Ryan White CARE Act: Factors that Impact HIV and AIDS Funding and
Client Coverage (23-JUN-05, GAO-05-841T).			 
                                                                 
The Ryan White Comprehensive AIDS Resources Emergency Act (CARE  
Act) was enacted in 1990 to respond to the needs of individuals  
and families living with the Human Immunodeficiency Virus (HIV)  
or Acquired Immunodeficiency Syndrome (AIDS). In fiscal year	 
2004, over $2 billion in funding was provided through the CARE	 
Act, the majority of which was distributed through Title I grants
to eligible metropolitan areas (EMA) and Title II grants to	 
states, the District of Columbia, and territories. Titles I and  
II use formulas to distribute grants according to a		 
jurisdiction's reported count of AIDS cases. Title II includes	 
grants for state-administered AIDS Drug Assistance Programs	 
(ADAP), which provide medications to HIV-infected individuals.	 
GAO was asked to discuss the distribution of funding under the	 
CARE Act. This testimony presents preliminary findings on (1) the
impact of CARE Act provisions that distribute funds based upon	 
the number of AIDS cases in metropolitan areas, (2) the impact of
CARE Act provisions that limit annual funding decreases, (3) the 
potential shifts in funding among grantees if HIV case counts	 
were incorporated with the AIDS cases that are currently used in 
funding formulas, and (4) the variation in eligibility criteria  
and funding sources among state ADAPs.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-841T					        
    ACCNO:   A27659						        
  TITLE:     Ryan White CARE Act: Factors that Impact HIV and AIDS    
Funding and Client Coverage					 
     DATE:   06/23/2005 
  SUBJECT:   Acquired immunodeficiency syndrome 		 
	     Data collection					 
	     Eligibility criteria				 
	     Eligibility determinations 			 
	     Federal aid to localities				 
	     Federal funds					 
	     Grants to states					 
	     Health care services				 
	     Infectious diseases				 
	     Jurisdictional authority				 
	     Program management 				 
	     AIDS Drug Assistance Program			 
	     HIV/AIDS						 

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GAO-05-841T

     

     * Background
     * CARE Act Funding Provisions Result in Disproportionate Fundi
          * Counting AIDS Cases within EMAs Twice Results in Unequal Fun
          * The Tiered Allocation of Title II Funds for Emerging Communi
     * Hold-Harmless Provisions and Grandfather Clause Benefit Cert
          * Title I Hold-Harmless Provision Has Primarily Benefited One
          * Grandfathering Maintains Eligibility for EMAs That No Longer
          * Title II Hold-Harmless Funding Could Diminish ADAP Severe Ne
     * Funding Impact of Using HIV Case Counts Would Depend on the
          * Current HIV Case Reporting Systems Have Limitations for Prov
          * The Use of HIV Case Counts in Funding Formulas Would Change
               * Methodological Approaches Used
               * Impact on Title II Base Grants
               * Differences in Case Reporting Systems Would Affect Distribut
          * Changes in Funding Would be Limited Initially if Certain For
     * State ADAP Eligibility Criteria and Funding Sources Vary Wid
          * Eligibility Criteria Contribute to Coverage Differences Amon
          * A Large Percentage of ADAPs' Funds Received from Sources Oth
          * Eligibility Criteria and Funding Sources Also Vary Among Sta
     * Concluding Observations
     * Contact and Acknowledgments
          * Order by Mail or Phone

Testimony

Before the Subcommittee on Federal Financial Management, Government
Information, and International Security, Committee on Homeland Security
and Governmental Affairs, U.S. Senate

United States Government Accountability Office

GAO

For Release on Delivery Expected at 2:30 p.m. EDT

Thursday, June 23, 2005

RYAN WHITE CARE ACT

Factors that Impact HIV and AIDS Funding and Client Coverage

Statement of Marcia Crosse

Director, Health Care

GAO-05-841T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss the Ryan White Comprehensive AIDS
Resources Emergency Act of 1990 (CARE Act).1 I will specifically address
factors that impact CARE Act funding of services for those with the Human
Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS)
and program coverage for CARE Act clients. As of December 2003, over 1
million individuals within the United States are estimated to be infected
with HIV, including about 406,000 individuals with AIDS. Administered by
the Health Resources and Services Administration (HRSA), the CARE Act
makes funds available to states and localities to provide health care,
medications, and support services to individuals and families affected by
HIV and AIDS.

In fiscal year 2004, more than $2 billion was provided through the CARE
Act for these health care and support services. The majority of these
funds were distributed under Title I and Title II within the CARE Act
through formula-derived base grants, which distribute funding to all
eligible jurisdictions, and through supplemental grants, which distribute
funding to a subset of all eligible jurisdictions. Title I provides
funding to all eligible metropolitan areas (EMA) according to an EMA's
number of AIDS cases.2 Title II provides funding to all states,
territories, and the District of Columbia. Within both of these titles are
formula grants intended to distribute funds proportionally to grantees
based upon a measure of each grantee's share of AIDS cases. Grantees'
reports of AIDS cases are used in funding formulas because when the CARE
Act was enacted in 1990, most jurisdictions tracked and reported AIDS
cases instead of HIV cases.

The CARE Act's reauthorizations in 1996 and 2000 modified the original
funding formulas. Prior to the 1996 reauthorization, the CARE Act measured
a jurisdiction's caseload by its cumulative count of AIDS cases, which is
the number of AIDS cases recorded since reporting began in 1981. The 1996
reauthorization changed the measurement of a jurisdiction's caseload to an
estimation of the number of living AIDS cases.3 This switch would have
resulted in large shifts of funding away from jurisdictions with a longer
history of the disease and a higher proportion of deceased cases than
other jurisdictions. The CARE Act includes hold-harmless provisions under
Title I and Title II that protect grantees from decreases in funding from
one year to the next. Title I of the CARE Act also includes a grandfather
clause for EMAs. A type of hold-harmless itself, this grandfather clause
guarantees that once a metropolitan area has become an EMA, it will
continue to receive funding under Title I, even if its caseload drops
below the threshold for eligibility. The most recent reauthorization of
the CARE Act in 2000 maintained these modifications, and it further
specified that HIV cases should be used in funding formulas no later than
fiscal year 2007. As of June 2005, HIV case counts have not been used to
distribute funding under the CARE Act.

1Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. S:S:
300ff-300ff-101 (2000). The CARE Act added a new title XXVII to the Public
Health Service Act. In general, because Title I of the CARE Act authorized
grants to metropolitan areas and Title II authorized grants to states,
these programs are referred to as Title I and Title II programs,
respectively.

2Under Title I, a metropolitan area with a population of at least 500,000
and 2,000 reported AIDS cases in the last 5 calendar years becomes
eligible to receive a portion of Title I funding.

A portion of Title II funding is for state AIDS Drug Assistance Programs
(ADAP), which provide medications to infected individuals. In fiscal year
2004, Title II base ADAP grants-the ADAP grant given to all states-totaled
$728 million, accounting for 36 percent of all CARE Act funding. The
programs are administered at the state level and each state is allowed
flexibility in determining its program eligibility criteria and the drugs
it provides. Some ADAPs establish waiting lists for eligible individuals
for a period of time when the ADAP cannot provide covered drugs.

To assist the subcommittee in its consideration of the CARE Act, my
testimony provides our preliminary findings on some of the issues we are
reviewing for the Chairman and other requesters. My remarks today will
focus on selected provisions of the CARE Act and ADAP. Specifically, I
will discuss

           1. the impact of CARE Act provisions on the distribution of funds
           that is based upon the number of AIDS cases in metropolitan areas,
           2. the impact of the CARE Act's hold-harmless provisions and a
           grandfather clause on the distribution of funds,
           3. the potential shifts in funding among grantees if HIV case
           counts had been incorporated in fiscal year 2004 funding formulas,
           and
           4. the variation in eligibility criteria and funding sources among
           the state ADAPs.

3HRSA calculates a jurisdiction's estimated living AIDS cases by using
data from the Centers for Disease Control and Prevention on the reported
AIDS case counts for the last 10 years and weighting those numbers to
account for the likelihood of deaths. We used this estimate in our
analyses of CARE Act funding formula allocations, and we refer to this
measure as the number of AIDS cases in our discussion of these analyses.

To address these issues and those within our broader review of the CARE
Act, we interviewed officials from HRSA and the Centers for Disease
Control and Prevention (CDC). CDC collects HIV and AIDS case counts from
states and territories. We also interviewed officials from the National
Alliance of State and Territorial AIDS Directors. We obtained and analyzed
data from HRSA regarding the distribution of CARE Act funding and from CDC
regarding AIDS and HIV case counts.4 We obtained and analyzed HIV case
counts from those states from which CDC does not accept these data because
they do not use names to identify the cases. CDC and the states provided
us with case counts that were available as of June 30, 2003, the cutoff
date for data used to determine fiscal year 2004 funding. HRSA provided us
with CARE Act funding distributions for fiscal year 2004.5 Based on the
information HRSA, CDC, and the states provided regarding its verification
of the reliability of these data, we determined these data to be
sufficiently reliable for the purposes of our analyses. We performed our
work from July 2004 through June 2005 according to generally accepted
government auditing standards. CDC and HRSA provided comments on the facts
contained in this statement, and we made changes as appropriate.

In brief, our analysis shows that certain CARE Act Title I and Title II
provisions related to the distribution of funds to metropolitan areas
result in variability between the amounts of funding per case among
grantees. States and territories that have EMAs within their borders
receive more funding per estimated living AIDS case than those without
EMAs because cases within EMAs are counted twice-once to determine Title I
funding to EMAs, and once again to determine a state's Title II grant.
Metropolitan areas that have been affected by the epidemic but do not have
the necessary number of AIDS cases to become EMAs and receive Title I
funding may qualify for funding as Emerging Communities under Title II.
However, the allocation of these grants is made by separating eligible
jurisdictions into two tiers based on their reported number of AIDS cases.
Because one half of the total Emerging Communities grant award is
allocated to each tier regardless of how many cases are in each tier, in
fiscal year 2004 jurisdictions in one tier received $1,052 per case while
jurisdictions in the other tier received $313 per case.

4The HIV case counts were calculated by subtracting the number of reported
deaths among HIV cases from the number of reported HIV cases.

5Our analyses include CARE Act funding and programs in the 50 states, the
District of Columbia, and Puerto Rico.

The hold-harmless provisions under Titles I and II and the grandfather
clause for EMAs under Title I sustain the funding and eligibility of CARE
Act grantees on the basis of a previous year's measurements of the number
of AIDS cases in these jurisdictions. By guaranteeing either a certain
percentage of previous years' funding amounts or an EMA's eligibility to
receive funding, these provisions make it more difficult for CARE Act
funding to track the most current distribution of the epidemic. The San
Francisco EMA has primarily benefited from Title I's hold-harmless
provision, receiving over 90 percent ($7,358,239) of the fiscal year 2004
Title I hold-harmless funding. San Francisco's current hold-harmless
funding can be traced to its 1995 base grant, which was determined using
the cumulative number of AIDS cases, living and dead, reported since 1981.
In essence, deceased cases are still being used to determine funding for
San Francisco. Hold-harmless provisions under Title II also sustain a
state's level of funding based on case counts from previous years. Because
funding for one of these Title II hold-harmless provisions is drawn from a
set-aside for states with a severe need for drug assistance, this
hold-harmless provision could affect the amount of funding received by
these severe-need states in the future. The grandfather clause in Title I
maintained the funding for 29 of the 51 EMAs that became eligible for
Title I base grants in the past. These EMAs, however, would not have
qualified for Title I base grants in fiscal year 2004 based upon their
case counts, which were below the eligibility threshold of 2,000 reported
AIDS cases in the last 5 calendar years.

