[House Hearing, 111 Congress]
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74-093

                                 2012__

2012

                    RYAN WHITE EXTENSION ACT OF 2009

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 9, 2009

                               __________

                           Serial No. 111-60


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov
?

                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman

JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JANICE D. SCHAKOWSKY, Illinois       SUE WILKINS MYRICK, North Carolina
CHARLES A. GONZALEZ, Texas           JOHN SULLIVAN, Oklahoma
JAY INSLEE, Washington               TIM MURPHY, Pennsylvania
TAMMY BALDWIN, Wisconsin             MICHAEL C. BURGESS, Texas
MIKE ROSS, Arkansas                  MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          PHIL GINGREY, Georgia
JIM MATHESON, Utah                   STEVE SCALISE, Louisiana
G.K. BUTTERFIELD, North Carolina
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA CHRISTENSEN, Virgin Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE BRALEY, Iowa
PETER WELCH, Vermont

                                  (ii)
                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
BART GORDON, Tennessee                   Ranking Member
ANNA G. ESHOO, California            RALPH M. HALL, Texas
ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
DIANA DeGETTE, Colorado              JOHN B. SHADEGG, Arizona
LOIS CAPPS, California               STEVE BUYER, Indiana
JAN SCHAKOWSKY, Illinois             JOSEPH R. PITTS, Pennsylvania
TAMMY BALDWIN, Wisconsin             MARY BONO MACK, California
MIKE ROSS, Arkansas                  MIKE FERGUSON, New Jersey
ANTHONY D. WEINER, New York          MIKE ROGERS, Michigan
JIM MATHESON, Utah                   SUE WILKINS MYRICK, North Carolina
JANE HARMAN, California              JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JOHN BARROW, Georgia                 MICHAEL C. BURGESS, Texas
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Ed Whitfield, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     3
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................     3
    Prepared statement...........................................     5
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     9
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, opening statement.................................    10
Hon. Eliot L. Engel, a Representative in Congress from the State 
  of New York, opening statement.................................    11
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    13
Hon. Jane Harman, a Representative in Congress from the State of 
  California, opening statement..................................    13
Hon. Kathy Castor, a Representative in Congress from the State of 
  Florida, opening statement.....................................    14
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................    15
Hon. Lois Capps, a Representative in Congress from the State of 
  California, opening statement..................................    16
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................    17
Hon. John P. Sarbanes, a Representative in Congress from the 
  State of Maryland, opening statement...........................    18
Hon. Betty Sutton, a Representative in Congress from the State of 
  Ohio, opening statement........................................    18
Hon. Donna M. Christensen, a Representative in Congress from the 
  Virgin Islands, opening statement..............................    19
Hon. Christopher S. Murphy, a Representative in Congress from the 
  State of Connecticut, opening statement........................    20
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, opening statement.......................................    21

                               Witnesses

Mary Wakefield, Administrator, Health Resources and Services 
  Administration, United States Department of Health and Human 
  Services.......................................................    22
    Prepared statement...........................................    25
Marcia Crosse, Ph.D., Health Care Director, U.S. Government 
  Accountability Office..........................................    53
    Prepared statement...........................................    56
Julie M. Scofield, Executive Director, National Alliance of State 
  and Territorial AIDS Directors.................................    67
    Prepared statement...........................................    69
Donna Elaine Sweet, M.D., MACP, AAHIVS, Professor, Department of 
  Internal Medicine, University of Kansas, School of Medicine, 
  Board Chair, American Academy of HIV Medicine..................    97
    Prepared statement...........................................    99

 
                    RYAN WHITE EXTENSION ACT OF 2009

                              ----------                              


                       TUESDAY, SEPTEMBER 9, 2009

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 11:07 a.m., in 
Room 2123, Rayburn House Office Building, Hon. Frank Pallone, 
Jr., [chairman of the subcommittee] presiding.
    Present: Representatives Pallone, Dingell, Eshoo, Engel, 
Green, DeGette, Capps, Harman, Barrow, Christensen, Castor, 
Sarbanes, Murphy, Sutton, Waxman (Ex Officio), Deal, Whitfield, 
Shimkus, Pitts, Burgess, Blackburn, Gingrey, and Barton (Ex 
Officio).
    Staff Present: Naomi Seiler, Health Policy Analyst; Camille 
Sealy, Legislative Fellow; Alvin Banks, Special Assistant; 
Miriam Edelman, Special Assistant; and Chad Grant, Minority 
Legislative Analyst.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. The subcommittee will be called to order. We 
are minus a gavel today, but I don't think we really need it. 
Let me announce this morning that the hearing this morning is 
on the Ryan White CARE Act of 2009--actually a discussion 
draft. So we don't have a bill number. I will recognize myself 
initially for an opening statement. This discussion draft has 
been circulated by Chairman Waxman and myself and is based, in 
large part, on the community consensus document that was put 
together by a large number of AIDS groups from all across the 
country. Though we will be using this discussion draft as a 
basis for our hearing today, it is very much a draft, and I am 
interested in having conversations with the minority as well as 
with the Senate in an effort to come up with a strong piece of 
legislation that can be passed by both Chambers and be signed 
into law by the President. The Ryan White CARE Act, as many of 
you know, was named after a young boy who contracted the AIDS 
virus from a blood transfusion and sadly lost his life to this 
horrible disease.
    Since his death in 1990 we as a Nation have made great 
strides in preventing and treating HIV/AIDS in large part due 
to the Ryan White program. Once a guaranteed death sentence, an 
HIV or AIDS diagnosis today means a complicated and expensive 
mix of drugs and therapies that can allow individuals to live 
longer and more prolific lives and, for many, new knowledge of 
the disease has allowed for better and more targeted prevention 
programs that have slowed the spread of HIV/AIDS. In spite of 
these advancements, however, there are nearly 40,000 new HIV/
AIDS infections reported each year, and according to the CDC, 
approximately 1.1 million Americans are currently living with 
the disease. Since the beginning of this epidemic, an estimated 
580,000 Americans with AIDS have died. So I think it is more 
crucial than ever, given the high number of Americans suffering 
from the disease, that we have the Ryan White program, 
accounting for roughly 10 percent--or I should say 19 percent 
of all Federal funds that are used on HIV/AIDS care, the 
program provides treatment and support services to individuals 
and families living with the AIDS virus and serves over half a 
million low-income Americans.
    The program is, without a doubt, extremely vital in our 
battle against this epidemic. In 2006, Congress reauthorized 
the Ryan White program and included a sunset provision that 
will eliminate the program entirely on October 1 of this year. 
I think I am pretty certain in saying that no one in this room 
today wants that to happen. That is why Chairman Waxman and I 
have released the draft legislation we are examining today. The 
discussion draft before us is based on the community consensus 
document and would make a few minor improvements to the Ryan 
White program. It eliminates the sunset provision so that we 
will never face a last-minute scramble to sustain vital 
services to our communities. In addition it would extend the 
current program for 3 years and provide more flexibility for 
the appropriators to adequately fund the Ryan White program to 
best serve the evolving needs of patients, families and 
communities.
    The discussion draft extends the exemption period for 
States that are still reporting their HIV cases under a code-
based system that will allow those States to get their names-
based systems fully up and running and to ensure their data is 
accurate and useful. In the same vein, it would also ensure 
that no transitional grant area, or TGA, would lose their 
status for the duration of this extension. It would continue to 
hold harmless provisions that were established during the 2006 
reauthorization which protects grantees from large increases in 
funding so that we don't disrupt the provision of care to 
patients. We have also included a few more technical tweaks to 
the current Ryan White program, all of which guarantee that 
patients continue to be able to access these life-saving and 
life-sustaining treatments and services.
    As I mentioned before, the Ryan White CARE Act is scheduled 
to sunset on September 30. So we must act now to ensure that 
the patients continue receiving the excellent care that this 
program provides. And I sincerely hope that we will be able to 
work in a productive, bipartisan, bicameral fashion to create a 
bill that will benefit over a million citizens fighting this 
disease in the United States. And I want to thank the AIDS 
community for their hard work in coming together on the 
consensus document. We greatly appreciate the work you have 
done. I will now recognize--well, Mr. Deal isn't here, so I 
have my colleague from Kentucky acting as the ranking member 
today. Mr. Whitfield is recognized.

  OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Whitfield. Chairman Pallone, thank you very much for 
holding this hearing on the discussion draft to reauthorize the 
Ryan White legislation. All of us are very supportive of the 
Ryan White program. And back in 2006 we were happy to work in a 
bipartisan manner to reauthorize that program for 3 years. We 
do take you at your word today to work with us in a bipartisan 
way as we move forward to reauthorize this draft. And I might 
say that while we love this program and we recognize the 
benefits of this program, I have two particular areas of 
concern. Number one, in the discussion draft we authorized such 
sums as necessary for 2010, 2012.
    When you consider the financial condition of our country 
right now, our constituents and practically every economist 
from every spectrum are very much concerned about the size of 
our debt. So number one, we spent about $2.2 billion on this 
program last year, and another reason that I really have 
concern about the open-endedness of this is that we have a 
tendency--not necessarily this committee, but I think all 
committees have a tendency of relinquishing more and more 
authority to appropriators. And that is precisely what this 
legislation does, such sums as necessary.
    So I think we would be better you have putting in a number 
that we authorize for the two reasons that I have mentioned. I 
would also say that another area that I am concerned about is 
the grandfathering of these transitional grant areas. There are 
requirements that must be met for the transitional grant areas 
to receive money. And under this discussion draft, if you had 
an area that was receiving grant money for the last 3 years, 
then they would automatically be grandfathered for another 3 
years. It certainly is possible that the need may be greater in 
some other area.
    So those are two areas that I particularly am concerned 
about. But once again, we are delighted that you are holding 
this important meeting on the discussion draft, and we hope 
that we can work with you and reach a consensus on this 
legislation and get it reported out of committee. Thank you 
very much.
    Mr. Pallone. Thank you. I recognize the chairman of our 
full committee, Mr. Waxman.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you very much, Mr. Chairman. Since its 
inception in 1990, the Ryan White program has played a critical 
role in addressing this country's AIDS/HIV epidemic. Today more 
than half a million Americans rely on the program for basic 
care, treatment and support services. It is hard to imagine how 
patients, their families and our States would be able to deal 
with the epidemic without this program in place, which is why 
it is so important that we act as quickly as possible to 
reauthorize the program.
    With today's hearing, we begin that process, which I hope 
will culminate in a piece of legislation that Members from both 
sides of the aisle can strongly support. I believe the 
discussion draft weare reviewing today makes for an excellent 
start towards that end. It contains no major changes to the program. 
Indeed, most of its sections either extend existing policies or clarify 
parts of current law that have caused confusion.
    Others make changes to mitigate the stabilizing funding 
decreases that have resulted from the application of the 2006 
reauthorization. We will hear more about these specific 
provisions from our witnesses today. I think an overarching 
theme that will emerge is that with some relatively plain fine-
tuning, the Ryan White program can continue to do its good 
work, providing services to those most in need for another 3 
years. This is especially important because of the program's 
looming sunset deadline of September 30. A quick 
reauthorization will give grantees the stability they need to 
plan, retain staff and maintain lifesaving services for their 
clients. The painful budget cuts that we are seeing in so many 
of our States make it all the more important to provide that 
stability. That said, I want to underscore the word ``draft'' 
that is in the title of the document that is the subject of 
today's hearing.
    This draft was informed by technical assistance from the 
administration as well as a community consensus paper that has 
been endorsed by nearly 300 organizations in 47 States. But 
this is just a starting point. We have already begun talking 
through various issues raised in the draft in a bipartisan 
fashion. Soon we will begin negotiations with our colleagues in 
the Senate with the commitment to doing our best to reach an 
agreement before the end of this month. That will take much 
hard work, but I believe we can get there. We simply have to.
    The people who depend on the Ryan White program for the 
services they need can't wait. I look forward to working with 
all our colleagues on this committee in ensuring that we reach 
this goal and that an even stronger Ryan White program will be 
in our communities for another 3 years. Thank you, Mr. 
Chairman.
    [The prepared statement of Mr. Waxman follows:]
    T4093A.001
    
    T4093A.002
    
    T4093A.003
    
    T4093A.004
    
    Mr. Pallone. Thank you, Chairman Waxman. Next, the 
gentleman from Pennsylvania, Mr. Pitts. He waives. The 
gentleman from Texas, Mr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman. You know, with all 
the focus on health care reform in Congress right now, the Ryan 
White CARE Act probably isn't foremost on the minds of 
Americans. In fact, probably many of our colleagues aren't even 
aware of what the CARE Act is, and what it does. You know, in 
an ideal world, we wouldn't have the CARE Act because we would 
have already found a cure and we would already have a reliable 
vaccine for this disease and prevent it before it occurs.
    And that still needs to be our foremost thought and our 
ultimate goal. I understand how dangerous HIV/AIDS is and how 
important it is to have adequate resources to prevent infection 
and to manage this disease. Over a million Americans are 
infected, and nearly a quarter of those individuals are unaware 
that they carry the infection and are thus at risk for 
continuing the spread. My home State of Texas is consistently 
in the top five with respect to the number of HIV and AIDS 
infections.
    I represent a district in north Texas that has been 
experiencing a rise in new cases. The face of AIDS has changed 
and we have a responsibility to ensure that the CARE Act is 
meeting the needs of those AIDS patients today. In the State of 
Texas, almost half of all HIV and AIDS infections are occurring 
in the African American population. The average HIV rate per 
100,000 population for Tarrant County, one of my counties, is 
three times greater in the African American community than in 
other communities. In fact, HIV infections are increasing 
throughout the south. We saw a spike of AIDS cases in the mid 
1990s and a decline in the late 1990s and now the rates have 
begun to increase again and climb ever upwards.
    In fact, Mr. Chairman, if we look at the way the Ryan White 
CARE Act is structured, it is also important for me to ensure 
that my constituents in both rural and urban areas be equally 
served by this act. The committee has made some important 
changes in the legislation, passed in a bipartisan manner out 
of this committee in 2006. Unfortunately, some of those changes 
never made it into law, and I hope we simply don't kick the can 
down the road and we invest the time necessary to really create 
the Ryan White CARE Act for the 21st century. I am saddened 
that it appears we are preparing to just push through a bill.
    We have proven just a few short years ago that this is an 
issue that Republicans and Democrats can agree on and can come 
together on. Congress has the opportunity to provide a better 
health care delivery system, moving from a palliative care 
model to a blended chronic care model that recognizes HIV as an 
increasingly manageable disease.
    And again, let me stress we need sufficient funding for 
vaccine research. We need sufficient funding about actually 
finding a cure. No one, no one should be come out on the short 
end of the stick because of where they live because Congress 
simply decided to rush something through. If we really care 
about this population we will focus on patients, focus on 
patients and make time, make sure that we take the time to work 
across the aisle to produce such a bill. Thank you, Mr. 
Chairman. I will yield back the balance of my time.
    Mr. Pallone. Thank you. Chairman Dingell.

