Program         1,473,622          2
New Mexico.....................................  Integrated Services Development              297,600          1
                                                  Initiative.
New Mexico.....................................  Radiation Exposure Screening and             429,919          2
                                                  Education Program.
----------------------------------------------------------------------------------------------------------------
    New Mexico Total...............................................................       $34,719,751         23
----------------------------------------------------------------------------------------------------------------
New York.......................................  Community Health Center Program...       $78,643,560         41
New York.......................................  Health Care for the Homeless......        10,281,355         13
New York.......................................  Migrant Health Center and Migrant          3,540,750          3
                                                  Health Programs.
New York.......................................  Public Housing Primary Care.......         1,519,924          3
New York.......................................  Healthy Communities Access Program         5,852,369          7
----------------------------------------------------------------------------------------------------------------
    New York Total.................................................................       $99,837,958         67
----------------------------------------------------------------------------------------------------------------
North Carolina.................................  Community Health Center Program...       $29,233,947         23
North Carolina.................................  Health Care for the Homeless......           748,825          3
North Carolina.................................  Migrant Health Center and Migrant          9,313,282          7
                                                  Health Programs.
North Carolina.................................  Healthy Communities Access Program         2,873,976          4
North Carolina.................................  Integrated Services Development              633,312          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    North Carolina Total...........................................................       $42,803,342         38
----------------------------------------------------------------------------------------------------------------
North Dakota...................................  Community Health Center Program...        $2,678,976          4
North Dakota...................................  Health Care for the Homeless......           321,223          1
North Dakota...................................  Healthy Communities Access Program           576,894          1
----------------------------------------------------------------------------------------------------------------
    North Dakota Total.............................................................        $3,577,093          6
----------------------------------------------------------------------------------------------------------------
Ohio...........................................  Community Health Center Program...       $33,043,646         21
Ohio...........................................  Health Care for the Homeless......         4,867,471          6
Ohio...........................................  Migrant Health Center and Migrant            829,458          1
                                                  Health Programs.
Ohio...........................................  Public Housing Primary Care.......         1,223,539          2
Ohio...........................................  Black Lung/Coal Miner Clinics                548,379          1
                                                  Program.
Ohio...........................................  Healthy Communities Access Program         1,307,407          2
Ohio...........................................  Integrated Services Development              297,600          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Ohio Total.....................................................................       $42,117,500         34
----------------------------------------------------------------------------------------------------------------
Oklahoma.......................................  Community Health Center Program...       $10,154,954         11
Oklahoma.......................................  Health Care for the Homeless......           783,350          2
Oklahoma.......................................  Migrant Health Center and Migrant            318,203          1
                                                  Health Programs.
Oklahoma.......................................  Healthy Communities Access Program           348,625          1
Oklahoma.......................................  Integrated Services Development              152,421          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Oklahoma Total.................................................................       $11,757,553         16
----------------------------------------------------------------------------------------------------------------
Oregon.........................................  Community Health Center Program...       $23,337,092         19
Oregon.........................................  Health Care for the Homeless......         3,804,369          7
Oregon.........................................  Migrant Health Center and Migrant          4,058,672          7
                                                  Health Programs.
Oregon.........................................  Healthy Communities Access Program         1,746,939          3
Oregon.........................................  Integrated Services Development            1,319,360          3
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Oregon Total...................................................................       $34,266,432         39
----------------------------------------------------------------------------------------------------------------
Palau..........................................  Community Health Center Program...          $666,817          1
----------------------------------------------------------------------------------------------------------------
    Palau Total....................................................................          $666,817          1
----------------------------------------------------------------------------------------------------------------
Pennsylvania...................................  Community Health Center Program...       $37,783,431         26
Pennsylvania...................................  Health Care for the Homeless......         4,903,898          4
Pennsylvania...................................  Migrant Health Center and Migrant          1,291,792          1
                                                  Health Programs.
Pennsylvania...................................  Public Housing Primary Care.......         2,730,328          4
Pennsylvania...................................  Black Lung/Coal Miner Clinics                619,716          3
                                                  Program.
Pennsylvania...................................  Healthy Communities Access Program         2,082,259          3
Pennsylvania...................................  Integrated Services Development              280,821          2
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Pennsylvania Total.............................................................       $49,692,245         43
----------------------------------------------------------------------------------------------------------------
Puerto Rico....................................  Community Health Center Program...       $32,039,892         19
Puerto Rico....................................  Health Care for the Homeless......           795,701          2
Puerto Rico....................................  Migrant Health Center and Migrant          7,264,377          6
                                                  Health Programs.
----------------------------------------------------------------------------------------------------------------
    Puerto Rico Total..............................................................       $40,099,970         27
----------------------------------------------------------------------------------------------------------------
Rhode Island...................................  Community Health Center Program...        $9,442,810          6
Rhode Island...................................  Health Care for the Homeless......           694,426          2
----------------------------------------------------------------------------------------------------------------
    Rhode Island Total.............................................................       $10,137,236          8
----------------------------------------------------------------------------------------------------------------
South Carolina.................................  Community Health Center Program...       $34,667,145         19
South Carolina.................................  Health Care for the Homeless......         1,624,365          4
South Carolina.................................  Migrant Health Center and Migrant          1,400,750          4
                                                  Health Programs.
South Carolina.................................  Public Housing Primary Care.......           396,628          1
South Carolina.................................  Healthy Communities Access Program         2,727,337          4
----------------------------------------------------------------------------------------------------------------
    South Carolina Total...........................................................       $40,816,225         32
----------------------------------------------------------------------------------------------------------------
South Dakota...................................  Community Health Center Program...        $6,898,656          7
South Dakota...................................  Health Care for the Homeless......           160,024          1
South Dakota...................................  Integrated Services Development              148,800          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    South Dakota Total.............................................................        $7,207,480          9
----------------------------------------------------------------------------------------------------------------
Tennessee......................................  Community Health Center Program...       $25,513,579         21
Tennessee......................................  Health Care for the Homeless......         2,016,153          4
Tennessee......................................  Migrant Health Center and Migrant            772,735          3
                                                  Health Programs.
Tennessee......................................  Black Lung/Coal Miner Clinics                159,781          1
                                                  Program.
Tennessee......................................  Healthy Communities Access Program         2,188,230          3
----------------------------------------------------------------------------------------------------------------
    Tennessee Total................................................................       $30,650,478         32
----------------------------------------------------------------------------------------------------------------
Texas..........................................  Community Health Center Program...       $75,161,952         47
Texas..........................................  Health Care for the Homeless......         6,804,614          8
Texas..........................................  Migrant Health Center and Migrant          7,079,143         12
                                                  Health Programs.
Texas..........................................  Public Housing Primary Care.......           920,248          2
Texas..........................................  Healthy Communities Access Program         4,831,103          6
Texas..........................................  Integrated Services Development              148,741          1
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Texas Total....................................................................       $94,945,801         76
----------------------------------------------------------------------------------------------------------------
U.S. Virgin Islands............................  Healthy Communities Access Program          $629,875          1
----------------------------------------------------------------------------------------------------------------
    U.S. Virgin Islands Total......................................................          $629,875          1
----------------------------------------------------------------------------------------------------------------
Utah...........................................  Community Health Center Program...        $8,902,972         10
Utah...........................................  Health Care for the Homeless......           982,901          1
Utah...........................................  Migrant Health Center and Migrant            483,178          1
                                                  Health Programs.
Utah...........................................  Healthy Communities Access Program           278,320          1
Utah...........................................  Integrated Services Development              272,800          1
                                                  Initiative.
Utah...........................................  Radiation Exposure Screening and             495,935          2
                                                  Education Program.
----------------------------------------------------------------------------------------------------------------
    Utah Total.....................................................................       $11,416,106         16
----------------------------------------------------------------------------------------------------------------
Vermont........................................  Community Health Center Program...        $3,042,555          3
Vermont........................................  Health Care for the Homeless......           434,479          1
----------------------------------------------------------------------------------------------------------------
    Vermont Total..................................................................        $3,477,034          4
----------------------------------------------------------------------------------------------------------------
Virgin Islands.................................  Community Health Center Program...        $1,519,153          2
----------------------------------------------------------------------------------------------------------------
    Virgin Islands Total...........................................................        $1,519,153          2
----------------------------------------------------------------------------------------------------------------
Virginia.......................................  Community Health Center Program...       $24,779,135         20
Virginia.......................................  Health Care for the Homeless......         1,225,902          2
Virginia.......................................  Migrant Health Center and Migrant          1,486,616          2
                                                  Health Programs.
Virginia.......................................  Black Lung/Coal Miner Clinics                470,991          1
                                                  Program.
Virginia.......................................  Healthy Communities Access Program         1,849,742          4
Virginia.......................................  Integrated Services Development              386,797          2
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    Virginia Total.................................................................       $30,199,183         31
----------------------------------------------------------------------------------------------------------------
Washington.....................................  Community Health Center Program...       $30,466,772         20
Washington.....................................  Health Care for the Homeless......         4,464,526          6
Washington.....................................  Migrant Health Center and Migrant          9,904,257          7
                                                  Health Programs.
Washington.....................................  Public Housing Primary Care.......           148,876          1
Washington.....................................  Healthy Communities Access Program         1,519,455          3
----------------------------------------------------------------------------------------------------------------
    Washington Total...............................................................       $46,503,886         37
----------------------------------------------------------------------------------------------------------------
West Virginia..................................  Community Health Center Program...       $22,846,454         27
West Virginia..................................  Health Care for the Homeless......           387,006          1
West Virginia..................................  Migrant Health Center and Migrant            761,767          1
                                                  Health Prorams.
West Virginia..................................  Black Lung/Coal Miner Clinics              1,245,591          1
                                                  Program.
West Virginia..................................  Healthy Communities Access Program           583,315          1
West Virginia..................................  Integrated Services Development              892,800          2
                                                  Initiative.
----------------------------------------------------------------------------------------------------------------
    West Virginia Total............................................................       $26,716,933         33
----------------------------------------------------------------------------------------------------------------
Wisconsin......................................  Community Health Center Program...       $12,693,589         13
Wisconsin......................................  Health Care for the Homeless......         1,889,961          3
Wisconsin......................................  Migrant Health Center and Migrant            713,793          1
                                                  Health Programs.
----------------------------------------------------------------------------------------------------------------
    Wisconsin Total................................................................       $15,297,343         17
----------------------------------------------------------------------------------------------------------------
Wyoming........................................  Community Health Center Program...        $2,329,730          2
Wyoming........................................  Health Care for the Homeless......           708,473          2
Wyoming........................................  Migrant Health Center and Migrant            215,036          1
                                                  Health Programs.
Wyoming........................................  Black Lung/Coal Miner Clinics                250,326          1
                                                  Program.
----------------------------------------------------------------------------------------------------------------
    Wyoming Total..................................................................        $3,503,565          6
----------------------------------------------------------------------------------------------------------------
Prepared on March 16, 2006.


                   HRSA/Bureau of Primary Health Care
          Grant Programs Totals by State for Fiscal Year 2005*
------------------------------------------------------------------------
                                            Number of      Financial
                                              Grants       Assistance
------------------------------------------------------------------------
Community Health Center Program...........        879      1,259,154,579
Health Care for the Homeless..............        178        133,170,992
Migrant Health Center and Migrant Health          135        122,158,130
 Programs.................................
Public Housing Primary Care...............         39         19,506,123
Black Lung/Coal Miner Clinics Program.....         15          5,890,107
Emergency Supplement for Florida Hurricane          5          1,287,918
 Relief...................................
Healthy Communities Access Program........        109         75,167,161
Integrated Services Development Initiative         40         11,120,717
Radiation Exposure Screening and Education          7          1,622,995
 Program..................................
------------------------------------------------------------------------
Prepared on March 16, 2006.