If the HIV case counts from state reporting systems had been used with
estimated living AIDS cases in allocating fiscal year 2004 Title II base
funding, about half of the states would have received increased funding
and the other half would have received decreased funding. Using two
different approaches, we found that at least 11 of the states with
increased funding were located in the South, the region with the highest
estimated number of people living with HIV or AIDS in 2003. All states
have established HIV case reporting systems, and the 2000 reauthorization
of the CARE Act required that HIV cases be used in determining formula
funding no later than fiscal year 2007. However, wide differences between
states' HIV case reporting systems-in their maturity and reporting
methods, for instance-could affect the use of HIV and AIDS case counts to
distribute CARE Act funding because an immature reporting system might not
capture an accurate count of a state's HIV cases. More mature systems have
longer histories of collecting newly diagnosed HIV cases and retroactively
reporting HIV cases that had been diagnosed before the reporting system
existed. We found that funding would have shifted to jurisdictions with
more mature HIV reporting systems, which includes many of the reporting
systems in the South. However, changes in funding would be largely offset,
at least initially, if the funding formulas included hold-harmless and
minimum grant provisions.

There is wide variation among state ADAPs in the eligibility criteria they
set for their programs and in the additional funding those programs
receive from sources other than their Title II base ADAP grant. States
determine what drugs they will cover for their ADAP clients and what
income level will make a client eligible for ADAP coverage, among other
criteria. States also vary in the amount of funding they receive from
other sources in addition to their Title II ADAP base grant. State ADAPs
can receive funding from a variety of sources, including transfers from
other CARE Act grants and contributions from states, that can lead to a
wide range of funding amounts per AIDS case. However, we did not find a
relationship between any one factor-a particular income eligibility
criterion, for example, or a type of additional funding beyond the base
grant-and the existence of a waiting list of ADAP clients that could not
be served at a particular time.

                                   Background

Over the course of the last quarter century, the epidemic has spread to
every region of the country. HIV and AIDS cases have been reported in all
states, the District of Columbia, and U.S. territories, but the impact of
the epidemic varies by region and within states. The South is estimated to
have the highest cumulative number of diagnosed AIDS cases, people living
with AIDS, and deaths from AIDS. In 2003, 7 of the 10 states with the
highest estimated rates of individuals living with HIV were located in the
South.

The CARE Act was enacted in 1990 to respond to the needs of individuals
and families living with HIV or AIDS and to direct federal funding to
areas disproportionately affected by the epidemic. Titles I and II of the
act provide base funding to affected EMAs and states based on the
proportion of each jurisdiction's caseload of AIDS cases. These titles
also establish other types of grants to provide supplemental funding.6 For
example, Title II includes Severe Need grants for states with demonstrated
need for supplemental funding to support their ADAPs. Title II also
includes funding for emerging communities that are affected by AIDS but do
not have the 2,000 AIDS cases reported in the last 5 calendar years in
order to be eligible for Title I funding as EMAs. In order to address the
impact of the disease on racial and ethnic minorities, Minority AIDS
Initiative grants are distributed through both Title I and Title II to
EMAs and states.

Metropolitan areas heavily affected by HIV or AIDS have always been
recognized within the structure of the CARE Act. We previously found that,
with combined funding under Title I and Title II, states with EMAs receive
more funding per AIDS case than states without EMAs.7 To adjust for this
situation, the 1996 reauthorization instituted a two-part formula for
Title II base funding that takes into account the number of AIDS cases
that reside within a state but outside of any EMA's jurisdiction. Under
this distribution formula, 80 percent of the Title II base grant is based
upon a state's proportion of all AIDS cases, and twenty percent of the
allocation is based on the number of AIDS cases within that state's
borders but outside of EMAs. A second provision included in 1996 protected
the eligibility of EMAs. The 1996 CARE Act amendments provided that once a
jurisdiction is designated an EMA, that jurisdiction is "grandfathered" so
it will always receive some amount of funding under Title I even if its
reported number of AIDS cases drops below the threshold for eligibility.
Hold-harmless provisions and the grandfather clause were maintained in the
2000 reauthorization of the CARE Act. Table 1 describes selected CARE Act
formula grants for Titles I and II.

6There are supplemental grants under Title I that are determined by a
competitive application process. For purposes of this testimony, these
Title I supplemental grants were not included.

7See GAO, Ryan White CARE Act of 1990: Opportunities Are Avalable to
Improve FundingEquity, GAO/T-HEHS-95-126 (Washington, D.C.: Apr. 5, 1995).
See also related GAO products at the end of this statement.

Table 1: Description of Selected CARE Act Title I and Title II Formula
Grants

Formula     Eligible                           Minimum      Hold-harmless  
grant       grantees      Distribution         grant        provisiona     
Title I     Jurisdictions Distributed among    No           Grant annually 
Base Grant  with 500,000  all EMAs based on                 declines to    
               or more in    proportion of all                 98%, 95%, 92%, 
               population    AIDS cases                        and 89% of the 
               and with                                        base year      
               2,000                                           grant,         
               reported AIDS                                   respectively.b 
               cases in the                                    In fifth and   
               most recent 5                                   all subsequent 
               calendar                                        years, EMA     
               years become,                                   receives 85%   
               and remain,                                     of base year   
               EMAs                                            grant.         
Title II    All 50        Eighty percent of    For states   Base formula   
Base Grant  states, the   base grant divided   with less    grant declines 
               District of   among                than 90 AIDS by 1% per year 
               Columbia, and states/territories   cases,       from the       
               U.S.          based upon their     $200,000;    fiscal year    
               territories   proportion of all    states with  2000 award. In 
                             AIDS cases. Twenty   90 or more   fifth and      
                             percent of base      AIDS cases,  subsequent     
                             grant is divided     $500,000;    years of       
                             among                for          provision,     
                             states/territories   territories, grant remains  
                             based upon           $50,000      at 95% of 2000 
                             proportion of all                 appropriation. 
                             AIDS cases that are               
                             located outside the               
                             EMAs within the                   
                             states'/territories'              
                             borders.                          
Title II    All 50        Distributed among    No           Grant declines 
ADAP Base   states, the   all                               by 1% per year 
Grant       District of   states/territories                from the       
               Columbia, and according to their                fiscal year    
               U.S.          proportion of all                 2000 grant. In 
               territories   AIDS cases                        fifth and      
                                                               subsequent     
                                                               years of       
                                                               provision,     
                                                               funding        
                                                               remains at 95% 
                                                               of 2000 grant. 
Title II    States and    Distributed among    No           No             
ADAP Severe territories   all qualifying                    
Need Grantc demonstrating states/territories                
               a severe need based upon their                  
               that prevents proportion of AIDS                
               them from     cases in all                      
               providing     qualifying                        
               medications   states/territories;               
               to clients in eligible                          
               a manner      states/territories                
               consistent    must also agree to                
               with Public   match 25% of their                
               Health        Severe Need grant                 
               Service                                         
               guidelines                                      
Title II    Jurisdictions Funds are divided    Minimum of   No             
Emerging    with more     into two tiers: 50%  $5 million   
Communities than 50,000   distributed among    for each     
Grant       in            communities with     tier         
               population,   1,000-1,999 AIDS                  
               not eligible  cases, and 50%                    
               for Title I,  distributed among                 
               and with      communities with                  
               500-1,999     500-999 AIDS cases,               
               reported AIDS based on their                    
               cases in the  proportion of AIDS                
               most recent 5 cases in Emerging                 
               calendar      Communities within                
               years         the tier                          