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Dingell. Good morning, Mr. Chairman. And thank you for 
holding this important hearing. I also want to thank today's 
witnesses for joining us. I wish to applaud the National 
Alliance of State and Territorial AIDS Directors, the AIDS 
action and other members of the Ryan White Working Group. Your 
year-long cooperation and collaboration and consensus and 
priorities from the HIV/AIDS communities will make our work 
easier. Today is an important hearing for many reasons. The 
first is the importance of the subject matter. The second is 
the fact that the Ryan White program will expire on September 
30 this year.
    That means we have a deadline against which we must work. 
We cannot let this program expire. Since 1990, the Ryan White 
program has been one of the most important pieces of our 
domestic response to the HIV/AIDS epidemic. It funds health 
care and support services for persons living with AIDS and HIV. 
The dollars spent here help over half a million people every 
year. As a payer of last resort, the Ryan White program is a 
critical piece of our social safety net, protecting some of our 
most vulnerable citizens, including more than 13,000 people 
living with HIV/AIDS in my home State of Michigan alone.
    I would also note that this is a program which is a very 
important defense to our society against the transmission and 
the expansion of the AIDS virus further into our society. 
According to the Kaiser Family Foundation, most of the patients 
who receive services from the Ryan White funds are low income. 
About 72 percent have incomes at or below the poverty level, 33 
percent are without insurance, 56 percent are underinsured. I 
am working hard to make sure we pass this important health care 
reform this year so that no American goes without insurance.
    However, even after all the proposed insurance market 
reforms go into effect, we will need extra funding for 
wraparound services that meet the specific needs of HIV/AIDS 
patients. The Ryan White program also helps to keep the doors 
of community health clinics open to people with HIV/AIDS that 
have no place else to turn.
    During our health care reform discussions, we have talked 
at length about the value of the medical home model that 
provides continuous coordinated and comprehensive care to 
individuals. Many of these HIV/AIDS clinics have been operating 
as medical homes before we even had the terminology and have 
been doing so with Ryan White funds.
    Finally, this program is vital to our States and 
metropolitan areas. Without Federal funding for the Ryan White 
programs, States and localities will be left on the hook for a 
substantial portion of HIV/AIDS care and the society will be 
greatly increased in the risk that it faces from HIV/AIDS.
    We cannot pass the burden on to the cities and the States 
and the communities, especially in the midst of calamitous 
budget shortfalls that they all confront. I urge my colleagues 
in this room to work collaboratively and unfortunately with 
great swiftness to ensure that we meet the September 30 
deadline and to minimize the disruption of funding and services 
for people living with HIV/AIDS.
    This program is too important to disappear and the dangers 
of letting that happen are far too great. I thank you, Mr. 
Chairman. I yield back the balance of my time.
    Mr. Pallone. Thank you, Chairman Dingell. Next is the 
gentleman from Georgia, Mr. Gingrey.
    Dr. Gingrey. Mr. Chairman, I will waive an opening 
statement.
    Mr. Pallone. The gentleman from Illinois, Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman. I would like to say 
to my colleagues, welcome back from our break. It is good to be 
here. And I look forward to a productive fall. This is a good 
start. Ryan White is supported, as was stated by many, by a 
bipartisan group of Members. I am not falling in the category 
that we have to move quickly or rapidly. I think we are 
learning that that is not always the best way to deal with 
public policy. We could do a simple reauthorization with no 
changes. Unfortunately we are falling down also the same trap 
as addressing draft bills, and I hope that if and when after 
this hearing we hear changes and corrections that we--in a bill 
finally gets submitted, that we would have a legislative 
hearing on the bill. It has been the history of this committee 
to do that. It hasn't been the current history of this 
committee to do that. So we are kind of back where we started 
from before the break, having hearings on draft legislation 
instead of real legislation. And I hope we change course with 
that. I am happy to be back and happy to see all my colleagues. 
And I yield back the balance of my time.
    Mr. Pallone. I thank the gentleman. The gentleman from New 
York, Mr. Engel.

 OPENING STATEMENT OF HON. ELIOT L. ENGEL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Engel. Thank you, Mr. Chairman, for holding this 
important hearing on the Ryan White CARE Act reauthorization. 
The Ryan White CARE Act holds very special significance to my 
State, New York, we are, unfortunately, home to 16 percent of 
the Nation's AIDS population. And so New York remains the 
epicenter of the HIV/AIDS crisis. New York has nearly 120,000 
residents living with HIV/AIDS, and our State and cities have 
been proud to partner with the Federal Government in providing 
care for many of these individuals. New York State receives 
more than $300 million in Ryan White funds under all parts of 
this Act to provide a range of health care and support 
services. Through Ryan White programs, 22,000 uninsured New 
Yorkers receive medications and ambulatory care services, and 
thousands more receive other essential services such as mental 
health, case management, nutrition and treatment and support 
services.
    These individuals must be guaranteed uninterrupted access 
to these vital services. It is critical that Congress act 
swiftly on the reauthorization of the Ryan White 
Reauthorization Act, which nationwide provides lifesaving 
medications, health care and support services to over half a 
million people. As you know, unlike most reauthorizations, 
Congress inserted a sunset provision into the Act in 2006, 
requiring congressional action by September 30 of this year, 
2009. Without action, this important program will be terminated 
and care will be jeopardized.
    While 3 years ago, this reauthorization was the subject of 
much disagreement and dissent--and I remember because I was in 
the middle of it--we are in a different place today. 
Fortunately, Members on both sides of the aisle and more than 
250 organizations in the U.S. have worked hard over the past 
year to develop legislative principles where there is much 
agreement. The committee draft proposal is for a 3-year 
reauthorization of the Ryan White HIV/AIDS Treatment 
Modernization Act. While some might ask why we again are 
working to reimplement relatively short reauthorization, there 
is good reason. The 2006 reauthorization took effect in 2007 
and included several significant changes that have not yet been 
fully implemented or assessed. In addition, greater policy 
discussions likely to impact the program such as the 
development of a national AIDS strategy and broader health care 
reform are underway. Indeed, the health reform legislation that 
we are continuing to develop once fully implemented will have a 
profound effect on our ability to provide access to health care 
and prevention services to individuals with HIV/AIDS 
nationwide.
    As currently drafted, we will reform the private insurance 
market and end the practice of excluding beneficiaries for pre-
existing conditions. We will reform Medicaid by allowing early 
treatment for individuals with HIV before they are disabled by 
AIDS in the first 3 years of enactment and will, in fact, 
expand the Medicaid eligibility to cover low-income childless 
adults.
    I am proud of the work I have done with you, Mr. Chairman, 
and others to ensure that. Long term we will create exchanges 
for the purpose of insurance with subsidies for low-income 
individuals; and finally, we will close the Medicare Part D 
donut hole over time. While these are significant changes in 
the health care delivery system, we will still need the Ryan 
White program, which remains the payer of last resort, to 
address unmet needs and services, particularly over the next 3 
years.
    In conclusion, Mr. Chairman, I want to commend you. I want 
to commend you for the draft bill which addresses many of the 
points raised in the community consensus document as well as 
the specific concerns of my home State. While there are some 
issues related to rebates and grant funding that I will 
continue to work with the Chairman on prior things to mark up, 
I support the draft bill and look forward to the discussion 
today. Again, Mr. Chairman, I want to emphasize our thanks to 
you, because you have been such an important integral player in 
this and have been so supportive that we really need to 
publicly thank all the work you have done. I yield back.
    Mr. Pallone. Thank you. The gentlewoman from Tennessee, 
Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman. I appreciate the 
hearing that we are having today and want to welcome our 
witnesses. In 2006, my colleagues and I passed what I think was 
a thoughtful bipartisan reauthorization of the Ryan White CARE 
Act. The reauthorization has proven very successful in the 
Tennessee HIV/AIDS community and has assisted more than 7,800 
low-income Tennesseans with medical services, medications, 
dental service, drug abuse, mental health and related health 
care needs. The Ryan White program provides an important safety 
net in assisting the underinsured in keeping health insurance 
and provides care to the uninsured. The program reinforces the 
fact that keeping people on private insurance provides great 
benefit to the individual and to the community. We have seen 
success with this program. As we move forward with the Ryan 
White reauthorization, it is imperative that this committee 
work in a bipartisan manner to best serve the recipients of 
this program and to meet their needs. Congressneeds to be good 
stewards of Federal funds. Our constituents--if we have learned 
anything in August, what we have learned from our constituents is that 
they see it as an imperative, and so should we, that we be good 
stewards of the Federal funds and that we place appropriate funding and 
spending limits in place and not open-end those authorizations. Access 
to care is one of the biggest concerns among my constituents.
    There are real problems in health care, but what we know is 
replacing private care with a government bureaucrat won't 
increase access and it will not fix our health care system. In 
Tennessee via the TennCare program, we have learned that lesson 
the hard way. My constituents also want us to spend less money 
to fix the problems that exist in health care, and my 
colleagues on this side of the aisle have joined me in offering 
plans for doing that. My constituents are telling us repeatedly 
that they do not want another $800 billion in higher taxes for 
a government-run plan that is not going to make health care 
better or cheaper or more available. They realize that there 
are issues that need to be addressed. Just as they realize 
there are programs that have worked in a bipartisan manner, and 
as we look at the Ryan White CARE Act, which has worked when 
appropriately addressed, my hope is that we are going to begin 
to start forward on a new path and that we will approach these 
issues working together in this committee. I thank the 
Chairman. I yield back.
    Mr. Pallone. Thank you. The gentlewoman from California, 
Ms. Harman.

  OPENING STATEMENT OF HON. JANE HARMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Harman. Thank you, Mr. Chairman. I choose to be an 
optimist, and I think the fact that this committee is basically 
together on the importance of the Ryan White Act may be a good 
omen for the health care fights in the next few weeks. It is 
crucial that we stay together on this cause and that we 
consider carefully the discussion draft which will be part of a 
hearing today--we are having a hearing in this committee--and 
resolve quickly what changes we want to make to that draft and 
enact it, hopefully on a--report it hopefully on a bipartisan 
basis. When we talk about HIV and AIDS, it is easy to forget 
the very human face of the disease. It has had a profound 
impact on the lives of many of my constituents and friends, and 
I am sure everyone on this committee can tell stories like 
this. But one of them was particularly well known. Elizabeth 
Glaser touched my life deeply. She contracted AIDS in a blood 
transfusion which she got giving birth in 1981, and unknowingly 
transmitted the virus to that child and to her subsequent 
child. When she became deathly ill with the disease, she 
dedicated her life to raising awareness of pediatric AIDS, and 
a foundation bearing her name raises millions of dollars to 
help others.
    So it is with Elizabeth in mind that I urge prompt action 
on the discussion draft. This program provides critical medical 
care and support services to people with HIV/AIDS across the 
country, and it is especially important to metropolitan areas 
like Los Angeles County which has the second highest number of 
HIV/AIDS patients in the country. Ryan White spends about $35 
million a year to help provide 25,000 Angelinos with care. The 
program is truly a safety net. It is a payer of last resort. So 
it only picks up the costs after other sources of funding are 
exhausted. It helps the neediest patients, as has been pointed 
out. A third of them have no insurance and more than half are 
underinsured. In the current economic climate, this care is 
absolutely a matter of life and death. Faced with a budget 
shortfall, California was forced to cut some of its funding for 
HIV/AIDS; and moreover rising unemployment and the growing 
ranks of the uninsured means more and more people are turning 
to this program for help. I will skip the examples. We all know 
what they are. For all the good it does, Ryan White comes at a 
relatively low cost. It represents less than 10 percent of 
Federal HIV/AIDS spending. I strongly urge that we pull 
together on a bipartisan basis and do the right thing and that 
is to enact the discussion draft I think close to its present 
form, but if small changes are needed to be made, let's make 
them on a bipartisan basis and get on with it. I yield back the 
balance of my time.
    Mr. Pallone. Thank you. The gentlewoman from Florida Ms. 
Castor.

  OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

    Ms. Castor. Chairman Pallone, thank you very much for 
convening this timely hearing to address the discussion draft 
that will reauthorize the Ryan White initiative. I look forward 
to the expert testimony today. We must act expeditiously 
because we are facing sunset and so many of our neighbors 
living with HIV and AIDS are depending on us. In my home State 
of Florida, the Ryan White initiative has prolonged the lives 
of many men and women affected by this devastating disease. In 
2004, Ryan White assisted well over 100,000 patients and nearly 
13,000 family members of people living with HIV and AIDS, and 
those numbers unfortunately continue to rise. The stories of 
the impact that the Ryan White initiative has had on my 
neighbors exemplify the strength of human nature to persevere 
and to meet adversity head on.
    I would like to share with you two short stories from back 
home in Florida, stories that display the life-changing impact 
that Ryan White has had on many lives. Christopher from Florida 
says, I was diagnosed with HIV back in the summer of 2000 and I 
was fresh out of college with no health insurance. It was only 
through government-assisted programs that were funded largely 
by the Ryan White initiative that I was able to have checkups 
and blood work done. I was a patient at Pinellas Care Clinic in 
St. Petersburg, Florida. I have since begun working and have 
had insurance for 4 years but could not have gotten through 
those 5 years without the assistance of the Ryan White 
initiative. Mary from Florida relayed to me, I have lived with 
HIV/AIDS since 1990. When I became ill in December 2008, I had 
to leave my part-time job. With copayments on medications and 
medical visits, I was at the point of choosing to eat or stop 
taking medical services. After contacting a Ryan White case 
management agency, I was helped out with financial assistance.
    I can honestly say if Ryan White had not been in place, I 
believe I would be dead. There are many like myself here in the 
United States who need just a little help to continue to be 
productive members of society. Mr. Chairman, the Ryan White 
initiative is the only true lifeline for many people living 
with HIV/AIDS, many of whom are oftentimes barred from private 
health insurance. So I strongly urge the committee to move 
quickly to update and reauthorize Ryan White before the 
September 30 sunset date. I yield back my time.
    Mr. Pallone. Thank you. The gentleman from Texas, Mr. 
Green.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for holding the hearing 
today on the discussion draft of the Ryan White CARE Act. Since 
its establishment in 1990, the Ryan White CARE Act has 
delivered much needed funding to States and urban areas with 
large numbers of individuals living with the AIDS virus. More 
than half of the Americans living with AIDS live in five 
States: New York, California, Florida, New Jersey and my home 
State of Texas. Unfortunately in my State of Texas, the number 
of individuals living with HIV and AIDS increased in the last 
10 years. With two eligible metropolitan areas and three 
transitional grant areas in our State, Texas relies on Ryan 
White dollars to provide quality life-prolonging care to Texans 
living with HIV and AIDS. In fact, Ryan White funding helped to 
provide critical care and support services to more than 18,000 
in 2006. My hometown of Houston is currently the eighth largest 
EMA in the Nation with approximately 10,000 individuals living 
with AIDS, according to the CDC statistics. In the community of 
Harris County, our hospital district utilizes more than $26 
million each year to coordinate essential health care and 
support service. There are 21,000 individuals in our community 
living with HIV and AIDS. The importance of the program cannot 
be underestimated. Without CARE Act funds many Americans living 
with HIV and AIDS would have no other source for treatment. The 
last time we reauthorized the CARE Act in 2006, we had quite a 
battle. And I am pleased nearly 300 HIV/AIDS groups came 
together across the U.S. to give this committee unified 
recommendations on the provisions to be included in the 
reauthorization of this bill. Many of their recommendations 
have been addressed in this draft. Our office has been in 
contact with several local HIV/AIDS organizations to ensure 
Texas will continue to be able to access the critical care 
services provided by the CARE Act in this draft and we look 
forward carefully at several provisions in the draft.
    Texas was held harmless in fiscal year 2009. Its base 
funding was held at 95 percent of 2006 levels even though the 
award would have declined more if based solely on case counts. 
Section 5 of the discussion draft allows a hold harmless 
funding to continue and eliminates the need for repeated 
legislative action by including this funding in the baseline 
appropriations request.
    We heard from groups in Texas about the need to include a 
fix for ADAP rebates and unobligated funds. Section 6 and 7 of 
the discussion draft takes steps to ensure that States will 
give some flexibility with unobligated funds from its program. 
Unobligated funds must be returned unless a waiver is granted, 
but the ability to have some flexibility in the section is 
important. Thus far, thecommittee has been working on a 
bipartisan basis on the discussion draft, and I hope we will continue 
to work together and quickly move the Ryan Act reauthorization out of 
our committee.
    As we know, the current legislation expires September 30, 
so we have a very limited amount of time to ensure funding 
continues to this program. I yield back my time.
    Mr. Pallone. Thank you. Our vice chair, the gentlewoman 
from California, Mrs. Capps.

   OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mrs. Capps. Thank you, Mr. Chairman. I am very pleased that 
the subcommittee is meeting on this very important subject. I 
thank the panelists in advance for being here today and for the 
testimony you will be giving. The reauthorization of the Ryan 
White CARE Act is a critical issue for this committee, for the 
HIV/AIDS community and indeed for our entire country. I look 
forward to a productive discussion today about how we can focus 
on the ways we can strengthen the CARE Act so that it continues 
to meet the health needs of persons living with the HIV disease 
and their families, especially as they are living longer, which 
is a good thing.
    This issue is especially important to my home State of 
California, as my colleagues who are from the same State are 
here as well, which has the second largest disease burden in 
the United States and a significant number of new cases each 
year, particularly amongst the Latino population. As you know, 
California is experiencing a severe budget crisis. State AIDS 
funding has been drastically reduced. My constituents and all 
those affected across the State need this assistance from Ryan 
White more than ever. Too often their livelihood and that of 
their families depends on this care. I want to associate myself 
with the remarks of my colleague from Texas, Dr. Burgess. As 
one who also represents portions of a rural area, three mid-
sized counties on the central coast of California, I am 
concerned funds are disproportionately assigned to more urban 
areas.
    I represent the main source of HIV services between Los 
Angeles and San Francisco, and I want to ensure that central 
coast providers have what they need to provide resources. 
September 30 will be here before we know it. We must act now to 
reauthorize this legislation. I am interested to hear from our 
panelists today about how we can work together, and we can work 
together in a bipartisan way I believe on this committee to 
ensure that the thousands of members of our HIV community in 
California and across the country continue to receive health 
care and support services. Thank you for your testimony. I look 
forward to hearing it. I yield back.
    Mr. Pallone. Thank you. The gentlewoman from California, 
Ms. Eshoo.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Eshoo. Thank you, Mr. Chairman, for holding this 
hearing today and for your leadership on this issue, which is 
such an important one to people across the country in every 
single community that have been diagnosed with HIV/AIDS and 
what the Ryan White CARE Act represents to them. It is a very, 
very important effort that has worked. It has received 
bipartisan support from the Congress. It has provided billions 
of dollars and most importantly, it has helped to not only 
improve lives, save lives but extend lives of our fellow 
citizens.
    So I am pleased that this reauthorization is a priority for 
the committee, obviously, as it is for me. When we reauthorized 
the Act 3 years ago, I thought that the legislation failed to 
uphold the tradition of the original legislation because it 
created a system of what I termed winners and losers in the 
allocation of Federal resources. At that time, I offered an 
amendment in committee with several of my colleagues from the 
California, New York and New Jersey delegations to increase the 
overall authorizations in the bill and to extend the hold 
harmless provisions of the bill by 2 years to ensure that the 
historic epicenters of the disease do not experience 
precipitous declines in funding levels from year to year.
    Unfortunately, our amendment was defeated by a single vote. 
Now this sounds like the old formula fights which brings out, I 
guess, maybe in some ways, the worst in Congress, but they are 
fought really hard. But there is a human face to this; and so 
if the funding is not at the appropriate levels and distributed 
appropriately, there are human beings that fall through the net 
and they are hanging on as it is. If not for the stop gap 
funding during the past two appropriations cycles and the 
fiscal year 2010 bill, my district and very importantly, the 
State of California, the largest in the Nation would have lost 
millions of critical dollars to help those living with AIDS and 
HIV and who were the most in need.
    So I look forward to reauthorizing this bill at appropriate 
funding levels, including the hold harmless provision, so that 
States will not experience destabilizing shifts in funding from 
year to year. People can't live that way, and so the funding 
should not be set up that way. My thanks to the witnesses that 
are here today for your incredible work that I think our entire 
country is grateful to you for.
    Thank you again, Mr. Chairman, for bringing this up, and I 
look forward to a really solid, fair, well-funded bill so that 
all of the promise that Ryan White CARE Act holds will really 
reach all the people that it was originally intended to. Thank 
you.
    Mr. Pallone. Thank you. The gentleman from Maryland, Mr. 
Sarbanes.

OPENING STATEMENT OF HON. JOHN P. SARBANES, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MARYLAND

    Mr. Sarbanes. Thank you very much, Mr. Chairman. It is a 
privilege to be able to consider this bill today. And thank you 
for bringing the draft to us. This is an absolutely critical 
reauthorization that we are considering. You know, nothing says 
more about who we are as a Nation than the way we step forward 
and respond to the needs of those who are living with HIV and 
AIDS. So this Ryan White CARE Act and the reauthorization of it 
is critical to who we are as a Nation. It bears repeating. I 
think CongressmanGreen mentioned this, but there are nearly 300 
organizations across the country who have worked together to form a 
consensus about what the recommendations should be and what should be 
included in this reauthorization.
    I want to salute every single one of those organizations 
for their work. That is an incredible level of advocacy and 
collaboration. It is why we are able to move this kind of 
legislation forward and it represents the best in terms of 
partnership between advocacy groups and people who are on the 
ground dealing with issues out there and those of us who are in 
Congress trying to respond. We are on a tight timeline, of 
course that has been alluded to. My hope is that we can work in 
a bipartisan fashion to get this legislation done so that we 
don't hit this hard sunset that we are concerned about. I think 
that can happen, and obviously starting right today as we begin 
our September business, starting with this issue puts us on the 
road to getting that done by the end of September.
    I do want to mention that Maryland has been hard hit by HIV 
and AIDS, Baltimore in particular, which is part of my 
district. There are some tremendous organizations throughout 
the State and in the city of Baltimore who have been working 
for many, many years to address these concerns. There is a 
group here today, Life Link, and actually I would like you to 
raise your hands just so people can see how many of you are out 
there. That is the kind of advocacy that has brought forward 
this kind of legislation, and I want to salute everybody who 
made the trip over to be at this hearing. I look forward to the 
testimony of the witnesses. I look forward to moving this bill 
in a timely way, and I yield back my time.
    Mr. Pallone. Thank you. The gentlewoman from Ohio, Ms. 
Sutton.

  OPENING STATEMENT OF HON. BETTY SUTTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF OHIO

    Ms. Sutton. Thank you, Chairman Pallone, for holding this 
important hearing on the reauthorization of the Ryan White CARE 
Act. Since it was passed in 1990, the Ryan White CARE Act has 
provided critically needed help to States and communities to 
provide treatment and services for individuals stricken with 
HIV and AIDS. This legislation, as we have heard, provides 
Federal funds to cities and States to ensure that necessary 
medical HIV and AIDS treatment can be given to all individuals, 
regardless of their race, age or social standing. We should be 
clear, Mr. Chairman, that AIDS is still epidemic in this 
country. According to the District's HIV/AIDS Administration in 
Washington, D.C., a reported 3 percent of District residents 
right outside of these committee doors are living with HIV and 
AIDS.
    As a matter of perspective, in this one city alone, that 
rate is higher than in West Africa. But we have a chance this 
month to offer continued protection to one of our Nation's most 
vulnerable populations, those living with HIV and AIDS. Those 
who are stricken with HIV and AIDS often live in urban areas 
and have trouble accessing the health care system.
    In 2008, Ohio ranked the 14th highest among the 50 States 
in cumulative reported AIDS cases. One of the hardest hit areas 
of the State is Cuyahoga County, part of which I represent. And 
last year there was a decrease in the number of new AIDS cases 
in the county, and that is good news but we cannot become 
complacent. Unfortunately in 2008, the county saw a slight 
increase in new HIV cases, and the disease continues to take a 
disproportionate toll on minority populations. While African 
Americans make up 29.3 of the Cuyahoga County population, they 
make up 56 percent of reported persons living with HIV and AIDS 
in the county. The Minority AIDS Initiative was created in 1998 
by Congress and the administration to address this very 
problem.
    The minority AIDS initiative has been a positive program 
and I look forward to hearing the results of the GAO report on 
this subject. We must continue to give our States and 
communities the funding they need to help those who have the 
disease. We must also increase education and outreach to 
prevent the spread of HIV and AIDS. The discussion draft we 
will review today makes some important changes that will 
strengthen the Ryan White CARE Act, and I am proud that the HIV 
and AIDS care community of Ohio supports this legislation and 
the discussion draft. I look forward to the testimony. I thank 
all of you who are here and for the work not only that you are 
here to do in this committee room, but I know that you are 
throughout our communities and our country. I yield back.
    Mr. Pallone. Thank you. The gentleman from Georgia Mr. 
Barrow.
    Mr. Barrow. I thank the Chair. I will waive an opening.
    Mr. Pallone. Thank you. The gentlewoman from the Virgin 
Islands, Ms. Christensen.

       OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 
       REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS

    Mrs. Christensen. Thank you, Mr. Chairman. Thank you in 
particular, Chairman Pallone, for turning to the Ryan White 
CARE Act as soon as we got back, as you promised in July. This 
is too important a program to get lost as we battle for health 
care reform. The September deadline looms large, and we have to 
act. Without action before the end of this month, this program, 
which has been a real lifeline to so many individuals and 
families in my district and all across our country, would be 
lost entirely. And that cannot happen. But one thing, I would 
have preferred to do a continuing resolution that would take us 
into mid next year and then do a more thorough job of 
reauthorizing the Act in 2010. There are important decisions 
and changes to be made to ensure that the benefits of this 
program reach those most in need and that it is adequately 
funded. In recent years, programs have been scraping by. ADAP 
waiting lists have left too many without care, and minority 
communities have not been developing the capacity we envisioned 
when we created the Minority AIDS Initiative. I also feel that 
there are some stakeholders who have not been adequately heard 
from.
    But the Ryan White program is also too important a program 
to allow it to become a political football in an election year. 
So after we protect the program from being eliminated, as per 
the sunset clause that was included in the last authorization, 
we will probably just have to kick the ball down the road a 
little longer just to keep the program on life support. But Mr. 
Chair and colleagues, I hope that this is the last time that we 
do this because we don't have adequate data, because reporting 
systems are not mature enough or because we are afraid to make 
the tough decisions to redirect the funding where it is most 
needed.
    Before I close, I want to remind everyone that people of 
color are 71 percent of new AIDS cases and 67 percent of people 
living with HIV and AIDS, that African Americans are the 
hardest hit, and African American women in particular. So 
addressing these vulnerable populations must be a central part 
of Ryan White moving forward. This means a strong Minority AIDS 
Initiative that provides not only adequate resources but 
technical assistance and a return to its original intent of 
building capacity. We also need to address the exploding 
numbers of hepatitis B and C infections and to do more to stem 
the spread of HIV infections in incarcerated populations and 
from ex-offenders into their home communities. I would like to 
welcome and thank our witnesses today. I hope we can fit in a 
follow-up hearing from where we can hear from some of the 
communities most affected by AIDS and the organizations that 
have been working to serve them. I yield back the balance of my 
time.
    Mr. Pallone. Thank you. The gentleman from Connecticut, Mr. 
Murphy.

      OPENING STATEMENT OF HON. CHRISTOPHER S. MURPHY, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF CONNECTICUT

    Mr. Murphy of Connecticut. Thank you, Mr. Chairman, for 
holding today's hearing on this discussion draft. And thank you 
so much to the numbers of advocates, people living with HIV/
AIDS and people caring for them are here. It wasn't so long ago 
where people that were living with the disease, people that 
were caring for those that had the disease felt pressure to 
live that life do that work in the shadows. And it says a lot 
about this Congress and this country and society that you now 
are at the forefront of advocating for a strong reauthorization 
of this law. In Connecticut, this program just has been 
critical to providing low-income individuals with the medical 
and support services that they need. Without this funding, 
millions of Americans and thousands of my constituents would 
struggle to find that cutting-edge medical service that has 
been increasingly successful in treating the disease. But to 
say that the transition through the last reauthorization of the 
program in Connecticut has been rocky would be an 
understatement.
    Since the 2006 reauthorization, the Connecticut delegation 
and those responsible for administering the program in the 
State have gone round and round with HRSA and the court system 
to ensure that the State's largest communities, in particular, 
New Haven and Hartford, which both actually exist outside of my 
district, received adequate funds through the program and were 
treated fairly through the interpretation of the law. The 
resulting congressional and legal battles have resulted in 
favorable treatment for Connecticut. But I am sure it is the 
preference of everyone involved to ensure that this current 
reauthorization does not result in the battles of the last 3 
years being played out again in Connecticut, in California or 
in other parts across this country. That is why, alongwith 
Representative Eshoo and others on the committee, I am encouraged that 
the draft legislation provides for the continuation and expansion of 
the law's hold harmless provisions, well addressing once and for all 
the need for a continued stop loss funding for jurisdictions that 
without it could face significant yearly funding decreases. Mr. 
Chairman, I am thrilled that we haven't wasted 24 hours on our return 
to Washington in getting started with this reauthorization. I am 
pleased to be here for this hearing and look forward to the testimony 
of our witnesses. I yield back.
    Mr. Pallone. Thank you. The ranking member of our full 
committee, Mr. Barton.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. Thank you, Mr. Chairman. I am glad that you are 
still doing opening statements. I am going to submit my formal 
statement for the record and just make a few remarks. First of 
all, I am glad that you are holding this hearing. Congressman 
Deal and myself brought up the Ryan White Reauthorization Act 
in the markup on the health care bill back in August. You and 
Chairman Waxman said that it was something needing to be done. 
And here we are. So that is good. We have looked at the draft 
bill. There are some good things in the bill. We like the fact 
that it is a 3-year reauthorization. That is a good thing, that 
it is not open ended. There are some bad things, some things--
you know, the fact it is open ended in terms of the 
appropriations, some of the grandfathering provisions.
    But having a bill before us, having a legislative hearing, 
being willing to do this are all good signs. Even though this 
is an opening statement, my question to you, Mr. Chairman, do 
you plan and Chairman Waxman plan on moving a bill fairly 
quickly or is this more of a get-input hearing?
    Mr. Pallone. We do plan to move a bill but not before we 
get more input from you, from the Republicans, and also from 
the Senate. But we realize that we have this October 1 
deadline. So we would like to move quickly.
    Mr. Barton. OK. Thank you, Mr. Chairman. And I think I can 
speak for all the Members of the minority, we are very willing 
to work in an expedited time frame. We do hope it is an open 
process and we are allowed to input into the system before the 
decisions are made. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. I think that concludes our opening 
statements. So we will move now to our witness. If you will 
come forward, we have one witness on our first panel who is Dr. 
Mary Wakefield, who is administrator for the Office of the 
Administrator, the Health Resources and Services 
Administration. Did I get that right?
    Ms. Wakefield. You did.
    Mr. Pallone. The second person is just there to help, not 
to testify, I understand.
    We, as you know, have 5-minute opening statements. They 
become part of the record. So I would now recognize you for 5 
minutes. Thank you.

 STATEMENT OF MARY WAKEFIELD, ADMINISTRATOR, HEALTH RESOURCES 
AND SERVICES ADMINISTRATION, UNITED STATES DEPARTMENT OF HEALTH 
                       AND HUMAN SERVICES

