[Senate Report 104-25]
[From the U.S. Government Publishing Office]
Calendar No. 47
104th Congress Report
SENATE
1st Session 104-25
_______________________________________________________________________
RYAN WHITE CARE REAUTHORIZATION ACT OF 1995
_______
April 3 (legislative day, March 27, 1995.--Ordered to be printed
_______________________________________________________________________
Mrs. Kassebaum, from the Committee on Labor and Human Resources,
submitted the following
R E P O R T
[To accompany S. 641]
The Committee on Labor and Human Resources, to which was
referred the bill (S. 641), to amend title XXVI of The Public
Health Service Act, having considered the same, reports
favorably thereon without amendment and recommends that the
bill do pass.
CONTENTS
Page
I. Summary of the bill..............................................1
II. Background and need for legislation..............................4
III. Legislative history and committee action........................11
IV. Committee views.................................................11
V. Cost estimate...................................................23
VI. Regulatory impact statement.....................................26
VII. Section-by-section analysis.....................................26
VIII.
Changes in existing law.........................................31
I. Summary of the Bill
As reported by the committee, the bill reauthorizes title
XXVI programs to ensure that individuals living with HIV and
AIDS receive appropriate services. The legislation contains
formulae, authorization for appropriation, and programmatic
changes to ensure that CARE Act programs are consistent with
demands created by the changing HIV and AIDS epidemic.
1. The current four-title structure of the Ryan White CARE
Act is maintained.
Title I: Provides emergency relief grants to eligible
metropolitan areas (EMA's) disproportionately affected
by the HIV epidemic. One-half of the title I funds are
distributed by formula; the remaining one-half is
distributed competitively.
Title II: Provides grants to States and territories
to improve the quality, availability, and organization
of health care and support services for individuals
with HIV disease and their families. The funds are
used: to provide medical support services; to continue
insurance payments; to provide home care services; and
to purchase medications necessary for the care of these
individuals. Funding for title II is distributed by
formula.
Title III(b): Supports early intervention services on
an out-patient basis--including counseling, testing,
referrals, and clinical, diagnostic, and other
therapeutic services. This funding is distributed by
competitive grants.
Title IV: Provides grants for research and services
for children and families.
2. A single appropriation for title I grants to eligible
metropolitan areas and title II grants to states is authorized
for fiscal year 1996.
A single appropriation should help unify the interest
of grantees in assuring funding for all individuals
living with AIDS, regardless of whether they live in
EMA's or states.
The appropriation is divided between the two titles
based on the ratio of fiscal year 1995 appropriations
for each title. Sixty-four percent is designated for
title I in fiscal year 1996. The Secretary is
authorized to develop and implement a method to adjust
the ratio of funding for title I and title II to
account for new title I cities and other relevant
factors for fiscal year 1997 through fiscal year 2000.
If the Secretary does not implement such a method,
separate appropriations for titles I and II are
authorized, beginning in fiscal year 1997 and extending
through fiscal year 2000.
3. New formulas are authorized for titles I and II based on
an estimation of the number of individuals living with AIDS and
the costs of providing services.
The present distribution formulas have led to
disparity in funding for individuals living with AIDS
based on where they live. This is due to: a caseload
measure which is cumulative, the absence of any measure
of service costs, and the counting of EMA cases by both
the titles I and II formulas.
The new formulas will include an estimate of living
cases of AIDS. This estimate is calculated by applying
a different weight to each year of cases reported to
the Centers for Disease Control and Prevention over the
most recent 10 year period. A cost index is determined
by using the average Medicare hospital wage index for
the 3 year period immediately preceding the grant
award. Over a 5 year period, hold-harmless floors for
the formulas are provided in order to assure that no
entity receives less than 92.5 percent of its 1995
allocation. The phase-in is provided to avoid
disruption of services to beneficiaries, while still
allowing for the redistribution of funds.
4. The addition of new title I cities will be limited.
The current designation criteria for title I cities
was developed to target emergency areas. Five years
after the initial enactment of the Ryan White CARE Act,
the epidemic persists. However, the needs of
potentially new title I cities are not the same as the
original cities. Title II funding has been used to
develop infrastructure in many of these metropolitan
areas, decreasing the relative need for new cities to
receive emergency title I funding.
To maintain the emergency nature of title I the
eligibility definition is refined to include only those
areas which have a population of at least 500,000
individuals and a cumulative total of more than 2,000
cases of AIDS in the preceding 5 years. To allow a
transition period, this requirement will not apply to
any area that is deemed eligible before fiscal year
1998.
5. A priority for the title I supplementary grants is
established.
The severity of illness has a major impact on the
delivery of services. The reauthorization establishes a
priority for the distribution of funds which accounts
for co-morbid conditions. Such conditions include
sexually transmitted diseases, substance abuse,
tuberculosis, severe mental illness, and homelessness.
6. The Special Projects of National Significance (SPNS) and
the AIDS Education and Training Centers are included in a new
title V.
Currently, SPNS is funded by a 10 percent title II
set-aside. The reauthorization bill provides that the
SPNS program will receive a 3 percent set-aside from
each of the other four titles. The SPNS project will
address the needs of special populations, assist in the
development of essential community-based service
infrastructure, and ensure the availability of services
for Native American communities.
The AIDS Education and Training Centers program is
transferred from Federal health professions education
legislation. This program provides funding for the
training of health personnel in the diagnosis,
treatment, and prevention of HIV disease. Its purpose
is to assure the availability of a cadre of trained
individuals for the CARE Act programs.
7. A statewide coordination and planning process is created
to improve coordination of services, including services in
title I cities and title II States.
8. Representation on the title I planning councils is
changed to more accurately reflect the demographics of the HIV
epidemic, and to adequately reflect appropriate communities,
subpopulations and providers.
9. Guidelines for a minimum State drug formulary are
authorized.
Therapeutics improve the quality of life of patients
with HIV disease and minimize the need for costly
inpatient medical care. The medical state of the art is
constantly changing. The guidelines will help ensure
that Food and Drug Administration approved therapies
are available to people living with HIV disease.
10. Administrative caps for titles I and II are extended to
contractors and subcontractors.
Administrative costs for grantees and subcontractors
are tightly defined and limited. This limitation will
maximize the amount of funding available to provide
services for people living with AIDS.
II. Background and Need for Legislation
general background
In March 1990, Congress enacted the Ryan White CARE Act,
honoring Ryan White, a young man who taught the Nation to
respond to the AIDS epidemic with hope and action rather than
fear. By the spring of 1990, over 128,000 people had been
diagnosed with AIDS in the United States; 78,000 had died of
the disease.
Today, more than 440,000 cases of AIDS have been reported
to the Centers for Disease Control and Prevention (CDC). More
than 243,000 men, women and children have died as the epidemic
has encompassed more of the Nation over the last 15 years. More
than 100 people in the United States die every day of AIDS--one
every 15 minutes.
The Nation continues to experience rapid growth in the
number of individuals diagnosed with AIDS. The first 100,000
AIDS cases in the United States were diagnosed over an 8 year
period. The second 100,000 cases were reported in a 2 year
period. In the last year alone over 80,000 AIDS cases have been
reported--more than 220 a day. AIDS has become the leading
killer of Americans aged 25-44.
The epidemic continues to grow, touching larger numbers of
people and more and more segments of our society. The
heterosexual transmission rate continues to increase; women,
teenagers, and minorities are even more at risk. One of every
two HIV infections now occurs in people under age 25. Suburban
and rural areas of the country are now feeling the full impact
of the epidemic. Those areas must now confront the same social,
economic and personal devastation that the original urban
epicenters have been battling since 1981.
The continued expansion of the AIDS epidemic in America is
a certainty. Yet, diagnosed AIDS cases measure only a fraction
of the problem. The National Commission on AIDS reported that,
based on CDC estimates, at least 1 million Americans were
already infected with HIV by 1993. Hundreds of thousands of
these Americans will require health care services in the
future. This crisis will severely challenge the Nation's health
care system well into the next century.
While a cure for HIV disease remains a distant hope,
science has made significant progress in developing treatments
for HIV disease. Therapies now exist that can help slow the
progression of HIV and fend off many of the opportunistic
infections associated with AIDS. In addition, prenatal
administration of AZT has also been shown to reduce the
intrauterine transmission of HIV. These developments have
resulted in longer survival rates for people diagnosed with
AIDS and have highlighted the importance of early intervention
and early treatment.
Public policy should adapt to the expanding epidemic and
the increase in scientific and medical information regarding
HIV. Effective policy should address the increasing service
needs that the epidemic creates and integrate the advances in
knowledge and understanding of the disease. In 1993, for
example, the Centers for Disease Control and Prevention revised
the AIDS case definition to more accurately reflect the
physiological progression of HIV disease. This change has
contributed to the 111 percent increase in AIDS diagnoses over
those reported in 1992, because people living with HIV are now
diagnosed earlier in the course of their disease.
The Ryan White CARE Act was originally introduced in 1990
in response to the need for HIV primary care and support
services. The major focus of public policy prior to the CARE
Act was on research, public education, surveillance and
prevention. These activities are still a necessary priority. In
addition, the CARE Act has helped people with HIV and AIDS to
obtain services to improve the quality of their lives.
The public health and economic burden of the AIDS epidemic
has not been reduced since the CARE Act was passed. While the
CARE Act has been a lifeline of support to many people, need
for services continues to grow faster than the resources
available to meet them. In fact, the steady expansion and
changed demographics of the epidemic and the increasing
survival rates for people living with AIDS has in some areas
increased the stress on local health care systems. This strain
is felt in both urban centers where the epidemic continues to
rage, and in smaller cities and rural areas, where the epidemic
is expanding rapidly.
In response, the committee ordered favorably reported the
Ryan White CARE Reauthorization Act of 1995. This
reauthorization provides accessible HIV primary care and
support services to the increasing number of people who need
them. That care, often begun in acute care facilities, is
generally very expensive and often goes un-reimbursed. The
demand for this type of expensive service can be reduced,
however, as people receive needed services in Ryan White funded
community-based, neighborhood health clinics and social service
agencies. Americans who might otherwise become ill and burden
our already overcrowded hospital emergency rooms will remain
healthy, working and productive members of our society.
hiv in rural areas
While the AIDS epidemic continues in urban areas of the
country, the number of new cases diagnosed in small urban
centers, suburban, and rural areas is reaching alarming levels.
According to the HIV/AIDS Surveillance Reports published by the
Centers for Disease Control and Prevention, the proportion of
all AIDS cases reported in areas with under 500,000 population
has grown from 9.5 percent to 17 percent. However, as the
epidemic has grown everywhere, the demand for medical and
support services in suburban and rural areas has also grown.
Some of the problems created by HIV disease in rural areas
are similar to those being confronted in large cities. The lack
of trained primary care providers, absence of long-term-care
facilities, scarcity of resources, and a scattered population
are a few of the obstacles that may be faced in developing
coordinated outpatient services programs.
Small rural hospitals and other rural providers may not be
able to provide the highly specialized services often required
by some persons with HIV disease. Primary care services are
also not often available, requiring some individuals and
families to travel very long distances to receive necessary
care.
Some of these problems might be alleviated if rural
hospitals and practitioners were better linked to the urban
centers with specialty and sub-specialty clinical services.
Some states have supported such linkages as HIV disease has
become prevalent in areas outside the original epicenters of
the epidemic. The demand and need for such linkages will only
continue to rise in the coming years.
hiv disease in urban areas
While the expansion of the epidemic into suburban and rural
areas is clear, 42 eligible metropolitan areas (EMA's)
currently receive title I funding, compared to only 16 when the
CARE Act was originally passed. In fiscal year 1996, nearly 50
cities are expected to be eligible. Seventy two percent of the
new AIDS diagnoses are reported in the current EMA's.
The epidemic in urban areas continues as it expands to
other parts of the country. These urban areas must address not
only the epidemic, but other co-morbid factors, including
tuberculosis, homelessness, substance abuse, mental illness,
and other STD's. These interrelationships vastly complicate the
treatment of HIV/AIDS and demand that support services respond
to many social ills.
HIV-specific problems and general health care delivery
issues continue to challenge public health officials. Municipal
hospitals continue to bear a disproportionate share of the AIDS
burden. People with HIV disease are drawn to these essentially
urban facilities even as other pressures are being placed on
them. Private hospitals, for example, continue to cut back on
charity care, and the large public hospitals are now forced to
deal with the HIV epidemic in the setting of many urban
tragedies.
children and families with hiv disease
As HIV spreads rapidly among intravenous drug users and
their sexual partners, entire families become infected and need
a full range of HIV health care and support services. As of
July 1994, nearly 5,000 children had received an AIDS
diagnosis. AIDS will be the fifth leading cause of death for
all children in this decade and a major cause of mental
retardation.
Minority communities have been particularly hard hit by the
expanding epidemic. Although African Americans and Latinos
represent 15 percent of the population, they comprise 45
percent of all reported AIDS cases--and 75 percent of all
women, children and youths with AIDS.
Many families find that obtaining access to essential
services can be a complicated and frustrating process. Women
with perinatally infected children, often ill and still
addicted to drugs, may have difficulty advocating effectively
for their children and have the most limited access to health
care for themselves as any group infected with HIV. The
availability of health care and support services for HIV
infected women and children ``under one roof'' is critical.
Essential to the success of this ``one-stop shopping''
model is a family centered system of case management. The
committee heard eloquent testimony to that effect from Anna, a
32-year-old Miami woman who, along with her twin 7-year-old
boys have been struggling through a maze of treatment and
support services since 1989 when they discovered they were all
living with HIV. Anna described the life saving support,
encouragement and assistance she received from Kim, her CARE
Act funded case manager. Kim helped Anna to assess her needs,
plan for the future, coordinate services and make referrals.
Through Kim's help, Anna testified that she learned to access
``the system'' to get her own and her children's medical needs
met. ``Kim was the only person at the time who understood and
empowered me'', Anna told the committee.
FORMULA ISSUES
There is a need as well to modify the titles I and II
formula provisions to take into account the changing face of
the HIV epidemic, which is documented above. The need for these
changes was first acknowledged in an April 1994 report of the
Department of Health and Human Services Inspector General (IG).
The IG stated ``Concerns about the funding formulas were raised
by many people we talked to as we designed the study * * * We
expect the formulas to be an important focus for discussion
during reauthorization.'' At the request of Senators Kassebaum
and Brown, the General Accounting Office (GAO) completed a
thorough review of the funding formulas to determine if they
resulted in an equitable distribution of limited Federal
resources.
There are large disparities in the current distribution of
CARE Act funding. For instance, the GAO notes that ``* * *
EMA's that were first eligible to receive title I funds were
funded at about $1,500 per case, on average, in fiscal year
1994. In contrast, during this same time EMA's that recently
became eligible to receive these funds were funded at only
$1,000 per case--one-third less than the older EMA's.'' In
addition, ``* * * per case funding was $1,000 in States without
an EMA, $1,700 in States where less than half the state
caseload lived in an EMA, and $2,200 in States where more than
half of the State's caseload lived in and EMA.''
According to the letter sent by the GAO to The Honorable
Nancy L. Kassebaum on February 14, 1995, disparities in both
formulas exist for the following reasons:
Both titles I and II include in their formulas
individuals living in EMA's (eligible metropolitan
areas). Because not all States have an EMA, counting
EMA cases for both titles can penalize States that do
not have EMA's, and to a lesser extent, States whose
EMA's contain a relatively small share of the State's
total caseload.