Source: HRSA.

aIf the distribution formula would otherwise result in decreased funding,
a hold-harmless provision may be triggered to mitigate the decrease in
funding.

bThe base year is the fiscal year prior to that in which the provision is
triggered.

cFunding for Severe Need grants may be reduced to maintain funding for
some states under a Title II hold-harmless provision.

The 2000 reauthorization specified that CARE Act Title I and Title II
funding formulas should use HIV case counts as early as fiscal year 2005
if such data were available and deemed "sufficiently accurate and
reliable" by the Secretary of Health and Human Services (HHS).8 The 2000
reauthorization also required that HIV data be used no later than the
beginning of fiscal year 2007. In June 2004 the Secretary of HHS
determined that HIV data were not yet ready to be used for the purposes of
allocating formula funding under Title I and Title II of the CARE Act. The
Secretary cited a 2004 Institute of Medicine (IOM) report, which
identified several limitations in the ability of states to provide
adequate and reliable HIV case counts for use in CARE Act formula
allocations.9

         CARE Act Funding Provisions Result in Disproportionate Funding

Some CARE Act provisions have led to jurisdictions receiving different
amounts of funding per AIDS cases. The counting of AIDS cases within EMAs
once to determine Title I funding and once again to determine Title II
funding results in states with EMAs receiving more funding per AIDS case
than states without an EMA. In addition, Emerging Communities grants are
awarded to eligible communities that are separated into two tiers based on
each community's AIDS cases reported in the most recent 5 calendar years.
Because one half of the total Emerging Communities grant award is
allocated to each tier regardless of the total number of reported AIDS
cases in each tier, a disproportionate amount of funding per case was
distributed among the grantees in fiscal year 2004.

Counting AIDS Cases within EMAs Twice Results in Unequal Funding per Case Across
States

States with EMAs receive more funding per AIDS case than jurisdictions
without EMAs because cases within EMAs are counted twice. The number of
AIDS cases used to allocate CARE Act Title I base grants for EMAs is also
used in the allocation of 80 percent of Title II base grants for states.
The remaining 20 percent is based on the number of AIDS cases in each
state outside of any EMA. This 80/20 split was established by the CARE
Act's 1996 amendments to address the fact that states with EMAs received
more funding per case than states without EMAs. However, even with the
80/20 split, states with EMAs still receive more funding per AIDS case.
States without an EMA receive no funding under the Title I distribution,
and thus, when total Title I and Title II CARE Act funds are considered,
states with EMAs receive more funding per AIDS case. 10 Appendix I shows
the combined fiscal year 2004 funding for all Title I and Title II funding
received by each state.

842 U.S.C. S: 300ff-13(a)(3)(D)(i)(2000).

9Institute of Medicine of the National Academies, Measurng What Matters:
Aocation, Planning, and Quality Assessment for the Ryan White CARE Act
(Washington, D.C.: The National Academies Press, 2004).

Table 2 illustrates the effect of counting EMA cases twice by comparing
the relationship between the percentage of a state's AIDS cases that are
within an EMA's jurisdiction and the amount of funding a state receives
per AIDS case. Table 2 shows that as the percentage of a state's AIDS
cases within EMAs increases, the total Title I and II funding per AIDS
case also increases for the state. For example, states with no AIDS cases
in EMAs received on average $3,592 per AIDS case. States with 75 percent
or more of their cases in EMAs received on average $4,955 per AIDS case,
or 38 percent more funding than states with no EMA. If the total Title I
and Title II funding had been distributed equally per AIDS case among all
grantees, each state would have received $4,782 per AIDS case.

Table 2: Total CARE Act Title I and II Funding per AIDS Case, Fiscal Year
2004

Percentage of state's AIDS cases in EMAs Average funding per AIDS casea 
None                                                             $3,592 
Less than 50 percent                                              3,954 
50 to 75 percent                                                  4,717 
75 percent or more                                                4,955 

Source: GAO analysis of HRSA data.

aIn order to isolate the effect of counting AIDS cases in EMAs twice, we
excluded from our analyses the nine states and six territories that
received minimum Title II base grant awards. Under Title II, states with
less than 90 cases receive no less than $200,000 in Title II base grant
and states with 90 or more cases receive at least $500,000.

The impact of counting EMA cases twice is that states with similar numbers
of AIDS cases can receive different levels of combined Title I and Title
II funding. For example, for fiscal year 2004 funding, Connecticut had
5,363 AIDS cases while South Carolina had 5,563 AIDS cases. However,
Connecticut had two EMAs that accounted for 91.3 percent of its cases
while South Carolina had none. Connecticut received $26,797,308 ($4,997
per AIDS case) in combined Title I and Title II funding while South
Carolina, with 200 more cases, received $20,705,328 ($3,722 per AIDS
case). Connecticut received 29 percent more funding than South Carolina, a
difference of $6,091,980, or $1,275 per AIDS case.