    Question 2. Ms. Duke, in your testimony, you refer to the 
importance of ``to serving the neediest first'' by developing a new 
medical index of severity that would drive funding. Every State and EMA 
is capable of demonstrating significant unmet needs in each area, but 
they suffer shortfalls in Federal support for medications under Part D 
of Medicare; primary care under Medicaid and other support services. Do 
you interpret serving the neediest first to mean the ``neediest 
individuals'' nationwide, or do you mean the ``neediest jurisdictions, 
because they are not the same?''
    Answer 2. In the case of health, health comes down to individuals. 
Our goal is to distribute CARE Act dollars equitably so that funding is 
available to serve individuals living with HIV/AIDS who cannot afford 
to pay for the care they need.

    Question 3. In assessing a jurisdiction's ``need'' for funding, you 
also reference taking into account other existing resources. Would you 
agree that it is short-cited to consider the resources that State and 
locals have committed to supplement the CARE Act, for example through a 
strong Medicaid program, in accessing the need for Ryan White funds? 
Many States have made a huge commitment to the health care of their 
poor and disabled citizens. Do you think it is fair to use that 
investment against them in allocating funding under Ryan White?
    Answer 3. The President's principles call for more equitable 
distribution of CARE Act funds. Important existing provisions in the 
legislation, such as maintenance of effort and the matching fund 
requirement, will continue to safeguard against the diversion or 
reduction of State and local funds away from critical HIV/AIDS 
services. We will continue to be vigilant to ensure that new CARE Act 
dollars will not be used to supplant State and local efforts.

    Question 4. What are the current mechanisms for estimating relative 
unmet need within and across jurisdictions? What points of evidence are 
relied on to make these estimates? And has the contribution of all four 
titles been included in those estimates?
    Answer 4. With the reauthorization of the CARE Act in 2000 HRSA/HAB 
has worked with our grantees and expert consultants to develop a 
methodology for estimating unmet need within their jurisdictions. Unmet 
need is defined as those who ``know their HIV status and are not 
receiving HIV-related services.'' Since fiscal year 2004, all title I 
and II grantees have been using this methodology to determine unmet 
need within their jurisdictions. The jurisdictions have been gathering 
data from many sources including Medicaid, Veterans Affairs hospitals, 
State prisons, and other providers of HIV care within their areas.
    Moreover, with the assistance of the consultants, HAB has reviewed 
all the grantee submissions and as a result, focused specific technical 
assistance to those grantees who continue to experience difficulty in 
using the methodology. Nevertheless, HAB believes that all grantees 
will be able to identify individuals meeting the unmet need definition 
within fiscal year 2006. With this information grantees will be better 
able to target their resources to those most in need within their 
jurisdictions. In determining unmet need, States have worked with other 
service providers including those funded under title III and IV to 
derive unmet need estimates.

    Question 5. Massachusetts currently uses a code-based system to 
identify HIV cases. They have had good feedback from CDC on the 
validity and reliability of this code-based system. In the 2000 
reauthorization of Ryan White, it was mandated that by 2004 the 
Secretary begin to collect ``accurate and reliable HIV data'' AND in 
deciding what is ``accurate and reliable,'' consideration should be 
given to the IOM study that was commissioned. The IOM study clearly 
states that both name-based and code-based would be equally acceptable 
if it was reliable. Why is the CDC demanding Massachusetts to collect 
names when it has never been established that their code-based system 
didn't work?
    Answer 5. CDC must collect HIV data in all States using the same 
standard, scientifically accurate and reliable system of patient 
identification that enables removal of duplicate cases across States 
(interstate de-duplication) to give an accurate national picture of the 
HIV epidemic. CDC's policy is to report HIV infection and AIDS cases 
surveillance data only from areas conducting confidential name-based 
reporting because this reporting has been shown to routinely achieve 
high levels of accuracy and reliability. HIV case surveillance that is 
conducted using coded patient identifiers has not been shown to 
routinely produce equally accurate, timely, or complete data compared 
to that conducted using confidential, name-based surveillance methods.
    CDC conducted a nationwide evaluation of interstate duplication 
that demonstrated substantial numbers of HIV cases in many States were 
actually repeat reports of individuals who had been previously 
diagnosed and reported in other States. This evaluation highlighted the 
need to establish a single, standard, and accurate patient identifier 
across all States to ensure that duplicate reports can be identified 
and eliminated from the national database. Based on the need for a 
scientifically reliable and accurate system of national HIV reporting, 
CDC recommended in July 2005 that all States implement name-based HIV 
surveillance.
    Because the legal authority for disease reporting resides with 
State and local health departments CDC continues to provide funding and 
technical assistance to States that use alternative methods for 
identifying patients in their HIV surveillance system. However, data 
from States using such alternative methods cannot be integrated into 
the national data system because there is no equitable, systematic or 
scientifically verified method of patient identification that can be 
used to remove duplicate reports across States regarding the same 
individual. CDC does not receive the names of individuals but 
identifies records from different States that have enough similarities 
to suggest that they may represent the same person. CDC sends the 
States information about these records, and the States then communicate 
directly with each other, using the patient name as the identifier, to 
identify duplicate reports across the States.
    Name-based public health surveillance has been the standard method 
used to identify individuals in population-based disease reporting 
systems since these programs were instituted in the United States 
during the beginning of the 20th century. All other reportable 
infectious and non-infectious disease surveillance systems use name as 
the patient identifier. These surveillance systems have a long history 
of providing accurate information that is critical for guiding public 
health programs while protecting patient confidentiality and privacy at 
the local, State and Federal level. When surveillance data are sent to 
CDC for developing a national disease registry, personal identifiers 
are maintained at the State or local level and not sent to CDC. AIDS 
surveillance has been conducted using the standard name-based 
surveillance approach since the early 1980s.
    Currently, 43 States use confidential name-based HIV case 
reporting. The remaining seven States and the District of Columbia use 
code or name-to-code reporting. Among those nine areas, there are eight 
different codes. Several of these States have notified CDC that they 
intend to implement name-based HIV surveillance in 2006.
Clarification to Response From Betty Duke
    At the time of Dr. Duke's statement at the Senate HELP Committee 
hearing, nine States and the District of Columbia continued to use 
code-based or name-to-code systems.
Transcript
    DUKE: My understanding--and I am not at CDC--but my understanding 
is that the interpretation of the law as it exists is that CDC must 
certify that the systems meet the standards of the law and that they 
have said that they can't certify code-based or name code-based 
systems. And we have about 13 or 14 States who have some situations. 
And I believe my colleagues at CDC can work with you on that--where 
they are having problems with compliance with what they view is the 
intent of the law.

    Question 6. How does the Administration plan to direct future RWCA 
allocations to States that have recently adopted name-based HIV 
surveillance systems and States that have immature HIV surveillance 
systems, where the CDC does not certify their HIV case reports? Does 
the Administration plan to estimate living HIV/AIDS cases in these 
States until such time that these cases are certified?
    Answer 6. In accordance with requirements in the CARE Act 
Amendments of 2000, to ensure that HIV case data are available from all 
States no later than fiscal year 2007, CDC continues to provide 
technical assistance to States to facilitate their change to name-based 
HIV surveillance systems.

    Question 7. What is the Administration's intent with regard to the 
current title structure of the Care Act? If changes are proposed, what 
is the true evidence that an altered title I/II structure would more 
effectively address unmet need across the country?
    Answer 7. The Administration, after much deliberation, has 
determined that the title structure of the Ryan White CARE Act should 
remain. The findings of both IOM and GAO are conclusive: without 
altering several legislative provisions that create structural barriers 
under titles I and II in the CARE Act, funding per AIDS case will 
continue to vary greatly. Because of the current structural barriers, 
the CARE Act will be unable to distribute funds equitably and 
effectively address unmet need across the country.

    Question 8. Eligible Metropolitan Areas have drawn in and provided 
services to many patients that live outside of these metropolitan 
areas. Over time, these cities have developed critical infrastructure 
that serve as models of comprehensive care that we aspire to provide to 
all people living with HIV/AIDS. Changes in the title I and title II 
structure could drastically reduce funding to these Metropolitan areas, 
dismantling some of the centers of excellence for HIV/AIDS care that we 
hold up as models. Would you agree that it would be counterproductive 
to reduce critical funding to cities that not only provide superior 
services, but also draw in patients from surrounding areas where such a 
comprehensive infrastructure is neither available nor likely feasible 
in the future?
    Answer 8. The President's principles call for more equitable 
distribution of CARE Act funds, which is paramount in the 
reauthorization. Proposed changes in the CARE Act are not intended to 
destabilize services, but are designed to assure that persons in need 
of HIV services and unable to pay for them shall be able to receive 
those services. By maintaining important provisions in current law, 
such as maintenance of effort and matching fund requirements, the 
Administration will ensure that States continue to contribute State and 
local funds to critical HIV/AIDS services.

    Question 9. The Administration's conception of prevention focuses 
solely on testing. It is listed as one of the Administration's Ryan 
White CARE Act Reauthorization principles and approximately half of the 
new funding for HIV/AIDS in the fiscal year 2007 President's Budget 
goes to increased HIV testing. Although HIV testing is an important 
intervention to help bring infected individuals into care, a testing-
only strategy neglects essential primary behavior change interventions 
that can protect at-risk groups by educating and empowering them to 
reduce or avoid the risk of becoming infected in the first place. 
Wouldn't you agree that the Administration should invest also in broad-
based HIV prevention strategies?
    Answer 9. To have the largest impact on the HIV epidemic, CDC 
utilizes a comprehensive approach to HIV prevention. HIV testing is 
only one part of CDC's three-pronged approach to HIV prevention. The 
three elements of this approach are: (1) HIV counseling, testing, and 
referral services; (2) HIV prevention with persons who are at high risk 
of acquiring HIV; and (3) HIV prevention with persons living with HIV.
    Comprehensive HIV prevention is a broad term that incorporates 
surveillance, research, prevention interventions and evaluation. CDC's 
surveillance and research activities help to better define and 
understand the HIV/AIDS epidemic across the Nation. CDC's prevention 
interventions and capacity building efforts are based on behavioral, 
laboratory and medical science and work to contain the spread of HIV 
and AIDS. Program evaluation and policy research and development assess 
intervention effectiveness and refine prevention approaches. Additional 
information about CDC's comprehensive approach to HIV prevention is 
contained in the attached fact sheet, ``Comprehensive HIV Prevention.''
    In Fiscal Year 2006, CDC received $651.1 million for domestic HIV/
AIDS prevention activities conducted by the National Center for HIV, 
STD, and TB Prevention. It is estimated that 14 percent of this total 
will be spent on surveillance activities; 9 percent on prevention 
research; 9 percent on capacity building/technical assistance efforts; 
63 percent on intervention activities including testing programs and 
other prevention activities carried out by State, local and community-
based organizations (CBOs); and 5 percent on program evaluation and 
policy development. An additional $68.6 million will be spent CDC-wide 
on efforts such as HIV school health education, safe motherhood, 
hemophilia programs, and preventing nosocomial transmission. The vast 
majority of CDC's domestic HIV/AIDS funding is spent extramurally 
through cooperative agreements to private-sector, State and local 
health departments, education agencies, non-governmental organizations, 
and CBOs.
    For fiscal year 2007, we have proposed expanding our HIV testing 
efforts. HIV testing is an integral part of CDC's HIV prevention 
strategy, as knowledge of one's HIV infection can help prevent spread 
of the infection to others. Studies have shown that when people know 
that they are infected with HIV, they are significantly more likely to 
protect their partners from infection than when they were unaware of 
their infection. We think that this initiative will identify a large 
number of previously undiagnosed cases, and help those persons link to 
care, treatment and counseling, and avoid transmitting HIV to others.
                       questions of senator burr
    Question 1. The President has proposed ``. . . to make $70 million 
available to States in need to bridge the existing gaps in coverage for 
Americans waiting for life-saving medications. These funds would help 
the States end current waiting lists and help support care for 
additional patients.''
    Will this new $70 million resource be more appropriately targeted 
than the Special Presidential ADAP Initiative so that States with ADAP 
Programs in ``severe need''--not just indicated by a single factor at a 
particular point in time but based on a variety of limitations and 
constraints over time--will have access to a portion of this funding on 
a more comprehensive and reasonable basis?
    Answer 1. The $70 million will be used to help the States end 
current ADAP waiting lists and help support care for additional 
patients. The funding mechanism is under discussion within the 
Department.

