[Congressional Record Volume 146, Number 37 (Wednesday, March 29, 2000)]
[Senate]
[Pages S1885-S1893]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. JEFFORDS (for himself, Mr. Kennedy, Mr. Frist, Mr. Hatch, 
        Mr. Dodd, Mr. Enzi, Mr. Harkin, Ms. Mikulski, Mr. Bingaman, Mr. 
        Wellstone, Mr. Reed and Mr. Biden):
  S. 2311. A bill to revise and extend the Ryan White CARE Act programs 
under title XXVI of the Public Health Service Act, to improve access to 
health care and the quality of health care under such programs, and to 
provide for the development of increased capacity to provide health 
care and related support services to individuals and families with HIV 
disease, and for other purposes; to the Committee on Health, Education, 
Labor, and Pensions.


                 ryan white care act amendments of 2000

  Mr. JEFFORDS. Mr. President, it gives me great pleasure to join my 
colleagues today in introducing the Ryan White Comprehensive AIDS 
Resources and Emergency Act Amendments of 2000; a measure that will 
reauthorize a national program of providing primary health care 
services for people living with HIV and AIDS. I especially want to 
commend Senators Hatch and Kennedy for the leadership they have 
provided since the inauguration of the legislation establishing the 
Ryan White programs over a decade ago. I also want to commend Senator 
Frist whose medical expertise played a critical role in key provisions 
of the bill and continues to be an invaluable resource to our efforts 
on the range of health issues that come before the Senate. Finally, I 
want to acknowledge Senator Enzi's recognition of the growing burden 
that AIDS and HIV is having on rural communities throughout the country 
and the need to address those gaps in services.

  Since its inception in 1990, the Ryan White program has enjoyed broad 
bipartisan support. When I looked back to the last time the Ryan White 
CARE Act was reauthorized in 1996, I was heartened to see that the 
measure had garnered a vote of 97 to 3 on its final passage. I urge my 
colleagues to examine this bill we are introducing today and to join me 
in working toward its passage.
  With this reauthorization, we mark the ten years through which the 
Ryan White CARE Act has provided needed health care and support 
services to HIV positive people around the country. Titles I and II 
have provided much needed relief to cities and states hardest hit by 
this disease, while Titles III and IV have had a direct role in 
providing healthcare services to underserved communities. Ryan White 
program dollars provide the foundation of care so necessary in fighting 
this epidemic.
  Fortunately, we have experienced significant success over the last 
decade, and especially over the last five years. The General Accounting 
Office recently released a report that found that CARE Act funds are 
reaching the infected groups that have generally been found to be 
underserved, including the poor, the uninsured, women, and ethnic 
minorities. In fact, these groups form a majority of CARE Act clients 
and are being served by the CARE Act in higher proportions than their 
representation in the AIDS population. The GAO also found that CARE Act 
funds support a wide array of primary care and support services, 
including the provision of powerful therapeutic regimens for people 
with HIV/AIDS that have dramatically reduced AIDS diagnoses and deaths.
  Mr. President, there have also been successes in the reduction of 
HIV/AIDS among women, infants and children. During the last 
reauthorization, Congressman Coburn and our colleague, Senator Frist, 
focused our attention on the needs of women living with HIV/AIDS and 
the problems associated with perinatal transmission of HIV. Since then, 
the CARE Act has helped to dramatically reduce mother-to-child 
transmission through more effective outreach, counseling, and 
voluntary testing of mothers at risk for HIV infection. Between 1993 
and 1998, perinatal-acquired AIDS cases declined 74% in the U.S. In 
this bill, I have continued to support efforts to reach women in need 
of care for their HIV disease and have included provisions to ensure 
that women, infants and children receive resources in accordance with 
the prevalence of the infection among them.

  Another key success has been the AIDS Drug Assistance Program. New 
therapies and improved systems of care have led to impressive 
reductions in the AIDS death rate and the number of new AIDS cases. 
From 1996 to 1998, deaths from AIDS dropped 54% while new AIDS cases 
have been reduced by 27%. However, these treatments are very expensive, 
do not provide a cure, and do not work for everyone.
  Much has occurred to change the course of the AIDS epidemic since the 
last reauthorization. A whole new class of therapeutic drugs called 
anti-retrovirals have been developed and people are living longer and 
the rate of increase of the number of new AIDS cases has begun to level 
off. AIDS, HIV, the people it infects and families that it has affected 
are not in the news today as often as they have been in the past. But 
for too many of us, this lack of bad news has created a false sense of 
complacency. The epidemic of HIV continues to grow, to infect whole new 
groups of people, and to expand both within our urban areas and beyond 
to our rural communities.
  While the rate of decline in new AIDS cases and AIDS deaths is 
leveling off, HIV infection rates continue to rise in many areas; 
becoming increasingly prevalent in rural and underserved urban areas; 
and also among women, youth, and minority communities. Local and state 
healthcare systems face an increasing burden of disease, despite our 
success in treating and caring for people living with HIV and AIDS. 
Unfortunately, rural and underserved urban areas are often unable to 
address the complex medical and support services needs of people with 
HIV infection.
  The bill being introduced today was developed on a bipartisan basis, 
working with other Committee Members, community stakeholders and 
elected officials at the state and local levels from whom we sought 
input to ensure that we addressed the most important

[[Page S1886]]

problems facing communities of people with HIV infection. Earlier this 
month, I held a hearing before the Committee on Health, Education, 
Labor, and Pensions to learn whether the program has been successful 
and whether it needed to be changed. We received testimony from Ryan 
White's mother, Jeanne White, from Surgeon General David Satcher, from 
a person living with AIDS, as well as state and local officials 
familiar with the importance of this program. I especially want to 
commend Dr. Chris Grace of Vermont who testified as to the particular 
challenges of providing care to people living with HIV/AIDS in rural, 
and sometimes remote, parts of the country. It was clear from our 
witnesses' statements that, despite the successes, challenges remain.
  To address these challenges, we have developed a bill that will 
improve access to care in underserved urban and rural areas. My bill 
will double the minimum base funding available to states through the 
CARE Act to assist them in developing systems of care for people 
struggling with HIV and AIDS. The bill also includes a new supplemental 
state grant that will target assistance to rural and underserved areas 
to help them address the increasing number of people with HIV/AIDS 
living outside of urban areas that receive assistance under Title I of 
the Act. Furthermore, these areas will be given preference for direct 
care grants and we have strengthened the AIDS Drug Assistance Program 
to supplement those states struggling to provide lifesaving drugs to 
their HIV/AIDS patients.
  We have not changed the unique flexibility of CARE Act programs; it 
remains primarily a system of grants to State and local jurisdictions. 
States and EMAs will still decide how to best prioritize and address 
the healthcare needs of their HIV-positive citizens.
  Today, there are few people who can say they have not been touched by 
this epidemic. Recently, I had the opportunity to visit with Jeanne 
White. We talked about the impact of this disease; about the loved ones 
it has taken, and the damage to the lives of those it has left behind--
about the infected, and about the affected. We talked about her son 
Ryan, and about my good friend David Curtis of Burlington, Vermont, who 
testified before my committee in 1995, but who passed away just last 
year. As an advocate of the program and as a person living with AIDS, 
David helped me to understand the terrible impact of this disease. Ryan 
White and David and countless others, worked long and hard to ensure 
that all people affected by AIDS could receive both the care and 
compassion they deserve.
  The AIDS epidemic, despite our success in developing treatments and 
providing systems of care, is still ravaging communities in this 
country. This program remains as vital to the public health of this 
nation as it was in 1990 and in 1996. As the AIDS epidemic reaches into 
rural areas and into underserved urban communities across the country, 
this legislation being introduced today will allow us to adapt our care 
systems to meet the most urgent needs in the communities hardest hit by 
the epidemic.
  I intend to see this bill become law this year so that the people 
struggling to overcome the challenges of HIV and AIDS continue to 
benefit from high quality medical care and access to lifesaving drugs. 
We have made incredible progress in the fight against HIV/AIDS and I 
want to be sure that every person in America that needs our assistance, 
benefits from our tremendous advances.
  Mr. President I ask unanimous consent that the text of this measure 
be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 2311

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Ryan White CARE Act 
     Amendments of 2000''.

     SEC. 2. REFERENCES; TABLE OF CONTENTS.

       (a) References.--Except as otherwise expressly provided, 
     whenever in this Act an amendment or repeal is expressed in 
     terms of an amendment to, or repeal of, a section or other 
     provision, the reference shall be considered to be made to a 
     section or other provision of the Public Health Service Act 
     (42 U.S.C. 201 et seq.).
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title.
Sec. 2. References; table of contents.

             TITLE I--AMENDMENTS TO HIV HEALTH CARE PROGRAM

  Subtitle A--Purpose; Amendments to Part A (Emergency Relief Grants)

Sec. 101. Duties of planning council, funding priorities, quality 
              assessment.
Sec. 102. Quality management.
Sec. 103. Funded entities required to have health care relationships.
Sec. 104. Support services required to be health care-related.
Sec. 105. Use of grant funds for early intervention services.
Sec. 106. Replacement of specified fiscal years regarding the sunset on 
              expedited distribution requirement.
Sec. 107. Hold harmless provision.
Sec. 108. Set-aside for infants, children, and women.