10For EMAs that cross state boundaries, we estimated the amount of funding
received by each state. Using data obtained from HRSA, we calculated the
number of AIDS cases from each state in these EMAs. We then calculated the
percentage of AIDS cases in each state and allocated the EMA funding to
each state based on this percentage. For example, approximately 96 percent
of the cases in the Boston EMA are in Massachusetts and 4 percent are in
New Hampshire. Consequently, we allocated 96 percent of the Boston EMA's
funding to Massachusetts and 4 percent to New Hampshire.

The Tiered Allocation of Title II Funds for Emerging Communities Results in
Funding Disparities Among States

The two-tiered division of Emerging Communities grants results in
disparities in funding per case among states. In addition to the base
grants for states, Title II provides a minimum of $10 million in
supplemental grants to states for communities with populations greater
than 50,000 that have a certain number of AIDS cases in the last 5
calendar years. The funding is equally split so that half the funding is
divided among the first tier of communities with 500 to 999 reported cases
in the most recent 5 calendar years while the other half is divided among
a second tier of communities with 1,000 to 1,999 reported cases in that
period. The funding is then allocated within each tier by the proportion
of reported cases in the most recent 5 calendar years in each community.

In fiscal year 2004, the two-tiered structure of Emerging Communities
funding led to large differences in funding per case because the total
number of AIDS cases in each tier was not equal. Twenty-nine communities
qualified for Emerging Communities grants in fiscal year 2004. Four of
these communities had between 1,000 and 1,999 reported cases and 25
communities had between 500 and 999 cases. This meant that 4 communities
with a total of 4,754 reported cases split $5 million while 25 communities
with a total of 15,994 cases split the remaining $5 million. This resulted
in the 4 communities receiving $1,052 per reported case while the other 25
received $313 per reported case. These 4 communities received 236 percent
more funding per case than the other 25. If the total $10 million Emerging
Communities funding had been distributed equally per case among the
communities, each would have received $482 per reported case. Table 3
lists the 29 emerging communities along with their AIDS case counts and
funding.

Table 3: Title II Emerging Communities in Fiscal Year 2004

                                         AIDS cases      Emerging Communities 
                                    reported in the     funding per AIDS case 
                                      most recent 5      reported in the most 
State Metropolitan area           calendar years   recent 5 calendar years 
Tenn. Memphis                              1,588                    $1,052 
Tenn. Nashville                            1,123                     1,052 
La.   Baton Rouge                          1,038                     1,052 
Ind.  Indianapolis                         1,005                     1,052 
S.C.  Columbia                               972                       313 
N.C.  Charlotte                              875                       313 
Del.  Wilmington                             801                       313 
Va.   Richmond                               783                       313 
N.C.  Raleigh-Durham-Chapel Hill             775                       313 
Miss. Jackson                                722                       313 
Ky.   Louisville                             705                       313 
N.Y.  Rochester                              681                       313 
Fla.  Fort Pierce-Port St. Lucie             636                       313 
N.C.  Greensboro-Winston-Salem               617                       313 
Ala.  Birmingham                             615                       313 
Okla. Oklahoma City                          608                       313 
Pa.   Pittsburgh                             602                       313 
Mass. Springfield                            588                       313 
N.J.  Monmouth-Ocean                         582                       313 
N.Y.  Buffalo-Niagara Falls                  581                       313 
S.C.  Greenville                             560                       313 
Ohio  Columbus                               558                       313 
Wisc. Milwaukee                              558                       313 
Utah  Salt Lake City                         555                       313 
Fla.  Sarasota                               539                       313 
S.C.  Charleston                             538                       313 
Ohio  Cincinnati                             517                       313 
Fla.  Daytona Beach                          514                       313 
R.I.  Providence                             512                       313 
         Total                               20,748 

Sources: GAO analysis of HRSA data.

Note: The 5 most recent calendar years are from 1998-2002.

    Hold-Harmless Provisions and Grandfather Clause Benefit Certain Grantees

Titles I and II of the CARE Act both contain provisions that benefit
certain grantees by protecting their funding levels. Title I has a
hold-harmless provision that guarantees that the Title I base grant
allocated to an EMA will be at least as large as a legislated percentage
of a previous year's funding. The Title I hold-harmless provision has
primarily benefited one EMA. Title I also contains a grandfather clause
that has resulted in a large number of EMAs maintaining funding despite no
longer meeting the eligibility criteria. One hold-harmless provision for
Title II ensures that the total of Title II and ADAP base grants awarded
to a state will be at least as large as the total of these grants it
received the previous year. This provision has had little impact thus far,
but it has the potential to reduce the amount of funding to states with
severe need in ADAPs because it is funded out of amounts reserved for that
purpose. The hold-harmless provision and the grandfather clause in Title I
and the hold-harmless provisions in Title II protect grantees from
decreases in funding from one year to the next, but they also make it more
difficult to shift funding in response to geographic movement of the
disease.

Title I Hold-Harmless Provision Has Primarily Benefited One EMA

In fiscal year 2004, the Title I hold-harmless provision primarily
benefited the San Francisco EMA. The hold-harmless provision guarantees
each EMA a specified percentage, as legislated by the CARE Act, of the
base grant it received in a previous year regardless of how much a
grantee's caseload may have decreased in the current year. An EMA's base
funding is determined according to its proportion of AIDS cases. If an EMA
qualifies for hold-harmless funding, that amount is added to the base
funding and distributed together as the base grant. The San Francisco EMA
received $7,358,239 in hold-harmless funding, or 91.6 percent of the
hold-harmless funding that was distributed. The second largest beneficiary
was Kansas City, which received $134,485, or 1.7 percent of the
hold-harmless funding. Table 4 lists the fiscal year 2004 hold-harmless
beneficiaries.

