[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.
          * * * * * * *