         Subtitle B--Amendments to Part B (Care Grant Program)

Sec. 121. State requirements concerning identification of need and 
              allocation of resources.
Sec. 122. Quality management.
Sec. 123. Funded entities required to have health care referral 
              relationships.
Sec. 124. Support services required to be health care-related.
Sec. 125. Use of grant funds for early intervention services.
Sec. 126. Authorization of appropriations for HIV-related services for 
              women and children.
Sec. 127. Repeal of requirement for completed Institute of Medicine 
              report.
Sec. 130. Supplement grants for certain States.
Sec. 131. Use of treatment funds.
Sec. 132. Increase in minimum allotment.
Sec. 133. Set-aside for infants, children, and women.

     Subtitle C--Amendments to Part C (Early Intervention Services)

Sec. 141. Amendment of heading; repeal of formula grant program.
Sec. 142. Planning and development grants.
Sec. 143. Authorization of appropriations for categorical grants.
Sec. 144. Administrative expenses ceiling; quality management program.
Sec. 145. Preference for certain areas.

         Subtitle D--Amendments to Part D (General Provisions)

Sec. 151. Research involving women, infants, children, and youth.
Sec. 152. Limitation on administrative expenses.
Sec. 153. Evaluations and reports.
Sec. 154. Authorization of appropriations for grants under parts A and 
              B.

     Subtitle E--Amendments to Part F (Demonstration and Training)

Sec. 161. Authorization of appropriations.

                   TITLE II--MISCELLANEOUS PROVISIONS

Sec. 201. Institute of Medicine study.

             TITLE I--AMENDMENTS TO HIV HEALTH CARE PROGRAM

  Subtitle A--Purpose; Amendments to Part A (Emergency Relief Grants)

     SEC. 101. DUTIES OF PLANNING COUNCIL, FUNDING PRIORITIES, 
                   QUALITY ASSESSMENT.

       Section 2602 (42 U.S.C. 300ff-12) is amended--
       (1) in subsection (b)--
       (A) in paragraph (2)(C), by inserting before the semicolon 
     the following: ``, including providers of housing and 
     homeless services''; and
       (B) in paragraph (4), by striking ``shall--'' and all that 
     follows and inserting ``shall have the responsibilities 
     specified in subsection (d).''; and
       (2) by adding at the end the following:
       ``(d) Duties of Planning Council.--The planning council 
     established under subsection (b) shall have the following 
     duties:
       ``(1) Priorities for allocation of funds.--The council 
     shall establish priorities for the allocation of funds within 
     the eligible area, including how best to meet each such 
     priority and additional factors that a grantee should 
     consider in allocating funds under a grant, based on the 
     following factors:
       ``(A) The size and demographic characteristics of the 
     population with HIV disease to be served, including, subject 
     to subsection (e), the needs of individuals living with HIV 
     infection who are not receiving HIV-related health services.
       ``(B) The documented needs of the population with HIV 
     disease with particular attention being given to disparities 
     in health services among affected subgroups within the 
     eligible area.
       ``(C) The demonstrated or probable cost and outcome 
     effectiveness of proposed strategies and interventions, to 
     the extent that data are reasonably available.
       ``(D) Priorities of the communities with HIV disease for 
     whom the services are intended.
       ``(E) The availability of other governmental and non-
     governmental resources, including the State medicaid plan 
     under title XIX of the Social Security Act and the State 
     Children's Health Insurance Program under title XXI of such 
     Act to cover health care costs of eligible individuals and 
     families with HIV disease.

[[Page S1887]]

       ``(F) Capacity development needs resulting from gaps in the 
     availability of HIV services in historically underserved low-
     income communities.
       ``(2) Comprehensive service delivery plan.--The council 
     shall develop a comprehensive plan for the organization and 
     delivery of health and support services described in section 
     2604. Such plan shall be compatible with any existing State 
     or local plans regarding the provision of such services to 
     individuals with HIV disease.
       ``(3) Assessment of fund allocation efficiency.--The 
     council shall assess the efficiency of the administrative 
     mechanism in rapidly allocating funds to the areas of 
     greatest need within the eligible area.
       ``(4) Statewide statement of need.--The council shall 
     participate in the development of the Statewide coordinated 
     statement of need as initiated by the State public health 
     agency responsible for administering grants under part B.
       ``(5) Coordination with other federal grantees.--The 
     council shall coordinate with Federal grantees providing HIV-
     related services within the eligible area.
       ``(6) Community participation.--The council shall establish 
     methods for obtaining input on community needs and priorities 
     which may include public meetings, conducting focus groups, 
     and convening ad-hoc panels.
       ``(e) Process for Establishing Allocation Priorities.--
       ``(1) In general.--Not later than 24 months after the date 
     of enactment of the Ryan White CARE Act Amendments of 2000, 
     the Secretary shall--
       ``(A) consult with eligible metropolitan areas, affected 
     communities, experts, and other appropriate individuals and 
     entities, to develop epidemiologic measures for establishing 
     the number of individuals living with HIV disease who are not 
     receiving HIV-related health services; and
       ``(B) provide advice and technical assistance to planning 
     councils with respect to the process for establishing 
     priorities for the allocation of funds under subsection 
     (d)(1).
       ``(2) Exception.--Grantees under subsection (d)(1)(A) shall 
     not be required to establish priorities for individuals not 
     in care until epidemiologic measures are developed under 
     paragraph (1).''.

     SEC. 102. QUALITY MANAGEMENT.

       (a) Funds Available for Quality Management.--Section 2604 
     (42 U.S.C. 300ff-14) is amended--
       (1) by redesignating subsections (c) through (f) as 
     subsections (d) through (g), respectively; and
       (2) by inserting after subsection (b) the following:
       ``(c) Quality Management.--
       ``(1) Requirement.--The chief elected official of an 
     eligible area that receives a grant under this part shall 
     provide for the establishment of a quality management program 
     to assess the extent to which medical services provided to 
     patients under the grant are consistent with the most recent 
     Public Health Service guidelines for the treatment of HIV 
     disease and related opportunistic infection and to develop 
     strategies for improvements in the access to and quality of 
     medical services.
       ``(2) Use of funds.--From amounts received under a grant 
     awarded under this part, the chief elected official of an 
     eligible area may use, for activities associated with its 
     quality management program, not more than the lesser of--
       ``(A) 5 percent of amounts received under the grant; or
       ``(B) $3,000,000.''.
       (b) Quality Management Required for Eligibility for 
     Grants.--Section 2605(a) (42 U.S.C. 300ff-15(a)) is amended--
       (1) by redesignating paragraphs (3) through (6) as 
     paragraphs (5) through (8), respectively; and
       (2) by inserting after paragraph (2) the following:
       ``(3) that the chief elected official of the eligible area 
     will satisfy all requirements under section 2604(c);''.

     SEC. 103. FUNDED ENTITIES REQUIRED TO HAVE HEALTH CARE 
                   RELATIONSHIPS.

       (a) Use of Amounts.--Section 2604(e)(1) (42 U.S.C. 300ff-
     14(d)(1)) (as so redesignated by section 102(a)) is amended 
     by inserting ``and the State Children's Health Insurance 
     Program under title XXI of such Act'' after ``Social Security 
     Act''.
       (b) Applications.--Section 2605(a) (42 U.S.C. 300ff-15(a)) 
     is amended by inserting after paragraph (3), as added by 
     section 102(b), the following:
       ``(4) that funded entities within the eligible area that 
     receive funds under a grant under section 2601(a) shall 
     maintain appropriate relationships with entities in the area 
     served that constitute key points of access to the health 
     care system for individuals with HIV disease (including 
     emergency rooms, substance abuse treatment programs, 
     detoxification centers, adult and juvenile detention 
     facilities, sexually transmitted disease clinics, HIV 
     counseling and testing sites, and homeless shelters) and 
     other entities under section 2652(a) for the purpose of 
     facilitating early intervention for individuals newly 
     diagnosed with HIV disease and individuals knowledgeable of 
     their status but not in care;''.

     SEC. 104. SUPPORT SERVICES REQUIRED TO BE HEALTH CARE-
                   RELATED.