Table 4: Title I Hold Harmless Funding, Fiscal Year 2004

                                                                          Base    Percent of 
                                                                         grant    base grant 
                                            Percentage of Hold-harmless    per        due to 
                              Hold-harmless hold-harmless   funding per   AIDS hold-harmless 
EMA                                 funding       funding     AIDS case  casea       funding 
San Francisco, Calif.            $7,358,239         91.6%        $1,020 $2,241         45.5% 
Kansas City, Mo.                    134,485           1.7           104  1,325           7.8 
Santa Rosa, Calif.                   22,614           0.3            47  1,268           3.7 
Sacramento, Calif.                   36,456           0.5            29  1,251           2.3 
Minneapolis-St.Paul, Minn.           33,770           0.4            27  1,248           2.1 
Bergen-Passaic, N.J.                 55,288           0.7            26  1,248           2.1 
Jersey City, N.J.                    58,310           0.7            24  1,245           1.9 
Oakland, Calif.                      50,744           0.6            18  1,239           1.4 
New Haven, Conn.                     42,573           0.5            14  1,236           1.2 
Tampa-St. Petersburg, Fla.           44,908           0.6            12  1,233           0.9 
San Jose, Calif.                     12,097           0.2            11  1,232           0.9 
Boston, Mass.                        60,284           0.8            10  1,231           0.8 
Nassau-Suffolk, N.Y.                 21,212           0.3             8  1,230           0.7 
Middlesex-Somerset-Hunterdon,                                                                
N.J.                                  8,315           0.1             7  1,228           0.5
Jacksonville, Fla.                   12,825           0.2             6  1,228           0.5 
San Juan, P.R.                       41,011           0.5             6  1,228           0.5 
Seattle, Wash.                        9,844           0.1             4  1,225           0.3 
Denver, Colo.                         6,745           0.1             3  1,225           0.3 
Cleveland, Ohio                       4,616           0.1             3  1,224           0.2 
West Palm Beach, Fla.                 8,523           0.1             2  1,224           0.2 
Newark, N.J.                         10,975           0.1             2  1,223           0.1 
All Other EMAs                            0             0             0  1,221           0.0 
Total                           $8,033,563b        100.0%                      

Source: GAO analysis of HRSA data.

Note: An EMA's base funding is determined according to its proportion of
AIDS cases. If an EMA qualifies for hold-harmless funding, that amount is
added to the base funding and distributed together as the base grant.

aThis was calculated by dividing the base formula funding received by each
EMA by the number of AIDS cases in the EMA. However, because of rounding
error, some of the calculations are slightly different than if the base
formula funding per AIDS case without a hold-harmless benefit ($1,221) is
added to the hold-harmless funding per AIDS case.

bIndividual entries do not sum to total because of rounding.

The funding impact of the hold-harmless provision varies among the EMAs
that benefit but it can be substantial. In order to place hold-harmless
funding in perspective, it is helpful to consider how much of an EMA's
Title I base grant was made up of hold-harmless funding. EMAs that did not
receive hold-harmless funding received approximately $1,221 in base grant
funding per AIDS case. Fiscal year 2004 base grant funding per AIDS case
in EMAs that received hold-harmless funding ranged from $1,223 (Newark) to
$2,241 (San Francisco). Thus, San Francisco received $1,020 more in base
grant funding per AIDS case than did EMAs that did not receive
hold-harmless funding. This hold-harmless funding represents approximately
46 percent of San Francisco's base grant. Because of its hold-harmless
funding, San Francisco, which had 7,216 AIDS cases in fiscal year 2004,
received a base grant equivalent to what an EMA with approximately 13,245
AIDS cases (84 percent more) would have received based on the proportion
of cases. Kansas City, the second largest hold-harmless grantee, received
about what an EMA with 9 percent more AIDS cases would have received.

The San Francisco EMA's 2004 hold-harmless funding was linked to
cumulative AIDS cases used to determine fiscal year 1995 funding. In
fiscal year 2004 San Francisco was guaranteed to receive 89 percent of its
fiscal year 2000 Title I base grant, but San Francisco's 2000 allocation
was also held harmless under the 1996 CARE Act reauthorization. Under the
1996 reauthorization, EMAs were guaranteed 95 percent of their 1995 base
grant in fiscal year 2000.11 San Francisco was the only EMA to qualify for
hold-harmless funding in 2000 because it was the only EMA that would have
received less than 95 percent of its fiscal year 1995 base grant. This
means that in fiscal year 2004 San Francisco was guaranteed approximately
85 percent of its fiscal year 1995 base grant of $19,126,679.12 Prior to
the 1996 reauthorization, funding was distributed among EMAs on the basis
of the cumulative count of diagnosed AIDS cases (that is, all cases
reported in an EMA both living and deceased since the beginning of the
epidemic in 1981). Because the application of the Title I hold-harmless
provision for San Francisco dates back to the 1996 reauthorization, San
Francisco's Title I base grant is determined in part by the number of
cumulative cases in the San Francisco EMA as of 1995.

11The amounts guaranteed in the Title I hold-harmless provisions differed
in the 1996 and 2000 CARE Act reauthorizations. In the 1996
reauthorization the guaranteed amounts ranged from 95 to 100 percent of
the 1995 base grant. In the 2000 reauthorization the guaranteed amounts
ranged from 85 to 98 percent of the 2000 base grant.

12The guaranteed amount is calculated by multiplying the two percentages
(89 and 95) together. In other words, in fiscal year 2004 San Francisco
was guaranteed to receive at least 89 percent of its fiscal year 2000
Title I base grant. Its fiscal year 2000 Title I base grant was guaranteed
to be no less than 95 percent of its fiscal year 1995 Title I base grant.

Grandfathering Maintains Eligibility for EMAs That No Longer Meet Certain
Eligibility Criteria

More than one half of the EMAs received Title I funding in fiscal year
2004 even though they were below Title I eligibility thresholds.13 These
EMAs' eligibility was protected under a CARE Act grandfather clause. Under
a grandfather clause established by the 1996 amendments to the CARE Act,
once a metropolitan area's eligibility is established, the area remains
eligible for Title I funding even if the number of reported cases in the
most recent 5 calendar years drops below the statutory threshold. We found
that in fiscal year 2004, 29 of the 51 EMAs did not meet the eligibility
thresholds, but their Title I funding was protected by a grandfather
clause (see table 5). The number of reported AIDS cases in the most recent
5 calendar years in the 29 EMAs ranged from 223 to 1,941. Title I funding
awarded to these 29 EMAs was about $116 million, or approximately 20
percent of the total Title I funding.