    Ms. Wakefield. Mr. Chairman, members of the committee, 
thank you for the opportunity to appear before you today to 
address reauthorization of the Ryan White HIV/AIDS program 
administered by the Health Resources and Services 
Administration within the Department of Health and Human 
Services. In addition, I would like to thank the Chairman, 
members of the committee and their staffs for all of their hard 
work on this very important legislation. Let me start by 
expressing the administration's strong support for continuation 
of the Ryan White program and its reauthorization. It is a key 
component of our Nation's fight against HIV/AIDS. Before I 
begin my testimony, I would like to announce that today the 
Centers for Medicare & Medicaid Services has released a new 
proposal to cover voluntary HIV infection screening for 
Medicare beneficiaries who are at risk for infection and for 
women who are pregnant. Today's proposed decision would allow 
high-risk Medicare beneficiaries to learn of their HIV status 
anytime by requesting an HIV screening test and, if necessary, 
seek appropriate counseling and therapy. I know you will look 
forward to hearing more about this new plan in the weeks to 
come as CMS accepts public comments and issues its final 
coverage decision. The Department of Health and Human Services 
is committed to helping promote the President's strategy to 
bring an end to the domestic HIV epidemic in this country, and 
this new proposal will allow those who may be at risk of 
infection to find out quickly and early so that they can start 
getting treatment.
    Ryan White provides critical medical care and support 
services to uninsured, underinsured and low-income people 
living with HIV/AIDS who have no other source of care. Through 
HRSA's HIV/AIDS Bureau, grants are awarded to cities, States 
and local community-based organizations for the purpose of 
providing primary medical care and support services to 
individuals living with HIV/AIDS. I saw this firsthand on my 
very first site visits as administrator to Ryan White grantees 
in Chicago and Philadelphia. There I observed the difference 
these programs make in patients' lives. With this in mind, I 
would like to talk broadly about the administration's vision 
for reauthorizing this program.
    Since its inception in 1990, the Ryan White program has 
been providing HIV-related care to a growing number of infected 
individuals. This year, approximately 529,000 individuals will 
receive Ryan White services. The program consists of parts A, 
B, C, D and F, which are differentiated by the types of 
services rendered and/or by the entities receiving funding.
    HRSA recommends a 4-year reauthorization to minimize 
disruption of funding and services for grantees and clients and 
to permit time for the implementation of health care reform 
policies and programs to examine the impact on Ryan White. The 
administration would also support a 3-year reauthorization 
consistent with the draft House bill. In addition, HRSA 
supports the language proposed in the Energy and Commerce draft 
legislation to eliminate the repeal language that was part of 
the last reauthorization. Presently, parts A and B grantees are 
subject to three different penalties if they have unused funds 
remaining by the end of the grant year. First, barring a waiver 
for formula funds, grantees must return any unspent formula and 
supplemental funds to HRSA at the end of the grant year.
    Second, grantees with more than 2 percent of unobligated 
formula funds at the end of the grant year will receive a 
reduction in their subsequent grant. Third, grantees with more 
than 2 percent of unobligated formula funds cannot apply for 
supplemental funds for the subsequent grant year. HRSA 
encourages amending these penalties for parts A and B grantees 
because of the financial and administrative burden it places on 
them. HRSA suggests eliminating the penalty that requires a 
decrease in a grantee's subsequent grant award by an amount 
equal to the unobligated balance remaining from the current 
year's award. The elimination of this provision helps to ensure 
that grantees will have sufficient funds so they will not have 
to interrupt service to individuals living with HIV/AIDS.
    In addition, HRSA recommends raising the threshold from 2 
percent to 5 percent for the penalty. It prevents grantees from 
receiving supplemental funds when they have unobligated formula 
funds. Both of these provisions are contained in the 
committee's current draft, and we are appreciative of their 
inclusion. HRSA also suggests offsetting future year awards for 
grants with unobligated balances as opposed to cancelation of 
the amount. The change from a deobligation to an offset would 
retain the intent of the law while simplifying penalty 
administration and expediting the redistribution of funds to 
other grantees to provide HIV/AIDS care. HRSA supports 
eliminating the distinction between EMAs and TGAs under part A. 
HRSA proposes designating part A grantees as EMAs when those 
grantees have greater than or equal to 1,000 cases of AIDS 
during the most recent period of five calendar years for which 
such data are available.
    By eliminating the EMA/TGA distinction, the appropriation 
for part A could be distributed proportionally across all 
highly impacted jurisdictions based on the number of living 
HIV/AIDS cases. This suggestion is supported by Energy and 
Commerce's draft legislation.
    Moreover, for the transition grant areas that are at risk 
of losing TGA status in future fiscal years, HRSA supports 
efforts to maintain part A award levels so that important HIV/
AIDS services in those jurisdictions are not interrupted. This 
recommendation is reflected in the Energy and Commerce draft 
legislation.
    Six transitional grant areas are at risk of losing their 
status under part A in fiscal year 2011 due to their inability 
to meet the definition of a TGA based on AIDS case counts. HRSA 
is eager to work with you to resolve this issue.
    We are over a quarter-century into the HIV/AIDS epidemic. 
With my background as a nurse and as a nurse educator, I know 
how important it is for us to train a new cadre of HIV health 
professionals to replace the first wave of experts that are 
nearing retirement. We also need a new generation of health 
care workers to meet the difficult clinical challenges that are 
emerging in a world where HIV infection, with treatment, is 
managed as a chronic condition. HRSA suggests implementing a 
program for AETC participantsthat provides training of 
sufficient duration to ensure that new health professionals are 
appropriately trained to provide HIV care and are strategically placed 
in areas with high need of HIV medical care.
    Finally, HRSA proposes to permit additional time for code-
based reporting States to transition to name-based reporting 
systems for living HIV/AIDS counts, upon which funding is 
based. Under current law, the exception for code-based 
reporting will expire at the end of fiscal year 2009 and, as of 
fiscal year 2010, all jurisdictions must report name-based 
data. Nine jurisdictions are still in the process of converting 
to named-based reporting systems. Without an extension, these 
code-based reporting States will be unable to receive funding 
after fiscal year 2009, which will disrupt services to patients 
with HIV/AIDS in those areas. We are appreciative of this being 
included in the draft legislation.
    In summary, I want to acknowledge the dedication of the 
advocacy community, its work on the consensus document, and its 
incredible commitment to those individuals with HIV/AIDS. The 
Obama administration is committed to working with you, with 
Congress, to reauthorize the Ryan White program and to ensure 
that critical services continue beyond September 30, 2009. I 
would be pleased to answer any questions you might have 
concerning the reauthorization of the Ryan White HIV/AIDS 
program.
    Thank you.
    [The prepared statement of Ms. Wakefield follows:]
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    Mr. Pallone. Thank you, Doctor.
    We are going to have questions from the members of the 
committee. Basically, we allow 5 minutes for each member. And I 
am just going to recognize myself initially.
    The Ryan White program is one that OMB has rated as highly 
effective. And I am sure HRSA will continue its good work in 
administering it, and I want to thank you for that.
    You said that the administration supports at least a 3-year 
extension. I think you actually mentioned 4, but you could live 
with 3. Would you tell us why that is the case? In other words, 
what would be the impact on grantees if we only had a shorter 
extension, you know, 1 or 2 years? Why are you saying 3 or 4?
    Ms. Wakefield. We are asking for a longer reauthorization 
because we think that it will provide greater stability for the 
program. And it would also provide us with additional time to 
evaluate the impact of changes that might be made to the 
program, and so those changes that would be affecting grantees.
    Also, we would have with that additional time more mature 
names-based surveillance systems in place and time to evaluate 
the impact of health care reform policies and programs and 
their implications for Ryan White.
    Mr. Pallone. OK. Well, my second question is about this 
code-based versus name-based. And I know you mentioned it 
several times there towards the end of your testimony.
    CDC's recommendation to the States is that they collect 
surveillance data from the States on a confidential names-based 
basis. But today, all States are in fact collecting names-based 
data, but their systems are at different stages, as you 
mentioned. Some have been collecting names-based data for 
enough years that CDC has deemed their systems mature. Others 
are still transitioning from earlier code-based systems.
    Now, under the current law, States can still report code-
based data if their names-based system isn't fully ready to 
accurately reflect HIV in the State. But how does HRSA account 
for the fact that code-based data may contain redundancies?
    Ms. Wakefield. Well, you are right, there are redundancies 
in code-based data. And so the way that is accounted for is 
through a 5 percent reduction that is taken in the counts of 
the cases, so taken in case counts that are reported from code-
based systems. So, 5 percent reduction taken in case counts 
that are reported through code-based systems.
    Mr. Pallone. Is there any other penalty with regard to 
these code-based States?
    Ms. Wakefield. Yes, there is a 5 percent cap on the 
increase of a grant award for subsequent grant awards. So, yes.
    Mr. Pallone. Now, have these penalties actually been 
applied to States that are still reporting, you know, some of 
the HIV cases as code-based?
    Ms. Wakefield. Yes, sir, they have.
    Mr. Pallone. And, I mean, I understand that the penalties 
help motivate States as they transition to the name-based 
reporting, and so that is why you have them.
    Now, the discussion draft would maintain current law for 
code-based reporting so the States continue their progress to 
name-based reporting, you know, would still be able to 
progress. But is it your understanding that the eight 
jurisdictions still using the code-based reporting are making 
enough progress towards this fully name-based system, or should 
we be doing something else to encourage it?
    Ms. Wakefield. We believe that all States that are still 
operating with code-based reporting are making the necessary 
changes and have a commitment to transition fully to name-based 
reporting.
    And, as you indicated, their systems are still in a process 
of maturing, and those jurisdictions are at different places in 
the evolution of their systems. But, yes, we are in contact 
with them, and we feel that they have commitment to continuing 
forward.
    Mr. Pallone. So you want to continue this policy of having 
certainly penalties but still allowing them to use the old 
system, at least temporarily.
    Ms. Wakefield. Yes, that is correct.
    Mr. Pallone. OK.
    Now, I don't think you mentioned the severity-of-need 
index. I wanted to mention that. One of the recommendations 
from the community consensus, and it is also in the discussion 
draft, is to clarify that HRSA should not yet begin 
implementation of the severity-of-need index.
    The 2006 reauthorization required HRSA to develop an index 
that could allow for distribution of funds based on concrete 
factors reflecting need. But tell me a little more about this 
index. I know you didn't mention it, but I would like to know, 
you know, what the idea is.
    Ms. Wakefield. So, in terms of the severity-of-need index, 
supplemental grants under parts A and B are awarded to areas 
and States that submit applications based on the need in the 
area or State on an objective and quantified basis. Currently, 
jurisdictions submit applications that are scored through an 
objective review process to determine level of need and 
subsequent funding.
    At Congress's direction, HRSA contracted with an 
organization to establish an HIV/AIDS severity-of-need 
collaboration to develop this index that you are referencing. 
The collaboration was comprised of a multi-tiered expert body 
broadly representative of HHS, HRSA staff, national experts, 
Ryan White program grantees, and consumers.
    Based on the Institute of Medicine's recommendations, there 
were four expert panels that were convened to identify relevant 
data sources and measures that demonstrate need in terms of 
area characteristics, patient coverage and need, associated 
costs, and so on.
    The panels then prepared written reports reviewing more 
than 56 variables and forwarded 19 for inclusion in a draft 
severity-of-need index. Some of the 19 remaining variables were 
eliminated for reasons such as lack of uniformly high-quality 
data at the State level.
    HRSA and our team that we contracted with has analyzed the 
recommendations of the panels, completed supplemental studies, 
and developed a draft model of severity-of-need index to be 
applied. The index uses data measures comparable across 
jurisdictions and is based on quantitative measures established 
from existing national data sources.
    We have also in 2008 contracted to conduct an independent 
analysis of that methodology. And the independent evaluators 
concluded that the process that was used to develop that 
severity-of-need index was comprehensive but some elements of 
the formulation failed to meet their intended purposes, so that 
the index, from that perspective, might be modified to better 
distribute supplemental funding based on need.
    The status of the severity-of-illness index at this point? 
Well, the 2007 and 2008 reports are in clearance in the 
Department, and we are working to get those reports to you as 
soon as possible.
    Mr. Pallone. OK. Thank you very much.
    Mr. Whitfield.
    Mr. Whitfield. Dr. Wakefield, thanks for being with us 
today, and we appreciate your input.
    In your opening statement, you mentioned that there is an 
HIV epidemic in the country today. What is the definition of an 
``epidemic,'' and is there a certain number of cases that you 
must have to be called an epidemic? Would you just clarify that 
for me, what that means?
    Ms. Wakefield. Applied here it is referring to, for us, the 
care that we provide of over 529,000 individuals served through 
our Ryan White AIDS program.
    Mr. Whitfield. So if it is over 500,000, it is an epidemic?
    Ms. Wakefield. And greater than a million diagnosed with 
HIV/AIDS in the United States.
    Mr. Whitfield. So, in the United States today, there are 
over a million people that have been diagnosed with AIDS?
    Ms. Wakefield. With HIV or AIDS, yes.
    Mr. Whitfield. I was just reading the Kaiser report on the 
HIV program, and it indicated that this number, 500,000 being 
treated, really cannot be totally verified because it may be 
duplicative. And it says specifically that there is no client-
level data collection system.
    Is that true, or is that not true?
    Ms. Wakefield. There are duplicate numbers that we try to 
account for in our funding allocation. So, yes, we know that 
there is some duplication. We do have strategies for trying to 
correct that duplication.
    Mr. Whitfield. But is it true that there is no client-level 
data collection system?
    Ms. Wakefield. Oh, we have----
    Mr. Whitfield. To help you out a little bit here, I was 
reading from the Henry Kaiser Family Foundation HIV/AIDS policy 
fact sheet. It says, ``. . . Although it is not possible to 
obtain an unduplicated count of clients because there is 
currently no client-level data collection system.''
    Ms. Wakefield. We do have client-level data that we are 
collecting and have available now, but just effective as of 
June of this year.
    Mr. Whitfield. So it went into effect June of this year?
    Ms. Wakefield. Just in the last few months, that is 
correct, on a client-level basis.
    Mr. Whitfield. And that would be nationwide and in the nine 
territories then?
    Ms. Wakefield. Yes, sir. But it is just within the last few 
months.
    Mr. Whitfield. OK. But it is in effect now, so we will be 
able to have a more accurate number.
    Ms. Wakefield. Yes, that is correct, going forward.
    Mr. Whitfield. OK.
    Now, on the transitional grant area proposal, in the 
discussion draft they are talking about the six transitional 
grant areas and they are asking that they be grandfathered. 
Now, I am certainly not an expert in the Ryan White Act, but it 
is my understanding that in order to obtain a grant you have to 
meet certain criteria, like so many thousand cases in whatever 
and whatever, which is the way it should be done because, with 
limited dollars, you want to go where it is most needed.
    So it would seem to me that if you just automatically 
grandfather six areas because they have had them the last 3 
years that you might be overlooking or underserving other areas 
that may need it even worse than those six. Do you have any 
comment on that?
    Ms. Wakefield. We do support continuation of those six, 
primarily to avoid disruption in services for the individuals 
currently being served and also so that there isn't an undue 
burden on areas that might be geographically located next to 
those six areas.
    Mr. Whitfield. But, you know, I guess since Ryan White was 
authorized first in 1990, there has always been this process 
that it be a 3-year grant period and then it would be 
reevaluated. So that doesn't concern you, then, that other 
areas may be underserved because you are going to allow these 
to be grandfathered?
    Ms. Wakefield. We are supportive of continuing the 
inclusion of those six areas, yes.
    Mr. Whitfield. OK. All right.
    Now, President Obama, like all of us, has expressed great 
concern about the Federal debt that we have today and the 
impact that that will have on our country. And I would just ask 
you, this legislation also provides open-ended appropriation, 
``such sums as necessary.'' And there has been a growth in this 
program from $200 million to about $2.3 billion.
    Do you think it is necessary to just have an open-ended 
``such sums as necessary'' considering the current financial 
situation we find ourselves in in this country?
    Ms. Wakefield. HHS does support the inclusion of the 
wording ``such sums as necessary'' for subsequent fiscal years 
for each part of the act. So, yes, we do support such sums.
    Mr. Whitfield. So you do support it.
    I see my time has expired.
    Mr. Pallone. Ms. Capps.
    Mrs. Capps. Thank you very much, Dr. Wakefield. I have a 
couple of questions for you during my time.
    One is to share with you my concern to learn that the 
Centers for Disease Control and Prevention, CDC, estimates that 
the number of births to women living with HIV has increased 
approximately 30 percent from 2000 to 2006.
    I mean, there are all kinds of new phenomena arising within 
this area of HIV/AIDS: chronic length of living with the 
disease and a whole new raft of issues that need to be 
addressed. I am sure you are considering this something that 
needs to be dealt with as well.
    Do you have any ideas or plans in place to address the 
needs of women and children and families in light of the 
growing numbers of HIV-positive women of child-bearing age? 
Perhaps you can discuss, if you will, how part D of the 
legislation will help to ensure that their needs are met.
    Ms. Wakefield. Well, you are right, part D is the part of 
the Ryan White program that is probably most targeted toward 
exactly the population of which you are concerned. It, of 
course, allocates funds through private and public 
organizations, community-based organizations, States and 
universities, and it can provide outpatient or ambulatory care 
directly to or through contracts that are awarded. It is really 
designed to serve women, infants, children living with HIV/AIDS 
support and provide support services to those individuals. That 
is really its key target population.
    We also have resources that are available through part F, 
the SPNS program it is referred to shorthand, that can be 
allocated to direct research and other activities to particular 
target populations. So that is another vehicle that I think it 
is safe to say could be added.
    Beyond that, parts A, parts B, and C also provide care to 
the population that you have just expressed concern about. But, 
as you indicated, part D is really targeted to mention women, 