    Question 2. Could you explain why when you combine the money that 
is going to each State--title I and II funding--a State like California 
receives $5,264 per AIDS case, while North Carolina receives $3,727, 
Mississippi receives $3,442 per case and Iowa just $3,340? [Source: GAO 
Testimony, June 23, 2005]
    Answer 2. Grantees do not receive the same level of title I and 
title II funding per person living with AIDS because of various formula 
provisions that impact the proportional allocation of funding. Below 
are three reasons for this variation as stated in the ``HIV/AIDS: 
Changes Needed to Improve the Distribution of Ryan White CARE Act and 
Housing Funds'' (GAO-06-332):
     Using AIDS Cases in Formulas--The CARE Act uses measures 
of AIDS cases that do not accurately reflect the number of persons 
living with AIDS. Title I and Title II CARE Act funding is based on 
case counts that could include deceased cases because the eligibility 
and allocation are determined using cumulative case counts. 
Additionally, the CARE Act's use of estimated living cases (ELCs), 
which are determined using the most recent 10 years of reported AIDS 
cases, to distribute the majority of formula funding does not take into 
account that many AIDS patients now live longer than 10 years after 
their disease is reported. HRSA has indicated that the GAO language 
above regarding using AIDS cases in formulas omits a very important 
factor: The 10-year band of AIDS cases is adjusted by a survival rate 
factor that compensates for the so called ``deceased cases'' in the 10-
year period. The survival rate factor is calculated for each year of 
the 10 years and is prepared by CDC to address the issue of those who 
have died.
     Double Counting--Some CARE Act Title I and Title II 
provisions related to metropolitan areas result in variability in the 
amount of funding per ELC among grantees. For instance, the counting of 
ELCs within the EMAs once for determining title I base grants and once 
again for determining title II base grants results in States with EMAs 
and Puerto Rico receiving more total title I and title II funding per 
ELC than States with no EMA or with comparatively few ELCs located in 
EMAs. Also, the division of Title II Emerging Communities into two 
tiers based on their number of reported AIDS cases in the past 5 years 
leads to funding differences among grantees.
     Hold Harmless Provision--The CARE Act hold harmless provisions 
under title I and title II and the grandfather clause for EMAs under 
title I makes the funding of certain grantees protected. For example, 
the CARE Act Title I hold harmless provision results in San Francisco 
EMA's funding being based in part on the number of deceased cases in 
the EMA in 1995. In addition, the title II hold harmless provision, 
which has had little impact thus far, has the potential to reduce the 
amount of funding to grantees for severe need of drug treatment funds 
because the hold harmless grantees are funded from amounts set aside 
for ADAP Severe Need grants. The Title I EMA grandfather clause 
protected the funding of more than one half of EMAs.
    The President's principles for Reauthorization of the Ryan White 
CARE Act, released July 27, 2005, address these three key issues 
impacting the proportional allocation of title I and title II funding. 
The principles would make the program more responsive by:
     Using HIV Cases in Formula--Maintain the current statutory 
requirement that all States submit HIV data by the start of fiscal year 
2007. Having the full scope of HIV is critical to successful care and 
treatment programs that prevent people from advancing to AIDS.
     Eliminating Double Counting--Eliminating the double 
counting of HIV/AIDS cases between major metropolitan areas (title I) 
and the States (title II).
     Eliminating Hold Harmless Provision--Eliminating current 
provisions that entitle cities to be ``held harmless'' in funding 
reductions.

    Quesiton 3. Does this discrepancy in funding have anything to do 
with a State's Medicaid generosity?
    Answer 3. No, funding for title I is awarded as formula grants and 
supplemental grants in accordance with provisions in the CARE Act. 
Title II funding provides grants to all 50 States, the District of 
Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and eligible U.S. 
Pacific Territories based on the number of reported AIDS cases. Title 
II also provides funding for the AIDS Drug Assistance Program (ADAP).
    To be eligible for a Title I Grant for Eligible Metropolitan Areas 
(EMAs), an area must have reported at least 2,000 AIDS cases during the 
previous 5 years and have a population of at least 500,000. Title I 
funding to EMAs includes formula and supplemental components. Formula 
grants are based on the estimated number of living cases of AIDS over 
the most recent 10-year period. Supplemental grants are awarded 
competitively based on demonstration of severe need and other criteria.
    Title II of the Ryan White CARE Act provides grants to all 50 
States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin 
Islands, and five newly eligible U.S. Pacific Territories and 
Associated Jurisdictions. Title II also funds the AIDS Drug Assistance 
Program (ADAP) and grants to States for Emerging Communities--areas 
reporting between 500 and 1,999 AIDS cases over the most recent 5 
years. Base title II grants are awarded to States and Territories using 
a formula that is based on reported AIDS cases. Additional title II 
funds are ``earmarked'' for State AIDS Drug Assistance Programs 
(ADAPs), which primarily provide medications. Fundable services also 
include treatment adherence and support, as well as health insurance 
coverage with prescription drug benefits. Three percent of the ADAP 
earmark is reserved for grants to States and Territories with severe 
need for medication assistance.

    Question 4. So it seems that the States with an EMA receive more 
money per case. What is double counting and do some States benefit from 
that as well? How do you suggest the Congress address the double 
counting issue?
    Answer 4. The most recent 10 years of Estimated Living AIDS Cases 
(ELCs) are calculated for all States and territories. Eighty percent of 
the title II base award is based upon each State's proportion of the 
total ELCs in all States and territories. The remaining 20 percent is 
based upon each State's proportion of the total ELCs in all States and 
territories that are located outside the Eligible Metropolitan Areas 
(EMAs) within a State. This is to give States without EMAs an extra 
boost and was enacted under the 1996 reauthorization law. However, this 
does result in the double counting; in effect, a portion, but not all 
of the cases attributed to an EMA in a State are counted twice in 
calculating the title II base award. Eliminating the ``double 
counting'' phenomenon would mean that the State's base award, in a 
State with EMA(s), would be based solely on the ELCs in the non-EMA 
area of the State.
    For example, the total number of estimated cases in Colorado is 
2,477 with 1,830 living within the EMA, and 647 living outside the EMA. 
Currently Colorado's award is based on 80 percent of the proportion in 
the State and 20 percent on the proportion outside the EMA. 
Additionally, the EMA receives title I funds based on the cases within 
the EMA. If we should eliminate the 80-20 provision of 1996, Colorado's 
base award would be based on the 647 cases living outside the EMA, with 
the EMA receiving funding for the cases within the EMA.
    The Administration's principles propose to eliminate double 
counting of AIDS cases between EMAs and States.

    Question 5. Included in the discussions of trying to bring greater 
equity to the distribution of funds within the Ryan White CARE Act is 
the concept of ``eliminating double counting.'' If eliminating double 
counting results only in redistributing title II funds according to 
AIDS cases outside of the Eligible Metropolitan Areas (EMAs), which is 
the way it appears in the Administration's principles and proposals, 
then some of the States with title I cities/EMAs will lose a 
significant amount of funding and be extremely disadvantaged. The only 
approach that will result in greater reasonableness and equity in the 
distribution of Ryan White CARE Act funds is combining the funding that 
is available through both title I and title II into one single ``care'' 
resource, and then distributing that total amount on a ``per capita'' 
(e.g., $/reported case of AIDS) basis.
    Could the Administration be supportive of combining the title I and 
title II funding into one single ``care'' resource?
    Answer 5. Central to the issue of equitable distribution of CARE 
Act funds is the issue of formula-driven provisions in the CARE Act. 
The Administration's reauthorization principles speak directly to this 
issue. Combining title I and II funding would not solve the equity 
issue. We believe that having core medical services under title I and 
minimum drug lists under title II more directly addresses the issue of 
equitable care than would combining titles I and II.

    Question 6. The Administration's reauthorization principles call 
for better coordination of State and local delivery of services. Could 
you explain what the problem is today and how you envision it to be 
improved?
    Answer 6. A coordinated effort between the States, cities, and 
other CARE providers is essential to effective, comprehensive care and 
prevention services. Currently, health care programs have a history of 
operating separately from each other, and some may not be accustomed to 
cooperating in the provision of services to clients. In some cases, 
this could be because program staff is uninformed about how to pursue 
the program linkages that are possible. Provider agencies also indicate 
that varying reporting requirements and the distribution of funding for 
similar services across several programs place limits on the time 
available for service coordination for clients.
    In order to improve the coordination of services, the Department 
would establish and maintain relationships with State AIDS officials 
and provide to them all information necessary to coordinate care and 
treatment with other federally funded projects. Activities may include 
educating program staff on opportunities for coordination and 
integration, promoting and supporting participatory HIV service 
planning processes at the State and local levels, and State and local 
flexibility in managing resources and enforcing regulations. These and 
other efforts would yield important information about what is 
effective, what needs to be changed, how the future of HIV programs can 
be shaped to ensure the optimum use of Federal resources to provide the 
best possible care and services to people living with HIV disease, and 
will ultimately maximize the efficiency and effectiveness of AIDS 
services.
                       questions of senator hatch
    Question 1. As one of the original authors of Ryan White, I want to 
be sure that the program will continue to be able to provide vital 
services to people living with HIV/AIDS. The epidemic has changed since 
the program's inception; and the legislation should adequately address 
those changes. I understand that defining the ``core medical services'' 
will play a major part in adjusting the legislation to make sure that 
the neediest patients are served first--can you tell me whose feedback 
will be included in determining those core services? More specifically, 
what will be the process to decide the core services index, the set of 
core medical services, and the list of core medications?
    Answer 1. Various groups have developed lists of ``core medical 
services'' for people living with HIV and AIDS. In particular, the IOM 
study, ``Public Financing and Delivery of HIV/AIDS Care,'' published in 
2004, defined eight broad areas that capture the critical components of 
HIV care as listed below.

     Outpatient primary care medical services;
     Medications, including HAART;
     Other drug therapies for HIV-related comorbidities;
     Laboratory and radiological services;
     Oral health care;
     Obstetrics and reproductive health services for HIV-
infected women;
     Outpatient mental health and substance abuse treatment and 
services;
     Home health and hospice care;
     Medical case management; and
     HIV prevention services.

    Question 2. Given that core activities would be defined at the 
Federal level, what administrative burdens would be released from the 
State and local levels, including the requirements for evaluation, 
consortium and other related planning bodies?
    Answer 2. The definition of core activities or services at the 
Federal level will still require CARE Act grantees to prioritize core 
service needs at the State, jurisdiction or local levels. As such, 
needs assessments for planning the prioritization and allocation of 
CARE Act funds will continue. It is anticipated, however, that more 
focused needs assessment, planning and priority setting processes will 
occur given the narrowing of the definition of eligible services under 
core activities.