The title I formula uses the cumulative number of
AIDS cases reported since 1981 as a caseload measure.
Since two-thirds of these cases are deceased, this
factor may penalize States and EMA's that have recently
experienced the most rapid growth in caseloads.
Neither the formula for title I nor II includes a
factor to reflect differences in EMA and State costs of
providing services to persons with AIDS. As a
consequence, EMA's and States that must pay more for
personnel and office space may not receive a level of
funding to purchase services comparable to those that
lower cost areas are able to purchase.
The title I formula uses AIDS incidence rates (cases
per capita) to measure EMAs' funding capacity but does
not consider their local tax bases. The AIDS incidence
rate factor was adopted as a means of targeting more
aid to EMA's whose funding capacity has been adversely
affected by high concentrations of AIDS cases. However,
not considering their tax bases can result in
overstating the funding capability of such EMA's that
have more limited tax bases.
Conversely, the title II formula uses per capita
income to measure the States' funding capacity, but it
does not measure the impact that a high concentration
of AIDS cases has on the funding capability of a State.
This can result in overstating the funding capability
of States with high concentrations of AIDS cases.
To remedy these problems, the GAO recommended new formulas
for titles I and II based on an estimation of the number of
individuals currently living with AIDS and the costs of
providing services. In addition, GAO recommended an adjustment
to offset statewide case counts, when such States also include
title I cities.
To estimate the number of individuals living with AIDS, the
GAO recommended applying different weights to the number of
AIDS cases identified by the Centers for Disease Control and
Prevention during each of the most recent 10-year period.
Developed with input from the CDC, the GAO suggested applying
the following weights: .06 for the first and second year during
such period, .08 during the third year, .10 during the fourth
year, .16 during the fifth and sixth year, .24 during the
seventh year, .40 during the eighth year, .57 during the ninth
year, and .88 during the tenth year.
The GAO recommended using the medicare average hospital
wage index. This index would provide a proxy to determine
relative differences in the cost of providing services to
people with AIDS in different portions of the country. In
addition, GAO recommended that 30 percent of the cost factor
should be constant to reflect the fact that drug prices across
different regions of the country are relatively stable.
The committee worked to identify which portion of title II
funding is similar in purpose to title I funding. All of title
I funding is devoted to medical and support services; while for
fiscal year 1995, 57 percent of title II funding is devoted to
medical and support services. To address funding differences
between States with and without EMA's, the committee adopted a
title II formula with two separate components. One portion of
the formula is based on the number of individuals living in EMA
and non-EMA areas. The remaining portion is based on the number
of individuals living in non-EMA areas only.
AUTHORIZATION OF APPROPRIATIONS FOR TITLES I AND II
The committee received comments from many interested
individuals and groups indicating that the current separate
authorization structure for titles I and II sets up a
competitive process for titles I and II grantees which disrupts
the unity of interests for people living with AIDS. For these
reasons, S. 641 includes a single authorization for the two
titles.
THE NEED FOR S. 641
The CARE Act was originally passed in 1990 to address some
of the most pressing problems in health services delivery
raised by the HIV epidemic. Today, S. 641 represents the
continuation of that comprehensive approach.
The HIV epidemic is one major problem which has compromised
the health and health care infrastructure of this country. Our
Nation's health care system was totally unprepared for the
advent of AIDS and HIV. Even when the full scope and severity
of the epidemic began to be reported, the planning and funding
that would be required to mount an appropriate response lagged.
The Ryan White CARE Act of 1990 was designed and passed
with near unanimity in the Senate to address those planning and
funding shortfalls. Two national commissions recommended and
supported the principles underlying the CARE Act as the most
effective means to address the burgeoning needs of people
living with HIV/AIDS. Title I of the act addresses the needs of
the metropolitan areas where HIV disease is most heavily
concentrated. Title II addresses the HIV epidemic on a
statewide basis, with a special emphasis on the needs of
smaller cities and rural areas and on services to families and
children with HIV disease. Title II also provides a basis for
hard-hit urban and nonurban areas to build an effective
continuum of care.
In considering reauthorizing the CARE Act, the committee
has received input from a wide variety of sources. Dr. June
Osborn, chair of the National Commission on AIDS from 1989-93,
testified before the committee that the structure of the CARE
Act has worked over the last 5 years and that it provides a
solid basis on which to build an effective response to the
changing epidemic over the next 5 years. National AIDS
organizations including the AIDS Action Council, the Campaign
for Fairness, the CAEAR Coalition, the National Association of
State and Territorial AIDS Directors, and National
Organizations Responding to AIDS, have also provided input.
These groups, as well as mayors, governors, Federal, State and
local public health officials, CARE Act funded service
providers and, most important, people living with HIV disease
are all in agreement that the CARE Act has been a success and a
lifeline of support to hundreds of thousands of people.
The committee heard testimony from individuals and
organizations which supported the existing four title structure
of the act, its emphasis and reliance upon local planning and
decision making, and the flexibility it provides in meeting the
needs of people living with HIV. They also testified that the
need for emergency relief remains as urgent today as it was in
1990. While the CARE Act has provided a lifeline of support and
relieved some of the strain, it has not stopped the epidemic
from dangerously taxing already overburdened health care
delivery systems.
Witnesses also testified regarding the problems associated
with the existing CARE Act. Funding disparities exist among
EMA's and among states. Title I EMA's have often been pitted
against title II States in a competition for scarce resources.
The epidemic has grown and it has changed. The witnesses
agreed that the reauthorized CARE Act should change to address
the needs of these newly affected groups.
The original CARE Act has demonstrated that alternatives to
inpatient care can alleviate some of the burden that both urban
and rural hospitals face. Examples of CARE Act success are
plentiful:
In Massachusetts, the average length of
hospitalization for people with AIDS in the State
declined from 11.8 days before CARE Act implementation
to 9.4 days after CARE Act implementation. During the
same period, the average length of stay for all other
diagnoses actually increased from 6.6 days to 7.0 days.
In Miami, the average length of stay for people with
HIV at Mercy Hospital was reduced from 14 days in 1991
to 8.4 days in 1994, through CARE Act funded discharge
planning, case management and outpatient medical and
support services.
In South Carolina, CARE Act funds supported the
opening of a primary care clinic in 1993 staffed with
HIV-trained nurses and physicians to serve patients
without Medicaid or other private health insurance. The
existence of the clinic significantly reduced the use
of hospital emergency rooms in Columbia.
In Missouri, CARE Act funds enabled the State through
its consortia to develop a network of 116 primary care
physicians to provide care to patients living in rural
areas. Uninsured patients are able to receive timely
medical care that costs less than if they had to travel
long distances to an urban center.
Evidence from four States (Florida, Hawaii, Minnesota
and Wisconsin) suggests that title II Health Insurance
Continuation Programs (HICP) have resulted in
significant cost savings. The four States estimated a
savings of $1.3 million over a 1 year period, or $9,384
per HICP client per year.
Title III(b) of the CARE Act has provided vital
primary care and other support services through health
centers in underserved areas which face an increasing
demand for HIV care. Services supported by title III(b)
reach 40,000 people with or at risk for HIV disease.
Under title IV of the CARE Act, services for women,
youth, infants and children are available in 26 States
and are delivered through 199 affiliated clinical
service sites. Title IV serves 11,900 HIV positive or
affected women and children.
S. 641 has preserved and improved upon the best aspects of
the original CARE Act. At the same time, in recognition of the
changes that have taken place over the last 5 years, the
committee has also made some necessary alterations. These
changes focus on the funding formulae used to distribute
resources to cities and States. The purpose of these changes is
to assure a more equitable allocation of funding, based on
where people with the illness are currently living.
While difficult to negotiate, these changes ultimately have
received the support of national AIDS organizations, public
health officials, and people with AIDS. With any formula
change, there is always the concern about the potential for
disruption of services to individuals now receiving them. To
address this concern, the bill maintains hold-harmless floors
designed and phased-in to assure that no entity receives less
than 92.5 percent of its 1995 allocation over the next 5 years.
The committee has also recognized a need to establish a
single authorization of appropriations for title I and title
II. Such an appropriation would be divided based on the ratio
of fiscal year 1995 appropriations to each of these two titles.
Thus 64 percent would be allocated to title I in fiscal year
1996.
A single appropriation is needed because it would compel
cities and States to work collaboratively in the future and
produce a sense on the part of grantees that their interests
are unified rather than competitive. It would also disregard
geographic interests. As such, funding priorities would focus
on the service needs of people living with HIV/AIDS nationwide,
rather than by jurisdictions, cities, or States.
III. Legislative History and Committee Action
S. 641 was introduced on March 28, 1995 by Senators
Kassebaum, Kennedy, Hatch, Jeffords, Frist, Pell, Dodd, Simon,
and Coats. The bill was referred to the Committee on Labor and
Human Resources.
In the executive session of the Committee on Labor and
Human Resources held on Wednesday March 29, 1995, S. 641 was
brought up for consideration. The bill was unanimously adopted
and favorably reported to the full Senate.
IV. Committee Views \1\
PART A
Through part A of S. 641, the committee intends that
urgently needed financial relief to health care facilities and
other service agencies and institutions continue to be directed
to those areas of the country that have been severely affected
by the HIV epidemic. The AIDS epidemic with its associated co-
morbid factors (including tuberculosis, sexually transmitted
diseases, substance abuse, homelessness, and severe mental
illness) pose profound challenges in meeting the needs of
people living with HIV and AIDS.
\1\ Public Health Service Act section sites and parts are utilized
for the purposes of this section.
---------------------------------------------------------------------------
The original purpose of the CARE Act to function as
emergency relief for high-incidence areas continues to be
important. The epidemic's impact on institutional and
organizational resources continues to place stress on the
health care infrastructure in areas with large number of AIDS
cases, affecting not only services available to people with HIV
but also to all citizens.
The overall guidance of the committee to areas receiving
emergency support under the reauthorized CARE Act is that part
A funds be used to both reduce individual and societal stresses
resulting from AIDS and the frequently associated co-morbid
urban, social and public health problems. CARE Act funds should
continue to be focused on individuals with HIV disease and
support the improvement and availability of quality, community-
based medical and support services which can contribute to
reduced utilization of in-patient hospitalization.
The changes made to existing law by the reauthorizing
legislation reflect the committee's understanding of the
epidemiological changes that have taken place over the last 5
years as presented by experts in the HIV/AIDS field, including
epidemiologists, medical and support service providers, and
people living with HIV disease. Similarly, the committee
recommends changes to existing law based on 5 years of Federal,
State and local administration of CARE Act programs.
Section 2601. Establishment of program of grants
It is the committee's intent to continue to direct
sufficient resources to cities with the greatest need by
limiting the time period within which AIDS cases are counted in
eligibility determinations and by limiting part A grants to
cities with a population of at least 500,000. This includes
those areas with a rapid growth of the epidemic and a large
enough population and sufficient health planning function to
utilize the planning council model to for planning the delivery
of health and support services for people with HIV disease.
These limitations identify true epidemic emergencies but
avoid the marked increases in the number of EMA's seen during
the reauthorization period. This restructuring is necessary, to
avoid a significant reduction in the amount of funding
available to any one city. Future eligibility based on current
law would dilute the act's purpose of providing ``emergency
relief,'' given that many of these newly eligible areas have
been receiving part B funds for 5 years. The committee feels
that, as the epidemic progresses, the term ``emergency'' should
denote a more rapid increase in AIDS cases--an absolute
threshold of 2,000 people with AIDS over a 5 year period.
Cities that experience this dramatic increase would certainly
be experiencing an emergency similar to that envisioned in the
original act. The committee intends that once an EMA becomes
eligible, it will remain eligible regardless of changes in
eligibility criteria or case counts. Furthermore to allow for a
period of transition, this change will not become effective
until FY 1998.
Section 2602. Administration and planning council
The committee believes that the planning council mechanism
can assure that part A moneys are effectively allocated and
administered. The community-based planning model represented by
the planning councils is a successful model of delivering
health care to vulnerable populations. The committee is
confident of the ability of the part A model to rapidly provide
appropriate HIV care services to people in the urban
communities hardest hit by the epidemic and strongly supports
the continuation of this model.
In carrying out its duty of establishing priorities for the
allocation of funds, it is the intent of the committee that the
planning council consider the effectiveness of various service
delivery mechanisms in terms of cost and outcome (i.e., number
of people served, reduction in hospital length-of-stays, et
cetera). It is not the intent of the committee to require
planning councils to research and document such measurements in
order to justify funding a certain priority. To the extent that
data are reasonably available, the planning council should
consider these factors. The committee does not intend that
planning councils use an excessive amount of resources to
implement this provision which would be better utilized to
provide services under the CARE Act. The committee affirms its
commitment to the local determination of the planning council
and the allocation of scarce resources in accordance with unmet
need of groups and subpopulations.
HRSA should support planning councils in their role of
assessing and addressing local administrative mechanisms that
may impede rapid allocation of funds and the effectiveness of
services in meeting need in an eligible metropolitan area. HRSA
should also assure that planning councils adhere to reasonable
and appropriate policies regarding conflict of interest. Such
policies should, at a minimum, assure that decisions about
vendor selection, are not undertaken by anyone associated with,
or who has a financial relationship to such vendors. The
reauthorization legislation continues to provide that the
grantee be responsible for activities to ensure program
effectiveness, including activities such as: vendor development
(ensuring that community-based organizations are supported in
the provision of culturally and linguistically appropriate
services to their communities); assuring these programs are
fulfilling the needs of people living with HIV/AIDS identified
by the planning council; and assuring that persons living with
HIV disease are satisfied with the care they are receiving
under those conditions.
The reauthorization legislation also grants authority to
the planning council, at its discretion, to engage in
activities to assess program effectiveness, to contract out
this function, to delegate this function to the grantee, or to
perform this function in conjunction with the grantee or the
grantee's administrative agency. Should the planning council
choose to contract out the program effectiveness function, the
grantee must provide all necessary information and support to
accomplish the function.
The bill further provides that, should this function be
delegated to the grantee, the grantee is bound to execute this
function within the 5 percent administrative cap unless the
planning council provides additional funding for this purpose.
The legislation grants authority to the planning council to
allocate such funding if the planning council determines that
to further the goal of program effectiveness the grantee
requires additional resources.
The legislation makes clear that each planning council
should be reflective of the demographics of the HIV epidemic
within its EMA, with a particular emphasis placed on
communities which are disproportionately affected and
historically underserved groups and subpopulations. The
legislation also clearly states that the planning council
membership include representatives of affected communities.
Nominations for council membership shall be identified through
an open process and selected based on publicized criteria which
will include a conflict-of-interest standard for each nominee.
The representation of people living with HIV/AIDS and
consumers of Ryan White services is of importance to the
effectiveness of the planning council process. People living
with HIV/AIDS on the planning council should, themselves,
reflect the range of affected communities. The committee seeks
to give a voice to the various groups and subpopulations
affected by HIV.
The committee strongly believes that HRSA should monitor
the policies of all EMA's regarding representation of
disproportionately affected communities at all levels of
decision-making in the planning council. In addition, the
committee recommends that HRSA establish a guidance standard
for all EMA's for the membership on the planning council by
people living with HIV/AIDS.