       (a) In General.--Section 2604(b)(1) (42 U.S.C. 300ff-
     14(b)(1)) is amended--
       (1) in the matter preceding subparagraph (A), by striking 
     ``HIV-related--'' and inserting ``HIV-related services, as 
     follows:'';
       (2) in subparagraph (A)--
       (A) by striking ``outpatient'' and all that follows through 
     ``substance abuse treatment and'' and inserting the 
     following: ``Outpatient health services.--Outpatient and 
     ambulatory health services, including substance abuse 
     treatment,''; and
       (B) by striking ``; and'' and inserting a period;
       (3) in subparagraph (B), by striking ``(B) inpatient case 
     management'' and inserting ``(C) Inpatient case management 
     services.--Inpatient case management''; and
       (4) by inserting after subparagraph (A) the following:
       ``(B) Outpatient support services.--Outpatient and 
     ambulatory support services (including case management), to 
     the extent that such services facilitate, enhance, support, 
     or sustain the delivery, continuity, or benefits of health 
     services for individuals and families with HIV disease.''.
       (b) Conforming Amendment to Application Requirements.--
     Section 2605(a) (42 U.S.C. 300ff-15(a)), as amended by 
     section 102(b), is further amended--
       (1) in paragraph (6) (as so redesignated), by striking 
     ``and'' at the end thereof;
       (2) in paragraph (7) (as so redesignated), by striking the 
     period and inserting ``; and''; and
       (3) by adding at the end the following:
       ``(8) that the eligible area has procedures in place to 
     ensure that services provided with funds received under this 
     part meet the criteria specified in section 2604(b)(1).''.

     SEC. 105. USE OF GRANT FUNDS FOR EARLY INTERVENTION SERVICES.

       (a) In General.--Section 2604(b)(1) (42 U.S.C. 300ff-
     14(b)(1)), as amended by section 104(a), is further amended 
     by adding at the end the following:
       ``(D) Early intervention services.--Early intervention 
     services as described in section 2651(b)(2), with follow-
     through referral, provided for the purpose of facilitating 
     the access of individuals receiving the services to HIV-
     related health services, but only if the entity providing 
     such services--
       ``(i)(I) is receiving funds under subparagraph (A) or (C); 
     or
       ``(II) is an entity constituting a point of access to 
     services, as described in paragraph (2)(C), that maintains a 
     relationship with an entity described in subclause (I) and 
     that is serving individuals at elevated risk of HIV disease; 
     and
       ``(ii) demonstrates to the satisfaction of the chief 
     elected official that no other Federal, State, or local funds 
     are available for the early intervention services the entity 
     will provide with funds received under this paragraph.''.
       (b) Conforming Amendments to Application Requirements.--
     Section 2605(a)(1) (42 U.S.C. 300ff-15(a)(1)) is amended--
       (1) in subparagraph (A), by striking ``services to 
     individuals with HIV disease'' and inserting ``services as 
     described in section 2604(b)(1)''; and
       (2) in subparagraph (B), by striking ``services for 
     individuals with HIV disease'' and inserting ``services as 
     described in section 2604(b)(1)''.

     SEC. 106. REPLACEMENT OF SPECIFIED FISCAL YEARS REGARDING THE 
                   SUNSET ON EXPEDITED DISTRIBUTION REQUIREMENTS.

       Section 2603(a)(2) (42 U.S.C. 300ff-13(a)(2)) is amended by 
     striking ``for each of the fiscal years 1996 through 2000'' 
     and inserting ``for a fiscal year''.

     SEC. 107. HOLD HARMLESS PROVISION.

       Section 2603(a)(4) (42 U.S.C. 300ff-13(a)(4)) is amended to 
     read as follows:
       ``(4) Limitations.--
       ``(A) In general.--With respect to each of fiscal years 
     2001 through 2005, the Secretary shall ensure that the amount 
     of a grant made to an eligible area under paragraph (2) for 
     such a fiscal year is not less than an amount equal to 98 
     percent of the amount the eligible area received for the 
     fiscal year preceding the year for which the determination is 
     being made.
       ``(B) Application of provision.--Subparagraph (A) shall 
     only apply with respect to those eligible areas receiving a 
     grant under paragraph (2) for fiscal year 2000 in an amount 
     that has been adjusted in accordance with paragraph (4) of 
     this subsection (as in effect on the day before the date of 
     enactment of the Ryan White CARE Act Amendments of 2000).''.

     SEC. 108. SET-ASIDE FOR INFANTS, CHILDREN, AND WOMEN.

       Section 2604(b)(3) (42 U.S.C. 300ff-14(b)(3)) is amended--
       (1) by inserting ``for each population under this 
     subsection'' after ``established priorities''; and
       (2) by striking ``ratio of the'' and inserting ``ratio of 
     each''.

         Subtitle B--Amendments to Part B (Care Grant Program)

     SEC. 121. STATE REQUIREMENTS CONCERNING IDENTIFICATION OF 
                   NEED AND ALLOCATION OF RESOURCES.

       (a) General Use of Grants.--Section 2612 (42 U.S.C. 300ff-
     22) is amended--
       (1) by striking ``A State'' and inserting ``(a) In 
     General.--A State''; and
       (2) in the matter following paragraph (5)--
       (A) by striking ``paragraph (2)'' and inserting 
     ``subsection (a)(2) and section 2613'';
       (b) Application.--Section 2617(b) (42 U.S.C. 300ff-27(b)) 
     is amended--

[[Page S1888]]

       (1) in paragraph (1)(C)--
       (A) by striking clause (i) and inserting the following:
       ``(i) the size and demographic characteristics of the 
     population with HIV disease to be served, except that by not 
     later than October 1, 2002, the State shall take into account 
     the needs of individuals not in care, based on epidemiologic 
     measures developed by the Secretary in consultation with the 
     State, affected communities, experts, and other appropriate 
     individuals (such State shall not be required to establish 
     priorities for individuals not in care until such 
     epidemiologic measures are developed);'';
       (B) in clause (iii), by striking ``and'' at the end; and
       (C) by adding at the end the following:
       ``(v) the availability of other governmental and non-
     governmental resources;
       ``(vi) the capacity development needs resulting in gaps in 
     the provision of HIV services in historically underserved 
     low-income and rural low-income communities; and
       ``(vii) the efficiency of the administrative mechanism in 
     rapidly allocating funds to the areas of greatest need within 
     the State;''; and
       (2) in paragraph (2)--
       (A) in subparagraph (B), by striking ``and'' at the end;
       (B) by redesignating subparagraph (C) as subparagraph (F); 
     and
       (C) by inserting after subparagraph (B), the following:
       ``(C) an assurance that capacity development needs 
     resulting from gaps in the provision of services in 
     underserved low-income and rural low-income communities will 
     be addressed; and
       ``(D) with respect to fiscal year 2003 and subsequent 
     fiscal years, assurances that, in the planning and allocation 
     of resources, the State, through systems of HIV-related 
     health services provided under paragraphs (1), (2), and (3) 
     of section 2612(a), will make appropriate provision for the 
     HIV-related health and support service needs of individuals 
     who have been diagnosed with HIV disease but who are not 
     currently receiving such services, based on the epidemiologic 
     measures developed under paragraph (1)(C)(i);''.

     SEC. 122. QUALITY MANAGEMENT.

       (a) State Requirement for Quality Management.--Section 
     2617(b)(4) (42 U.S.C. 300ff-27(b)(4)) is amended--
       (1) by striking subparagraph (C) and inserting the 
     following:
       ``(C) the State will provide for--
       ``(i) the establishment of a quality management program to 
     assess the extent to which medical services provided to 
     patients under the grant are consistent with the most recent 
     Public Health Service guidelines for the treatment of HIV 
     disease and related opportunistic infections and to develop 
     strategies for improvements in the access to and quality of 
     medical services; and
       ``(ii) a periodic review (such as through an independent 
     peer review) to assess the quality and appropriateness of 
     HIV-related health and support services provided by entities 
     that receive funds from the State under this part;'';
       (2) by redesignating subparagraphs (E) and (F) as 
     subparagraphs (F) and (G), respectively;
       (3) by inserting after subparagraph (D), the following:
       ``(E) an assurance that the State, through systems of HIV-
     related health services provided under paragraphs (1), (2), 
     and (3) of section 2612(a), has considered strategies for 
     working with providers to make optimal use of financial 
     assistance under the State medicaid plan under title XIX of 
     the Social Security Act, the State Children's Health 
     Insurance Program under title XXI of such Act, and other 
     Federal grantees that provide HIV-related services, to 
     maximize access to quality HIV-related health and support 
     services;
       (4) in subparagraph (F), as so redesignated, by striking 
     ``and'' at the end; and
       (5) in subparagraph (G), as so redesignated, by striking 
     the period and inserting ``; and''.
       (b) Availability of Funds for Quality Management.--
       (1) Availability of grant funds for planning and 
     evaluation.--Section 2618(c)(3) (42 U.S.C. 300ff-28(c)(3)) is 
     amended by inserting before the period ``, including not more 
     than $3,000,000 for all activities associated with its 
     quality management program''.
       (2) Exception to combined ceiling on planning and 
     administration funds for states with small grants.--Paragraph 
     (6) of section 2618(c) (42 U.S.C. 300ff-28(c)(6)) is amended 
     to read as follows:
       ``(6) Exception for quality management.--Notwithstanding 
     paragraph (5), a State whose grant under this part for a 
     fiscal year does not exceed $1,500,000 may use not to exceed 
     20 percent of the amount of the grant for the purposes 
     described in paragraphs (3) and (4) if--
       ``(A) that portion of such amount in excess of 15 percent 
     of the grant is used for its quality management program; and
       ``(B) the State submits and the Secretary approves a plan 
     (in such form and containing such information as the 
     Secretary may prescribe) for use of funds for its quality 
     management program.''.