    Question 3. The structure of the Ryan White CARE Act has 
historically allowed for maximized State and local control. Services 
have long been made available through processes that assure 
prioritization of services based on needs assessment activities, 
epidemiological profiles and gap analysis processes. It seems 
reauthorization could limit this flexibility by saying that the 
Secretary, presumably through HRSA, will establish a set core of 
medical services and a set of core medications. If that happens, how 
will flexibility and local control be maintained?
    Answer 3. While the President's principles indicate that 75 percent 
of grant funds should be used for core services, responsibility for 
planning and allocation of grant funds supporting both the core 
services and other non-core services will remain with those responsible 
for administering both the EMA and State grants. HAB will continue to 
hold these entities accountable for meeting their responsibilities in 
line with CARE Act requirements. Local control will remain along with 
flexibility within the statutory framework of the CARE Act.

    Question 4. I have been working closely with the Utah Department of 
Health on this issue. To date, States have not received an adequate 
amount of funding to meet the present needs. Utah's ADAP program was 
closed recently for a 5-month period of time because of limited funding 
and program utilization growth. The President has recently called for 
increased HIV prevention and testing outreach. Although the President's 
budget includes an additional $93M for increased HIV testing among 
high-risk populations, there is obviously concern with any prevention 
activities which may reduce funding for care and treatment. What 
present requirements will be reduced or eliminated in order to make 
room for prevention activities through the title II programs, 
specifically?
    Answer 4. The Administration's reauthorization principles propose 
creating stricter payer of last resort provisions that will ensure that 
CARE Act funds will be increasingly directed to fill gaps in service 
provisions for those persons who have no other source of payment for 
HIV/AIDS care and treatment. In addition, proposed provisions such as 
the implementation of routine voluntary HIV testing in public 
facilities and by private healthcare providers will be a key element in 
prevention efforts. Thus, the number of available providers of 
prevention services would increase, lessening the burden of prevention 
service provision on States. The proposals call for State and local 
care delivery coordination which would maximize efficiency and 
effectiveness of HIV/AIDS services between the State, local 
jurisdictions and community-based service providers, including key 
providers of HIV/AIDS prevention and outreach services.

    Question 5. Do you feel that current eligibility requirements for 
Eligible Metropolitan Areas (EMAs) and Emerging Communities (ECs) 
appropriately address the epidemic? (If not, would changing those 
requirements and eliminating hold harmless provisions be a step in the 
right direction?)
    Answer 5. The current eligibility requirements for EMAs, 
established in 1996, define an EMA having 2,000 AIDS cases in the most 
recent 5-year period and a population of at least 500,000. With the 
changing nature of the epidemic, spurred in large part by advances in 
treatment, the move to using HIV disease data will better represent the 
nature of the epidemic in areas. Lowering the threshold number of AIDS 
cases will increase the number of eligible EMAs, some of whom are 
currently Emerging Communities (EC) under title II. If the eligibility 
requirements for EMA designation were changed, there would be no need 
for an EC initiative under title II. Instead, EC dollars would be 
redirected to the State title II base grant. States would have the 
authority to plan for and deliver either directly or through consortia 
CARE Act services in those former EC areas.
                       questions of senator dodd
    Question 1. Title IV provides an important link to care, services 
and research for women, children, youth and families affected by HIV/
AIDS. Title IV saves lives by providing treatment and care, improves 
quality of life by keeping people healthier, and saves money by 
reducing hospitalization.
    Title IV projects have led the way in reducing mother-to-child 
transmission from more than 2,000 babies born HIV-positive each year to 
fewer than 200. In my home State of Connecticut, a total of 213 babies 
have been born to HIV-positive mothers since 2002. Of that total only 
one baby has been confirmed as HIV-positive. But the battle against 
mother-to-child transmission is far from being won. As long as women of 
child-bearing age are living with HIV disease, we must stay focused on 
supporting and strengthening programs that outreach to HIV-infected 
pregnant women. Title IV programs bring HIV-infected pregnant women 
into care and help them adhere to their treatment regimens for the 
duration of their pregnancy and delivery. Following delivery, title IV 
nurses and case managers follow up to ensure the mother is 
administering the required 6-week treatment regimen to the newborn.
    Given these successes, performed each and every day by title IV 
projects across the country, do you agree that the title IV model of 
care should be continued, strengthened and expanded in reauthorization?
    Answer 1. The Administration's reauthorization principles did not 
propose to disassemble the title IV model. In addition, it is believed 
that by assuring the funding and availability of ``core medical 
services,'' which will no doubt include prenatal and postnatal primary 
care treatment of HIV-infected women and their children, the title IV 
program would be strengthened.

    Question 2. We have concerns that title IV would be severely 
damaged if funds were set aside for ``core medical services,'' which 
are articulated in the President's principles as ``basic, primary care 
and medication needs.'' There are two reasons for this. First, title IV 
is successful because it offers a broad range of family-centered 
services that are essential to getting mothers to take care of their 
own health, to keep children in care, to give mom the support she 
needs--like child care and transportation--to get her kids and herself 
to doctor appointments and the pharmacy, and to reaching out to HIV-
infected youth and keeping them in care. Second, 80 percent of title 
IV's consumers have Medicaid, so for most patients, their doctor 
appointments and medications are already paid for by another source. 
What isn't necessarily paid for by other sources, and what is key to 
title IV, is the services that bring marginalized families struggling 
with HIV into medical care.
    So, my question to you is what changes would the Administration 
like to see made to title IV? And, specifically, do you want Congress 
to apply a set-aside of title IV funds for ``core medical services?''
    Answer 2. Although the title IV program of the CARE Act is 
structured differently than the other titles, in essence the main goal 
is to assure that its clients receive core medical services, including 
primary medical care and medications. Because there is no final 
definition of core medical services as yet, it is difficult to predict 
which, if any, of the title IV funded services may face a possible 
reduction in funding. It is anticipated that many CARE Act programs may 
have to make modifications to their programs based on the application 
of the requirement to spend 75 percent of their funds on ``core medical 
services.'' However, the change is designed to assure quality health 
care for HIV-infected individuals and uniformity of services for CARE 
Act clients across the country.

    Question 3. We really need to do better by African-American women. 
The President spoke about this in his State of the Union address. Yet, 
the Administration's principles were virtually silent on the fact that 
88 percent of people served by title IV are people of color.
    What plans does HRSA have for making sure that the title IV family-
centered care model, which has been a lifeline for women of color and 
their families since 1988, is able to serve more families of color?
    Answer 3. The title IV program will continue to reach out to 
communities of color through its programs, as well as through the use 
of the Minority AIDS Initiative funding, to identify, enroll in 
services and retain in services women of color and their families. The 
program has utilized many unique approaches to outreach in communities 
of color, including through faith-based and community-based non-
clinical programs that provide HIV prevention and education services 
and make referrals for counseling and testing. Utilizing these 
approaches reaches women in settings that are non-threatening and 
conducive to open and honest exchange of information about issues such 
as HIV.

    Question 4. In the current law, CARE Act grantees may obtain a 
waiver permitting a lower proportion of their respective program funds 
to be set aside if the eligible metropolitan area or State can 
demonstrate that women, infant, children and youth are already 
receiving substantial HIV/AIDS primary care and related health services 
through one or more Federal and/or State funded programs. I am 
concerned that these waivers are too easy to obtain. Waivers should be 
subject to annual review, especially if case reporting does not shift 
to HIV status in 2007. A delay in HIV data reporting would deny 
necessary services to women, infant, children, and youth.
    How many title I and title II grantees have requested a waiver to 
treat women, infant, children and youth? What are the criteria HRSA 
uses to evaluate waiver requests?
    Answer 4. Because CARE Act funded programs are the payer of last 
resort, women, infants, children or youth (WICY) living with HIV/AIDS 
in certain States and title I eligible metropolitan areas (EMAs) who 
qualify for Medicaid, the State Children's Health Program (SCHIP) or 
other eligible Federal or State funded programs, may have most of their 
HIV/AIDS primary care needs met through non-CARE Act resources. In such 
cases, CARE Act funds will pay for health and related support services 
not covered by the other programs such as nutritional services, case 
management, transportation, childcare and emergency assistance, which 
typically cost less than primary care. Thus, some EMAs and/or States 
may not need to use a proportionate share of their grant funds in order 
to address the HIV/AIDS care needs of one or more of these priority 
populations, which is why the Congress established a waiver provision.
    To obtain a waiver for a particular priority population in any 
given fiscal year, an EMA or State must submit a request and document 
that the population is receiving HIV/AIDS health services through 
Medicaid, (SCHIP) or other eligible program expenditures. Documentation 
must be submitted within 120 days after the budget end date, and are 
carefully reviewed to insure that they comply with HRSA guidelines as 
follows:

1. Documented waiver expenditures must be clearly identified by source 
    and qualify as eligible State or Federal expenditures.
2. Waiver expenditures must be for outpatient HIV/AIDS care only.
3. Expenditure data may NOT be aggregated, but rather must be 
    documented separately for each priority population for which a 
    waiver is requested.
4. As a general principle, expenditures to justify waiving the set-
    aside requirement should correspond to the fiscal year for which 
    the waiver is being sought. At a minimum, documented expenditures 
    must:

     Reflect an unbroken, continuous 12-month time period; and,
     Include at least 6 months worth of expenditures that 
correspond to the fiscal year for which the waiver is requested.

    In addition, grantees requesting a waiver more than once must use 
consistent methods to document waiver-related expenditure data from 1 
year to the next, and the documentation is subject to audit. Failure to 
document full compliance with HRSA's WICY waiver guidelines may result 
in grant funds being delayed for the next funding cycle until the 
grantee demonstrates that appropriate corrective actions are being 
taken to assure full compliance in the future.
    A review of title I and II WICY related documentation for fiscal 
year 2004 (the most recent year for which such data has been submitted) 
was recently completed; the results are summarized below.
    Title I: A review by HRSA found that all 51 (100 percent) EMAs 
provided documentation of required WICY spending and/or waiver-related 
expenditures for fiscal year 2004.
     42 EMAs (82 percent) documented full compliance with the 
WICY requirement that met or exceeded their minimum spending levels for 
all priority populations. These are:


------------------------------------------------------------------------

------------------------------------------------------------------------
Atlanta (GA)....................  Jacksonville (FL).  Ponce (PR)
Austin (TX).....................  Kansas City (MS)..  Portland (OR)
Baltimore (MD)..................  Los Angeles (CA)..  Sacramento (CA)
Boston (MA).....................  Las Vegas (NV)....  San Antonio (TX)
Caguas (PR).....................  Miami-Dade (FL)...  San Bernardino
                                                       (CA)
Chicago (IL)....................  Middlesex (NJ)....  San Diego (CA)
Cleveland (OH)..................  Nassau/Suffolk      San Francisco (CA)
                                   (NY).
Denver (CO).....................  New Haven (CT)....  San Jose (CA)
Detroit (MI)....................  Newark (NJ).......  San Juan (PR)
Dutchess Co (NY)................  Norfolk (VA)......  Seattle (WA)
Fort Worth (TX).................  Oakland (CA)......  St. Louis (MO)
Hartford (CT)...................  Orlando (FL)......  Tampa (FL)
Houston (TX)....................  Philadelphia (PA).  Vineland (NJ)
Jersey City (NJ)................  Phoenix (AZ)......  West Palm Beach
                                                       (FL)
------------------------------------------------------------------------