Effective participation in decision-making processes
requires more than just filling a designated slot on the
planning council. HRSA should monitor the effectiveness of
planning councils in fostering the active and meaningful
participation of people living with HIV/AIDS, and actively
address noncompliance with representation requirements through
its administrative authority. The committee encourages planning
councils to facilitate less cumbersome participation in the
planning council process for people living with HIV/AIDS by
addressing such practical considerations as travel
reimbursements, travel vouchers and child care. The committee
also encourages planning councils to provide adequate
orientation for all persons serving on the council, including
persons living with HIV/AIDS to facilitate their effective
participation on the planning council.
The committee intends that provider representatives on the
planning council have a history of delivering services to
affected communities and people with HIV. The committee has
added planning council membership of other Federal HIV programs
in order to maximize coordination and integration of services.
For the purposes of this section, other Federal HIV programs
include HOPWA programs and AIDS dental reimbursement programs.
Section 2603. Type and distribution of grants
Formula
The committee intends that the Secretary implement the
formula developed by the General Accounting Office as such
formula is codified. Interpretation of the legislative language
should be accomplished with the input of the General Accounting
Office based on the methodology developed by the GAO for the
committee.
Supplemental Grants
The committee feels that an external review of applications
is the most effective means of distributing supplemental grant
funds.
The committee intends that, in awarding supplemental grants
to eligible grantees, the Secretary give priority (added
weight) to the criteria of severe need and ability to expend
resources to meet that need. The Secretary may consider other
definitions of severe need but, within the review criteria,
should consider high rates of co-morbidities (as defined in the
legislation), people with AIDS previously unknown to the area,
and homelessness as the most appropriate measurements of such
need. The committee does not intend that the planning council
conduct resource-intensive documentation of these co-
morbidities at the individual level, but may document the
existence of these public health problems more generally in the
local population.
It is the intent of the committee that the Secretary
designate 50 percent of the amounts available for part A awards
for supplemental grants in each fiscal year. Of the 50 percent
designated for supplemental grants, the Secretary shall reserve
such sums as necessary to fund the hold-harmless provisions
built into the allocation formula for the 50 percent of part A
funds designated for formula grants. The caps on losses in the
formula grant awards shall be achieved by providing additional
sums to those cities that fall below the annually designated
floor, rather than putting additional sums through the
allocation formula.
Regarding the evaluation of supplemental grant
applications, the committee expects that HRSA will develop a
process which includes an evaluation of the ability of grantees
and subcontractors to spend resources quickly and efficiently.
To the extent possible, this evaluation should include review
of financial reports and other relevant data on grantee
expenditures.
Section 2604. Use of amounts
The committee wishes to stress that capacity building is an
important and legitimate expenditure of funds under part A of
the Ryan White CARE Act. Part A is intended to enhance the
capacity of existing or new organizations to provide and
improve services for people living with HIV/AIDS. Capacity
building may include the provision of technical assistance in
order to improve the ability of organizations to provide or
expand services. Planning councils should expect a direct
relationship between capacity building and expansion, quality,
or improvement of services.
The determinative authority of the planning councils must
be maintained so that they can assess gaps in essential
services as well as address these gaps. The planning council
should evaluate the needs of a community and the availability
of culturally, linguistically and geographically appropriate
services. Planning councils are uniquely positioned to identify
the need to develop the capacity of HIV/AIDS services for
historically underserved groups and subpopulations.
It is the intent of the committee that substance abuse
treatment and mental health service programs for people with
HIV disease be eligible for funding under part A. Substance
abuse treatment includes all modalities, including
detoxification, outpatient counseling, and methadone
maintenance. Mental health services similarly include
outpatient mental health services (including individual
counselling, health care, assessment, and psychotherapy), and
support groups (including group therapy). Consistent with the
act, Ryan White funds continue to serve as the funding of last
resort when other resources are inadequate or unavailable.
Section 2605. Single application and grant award
It is the understanding of the committee that the current
mechanism of distributing part A awards in separate formula and
supplemental grants has created additional and unnecessary
administrative burdens at the Federal and local levels.
Grantees must complete two separate applications and track the
expenditures of two separate grants. In meeting two sets of
administrative demands, service providers (some of whom receive
two contracts for the same service under the current
distribution mechanism) must also devote more time and
resources than necessary to nonservice related
responsibilities.
To minimize these administrative burdens, the committee
gives authority to the Secretary to develop administrative
mechanisms at the Federal level to award both the formula and
supplemental awards as a single grant based on the submission
of a single grant application. Any changes made by the
Secretary should not result, however, in grantees receiving
their grants any later than 90 days after the appropriations
bill is signed. In addition, such a process should be phased
in, in order to minimize potential local or administrative
complications and to ensure that no gap in funding will occur.
Section 2606. Technical assistance
The committee believes that HRSA should provide an
effective technical assistance network, including peer-based
technical assistance, for all eligible metropolitan areas that
are able to address issues of inclusion and representation,
epidemiology, community planning, development of needs
assessments and conflict resolution. The committee also
encourages HRSA to conduct semiannual or annual meetings for
information sharing, technology transfer, skills building and
strategic advice. Participants in such meetings should include
representatives from city and county health departments
(grantees), planning council co-chairs, consumers and
administrative agencies.
Peer-based technical assistance in conjunction with
planning grants should be provided to communities newly
eligible for Part A funding. The committee believes that EMA's
that have effectively implemented the program have a great deal
of expertise to offer those seeking to work through similar
issues. New EMA preparation includes: implementation of
community-wide needs assessments; a plan for the rapid
distribution of funds as required by law; the development of
community representation on planning councils; the creation of
effective by-laws, organizational structures and procedures,
including conflict resolution; and fostering productive working
relationships with affected communities, local administrative
agencies and the local health department.
HRSA should include all planning council chairs, (co)chairs
and/or vice-chairs, or other council leadership, along with the
grantees, in all HRSA information dissemination, including
mailings, telefacsimile and other communication, to facilitate
better communication and information flow.
The committee believes that HRSA should provide a greater
level of technical assistance to the planning councils and
grantees on such issues such as inclusion of communities of
color, women, persons living with HIV/AIDS on the planning
council, and process and outcome evaluations.
PART B
The committee views the current structure of the part B
program as an effective means for states to direct CARE Act
resources where they see the greatest need. The changes made to
the formula distribution of part B funds to States should not
be construed as a restriction on the State's flexibility in
determining how to allocate its resources or that States must
spend a certain amount of part B dollars in any one area. The
entire amount of part B funds allocated to a State can be
expended on any combination of the 4 programs as outlined in
the legislation, except that the 50 percent consortia
requirement for States with more than 1 percent of all AIDS
cases remains in effect.
In establishing a formula which includes distributing 50
percent of the amounts available for part B grants based on
non-EMA cases, the committee intends to increase the resources
available to States that have not benefited from direct funding
to cities. The committee intends that States would continue to
address the needs of individuals in EMA's and non-EMA areas
with the flexibility currently afforded States under the CARE
Act of 1990. The committee expects that HRSA will continue to
work with part A and B grantees to collaborate on allocating
resources appropriately across the entire State.
Section 2612. General use of grants
The Committee has retained the provision in section
2612(b), regarding a set-aside of 15 percent of funding under
title II for services for infants, children, women and
families, as authorized under current law. The Committee urges
HRSA to monitor compliance to ensure that the purposes of this
provision are fully met.
Section 2616. Provision of treatments
The committee feels strongly that people living with HIV
should have access to life-prolonging therapies and encourages
States to do all they can to maximize such access. The
committee acknowledges that the costs of AIDS drug therapies
are expensive and that discretionary Ryan White funding alone
will never meet the need.
It is the intent of the committee that the Secretary work
with States, providers, and affected communities to develop a
recommended minimum formulary for the provision of FDA-approved
pharmaceutical drug therapies. Prophylactic therapies for
certain opportunistic infections are widely recognized to be
cost-effective means to reduce inpatient costs. States are
expected to document the progress made, either through the drug
assistance program or other public program, in meeting the
recommended minimum formulary.
Section 2617. Statewide coordinated statement of need
Although the CARE Act provides the opportunity for the
development of plans specific to States and to local areas, the
committee believes that improved coordination among the various
efforts mandated under the Act is necessary. To that end, the
committee has provided for the development of a Statewide
Coordinated Statement of Need (SCSN). The committee emphasizes
that the purpose of the SCSN is to define need, not allocate
resources. In addition, the committee believes that the SCSN
should build on and not supplant the needs assessment processes
conducted by the planning councils. The committee seeks to
maximize coordination, integration, and effective linkage, not
duplicate processes which are already in place and working
well. The SCSN process is not meant to affect part A planning
councils discretion in making resource allocation decisions.
Should the part B grantee fail to convene the SCSN process
or should that process fail to accomplish a statewide
coordinated statement of need, no penalty will result to other
grantees under this part as long as representatives of such
grantees have participated in the process in good faith as
required by the statute. The requirement that grantees
participate in the SCSN process shall take effect in the first
year following enactment. However, the requirement that
programs provided by grantees be consistent with the SCSN does
not take effect until fiscal year 1997, the first year that
such consistency will be possible.
The legislation makes clear that part B grantees are not
required to fund participation in the Statewide Coordinated
Statement of Need (SCSN) process. Nonetheless, the committee
strongly encourages grantees under part B to provide the funds
necessary to assure adequate and broad, statewide participation
of people living with HIV/AIDS and other representatives of
historically underserved communities and subpopulations in the
SCSN process. The committee wishes to stress, as well, that
grantees under part B are required to make every effort to
assure the representation from each part A planning council
within its jurisdiction and grantees under part C, D, and F.
Finally, in order to maximize the potential for coordination
and collaboration, States are encouraged to include other major
providers of HIV health care and support services that may not
receive funding under the CARE Act.
Section 2618. Amount of CARE grants
The committee intends that the Secretary implement the
formula developed by the General Accounting Office as such
formula is codified. Interpretation of the legislative language
should be accomplished with the input of the General Accounting
Office on the methodology developed by the GAO for the
committee.
The legislation states that 50 percent of amounts available
for part B grants shall be distributed based on a 10-year
cumulative weighted case count of AIDS cases in the State
outside of EMA'. For EMA's that cross state boundaries, it is
the intent of the committee that, for the purposes of counting
non-EMA State AIDS cases, the cases within such an EMA be
apportioned to the appropriate State. For example, the
Philadelphia, PA, EMA includes counties in the State of New
Jersey. To calculate the non-EMA cases in Pennsylvania, the
total statewide count shall be reduced by those Philadelphia
EMA cases residing in Pennsylvania. Similarly, the statewide
count for New Jersey shall be reduced by the number of
Philadelphia cases living in New Jersey (as well as the cases
living in other New Jersey EMA's).
The legislation also includes a ratable reduction provision
in the event that amount appropriated for part B is less than
the amount appropriated in FY 1995. It is the intent of the
committee that the loss limit in the given fiscal year be
multiplied by the percentage of appropriations available
compared to FY 1995. For example, if in FY 1997 the
appropriations for part B were reduced by 10 percent, the loss
limit would be changed from 97 percent to 87.3 percent [i.e.,
(97 percent) (90 percent) = 87.3 percent.].
Unfortunately, the committee is not able to protect any
State against loss resulting from a reduced appropriation.
Those States whose awards are reduced in order to ensure
meeting the loss cap may experience a loss (compared to FY
1995) of up to the percentage of appropriations available
compared to FY 1995. For example, if appropriations are reduced
by 10 percent in FY 1997, those states whose awards are higher
than their FY 1995 award are proportionately reduced in order
to ensure that each State receives 87.3 percent of its FY 1995
award. In this hypothetical example, States experiencing such a
proportional deduction cannot receive less than 90 percent of
their FY 1995 award.
Additionally, the legislation increases the administrative
expense limitation for states. This change is included because
the committee recognizes that additional resources are needed
to administer this program in the many diverse areas of each
state. Additionally, this change is included because the
committee recognizes the added administrative costs required to
manage the four different title II component programs.
Section 2621. Grievance procedures
The committee notes that, elsewhere in the legislation
regarding part A grantees, planning councils are required to
develop local procedures to address grievances, disputes and
conflicts of interest. HRSA should work with part B grantees to
develop similar local procedures and processes. To build on
this locally based conflict resolution system, the
reauthorization bill directs HRSA to work with members of the
CARE Act community to jointly develop an appropriate Federal
role in the event that these local procedures fail.
In carrying out section 2621, it is the intent of the
committee that HRSA engage in a process with grantees, planning
councils and consumers to jointly develop a grievance procedure
for addressing allegations of egregious violations of the
letter of the act. In developing that procedure, participants
should consider mechanisms to: determine whether a violation
has occurred, confirm that locally developed procedures have
been exhausted, mediate and arbitrate a solution and,
ultimately, impose appropriate sanctions, including the
reduction of grant awards. Participants should consider the use
of a peer review committee as a possible mechanism to carry out
these functions.
PART C--Subpart II
The committee wishes to underscore the need for linkages to
exist between grantees and other HIV/AIDS providers operating
in the area to be served by the grantee. The committee
encourages HRSA to monitor a grantees demonstrated linkages to
other HIV/AID Service resources in the area to be served.
The committee acknowledges the need for adequate input from
people living with HIV/AIDS in the development of a continuum
of HIV care services. The committee encourages HRSA to monitor
such participation for each grantee.
Part C grants are administered through the Bureau of
Primary Health Care (BPHC) at HRSA. The committee also
encourages HRSA to coordinate meetings and other opportunities
for coordination among all parts of the legislation,
particularly those carried out by the Division of HIV Services.
The committee supports efforts currently underway to
centralize oversight of the part C programs within the BPHC at
HRSA and requests that this centralization be completed by FY
1996. The committee directs the regional program managers to
report to the director of the BPHC so that part C programs can
benefit from the expertise located in BPHC and HRSA generally.
Section 2651. Provision of primary care services
The committee directs HRSA to convene a process, utilizing
current and prospective grantees, in order to draft guidelines
designed to articulate the necessary role of primary care
services to people living with HIV/AIDS served with funds
provided under this part. Early intervention services, the
primary focus of part C grants, are expected to include a
continuum of services, including, but not limited to: HIV
primary care, prophylaxis, therapeutics, acute care and
treatment monitoring. For current grantees with the capacity to
provide direct services, the committee expects that people
living with HIV/AIDS be afforded full access to such services.
The committee recognizes that some part C grantees operate as a
consortia of services specifically designed for HIV/AIDS. These
programs and the guidelines developed must meet the needs of
people living with HIV/AIDS and assure that direct services are
provided consistent with the needs of consumers.
Section 2654. Planning grants
It is the intent of the committee that the preferences for
rural and underserved areas apply only to planning grants. It
is the view of the committee that rural areas are in particular
need of such system development. The committee also recognizes
that underserved communities continue to exist in urban and
suburban areas of the country. Health care programs for
populations with unique needs are lacking. The purpose of the
planning grants is to assist providers in developing HIV
primary care delivery systems.
PART D
Section 2671. Grants for coordinated services and access to research
for children, youth, and families
Part D was enacted to provide funds for coordinated health
and social services in association with voluntary participation
in research programs. Through this section the committee
affirms its commitment to the provision of innovative
comprehensive HIV care systems for children, youth, and
families with or affected by HIV. Grants made through this
section to public and not-for-profit entities provide or
arrange for coordinated HIV services to the public for the
purpose of supporting or maintaining comprehensive, community-
based, culturally competent, family or youth centered HIV care
systems. Projects facilitate the voluntary participation of
children, youth, and women with HIV disease in qualified
research protocols. The committee understands that
participation of children, youth, and pregnant women in HIV
research programs has been successful when projects were
convenient to women and children with HIV disease, when they
were sensitive to nontraditional services such as child care
and transportation costs and when the research was conducted
within an established, comprehensive HIV care system.