     SEC. 123. FUNDED ENTITIES REQUIRED TO HAVE HEALTH CARE 
                   RELATIONSHIPS.

       Section 2617(b)(4) (42 U.S.C. 300ff-27(b)(4)), as amended 
     by section 122(a), is further amended by adding at the end 
     the following:
       ``(H) that funded entities maintain appropriate 
     relationships with entities in the area served that 
     constitute key points of access to the health care system for 
     individuals with HIV disease (including emergency rooms, 
     substance abuse treatment programs, detoxification centers, 
     adult and juvenile detention facilities, sexually transmitted 
     disease clinics, HIV counseling and testing sites, and 
     homeless shelters), and other entities under section 2652(a), 
     for the purpose of facilitating early intervention for 
     individuals newly diagnosed with HIV disease and individuals 
     knowledgeable of their status but not in care.''.

     SEC. 124. SUPPORT SERVICES REQUIRED TO BE HEALTH CARE-
                   RELATED.

       (a) Technical amendment.--Section 3(c)(2)(A)(iii) of the 
     Ryan White CARE Act Amendments of 1996 (Public Law 104-146) 
     is amended by inserting ``before paragraph (2) as so 
     redesignated'' after ``inserting''.
       (b) Services.--Section 2612(a)(1) (42 U.S.C. 300ff-
     22(a)(1)), as so designated by section 121(a), is amended by 
     striking ``for individuals with HIV disease'' and inserting 
     ``, subject to the conditions and limitations that apply 
     under such section''.
       (c) Conforming Amendment to State Application 
     Requirement.--Section 2617(b)(2) (42 U.S.C. 300ff-27(b)(2)), 
     as amended by section 121(b), is further amended by adding at 
     the end the following:
       ``(F) an assurance that the State has procedures in place 
     to ensure that services provided with funds received under 
     this section meet the criteria specified in section 
     2604(b)(1)(B); and''.

     SEC. 125. USE OF GRANT FUNDS FOR EARLY INTERVENTION SERVICES.

       Section 2612(a) (42 U.S.C. 300ff-22(a)), as amended by 
     section 121, is further amended by adding at the end the 
     following:
       ``(6) Early intervention services.--The State, through 
     systems of HIV-related health services provided under 
     paragraphs (1), (2), and (3) of section 2612(a), may provide 
     early intervention services, as described in section 
     2651(b)(2), with follow-up referral, provided for the purpose 
     of facilitating the access of individuals receiving the 
     services to HIV-related health services, but only if the 
     entity providing such services--
       ``(A)(i) is receiving funds under section 2612(a)(1); or
       ``(ii) is an entity constituting a point of access to 
     services, as described in section 2617(b)(4), that maintains 
     a referral relationship with an entity described in clause 
     (i) and that is serving individuals at elevated risk of HIV 
     disease; and
       ``(B) demonstrates to the State's satisfaction that no 
     other Federal, State, or local funds are available for the 
     early intervention services the entity will provide with 
     funds received under this paragraph.''.

     SEC. 126. AUTHORIZATION OF APPROPRIATIONS FOR HIV-RELATED 
                   SERVICES FOR WOMEN AND CHILDREN.

       Section 2625(c)(2) (42 U.S.C. 300ff-33(c)(2)) is amended by 
     striking ``fiscal years 1996 through 2000'' and inserting 
     ``fiscal years 2001 through 2005''.

     SEC. 127. REPEAL OF REQUIREMENT FOR COMPLETED INSTITUTE OF 
                   MEDICINE REPORT.

       Section 2628 (42 U.S.C. 300ff-36) is repealed.

     SEC. 128. SUPPLEMENT GRANTS FOR CERTAIN STATES.

       Subpart I of part B of title XXVI of the Public Health 
     Service Act (42 U.S.C. 300ff-11 et seq.) is amended by adding 
     at the end the following:

     ``SEC. 2622. SUPPLEMENTAL GRANTS.

       ``(a) In General.--The Secretary shall award supplemental 
     grants to States determined to be eligible under subsection 
     (b) to enable such States to provide comprehensive services 
     of the type described in section 2612(a) to supplement the 
     services otherwise provided by the State under a grant under 
     this subpart in areas within the State that are not eligible 
     to receive grants under part A.
       ``(b) Eligibility.--To be eligible to receive a 
     supplemental grant under subsection (a) a State shall--
       ``(1) be eligible to receive a grant under this subpart; 
     and
       ``(2) demonstrate to the Secretary that there is severe 
     need (as defined for purposes of section 2603(b)(2)(A) for 
     supplemental financial assistance in areas in the State that 
     are not served through grants under part A.
       ``(c) Application.--A State that desires a grant under this 
     section shall, as part of the State application submitted 
     under section 2617, submit a detailed description of the 
     manner in which the State will use amounts received under the 
     grant and of the severity of need. Such description shall 
     include--
       ``(1) a report concerning the dissemination of supplemental 
     funds under this section and the plan for the utilization of 
     such funds;
       ``(2) a demonstration of the existing commitment of local 
     resources, both financial and in-kind;
       ``(3) a demonstration that the State will maintain HIV-
     related activities at a level that is equal to not less than 
     the level of such activities in the State for the 1-year 
     period preceding the fiscal year for which the State is 
     applying to receive a grant under this part;
       ``(4) a demonstration of the ability of the State to 
     utilize such supplemental financial resources in a manner 
     that is immediately responsive and cost effective;
       ``(5) a demonstration that the resources will be allocated 
     in accordance with the local demographic incidence of AIDS 
     including appropriate allocations for services for

[[Page S1889]]

     infants, children, women, and families with HIV disease;
       ``(6) a demonstration of the inclusiveness of the planning 
     process, with particular emphasis on affected communities and 
     individuals with HIV disease; and
       ``(7) a demonstration of the manner in which the proposed 
     services are consistent with local needs assessments and the 
     statewide coordinated statement of need.
       ``(d) Amount Reserved for Emerging Communities.--
       ``(1) In general.--For awarding grants under this section 
     for each fiscal year, the Secretary shall reserve the greater 
     of 50 percent of the amount to be utilized under subsection 
     (e) for such fiscal year or $5,000,000, to be provided to 
     States that contain emerging communities for use in such 
     communities.
       ``(2) Definition.--In paragraph (1), the term `emerging 
     community' means a metropolitan area--
       ``(A) that is not eligible for a grant under part A; and
       ``(B) for which there has been reported to the Director of 
     the Centers for Disease Control and Prevention a cumulative 
     total of between 1000 and 1999 cases of acquired immune 
     deficiency syndrome for the most recent period of 5 calendar 
     years for which such data are available.
       ``(e) Appropriations.--With respect to each fiscal year 
     beginning with fiscal year 2001, the Secretary, to carry out 
     this section, shall utilize 50 percent of the amount 
     appropriated under section 2677 to carry out part B for such 
     fiscal year that is in excess of the amount appropriated to 
     carry out such part in fiscal year preceding the fiscal year 
     involved.

     SEC. 129. USE OF TREATMENT FUNDS.