13To be eligible for Title I funding, an area must have reported more than
2,000 AIDS cases during the most recent 5 calendar years and have a
population of at least 500,000. These criteria differ from those used to
calculate funding allocations, which are determined using the number of
AIDS cases. AIDS cases are calculated by applying annual national survival
weights to the most recent 10 years of reported AIDS cases and adding the
totals from each year. In the 1990 CARE Act, EMAs were defined as a
metropolitan area with a cumulative count of more than 2,000 AIDS cases or
a cumulative count of AIDS cases that exceeded one-quarter of one percent
of its population.

Table 5: Grandfathered EMAs, Fiscal Year 2004

                                           Number of AIDS cases               
                                           reported in the most Total Title I 
EMA                                  recent 5 calendar years       funding
Riverside-San Bernardino, Calif.                       1,941    $6,823,183 
New Haven, Conn.                                       1,717     7,069,348 
Oakland, Calif.                                        1,633     6,611,607 
Nassau-Suffolk, N.Y.                                   1,560     5,951,789 
Norfolk, Va.                                           1,502     4,820,201 
Seattle, Wash.                                         1,459     5,842,615 
Jacksonville, Fla.                                     1,423     4,863,093 
Orange County, Calif.                                  1,422     5,233,329 
St. Louis, Mo.                                         1,247     4,371,154 
Jersey City, N.J.                                      1,226     5,884,194 
Las Vegas, Nev.                                        1,182     4,473,401 
Denver, Colo.                                          1,167     4,529,097 
Austin, Tex.                                           1,149     3,800,250 
Bergen-Passaic, N.J.                                   1,067     4,814,704 
Hartford, Conn.                                        1,059     4,552,237 
San Antonio, Tex.                                      1,034     3,833,443 
Cleveland, Ohio                                          970     3,486,936 
Portland, Oreg.                                          937     3,567,475 
Fort Worth, Tex.                                         854     3,373,450 
Kansas City, Mo.                                         822     3,240,813 
Minneapolis, Minn.                                       794     3,093,915 
Sacramento, Calif.                                       717     2,968,051 
Ponce, P.R.                                              710     2,718,331 
Middlesex-Somerset-Hunterdon, N.J.                       682     2,723,697 
San Jose, Calif.                                         656     2,656,550 
Caguas, P.R.                                             411     1,816,647 
Dutchess County, N.Y.                                    255     1,231,242 
Vineland-Millville-Bridgeton, N.J.                       238       847,898 
Santa Rosa, Calif.                                       223     1,107,428 
Total                                                         $116,306,348 

Source: GAO analysis of CDC and HRSA data.

Note: The 5 most recent calendar years are from 1998-2002.

As discussed earlier, some metropolitan areas are designated as emerging
communities because their caseloads are not large enough to make them
eligible for Title I funding as EMAs. However, some emerging communities
had more reported AIDS cases in the last 5 years than some of the EMAs
that have been grandfathered.14 For example, for fiscal year 2004 Memphis,
a designated emerging community, had 1,588 reported AIDS cases during the
most recent 5 calendar years, which is more than the number of cases
reported in 26 EMAs. This results in variability in funding per case
caused by grandfathering EMAs.

Title II Hold-Harmless Funding Could Diminish ADAP Severe Need Grants in the
Future

A Title II hold-harmless provision could diminish ADAP Severe Need grant
amounts in the future because the provision and the grants are funded from
the same set-aside of funds. If larger amounts are needed to fund the
hold-harmless provision in the future, the Severe Need grant states could
get less than the grant amounts they would otherwise receive.

Fiscal year 2004 was the first time that any states triggered this Title
II hold-harmless provision, which was established by the 2000 amendments.
Severe Need grants are funded by setting aside three percent of the total
CARE Act Title II funding for ADAPs.15 The Title II hold-harmless
provision, also funded by the 3 percent set-aside for Severe Need grants,
guarantees that the total of Title II and ADAP base grants made to a state
will be at least as large as the grants made the previous year. In fiscal
year 2004 eight states became eligible for this hold-harmless funding. To
provide these jurisdictions with hold-harmless funding, HRSA officials
told us they used funds from the 3 percent set-aside for Severe Need
grants. In 2004, the 3 percent set-aside for Severe Need grants was $22.5
million. Of these funds, $1.6 million, or 7 percent, was used to provide
this Title II hold-harmless protection. (See table 6.) The remaining $20.8
million, or 93 percent of the set-aside amount, was distributed in Severe
Need grants.

14Both EMA eligibility and emerging community funding are based on the
number of AIDS cases reported in the most recent 5 calendar years.

15To be eligible for a Severe Need grant, a state must have met at least
one of four eligibility criteria as of January1, 2000. It must have
limited (1) the eligibility of ADAP clients to those with incomes at or
below 200 percent of the federal poverty level, (2) the number of ADAP
clients by using medical eligibility restrictions, (3) the number of
antiretroviral drugs covered in its drug formulary, or (4) the number of
opportunistic infection medications to less than 10 in its drug formulary.
(Opportunistic infections are illnesses such as parasitic, viral, and
fungal infections, and some types of cancer, some of which usually do not
cause disease in people with normal immune systems.) Having met the
eligibility criteria, a state can then apply for the Severe Need grants
each year by agreeing to provide the statutorily required 25 percent state
match through state funds or in-kind services.

Table 6: States that Received Title II Hold-Harmless Funding from Severe
Need Set-Aside; Fiscal Year 2004

State        Hold-harmless amount 
Arkansas                  $23,705 
Kansas                     22,168 
New Mexico                 55,171 
North Dakota                1,820 
Oklahoma                   96,423 
Tennessee               1,300,502 
Utah                      119,695 
Vermont                       128 
Total                  $1,619,612 

Source: HRSA.