infants, children, and young adults.
    Mrs. Capps. Thank you. And part of our goal, then, in our 
communities especially, is to identify and encourage people to 
get tested so that they can understand that they are and that 
they get into some of these programs and be able to deal with 
it early on.
    To that topic, I am concerned. You heard in several opening 
statements about the impact of several of our State budgets on 
the ability to care for HIV and AIDS patients. I have heard 
just horrendous stories in my district in California about 
matters of life and death, really, if our State budget is going 
to cut so drastically the services upon which people depend for 
their care. They are going to have to choose between their 
medicine and their food.
    I mean, I am sure it is not just confined to my district. I 
can see people in your audience nodding, and I know this is a 
story across the country now.
    How can we respond, how can HRSA respond to work with some 
of our States where this is such a huge challenge right now?
    Ms. Wakefield. Well, you are right, we have been hearing 
from a number of States about the challenges that they are 
facing locally. And certainly California is one of those States 
that we are trying to monitor and work with as closely as 
possible.
    On the front end, the administration, of course, strongly 
supports continuation of this program, first and foremost, to 
provide vital funding to States and cities to provide services 
to people living with HIV/AIDS.
    In part, perhaps, to address your question, it might be 
useful for you to know, too, that the President's fiscal year 
2010 budget request provides and asks for an increase of about 
$53.9 million over the fiscal year 2009 omnibus level. That 
funding would continue to support over 2,300 providers that 
would help half a million individuals living with HIV/AIDS 
obtain access to life-sustaining care and services. So, in 
fact, there is an additional request--a request for additional 
funding, I should say, that should help to mitigate a bit of 
those concerns.
    But bottom line, we are aware of that and working as 
closely as we can with jurisdictions and States that are 
feeling particular pressure to maintain their services to this 
very vulnerable population.
    Mrs. Capps. Well, you can be assured there are many Members 
of our Congress, including in this committee, who will seek to 
look for further funds if that is necessary as we see some of 
these State budgets unfold. I don't think it has really hit yet 
as hard as we are going to see in the coming months, where we 
are really facing in our communities--it is not just this 
population, unfortunately, but this is one that has clearly 
made itself known to me. And I know my colleagues will share in 
wanting to help you if there is any emergency funding that can 
be made available.
    And surely the increase in the budget for next year is 
going to be something--it was intended, I am sure, to expand 
services, but at least it will provide that stopgap, hopefully, 
for some of the States where the bottom is falling out.
    And I appreciate your awareness of and concern for this 
situation.
    Ms. Wakefield. Again, we are aware, we are concerned. And 
we have been trying to collect data, or information at least, 
anecdotally from our contacts in each of the States. So we have 
a little bit of a litmus test about how things are going at the 
State level. We will continue to try and do that and then share 
that information.
    Mrs. Capps. We will encourage them locally to reach out to 
you, let you know what the status is.
    Thank you.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    Ranking Member Mr. Barton.
    Mr. Barton. Thank you, Mr. Chairman. I don't think I will 
take up my full 5 minutes.
    Dr. Wakefield, I am assuming that you are here as the 
official representative of the Obama administration. Is that 
correct?
    Ms. Wakefield. I am here representing the administration 
and HHS.
    Mr. Barton. OK, so you speak for them.
    Ms. Wakefield. Are you inquiring, sir, about whether or not 
the testimony is----
    Mr. Barton. Well, I am just saying, if you give an answer 
and I like it, I can depend that that is the position of the 
Obama administration?
    Ms. Wakefield. I am speaking as the HRSA Administrator. But 
the testimony that I have shared with you has been developed 
and reviewed with full collaboration.
    Mr. Barton. Well, sometimes, in both administrations, 
Democrat and Republican, we have officials come and when we ask 
them if they are on the record for the administration, they hem 
and haw and then say that it is their personal position.
    So I am not being devious. I am glad the chairman is 
holding the hearing, and I am glad you are here. But as the 
senior Republican, I want to ask some pretty straight 
questions, and if you give straight answers, I want to know 
that that is where the Obama position is. That is all.
    Ms. Wakefield. And, if I might, I guess what I would add on 
the hemming and hawing part, what I would add is that it is of 
course a normal protocol in either administration for the 
administrations to release their official statement of 
administration policy at some point between committee hearings 
and markup and floor action. So that is the venue for that 
official administration position.
    Mr. Barton. Well, I think we have spent a minute and a half 
of my time hemming and hawing already, so you are already at 
the top of the list in being able to do the Texas Two-Step. I 
am in awe of your ability to say nothing----
    Ms. Wakefield. I went at the school at the University of 
Texas at Austin.
    Mr. Barton. I knew that. My wife did, too, so we are a 
mixed marriage.
    Anyway, let me ask the first question. This is an 
authorizing committee. We try to set the policy and set the 
provisions, and then we pass it over to the Appropriation 
Committee and they are supposed to implement by passing funding 
bills that do what we say.
    This draft, one of the problems that the Republicans have 
is that it uses the term ``such sums,'' and Mr. Whitfield has 
already discussed that.
    Does the Obama administration have a problem in working 
with the chairman and the ranking members on the Republican 
side before this bill is marked up to change that language from 
``such sums'' to specific sums that everybody agrees are 
appropriate?
    And I don't think we have a huge difference in funding 
priorities. At least if we do, I am not aware of it.
    Ms. Wakefield. We don't oppose ``such sums,'' but we would 
be happy to work with the committee going forward.
    Mr. Barton. Well, we want--and, again, I think even my 
distinguished chairman, Mr. Waxman, and the subcommittee 
chairmen would agree that if we can agree on what that amount 
should be, it is better from our committee perspective to tell 
the appropriators where to spend the money.
    So you are willing to work with----
    Ms. Wakefield. We are willing to work with you, sir.
    Mr. Barton. Not just with me, but also with Mr. Pallone and 
Mr. Waxman.
    You know, I might point out that if we had the vote right 
now, my side would win. We have five, and they have two. But 
they probably have seven out in the annex eating pizza, so they 
would probably bring them in.
    My second--again, Mr. Whitfield talked about this. The 
provision in the draft bill that grandfathers the transitional 
grant areas, first, we don't have a problem with there being 
transitional grants, and we don't have a problem that those be 
authorized an additional 3 years.
    Our problem is, if we are really trying to solve the 
problem of helping those families and individuals that have 
AIDS, that population does change over time and its location 
changes over time. We would like to have some ability to move 
the money where the people are that still need assistance as 
opposed to where they may have been in the past.
    So we are not opposing transitional grants. We are not 
really even totally opposing the grandfathering. But we would 
like to work again with Mr. Waxman and Mr. Pallone and others 
on the majority, with the Obama administration, to see if we 
couldn't move some of those grants into areas where there is 
more need today. And that is, I think, what Mr. Whitfield was 
trying to get at.
    Do you have an opposition to at least discussing that 
issue?
    Ms. Wakefield. I would say that we share and are concerned 
about ensuring that there is stability of infrastructure to 
meet the needs of individuals with HIV/AIDS. So that is our 
very first priority, to make sure that there isn't disruption 
in availability of care to those populations.
    Mr. Barton. I understand that.
    Well, Mr. Chairman, my time has expired. We fully--I want 
to really emphasize this. I was chairman when we passed the 
last reauthorization bill in 2006, and I was very proud that 
that was one of the things that we did during my chairmanship. 
I am very glad that you and Mr. Waxman are trying to do a 
reauthorization bill. The Republicans really want to work to 
make that happen. We feel it is important from a committee 
perspective and from a policy perspective that we continue to 
have this bill in law, not in someappropriation rider that is 
year-to-year. And we also agree that, as the need changes and the 
location changes, we need to update the bill, update the law. We hope 
that we can do that in a very timely fashion and move this bill on a 
bipartisan basis.
    And, with that, I would yield back, Mr. Chairman.
    Mr. Pallone. Thank you, Mr. Barton.
    Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    I just had a couple questions.
    First off, can you just be a little more specific about 
what it means to ``not yet be mature'' in this transition from 
code-based reporting to name-based reporting? I mean, what does 
that actually reflect?
    Ms. Wakefield. So, for example, some States have had 
statutes at the State level that, for different reasons, had to 
be addressed in order for them to be able to produce these 
data. So that is one potential problem that has affected some 
States.
    Every State has its own set of circumstances in terms of 
being able to collect that information and aggregate it and 
make it available. So the process is really varying on a State-
by-State basis. Data are collected from different sources. And, 
as I mentioned, there isn't any one uniform pattern that was 
established initially that they are all working from, in terms 
of reporting those data.
    There is just the challenge of getting all of the people 
that have HIV reported by name. And, as I said, States have in 
some cases better circumstances in collecting that information, 
in other circumstances not as much infrastructure initially to 
be able to collect that data. So it really has been a fair 
variation State by State.
    Mr. Sarbanes. And typically the range in terms of making 
the transition on a time basis has been 2 or 3 years, is what 
it is taking people? Or----
    Ms. Wakefield. Probably a little bit longer than that, more 
like a 3- to 5-year period of time to make the transition.
    Mr. Sarbanes. OK. OK.
    The other question I had is--I was looking at some of the 
statistics in terms of the Ryan White program: serving half a 
million people across the country, of which 33 percent are 
uninsured and 56 percent are underinsured.
    And there has been some allusion, of course, as there would 
be, to the fact that we are wrestling here with a larger health 
insurance reform effort, where we would hope that we would get 
to a place where there is much broader coverage available to 
people and we don't have the same numbers of either uninsured 
or underinsured people.
    But I also anticipate that we shouldn't fall into the trap 
of thinking that because we will find ways of providing better 
coverage going forward for the whole population of the country, 
including those who live with HIV and AIDS, that somehow there 
will be some kind of one-for-one corollary in terms of reducing 
this support that exists through this program.
    So I wonder if you could speak to the fact, as I see it, 
that so much of what makes this successful is that it is 
approached from, sort of, the public health standpoint, with 
resources flowing to collaborative networks that exist in 
States and at the community level, and that that kind of 
infrastructure support needs to continue regardless of what the 
individual coverage status is that a particular person may 
have.
    So if you could just speak to that.
    Ms. Wakefield. The Ryan White HIV/AIDS program does fill 
really significant gaps currently, and it provides critical 
capacity to reach underserved populations, the very people that 
you were just describing, percentages of uninsured and 
underinsured. And currently about 72 percent of the people who 
are served, for example, are below the poverty level.
    The administration believes that the Ryan White HIV/AIDS 
program will continue to play a vital role after health care 
reform is enacted, for example because of some of the services 
that are provided through it--services such as medical 
transportation, nutrition services, case management services--
that are part of not the core services part of Ryan White but 
rather the support services, for which resources are currently 
allocated and used across the country, casting this, just as 
you indicated, as a broader public health, community approach 
to care.
    Mr. Sarbanes. Thank you. I mean, I guess I am just trying 
to make the point that there is a--and it is really the case 
management side of things--dimension to what is offered through 
these resources that will continue to be absolutely critical 
even if an individual now has access to insurance coverage 
through more conventional means as a result of some of the 
reforms we have put in place.
    If we don't bring this other lens to the table and continue 
to sustain it, then many of the gains we are trying to make 
will be lost. So I appreciate your testimony on that and yield 
back my time.
    Mr. Pallone. Thank you.
    Mr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman.
    Dr. Wakefield, thank you for being here today. I am going 
to ask you a question that Chairman Pallone already asked you. 
And I am a little scared to do it because I didn't understand 
the answer you gave him, and so I am hoping you will give us 
the translation.
    When you talked about the severity-of-need index, you gave 
a very complex answer. But can you tell us just what that means 
to our districts and our constituents, what that means to the 
folks back home?
    Ms. Wakefield. Right now, the data associated with the 
severity-of-need index is on our Web site. So your folks back 
home could actually take a look at how the data are collected 
and what they are displaying. So that information is accessible 
that way.
    Our formal report to you, however, is still in process. 
And, as I mentioned, we hope to get that to you shortly.
    Mr. Burgess. So what is the practical implication for the 
folks back home? They go to the Web site, they check out the 
data. Are there, in fact, additional funds that they could 
plus-up with now? Or is that awaiting your report back to us?
    Ms. Wakefield. That is correct, waiting. There are not 
dollars associated with this at this point in time.
    Mr. Burgess. OK. Thank you. That is helpful.
    You also talked a little bit about moving from a palliative 
care model to a chronic care model. Can you briefly just 
explain what that will look like?
    Ms. Wakefield. Sure. The reference is really a bit more 
about where we have come from in terms of the treatment of HIV/
AIDS, moving from a time when we didn't have available the 
available drugs, pharmaceuticals to treat and extend the lives 
of individuals. So we are at a very different place currently 
in terms of treatment of care of patients than we were when 
this epidemic first began and as it developed.
    Mr. Burgess. Correct. And is that likely to affect your 
funding model? Because clearly now the emphasis is much more on 
the life-extending drugs and the disease management drugs that 
are available but also happen to be fairly expensive and come 
with some other costs of side effects and that sort of thing.
    Ms. Wakefield. Yes, and so we have grantees that request 
funding to be able to deliver services using a chronic care 
model through case management and so on.
    Mr. Burgess. Now, is that in widespread usage throughout 
all of the communities?
    Ms. Wakefield. Yes, I mean, in terms of how grantees are 
working to deliver care to patients. Right now what we are 
seeing in terms of allocation of funding is more dollars 
available, for example, for drug therapy, pharmaceuticals, and 
less money having to be devoted, for example, to hospice care. 
So that would be an example of a change in----
    Mr. Burgess. OK. And you did make the statement at one 
point that your first priority is the stability of 
infrastructure. And I just wanted to be clear. Really, our 
first priority is treating patients. And if treating patients 
is providing them with the therapeutic cocktails they need to 
extend their lives and minimize their symptoms, that should be 
our first priority.
    Ms. Wakefield. Absolutely.
    Mr. Burgess. Let me ask you a question. I actually may be 
very brief. I may submit this in writing. You just referenced 
the health care workforce, which is extremely important to me. 
But, as I recall from our previous work on reauthorization of 
Ryan White, the health care workforce is not really 
specifically addressed in the bill; that comes in other parts 
of what we are doing. Is that not correct?
    Ms. Wakefield. Well, health care workforce is addressed a 
bit through part F, for example, through the education training 
centers that exist, and can provide at least short-term 
information to health care providers to help them deliver 
health care services.
    So we do have funding that goes to universities, for 
example, I believe about 11 of them, 11 education training 
centers, to help with at least short-term training of HIV/AIDS 
health care providers. That is what exists currently.
    Mr. Burgess. OK. And, again, I may submit some additional 
questions about that in writing to you.
    Let me just briefly reference--Dr. Christensen referenced 
incarcerated populations. And we have a significant problem in 
our area back in Fort Worth with people who have spent time in 
prison, come back with a new diagnosis, and may bring that 
illness back with them to their homes when they are re-entered 
into society.
    Is there anything over the horizon that you are looking at 
in being able to capture these problems when the person is 
incarcerated and then an educational way to help mitigate that 
problem as they come back into the community?
    Ms. Wakefield. We have some of our HIV/AIDS clinics that do 
pay special attention to the very population that you are 
describing right now.
    We also are looking at supporting models of care that 
target the population moving from incarceration back into 
community. And we have a particular initiative that focuses 
explicitly in that area that is ongoing now. I don't have 
results I could report to you at this point, but it is ongoing.
    Mr. Burgess. Again, we may submit something in writing to 
you on that.
    And then, just finally, who is the head of the Center for 
Medicare and Medicaid Services currently?
    Ms. Wakefield. We have an acting head.
    Mr. Burgess. Is that a problem?
    Ms. Wakefield. I enjoy really very good relationships with 
my CMS colleagues. I haven't had any difficulties in terms of 
my meeting my information needs.
    Mr. Burgess. Well, when you visit back with the 
administration, we would benefit, I think, from having a full-
time Administrator. It is, after all, the largest insurance 
company on the face of the earth, and they need a full-time 
CEO.
    I will yield back, Mr. Chairman.
    Mr. Pallone. Ms. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman.
    Dr. Wakefield, we welcome your experience and your 
expertise that you are bringing to the office.
    As I said in my opening statement, many of us are concerned 
that the Minority AIDS Initiative was never really allowed to 
live up to its objective of creating the local infrastructure 
in minority communities. And Dr. Parham has been through this 
with us since its inception. And then changes were made that 
made it hard for these small organizations to compete for 
funding. They have been assessed on outcomes that were really 
not appropriate for what they were being asked to do.
    And given that the hardest-hit communities remain those of 
color--and I quoted 71 percent of new AIDS cases and 67 percent 
of people living with AIDS are people of color--what do you 
envision, what would you recommend, from the perspective of the 
HRSA Administrator, to ease the existing disparities, 
particularly among communities of color?
    And what do you envision as perhaps a larger role for the 
one and only National Minority AIDS Education and Training 
Center, which is doing great work but with a lot of 
limitations?
    Ms. Wakefield. We are very supportive of our training 
centers, including the one that you reference. And we are also 
supportive in terms of preparing the next generation of health 
care providers, of additional resources going to those training 
centers, to provide for education and training over a longer 
period of time so that our next generation of health care 