     5 EMAs (10 percent) submitted required Waiver 
Documentation for one or more priority populations that complied fully 
with HRSA guidelines, and documented meeting their title I minimum 
spending requirement for any non-waived populations. These are:


------------------------------------------------------------------------

------------------------------------------------------------------------
Fort Lauderdale, FL: children.............  New York, NY: all priority
                                             populations.
New Orleans, LA: children.................  Washington, DC: all priority
                                             populations.
Minneapolis, MN: all priority populations.
------------------------------------------------------------------------

     4 EMAs (8 percent) requested a waiver but HRSA has not 
approved it due to incomplete documentation of waiver expenditures. 
These are:


------------------------------------------------------------------------

------------------------------------------------------------------------
Bergen/Passaic, NJ: infants & children....  Orange County, CA: children
Dallas, TX: women.........................  Santa Rosa, CA: women
------------------------------------------------------------------------

    Title II: 51 (96 percent) of 53 title II grantees required to 
submit WICY Expenditure Reports and/or WICY Waiver Documentation for 
fiscal year 2004 (all 50 States, the District of Columbia, Puerto Rico, 
and the Virgin Islands) have done so. Please note: The territories of 
American Samoa, Federated States Micronesia, Guam, the Marshall 
Islands, Northern Marianas, and Republic of Palau are exempt because of 
the very small WICY population that they each serve. Below is a summary 
of HRSA's review of title II compliance with this requirement for that 
fiscal year.
     26 grantees (49 percent) met or exceeded their minimum 
spending requirements in fiscal year 2004:


----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Alabama..............................  Iowa...................  New Jersey.............  Utah
Arkansas.............................  Kansas.................   Ohio..................  Virginia
California...........................  Kentucky...............  Oregon.................  Washington
Colorado.............................  Maryland...............  Pennsylvania...........  West Virginia
Connecticut..........................  Michigan...............  Puerto Rico............  Wisconsin
Hawaii...............................  Nevada.................  Rhode Island...........  Wyoming
Indiana..............................  .......................  Texas..................
----------------------------------------------------------------------------------------------------------------

     16 grantees (30 percent) submitted required Waiver 
Documentation for one or more priority populations that complied fully 
with HRSA guidelines, and documented meeting their title I minimum 
spending requirement for any non-waived populations.

    Arizona: children
    District of Columbia: all populations
    Florida: children
    Illinois: all populations
    Louisiana: children, youth
    Maine: children, women
    Massachusetts: all populations
    Missouri: children
    Nebraska: children
    New Mexico: children, youth
    New York: all populations
    North Carolina: infants, children, youth
    North Dakota: all populations
    South Carolina: children
    South Dakota: all populations
    Vermont: children, youth

     6 States (11 percent) did not satisfy their minimum 
spending level for one or more priority populations, and still need to 
request a waiver and/or provide required documentation.

    Alaska: children
    Delaware: children, women
    Georgia: children
    Idaho: children
    Montana: children
    Oklahoma: children

     2 States (3.8 percent) did not satisfy their required 
minimum spending level for one or more priority populations and 
requested a waiver based on Medicaid spending. However, they have not 
yet obtained required documentation from their State Medicaid office 
for a 12-month period that includes at least 6 months that correspond 
to the title II fiscal year.


------------------------------------------------------------------------

------------------------------------------------------------------------
New Hampshire: children, youth............  Tennessee: women
------------------------------------------------------------------------

     2 grantees (3.8 percent) required to submit WICY 
Expenditure Reports and/or Waiver Documentation for fiscal year 2004 
have not done.

    Question 5. Medicaid is the largest public payer of HIV/AIDS care 
in the United States. It accounts for more than half of Federal 
spending on HIV/AIDS and is a critical source of care for people living 
with HIV/AIDS. States have broad flexibility in determining Medicaid 
benefit packages that can limit the scope of services provided. For 
example, some States limit the number of prescriptions, hospital 
inpatient days, and physician visits allowed per month or year, while 
other States, such as Connecticut, have less restrictive services. In 
his principles for reauthorization, the President recommends that 
unspent funds from titles I and II be reverted to the Secretary of HHS 
for redistribution to States with the greatest need. This 
redistribution would result in substantial losses in funding for some 
States and gains in others. Those States with restrictive Medicaid 
packages would receive more Ryan White dollars than States with more 
comprehensive Medicaid packages.
    So my question is how do you ensure that all people living with 
HIV/AIDS in the United States have access to comprehensive care and 
treatment without punishing States that have good entitlement programs?
    Answer 5. The CARE Act was designed to build around the core of 
Medicaid services for people living with HIV/AIDS either by filling in 
the gaps in covered services for people who already had Medicaid or by 
providing services to individuals unable to afford them but were also 
ineligible for Medicaid. Medicaid is at the center of the care delivery 
system for people living with HIV/AIDS. CARE Act grantees recognize 
that services that are eligible under Medicaid and other third party 
payers must be billed first to those payers and that the CARE Act is 
the payer of last resort. In many States, CARE Act services have 
supplemented Medicaid services by providing support for additional 
medications where Medicaid has limits on the number of prescriptions 
per month per client. In other cases, CARE Act funds have supported 
ancillary or support services which the Medicaid program in that 
particular State does not cover. With reauthorization, CARE Act funds 
would continue to either supplement or complement Medicaid services 
within a State while maintaining its role as payer of last resort.
                       questions of senator reed

HIV and Names Based Reporting

    Background: Confidentiality is a crucial issue in medical care but 
of particular importance in the case of HIV. This bill is named for a 
child who suffered the stigma of HIV. Protecting confidentiality was a 
motivating factor for many States introducing code-based reporting 
systems. Under the 2000 CARE Act reauthorization, HIV case counts are 
required to be included in funding formulas no later then fiscal year 
2007. States have been collecting HIV data, but some States have been 
doing so with a code-based system. Only in July of last year was my 
State's AIDS Director first notified by CDC that it strongly 
recommended name-based counts and the agency only certifies name-based 
case counts. For States that report HIV by code or have recently 
changed to names systems and have incomplete HIV names data, a change 
in case reporting could result in drastic changes in funding that do 
not accurately account for the number of persons affected by HIV within 
the State. GAO's June 2005 testimony of Marcia Crosse, Factors that 
Impact HIV and Aids Funding and Client Coverage, notes ``states that 
would benefit from the use of HIV cases tend to be those with the 
oldest HIV case reporting systems.''

    Question 1. What is the rationale for pushing States to names-based 
systems?
    Answer 1. CDC must collect HIV data in all States using the same 
standard, scientifically accurate and reliable system of patient 
identification that enables removal of duplicate cases across States 
(interstate de-duplication) to give an accurate national picture of the 
HIV epidemic. CDC's policy is to report HIV infection and AIDS cases 
surveillance data only from areas conducting confidential name-based 
reporting because this reporting has been shown to routinely achieve 
high levels of accuracy and reliability. HIV case surveillance that is 
conducted using coded patient identifiers has not been shown to 
routinely produce equally accurate, timely, or complete data compared 
to that conducted using confidential, name-based surveillance methods.
    CDC conducted a nationwide evaluation of interstate duplication 
that demonstrated substantial numbers of HIV cases in many States were 
actually repeat reports of individuals who had been previously 
diagnosed and reported in other States. This evaluation highlighted the 
need to establish a single, standard, and accurate patient identifier 
across all States to ensure that duplicate reports can be identified 
and eliminated from the national database. Based on the need for a 
scientifically reliable and accurate system of national HIV reporting, 
CDC recommended in July 2005 that all States implement name-based HIV 
surveillance.
    Name-based public health surveillance has been the standard method 
used to identify individuals in population-based disease reporting 
systems since these programs were instituted in the United States 
during the beginning of the 20th century. All other reportable 
infectious and non-infectious disease surveillance systems use name as 
the patient identifier. These surveillance systems have a long history 
of providing accurate information that is critical for guiding public 
health programs while protecting patient confidentiality and privacy at 
the local, State and Federal level. When surveillance data are sent to 
CDC for developing a national disease registry, personal identifiers 
are maintained at the State or local level and not sent to CDC. AIDS 
surveillance has been conducted using the standard name-based 
surveillance approach since the early 1980s.
    Currently, 43 States use confidential name-based HIV case 
reporting. The remaining seven States and the District of Columbia use 
code or name-to-code reporting. Among those nine areas, there are eight 
different codes. Several of these States have notified CDC that they 
intend to implement name-based HIV surveillance in 2006.

    Question 2. For States that have not yet made the transition to a 
names-based system, what resources will be made available to them and 
how will CARE Act funding be calculated if the case data is not 
complete?
    Answer 2. In accordance with requirements in the CARE Act 
Amendments of 2000, to ensure that HIV case data are available from all 
States no later than fiscal year 2007, CDC continues to provide 
technical assistance to States to facilitate their change to name-based 
HIV surveillance systems.

HIV and Medications

    Background: As you know, access to medications for patients with 
HIV is becoming an increasing challenge. Many AIDS Drug Assistance 
Programs (ADAP) have waiting lists and many more are barely able to 
keep up with increasing demand. In addition, the recently passed Budget 
Reconciliation gives States the power--for the first time ever--to deny 
medications to Medicaid patients with HIV who are unable to pay cost 
sharing. In some cases, a person making $800 a month could be asked to 
pay $120 for a single bottle of HIV medications. The new Medicare Part 
D prescription drug benefit is not much of a benefit for many people 
with HIV either. As I am sure you are aware, the Part D plans contain 
what has come to be known as the ``donut hole'' between $2,250 and 
$5,100 in out of pocket costs. Given that the estimated average cost 
for 1 year of treatment for HIV is between $10,000 and $34,000, most 
persons with HIV medications will quickly reach the $2,250 threshold. 
However, many of the patients will be unable to afford the full cost of 
their medications during this lapse in coverage and may stop taking 
their medications.
    It is my understanding that ADAP funds could be used to assist 
patients with drug costs during the ``donut hole'' but these subsidies 
would not count towards the $5,100 out-of-pocket spending limit because 
they are Federal dollars.

    Question 3. Are States permitted to use ADAP funds to assist 
Medicaid and Medicare patients with co-pays and cost sharing 
requirements?
    Answer 3. AIDS Drug Assistance Programs (ADAPs), in accordance with 
State program policy, can pay premiums, deductibles, co-insurance, and 
co-pays. ADAP can also help pay for the costs of the Medicare Part D 
prescription drug benefit. It is important to understand that ADAP 
contributions cannot be counted toward TrOOP requirements and, thus, 
ADAP contributions would delay someone reaching the catastrophic 
coverage level, particularly for partial low-income subsidy (LIS) and 
basic benefit individuals.

    Question 3a. Can these expenditures be counted toward the $5,100 
Part D catastrophic limit?
    Answer 3a. No.

    Question 4. What financial impact will this have on States?
    Answer 4. States will continue to support clients who are eligible 
for Medicare Part D up to their TrOOP requirement. At this point, State 
ADAP will cover the full costs of HIV/AIDS related medications for the 
client until that individual meets their TrOOP requirement.

President's Principles--Severity of Need Index

    Background: The treatment of HIV is extremely complex. 
Noncompliance with medication regiments can reduce their effectiveness 
and can even result in the development of harmful drug resistance. It 
is crucial that required medications are provided but other support is 
also necessary to ensure compliance. Compliance also depends on 
treating co-morbid medical conditions, mental health and substance 
abuse conditions, and ensuring secure social situations.