Comprehensive care systems
It is the intent of the committee for this program to be
flexible but to organize, coordinate and support a broad range
of HIV services linking institutional and community-based
providers. Grantees may provide a wide range of health services
and may make referrals for or provide for services to
facilitate access to care. Five percent of the funds
appropriated under this section may be used to provide training
and technical assistance to projects. This assistance may
include the development of innovative models of care, new
therapies, outreach to minority communities advance provider
training and improve the coordination with research programs.
Patient participation in research protocols
The committee intends for this program to be administrated
by the Secretary, acting through the Administrator of HRSA, in
consultation with the Director of the National Institutes of
Health. The committee expects that this collaboration will
result in improved research results, improved access for people
who might not have otherwise participated in research and in
better use of research dollars by coordination of ancillary
services. It is the committee's goal to bridge the gap between
the patients and research through the title IV programs and not
to recreate arrangements that are already in place. The
committee intends that these resources are not to be used to
directly fund research.
It is the committee's intent for all patients to be offered
research opportunities, but it is not the intent of the
committee to have patients forced into study participation. The
committee believes that well-designed and accessible research
will attract participants. Occasional patients are expected to
refuse the opportunity to enroll in research programs. However,
if substantial rates of refusal do occur, then grantees should
review the available research opportunities and determine if
they are appropriate for its patients.
Part D of this Act requires that the Secretary constitute
an independent panel to review existing research protocols
which have either been approved by the National Institutes of
Health or approved by other for-profit or non-profit entities.
The panel shall review these protocols and approve those which
it determines provide greater benefit to children, youth, and
pregnant women. For the purpose of this section, the committee
also intends that all protocols approved by the National
Institutes of Health shall be deemed to be approved by the
independent panel.
The committee expects that the panel will rule not only on
the scientific merits of the project, but also the feasibility
of the program to be performed in outpatient community sites.
The committee has also provided for the panel to review each
protocol's potential clinical benefit but it does not intend
that this standard of potential benefit be interpreted
narrowly. Rather, it must be realized that research may offer
little guaranteed benefit for study participants, but such
research does offer potential clinical benefit to study
participants if research success is achieved.
The committee intends that each grantee under this section
affiliate itself with no less than one protocol approved by
this independent panel. However, each grantee may also
affiliate itself with protocols which are not approved by the
independent panel. Furthermore, the committee does not intend
that study participants participate only in the protocols
approved by the independent panel. Rather, they may participate
in other protocols offered by the grantee.
The Secretary is allowed discretion to fund programs that
are not in noncompliance on a limited basis. The committee
agrees that waivers of compliance may be needed as part of
research arrangements. In such instances the committee intends
for programs to develop remedial measures expeditiously and to
seek new research opportunities for patients. The committee
also recognizes that both profit-making, and nonprofit private
research entities can contribute to the AIDS research effort.
The committee believes that the facilitation of children,
youth, and women in all approved programs will improve the
chance of research success and increase the access to state-of-
the-art trials.
PART F
Section 2691. Special projects of national significance
It is the intent of the committee that 3 percent of the
total amounts appropriated for parts A, B, C, and D be
calculated in determining the amount of funding available for
these projects.
The committee recognizes the successful results of Special
Projects of National Significance in areas such as mental
health services, advocacy services, services to youth. and
services to Native Americans. The committee intends that part A
and part B grantees shall have the ability to fund projects
begun as a Special Project of National Significance (either
under the original act or the reauthorization legislation) in
order to continue and replicate successful and innovative
service models.
APPROPRIATION FOR PART A AND PART B
Section 2677. Authorization of appropriations
This section would create a single appropriation for part A
and part B. For fiscal year 1996, the committee intends that 64
percent of the appropriation would be allocated for the
purposes of part A. The committee intends that part A and part
B continue to function separately from each other. Grants for
part A would still be allocated directly to EMA's and for part
B would be allocated to States. Furthermore, the Secretary
shall maintain funding for part A and part B as separate
accounts once the single appropriation has been divided based
on the set-aside ratios.
Because the relative needs for funding under part A and B
may change over time, the committee intends to have the
Secretary adjust the set-aside ratios based on a method
developed by the Secretary. In developing the method, the
Secretary should consider the impact of the addition of new
title I cities and other relevant factors. In developing the
methodology, the Secretary should receive the input of affected
communities, organizations, and other experts.
If the Secretary determines that this methodology is not
feasible, then the committee intends that there should be two
separate appropriations for fiscal year 1997 through fiscal
year 2000.
GENERAL
The Committee notes that funds are not authorized under
this Act for any program that includes distribution, exchange,
or preparation for the distribution or exchange of needles to
any person for the purpose of using illicit intravenous drugs.
The Committee also notes that the primary purpose of the
CARE act is to make health and support services available to
individuals with HIV disease. The Committee urges HRSA to
monitor the amount of funds used for administration, planning,
and evaluation and for non-health related services, such as
housing, to ensure that the primary purposes of the Act are
met.
In general, the Committee encourages public and private
partnerships to address the service needs of individuals living
with HIV and AIDS. Such partnerships would complement the
limited Federal resources available to care for such
individuals.
V. Cost Estimate
U.S. Congress,
Congressional Budget Office,
Washington, DC, April 3, 1995.
Hon. Nancy Landon Kassebaum,
Chairman, Committee on Labor and Human Resources, U.S. Senate,
Washington, DC.
Dear Madam Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 641, the Ryan White
CARE Reauthorization Act of 1995.
Enactment of S. 641 would not affect direct spending or
receipts. Therefore, pay-as-you-go procedures would not apply
to the bill.
If you wish further details on this estimate, we will be
pleased to provide them.
Sincerely,
James L. Blum
(For June E. O'Neill, Director).
Enclosure.
congressional budget office cost estimate
1. Bill number: S. 641.
2. Bill title: The Ryan White CARE Reauthorization Act of
1995.
3. Bill status: As ordered reported by the Senate Committee
on Labor and Human Resources on March 29, 1995.
4. Bill purpose: S. 641 would reauthorize various programs
established pursuant to the Ryan White CARE Act of 1990. In
addition, the bill would make changes in requirements for some
of the programs.
5. Estimated cost to the Federal Government: The following
table summarizes the estimated authorizations and outlays that
would result from this bill under two different sets of
assumptions. The first includes the effects of the program
changes proposed by the bill and adjusts the estimated amounts
for projected inflation after 1995. The second makes no
allowance for projected inflation.
------------------------------------------------------------------------
Projected Under S. 641
-----------------------------------------------------
1995 1996 1997 1998 1999 2000
------------------------------------------------------------------------
Estimated
Authorizations of
Appropriations--as
suming program
changes and
adjustments for
projected
inflation
Emergency relief.. 357 368 381 395 409 423
CARE grants....... 198 205 212 220 228 236
Early intervention
grants........... 52 57 59 61 63 65
Grants for
coordinated
services......... 26 27 28 29 30 31
AIDS education and
training......... 16 17 17 18 19 19
Special projects.. (\1\) 25 25 25 25 25
-----------------------------------------------------
Total
estimated
authorizati
ons........ 647 699 723 748 773 799
=====================================================
Estimated outlays
from
authorizations in
S. 641........... NA 336 643 742 767 794
Estimated outlays
from
appropriations in
1995 and previous
years............ 597 331 71 ....... ....... .......
-----------------------------------------------------
Total
estimated
outlays.... 597 667 714 742 767 794
=====================================================
Estimated
Authorizations of
Appropriations--as
suming continued
funding at the
1995 level,
adjusted for
program changes
Total estimated
authorizations... 647 677 677 677 677 677
Total estimated
outlays.......... 597 656 674 677 677 677
------------------------------------------------------------------------
Notes: Details may not add to totals because of rounding NA=Not
applicable.
\1\ Special projects authorization amount for 1995 is included in the
CARE grants total.
The costs of this bill fall within budget function 550.
6. Basis of estimate: S. 641 reauthorizes funding for Ryan
White CARE Act programs at such sums as may be necessary for
fiscal years 1996 through 2000. Because the bill changes the
requirements for some of the programs, CBO estimated the
changes in funding that would be necessary to meet the
requirements of the bill.
Emergency relief grants
The bill would limit eligibility for emergency relief
grants to metropolitan areas with more than 500,000 residents,
but would exempt areas that were eligible as of March 31, 1995,
from this requirement. The bill also would limit eligibility
for the grants to cities with a cumulative 5-year total of more
than 2000 cases of AIDS, beginning in fiscal year 1997.
According to the Department of Health and Human Services (HHS),
these limitations would prevent growth in the number of
eligible grantees. The estimated authorization levels in the
above table are based on the 1995 appropriations of $357
million. Under the assumption that appropriations are increased
to reflect projected inflation, estimated authorization amounts
would increase to $368 million in fiscal year 1996, and to $423
million in fiscal year 2000.
CARE grants
S. 641 would reauthorize and make several changes to the
program to provide grants for the operation of HIV service
delivery consortia under Title II of the Ryan White CARE Act.
CBO estimated the authorization levels for fiscal years 1996
through 2000 by adjusting the amount appropriated for fiscal
year 1995, $198 million, for the effects of changes to the
current program as explained below. Taking into account all
these elements and assuming that appropriations are increased
to reflect projected inflation, CBO estimates authorization
amounts for Title II programs as amended by the bill at $205
million in fiscal year 1996, increasing to $236 million in
fiscal year 2000.
The bill would remove the authorization for special
projects of national significance in Title II. This program is
currently authorized at a maximum of 10 percent of Title II
funding. In the past three years, this program was funded at an
average of 4.3 percent of Title II funding. CBO estimated the
decrease in authorization amounts resulting from removal of
this program by applying the average percentage to estimated
authorization levels for Title II for fiscal years 1996 through
2000. The estimated savings are $9 million to $11 million a
year.
The bill would increase the maximum percentage of funding
for such grants that can be used for administrative, planning,
and evaluation functions from 10 percent to 15 percent of grant
amounts. CBO estimates that an additional $10 million to $11
million each year would be required to maintain current service
levels.
Early intervention grants
The bill would reauthorize early intervention grants and
increase the maximum percentage of funding for such grants that
can be used for administrative functions from 5 percent to 10
percent of grant amounts. This change would require additional
funding to maintain current service levels. The program is
funded at $52 million in fiscal year 1995. CBO estimates that
this provision would require $3 million in additional funding
in each fiscal year. After allowing for this change and
assuming that appropriations are increased to reflect projected
inflation, CBO estimates the authorization amount as $57
million for 1996, growing to $65 million by 2000.
Grants for coordinated services
S. 641 would reauthorize funding for grants to coordinate
systems of care for women and children at such sums as may be
necessary for fiscal years 1996 through 2000. The estimated
authorization levels in the above table are based on the 1995
appropriation of $26 million in fiscal year 1995. Under the
assumption that appropriations are increased to reflect
projected inflation, estimated authorization amounts would
increase to $27 million in fiscal year 1996, and to $31 million
in 2000.
AIDS education and training centers
S. 641 would reauthorize funding to train health
practitioners in treatment of individuals who are HIV-positive.
The estimated authorization amounts in the above table are
based on the 1995 appropriation of $16 million. Assuming that
appropriations are increased to reflect projected inflation,
estimated authorization amounts would increase to $17 million
in 1996, and to $19 million in 2000.
Special projects
The bill would authorize funding for programs for the care
and treatment of individuals who are HIV-positive at a maximum
of $25 million each year for fiscal years 1996 through 2000.
This estimate assumes that all authorizations are fully
appropriated at the beginning of each fiscal year. Outlays are
estimated using spending rates computed by CBO on the basis of
recent program data.
7. Pay-as-you-go considerations: None.
8. Estimated cost to State and local governments: The Ryan
White Act requires states that receive funding under Titles II
and III of the act to provide non-federal matching
contributions and specifies the amount of such contributions.
Non federal funds could come from state and local governments.
9. Estimate comparison: None.
10. Previous CBO estimate: None.
11. Estimate prepared by: Connie Takata.
12. Estimate approved by: Robert A. Sunshine for Paul N.
Van de Water; Assistant Director for Budget Analysis.
VI. Regulatory Impact
The committee has determined that there will be no increase
in the regulatory burden of paperwork as the result of this
bill.
VII. Section-by-Section Analysis
Section 1. Short title
The short title is the ``Ryan White CARE Reauthorization
Act of 1995.''
Section 2. References
Specifies that amendments are being made to title XXVI of
the Public Health Service Act.
Section 3. General Amendments
(a) Establishment of grant program
Amended section 2601. The ending date for determining EMA
eligibility will be March 31, 1995 for fiscal year 1996 and
December 31 of the most recent calendar year thereafter. The
EMA qualifying factor of 2,000 or more cumulative AIDS cases is
changed to 2,000 or more cumulative cases for the most recent 5
year period and the qualifying factor based on incidence is
eliminated. A new criteria is established requiring an area to
have 500,000 or more in population, except for areas eligible
as of March 31, 1994. EMA's currently receiving grants will
remain eligible.
Amended section 2602. Specifies that HIV Health Services
Planning Councils (HHSPC) will reflect the demographics of the
epidemic in the involved area, with particular consideration
given to disproportionately affected and historically
underserved groups. Nominations for membership will be
identified through an open process based on locally delineated
and publicized criteria, including a conflict-of-interest
standard for each nominee. Provides that an HHSPC may not be
chaired solely by an employee of the grantee. Further provides
that HHSPC priorities for the allocation of funds will be based
on documented needs, cost and outcome effectiveness, priorities
of the targeted HIV-infected community, and availability of
other resources. Requires that a HHSPC participate in the
development of a Statewide Coordinated Statement of Need.
Requires the establishment of specific HHSPC dispute resolution
procedures and for the development of methods for community
input on needs and priorities. Allows a HHSPC the discretion to
assess the effectiveness of services in meeting identified
needs. Makes technical changes to the required categories of
HHSPC representatives and adds categories for organizations
serving children, women, youth, and families and for grantees
under other Federal HIV programs.
Amended section 2603. Extends grant authority and provides
that a grantee must successfully demonstrate inclusive HHSPC
membership and that proposed services are consistent with the
Statewide Coordinated Statement of Need. Provides that priority
for supplemental grants will be based on prevalence of diseases
which affect the impact of HIV disease, of homelessness, and of
cases in individuals previously unknown to the area. Adds a
grant schedule ensuring maintenance of 1995 EMA grant amounts,
on a gradually descending basis, through the year 2000 and
requires the Secretary to reserve a percentage of the amount
appropriated under part A for that purpose.
Amended section 2604. Adds substance abuse treatment,
mental health treatment, treatment education, and prophylactic
treatment for opportunistic infections to language on grant
purpose. Includes substance abuse treatment programs, mental
health programs, and private for-profit entities among entities
eligible for financial assistance. Private for-profit entities
may become eligible when no other provider of quality HIV care
exists in the area. Specifies that entities receiving
allocations from the grantee will not use in excess of 12.5
percent for administration and further specifies permissible
administrative activities.
