[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.]