       (a) State duties.--Section 2616(c) (42 U.S.C. 300ff-26(c)) 
     is amended--
       (1) in the matter preceding paragraph (1), by striking 
     ``shall--'' and inserting ``shall use funds made available 
     under this section to--'';
       (2) by redesignating paragraphs (1) through (5) as 
     subparagraphs (A) through (E), respectively and realigning 
     the margins of such subparagraphs appropriately;
       (3) in subparagraph (D) (as so redesignated), by striking 
     ``and'' at the end;
       (4) in subparagraph (E) (as so redesignated), by striking 
     the period and ``; and''; and
       (5) by adding at the end the following:
       ``(F) encourage, support, and enhance adherence to and 
     compliance with treatment regimens, including related medical 
     monitoring.'';
       (6) by striking ``In carrying'' and inserting the 
     following:
       ``(1) In general.--In carrying''; and
       (7) by adding at the end the following:
       ``(2) Limitations.--
       ``(A) In general.--No State shall use funds under paragraph 
     (1)(F) unless the limitations on access to HIV/AIDS 
     therapeutic regimens as defined in subsection (e)(2) are 
     eliminated.
       ``(B) Amount of funding.--No State shall use in excess of 
     10 percent of the amount set-aside for use under this section 
     in any fiscal year to carry out activities under paragraph 
     (1)(F) unless the State demonstrates to the Secretary that 
     such additional services are essential and in no way diminish 
     access to therapeutics.''.
       (b) Supplement Grants.--Section 2616 (42 U.S.C. 300ff-
     26(c)) is amended by adding at the end the following:
       ``(e) Supplemental Grants for the Provision of 
     Treatments.--
       ``(1) In general.--From amounts made available under 
     paragraph (5), the Secretary shall award supplemental grants 
     to States determined to be eligible under paragraph (2) to 
     enable such States to provide access to therapeutics to treat 
     HIV disease as provided by the State under subsection 
     (c)(1)(B) for individuals at or below 200 percent of the 
     Federal poverty line.
       ``(2) Criteria.--The Secretary shall develop criteria for 
     the awarding of grants under paragraph (1) to States that 
     demonstrate a severe need. In determining the criteria for 
     demonstrating State severity of need (as defined for purposes 
     of section 2603(b)(2)(A)), the Secretary shall consider 
     whether limitation to access exist such that--
       ``(A) the State programs under this section are unable to 
     provide HIV/AIDS therapeutic regimens to all eligible 
     individuals living at or below 200 percent of the Federal 
     poverty line; and
       ``(B) the State programs under this section are unable to 
     provide to all eligible individuals appropriate HIV/AIDS 
     therapeutic regimens as recommended in the most recent 
     Federal treatment guidelines.
       ``(3) State requirement.--The Secretary may not make a 
     grant to a State under this subsection unless the State 
     agrees that--
       ``(A) the State will make available (directly or through 
     donations from public or private entities) non-Federal 
     contributions toward the activities to be carried out under 
     the grant in an amount equal to $1 for each $4 of Federal 
     funds provided in the grant; and
       ``(B) the State will not impose eligibility requirements 
     for services or scope of benefits limitations under 
     subsection (a) that are more restrictive than such 
     requirements in effect as of January 1, 2000.
       ``(4) Use and coordination.--Amounts made available under a 
     grant under this subsection shall only be used by the State 
     to provide AIDS/HIV-related medications. The State shall 
     coordinate the use of such amounts with the amounts otherwise 
     provided under this section in order to maximize drug 
     coverage.
       ``(5) Funding.--
       ``(A) Reservation of amount.--The Secretary may reserve not 
     to exceed 4 percent, but not less than 2 percent, of any 
     amount referred to in section 2618(b)(2)(H) that is 
     appropriated for a fiscal year, to carry out this subsection.
       ``(B) Minimum amount.--In providing grants under this 
     subsection, the Secretary shall ensure that the amount of a 
     grant to a State under this part is not less than the amount 
     the State received under this part in the previous fiscal 
     year, as a result of grants provided under this 
     subsection.''.
       (c) Supplement and not Supplant.--Section 2616 (42 U.S.C. 
     300ff-26(c)), as amended by subsection (b), is further 
     amended by adding at the end the following:
       ``(f) Supplement not supplant.--Notwithstanding any other 
     provision of law, amounts made available under this section 
     shall be used to supplement and not supplant other funding 
     available to provide treatments of the type that may be 
     provided under this section.''.

     SEC. 130. INCREASE IN MINIMUM ALLOTMENT.

       (a) In General.--Section 2618(b)(1)(A)(i) (42 U.S.C. 300ff-
     28(b)(1)(A)(i)) is amended--
       (1) in subclause (I), by striking ``$100,000'' and 
     inserting ``$200,000''; and
       (2) in subclause (II), by striking ``$250,000'' and 
     inserting ``$500,000''.
       (b) Technical Amendment.--Section 2618(b)(3)(B) (42 U.S.C. 
     300ff-28(b)(3)(B)) is amended by striking ``and the Republic 
     of the Marshall Islands'' and inserting ``, the Republic of 
     the Marshall Islands, the Federated States of Micronesia, and 
     the Republic of Palau''.

     SEC. 131. SET-ASIDE FOR INFANTS, CHILDREN, AND WOMEN.

       Section 2611(b) (42 U.S.C. 300ff-21(b)) is amended--
       (1) by inserting ``for each population under this 
     subsection'' after ``State shall use''; and
       (2) by striking ``ratio of the'' and inserting ``ratio of 
     each''.

     Subtitle C--Amendments to Part C (Early Intervention Services)

     SEC. 141. AMENDMENT OF HEADING; REPEAL OF FORMULA GRANT 
                   PROGRAM.

       (a) Amendment of Heading.--The heading of part C of title 
     XXVI is amended to read as follows:

       ``Part C--Early Intervention and Primary Care Services''.

       (b) Repeal.--Part C of title XXVI (42 U.S.C. 300ff-41 et 
     seq.) is amended--
       (1) by repealing subpart I; and
       (2) by redesignating subparts II and III as subparts I and 
     II.
       (c) Conforming Amendments.--
       (1) Information regarding receipt of services.--Section 
     2661(a) (42 U.S.C. 300ff-61(a)) is amended by striking 
     ``unless--'' and all that follows through ``(2) in the case 
     of'' and inserting ``unless, in the case of''.
       (2) Additional agreements.--Section 2664 (42 U.S.C. 300ff-
     64) is amended--
       (A) in subsection (e)(5), by striking ``2642(b) or'';
       (B) in subsection (f)(2), by striking ``2642(b) or''; and
       (C) by striking subsection (h).

     SEC. 142. PLANNING AND DEVELOPMENT GRANTS.

       (a) Allowing Planning and Development Grant to Expand 
     Ability to Provide Primary Care Services.--Section 2654(c) 
     (42 U.S.C. 300ff-54(c)) is amended--
       (1) in paragraph (1), to read as follows:
       ``(1) In general.--The Secretary may provide planning and 
     development grants to public and nonprofit private entities 
     for the purpose of--
       ``(A) enabling such entities to provide HIV early 
     intervention services; or
       ``(B) assisting such entities to expand the capacity, 
     preparedness, and expertise to deliver primary care services 
     to individuals with HIV disease in underserved low-income 
     communities on the condition that the funds are not used to 
     purchase or improve land or to purchase, construct, or 
     permanently improve (other than minor remodeling) any 
     building or other facility.''; and
       (2) in paragraphs (2) and (3) by striking ``paragraph (1)'' 
     each place that such appears and inserting ``paragraph 
     (1)(A)''.
       (b) Amount; duration.--Section 2654(c) (42 U.S.C. 300ff-
     54(c)), as amended by subsection (a), is further amended--
       (1) by redesignating paragraph (4) as paragraph (5); and
       (2) by inserting after paragraph (3) the following:
       ``(4) Amount and duration of grants.--
       ``(A) Early intervention services.--A grant under paragraph 
     (1)(A) may be made in an amount not to exceed $50,000.
       ``(B) Capacity development.--
       ``(i) Amount.--A grant under paragraph (1)(B) may be made 
     in an amount not to exceed $150,000.
       ``(ii) Duration.--The total duration of a grant under 
     paragraph (1)(B), including any renewal, may not exceed 3 
     years.''.
       (c) Increase in limitation.--Section 2654(c)(5) (42 U.S.C. 
     300ff-54(c)(5)), as so redesignated by subsection (b), is 
     amended by striking ``1 percent'' and inserting ``5 
     percent''.

     SEC. 143. AUTHORIZATION OF APPROPRIATIONS FOR CATEGORICAL 
                   GRANTS.

       Section 2655 (42 U.S.C. 300ff-55) is amended by striking 
     ``1996'' and all that follows

[[Page S1890]]

     through ``2000'' and inserting ``2001 through 2005''.

     SEC. 144. ADMINISTRATIVE EXPENSES CEILING; QUALITY MANAGEMENT 
                   PROGRAM.

       Section 2664(g) (42 U.S.C. 300ff-64(g)) is amended--
       (1) in paragraph (3), to read as follows:
       ``(3) the applicant will not expend more than 10 percent of 
     the grant for costs of administrative activities with respect 
     to the grant;'';
       (2) in paragraph (4), by striking the period and inserting 
     ``; and''; and
       (3) by adding at the end the following:
       ``(5) the applicant will provide for the establishment of a 
     quality management program to assess the extent to which 
     medical services funded under this title that are provided to 
     patients are consistent with the most recent Public Health 
     Service guidelines for the treatment of HIV disease and 
     related opportunistic infections and that improvements in the 
     access to and quality of medical services are addressed.''.

     SEC. 145. PREFERENCE FOR CERTAIN AREAS.

       Section 2651 (42 U.S.C. 300ff-51) is amended by adding at 
     the end the following:
       ``(d) Preference in Awarding Grants.--Beginning in fiscal 
     year 2001, in awarding new grants under this section, the 
     Secretary shall give preference to applicants that will use 
     amounts received under the grant to serve areas that are 
     otherwise not eligible to receive assistance under part A.''.

         Subtitle D--Amendments to Part D (General Provisions)

     SEC. 151. RESEARCH INVOLVING WOMEN, INFANTS, CHILDREN, AND 
                   YOUTH.