Amended section 2605. Specifies that political subdivisions
must assure maintenance of expenditures equal to those in the
preceding fiscal year, rather than for the 1-year fiscal period
preceding the original grant. Updates application requirements
language to include participation in the Statewide Coordinated
Statement of Need process. Provides that the Secretary may
phase in a single application requirement and single grant
award for grants under part A.
Amended section 2606. Requires (rather than permits) the
Administrator of the Health Resources Services Administration
(HRSA) to provide technical assistance, including peer based
assistance to new EMA's establishing planning councils. Allows
the Administrator to make planning grants to projected newly
eligible EMA's, not to exceed $75,000 per area or a total of 1
percent of the part A appropriation for the fiscal year.
Provides that such grant amounts will be deducted from first
year formula amounts for the involved area.
(b) CARE grant program
Amended section 2613. Allows private for-profit entities
that are the only available source of care to participate in
HIV Care consortia. Adds substance abuse treatment, mental
health treatment, prophylactic treatment for opportunistic
infections, and treatment education to the services that may be
provided through a consortium. Includes youth centered care as
part of the application planning requirement and includes
community-based providers and organizations with a history of
serving children, youth, women, and families in the entities
that must be consulted for consortium planning.
Amended section 2616. Requires the Secretary to review the
status of State drug reimbursement programs and assess barriers
to availability of prophylactic treatments for opportunistic
infections (including active tuberculosis). Requires the
Secretary to establish a recommended minimum formulary of drug
therapies. The State will be required to document progress in
treatment availability and to develop plans for full
implementation of the formulary.
Amended section 2617. Requires at least one annual meeting
of specified grantee representatives for the purpose of
developing the Statewide coordinated statement of need. Adds to
the State application requirement a description of how
allocation and utilization are consistent with the Statewide
Coordinated Statement of Need.
Amended section 2618. Increases limits on the portion of
grants that a State may use for planning and evaluation and for
administration to 10 percent each, or 15 percent in total;
specifies that entities receiving grant funds from a State will
be limited to 12.5 percent for administration. Provides that a
State receiving the minimum allotment may not use more than an
amount required to support one full-time-equivalent employee
for those purposes.
Amended section 2619. Requires (rather than permits) the
Secretary to provide technical assistance for grant activities,
including the development and implementation of the Statewide
Coordinated Statements of Need.
New section 2621. Requires HRSA to establish grievance
procedures within 90 days to address allegations of egregious
violations under each part of title XXVI. The procedures will
include an appropriate enforcement mechanism.
New section 2622. Requires that the Secretary ensure
coordination between HRSA, the Centers for Disease Control and
Prevention, and the Substance Abuse and Mental Health Services
Administration regarding planning and implementation of Federal
HIV programs. The Secretary will be required to submit periodic
reports to relevant congressional committees on integration and
coordination of efforts at the Federal, State, and local levels
and addressing Federal barriers to program integration.
(c) Early intervention services
Amended section 2651. Adds requirement that at least 50
percent of the grant be used to provide a continuum of HIV
primary medical care, including appropriate dental services, to
individuals confirmed to be living with HIV. Requires most
grantees to use at least 50 percent of grants to provide
testing, counseling and treatment services at sites where other
primary care services are rendered. Requires family planning
and hemophilia centers to ensure services through linkage with
primary care providers. Allows for participation of private
for-profit entities when such entities are the only available
provider of quality HIV care in the area.
Amended section 2652. Updates minimum qualification for
participation of private for-profit entities when such entities
are the only available provider of quality HIV care in the
area.
Amended section 2654. Provides that the Secretary may
provide planning grants not to exceed $50,000 to develop
primary care delivery systems. Specifies that preference is
granted to entities that would provide primary care services in
rural or underserved communities and limits planning
expenditures to 1 percent of a fiscal year's appropriation.
Amended section 2655. Authorizes appropriations of such
sums as may be necessary through fiscal year 2000.
Amended section 2664. The limit of 5 percent for
administrative expenses is increased to 10 percent for
planning, evaluation, and technical assistance. Specifies that
a grantee must demonstrate consistency with the Statewide
coordinated statement of need and agree to participate in
ongoing revisions of that statement.
(d) Grants
Amended section 2671. Renames this section the ``Grants for
Coordinated Services and Access to Research for Children,
Youth, and Families.'' Replaces pediatric demonstration grants
with grants to public and private nonprofit entities to provide
outpatient health care and support services for children,
youth, and women with HIV disease and their families; to
support the provision of such care with HIV prevention and
research programs; and to facilitate voluntary participation of
children, youth, and women in qualified research protocols.
Requires assurances that grants will be used primarily for
children, youth, and women and that grantees will facilitate
voluntary research participation, will coordinate services with
other title XXVI providers and providers under the Maternal and
Child Health block grant, and will participate in the Statewide
Coordinated Statement of Need. Establishes procedures for
protection of research participants. Allows the Secretary to
use up to 5 percent of appropriations for training and
technical assistance. Requires annual evaluations, which may
include recommendations for improved access and participation.
Allows the Secretary discretion to grant temporary waivers of
required assurances. Authorizes appropriations of such sums as
may be necessary for fiscal years 1996 through 2000. Renames
Part D ``Grants for Coordinated Services and Access to Research
for Children, Youth, and Families.''
(e) Demonstration and training
Establishes a new PART F entitled ``Demonstration and
Training.'' Subparts under the new part are, ``Subpart I--
Special Projects of National Significance'' and ``Subpart II--
AIDS Education and Training Centers.''
New section 2691. The Secretary shall use the greater of
$20 million or 3 percent of the amount appropriated for each of
parts A, B, C, and D, not to exceed $25 million, for grants to
public and nonprofit private entities for special programs
related to innovative treatment models for the care and
treatment of individuals with HIV disease, including models to
address the needs of special populations, to assist in
developing essential community-based service delivery
infrastructure, to ensure the availability of services for
Native Americans, and for other specified purposes. Projects
must be consistent with the Statewide Coordinated Statement of
Need. The Secretary must disseminate information on successful
models and may provide peer-based technical assistance for that
purpose.
(f) HIV/AIDS Communities, Schools, Centers
New section 2692. Transfers authority for AIDS education
and training centers from title VII (Health Professions
Education) to title XXVI and makes technical corrections.
Authorizes appropriations of such sums as may be necessary for
fiscal years 1996 through 2000.
Section 4. Amount of Emergency Relief Grants
Amended section 2603. Changes the Part A formula
distribution factor. The new distribution factor will equal the
estimated number of living AIDS cases in the area multiplied by
a cost index for the eligible area based on the Medicare area
wage index for hospitals. Specifies that the estimated number
of living AIDS cases will be calculated by multiplying cases
reported over the most recent 10 year period by a percentage
schedule representing estimated survival rates. Establishes the
cost index for eligible areas in Puerto Rico, Guam, and the
Virgin Islands at 1.0. Allows the Secretary to adjust a fiscal
year EMA grant to reflect unexpended funds from the preceding
year.
Section 5. Amount of CARE Grants
Amended section 2618. Changes the distribution factor for
part B to the average of the State distribution factor and the
non-EMA distribution factor. The State distribution factor will
be determined by multiplying the number of estimated living
AIDS cases by the State or territory cost index. The non-EMA
distribution factor will be determined by multiplying the
number of estimated living AIDS cases (less the estimated
number of living AIDS cases within an eligible area) by the
State or territory cost index. Estimated living AIDS cases and
the cost index would be determined as in section 4, except that
a method for computing a statewide hospital wage index is
specified. Allows the Secretary to adjust the grant for a
fiscal year to reflect unexpended funds from the preceding
years grant. Sets minimum grant amounts for States through the
year 2000 based on 1995 grant levels; reduces the minimums if
appropriations for a year are below the 1995 level. Provides
for a proportionate reduction in grants to States receiving
more than their 1995 levels, so long as the reduction does not
bring any such State's grant below the 1995 level. Further
specifies the minimum allotment as $100,000 for States (or the
District of Columbia) with less than 90 living cases and as
$250,000 for States (or the District of Columbia) with more
than 90 living cases.
Section 6. Consolidation of Authorizations of Appropriations
New section 2677. Authorizes a combined appropriation for
parts A and B of such sums as may be necessary for fiscal years
1996 through 2000, and provides that 64 percent of
appropriations will be allocated to part A, 36 percent to part
B. Requires the Secretary to develop and implement a
methodology for adjusting these part A and B percentages in
fiscal years 1997 through 2000 based on grants to newly
eligible EMA's and other relevant factors and requires the
Secretary to submit a report on the methodology to appropriate
committees of Congress. Authorizes continued separate
appropriations if the Secretary fails to implement this
methodology.
Section 7. Effective Date
Provides that amendments are effective October 1, 1995,
except that changes in the time period used to establish
caseloads for EMA eligibility and in permissible uses for EMA
grants are effective on enactment and changes in the caseload
criteria for EMA eligibility are effective October 1, 1997.
VIII. Changes in Existing Law
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (existing law proposed to be omitted is enclosed in
black brackets, new matter is printed in italic, existing law
in which no change is proposed is shown in roman):
* * * * * * *
Public Health Service Act
Ryan White CARE Reauthorization Act of 1995
* * * * * * *
SEC. 2601. ESTABLISHMENT OF PROGRAM OF GRANTS.
(a) Eligible Areas.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall, subject to subsection (b), make grants
in accordance with section 2603 for the purpose of assisting in
the provision of the services specified in 2604 2 in any
metropolitan area for which, as of June 30, 1990, in the case
of grants for fiscal year 1991, and as of [March 31 of the most
recent fiscal year] March 31, 1995, and December 31 of the most
recent calendar year thereafter for which such data is
available in the case of a grant for any subsequent [fiscal
year--
[(1) there has been reported to and confirmed by the
Director of the Centers for Disease Control and Prevention a
cumulative total of more than 2,000 cases of acquired immune
deficiency syndrome; or
[(2) the per capita incidence of cumulative cases of such
syndrome (computed on the basis of the most recently available
data on the population of the area) is not less than 0.0025.]
fiscal year, there has been reported to and confirmed by, for
the 5-year period prior to the fiscal year for which the grant
is being made, the Director of the Centers for Disease Control
and Prevention a cumulative total of more than 2,000 cases of
acquired immune deficiency syndrome.
* * * * * * *
(c) Population of Eligible Areas.--The Secretary may not
make a grant to an eligible area under subsection (a) after the
date of enactment of this subsection unless the area has a
population of at least 500,000 individuals, except that this
subsection shall not apply to areas that are eligible as of
March 31, 1994. For purposes of eligibility under this title,
the boundaries of each metropolitan area shall be those in
effect in fiscal year 1994.
(d) Continued Funding.--A metropolitan area that has
received a grant under this section for the fiscal year in
which this subsection is enacted, shall be eligible to receive
such a grant in subsequent fiscal years.
SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL.
* * * * * * *
(b) HIV Health Services Planning Council.--
(1) Establishment.--To be eligible for assistance
under this part, the chief elected official described
in subsection (a)(1) shall establish or designate an
HIV health services planning council that shall
[include representatives of--
[(A) health care providers;
[(B) community-based and AIDS service
organizations;
[(C) social service providers;
[(D) mental health care providers;
[(E) local public health agencies;
[(F) hospital planning agencies or health
care planning agencies;
[(G) affected communities, including
individuals with HIV disease;
[(H) non-elected community leaders;
[(I) State government;
[(J) grantees under subpart II of part C;
and;
[(K) the lead agency of any Health Resources
and Services Administration adult and pediatric
HIV-related care demonstration project
operating in the area to be served.] reflect in
its composition the demographics of the
epidemic in the eligible area involved, with
particular consideration given to
disproportionately affected and historically
underserved groups and subpopulations.
Nominations for membership on the council shall
be identified through an open process and
candidates shall be selected based on locally
delineated and publicized criteria. Such
criteria shall include a conflict-of-interest
standard for each nominee.
(2) Representation.--The HIV health services planning
council shall include representatives of--
(A) health care providers, including
federally qualified health centers;
(B) community-based organizations serving
affected populations and AIDS service
organizations;
(C) social service providers;
(D) mental health and substance abuse
providers;
(E) local public health agencies;
(F) hospital planning agencies or health care
planning agencies;
(G) affected communities, including people
with HIV disease or AIDS and historically
underserved groups and subpopulations;
(H) nonelected community leaders;
(I) State government (including the State
medicaid agency and the agency administering
the program under part B);
(J) grantees under subpart II of part C;
(K) grantees under section 2671, or, if none
are operating in the area, representatives of
organizations with a history of serving
children, youth, women, and families living
with HIV and operating in the area; and
(L) grantees under other Federal HIV
programs.
[(2)] (3) Method of providing for council.--
* * * * * * *
(C) Chairperson.--A planning council may not
be chaired solely by an employee of the
grantee.
[(3)] (4) Duties.--The planning council established
or designated under paragraph (1) shall--
(A) establish priorities for the allocation
of funds within the eligible [area]; area based
on the--
(i) documented needs of the HIV-
infected population;
(ii) cost and outcome effectiveness
of proposed strategies and
interventions, to the extent that such
data are reasonably available, (either
demonstrated or probable);
(iii) priorities of the HIV-infected
communities for whom the services are
intended; and
(iv) availability of other
governmental and nongovernmental
resources;
(B) develop a comprehensive plan for the
organization and delivery of health services
described in section 2604 that is compatible
with any existing State or local plan regarding
the provision of health services to individuals
with HIV disease; [and]
(C) assess the efficiency of the
administrative mechanism in rapidly allocating
funds to the areas of greatest need within the
eligible area[.] and at the discretion of the
planning council, assess the effectiveness,
either directly or through contractual
arrangements, of the services offered in
meeting the identified needs;
(D) participate in the development of the
Statewide coordinated statement of need
initiated by the State health department;
(E) establish operating procedures which
include specific policies for resolving
disputes, responding to grievances, and
minimizing and managing conflict-of-interests;
and
(F) establish methods for obtaining input on
community needs and priorities which may
include public meetings, conducting focus
groups, and convening ad-hoc panels.
SEC. 2603. TYPE AND DISTRIBUTION OF GRANT.
(a) Grants Based on Relative Need of Area.--
* * * * * * *
(2) Expedited distribution.--[Not later than--
[(A) 90 days after an appropriation becomes
available to carry out this part for fiscal
year 1991; and
[(B) 60 days after an appropriation becomes
available to carry out this part for each of
fiscal years 1992 through 1995; the Secretary
shall,] Not later than 60 days after an
appropriation becomes available to carry out
this part for each of the fiscal years 1996
through 2000, the Secretary shall, except in
the case of waivers granted under section
2605(c), disburse 50 percent of the amount
appropriated under section [2608] 2677 for such
fiscal year through grants to eligible areas
under section 2601(a), in accordance with
paragraph (3). The Secretary shall reserve an
additional percentage of the amount
appropriated under section 2677 for a fiscal
year for grants under part A to make grants to
eligible areas under section 2601(a) in
accordance with paragraph (4).
* * * * * * *
[(3) Amount of grant.--
[(A) In general.--
[(i) Subject to the extent of amounts
made available in appropriations Acts,
a grant made for purposes of this
paragraph to an eligible area shall be
made in an amount equal to the product
of--
[(I) an amount equal to the
amount available for
distribution under paragraph
(2) for the fiscal year
involved; and
[(II) the percentage
constituted by the ratio of the
distribution factor for the
eligible area to the sum of the
respective distribution factors
for all eligible areas.