providers can meet the needs of the population that is 
affected.
    And, as you indicated, we have a high proportion of 
minorities who are HIV/AIDS infected. So that is a concern for 
us. And we look to our training centers, as you indicated, to 
be supportive in terms of preparing health care providers to 
better meet those health care needs.
    We also, of course, have the Minority HIV/AIDS Initiative. 
And that is threaded through various parts of the Ryan White 
CARE Act and provides resources and services for the particular 
population for which you have expressed your personal concern.
    Mrs. Christensen. Our intention originally was that the 
organizations within that community would be helped to develop 
the capacity, and that really didn't happen.
    Are you in favor of building capacity from within the 
communities rather than bringing organizations from outside to 
work with the communities? Do you tend to the side of having 
the communities build that capacity themselves? Because I think 
that is where we have failed to, you know, really meet the 
goals.
    Ms. Wakefield. Well, there are pieces, of course, of Ryan 
White that really allow for local community input about 
strategies that might be best aligned to meet the needs of the 
individuals in their communities. So, as the program is 
currently deployed, not everything, of course, is dictated from 
the Federal level, but rather we work with potential grantees 
when they submit, for example, proposals for supplemental 
funding, and they identify locally what their priority needs 
might be for the populations that they serve.
    I think that it is very important, that we listen to local 
communities and that we are receptive to the strategies that 
they are recommending about how to best meet their communities' 
needs.
    Mrs. Christensen. Well, I am sure, you know, particularly 
the Congressional Black Caucus, which was instrumental in 
getting this started, would be interested in sitting down and 
discussing this with you further.
    On the hold-harmless proposal in the consensus document, I 
tend to agree with the minority position, which agrees that in 
2010 it should be set at no less than 95 percent of funding for 
2009, but disagrees on 2011 and 2012. This group would like to 
see the formula funding for parts A and B better match the 
number of HIV and AIDS cases in each jurisdiction rather than 
staying at the 100 percent.
    And it just seems to me, and wouldn't you agree, that 
following what the minority view has suggested--and these are 
places like the Southern AIDS Coalition that represents a part 
of the country which is becoming the epicenter of this 
disease--but wouldn't you agree that their proposal would be a 
better way of ensuring that the funding follow the epidemic?
    Ms. Wakefield. HRSA recommends that we continue hold-
harmless provisions for part A and part B grantees. We will, of 
course, look and provide technical assistance as you make 
determinations about what more specific provisions you would be 
interested in pursuing as a committee. We will be happy to work 
with your committee staff--the program will be happy to work 
with your committee staff as you have different approaches to 
that, to hold harmless. But bottom line, we recommend 
continuing hold-harmless provisions for both A and B.
    Mrs. Christensen. My time is up. Thank you.
    Mr. Pallone. Thank you.
    Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman.
    The benefit of the hearing process that we are going 
through is it reminds us and get into more specifics than we 
generally would do. And that is why I like to attend them as 
much as I can, because I learn tons. So excuse me if I am 
asking some basic stuff.
    So I have in the Ryan White program--and my first time I 
was really lobbied on this was a young boy in rural southern 
Illinois who was a hemophiliac and had a blood transfusion. He 
and his mom came in and said, ``This is an important program 
for us.'' And so that is why I think there is a bipartisan 
support.
    So you have part A based upon HIV and AIDS cases. You have 
part B, which is a supplemental, based upon formulas of more 
crises in an area, is that correct? Or you want to impact more 
money sooner rather than later?
    Ms. Wakefield. Part B for States and territories and 
emerging communities, so communities that might have a smaller 
number of cases but look like they might be increasing.
    Also, in addition to--I think you mentioned maybe some 
discretionary funding in part B, true, ``supplemental 
funding,'' that might have been the term. There also is base or 
formula funds associated with part B, as well. So it has a 
formula component; it also has a supplemental component.
    Mr. Shimkus. And then part C goes to early intervention 
clinics?
    Ms. Wakefield. Yes, that is correct.
    Mr. Shimkus. Have we been able to do--obviously, we all 
know that education is a key to helping address and solve and 
mitigate health care risk across the board, whether it is HIV/
AIDS or whether it is H1N1 or whatever else. And that is really 
an important, critical aspect.
    Do we see in the early intervention clinics, does that have 
an educational component? Or is that like the first stop for 
someone who is--where they figure out they have something wrong 
and the clinic is their first stop?
    Ms. Wakefield. For part C you are asking about?
    Mr. Shimkus. Right.
    Ms. Wakefield. That is discretionary funding. And that 
provides core medical and support services to people who are 
living with HIV/AIDS now, and so to folks in the service areas 
for those community organizations.
    Mr. Shimkus. And D is the family component, which is women, 
infants, children, and students, another formula-based?
    Ms. Wakefield. No, that one is discretionary.
    Mr. Shimkus. And it is based upon what? I mean, you all 
have the discretion, obviously, but what are some of the 
parameters that you use?
    Ms. Wakefield. Sure. So individuals or organizations, I 
should say, apply for funding----
    Mr. Shimkus. It is a granting process.
    Ms. Wakefield. Exactly. Correct. Yes.
    Mr. Shimkus. And then the F--which it took me a while to 
figure out that this is all part of F--you have the dental, 
which I thinkis easy to understand, and the AETCs and the SPNS, 
and I found out where that was. They are the ``special projects of 
national significance.'' That is another grant program?
    Ms. Wakefield. That is correct.
    Mr. Shimkus. And then the MAI is Minority AIDS Initiative, 
which I think Representative Christensen has just elaborated on 
the importance of that. Think we all fully understand those 
issues.
    From the minority's side, again, I think we would really 
want to encourage--because these are specific programs which 
have specific authorizations, hopefully based upon cases and 
money spent and historical aspects. And we do know populations 
shift. This is going to be an issue of ``follow the money,'' if 
you haven't figured that out now, because people are going to 
say, ``OK, we have areas that have historically been high. We 
don't want to disenfranchise that pool of money.''
    I am from Illinois. Chicago is a big area. They are always 
talking to me about, ``Let's don't hurt Chicago.'' But I am a 
rural representative. So what if there is a migration into 
rural areas and that population shift is significant enough to 
start having an impact? So, whether we like it or not, like my 
colleague Congresswoman Capps said, this is really going to be 
a ``follow the money'' issue.
    So the question is on--that is why the ``such sums as may 
be desired'' is problematic for us in a period of increasing 
deficits and the national debt threefold so far in just this 
year. It is hard for us to go back to the public and say, 
``Blank check. We don't know.'' It would be much better if we 
did some analysis, saying, ``Here is the population, here is 
the need, here is the amount we need.''
    And we have historically been able to come back for a 
supplemental request and added money if we guess wrong, and I 
mean terribly wrong. But I would respectfully suggest that we 
go back and work with the committee to hone down a number. In 
this environment that we are in today, ``such sums as may be 
requested'' I think is a tough one to overcome, because it will 
be attacked across the board.
    And with that, thank you, Mr. Chairman.
    Mr. Pallone. The gentleman from Georgia, Mr. Gingrey.
    Dr. Gingrey. Mr. Chairman, thank you.
    And it is amazing how often this happens, that you sit here 
for an hour, hour and a half, waiting. You have this prize 
question you are itching to ask, and the guy or the gal just 
before you asks your question. And Mr. Shimkus just did that. 
But I think it is such a good point, that I want to ask the 
question again.
    And, Dr. Wakefield, first of all, let me just say thank 
you. I think your testimony has been very forthright and 
interesting and informative.
    But, yes, what Representative Shimkus said in regard to 
``such sums as may be necessary,'' and Representative Whitfield 
brought it up earlier on this side in his line of questioning, 
and your response to that was kind of, ``Well, the language is 
OK with me,'' rather than what I guess he hoped.
    And what maybe Representative Shimkus and certainly myself 
would like to suggest is this makes it a very difficult vote 
for those of us on the Republican side and maybe for 52 of the 
majority party when we get to the floor because of the climate 
that we are in, the very difficult times, this estimation of $9 
trillion worth of deficit over the next 10 years and $1.8 
trillion in 2009.
    The American people that were so fired up and feisty and in 
our face at these town hall meetings, it wasn't just about 
their concern about a government takeover of our health care 
system, although certainly many Medicare patients were there 
and concerned about cuts to Medicare. A lot of these people 
were outraged over the continuation from the Republican 
majority for 12 years and now the first 9 months of the Obama 
administration and the majority of the Democrats over the last 
2\1/2\ years, it is just more of the same and getting worse.
    So the point that has been made about that, I think it 
should be well-taken by you, and I hope it is, because if 
President Obama--and I truly believe he does want bipartisan 
support for many initiatives, and he will talk about that, I am 
sure, tonight. But if you are going to get that, don't put 
language like that in a bill where our constituents go nuts 
over that. And so, you know, to specifically say to spend a 
certain amount, up to a certain amount, then the appropriators 
can go up to that amount if they need to. And, as John Shimkus 
said, we could always come back and add, if necessary.
    Now, let me--and I want you to respond. And, fortunately, I 
have a little extra time. The chairman has been generous 
because I didn't make an opening statement. And I will give you 
sufficient time to respond.
    I am also concerned about this issue of this ``hold 
harmless'' these jurisdictions. It would seem to me that if we 
have a certain amount of money to allocate for something of 
this importance, HIV/AIDS and trying to eradicate this disease 
in our lifetime, I hope, and to make life more palatable and 
tolerable and possibly even help these patients, 500,000 or 
more, I think you mentioned, nationwide, to be productive 
citizens, God help them. And we need to help them, no question 
about it.
    But if you have areas where the caseload is going down and 
you have other areas where the caseload is going up, you made 
the statement, ``Well, you know, we still have those 
infrastructure needs, and they don't go away.'' Well, I think 
they do go away, maybe not in straight-line proportionality. 
And, therefore, in the districts where you are seeing more 
patients, I would guess that the infrastructure need funding 
goes up, too, maybe, again, not in a straight line.
    So explain to me once again why you wouldn't want to 
reallocate this money and do this hold-harmless deal instead, 
where you can only cut a maximum of 5 percent in year 1 and no 
cuts in year 2 and year 3? I mean, money doesn't grow on trees, 
and I am sure you would agree with that, Doctor. So, once 
again, if you don't mind explaining to us why you would support 
something like that, that kind of language?
    Ms. Wakefield. So, HRSA recommends continuing hold-harmless 
provisions for both parts A and B grantees.
    The hold-harmless provisions were included in the 2006 
reauthorization to prevent, as you indicated, destabilization 
of the HIV care infrastructure and also from significant 
funding shifts due to funding formula distributions from year 
to year. We are sensitive to the impact of funding changes on 
systems of care, as I indicated. And for those reasons, as well 
as for administrative simplification reasons, that is our 
recommendation.
    With regard to your comment about the ``such sums'' 
language in the legislation, HRSA will of course implement the 
program exactly the way the Congress suggests, in terms of 
spending. We will expend those funds to support these very 
critical programs.
    The ``such sums'' language that is included in the bill is, 
as I mentioned, certainly acceptable to HRSA. And we look 
forward to working with you to ensure that the funding that is 
allocated to this program meets community needs and is 
judiciously spent. So those are also very important from our 
perspective, that the community need is met and that those 
resources are very judiciously spent.
    Dr. Gingrey. Dr. Wakefield, thank you. And I am glad you 
would be willing to work with us. Because, as I point out, this 
is a bill that I don't think very many Members on either side 
of the aisle would want to be on record of voting against, but 
the ``such sums as necessary'' just makes it more difficult.
    And I think, as others have said before me, that this is 
certainly a time where we need to be, at the Federal level 
spending the taxpayers' money, we need to be tightening our 
belt. I mean, you know, you look at things like a dual-engine 
program for the joint strike fighter, and I could go on and 
name many things, sacred cows that we just continue to pour 
money into.
    And so, if we can tighten our belts on this and be wise 
about how we spend the money and get the money to where it is 
needed in regard to these HIV/AIDS patients, rather than just 
continuing to support an infrastructure somewhere that has 
fewer and fewer patients to deal with--people may be sitting 
around, kind of, twiddling their thumbs a little bit, Doctor. 
You know, you may want to refute me on that. But that is my 
concern; it is being fiscally responsible with the American 
taxpayers' money.
    And, Mr. Chairman, I yield back.
    Mr. Pallone. Thank you.
    The gentlewoman from Colorado, Ms. DeGette.
    Ms. DeGette. Thank you very much, Mr. Chairman.
    Dr. Wakefield, I just wanted to follow up. I wanted to talk 
to you a little bit about the policy here. And I wanted to 
follow up on something that Mr. Burgess brought up very 
briefly, and that is the need that you talk about in your 
testimony for the training of new HIV health care 
professionals.
    I am wondering if you can describe the projections of how 
many new HIV health professionals we need.
    Ms. Wakefield. I don't have numbers with me or an 
estimation with me. I would be happy to go back and then 
provide that information for you.
    Ms. DeGette. That would be very, very helpful for us, 
especially with respect to the concerns expressed on the other 
side of the aisle on budget and so on, because that may play 
into how much this is really going to cost.
    How much unique training do HIV health care professionals 
need to have?
    Ms. Wakefield. First of all, because of the length of the 
epidemic, the individuals, the clinicians who were first 
educated and were taking care of this population are basically 
now, after 25 years, some of them are now coming close to 
retirement. So that population of health care providers, some 
of them will extend obviously longer.
    But it is really about bringing in training for that next 
generation of providers moving forward. Some of the most 
significant challenges are about managing and helping to 
support patients, for example, that have comorbidities, 
multiple diseases at one time, so an individual with diabetes, 
for example, that is also diagnosed with AIDS, and providing 
care to those populations with those codiseases or 
comorbidities over time in a chronic care fashion. So that is a 
different set of challenges than we were dealing with at the 
beginning of this epidemic, requiring a different set of 
skills.
    Ms. DeGette. The other different set of challenges is the 
increased use and effectiveness of pharmaceuticals.
    Ms. Wakefield. So you make a really good point because many 
of the pharmaceuticals, for example, are pretty significant. In 
terms of their complexity, you can have difficulties, again to 
your point, with drug interactions and toxicities. That is 
another set as well as still, frankly, some residual stigma 
associated with this disease. So that is another area that 
clinicians are helped by being trained--by having education 
about this particular disease that isn't common to diabetes, 
congestive heart failure and other chronic illnesses.
    Ms. DeGette. But are there changes that we need to make to 
the Ryan White program to accommodate this training that we are 
going to have to be providing to the next generation of 
providers?
    Ms. Wakefield. So through the testimony that I provided 
earlier, and mentioning the increased funding amounts that we 
support for the educational training centers, is a strategy to 
ensure that providers have that necessary training.
    Ms. DeGette. So it is really more funding, not necessarily 
types of training.
    Ms. Wakefield. But we also have resources that are made 
available through our SPNS, our projects of national 
significance, to look at new care models and new care models 
for a specific populations, the type that, for example, 
Congressman Burgess mentioned, that is people transitioning 
from incarceration back into community and what that takes to 
meet the health care needs of that special population.
    Ms. DeGette. OK. Just one last area I want to talk about--
that is food and nutrition--because, as you know, those are 
critical components for the survival of people living with HIV 
and AIDS. We have a wonderful, wonderful program in Denver, 
Project Angel Heart, that focuses on nutrition for folks with 
HIV/AIDS. It can reduce the side effects of antiretroviral 
medications, make them easier to tolerate. And also a lot of 
these medications don't work if you don't take them with food. 
So I am wondering if you can discuss HRSA's recent guidance on 
food and nutrition. And while you are looking for the guidance, 
I am wondering if you have recommendations for food and 
nutrition services under parts A and B of the Ryan White 
program.
    Ms. Wakefield. So in terms of nutrition services, we have a 
definition of medical nutrition therapy and--medical nutrition 
therapy that is considered a core service. So we have core 
services and a category of services that fall under that 
definition or fall within that category. We also have a set of 
services that fall into a category referred to as support 
services. So I am talking about medical nutritional therapy 
inside the core nutritional. And that medical nutritional 
therapy in those circumstances provided by a licensed 
registered dietitian outside of a primary care visit, the 
provision of food, nutritional services, nutritional 
supplements may be provided pursuant to a physician's 
recommendation and then with a nutritional plan developed by a 
licensed registered dietitian. Nutritional services that are 
not provided by a licensed registered dietitian are considered 
a support service. Food nutritional services and supplements 
that are not provided pursuant to a physician's recommendation, 
again, linked to a nutritional plan developed by that dietitian 
are considered support services. So you can see where 
nutritional services track differently as a core medical 
service and what is required there versus nutritional services 
that track through the support services category.
    Ms. DeGette. Thank you.
    Thank you very much, Mr. Chairman.
    Mr. Pallone. Thank you. And thank you for your testimony. 
We may have some additional questions that Members will send 
forth. I know Mr. Burgess mentioned in particular. But we will 
get those to you fairly quickly so you can respond.
    Thank you very much. We appreciate it.
    Then I would ask the second panel to come forward.
    Thank you for being with us today. Let me introduce each of 
you on the second panel from my left to right. First is Marcia 
Crosse. Dr. Marcia Crosse is the Health Care Director for the 
U.S. Government Accountability Office. Second is Ms. Julie 
Scofield, who is Executive Director of the National Alliance of 
State and Territorial AIDS Directors. And third is Dr. Donna 
Elaine Sweet, who is a professor at the Department of Internal 
Medicine at the University of Kansas School of Medicine and 
Board Chair of the American Academy of HIV Medicine.
    We try to ask you to limit your remarks to 5 minutes. Of 
course, you can always submit your statement for the record, 
and after you are done, we will take some questions from the 
Members.
    I will start on my left with Dr. Crosse.