    Question 5. What is the current State of developing a severity of 
need index at HRSA and how do you plan to take into account such 
complicated and diverse factors as mental illness, drug abuse, 
hepatitis C co-infection, and housing costs?
    Answer 5. Both the IOM Report ``Measuring What Matters'' and recent 
GAO reports have concluded that there are large differences across EMAs 
and States in allocations per estimated living AIDS case due in part to 
the double counting provision in current law. A ``severity of need'' 
formula that is based on more objective, quantitative, and nationally 
available data would distribute funding more equitably to address 
disease burden, costs of providing care, and available area resources. 
The HRSA has continued to study the IOM's recommendations and is 
exploring possible quantitative indicators of severity of need that 
could be used as means to improve the process for determining the 
amount of funds a grantee may receive. As part of this exploratory 
process, HRSA is consulting with national experts and its grantees to 
ensure a severity of need measure does not penalize generous States nor 
reward States that have failed to contribute resources to address the 
HIV/AIDS epidemic within their jurisdiction.

    Question 6. We have concerns that title IV would be severely 
damaged if funds were set aside for ``core medical services.'' First, 
title IV is successful because it offers a broad range of family-
centered services that are essential to mothers struggling to take care 
of their own health and the health of their children, to giving mom the 
support she needs, like child care and transportation to doctor 
appointments and pharmacies, and to reaching out to HIV-infected youth. 
Second, 80 percent of title IV's consumers have Medicaid, so for most 
patients, doctor appointments and medications are paid for by another 
source. What isn't necessarily covered by other sources, and what is 
key to title IV, are the services that bring marginalized families 
struggling with HIV into care.
    So, my question to you is what changes would the Administration 
like to see made to title IV? And, specifically, do you want Congress 
to apply a set-aside of title IV funds for ``core medical services?''
    Answer 6. Although the title IV program of the CARE Act is 
structured differently than the other titles, in essence the main goal 
is to assure that its clients receive core medical services, including 
primary medical care and medications. Because there is no final 
definition of core medical services as yet, it is difficult to predict 
which, if any, of the title IV funded services may face a possible 
reduction in funding. It is anticipated that many CARE Act programs may 
have to make modifications to their programs based on the application 
of the requirement to spend 75 percent of their funds on ``core medical 
services.'' However, the change is designed to assure quality health 
care for HIV-infected individuals and uniformity of services for CARE 
Act clients across the country.
                      questions of senator clinton
    Question 1. In a response to a letter I sent to you in October with 
my colleagues in the New York delegation outlining our concerns over 
the President's principles, you stated that the principles are 
``proposing to target Federal funds to the most heavily impacted 
communities and to serve the neediest first.'' Such a statement would 
seem to indicate strong Administration support for New York, the State 
that has borne the brunt of this epidemic, and, in 2004, had more new 
HIV infections than any other State.
    Yet, if the Administration's principles were implemented, New York 
would experience decreases in funding that would devastate our ability 
to provide care and treatment to people living with HIV. Specifically, 
the principles would require 75 percent of funds to be spent on a yet-
to-be-defined list of medical services, establish a severity of need 
index that would take into account State spending, and make changes in 
the title II formula that would shift funding away from areas with 
title I eligible metropolitan areas. Could you please detail exactly 
how the Administration's proposal for reauthorization would help, not 
hurt, heavily impacted communities with demonstrated need, like New 
York?
    Answer 1. The President's principles call for more equitable 
distribution of CARE Act funds, which is paramount in the 
reauthorization. Changes in the CARE Act are not intended to 
destabilize services, but are designed to assure that persons in need 
of HIV services and unable to pay for them shall be able to receive 
those services, both in urban communities and in rural communities. By 
maintaining important provisions in the legislation, such as 
maintenance of effort and matching fund requirements, the 
Administration will ensure that States continue to contribute State and 
local funds to critical HIV/AIDS services to minimize any impact that 
redistribution of CARE Act funds might have.

    Question 2. The Administration's principles call for developing a 
severity of need index that takes into account the resources that State 
and local governments have provided to address the epidemic. Such a 
principle acts as a disincentive to providing additional funding, and 
may result in State and local governments shifting resources away from 
AIDS programs so they will not be penalized by this new severity of 
need index. Has the Government taken into account the increased burden 
that might be placed upon the Ryan White program if this principle were 
to be put into effect?
    Answer 2. The President's principles call for more equitable 
distribution of CARE Act funds. Important provisions in the current 
law, such as maintenance of effort, payer of last resort and matching 
fund requirements, will continue to safeguard against the diversion or 
reduction of State and local funds away from critical HIV/AIDS 
services. We will continue to be vigilant to ensure that new CARE Act 
dollars will not be used to supplant State and local efforts.

    Question 3. Currently, the Ryan White CARE Act provides funding 
that helps people living with AIDS not only gain access to medication, 
but the support services that help them not only enter, but remain 
within our health care system, like nutrition services, case management 
and emergency housing assistance. The President's principles call for 
75 percent of all CARE Act funding to be directed to an as-yet-
undefined set of core medical services. What specific services does the 
Administration propose to designate core medical services? If the 
services listed above are excluded, what is the Administration's 
rationale for excluding them? In addition, during the hearing, you 
mentioned that the Administration has looked at several examples of 
core medical service lists in formulating its principles. It would be 
helpful to learn which lists were examined by the Administration in 
formulating their principles.
    Answer 3. Various groups have developed lists of ``core medical 
services'' for people living with HIV and AIDS. In particular, the IOM 
study, ``Public Financing and Delivery of HIV/AIDS Care,'' published in 
2004, defined eight broad areas that capture the critical components of 
HIV care as listed below:

     Outpatient primary care medical services;
     Medications, including HAART;
     Other drug therapies for HIV-related comorbidities;
     Laboratory and radiological services;
     Oral health care;
     Obstetrics and reproductive health services for HIV-
infected women;
     Outpatient mental health and substance abuse services;
     Home health and hospice care;
     Medical case management; and
     HIV prevention services.

    Question 4. The development of a needs-based index is of concern 
insofar as data that would be used to make allocation decisions might 
not be universally available. For example, one important measure of 
need would be HIV cases, but we know that name-based HIV surveillance 
data is not collected in all States. Since data are not universally 
available for even the most basic measure of need for HIV services, can 
you explain how the Administration plans to develop a meaningful, 
scientifically sound, feasible needs-based funding formula?
    Answer 4. The Administration's CARE Act reauthorization principles 
call for the establishment of objective indicators to determine 
severity of need (SON) for funding of core medical services and 
proposes that such an index take into account HIV prevalence, poverty 
rates, availability of resources including local, State and Federal 
programs and support, and private resources. There are established 
national data bases from sources including Census, Labor, CDC, CMS, and 
HRSA that are being examined by HRSA in response to the IOM report, 
``Measuring What Matters: Allocations, Planning, and Quality Assessment 
for the Ryan White CARE Act,'' that may be utilized in the development 
of a meaningful and scientifically sound needs-based funding formula. 
Insofar as the status of HIV surveillance data collection by all 
States, the CARE Act requires that all States have HIV reporting in 
place by 2007 to receive formula grants under titles I and II of the 
act. The fact that the SON index will need to take into account HIV 
data means that there will need to be close coordination in the 
implementation of both HIV data and the SON index proposals.

    Question 5. The Administration has proposed a $70 million increase 
in funding for the Ryan White CARE Act for fiscal year 2007. How many 
of these dollars will go toward increasing funding in already existing 
programs other than the AIDS Drug Assistance Program (ADAP)?
    Answer 5. The Administration has proposed an increase of $95 
million in funding for the Ryan White CARE Act for fiscal year 2007. Of 
this amount, the $70 million increase in funding would help the States 
end current ADAP waiting lists and support care for additional 
patients. The entire $70 million has been requested in title II, which 
supports ADAP. The additional $25 million increase is to expand 
outreach by providing as many as 25 HIV community action grants to 
community and faith-based organizations to provide technical assistance 
and sub-awards to grassroots organizations. HRSA believes that the 
requested funds would not be subject to the current statutory 
provisions of the CARE Act including: Hold Harmless, Emerging 
Communities, Maintenance of Effort, State Matching, and Formula 
distribution.

    Question 6. The Ryan White CARE Act is designed to be the payer of 
last resort. In many States, Medicaid and State funds help pay for 
medical services. Implementing a 75 percent rule would likely lead 
States to limit coverage of medical services through Medicaid and State 
funds and begin paying for them with Ryan White CARE Act funds. As a 
result, what had been the payer of last resort would become the payer 
of first resort. How has the Administration accounted for the increased 
burden that will be placed on the CARE Act through the implementation 
of this rule? Will implementation of this provision result in increased 
numbers of uninsured individuals, and if so, who will then assume the 
costs of care?
    Answer 6. As the payor of last resort, the CARE Act was designed to 
build around the core of Medicaid services for people living with HIV/
AIDS either by filling in the gaps in covered services for people who 
already had Medicaid or by providing services to individuals unable to 
afford them but were also ineligible for Medicaid. Medicaid is at the 
center of the care delivery system for people living with HIV/AIDS. 
CARE Act grantees recognize that services that are eligible under 
Medicaid and other third party payers must be billed first to those 
payers and that the CARE Act is the payer of last resort. By 
maintaining important provisions in the current law, such as 
maintenance of effort and matching fund requirements, the 
Administration will ensure that States continue to contribute State and 
local funds to critical HIV/AIDS services.

    Question 7. Why did the Administration choose 75 percent as the 
minimum threshold States should meet in providing core medical 
services? Do any States or eligible metropolitan area (EMA) currently 
meet the 75 percent threshold? Is there research to suggest that 
imposing this type of requirement will result in better managed 
services?
    Answer 7. Advancements in HIV/AIDS care and treatment mean that 
people living with HIV/AIDS are living longer and healthier lives. 
Efforts to identify persons earlier in disease progression and bring 
them into care also means an increasing number of uninsured or 
underinsured are dependent on the CARE Act for care and treatment. 
Under current law, the Ryan White CARE Act (RWCA) providers have a 
broad range of services they may offer their patients. Although all 
services have value, only some can be considered life-saving and life-
extending. In addition, the services offered to RWCA beneficiaries vary 
across geographic regions. This proposed change is designed to foster 
health among HIV-infected individuals and uniformity of services across 
the country by designating a basic set of core health care services for 
RWCA beneficiaries. The components of core services have not been 
defined but would, at a minimum, include health care services and 
medications for which 71 percent of CARE Act funding was directed in 
2004. Thus the 75 percent minimum is in line with program expectations 
and supported by program data. Both title I and title II program 
guidances describe the elements of a continuum of care and utilize the 
term ``core services.'' In the 2005 title I guidance, grantees were 
asked to prioritize essential core services, describe the priority 
setting and allocations processes, and how data were used in this 
process to increase access to core services. Grantees were also asked 
to justify other sources of core services if funds are not allocated to 
these services. For the top services they identified, including core 
services, grantees were asked to develop one or more service goals for 
each priority with time-limited and measurable program objectives.

    Question 8. The Administration has included as part of its 
principles for reauthorization a call to eliminate the 80-20 formula 
allocation in title II, claiming this allocation leads to funding 
discrepancies between States with title I EMAs and States without title 
I EMAs. However, when doing an analysis of funding from all four 
titles, this discrepancy in funding is no longer apparent. Why is the 
Administration focusing solely on title I and II, rather than examining 
total CARE Act funding received within States?
    Answer 8. The Administration is focusing on legislative provisions 
in the CARE Act that affect the equitable distribution of funds. These 
apply entirely to the title I and title II programs. The remaining 
programs under the CARE Act are discretionary grant programs and 
awarded based principally on the lack of availability of other CARE Act 
resources in the State, locality, or community applying for such 
resources.