[(ii) For purposes of clause (i)(II),
the term ``distribution factor'' means
the sum of--
[(I) an amount equal to the
product of 3 and the amount
determined under subparagraph
(B) for the eligible area
involved; and
[(II) an amount equal to the
product of the amount
determined under subparagraph
(B) for the eligible area and
the amount determined under
subparagraph (C) for the area.
[(B) Amount relating to cumulative number of
cases.--The amount determined in this
subparagraph in an amount equal to the ratio
of--
[(i) an amount equal to the
cumulative number of cases of acquired
immune deficiency syndrome in the
eligible area involved, as indicated by
the number of such cases reported to
and confirmed by the Director of the
Centers for Disease Control and
Prevention by the applicable date
specified in section 2601(a); to
[(ii) an amount equal to the sum of
the respective amounts determined under
clause (i) for each eligible area for
which an application for a grant for
purposes of this paragraph has been
approved.
[(C) Amount relating to per capita incidence
of cases.--The amount determined in this
subparagraph is an amount equal to the ratio
of--
[(i) the per capita incidence of
cumulative cases of acquired immune
deficiency syndrome in the eligible
area involved (computed on the basis of
the most recently available data on the
population of the area); to
[(ii) the per capita incidence of
cumulative such cases in all eligible
areas for which applications for grants
for purposes of this paragraph have
been approved (computed on the basis of
the most recently available data on the
population of the areas).]
(3) Amount of grant.--
(A) In general.--Subject to the extent of
amounts made available in appropriations Acts,
a grant made for purposes of this paragraph to
an eligible area shall be made in an amount
equal to the product of--
(i) an amount equal to the amount
available for distribution under
paragraph (2) for the fiscal year
involved; and
(ii) the percentage constituted by
the ratio of the distribution factor
for the eligible area to the sum of the
respective distribution factors for all
eligible areas.
(B) Distribution factor.--For purposes of
subparagraph (A)(ii), the term ``distribution
factor'' means the product of--
(i) an amount equal to the estimated
number of living cases of acquired
immune deficiency syndrome in the
eligible area involved, as determined
under subparagraph (C); and
(ii) the cost index for the eligible
area involved, as determined under
subparagraph (D).
(C) Estimate of living cases.--The amount
determined in this subparagraph is an amount
equal to the product of--
(i) the number of cases of acquired
immune deficiency syndrome in the
eligible area during each year in the
most recent 120-month period for which
data are available with respect to all
eligible areas, as indicated by the
number of such cases reported to and
confirmed by the Director of the
Centers for Disease Control and
Prevention for each year during such
period; and
(ii) with respect to--
(I) the first year during
such period, .06;
(II) the second year during
such period, .06;
(III) the third year during
such period, .08;
(IV) the fourth year during
such period, .10;
(V) the fifth year during
such period, .16;
(VI) the sixth year during
such period, .16;
(VII) the seventh year during
such period, .24;
(VIII) the eighth year during
such period, .40;
(IX) the ninth year during
such period, .57; and
(X) the tenth year during
such period, .88.
(D) Cost Index.--The amount determined in
this subparagraph is an amount equal to the sum
of--
(i) the product of--
(I) the average hospital wage
index reported by hospitals in
the eligible area involved
under section 1886(d)(3)(E) of
the Social Security Act for the
3-year period immediately
preceding the year for which
the grant is being awarded; and
(II) .70; and
(ii) .30.
(E) Unexpended funds.--The Secretary may, in
determining the amount of a grant for a fiscal
year under this paragraph, adjust the grant
amount to reflect the amount of unexpended and
uncanceled grant funds remaining at the end of
the fiscal year preceding the year for which
the grant determination is to be made. The
amount of any such unexpended funds shall be
determined using the financial status report of
the grantee.
(F) Puerto rico, virgin islands, guam.--For
purposes of subparagraph (D), the cost index
for an eligible area within Puerto Rico, the
Virgin Islands, or Guam shall be 1.0.
(4) Increase in grant.--With respect to an eligible
area under section 2601(a), the Secretary shall
increase the amount of a grant under paragraph (2) for
a fiscal year to ensure that such eligible area
receives not less than--
(A) with respect to fiscal year 1996, 98
percent;
(B) with respect to fiscal year 1997, 97
percent;
(C) with respect to fiscal year 1998, 95.5
percent;
(D) with respect to fiscal year 1999, 94
percent; and
(E) with respect to fiscal year 2000, 92.5
percent;
of the amount allocated for fiscal year 1995 to such
entity under this subsection.
(b) Supplemental Grants.--
(1) In general.--Not later than 150 days after the
date on which appropriations are made under section
[2608] 2677 for a fiscal year, the Secretary shall
disburse the remainder of amounts not disbursed under
section 2603(a)(2) for such fiscal year for the purpose
of making grants under section 2601(a) to eligible
areas whose application under section 2605(b)--
* * * * * * *
(D) demonstrates the ability of the area to
utilize such supplemental financial resources
in a manner that is immediately responsive and
cost effective; [and]
(E) demonstrates that resources will be
allocated in accordance with the local
demographic incidence of AIDS including
appropriate allocations for services for
infants, children, women, and families with HIV
disease[.];
(F) demonstrates the inclusiveness of the
planning council membership, with particular
emphasis on affected communities and
individuals with HIV disease; and
(G) demonstrates the manner in which the
proposed services are consistent with the local
needs assessment and the Statewide coordinated
statement of need.
(2) Priority.--
(A) Severe need.--In determining severe need
in accordance with paragraph (1)(B), the
Secretary shall give priority consideration in
awarding grants under this section to any
qualified applicant that demonstrates an
ability to spend funds efficiently and
demonstrates a more severe need based on
prevalence of--
(i) sexually transmitted diseases,
substance abuse, tuberculosis, severe
mental illness, or other diseases
determined relevant by the Secretary,
which significantly affect the impact
of HIV disease in affected individuals
and communities;
(ii) AIDS in individuals, and
subpopulations, previously unknown in
the eligible metropolitan area; or
(iii) homelessness.
(B) Prevalence.--In determining prevalence of
diseases under subparagraph (A), the Secretary
shall use data on the prevalence of the
illnesses described in such subparagraph in
HIV-infected individuals unless such data is
not available nationally. Where such data is
not nationally available, the Secretary may use
the prevalence (with respect to such illnesses)
in the general population.
[(2)] (3) Remainder of amounts.--In determining the
amount of funds to be obligated under paragraph (1),
the Secretary shall include amounts that are not paid
to the eligible areas under expedited procedures under
section 2603(a)(2) as a result of--
* * * * * * *
[(3)] (4) Amount of grant.--The amount of each grant
made for purposes of this subsection shall be
determined by the Secretary based on the application
submitted by the eligible area under section 2605(b).
[(4)] (5) Failure to submit.--
* * * * * * *
SEC. 2604. USE OF AMOUNTS.
* * * * * * *
(b) Primary Purposes.--
(1) In general.-- * * *
* * * * * * *
(A) outpatient and ambulatory health and
support services, including case management
substance abuse treatment and mental health
treatment, and comprehensive treatment services
which shall include treatment education and
prophylactic treatment for opportunistic
infections, for individuals and families with
HIV disease; and
* * * * * * *
(2) Appropriate entities.--
(A) In general.--Subject to subparagraph (B), direct
financial assistance may be provided under paragraph
(1) to public or nonprofit private entities, or private
for-profit entities if such entities are the only
available provider of quality HIV care in the area,
including hospitals (which may include Department of
Veterans Affairs facilities), community-based
organizations, hospices, ambulatory care facilities,
community health centers, migrant health centers, [and
homeless health centers], homeless health centers,
substance abuse treatment programs, and mental health
programs.
* * * * * * *
(e) Administration [and Planning].--[The chief]
(1) In general.--The chief executive officer of an
eligible area shall not use in excess of 5 percent of
amounts received under a grant awarded under this part
for administration[, accounting, reporting, and program
oversight functions]. An entity (including
subcontractors) receiving an allocation from the grant
awarded to the chief executive officer under this part
shall not use in excess of 12.5 percent of amounts
received under such allocation for administration.
(2) Administrative activities.--For the purposes of
paragraph (1), amounts may be used for administrative
activities that include--
(A) routine grant administration and
monitoring activities, including the
development of applications for part A funds,
the receipt and disbursal of program funds, the
development and establishment of reimbursement
and accounting systems, the preparation of
routine programmatic and financial reports, and
compliance with grant conditions and audit
requirements; and
(B) all activities associated with the
grantee's contract award procedures, including
the development of requests for proposals,
contract proposal review activities,
negotiation and awarding of contracts,
monitoring of contracts through telephone
consultation, written documentation or onsite
visits, reporting on contracts, and funding
reallocation activities.
(3) Subcontractor administrative costs.--For the
purposes of this subsection, subcontractor
administrative activities include--
(A) usual and recognized overhead, including
established indirect rates for agencies;
(B) management oversight of specific programs
funded under this title; and
(C) other types of program support such as
quality assurance, quality control, and related
activities.
* * * * * * *
SEC. 2605. APPLICATION.
(a) In General.--To be eligible to receive a grant under
section 2601, an eligible area shall prepare and submit to the
Secretary an application, in accordance with subsection (c)
regarding a single application and grant award, at such time,
in such form, and containing such information as the Secretary
shall require, including assurances adequate to ensure--
* * * * * * *
(1) * * *
* * * * * * *
(B) that the political subdivisions within
the eligible area will maintain the level of
expenditures by such political subdivisions for
HIV-related services for individuals with HIV
disease at a level that is equal to the level
of such expenditures by such political
subdivisions for the [1-year period preceding
the first fiscal year for which a grant is
received by the eligible area] preceding fiscal
year; and
* * * * * * *
(4) * * *
* * * * * * *
(B) by an entity that provides health
services on a prepaid basis; [and]
(5) to the maximum extent practicable, that--
* * * * * * *
(C) a program of outreach will be provided to
low-income individuals with HIV-disease to
inform such individuals of such services[.];
and
(6) that the applicant has participated, or will
agree to participate, in the Statewide coordinated
statement of need process where it has been initiated
by the State, and ensure that the services provided
under the comprehensive plan are consistent with the
Statewide coordinated statement of need.
(b) [Additional] Application.--An eligible area that
desires to receive a grant under section 2603(b) shall prepare
and submit to the Secretary an [additional application]
application, in accordance with subsection (c) regarding a
single application and grant award, at such time, in such form,
and containing such information as the Secretary shall require,
including the information required under such subsection and
information concerning--
* * * * * * *
(3) the average cost of providing each category of
HIV-related health services and the extent to which
such cost is paid by third-party payors; [and]
(4) the aggregate amounts expended for each such
category of services[.]; and
(c) Single Application and Grant Award.--
(1) Application.--The Secretary may phase in the use of
a single application that meets the requirements of
subsections (a) and (b) of section 2603 with respect to
an eligible area that desires to recieve grants under
section 2603 for a fiscal year.
(2) Grant award.--The Secretary may phase in the
awarding of a single grant to an eligible area that
submits an approved application under paragraph (1) for
a fiscal year.
[(c)](d) Date Certain for Submission.--
(1) Requirement.--Except as provided in paragraph
(2), to be eligible to receive a grant under section
2601(a) for a fiscal year, an application under
subsection (a) shall be submitted not later than 45
days after the date on which appropriations are made
under section [2608] 2677 for the fiscal year.
* * * * * * *
[(d)](e) Requirements Regarding Imposition of Charges for
Services.--
* * * * * * *
SEC. 2606. TECHNICAL ASSISTANCE.
The Administrator of the Health Resources and Services
Administration [may] shall, beginning on the date of enactment
of this title, provide technical assistance, including peer
based assistance to assist newly eligible metropolitan areas in
the establishment of HIV health services planning councils and,
to assist entities in complying with the requirements of this
part in order to make such entities eligible to receive a grant
under this part. The Administrator may make planning grants
available to metropolitan areas, in an amount not to exceed
$75,000 for any metropolitan area, projected to be eligible for
funding under section 2601 in the following fiscal year. Such
grant amounts shall be deducted from the first year formula
award to eligible areas accepting such grants. Not to exceed I
percent of the amount appropriated for a fiscal year under
section 2677 for grants under part A may be used to carry out
this section.
* * * * * * *
[SEC. 2608. AUTHORIZATION OF APPROPRIATIONS]
[There are authorized to be appropriated to make grants
under this part, [$275,000,000 in each of the fiscal years 1991
and 1992, and such sums as may be necessary in each of the
fiscal years 1993 through 1995] such sums as may be necessary
in each of the fiscal years 1996, 1997, 1998, 1999, and 2000.]
* * * * * * *
PART B--CARE GRANT PROGRAM
SEC. 2613. GRANTS TO ESTABLISH HIV CARE CONSORTIA.
(a) * * *
(1) is an association of one or more public, and one
or more nonprofit private (or private for-profit
providers or organizations if such entities are the
only available providers of quality HIV care in the
area), health care and support service providers and
community based organizations operating within areas
determined by the State to be most affected by HIV
disease; and
* * * * * * *
(2) * * *
* * * * * * *
(A) essential health services such as case
management services, medical, nursing,
substance abuse treatment, mental health
treatment, and dental care, diagnostics,
monitoring, prophylactic treatment for
opportunistic infections, treatment education
to take place in the context of health care
delivery, and medical follow-up services,
mental health, developmental, and
rehabilitation services, home health and
hospice care; and
* * * * * * *
(c)Application.--
(1) * * *
* * * * * * *
(C) demonstrates that adequate planning has
occurred to meet the special needs of families
with HIV disease, including family centered and
youth centered care;
* * * * * * *
(2) Consultation.--* * *
* * * * * * *
(A)(i) * * *
* * * * * * *
(ii) in the case of a public health agency
that does not directly provide such HIV-related
health care services such agency shall consult
with an entity or entities that directly
provide ambulatory and outpatient HIV-related
health care services within the geographic area
to be [served; and]served;
(B) not less than one community-based
organization that is organized solely for the
purpose of providing HIV-related support
services to individuals with HIV disease[.];
(C) grantees under section 2671 and
representatives of organizations with a history
of serving children, youth, women, and families
with HIV and operating in the community to be
served; and
(D) representatives of community-based
providers that are necessary to provide the
full continuum of HIV-related health care
services, which are available within the
geographic area or be served.
[(d) Definition.--As used in this part, the term ``family
centered care'' means the system of services described in this
section that is targeted specifically to the special needs of
infants, children, women, and families. Family centered care
shall be based on a partnership between parents, professionals,
and the community designed to ensure an integrated,
coordinated, culturally sensitive, and community-based
continuum of care for children, women and families with HIV
disease.]
(d) Definition.--As used in this part, the terms ``family
centered care'' and ``youth centered care'' mean the system of
services described in this section that is targeted
specifically to the special needs of infants, children
(including those orphaned by the AIDS epidemic), youth, women,
and families. Family centered and youth centered care shall be
based on a partnership among parents, extended family members,
children and youth, professionals, and the community designed
to ensure an integrated, coordinated, culturally sensitive, and
community-based continuum of care.
* * * * * * *
SEC. 2616. PROVISION OF TREATMENTS.