STATEMENTS OF MARCIA CROSSE, PH.D., HEALTH CARE DIRECTOR, U.S. 
GOVERNMENT ACCOUNTABILITY OFFICE; JULIE M. SCOFIELD, EXECUTIVE 
   DIRECTOR, NATIONAL ALLIANCE OF STATE AND TERRITORIAL AIDS 
    DIRECTORS; AND DONNA ELAINE SWEET, M.D., MACP, AAHIVS, 
   PROFESSOR, DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF 
 KANSAS, SCHOOL OF MEDICINE, BOARD CHAIR, AMERICAN ACADEMY OF 
                          HIV MEDICINE

                   STATEMENT OF MARCIA CROSSE

    Ms. Crosse. Thank you, Mr. Chairman, members of the 
subcommittee. I am pleased to be here today to discuss the Ryan 
White program. As we have heard, this year about $2.2 billion 
was provided through the program to assist over 500,000 mostly 
low-income, underinsured or uninsured individuals living with 
HIV/AIDS. The majority of this funding was distributed through 
part A grants to qualifying metropolitan areas and part B 
grants to States, the District of Columbia and territories.
    Most of this funding is distributed to grantees either as 
base or supplemental grants. Base grants are distributed by 
formula, and HRSA uses a grantee share of living HIV/AIDS cases 
to determine the amount of the grant. Supplemental grants are 
generally awarded through a competitive process based on the 
demonstration of severe need and other criteria.
    In addition, the Minority AIDS Initiative, or MAI, grants 
as we have heard, are separate supplemental grants intended to 
address disparities for minorities in access to treatment and 
health outcomes.
    Three other parts of the program provide lower levels of 
funding to public and private nonprofit organizations for 
specific purposes and include part D grants for family-centered 
comprehensive care to children, youth, women and their 
families.
    When the Ryan White CARE Act was last reauthorized in 2006, 
Congress made a number of changes in the structure and funding 
requirements of the program with the goals of better targeting 
funding to areas of need and increasing the proportion of 
funding going to direct service delivery. For example, Congress 
changed the process by which HRSA awards MAI grants under part 
A and part B from a formula based solely on demographics to a 
competitive process to better target funding. The legislation 
also capped at 10 percent the amount that part D grantees could 
spend on administrative expenses to increase the funding for 
services. Congress included mandates for GAO to study the 
changes to the MAI award process and the part D allowance for 
administrative expenses.
    My testimony today is based on our March 2009 report on the 
MAI provisions and our December 2008 report on the part D 
administrative expense cap. We found that the new competitive 
process for awarding MAI grants altered funding for part A and 
part B grantees from what they would have received under the 
old formula-based process. For example, in fiscal year 2007, 
Phoenix received about 40 percent less than it would have 
received under the old formula, while Houston received about 11 
percent more. All part A grantees that applied for MAI funding 
received it, with grant amounts in fiscal year 2007 ranging 
from $50,000 to $9.3 million. All part B grantees that applied 
for MAI funding also received it; however, half of the part B 
grantees decided that the new administrative requirements, 
including a separate application for MAI funds and increased 
reporting requirements, were not worth the amount of funds that 
they expected to receive, and therefore they chose not to 
apply. For the part B grantees that submitted applications, 
fiscal year 2007 MAI funding ranged from $2,500 to about $1.5 
million.
    The change to a competitive MAI grant process did not 
appear to bring in new service providers or change the approach 
to reaching minority populations. Grantees told us that they 
generallyfunded the same service providers and initiatives to 
reduce minority health disparities as they had in prior years.
    With regard to the part D administrative expense gap, we 
found that grantees were in compliance with the gap, having 
charged 10 percent or less of their grant award for 
administrative expenses, such as rent and utilities. However, 
about half of the grantees reported that not all of their part 
D administrative expenses were covered by the 10 percent 
allowance, and they were forced to use money from their 
organizations' general operating budgets or other sources to 
cover their actual costs.
    In addition, grantees such as universities that had 
negotiated indirect cost rates with the Federal Government 
could spend more of their part D grants on such expenses 
because they could also charge for indirect costs. These 
grantees reported spending up to 26 percent of their part D 
grants on indirect costs in addition to the 10 percent allowed 
under the cap. While the goal of the cap was to increase 
services, grantees reported that the cap had not altered either 
the amount or type of services they provide, and that the cap 
made it necessary for clinical staff to perform administrative 
tasks.
    In summary, our review of the first year's implementation 
of these provisions did not demonstrate a major increase in 
services; however, it remains to be seen whether the move to a 
competitive MAI grant process or the part D administrative 
expense cap will meet the goals of better targeting funding to 
areas of need and increasing the proportion of funding going to 
direct services delivery moving forward.
    Mr. Chairman, this completes my prepared remarks. I would 
be happy to respond to any questions you or other members of 
the subcommittee may have.
    Mr. Pallone. Thank you.
    [The prepared statement of Ms. Crosse follows:]
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    Mr. Pallone. Ms. Scofield.

                 STATEMENT OF JULIE M. SCOFIELD

    Ms. Scofield. Good afternoon, Mr. Chairman, members of the 
committee. I am Julie Scofield, Executive Director of the 
National Alliance of State and Territorial AIDS Directors, 
NASTAD. Thank you for inviting me to speak with you today about 
the urgent need to extend the Ryan White program, which sunsets 
on September 30.
    NASTAD and the HIV/AIDS community appreciates the long-
standing support of the Energy and Commerce Committee and the 
House of Representatives for the Ryan White program and the 
domestic HIV/AIDS prevention programs that are extremely 
important to Americans living and at risk for HIV/AIDS. State 
AIDS directors in all 50 States, the District of Columbia, 
Puerto Rico, the U.S. Virgin Islands and 6 U.S. territories 
represented by NASTAD administer over $1.2 billion in Ryan 
White part B base and AIDS drug assistance program funds each 
year to provide comprehensive care and treatment for 
individuals living in their jurisdictions.
    NASTAD, along with AIDS Action, cochairs the Ryan White 
Work Group, an affiliated work group of the Federal AIDS Policy 
Partnership. The Ryan White Work Group is a coalition of 
national, local and community-based service providers and HIV/
AIDS organizations. The work group developed the Community 
Consensus document which currently has over 300 signatures from 
47 States, D.C. and Puerto Rico.
    There is an exceptional level of cohesiveness in the 
community around the path for extending the Ryan White program 
and a growing call for action by the September 30 deadline. I 
am submitting the Community Consensus document for the hearing 
record.
    The community is extremely pleased to see that the draft 
legislation closely follows the Community Consensus document, 
and even more pleased with the leadership being demonstrated by 
the committee to act quickly.
    NASTAD and the HIV/AIDS community support a 3-year 
extension of Ryan White that essentially restarts the clock and 
continues many important provisions for grantees. These include 
the continuation of protections and penalties for States with 
maturing names-based HIV reporting systems, hold harmless 
protection, along with the extension of protection for 
transitional grant areas and their eligibility. In order to 
maintain health stability for persons living with HIV/AIDS, it 
is essential to secure an extension of the Ryan White program 
as soon as possible while the larger issues of health reform 
and the development of a national HIV/AIDS strategy are 
developed, implemented and assessed. We also welcome the 
administration's proposal for a 4-year extension.
    NASTAD is extremely pleased to see that the discussion 
draft addresses an issue that has caused undue burden on State 
grantees. The current law contains a provision that penalizes 
part A and b grantees if they have more than 2 percent of their 
award unobligated at the end of a grant year by making them 
ineligible for the supplemental components of their awards and 
reducing their grant awards in subsequent years. This provision 
prevents administrative difficulties for grantees which must 
work with subgrantees; deal with budget cuts, hiring freezes, 
spending caps; as well as manage a variety of funding sources 
with varying grant periods.
    The presence of unobligated funds does not signal a lack of 
need for these funds; instead, it often reflects the presence 
of factors that are extremely difficult to manage. NASTAD 
supports raising the unobligated threshold from 2 to 5 percent. 
By eliminating the penalty that decreases a State's subsequent 
year's award by the entire amount of their unobligated balance, 
States will be able to retain the funds necessary to provide 
services to their clients. NASTAD believes that the penalty 
which makes grantees ineligible for supplemental funding should 
also be eliminated in order to ensure that jurisdictions have 
all possible funding.
    Related to this issue is a provision governing the use of 
rebate dollars accrued through a mix of Federal and State ADAP 
funds. HRSA has instructed States that they must spend their 
rebate dollars before the Federal grant award. This policy 
created a problem, particularly when combined with the new 
stringent rules regarding unobligated balances. Regardless of 
how rebate income is classified, the Ryan White program 
requires rebates to be put back into the program. The 
discussion draft goes far in clarifying this technical issue. 
We ask that the language be further changed to allow Statesto 
spend rebate funds after program funds in all cases, not just if doing 
so would avoid triggering a penalty. ADAPs are administratively very 
complex programs, and States need the utmost flexibility to ensure that 
dollars stretch as far as possible, particularly in these fiscally 
challenging times.
    The National Alliance of State and Territorial AIDS 
Directors thanks the Chairman and the rest of the committee for 
their thoughtful consideration of NASTAD and the community's 
recommendations for extending the Ryan White program. We ask 
that you continue to prioritize passage of this important 
legislation and appreciate your ongoing attention to the 
September 30 deadline. NASTAD and the Ryan White Work Group 
will continue to do all that we can to support you in these 
efforts.
    Mr. Pallone. Thank you, Ms. Scofield.
    [The prepared statement of Ms. Scofield follows:]
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    Mr. Pallone. Dr. Sweet.