       (a) Elimination of Requirement To Enroll Significant 
     Numbers of Women and Children.--Section 2671(b) (42 U.S.C. 
     300ff-71(b)) is amended--
       (1) in paragraph (1), by striking subparagraphs (C) and 
     (D); and
       (2) by striking paragraphs (3) and (4).
       (b) Information and Education.--Section 2671(d) (42 U.S.C. 
     300ff-71(d)) is amended by adding at the end the following:
       ``(4) The applicant will provide individuals with 
     information and education on opportunities to participate in 
     HIV/AIDS-related clinical research.''.
       (c) Quality Management; Administrative Expenses Ceiling.--
     Section 2671(f) (42 U.S.C. 300ff-71(f)) is amended--
       (1) by striking the subsection heading and designation and 
     inserting the following:
       ``(f) Administration.--
       ``(1) Application.--''; and
       (2) by adding at the end the following:
       ``(2) Quality management program.--A grantee under this 
     section shall implement a quality management program.''.
       (d) Coordination.--Section 2671(g) (42 U.S.C. 300ff-71(g)) 
     is amended by adding at the end the following: ``The 
     Secretary acting through the Director of NIH, shall examine 
     the distribution and availability of ongoing and appropriate 
     HIV/AIDS-related research projects to existing sites under 
     this section for purposes of enhancing and expanding 
     voluntary access to HIV-related research, especially within 
     communities that are not reasonably served by such 
     projects.''.
       (e) Authorization of Appropriations.--Section 2671(j) (42 
     U.S.C. 300ff-71(j)) is amended by striking ``fiscal years 
     1996 through 2000'' and inserting ``fiscal years 2001 through 
     2005''.

     SEC. 152. LIMITATION ON ADMINISTRATIVE EXPENSES.

       Section 2671 (42 U.S.C. 300ff-71) is amended--
       (1) by redesignating subsections (i) and (j), as 
     subsections (j) and (k), respectively; and
       (2) by inserting after subsection (h), the following:
       ``(i) Limitation on Administrative Expenses.--
       ``(1) Determination by secretary.--Not later than 12 months 
     after the date of enactment of the Ryan White Care Act 
     Amendments of 2000, the Secretary, in consultation with 
     grantees under this part, shall conduct a review of the 
     administrative, program support, and direct service-related 
     activities that are carried out under this part to ensure 
     that eligible individuals have access to quality, HIV-related 
     health and support services and research opportunities under 
     this part, and to support the provision of such services.
       ``(2) Requirements.--
       ``(A) In general.--Not later than 180 days after the 
     expiration of the 12-month period referred to in paragraph 
     (1) the Secretary, in consultation with grantees under this 
     part, shall determine the relationship between the costs of 
     the activities referred to in paragraph (1) and the access of 
     eligible individuals to the services and research 
     opportunities described in such paragraph.
       ``(B) Limitation.--After a final determination under 
     subparagraph (A), the Secretary may not make a grant under 
     this part unless the grantee complies with such requirements 
     as may be included in such determination.''.

     SEC. 153. EVALUATIONS AND REPORTS.

       Section 2674(c) (42 U.S.C. 399ff-74(c)) is amended by 
     striking ``1991 through 1995'' and inserting ``2001 through 
     2005''.

     SEC. 154. AUTHORIZATION OF APPROPRIATIONS FOR GRANTS UNDER 
                   PARTS A AND B.

       Section 2677 (42 U.S.C. 300ff-77) is amended to read as 
     follows:

     ``SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated--
       ``(1) such sums as may be necessary to carry out part A for 
     each of the fiscal years 2001 through 2005; and
       ``(2) such sums as may be necessary to carry out part B for 
     each of the fiscal years 2001 through 2005.''.

     Subtitle E--Amendments to Part F (Demonstration and Training)

     SEC. 161. AUTHORIZATION OF APPROPRIATIONS.

       (a) Schools; Centers.--Section 2692(c)(1) (42 U.S.C. 300ff-
     111(c)(1)) is amended by striking ``fiscal years 1996 through 
     2000'' and inserting ``fiscal years 2001 through 2005''.
       (b) Dental Schools.--Section 2692(c)(2) (42 U.S.C. 300ff-
     111(c)(2)) is amended by striking ``fiscal years 1996 through 
     2000'' and inserting ``fiscal years 2001 through 2005''.

                   TITLE II--MISCELLANEOUS PROVISIONS

     SEC. 201. INSTITUTE OF MEDICINE STUDY.

       (a) In General.--Not later than 120 days after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall enter into a contract with the Institute of 
     Medicine for the conduct of a study concerning the 
     appropriate epidemiological measures and their relationship 
     to the financing and delivery of primary care and health-
     related support services for low-income, uninsured, and 
     under-insured individuals with HIV disease.
       (b) Requirements.--
       (1) Completion.--The study under subsection (a) shall be 
     completed not later than 21 months after the date on which 
     the contract referred to in such subsection is entered into.
       (2) Issues to be considered.--The study conducted under 
     subsection (a) shall consider--
       (A) the availability and utility of health outcomes 
     measures and data for HIV primary care and support services 
     and the extent to which those measures and data could be used 
     to measure the quality of such funded services;
       (B) the effectiveness and efficiency of service delivery 
     (including the quality of services, health outcomes, and 
     resource use) within the context of a changing health care 
     and therapeutic environment as well as the changing 
     epidemiology of the epidemic;
       (C) existing and needed epidemiological data and other 
     analytic tools for resource planning and allocation 
     decisions, specifically for estimating severity of need of a 
     community and the relationship to the allocations process; 
     and
       (D) other factors determined to be relevant to assessing an 
     individual's or community's ability to gain and sustain 
     access to quality HIV services.
       (c) Report.--Not later than 90 days after the date on which 
     the study is completed under subsection (a), the Secretary of 
     Health and Human Services shall prepare and submit to the 
     appropriate committees of Congress a report describing the 
     manner in which the conclusions and recommendations of the 
     Institute of Medicine can be addressed and implemented.

  Mr. KENNEDY. Mr. President, it is a privilege to join Senators 
Jeffords, Frist, Dodd, Hatch, Bingaman, and Wellstone in introducing 
the Ryan White CARE Reauthorization Act. I commend Senator Jeffords for 
his leadership and commitment in making this legislation a top priority 
of the Health, Education, Labor, and Pensions Committee for enactment 
this year. I commend Senator Frist for his medical knowledge and 
expertise in drafting this legislation. Senator Dodd has been strongly 
committed to this issue for many years and I am pleased that he 
continues his commitment this year. Senator Hatch joined me more than a 
decade ago when we first introduced this legislation, and he has 
remained committed and involved ever since, and I commend his 
leadership. Senators Bingaman and Wellstone are members of our Senate 
Committee, and they have shown a great deal of interest in making sure 
that these resources reach rural Americans and other emerging 
populations.
  Over the past twenty years, the nation has made extraordinary 
progress in responding to the AIDS epidemic. Medical advances, new and 
effective treatments, and the development of an HIV care infrastructure 
in every state have dramatically improved the access to care for 
individuals and families with HIV who would otherwise not be able to 
afford such care. By providing life-sustaining health and related 
support services, we have reduced the spread of AIDS.
  The CARE Act has contributed to the significant drop in new AIDS 
cases. AIDS-related deaths have decreased significantly, dropping 42% 
from 1996 to 1997, and 20% from 1997 to 1998. Persons with HIV/AIDS are 
living longer and healthier lives because of the CARE Act.
  Perinatal HIV transmission from mother to child has been reduced by 
75% from 1992 to 1997. We are closing the gap in health care 
disparities in vulnerable populations such as communities of color, 
women, and persons with HIV who are uninsured and underinsured.
  Medications have made a difference too. Highly active anti-retroviral

[[Page S1891]]