    Question 9. There are several EMAs that serve people with AIDS from 
more than one State. For example, the Kansas City EMA serves patients 
in Missouri, a State with an EMA, and Kansas, a State without an EMA. 
How has the Administration factored in the negative impact that 
elimination of the 80-20 formula will have upon States without EMAs 
that rely upon an EMA to provide services to many of its residents?
    Answer 9. Under the President's principles, the concept of double 
counting would be eliminated. With regards to the situation in Kansas, 
the State would receive the benefit of the proportion of estimated 
living AIDS cases within the State that are outside of the boundaries 
of the EMA. In Kansas, approximately 64 percent of the cases fall into 
this category. In the State of Missouri, only 24 percent of the State's 
AIDS cases reside outside of the EMA area. This same methodology would 
be true for other EMAs/States where the EMA crosses State lines.

    Question 10. The President's principles call for the implementation 
of routine HIV testing in public facilities. How does the 
Administration propose to pay for routine testing in these facilities?
    Answer 10. An important feature of recommendations for routine HIV 
screening in health care settings is that screening becomes eligible 
for third-party reimbursement, analogous to other recommended screening 
(e.g., Chlamydia screening, mammography, cholesterol screening). 
Detecting HIV infection earlier through HIV screening (and optimizing 
opportunities for effective treatment and prevention) has been shown to 
be cost-effective, even in settings of low HIV prevalence. CDC 
anticipates that payers will be encouraged to cover screening, either 
separately or as part of the basis for payment to hospitals. Because 
HIV screening is cost-effective, some facilities may also choose to 
absorb the cost, or to redirect funds from other, less cost-effective 
programs. Public funds will continue to be necessary to support 
screening programs for indigent persons who have no health care 
coverage.

    Question 11. The Administration has endorsed opt-out testing. In 
this form of testing, a patient will be automatically tested unless he 
or she declines to be tested. How does counseling fit into this 
paradigm?
    Answer 11. Opt-out HIV screening has been endorsed for health care 
settings. Under opt-out testing, the patient is notified that HIV 
screening for all patients is routine, and the patient has the 
opportunity to ask questions and to decline testing. The provision of 
counseling at the time of disclosure of results will not change from 
current practices for persons who test positive for HIV. However, 
prevention counseling (i.e., pre-test counseling with the development 
of a risk reduction plan, and post-test counseling for HIV-negative 
persons) is not recommended in conjunction with HIV screening programs 
in health care settings. Several studies have shown that both patients 
and providers often perceive such counseling to be a barrier. Because 
of time constraints and other considerations, when conventional 
counseling and testing are recommended for health care settings, most 
patients receive neither. CDC's position, supported by numerous 
professional and consumer organizations, is that HIV screening in 
health care settings should be treated as an intervention distinct from 
HIV counseling as a prevention intervention. HIV counseling should be 
part of routine health promotion counseling in health care settings. In 
episodic care settings (such as emergency departments and acute care 
settings where confidentiality is difficult to achieve) it is usually 
not practical, and often not appropriate, to engage in intimate 
discussions of sexual or drug using behaviors. Experience has shown 
that for patients who are familiar with HIV and its consequences, such 
counseling is not necessary; for patients with substantial behavioral 
risks for HIV, counseling is likely insufficient. Please note that CDC 
is not recommending an opt-out approach in non-health care settings. In 
these settings, CDC's recommendations to provide counseling at the time 
of testing remain unchanged.

    Question 12. If HIV testing and counseling were to be incorporated 
into primary care services, how does the Administration propose to 
ensure that in a routine exam, the patient and doctor will be able to 
have a comprehensive conversation about HIV testing? Is the 
Administration proposing additional reimbursements for doctors as an 
incentive for providing testing as part of routine health care?
    Answer 12. CDC's proposed revised recommendations suggest that all 
persons receive HIV screening; they do not recommend that doctors have 
a comprehensive conversation about HIV testing with all patients. CDC 
proposes that HIV testing be treated like any other screening or 
diagnostic test. CDC anticipates that providers will use their clinical 
judgment in determining how much health promotion or education about 
HIV is warranted for each patient. Ample data from the National Health 
Interview Survey indicate that, by the mid-1990s, the U.S. population 
exhibited high levels of knowledge about HIV, HIV testing, and risk 
factors for HIV transmission. Emerging data suggest that singling out 
HIV testing (by imposing specific requirements for counseling or pre-
test information) is likely to perpetuate the stigma surrounding HIV 
testing. Qualitative research among high-risk consumers indicates that 
most already perceive HIV testing to be part of routine health 
maintenance, like mammograms or blood pressure checks. U.S. health care 
providers already conduct 14 million to 16 million HIV tests annually. 
Routine HIV screening has been shown to be cost effective, and CDC 
anticipates that routine HIV screening will be eligible for third-party 
reimbursement by those who already fund guideline-concordant care (such 
as private insurers, Medicare, and Medicaid.)

    Question 13. Assuming the current allocations for funding, and 
based on the most recent reports sent in by grantees, how many people, 
in both whole numbers and percentage by titles and States, is the CARE 
Act serving?
    Answer 13.

  Number of Duplicated Clients Served by Ryan White CARE Act Programs*
------------------------------------------------------------------------
             Program                   2002         2003         2004
------------------------------------------------------------------------
Title I..........................      778,457      840,421      736,813
Title II.........................      605,414      650,014      652,159
Title III........................      300,369      302,741      322,417
Title IV.........................      194,666      199,858      215,819
ADAP.............................      136,345      143,711      142,653
------------------------------------------------------------------------
* Clients may receive services from multiple providers that may, in
  turn, receive funding from one or more CARE Act programs. Thus, client
  counts by title are not mutually exclusive. In addition, while data
  are unduplicated at the provider level, any summary of the total
  number of clients served and their demographic characteristics at the
  grantee or national level may result in duplicated client counts.


                     Ryan White CARE Act, 2002-2004
              Number of Duplicated Clients Served by State*
------------------------------------------------------------------------
         State/Territory               2002         2003         2004
------------------------------------------------------------------------
Alaska...........................          603          603          587
Alabama..........................        7,675       12,045       11,884
Arkansas.........................        1,616        1,637        1,893
Arizona..........................       14,622       18,373       18,042
California.......................      156,605      153,327      147,530
Colorado.........................        8,705        7,886       10,678
Connecticut......................       14,968       14,010       16,028
Washington, DC...................       20,424       40,766       13,870
Delaware.........................        3,696        3,584        3,741
Florida..........................      144,920      144,005      120,708
Georgia..........................       28,661       23,402       25,427
Hawaii...........................        1,637        1,798        1,974
Iowa.............................        1,361        1,846        1,556
Idaho............................          401          602          490
Illinois.........................       25,885       29,528       33,033
Indiana..........................        3,542        1,947        4,399
Kansas...........................        2,378        2,804        3,542
Kentucky.........................        3,446        3,890        3,825
Louisiana........................       21,919       22,853       22,328
Massachusetts....................       24,433       22,291       22,805
Maryland.........................       25,915       31,670       27,424
Maine............................          840        1,154        1,042
Michigan.........................       14,581       12,786       12,319
Minnesota........................        5,983        6,481        6,964
Missouri.........................       14,057       15,321       15,009
Mississippi......................        3,835        4,421        4,312
Montana..........................          368          519          361
North Carolina...................       12,425       13,585       13,917
North Dakota.....................           60           65           56
Nebraska.........................        1,700        1,454        1,673
New Hampshire....................        1,864        1,258        1,426
New Jersey.......................       53,437       52,968       46,744
New Mexico.......................        1,406        1,581        1,592
Nevada...........................        6,665        6,363        7,521
New York.........................      153,586      177,912      156,492
Ohio.............................       17,270       15,244       15,521
Oklahoma.........................        2,845        2,873        2,789
Oregon...........................        6,276        5,294        5,916
Pennsylvania.....................       53,019       47,113       64,483
Puerto Rico......................       18,370       18,521       23,363
Rhode Island.....................        3,304        2,975        3,468
South Carolina...................        9,336       10,255       13,824
South Dakota.....................           74          205          214
Tennessee........................       12,969       14,868       19,169
Texas............................      102,954      134,857      100,118
Utah.............................        1,598        2,927        2,918
Virginia.........................       11,128       11,253       10,098
Virgin Islands...................          324          443          231
Vermont..........................          655          672          611
Washington.......................       11,211       11,425       12,357
Wisconsin........................        7,739        6,343        6,359
West Viriginia...................          872          828        1,032
Wyoming..........................           **          125           64
------------------------------------------------------------------------
*Clients may received services from multiple providers with a
  State.Thus, client counts by title are not mutually exclusive. In
  addition, while dataare unduplicated at the provider level, any
  summary of the total number of clients served and their demographic
  characteristics at the grantee or national level may result in
  duplicated client counts.
**No data reported

    Question 13a. Since the President's principles call for holding 
grantees accountable for client-level data counts, how are the numbers 
of clients currently compiled, and what is the level of accuracy in 
these estimates?
    Answer 13a. Every year, recipients of CARE Act funds (grantees and 
their service providers) are required to report to the Health Resources 
and Services Administration's HIV/AIDS Bureau (HRSA/HAB) how those 
funds have been used to provide services to low-income and underserved 
individuals and families living with HIV/AIDS. The Ryan White CARE Act 
Data Report (CADR) is the annual reporting instrument that must be 
completed by agencies and organizations receiving funds to describe: 
(1) characteristics of their organization; (2) the number and 
characteristics of clients they served; (3) the types of services 
provided; and 4) the number of clients receiving these services and the 
number of client visits by type of service. Agencies/organizations that 
provide counseling and testing services report on the number of 
individuals receiving these services. In addition, providers of 
ambulatory/outpatient medical care provide some information on the 
outcomes of their services.
    The utility of CADR data is limited by duplicated client counts. 
CADR data as collected and reported by individual service providers are 
generally unduplicated. However, since an individual client may receive 
services from more than one provider, there is no way of knowing that 
the counts of individuals served by one provider are not also included 
in the counts of another service provider. Thus, aggregating the 
provider data to the grantee, State and/or national level results in 
duplicate client counts. The estimated rate of duplication for CARE Act 
data at the national level is 45 percent to 55 percent.