* * * * * * *
[(c) State Duties.--In carrying out this section the State
shall--
[(1) determine, in accordance with guidelines issued
by the Secretary, which treatments are eligible to be
included under the program established under this
section;
[(2) provide assistance for the purchase of
treatments determined to be eligible under paragraph
(1), and the provision of such ancillary devices that
are essential to administer such treatments;
[(3) provide outreach to individuals with HIV
disease, and as appropriate to the families of such
individuals; and
[(4) facilitate access to treatments for such
individuals.]
(c) Standards for Treatment Program.--In carrying out this
section, the Secretary shall--
(1) review the current status of State drug
reimbursement programs and assess barriers to the
expended availability of prophylactic treatments for
opportunistic infections (including active
tuberculosis; and
(2) establish, in consultation with States,
providers, and affected communities, a recommended
minimum formulary of pharmaceutical drug therapies
approved by the Food and Drug Administration.
In carrying out paragraph (2), the Secretary shall
identify those treatments in the recommended minimum
formulary that are for the prevention of opportunistic
infections (including the prevention of active
tuberculosis).
(d) State Duties.--
(1) In general.--In implementing subsection (a),
States shall document the progress made in making
treatments described in subsection (c)(2) available to
individuals eligible for assistance under this section,
and to develop plans to implement fully the recommended
minimum formulary of pharmaceutical drug therapies
approved by the Food and Drug Administration.
(2) Other mechanisms for providing treatments.--In
meeting the standards of the recommended minimum
formulary developed under subsection (c), a State may
identify other mechanisms such as consortia and public
programs for providing such treatments to individuals
with HIV.
SEC. 2617. STATE APPLICATION.
* * * * * * *
(B) Description of Intended Uses and Agreements.--* * *
* * * * * * *
(2) * * *
* * * * * * *
(A) the services and activities to be
provided and an explanation of the manner in
which the elements of the program to be
implemented by the State with such assistance
will maximize the quality of health and support
services available to individuals with HIV
disease throughout the State; [and]
* * * * * * *
(C) a description of how the allocation and
utilization of resources are consistent with
the State coordinated statement of need
including traditionally underserved populations
and subpopulations) developed in partnership
with other grantees in the State that receive
funding under this title;
(3) the public health agency administering the grant
for the State shall convene a meeting at least annually
of individuals with HIV who utilize services under this
part (including those individuals from traditionally
underserved populations and subpopulations) and
representatives of grantees funded under this title
(including HIV health services planning councils, early
intervention programs, children, youth and family
service projects, special projects of national
significance, and HIV care consortia) and other
providers (including federally qualified health
centers) and public agency representatives with the
State currently delivering HIV services to affected
communities for the purpose of developing a Statewide
coordinated statement of need; and The State shall not
be required to finance attendance at the meetings
described in paragraph (3). A State may pay the travel-
related expenses of individuals attending such meetings
where appropriate and necessary to ensure adequate
participation.
[(3)] (4) an assurance by the State that--
* * * * * * *
SEC 2618. DISTRIBUTION OF FUNDS.
(a) Special Projects of a National Significance.--
(1) In general.--Of the amount appropriate under
section [2620] 2677 for each fiscal year, the Secretary
shall use not to exceed 10 percent of such amount to
establish and administer a special projects of national
significance program to award direct grants to public
and nonprofit private entities including community-
based organizations to fund special programs for the
care and treatment of individuals with HIV disease.
(b) Amount of Grant to State.--
(1) Minimum allotment.--Subject to the extent of
amounts made available under section 2620, the amount
of a grant to be made under this part for--
[(A) each of the several States and the
District of Columbia for a fiscal year shall be
the greater of--
[(i) $100,00, and
[(ii) an amount determined under
paragraph (2); and
[(B) each territory of the United States, as
defined in paragraph 31, shall be an amount
determined under paragraph (2).
[(2) Determination.--
[(A) Formula.--The amount referred to in
paragraph (1)(A)(ii) for a State and paragraph
(1)(B) for a territory of the United States
shall be the product of--
[(i) an amount equal to the amount
appropriate under section 2620 for the
fiscal year involved; and
[(ii) the ratio of the distribution
factor for the State or territory to
the sum of the distribution factors for
all the States or territories.
[(B) Distribution factor.--As used in
subparagraph (A)(ii), the term ``distribution
factor'' means--
[(i) in the case of a State, the
product of--
[(I) the number of cases of
acquired immune deficiency
syndrome in the State, as
indicated by the number of
cases reported to and confirmed
by the Secretary for the 2 most
recent fiscal years for which
such data are available; and
[(II) the cube root of the
ratio (based on the most recent
available data) of--
[(aa) the average per
capita income of
individuals in the
United States
(including the
territories); to
[(bb) the average per
capita income of
individuals in the
State; and
[(ii) in the case of a territory of
the United States the number of
additional cases of such syndrome in
the specific territory, as indicated by
the number of cases reported to and
confirmed by the Secretary for the 2
most recent fiscal years for which such
data is available.
[(3) Definitions.--As used in this
subsection--
[(A) the term ``State'' means each of the 50
States, the District of Columbia and the
Commonwealth of Puerto Rico; and
[(B) the term ``territory of the United
States'' means the Virgin Islands, Guam,
American Samoa, the Commonwealth of the
Northern Mariana Islands, and the Republic of
the Marshall Islands.]
(1) Minimum Allotment.--Subject to the extent of
amounts made available under section 2677, the amount
of a grant to be made under this part for--
(A) each of the several States and the
District of Columbia for a fiscal year shall be
the greater of--
(i)(I) with respect to a State or District
that has less than 90 living cases of acquired
immune deficiency syndrome, as determined under
paragraph (2)(D), $100,000; or
(i)(II) with respect to a State or
District that has 90 or more living
cases of acquired immune deficiency
syndrome, as determined under paragraph
(2)(D), $250,000;
(ii) an amount determined under
paragraph (2); and
(B) each territory of the United States, as
defined in paragraph (3), shall be an amount
determined under paragraph (2).
(2) Determination.--
(A) Formula.--The amount referred to in
paragraph (1)(A)(ii) for a State and paragraph
(1)(B) for a territory of the United States
shall be the product of--
(i) an amount equal to the amount
appropriated under section 2677 for the
fiscal year involved for grants under
part B; and
(ii) the percentage constitute by the
sum of--
(I) the product of .50 and the ratio
of the State distribution factor for
the State or territory (as determined
under subsection (B)) to the sum of the
respective State distribution factors
for all States or territories; and
(II) the product of .50 and the ratio
of the non-EMA distribution factor for
the State or territory (as determined
under subparagraph (C)) to the sum of
the respective distribution factors for
all States or territories.
(B) State Distribution Factor.--For purposes
of subparagraph (A)(ii)(I), the term ``State
distribution factor'' means the product of--
(i) an amount equal to the estimated
number of living cases of acquired
immune deficiency syndrome in the State
or territory involved, as determined
under subparagraph (D); and
(ii) the cost index for the State or
territory involved, as determined under
subparagraph (E).
(C) Non-Ema Distribution Factor.--For
purposes of subparagraph (A)(ii)(II), the term
``non-ema distribution factor'' means the
products of--
(i) an amount equal to the sum of--
(I) the estimated number of
living cases of acquired immune
deficiency syndrome in the
State or territory involved, as
determined under subparagraph
(D); less
(II) the estimated number of
living cases of acquired immune
deficiency syndrome in such
State or territory that are
within an eligible area (as
determined under part A); and
(ii) the cost index for the State or
territory involved, as determined under
subparagraph (E).
(D) Estimate of Living Cases.--The amount
determined in this subparagraph is an amount
equal to the product of--
(i) the number of cases of acquired
immune deficiency syndrome in the State
or territory during each year in the
most recent 120-month period for which
data are available with respect to all
States and territories, as indicated by
the number of such cases reported to
and confirmed by the Director of the
Centers for Disease Control and
Prevention for each year during such
period; and
(ii) with respect to each of the
first through the tenth year during
such period, the amount referred to in
2603(a)(3)(C)(ii).
(E) Cost Index.--
(i) The amount determined in this
subparagraph is an amount equal to the
sum of--
(I) the amount determined
under clause (ii) for a fiscal
year;
(II) the product of--
(aa) the average
hospital wage index
reported by hospitals
in the State or
territory involved
under section
1886(d)(3)(E) of the
Social Security Act for
the 3-year period
immediately preceding
the year for with the
grant is being awarded;
and
(bb) .70; and
(III) .30.
(ii) The amount determined in this
clause for a fiscal year is an amount
equal to the percentage constituted by
the ratio of--
(I) the total amount--
(aa) of salaries
reported by each
hospital within the
State or territory
under the medicare
prospective payment
system under title
XVIII of the Social
Security Act for the
fiscal year involved;
divided by
(bb) the total number
of hours worked by
those included in the
reported salaries under
subclause (II) for the
fiscal year involved,
as determined under
regulations promulgated
by the Secretary; and
(ii) the sum of the amount determined
under subclause (I) with respect to all
States and territories.
(F) Puerto Rico, Virgin Islands, Guam.--For
purposes of subparagraph (D), the cost index
for Puerto Rico, the Virgin Islands, and Guam
shall be 1.0.
(G) Unexpended Funds.--The Secretary may, in
determining the amount of a grant for a fiscal
year under this subsection, adjust the grant
amount to reflect the amount of unexpended and
uncanceled grant funds remaining at the end of
the fiscal year preceding the year for which
the grant determination is to be made. The
amount of any such unexpended funds shall be
determined using the financial status report of
the grantee.
(H) Limitation.--
(i) In general.--The Secretary shall
ensure that the amount of a grant
awarded to a State or territory for a
fiscal year under this part is equal to
not less than--
(I) with respect to fiscal
year 1996, 98 percent;
(II) with respect to fiscal
year 1997, 97 percent;
(III) with respect to fiscal
year 1998, 95.5 percent;
(IV) with respect to fiscal
year 1999, 94 percent; and
(V) with respect to fiscal
year 2000, 92.5 percent;
of the amount such State or territory
received for fiscal year 1995 under
this part. In administering this
subparagraph, the Secretary shall, with
respect to States that will receive
grants in amounts that exceed the
amounts that such States received under
this part in fiscal year 1995,
proportionally reduce such amounts to
ensure compliance with this
subparagraph. In making such
reductions, the Secretary shall ensure
that no such State receives less than
that State received for fiscal year
1995.
(ii) Ratable reduction.--If the
amount appropriated under section 2677
and available for allocation under this
part is less than the amount
appropriated and available under this
part for fiscal year 1995, the
limitation contained in clause (i)
shall be reduced by a percentage equal
to the percentage of the reduction in
such amounts appropriated and
available.''.
(c) Allocation of Assistance by States.--
* * * * * * *
[(3) Planning and evaluations.--A State may not use
in excess of 5 percent of amounts received under a
grant awarded under this part for planning and
evaluation activities.
[(4) Administration.--A State may not use in excess
of 5 percent of amounts received under a grant awarded
under this part for administration, accounting,
reporting, and program oversight functions.]
(3) Planning and evaluations.--Subject to paragraph
(5) and except as provided in paragraph (6), a State
may not use more than 10 percent of amounts received
under a grant awarded under this part for planning and
evaluation activities.
(4) Administration.--
(A) In general.--Subject to paragraph (5) and
except as provided in paragraph (6), a State
may not use more than 10 percent of amounts
received under a grant awarded under this part
for administration. An entity (including
subcontractors) receiving an allocation from
the grant awarded to the State under this part
shall not use in excess of 12.5 percent of
amounts received under such allocation for
administration.
(B) Administrative activities.--For the
purposes of subparagraph (A), amounts may be
used for administrative activities that include
routine grant administration and monitoring
activities.
(C) Subcontractor administrative costs.--For
the purposes of this paragraph, subcontractor
administrative activities include--
(i) usual and recognized overhead,
including established indirect rates
for agencies;
(ii) management oversight of specific
programs funded under this title; and
(iii) other types of program support
such as quality assurance, quality
control, and related activities.
(5) Limitation on Use of Funds.--Except as provided
in paragraph (6), a State may not use more than a total
of 15 percent of amounts received under a grant awarded
under this part for the purposes described in
paragraphs (3) and (4).
(6) Exception.--With respect to a State that receives
the minimum allotment under subsection (a)(1) for a
fiscal year, such State, from the amounts received
under a grant awarded under this part for such fiscal
year for the activities described in paragraph (3) and
(4), may, notwithstanding paragraphs (3), (4), and (5),
use not more than that amount required to support one
full-time-equivalent employee.
[(5)] (7) Construction.--A State may not use amounts
received under a grant awarded under this part to
purchase or improve land, or to purchase, construct, or
permanently improve (other than minor remodeling) any
building or other facility, or to make cash payments to
intended recipients of services.
* * * * * * *
SEC. 2619. TECHNICAL ASSISTANCE
The Secretary [may] shall provide technical assistance in
administering and coordinating the activities authorized under
section 2612, including technical assistance for the
development and implementation of Statewide coordinated
statements of need.
[SEC. 2620. AUTHORIZATION OF APPROPRIATIONS
[There are authorized to be appropriated to make grants
under this part, [$275,000,000 in each of the fiscal years 1991
and 1992, and such sums as may be necessary in each of the
fiscal years 1993 through 1995] such sums as may be necessary
in each of the fiscal years 1996, 1997, 1998, 1999, and 2000.]
* * * * * * *
PART B--CARE GRANT PROGRAM
* * * * * * *
SEC. 2621. GRIEVANCE PROCEDURES.
Not later than 90 days after the date of enactment of this
section, the Administration, in consultation with affected
parties, shall establish grievance procedures, specific to each
part of this title, to address allegations of egregious
violations of each such part. Such procedures shall include an
appropriate enforcement mechanism.
SEC. 2622. COORDINATION.
The Secretary shall ensure that the Health Resources and
Services Administration, the Centers for Disease Control and
Prevention, and the Substance Abuse and Mental Health Services
Administration coordinate the planning and implementation of
Federal HIV programs in order to facilitate the local
development of a complete continuum of HIV-related services for
individuals with HIV disease and those at risk of such disease.
The Secretary shall periodically prepare and submit to the
relevant committees of Congress a report concerning such
coordination efforts at the Federal, State, and local levels as
well as the existence of Federal barriers to HIV program
integration.
* * * * * * *
SEC. 2651. ESTABLISHMENT OF PROGRAM.
* * * * * * *
(b) Purposes of Grants.--
(1) In General.--The Secretary may not make a grant
under subsection (a) unless the applicant for the
[grant agrees to expend the grant for the purposes of
providing, on an outpatient basis, each of the early
intervention services specified in paragraph (2) with
respect to HIV disease.] grant agrees to--
(A) expend the grant for the purposes of
providing, on an out-patient basis, each of the
early intervention services specified in
paragraph (2) with respect to HIV disease; and
(B) expend not less than 50 percent of the
amount received under the grant to provide a
continuum of primary care services, including,
as appropriate, dental care services, to
individuals confirmed to be living with HIV.
* * * * * * *
(4) Requirement of Availability of all early
intervention services through each grantee.--[The
Secretary]
(A) In general.--The Secretary may not make a
grant under subsection (a) unless the applicant
for the grant agrees that each of the early
intervention services specified in paragraph
(2) will be available through the grantee. With
respect to compliance with such agreement, such
a grantee may expend the grant to provide the
early intervention services directly, and may
expend the grant to enter into agreements with
public or nonprofit private entities, or
private for-profit entities if such entities
are the only available provider of quality HIV
care in the area, under which the entities
provide the services.