therapies have given a second lease on life to many Americans with HIV/
AIDS. An estimated 80% of persons in treatment have used one or more of 
these new and effective drugs.
  HIV health care and supportive services have also made a difference. 
An estimated 600,000 persons have received HIV services through the 
Ryan White CARE Act, including primary care, substance abuse treatment, 
dental care, hospice care, and other specialized HIV health care 
services, and the availability of these services has enabled them to 
lead productive lives.
  In Massachusetts, for example, we have seen an overall 77% decline in 
AIDS and HIV-related deaths since 1995. At the same time, however, like 
many other states, we are concerned about the changing HIV/AIDS trends 
and profiles. AIDS and HIV cases increased in women by 11% from 1997 to 
1998, and 55% of persons living with AIDS in the state are persons of 
color.
  Clearly, we have had significant successes in fighting AIDS. We have 
come a long way from the days when ideology dictated care for people 
with AIDS and not sound public health policy. Fortunately, with the 
leadership of Senator Hatch and Senator Jeffords and our bipartisan 
coalition, we were able to enact the Ryan White CARE Act in memory of 
Ryan White. He was a young man with hemophilia who contracted AIDS 
through blood transfusions, and touched the world's heart through his 
valiant efforts to speak out against the ignorance and discrimination 
faced by many persons living with AIDS. His mother, Jeanne White 
carried on her son's message after Ryan's death in 1990. She was 
instrumental in the passage of the Care Act in 1990 and then again in 
1996 and now in 2000.
  The enactment of the Ryan White CARE Act in 1900 provided an 
emergency response to the devastating effects of HIV on individuals, 
families, communities, and state and local governments. The CARE Act 
signaled a comprehensive approach by targeting funds to respond to the 
specific needs of communities. Title I targets the hardest hit 
metropolitan areas in the country. Local planning and priority setting 
requirements under Title I assure that each of the Eligible 
Metropolitan Areas respond to the local HIV/AIDS demographics.
  Title II of the Act funds emergency relief to the states. It helps 
them to develop an HIV care infrastructure and provide effective and 
life-sustaining HIV/AIDS drug therapies through the AIDS Drug 
Assistance Program to over 61,000 persons each month.
  Title III funds community health centers and other primary health 
care providers that serve communities with a significant and 
disproportionate need for HIV care. Many of these community health 
centers are located in the hardest hit areas, serving low income 
communities.
  Finally, Title IV of the CARE Act is designed to meet the specific 
needs of women, children and families.
  While the CARE Act has benefited large numbers of Americans in need, 
a number of critical areas remain where improvements are essential if 
we are to meet the growing needs in our communities. We know that of 
the estimated 750,000 persons living with HIV/AIDS in the United 
States, over 215,000 know their HIV status, yet are not in care. New 
health care access points are needed to bring these persons into care. 
At the same time, the CARE Act programs currently serving an estimated 
600,000 persons annually are challenged more than ever in meeting the 
growing need and demand for services. The Centers for Disease Control 
and Prevention estimates that the need will continue to grow since we 
have an estimated 40,000 new cases of HIV/AIDS annually in the United 
States.
  Also, not everyone is benefiting from the advances in the development 
of new and effective drug treatments. The skyrocketing costs of 
expensive AIDS drugs, estimated at $15,000 annually per person, has led 
26% of the CARE Act's AIDS Drug Assistance Programs to cap enrollment, 
establish waiting lists, or limit eligibility. Guaranteeing that 
effective drug treatments are available and affordable to all persons 
with HIV/AIDS has always been a priority for the CARE Act. Reducing 
barriers to access in communities of color and other vulnerable 
populations is a priority for this reauthorization.

  We are fortunate in Massachusetts to have a state budget that has 
also been able to provide funding for primary care, prevention, and 
outreach efforts, but no state by itself can provide the significant 
financial resources to help persons living with HIV to obtain needed 
medical and support access.
  We still find serious disparities in access to HIV health care in 
communities of color, women, the uninsured and underinsured. The 
demographics of the epidemic have been steadily changing. The majority 
of new AIDS cases reported are among racial and ethnic minority 
populations and groups that traditionally have faced heavy barriers in 
obtaining adequate health care services. While African Americans make 
up 12% of the general population, they account for 45% of new AIDS 
cases. 80% of new AIDS cases are occurring in women of color. As many 
as half of all new infections are occurring in people under the age of 
25, and one quarter of all new infections are occurring in persons 
under the age of 22. The CARE Act must be able to adjust to meet these 
changing trends in the HIV/AIDS epidemic. Geographic shifts in the 
epidemic as well as the availability of new sources of financing for 
HIV/AIDS care must be taken into account to assure equity in how the 
federal government and states respond to the epidemic.
  The CARE Act must continue to provide resources to help local 
communities to plan and to set priorities for CARE dollars. We must 
develop better ways to measure the severity of need and the health 
disparities, and assure that these improvements are taken into account 
in HIV planning, in establishing priorities, and in allocating funds.
  This bill addresses these new challenges in ensuring access to HIV 
drug treatments for all, reducing health disparities in vulnerable 
communities, and improving the distribution and quality of services 
under the CARE Act. Proposed changes will ensure greater access to care 
in low income, historically underserved urban and rural communities, by 
increasing targeted funding to areas where the HIV care infrastructure 
may not exist. This bill also focuses on quality and accountability of 
HIV service delivery by requiring effective quality management 
activities that ensure their consistency with Public Health Service 
guidelines, and by making changes to ensure that CARE Act dollars are 
used for their intended purposes.
  These improvements are intended to close the gap in health care 
disparities and improve inequities in services and funding among 
states. They will build capacity in underserved rural and urban areas, 
and focus state and local program priorities on underserved populations 
and persons not in care. They will develop new points of entry 
relationships to improve coordination of care. They will increase early 
access to care, in order to begin HIV treatment earlier and improve the 
quality of care that patients receive.
  We know that the CARE Act has made a difference not only in the lives 
of persons with HIV/AIDS, but also in the lives of countless loved ones 
who have seen despair turned to hope through support of CARE Act 
services. The story of Lory in Massachusetts is a compelling example of 
young woman living with HIV, unable to work full-time, and unable to 
afford anti-retroviral medications without Ryan White CARE Act 
assistance. The support she has received from the caring staff at 
Fenway Clinic in Boston is impressive. As Lory told us at our committee 
hearing on March 2nd on the reauthorization of the Act ``It is not an 
exaggeration when I tell you that without Fenway I would be dead. They 
have saved my life.''
  I'm sure that Lory's eloquent testimony is true of countless others 
across the country who are living with this tragic disease. The Ryan 
White CARE Act has made an enormous difference in their lives. I look 
forward to early action by Congress on this important legislation, so 
that we can continue to help as many people as possible.
  Mr. FRIST. Mr. President, the Centers for Disease Control and 
Prevention estimate that between 650,000 and 900,000 Americans are 
currently living with human immunodeficiency virus (HIV), of whom 
280,000 have acquired immune deficiency syndrome (AIDS). As of June 
1999, there were 8,814 people in my home state of Tennessee living with 
HIV/AIDS. As a physician, I have seen first hand the deadly impact of