    Question 13b. Given that the IOM has stated that code-based systems 
can be used accurately and effectively, how is HRSA working with code-
based States to increase the accuracy of the system?
    Answer 13b. CDC appreciates the opportunity to clarify our 
understanding of the IOM's findings presented in the report entitled 
``Measuring What Matters'' and to describe our technical assistance 
activities with States that are implementing HIV reporting systems 
using patient identifiers other than the name of the person diagnosed 
with an HIV infection. CDC, rather than HRSA, has the charge to develop 
a nationwide HIV/AIDS surveillance system.
    The IOM did not evaluate the accuracy or effectiveness of code-
based systems. The IOM noted in the report that it was beyond its 
capacity to evaluate the HIV case-reporting system of each State and 
territory. Additionally, the IOM did not evaluate the use of HIV 
reporting data for public health purposes, such as epidemic 
surveillance. The IOM focused on the issue of ``whether incorporating 
HIV reporting into the RWCA formulas would provide a better 
representation of HIV disease-related resource needs across 
jurisdictions and more fairly channel scarce RWCA resources.'' The IOM 
concluded that the reporting of HIV cases was not complete and accurate 
enough nationwide to allow these HIV case numbers to be used in 
determining how funds from the Ryan White CARE Act should be allocated 
among States and metropolitan areas.
    Despite these recognized limitations, the IOM provided three 
recommendations for improving national HIV reporting for the purpose of 
resource allocation:
    (a) ``The CDC should accept reported HIV cases from all States. 
Until this occurs, large numbers of HIV cases will not be included in 
the national HIV reporting system, and there will be no reliable 
centralized way to use reported HIV cases to apportion CARE Act funds. 
CDC should work with all States to develop and evaluate methods for 
unduplicating HIV cases regardless of whether such cases are code- or 
name-based. The Secretary of HHS should provide CDC with the funding to 
provide the technical assistance to States necessary to support the 
integration of code- with name-based data into the national HIV 
reporting database. Because of the importance of obtaining consistent 
data from all jurisdictions, the CDC should include HIV reporting data 
from code-based States and estimate the degree of overcounting due to 
duplication while procedures and infrastructure for definitive 
unduplication are developed.
    (b) CDC should collaborate with all States to periodically assess 
and compare the completeness and timeliness of their HIV reporting 
systems.
    (c) The Secretary of HHS should provide additional funds to CDC to 
assist States in improving the completeness and timeliness and overall 
comparability of their HIV reporting systems. Enhancing electronic 
laboratory reporting in all States is critical in achieving this goal. 
Pharmacy-based surveillance, with a focus on the ADAP, is another 
potential source of information for enhancing completeness.''
    The IOM did not recommend that CDC accept code-based data because 
``code-based systems can be used accurately and effectively,'' but 
rather the IOM determined that there was insufficient evidence to 
conclude that no potential method could be developed to integrate data 
from both of these systems for the purpose of de-duplicating cases 
across States. The committee also noted that code-based reporting 
systems were developed by some States after substantial political 
debate, and altering those systems would require significant 
legislative changes, time, and effort.
    The IOM did not have available the final results of the Interstate 
Duplication Evaluation Project when it made these recommendations. The 
Interstate Duplication Evaluation project made clear that technical 
problems made it impossible to efficiently include code-based reports. 
These problems included: (1) the variety of codes used by the different 
States conducting this type of surveillance; (2) the lack of a central, 
standardized, national database with code-based reports; and (3) the 
inability of States using codes to adequately communicate with States 
using names regarding potential duplicate records. Therefore, only 
name-based reports could be included. The results of this assessment 
indicated that the number of duplicate reports for non-AIDS HIV cases 
varied a great deal from State to State, and exceeded the proportion of 
duplicate case reports for AIDS cases. CDC's policy is to accept only 
HIV infection and AIDS case surveillance data from the areas conducting 
confidential name-based reporting because name-based reporting has been 
evaluated and has historically achieved high levels of accuracy and 
reliability.
    CDC is providing technical assistance to States transitioning from 
code- to name-based systems to assure that their data can be integrated 
into the national HIV (non-AIDS and AIDS) data system as quickly as 
possible. CDC has assisted the seven States that have made the 
transition to name-based systems since the IOM report was published in 
2004. Currently 43 States have adopted use of name-based systems of HIV 
reporting.
    CDC continues to provide funding and technical assistance to States 
that use code-based methods for identifying patients in their HIV 
surveillance system. CDC is implementing and disseminating methods for 
conducting evaluations of the accuracy and reliability of reporting 
systems within States, regardless of reporting method. CDC is deploying 
data management software that integrates functions that will allow 
areas to use standardized methods to evaluate their systems based on 
recently completed pilot studies. In addition, CDC regularly offers 
technical assistance to areas using code-based systems that have not 
received this software. This assistance includes the software, and 
relevant documentation, that was used in the pilots.

    Question 14. How is HRSA working with the CDC to help high-
incidence States prevent new infections and reduce incidence rates? 
What specific programs does HRSA have to help high-incidence States 
serve the needs of newly detected individuals?
    Answer 14. The CDC Advancing HIV Prevention Initiative aims to 
reduce HIV transmission by encouraging people to learn their HIV 
status; provide referrals to care, treatment, and prevention services; 
and to prioritize prevention services for persons with HIV. All of the 
CDC initiative's main precepts directly affect HIV care and the Health 
Resources and Services Administration (HRSA) HIV/AIDS Bureau's (HAB) 
programs: to make HIV testing a routine part of medical care; to 
prevent new infections by working with persons diagnosed with HIV and 
their partners; and to further decrease perinatal transmission by 
screening all pregnant women for HIV. HAB is working closely with the 
CDC to collaborate on projects that support the initiative, as well as 
working to promote HIV prevention, counseling, and testing in our HRSA 
programs. Activities that support the CDC's initiative currently 
include: training providers on HIV counseling and testing, use of the 
Rapid test and integrating HIV prevention into clinical care through 
our AIDS Education and Training Centers (AETC) programs; testing models 
that integrate prevention activities into clinical care settings; 
collaboration with CDC and other agencies to identify methods to 
streamline and integrate case management services; and ways to promote 
perinatal counseling and testing activities. In addition, CDC and HAB 
worked together in an effort to quantify the impact of this initiative 
on HIV care and treatment programs.

    Question 15. In the past 3 fiscal years, what percentage of funding 
by title has gone to the administrative tap? In addition to the SPNS 
program, how has this evaluation tap been used on a title-by-title 
basis?
    Answer 15. All Ryan White Titles are reduced less than 1 percent 
for administrative costs. These costs include program costs budgeted 
centrally. An example of this is the review of grant applications which 
are conducted by the Division of Independent Review in the Office of 
the Administrator. This office procures contract services to assure 
that HRSA's grants and contracts have an independent review that 
assures that the process if fair, open, and competitive.
    As specified in an Agency's appropriations language, PHS Evaluation 
funds support critical evaluation activities throughout HHS. These 
evaluations, and the data collection and analysis that support them, 
improve program performance by ensuring that timely and accurate 
information is available to support funding and management decisions. 
PHS Evaluation funds are used to promote health care quality 
improvements through research using scientific evidence regarding all 
aspects of health care including the Ryan White Special Projects of 
Nation Significance (SPNS). In Ryan White, PHS Evaluation funds are 
used solely for the SPNS program.

    Question 16. Could you please explain how HRSA is working with 
community health centers (CHC) to provide care to individuals with HIV? 
How much funding from the CARE Act is being directed to CHC-provided 
services, and how many HIV+ individuals are being served by these CHCs?
    Answer 16. The HIV/AIDS Bureau works closely with the Bureau of 
Primary Health Care to provide outpatient primary care and support 
services for people living with HIV who receive care in Ryan White CARE 
Act funded programs and in community health centers. Community health 
centers receive funding from each Title of the Ryan White CARE Act.


----------------------------------------------------------------------------------------------------------------
                                                                              Amount of CARE   # of HIV+ Clients
                                                          # of CHCs Funded   Funding to CHCs    Served in these
                                                              by RWCA*          in FY 2004           CHCs**
----------------------------------------------------------------------------------------------------------------
Title I................................................                 73        $25,751,980             33,198
Title II...............................................                 71        $14,281,670             28,602
Title III..............................................                130        $59,232,352             48,708
Title IV...............................................                  7        $ 3,301,092             11,518
----------------------------------------------------------------------------------------------------------------
* Community health centers may receive funding from multiple CARE Act programs. Counts of CHCs by title are not
  mutually exclusive.
** Clients may have received services from multiple providers that may, in turn, receive funding from one or
  more CARE Act programs. Thus, client counts by title are not mutually exclusive. In addition, while data are
  unduplicated at the provider level, any summary of the total number of clients served and their demographic
  characteristics at the grantee or national level may result in duplicated client counts.

    Additionally, title IV programs identify HIV-positive pregnant 
women and connect them with care that can improve their health and 
prevent perinatal transmission.
    Title III and IV program services are integrated into CHCs and 
include:

     Risk-reduction counseling on prevention, antibody testing, 
medical evaluation, and clinical care; including prenatal and dental 
care.
     Antiretroviral therapies; protection against opportunistic 
infections; and ongoing medical, oral health, nutritional, 
psychosocial, and other care services for HIV-infected clients;
     Case management to ensure access to services and 
continuity of care for HIV-infected clients;
     Mental Health Services; and
     Attention to other health problems that commonly occur 
with HIV infection, including tuberculosis and substance abuse.

    Question 17. How many health care professionals are trained by the 
AETCs per year? What recommendations would HRSA make to ensure that 
AETCs are able to train all health professionals who seek to serve 
individuals with HIV?
    Answer 17. During the grant year 2003-04, the AETCs conducted a 
total of 14,211 training events. These events amounted to 47,585 hours 
of instruction. A total of 6,704 group trainings took place, 
representing Level I-IV training events. An estimated 73,239 
individuals attended these group trainings. In addition, 5,166 
individual clinical consultation events as well as 2,341 technical 
assistance (TA) training events took place.
    Trainers reported that 142,393 participants attended Level I-IV 
training events. (This number is a duplicated count of providers 
trained because the same individual could attend multiple trainings 
throughout the year.) Level V training events did not report number of 
participants.
    The program targets providers who treat minority, underserved, and 
vulnerable populations in communities most affected by the HIV 
epidemic.

    Question 18. Could you please outline the ways in which you work 
with the CDC to develop HIV and AIDS case counts in each State? What 
are your current state-by-state estimates of incidence and prevalence 
for HIV and AIDS?
    Answer 18. CDC provides HRSA the following types of data:
    (1) Every year CDC provides AIDS case counts for States and EMAs, 
based on reports to local and State health departments by name for the 
previous 10 12-month periods. These data are not adjusted in any way 
and constitute crude counts of reported cases. This is prescribed in 
the current Ryan White Care Act legislation.
    (2) CDC also provides reported cumulative AIDS case counts to 
identify areas that qualify as EMAs and Emerging Communities.
    (3) Until recently, CDC has provided HRSA with incidence and 
prevalence data on AIDS diagnoses, as well as prevalence data on HIV 
diagnoses for 33 States, adjusted for reporting delays and risk 
redistribution based on case report data submitted by the States. The 
last set of these data provided to HRSA included estimates for cases 
diagnosed through 2004. Data on HIV (not AIDS) were only included from 
States with confidential, name-based HIV reporting. AIDS data from all 
States were included in these data tables because all States use 
confidential, name-based reporting for AIDS surveillance. These data 
were not used directly within a formula to determine funding, but are 
provided to the States to include in their applications in order to 
depict the epidemiologic picture of the HIV/AIDS burden in their area. 
However, this assistance is no longer needed. As part of the CDC 
program called ``Epidemiologic Capacity Building'' CDC has been 
providing the States with software to conduct the necessary analyses 
using their own data to generate these estimates. The States will be 
able to generate their own numbers for completing their applications. 
Therefore, CDC informed HRSA in 2005 that it would no longer provide 
these estimates to HRSA.
    The latest published estimates of HIV and AIDS were published in 
the CDC HIV Surveillance Report, Volume 16 (http://www.cdc.gov/hiv/
topics/surveillance/resources/reports/2004report/pdf/
2004SurveillanceReport.pdf).
    AIDS prevalence data are available from all States, and HIV (not 
AIDS) prevalence data were published from 33 States with long-standing, 
HIV reporting. AIDS incidence data are provided in Table 3; HIV 
incidence data are not available. Unlike data provided to HRSA for use 
in funding allocations, the data published in this report were adjusted 
for reporting delays. CDC recommends that unadjusted data be used for 
funding allocations.

    [Whereupon, at 4:20 p.m., the committee was adjourned.]

                                    

      
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