(B) Other Requirements.--Grantees described
in--
(i) paragraphs (1), (2), (5), and (6)
of section 2652(a) shall use not less
than 50 percent of the amount of such a
grant to provide the services described
in subparagraphs (A), (B), (D), and (E)
of section 2651(b)(2) directly and on-
site or at sites where other primary
care services are rendered; and
(ii) paragraphs (3) and (4) of
section 2652(a) shall ensure the
availability of early intervention
services through a system of linkages
to community-based primary care
providers, and to establish mechanisms
for the referrals described in section
2651(b)(2)(C), and for follow-up
concerning such referrals.
* * * * * * *
SEC. 2652. MINIMUM QUALIFICATIONS OF GRANTEES.
* * * * * * *
(b) Status as Medicaid Provider--
(1) In general.-- * * *
* * * * * * *
(B) the applicant for the grant will enter
into an agreement with a public or nonprofit
private entity, or a private for-profit entity
if such entity is the only available provider
of quality HIV care in the area, under which
the entity will provide the service, and the
entity has entered into such a participation
agreement and is qualified to receive such
payments.
* * * * * * *
SEC. 2654. MISCELLANEOUS PROVISIONS.
* * * * * * *
(c) Planning and Development Grants.--
(1) In general.--The Secretary may provide planning
grants, in an amount not to exceed $50,000 for each
such grant, to public and nonprofit private entities
that are not direct providers of primary care services
for the purpose of enabling such providers to provide
HIV primary care services.
(2) Requirement.--The Secretary may only award a
grant to an entity under paragraph (1), if the
Secretary determines that the entity will use such
grant to assist the entity in qualifying for a grant
under section 2651.
(3) Preference.--In awarding grants under paragraph
(1), the Secretary shall give preference to entities
that would provide HIV primary care services in rural
or underserved communities.
(4) Limitation.--Not to exceed 1 percent of the
amount appropriated for a fiscal year under section
2655 may be used to carry out this section.
SEC. 2655. AUTHORIZATION OF APPROPRIATIONS.
For the purpose of making grants under section 2651, there
are authorized to be appropriated [$75,000,000 for fiscal years
1991, and such sums as may be necessary for each of the fiscal
years 1992 through 1995.] such sums as may be necessary in each
of the fiscal years 1996, 1997, 1998, 1999, and 2000.
* * * * * * *
SEC. 2664. ADDITIONAL REQUIRED AGREEMENTS.
* * * * * * *
(g) Administration of Grant.-- * * *
* * * * * * *
(2) the applicant will establish such procedures for
fiscal control and fund accounting as may be necessary
to ensure proper disbursement and accounting with
respect to the grant; [and]
(3) the applicant will not expend more than [5
percent] 10 percent including planning, evaluation and
technical assistance of the grant for administrative
expenses with respect to the grant[.]; and
(4) the applicant will submit evidence that the
proposed program is consistent with the Statewide
coordinated statement of need and agree to participate
in the ongoing revision of such statement of need.
* * * * * * *
[PART D--GENERAL PROVISIONS
[SEC. 2671. DEMONSTRATION GRANTS FOR RESEARCH AND SERVICES FOR
PEDIATRIC PATIENTS REGARDING ACQUIRED IMMUNE
DEFICIENCY SYNDROME.
[(a) In General.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and the Director of the National Institutes of
Health, shall make demonstration grants to community health
centers, and other appropriate public or nonprofit private
entities that provide primary health care to the public, for
the purpose of--
[(1) conducting, at the health facilities of such
entities, clinical research on therapies for pediatric
patients with HIV disease as well as pregnant women
with HIV disease; and
[(2) with respect to the pediatric patients who
participate in such research, providing health care on
an outpatient basis to such patients and the families
of such patients.
[(b) Minimum Qualifications of Grantees.--The Secretary may
not make a grant under subsection (a) unless the health
facility operated by the applicant for the grant serves a
significant number of pediatric patients and pregnant women
with HIV disease.
[(c) Cooperation With Biomedical Institutions.--
[(1) Design of research protocol.--The Secretary may
not make a grant under subsection (a) unless the
applicant for the grant--
[(A) has entered into a cooperative agreement
or contract with an appropriately qualified
entity with expertise in biomedical research
under which the entity will assist the
applicant in designing and conducting a
protocol for the research to be conducted
pursuant to the grant; and
[(B) agrees to provide the clinical data
developed in the research to the Director of
the National Institutes of Health.
[(2) Analysis and evaluation.--The Secretary, acting
through the Director of the National Institutes of
Health--
[(A) may assist grantees under subsection (a)
in designing and conducting protocols described
in subparagraph (A) of paragraph (1); and
[(B) shall analyze and evaluate the data
submitted to the Director pursuant to
subparagraph (B) of such paragraph.
[(d) Case Management.--The Secretary may not make a grant
under subsection (a) unless the applicant for the grant agrees
to provide for the case management of the pediatric patient
involved and the family of the patient.
[(e) Referrals for Additional Services.--The Secretary may
not make a grant under subsection (a) unless the applicant for
the grant agrees to provide for the pediatric patient involved
and the family of the patient--
[(1) referrals for inpatient hospital services,
treatment for substance abuse, and mental health
services; and
[(2) referrals for other social and support services,
as appropriate.
[(f) Incidental Services.--The Secretary may not make a
grant under subsection (a) unless the applicant for the grant
agrees to provide the family of the pediatric patient involved
with such transportation, child care, and other incidental
services as may be necessary to enable the pediatric patient
and the family of the patient to participate in the program
established by the applicant pursuant to such subsection.
[(g) Application.--The Secretary may not make a grant under
subsection (a) unless an application for the grant is submitted
to the Secretary and the application is in such form, is made
in such manner, and contains such agreements, assurances, and
information as the Secretary determines to be necessary to
carry out this section.
[(h) Evaluations.--The Secretary shall, directly or through
contracts with public and private entities, provide for
evaluations of programs carried out pursuant to subsection (a).
[(i) Definition.--For purposes of this section, the term
``community health center'' has the meaning given such term in
section 330(a).
[(j) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated $20,000,000 for fiscal year 1991, and such sums as
may be necessary for each of the fiscal years 1992 through
1995.]
Part D--Grants for Coordinated Services and Access to Research for
Children, Youth, and Families
SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR
CHILDREN, YOUTH, AND FAMILIES.
(a) In General.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, and in consultation with the Director of the
National Institutes of Health, shall award grants to
appropriate public or nonprofit private entities that, directly
or through contractual arrangements, provide primary care to
the public for the purpose of--
(1) providing outpatient health care and support
services (which may include family-centered and youth-
centered care, as defined in this title, family and
youth support services, and services for orphans) to
children, youth, women with HIV disease, and the
families of such individuals, and supporting the
provision of such care with programs of HIV prevention
and HIV research; and
(2) facilitating the voluntary participation of
children, youth, and women with HIV disease in
qualified research protocols at the facilities of such
entities or by direct referral.
(b) Eligible Entities.--The Secretary may not make a grant
to an entity under subsection (a) unless the entity involved
provides assurances that--
(1) the grant will be used primarily to serve
children, youth, and women with HIV disease;
(2) the entity will enter into arrangements with one
or more qualified research entities to collaborate in
the conduct or facilitation of voluntary patient
participation in qualified research protocols;
(3) the entity will coordinate activities under the
grant with other providers of health care services
under this title, and under title V of the Social
Security Act;
(4) the entity will participate in the Statewide
coordinated statement of need under section 2619 and in
the revision of such statement; and
(5) the entity will offer appropriate research
opportunities to each patient, with informed consent.
(c) Application.--The Secretary may not make a grant under
subsection (a) unless an application for the grant is submitted
to the Secretary and the application is in such form, is made
in such manner, and contains such agreements, assurances, and
information as the Secretary determines to be necessary to
carry out this section.
(d) Patient Participation in Research Protocols.--
(1) In general.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and the Director of the Office of AIDS
Research, shall establish procedures to ensure that
accepted standards of protection of human subjects
(including the provision of written informed consent)
are implemented in projects supported under this
section. Receipt of services by a patient shall not be
conditioned upon the consent of the patient to
participate in research.
(2) Research protocols.--
(A) In General.--The Secretary shall
establish mechanisms to ensure that research
protocols proposed to be carried out to meet
the requirements of this section, are of
potential clinical benefit to the study
participants, and meet accepted standards of
research design.
(B) Review panel.--Mechanisms established
under subparagraph (A) shall include an
independent research review panel that shall
review all protocols proposed to be carried out
to meet the requirements of this section to
ensure that such protocols meet the
requirements of this section. Such panel shall
make recommendations to the Secretary as to the
protocols that should be approved. The panel
shall include representatives of public and
private researchers, providers of services, and
recipients of services.
[(e) Training and Technical Assistance.--The Secretary,
acting through the Administrator of the Health Resources and
Services Administration, may use not to exceed five percent of
the amounts appropriated under subsection (h) in each fiscal
year to conduct training and technical assistance (including
peer-based models of technical assistance) to assist applicants
and grantees under this section in complying with the
requirements of this section.
(f) Evaluations and Data Collection.--
(1) Evaluations.--The Secretary shall provide for the
review of programs carried out under this section at
the end of each grant year. Such evaluations may
include recommendations as to the improvement of access
to and participation in services and access to and
participation in qualified research protocols supported
under this section.
(2) Reporting requirements.--The Secretary may
establish data reporting requirements and schedules as
necessary to administer the program established under
this section and conduct evaluations, measure outcomes,
and document the clients served, services provided, and
participation in qualified research protocols.
(3) Waivers.--Notwithstanding the requirements of
subsection (b), the Secretary may award new grants
under this section to an entity if the entity provide
assurances, satisfactory to the Secretary, that the
entity will implement the assurances required under
paragraph (2), (3), (4), or (5) of subsection (b) by
the end of the second grant year. If the Secretary
determines through the evaluation process that a
recipient of funds under this section is in material
noncompliance with the assurances provided under
paragraph (2), (3), (4), or (5) of subsection (b), the
Secretary may provide for continued funding of up to
one year if the recipient provides assurances,
satisfactory to the Secretary, that such noncompliance
will be remedied within such period.
(g) Definitions.--For purposes of this section:
(1) Qualified research entity.--The term ``qualified
research entity'' means a public or private entity with
expertise in the conduct of research that has
demonstrated clinical benefit to patients.
(2) Qualified research protocol.--The term
``qualified research protocol'' means a research study
design of a public or private clinical program that
meets the requirements of subsection (d).
(h) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section, such sums as may
be necessary for each of the fiscal years 1996 through 2000.
* * * * * * *
SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Subject to subsection (b), there are
authorized to be appropriated to make grants under parts A and
B, such sums as may be necessary for each of the fiscal years
1996 through 2000. Of the amount appropriated under this
section for a fiscal year, the Secretary shall make available
64 percent of such amount to carry out part A and 36 percent of
such amount to carry out part B.
(b) Development of Methodology.--
(1) In general.--With respect to each of the fiscal
years 1997 through 2000, the Secretary shall develop
and implement a methodology for adjusting the
percentages referred to in subsection (a) to account
for grants to new eligible areas under part a and other
relevant factors. Not later than 1 year after the date
of enactment of this section, the Secretary shall
prepare and submit to the appropriate committees of
Congress a report regarding the findings with respect
to the methodology developed under this paragraph.
(2) Failure to implement.--If the Secretary fails to
implement a methodology under paragraph (1) by October
1, 1996, there are authorized to be appropriated--
(A) such sums as may be necessary to carry
out part A for each of the fiscal years 1997
through 2000; and
(B) such sums as may be necessary to carry
out part B for each of the fiscal years 1997
through 2000.
* * * * * * *
PART F--DEMONSTRATION AND TRAINING
Subpart I--Special Projects of National Significance
SEC. 2691. SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE.
(a) In General.--Of the amount appropriated under each of
parts A, B, C, and D of this title for each fiscal year, the
Secretary shall use the greater of $20,000,000 or 3 percent of
such amount appropriated under each such part, but not to
exceed $25,000,000, to administer a special projects of
national significance program to award direct grants to public
and nonprofit private entities including community-based
organizations to fund special programs for the care and
treatment of individuals with HIV disease.
(b) Grants.--The Secretary shall award grants under
subsection (a) based on--
(1) the need to assess the effectiveness of a
particular model for the care and treatment of
individuals with HIV disease;
(2) the innovative nature of the proposed activity;
and
(3) the potential replicability of the proposed
activity in other similar localities or nationally.
(c) Special Projects.--Special projects of national
significance shall include the development and assessment of
innovative service delivery models that are designed to--
(1) address the needs of special populations;
(2) assist in the development of essential community-
based service delivery infrastructure; and
(3) ensure the ongoing availability of services for
Native American communities to enable such communities
to care for Native Americans with HIV disease.
(d) Special Populations.--Special projects of national
significance may include the delivery of HIV health care and
support services to traditionally underserved populations
including--
(1) individuals with families with HIV disease living
in rural communities;
(2) adolescents with HIV disease;
(3) Indian individuals and families with HIV disease;
(4) homeless individuals and families with HIV
disease;
(5) hemophiliacs with HIV disease; and
(6) incarcerated individuals with HIV disease.
(e) Service Development Grants.--Special projects of
national significance may include the development of model
approaches to delivering HIV care and support services
including--
(1) programs that support family-based care networks
critical to the delivery of care in minority
communities;
(2) programs that build organizational capacity in
disenfranchised communities;
(3) programs designed to prepare AIDS service
organizations and grantees under this title for
operation within the changing health care environment;
and
(4) programs designed to integrate the delivery of
mental health and substance abuse treatment with HIV
services.
(f) Coordination.--The Secretary may not make a grant under
this section unless the applicant submits evidence that the
proposed program is consistent with the Statewide coordinated
statement of need, and the applicant agrees to participate in
the ongoing revision process of such statement of need.
(g) Replication.--The Secretary shall make information
concerning successful models developed under this part
available to grantees under this title for the purpose of
coordination, replication, and integration. To facilitate
efforts under this subsection, the Secretary may provide for
peer-based technical assistance from grantees funded under this
part.
Subpart II--AIDS Education and Training Centers
SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTER.
(a) Schools; centers
(1) In general * * *
* * * * * * *
(A) training health personnel, including
practitioners in title XXVI programs and other
community providers, in the diagnosis,
treatment, and prevention of HIV infection and
disease;
[(A)] (B) to train the faculty of schools of,
and graduate department or programs of,
medicine, nursing, osteopathic medicine,
dentistry, public health, allied health, and
mental health practice to teach health
professions students to provide for the health
care needs of individuals with HIV disease; and
[(B) to train practitioners to provide for
the health care needs of such individuals;]
[(C) with respect to improving clinical
skills in the diagnosis, treatment, and
prevention of such disease, to educate and
train the health professionals and clinical
staff of schools of medicine, osteopathic
medicine, and dentistry; and]
[(D)] (C) to develop and disseminate
curricula and resource materials relating to
the care and treatment of individuals with such
disease and the prevention of the disease among
individuals who are at risk of contracting the
disease.
(b) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section, such sums as may
be necessary for each of the fiscal years 1996 through 2000.
* * * * * * *