                  STATEMENT OF DONNA E. SWEET

    Dr. Sweet. Chairman Pallone and distinguished members of 
the committee, I am honored to be here today to discuss the 
reauthorization and extension of the Ryan White program, 
specifically part C. I will keep my comments brief. I have 
submitted a full testimony for the record, and my credentials 
are in there, but I am here today as medical director of a part 
C Ryan White clinic in Wichita, Kansas, the other KU, who also 
sees patients in outreach clinics in Garden City, Salina and 
Pittsburgh. I am also a credentialed specialist in HIV/AIDS and 
the current Board Chair of the American Academy of HIV 
Medicine, headquartered here in Washington, D.C.
    The mission of my part C program is to provide care and 
early intervention services to all HIV-positive individuals in 
the State of Kansas regardless of their ability to pay. Part C 
clinics provide care nationally to approximately 250,000 people 
living with HIV, as well as providing HIV-related counseling 
and testing. Many have mixed sources of funding, including some 
or all parts of the Ryan White program.
    Today I would like to take you inside a part C clinic to 
the front lines of medicine, fighting for the lives of people 
living with HIV. My part C clinic provides care and treatment 
to 1,246 patients. Of these, 40 percent would have no coverage 
at all if it were not for the Ryan White CARE Act. We provide 
ongoing, comprehensive care to an ever-increasing number of 
patients.
    My clinic has an average annual increase of over 100 new 
patients a year; however, we are still working off the same 
number of Ryan White dollars we received since 1999. As a 
result, in the last 10 years my clinic patient load has 
doubled, and yet my funding has remained the same. To 
supplement our insufficient Federal dollars, we often do things 
like annual bake sales, picnics, and other things that the 
community does in order to support the clinic and its patients.
    There has been some discussion over the recent years of the 
concept of the patient-centered medical home. That is what my 
Ryan White part C clinic is and has been since 1994. In my 
clinic, case management, psychological counseling, dental care, 
pharmacy management, adherence counseling and, when needed, 
palliative care are all brought together under one roof. This 
approach has been central to our ability to retain patients in 
long-term care.
    The real effect of the Ryan White program if it were 
allowed to lapse for even a short amount of time would be seen 
on the front lines of the disease in clinics like mine. For my 
clinic that would mean losing access to part C money that pays 
for care and treatment of over 40 percent of my patients, part 
B money that funds my case managers, and ADAP money that 
provides drugs for patients who cannot afford them, nearly 80 
percent of the total. On June 1, I would no longer be able to 
pay my staff and they would have to be let go. I have not had 
any staff turnover in 5 years, and my people are well trained 
in caring for my HIV patients. They are well qualified and 
would no doubt have no trouble finding other employment; 
however, the loss to my clinic would be irreversible. If the 
Ryan White program were to face a gap in service of even a few 
months, years of investment in staff and infrastructure would 
be lost.
    Without part C, my patients would have no other place to go 
for the lifesaving services and treatment that we can now 
offer. Without care, patients' lives would be lost. Over the 
last 20 years, HIV has become a highly manageable disease with 
proper care and treatment. In the mid-1990s, mortality rates 
plummeted with the new medicines and treatments which allowed 
better ways of fighting the virus. Patients are living longer, 
which brings about a new set of medical challenges. Treating 
HIV is enormously complex, but it becomes even more so when you 
are faced now with the medical needs of elderly patients.
    Fortunately in my clinic, I now see only 15 to 20 AIDS 
deaths a year, but that number will increase dramatically if 
the population loses access to the care they need. The Ryan 
White program is invaluable to the patients and the providers 
that it funds, and Congress must not delay in reauthorizing it. 
Over the past year, numerous HIV and AIDS organizations have 
come together through the Federal AIDS Policy Partnership, or 
FAPP, to form a consensus on reauthorizing the program. I have 
participated in those discussions, and I urge the committee to 
consider the recommendations of the consensus document which 
you have received. Among those recommendations, however, I 
would like to highlight a few that are important to me and my 
clinic.
    The CARE Act needs to be reauthorized for at least 3 years, 
and I also like the administration's 4. We need to have 
assurance of a stable and continuous funding stream in order to 
care for our patients in the best way possible. Authorization 
levels included in legislation that was under discussion this 
year was a 3.7 percent increase for the majority of the parts, 
significantly less than the annual increase for community 
health centers. As someone running a clinic that really has to 
do its own fundraising to keep its doors open, I would 
appreciate consideration of language authorizing such sums as 
necessary in the program because we have not been getting what 
is necessary. And thirdly, the provision of core medical 
services, the 75/25 rule needs to be protected. Additional 
recommendations are listed, and I will urge the committee to 
thoughtfully consider them.
    But in closing, I would like to leave the committee with a 
few thoughts. Without the Ryan White program, my clinic never 
would have been created. Without a timely reauthorization, it 
may cease to exist. And without the clinic my patients will not 
receive the care they need. And without that care, the disease 
they live with every day may unnecessarily and prematurely 
claim their lives.
    The Ryan White program works. It is critical to the care 
and treatment of those affected by this Nation's largest 
epidemic, and I urge the committee to authorize the program 
with all due haste.
    Thank you for the opportunity to testify today about Ryan 
White part C. This concludes my testimony, but I would be more 
than happy to answer questions.
    [The prepared statement of Dr. Sweet follows:]
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    Mr. Pallone. Thank you, Dr. Sweet.
    We will now take some questions from the Members. I am 
going to try to get in three questions here in my 5 minutes or 
so. So first I will start with Ms. Scofield.
    In fiscal 2009, 29 States and 3 territories were held 
harmless for base funding or ADAP funds or both, and hold 
harmless is specifically intending to make sure that States 
don't face precipitous declines in funding that would 
destabilize systems and services. Can you tell us more about 
why the Community Consensus, including groups from States with 
both older and newer epidemics, supports the extensions of the 
hold harmless protections?
    Ms. Scofield. Thank you. Well, I think all of us in the 
community understand that none of the components of Ryan White 
have received adequate funding in the last several years. Our 
estimates of need surpass what has been appropriated by about 
$500 million. So that is part of the issue at hand.
    In addition, however, when the last reauthorization 
occurred, there were changes in virtually every aspect of every 
formula of the program, and it has taken a long time for the 
dust to settle on the last reauthorization. Money did move 
around the country. So we are seeing how funds are being 
reallocated as a result of those formula changes. And in the 
first year after implementation of the last reauthorization, 
there were some significant increases to some jurisdictions. 
And so jurisdictions really were challenged to be able to 
obligate and use well all the funds that were provided.
    I think all of us recognize that in this current fiscal 
environment what is needed more than anything else is stability 
in funding. We estimate that State HIV/AIDS programs lost over 
$150 million in State resources in fiscal year 2009, and so 
really this is not the time for there to be anything but 
stability in their Federal allocations.
    Mr. Pallone. Thank you.
    Dr. Sweet, you also talked about the lack of funding. I 
wanted to ask you about that. Part C provides grants directly 
to service providers to support outpatient HIV early 
intervention, and part C also funds planning grants and 
capacity development grants. This year part C was appropriated 
$201.9 million, which was only a 1.56 percent increase over 
fiscal year 2008. Do you agree that this 1.56 increase for 2008 
is simply inadequate? And what has the impact of limited 
funding been on your clinic and other part C providers?
    Dr. Sweet. Well, thank you. It has certainly been 
inadequate. We have had level funding, which means rescissions 
each year over the last 10 years. We just went through an 
expansion grant process. The need is so tremendous, they had a 
lot of good grant applications, but were able to fund very, 
very few. Dr. Parham Hopson and Dr. Cheever, who were back here 
supporting Dr. Wakefield, I have known them for many years, and 
I know that they are also concerned about the fact that they 
have many, many people demonstrating need, like my clinics, but 
the money that was available for expansion grants was simply 
not enough to give almost anybody what they needed.
    So yes, we need more. And I think it is interesting that 
such sums as necessary wasn't part of the last reauthorization. 
But as I have read the bills prior to that starting in 1990, 
there were never any moneys put in as specified amounts. It 
always said ``such sums'' until this last time. So whatever has 
been in it is inadequate, and I think, as Julie said, what we 
need is across-the-board increased funding for all of our 
programs.
    What it has done for my clinic is simply made me truly--the 
75/25 doesn't mean much to me because I spend 95 percent on 
medical care. Between the laboratory studies, the CD forecasts, 
the viral loads, the genotypes that I need to do to do quality 
medical care, I have simply had to cut out all of the other 
niceties other than case management. Transportation, food 
services, things like that I now do through individual 
fundraising, philanthropic things in the community because 
there is just not enough money in the grant to do the medical 
care.
    Mr. Pallone. I appreciate that. Those are good examples.
    Going back to Ms. Scofield again about the TGAs. According 
to HRSA, there are six TGAs that are in danger of losing their 
status in fiscal year 2011, and the Community Consensus 
document recommends extending their status as TGAs for the next 
3 years, basically the length of the extension that is in this 
draft. Can you elaborate on this recommendation? Why does the 
committee feel it is important to ensure this continued funding 
for these areas?
    Ms. Scofield. Well, for one thing, TGA eligibility is based 
on reported AIDS cases, because we don't have HIV and AIDS in 
all of the jurisdictions. So we know that many TGAs are serving 
clients with HIV well beyond the number of clients that they 
have with AIDS. So that is first and foremost.
    Secondly, I think that we all appreciate that as new 
jurisdictions may meet the case threshold, they may also become 
eligible to become TGAs. That just really has not happened. And 
if you really change and allow these TGAs to lose their 
funding, there is no guarantee that the States are going to be 
able to supplant that money. Given the State budget outlook at 
the moment, if TGAs lose those resources, the States simply are 
not going to be able to step in and replace those funds. And 
even though some of that TGA resource might flow into part B 
and be available, it would just go out through the regular 
formula. So again, there would be no guarantee that those TGAs 
would be left with any of the same resources to provide 
services.
    Mr. Pallone. All right. Thank you very much.
    Dr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman.
    Dr. Sweet, let me just be sure that I am understanding 
correctly. In the last reauthorization of the program, funding 
for part C was to increase by 3.7 percent per year, but the 
amount of funding that Mr. Pallone just described was a 1.7 
percent increase. Was that a discrepancy between what we 
authorized and what the appropriators came up with?
    Dr. Sweet. I believe that is true. And there were also 
increased--in terms of an individual clinic like mine, the 
increase went into new clinics where there are places that have 
been talked about many times with new small groups of HIV-
infected patients that certainly don't meet TGA or EMA 
criteria, but where they desperately needed funding. So there 
have been new Ryan White seed clinics that have been funded 
through this time, and the new money went to those. It did not 
go to increasing the base funds of those of us who have had 
clinics.
    Mr. Burgess. In a perfect world, had that 3.7 percent 
increase been funded and made available to your clinic under 
the part C funds, would that have been a satisfactory amount 
for you to keep up with what you are doing? When you describe 
level funding, is that a consequence of inflation that is 
eating up the increases that are built into the authorization 
amounts?
    Dr. Sweet. I don't think it would have been sufficient to 
do all of the things I would like to do for my patients, 
realizing, again, my base grant for part C in very specific 
terms right now is $80,000 less than it was 10 years ago 
because of level funding and rescissions.
    Mr. Burgess. Is that in actual dollars or constant dollars?
    Dr. Sweet. Actual dollars. And it does not take into 
account the fact that there is a 2.5 to 3 percent increase in 
basic medical costs. My salaries have gone up in terms of the 
staff, the fringe benefits, the medical equipment and supplies 
that I buy. So truly, I have faced each year with increased 
patients, a declining amount of money per patient to be able to 
take care of them. It has made us very efficient, but we are at 
that point now where there is no more efficiency to be strung 
out on that string. So we are actually--our base fund is less 
than it was because of the 1 to 2 percent rescission that we 
pay back to the government on any grant.
    Mr. Burgess. Explain to me about the rescission, because I 
am not quite sure I understand that.
    Dr. Sweet. Well, I am not too sure I understand it. We have 
GAO here, too. But it is the amount of money that is sort of 
taken back. Even though you are level funded, there is a little 
bit of it that stays with the Feds in order to administer the 
program at a Federal level. That is a clinically-oriented 
approach to a rescission.
    Mr. Burgess. We will get to that in just a minute, but let 
me follow up on this.
    You have heard some discussion up here about, we need a 
number in there or such sums. I mean, here is our problem. We 
are an authorizing committee, and I always like to point out 
the first time I went out to visit the NIH, I really understood 
the difference between an authorizer and appropriator because 
there are no buildingsnamed after authorizers. They are all 
named after appropriators. So herein is our problem.
    I mean, you heard Ranking Member Barton talk about this. We 
want your input on that number. I would like to see us put a 
number in there and then hold the appropriators' feet to the 
fire on delivering of that number. We are not doing that well 
with having a number in there now, but how are we going to be 
able to even know that we are even close to the target if we 
don't describe any sort--if we don't give them any sort of 
target to meet? If they always underfund us by 50 percent, OK, 
we will increase it by 50 percent. There is some logic to 
follow there. But if we just leave an open-ended discussion at 
the level of the appropriations, I don't want to leave it up to 
them to make those decisions because we all know appropriators 
are very, very busy, important people. They have a lot of 
things to worry about, and the very tiny amounts of money we 
are talking about in Ryan White may not even cross their radar 
screen.
    So help us. All I am saying is, help us with that. When Mr. 
Pallone writes the bill, I would like to see us put a number in 
there that is realistic.
    Dr. Sweet. Well, I can tell you, the coalition has thought 
a great deal about this, all of the 300-plus organizations that 
have been discussing this. And what we said for the 2010 
coalition request for part C alone was an increase of $66.4 
million over the $268.3 million that was otherwise requested. 
So we think at least $66 million more.
    I think the other way that one could get at that number, 
and I am sure that the HRSA people can help us, me and you, 
because we just went through this expansion grant cycle, and I 
know that they had a tremendous number of very good 
applications that they could not support, so finding out what 
those grants would have added up to would be another very ``in 
real time'' look at what community-based clinics like mine are 
facing and how desperate we are to get some increased base 
funding.
    Mr. Burgess. I would just be careful, though, about do we 
want to create a wish list in what we would see in an ideal 
world, or what you need to run your clinic now, today, next 
year, the year following and the year following? We do have to 
be realistic in our assignment of that number. I think you have 
just described to me what would be a 30 or 40 percent increase. 
Did I do the math correctly on that?
    Dr. Sweet. Yes. I think it is 30 percent.
    What I would be happy with in my clinic is increased 
laboratory and dental and case management services. Those are 
things where I am really, really struggling. I have a chairman 
who believes in giving my time away. He says I can do that all 
I want, but when the lab bill comes, you, Dr. Burgess, know 
what a lab bill is like when you spend the money, and then you 
don't have the money to pay it back. And as an example, 
Medicaid in my State, I pay $350 for a genotype. If someone is 
failing therapy, their virus goes up, you need a genotype. That 
is state of the art. That genotype costs me $350 for my 
reference lab. Medicaid in my State pays $220.
    Mr. Burgess. He is going to fix that in the health care 
bill. He told me because he loves us, he is going to fix that.
    Dr. Sweet. I have some fears about Medicaid covering this 
patient population because that would make it even harder.
    So laboratory services are one of the things that kill us 
in terms of outreach of our clinics and what we actually do 
because it takes us about $160 a quarter to do the basic 
laboratory management, and those costs go up all the time. So 
if you ask me, if I could get 15 percent increase, I could 
probably right my clinic. Do I think I will get that? No. But I 
do think the ``such sums'' language is just all of our--the 
community's attempt to get people to understand that we have 
been terribly underfunded for a long period of time. With that 
said, I can understand why you don't want to give away the 
budget.
    Mr. Burgess. Well, it is not even a question of that. There 
are so many other competing constituencies out there. It 
becomes difficult to advocate for the Ryan White funds when 
there are other equally compelling cases to be made at the same 
time.
    Now, on the issue of laboratory funding and the genotype, 
because--is there a structural problem with the way we are 
assigning or we are allocating that expense? I mean, that seems 
like a fundamental problem within the Medicaid system, and I 
suspect it is not just for the Ryan White part C clinics that 
are being affected. I suspect that is something that occurs 
much more frequently, and that may be a structural defect that 
we should correct in whatever we decide to do here in the 
coming weeks with this bigger bill. So that insight is valuable 
as well.
    Dr. Crosse, I apologize. I ran out of time. I will submit a 
question in writing. I do want to get some additional 
information on the hold harmless issue. I am worried that we 
are not giving the money where it is actually needed and where 
patient care is actually required. But we will save that for 
the written response.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    Dr. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman.
    Dr. Crosse, I will begin with you. One of the findings that 
applies to most of the Minority AIDS Initiative's part D 
grantees is that the 10 percent cap was difficult to live with, 
and in order not to sacrifice services, they really stretched 
everything else. Several have asked for indirect cost rates, 
and they reported spending 26 percent of their part D above the 
10 percent. Doesn't that warrant some kind of a recommendation 
regarding the cap? And what would you recommend?
    Ms. Crosse. Well, the problem that we saw with the part D 
grantees was mostly in small organizations. For the part D 
grantees that were part of university-based health care systems 
or other kind of larger provider structures, they had 
sufficient other kinds of general funding available to cover 
some of these things like----
    Mrs. Christensen. Can I just say that the Minority AIDS 
Initiative is really to try to get to those small organizations 
and build the capacity in those small organizations?
    Ms. Crosse. The administrative expense cap was just for the 
part D grantees, and so that didn't apply to the part A and 
part B grantees, which was really the focus of most of the work 
we did on Minority AIDS Initiatives.
    The Minority AIDS Initiative work that we did really 
focused on the grants flowing to the part A and part B 
grantees. There, one of the issues was that the--just the 
funding for the States was quite low. It was about $7 million 
in total that went out to the part B grantees. Then so when 
States were generally receiving something in the order of tens 
of thousands of dollars, that wasn't enough for them to be able 
to establish new clinics, create new infrastructure to be able 
to move care more directly into the minority communities, as I 
know you have expressed as a goal of this program.
    The part A grantees generally were receiving several 
hundred thousand dollars. Again, when they had existing 
infrastructure that they wanted to continue to provide funds 
to, there wasn't enough funding, there wasn't enough increase 
in funding even with the switch to a competitive process where 
new clinics could be established in minority neighborhoods to 
improve some of the problems about access, transportation 
difficulties, clinics focused particularly on minority 
populations that, you know, had been one of the concerns 
driving this program.
    And so what we found was that, yes, the dollars were going 
to provide services to minority patients, but it wasn't 
creating new service providers. It wasn't creating new streams 
of service or new kinds of structures to bring these services 
to the communities of color.
    Mrs. Christensen. Thank you.
    Ms. Scofield, thank you for the answers that you have 
already given. They were very helpful. I am unclear on where 
NASTAD stands on the severity of need index. Does NASTAD 
believe that these should be components of the funding 
allocation process, perhaps not next year but at some point?
    Ms. Scofield. We believe it absolutely is not ready for 
prime time. All of the indicators that have gone into it, we 
are pretty convinced that not all of them are able to be 
collected in a consistent manner across all jurisdictions. And 
frankly, we think it has a lot more work to be done before it 
would be ready to be used in any formula for the allocation of 
resources.
    Mrs. Christensen. Do you think it should be a part of the 
process that we should work towards?
    Ms. Scofield. You know, from my perspective, the best 
indication or the best thing to be using in a formula is 
disease burden as it relates to living HIV and AIDS cases. I 
think that actually is the best measure of making sure that the 
resources go where the epidemic actually is.
    Mrs. Christensen. OK. Dr. Sweet, thank you also for your 
testimony. I think it was representative of many part C and 
other grantees under Ryan White across the country with the 
tough times making ends meet. So thank you for your commitment.
    Other than the money--and you may have mentioned this in 
response to Dr. Burgess, but my question was, other than money, 
are there changes in the bill that you would like to see that 
are not in our proposed legislation? And where do you stand on 
the medical and nutritional--the medical nutrition and medical 
transportation proposals?
    Dr. Sweet. Well, certainly I very much appreciate the bill 
draft that you wrote. I think it does reflect what the 
community is asking. These meetings and phone calls have been--
I mean, when you put 300 voices on a phone call, it becomes 
difficult. And I think the fact that there has been a Community 
Consensus is something we should all be proud of because we 
have worked to make it a consensus.
    The last question is more difficult because that last 
question is all about the money. Certainly in the best of 
worlds, I would love to have more nutrition money, more 
transportation money. Those are the two things that my patients 
need that I would love to give more of. But when I have to--in 
this day and age, I can get someone to live 20, 30, 40 years if 
they get the right medicines, the right medical treatment and I 
do it right. So that medical care has to be preeminent in what 
I do. And consequently, the other support services that I would 
like to do I have to short shrift in order to do the medical 
care.
    So that is all about the money. If I had enough money, then 
the 75/25 wouldn't be an issue. And I would love to be able to 
do go back to the days when I was able to offer nutritional 
supplementations and a lot more transportation than I can now.
    And back to the amount of money, I just thought, Dr. 
Burgess, I applied for a 20 percent increase with my expansion 
grant, and that would have made me much wholer and much more 
able to give more comprehensive services. So about 20 percent 
would be what my clinic needs, in answer to your question, over 
what I get now.
    Mrs. Christensen. Thank you.
    Mr. Pallone. Thank you. I thank all of you really. This was 
very helpful in terms of, you know, our moving forward with 
this bill. You know, Dr. Burgess and there may have been others 
mentioned that they will submit additional questions for the 
record. And we ask that Members submit those to the committee 
clerk within 10 days or so, and you would be notified when 
those come through.
    But again, I want to thank you all. I know there weren't a 
lot of Members here for the last panel, but the questions were 
good, and the answers were very helpful. So thank you.
    And without objection, this meeting of the subcommittee is 
adjourned.
    [Whereupon, at 1:54 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]