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this disease on patients, and have also seen first hand what can happen 
if the prevalence of AIDS goes unchecked. On February 24, 2000, as 
chairman of the Foreign Relations Subcommittee on Africa, I held a 
hearing on the AIDS crisis in Africa. In Africa, this disease has 
reached truly pandemic proportions, causing cultural and economic 
devastation. Every day, there are 16,000 new infections globally, 
despite the great strides we have made in the treatment and prevention 
of this condition.
  Ironically and unfortunately, the new advancements in treatment may 
have caused many to become complacent. A survey co-authored by Yale 
revealed that more than 80% of our youth do not believe they are at 
risk for HIV infections. However, the fact is that the number of new 
infections among adolescents continues to rise and it is rising 
disproportionally among minorities. AIDS remains the leading cause of 
death among African-Americans 25-44 years of age and the second leading 
cause of death among Latinos in the same age range. Furthermore, in 
1998, African-American and Hispanic women accounted for 80% of the 
total AIDS cases reported for women nationwide. In my own state of 
Tennessee, 59% of the new AIDS cases were among African-Americans, who 
make up 45% of the total AIDS cases in the state. Since its original 
discovery, it is estimated that over 13.9 million have died worldwide 
and over 400,000 have died in the United States as a result of HIV/
AIDS. Fortunately, over the last 15 years, we have doubled the life 
expectancy of people with AIDS, developed new and powerful drugs for 
the treatment of HIV infection, and made advances in the treatment and 
prevention of AIDS-related opportunistic infections.
  Another important component in the struggle against HIV/AIDS has been 
the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, which 
I am pleased to join with Senator Jeffords in supporting today. The 
Ryan White CARE Act, a unique partnership between federal, local, and 
state governments; non-profit community organizations, health care and 
supportive service providers. For the last decade, this Act has 
successfully provided much needed assistance in health care costs and 
support services for low-income, uninsured and underinsured individuals 
with HIV/AIDS.
  Through programs such as AIDS Drug Assistance Program (ADAP), which 
provides access to pharmaceuticals, the CARE Act has helped extend and 
even save lives. Last year alone, nearly 100,000 people living with HIV 
and AIDS received access to drug therapy because of the CARE Act. Half 
the people served by the CARE Act have family incomes of less than 
$10,000 annually, which is lower than the $12,000 annual average cost 
of new drug ``cocktails'' for treatment. The CARE Act is critical in 
ensuring that the number of people living with AIDS continues to 
increase, as effective new drug therapies are keeping HIV-infected 
persons healthy longer and dramatically reducing the death rate. 
Investments in enabling patients with HIV to live healthier and more 
productive lives have helped to reduce overall health costs. For 
example, the National Center for Health Statistics reported that the 
nation has seen a 30% decline in HIV related hospitalizations, which 
results in nearly one million fewer HIV related hospital days and a 
savings of more than $1 billion.
  During the 104th Congress, I had the pleasure of working with Senator 
Kassebaum on the Ryan White CARE Act Amendments of 1996 to ensure this 
needed law was extended. Today I am pleased to join Senator Jeffords as 
an original cosponsor to the Ryan White CARE Act Amendments of 2000, 
which will further improve and extend this law. Senator Jeffords, who 
has done a terrific job in crafting this bill, has already outlined 
some specifics of this legislation, however, I would like to conclude 
by discussing a specific provision which I am grateful Senator Jeffords 
included in this reauthorization.
  This bill contains a provision, under Title II of this Act, to 
address the fact that the face of this disease is changing and is 
moving into and affecting more rural communities. A recent GAO audit 
found that rural areas may offer more limited medical and social 
services than cities because urban areas generally receive more money 
per AIDS case. To help address this concern, this new provision will 
provide supplemental grants to States for additional HIV/AIDS services 
in underserved areas. One important aspect of this provision is the 
creation of supplemental grants for emerging metropolitan communities, 
which do not qualify for Title I funding but have reported between 
1,000 and 2,000 AIDS cases in the last five years. Currently, this 
provision would provide 7 cities, including Memphis and Nashville, a 
general pot of money to divide of at least $5 million in new funding 
each year, or 25% of new monies under Title II, whichever is greater.
  Mr. President, I would like to thank Senator Jeffords for his 
leadership on this issue, and Sean Donohue and William Fleming of his 
staff for all their expertise in drafting this bill. I would also like 
to thank Senator Kennedy and Stephanie Robinson of his staff for their 
work and dedication to this issue. I would also like to thank Dr. Bill 
Moore of the Tennessee Department of Health and Mr. Joe Interrante of 
Nashville CARES for their counsel and assistance on this legislation 
and for their efforts in helping Tennesseans with HIV/AIDS.
  Mr. DODD. Mr. President, I am pleased to join Senators Kennedy, 
Jeffords, Frist, Hatch, Bingaman, Harkin, Wellstone, Reed, Enzi, and 
Mikulski in sponsoring the Ryan White CARE Reauthorization Act, 
legislation which will provide for the continuation of critical support 
services for those living with HIV and AIDS. I thank Senators Jeffords 
and Kennedy for their leadership and commitment to this important bill, 
and commend their efforts to ensure that the reauthorization 
legislation addresses the new challenges of the HIV/AIDS epidemic.
  Over the last two decades, our Nation has made tremendous advances in 
responding to the HIV/AIDS epidemic. We've all been encouraged by the 
recent reports that the number of AIDS cases dropped last year for the 
first time in the 16 year history of the epidemic. The new combination 
therapies largely responsible for this change in course have brought 
new hope to families devastated by this disease. Although it was 
unimaginable just a few years ago, it now appears possible that we may 
soon view AIDS, if not as curable, than at least as a manageable, 
chronic illness.
  But, despite these advances in treatment options, the HIV/AIDS 
epidemic remains an enormous health emergency in the United States, 
with the number of AIDS cases in the U.S. nearly doubling during the 
last five years. According to a study sponsored by the U.S. Public 
Health Service, approximately 250,000 to 300,000 people living with HIV 
or AIDS currently receive no medical treatment. Therefore, while we 
must sustain our efforts in the areas of research and education, it is 
also critical that we continue to provide resources to help states and 
disproportionately affected communities develop the necessary 
infrastructure to provide HIV/AIDS care. One of the most important 
changes made to the Ryan White programs by this Reauthorization Act is 
the emphasis on the need for early diagnosis of the disease. This new 
emphasis is reflected in the bill's provisions relating to early 
intervention activities, which will support early diagnosis and 
encourage linkages into care for populations at high risk for HIV.
  In the decade since the enactment of the Ryan White CARE Act we've 
seen a transformation in the face of AIDS. Since women and children are 
disproportionately represented among the newly infected, I am 
especially pleased that this bill provides for the coordination of Ryan 
White and State Children's Health Insurance Program (SCHIP) funds, and 
includes a set-aside for infants, children, and women proportionate to 
the percentage each group represents in the eligible funding area's 
AIDS affected population.
  During the decade of the Ryan White CARE Act, we've also seen a shift 
in the challenges facing providers. Ten years ago, Ryan White providers 
focused primarily on helping people while they died. Now, more and 
more, providers are moving into the business of helping individuals 
infected with HIV live long and full lives. But, while the discovery of 
powerful drug therapies has improved the quality and length of life for 
many who are HIV positive, access to these drugs and to

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other critical health services is still difficult for many, since AIDS 
is fast becoming a disease of poverty. The CARE Act's AIDS Drug 
Assistance Programs remain a lifeline for low-income individuals who 
cannot afford the costs of regular care and expensive AIDS drug 
regimens (now estimated at $15,000 annually per person).
  The CARE Act has made a difference to the lives of countless 
individuals and families affected by a devastating disease. While there 
is hope for the future, the changing demographics of the disease 
present new challenges. The Ryan White CARE Act Amendments of 2000 
address these challenges while maintaining those aspects of the Act 
that demonstrate proven results. I look forward to working with 
Congress as we move forward with the reauthorization, so that the 
thousands of people who rely on the services of Ryan White programs can 
continue to maintain their dignity and quality of life.
  Mr. WELLSTONE. Mr. President, I join with my colleagues on the HELP 
committee to cosponsor the Ryan White Care Act Amendments of 2000. I do 
this with pride in what has been accomplished since I last cosponsored 
the reauthorization of the Ryan White Care Act in 1996. This 
legislation since 1991 has enabled the development of community driven 
systems of care for low-income, uninsured, and underinsured individuals 
and families affected by HIV disease.
  Last year alone, the Ryan White CARE Act served an estimated half 
million people living with HIV and AIDS and affected the lives of 
millions more. Nearly 6 in 10 of these people were poor. Last year, 
this legislation enabled approximately 100,000 people living with HIV 
and AIDS to receive drug therapy. This is particularly important 
because half of the people served by the Act have incomes less than 
$10,000 a year--and the new drug treatments cost more than $12,000 
annually.
  According to the National Center for Health Statistics, between 1995 
and 1997, there has been a 30 percent decline in HIV related 
hospitalizations, representing a savings of more than $1 billion. Since 
1991, according to Sandra Thurman, Director of the Office of National 
AIDS Policy, the CARE Act has helped to reduce AIDS mortality by 70 
percent; to reduce mother-child transmission of HIV by 75 percent; and 
to enhance both the length and quality of life for people living with 
HIV/AIDS.
  The epidemic is far from over. Each year there are 40,000 new HIV 
infections in the U.S., and the death rate is no longer dropping so 
quickly. Although people with HIV disease are living much longer, the 
highly touted multi-drug therapies are beginning to fall short of their 
prayed for effectiveness, and they do not work for everyone.
  In addition, the nature of the epidemic is changing. HIV/AIDS is 
devastating communities of color. AIDS is the leading cause of death 
for African-Americans aged 25 to 44, and the second leading cause of 
death among Latino Americans of the same age group. HIV/AIDS also 
disproportionately affects younger Americans. Half of the 40,000 new 
infections each year occur in individuals under age 25. AIDS is killing 
the youngest, potentially most productive members of our society. 
Without a renewed commitment to research, prevention, and culturally 
sensitive treatment, the rates of infection and death will continue to 
ravage communities of color.
  It is a testament to the success of this legislation that there is 
such unanimity among the committee members and all of the diverse group 
of stakeholders that the Ryan White Care Act needs to be reauthorized. 
The amendments included in this legislation are designed to increase 
the accountability of the overall program; to meet the challenges of 
the changing nature of the epidemic; to improve the quality of care; 
and to reach those affected by this plague who have not been reached 
before. We often say ``Leave no child behind'' and everyone agrees. We 
must also say, ``let's leave no one afflicted by this dread disease 
untreated''.
  Provisions for quality management around clinical practice will bring 
best practices to patients. Holding grantees accountable for quality 
management and relevance of programs means the money appropriated will 
be well spent. This is good medicine and responsible lawmaking.
  Allowing for flexibility in how the AIDS Drug Assistance Program 
(ADAP) funds are spent will provide more low-income individuals with 
life-prolonging medications. Focusing on early intervention services to 
support early diagnosis will get patients into treatment faster and 
hopefully also slow the spread of the disease. Requiring grantees to 
develop and maintain linkages with key points of entry to the medical 
system, such as mental health and substance abuse treatment centers, 
will dramatically improve treatment, slow the spread of the disease, 
and reach previously unserved people. This is good prevention.
  In 1990, the HIV/AIDS epidemic was primarily limited to large cities; 
hence the majority of funds were granted to cities. Over the last 
decade, unfortunately, the epidemic has spread to more rural areas and 
to different populations. This bill requires that funds be spent in 
accordance with local demographics. Several provisions in this bill 
will allow more funds to go to less populated areas and to provide 
special grants for infants, youth and women. This is good allocation of 
resources based on needs.
  This bill also contains fiscally responsible caps on administrative 
costs, and requires all grantees to coordinate with Medicaid and the 
State Children's Health Insurance Program. This makes good fiscal 
sense.
  Mr. President, the Ryan White CARE Act has saved lives and serves 
hundreds of thousands of needy people yearly. The Ryan White CARE Act 
has a proven record of success; let's build on that success. This 
federal legislation needs to be reauthorized now, as proposed, to meet 
the continuing needs and new challenges presented by the changing 
nature of the HIV/AIDS epidemic.
  That is why I urge all Senators to join in cosponsoring and passing 
the Ryan White CARE Act Amendments of 2000, and I urge the members of 
the Appropriations Committee to provide the funds to fully implement 
it.
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