The potential exists for this Title II hold-harmless provision to diminish
the size of Severe Need grants in the future if larger amounts are needed
to fund the hold-harmless protections. The total amount of Severe Need
grant funds available in fiscal year 2004 to distribute among the eligible
states was less than it would have been without the hold-harmless
deduction. In fiscal year 2004 not all 25 of the states eligible for
Severe Need grants made the required match in order to receive the grant.
Consequently, the size of the severe need grants received by each state
was not less than what they would have received if all eligible states
made the match. In future years, if all of the eligible states make the
match, and if there are also states that qualify to receive hold-harmless
funds, the Severe Need grant states would get less than the amounts they
would have otherwise received.

  Funding Impact of Using HIV Case Counts Would Depend on the Adequacy of HIV
             Reporting Systems and the Number of Reported HIV Cases

If HIV case counts had been used with AIDS case counts in allocating Title
II base funding, about half of the states would have received increased
funding and the other half would have received less funding.16 Under the
2000 CARE Act reauthorization, HIV case counts are required to be included
in CARE Act funding formulas no later than fiscal year 2007. While all
states have established HIV case reporting systems, there are currently
characteristics of these systems that limit the use of HIV case counts in
the distribution of CARE Act funds. In order to gauge the funding impact
of using the data as they currently exist, we developed two theoretical
approaches for doing so. Using these two approaches, we found that some
fiscal year 2004 Title II base funding would have shifted to southern
states if HIV case counts had been used with AIDS case counts in the
distribution of funds.17 We also found that funding would tend to shift to
jurisdictions with older HIV reporting systems, regardless of their
location. Changes in funding due to the inclusion of HIV cases would be
largely offset, at least initially, if the funding formulas retained
hold-harmless and minimum grant provisions.

Current HIV Case Reporting Systems Have Limitations for Providing Case Counts
for Funding Allocations

In its 2004 report, IOM identified several limitations in the ability of
states to provide HIV case counts for use in CARE Act funding
allocations.18 Among these limitations, IOM found that the maturity of HIV
case reporting systems varies widely across states. The earliest HIV
reporting systems were established in Colorado, Minnesota, and Wisconsin
in 1985, while five jurisdictions implemented their systems since 2003.
Case reporting systems need time to become fully mature and operational,
and it takes time to make practitioners aware of the requirement to report
new HIV cases and the methods for doing so. Existing cases also need to be
reported and entered into the system. States with newer systems may not
have collected and entered data on existing cases, and, consequently, may
underreport the number of HIV cases in the state. Underreporting of HIV
cases could result in jurisdictions receiving less funding than they would
be entitled to based on the actual number of HIV and AIDS cases.

16We chose Title II base grants to illustrate the effect of using HIV case
counts in funding formulas. All of our analyses were conducted using
estimated living AIDS cases.

17The Census Bureau lists the following jurisdictions as being in the
South: Alabama, Arkansas, Delaware, District of Columbia, Florida,
Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina,
Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

18Institute of Medicine of the National Academies, Measuring What Matters:
Alocation, Planning, and Quality Assessment for the Ryan White CARE Act
(Washington, D.C.: The National Academies Press, 2004), pp. 87-134.

IOM also found that differences in how states report HIV case counts to
CDC could preclude their use in the distribution of CARE Act funds. Some
state HIV case reporting systems are name-based while others are
code-based. Currently, CDC will only accept name-based case counts.19
Therefore, state-reported HIV cases that use codes rather than names would
not be counted in allocating CARE Act funds, if HIV case counts were used
in funding formulas. Twelve states, the District of Columbia, and
Philadelphia, PA, have some form of a code-based system rather than a
name-based system.20 CDC does not accept the code-based data principally
because methods have not been developed to make certain that a
code-reported HIV case is only being counted once across all reporting
jurisdictions.21 Table 7 shows whether state HIV case counts are accepted
by CDC and the year in which each state established its HIV reporting
system.

19CDC has established a set of performance standards for accepting case
counts from HIV reporting systems. These standards include that case
reporting be complete (greater than or equal to 85 percent of cases are
reported) and timely (greater than or equal to 66 percent of cases
reported within 6 months of diagnosis) and that evaluation studies
demonstrate that the approach used to conduct surveillance must result in
accurate case counts (less than or equal to 5 percent of reported cases
are duplicates). As of June 2005, CDC has determined that the only systems
which have been evaluated that meet these standards use confidential,
name-based reporting. Some jurisdictions use codes instead of names to
secure the privacy of the individuals being counted.

20Pennsylvania has a name-based reporting system for all areas of the
state except Philadelphia. The city received special permission to
establish a code-based system. Philadelphia implemented such a system in
2004, but it is separate from the Pennsylvania reporting system.

21CDC also has other concerns about code-based reporting. For example,
code-based reporting places a greater burden on health care providers
because submitted codes are frequently incomplete and require extensive
follow-up by surveillance personnel with providers to resolve potential
duplicate reports on the same person.

Table 7: CDC Acceptance of State HIV Case Counts and Year of Establishment
of State HIV Reporting Systems

              CDC-accepted                          Not accepted
Alabama (1988)   New Hampshire       California (2002)   Massachusetts     
                    (2005)b                                 (1998)            
Alaska (1999)                        Delaware (2001)                       
                    New Jersey (1992)                       Montana (2000)    
Arizona (1987)                       District of                           
                    New Mexico (1998)   Columbia (2001)     Oregon (2001)     
Arkansas (1989)                                                            
                    New York (2000)     Hawaii (2001)       Rhode Island      
Colorado (1985)                                          (2000)            
                    North Carolina      Illinois (1999)                       
Connecticut      (1990)                                  Vermont (2000)    
(2005)a                              Maine (1999)                          
                    North Dakota                            Washington (1999) 
Florida (1997)   (1988)              Maryland (1994)     
                                                            
Georgia (2004)   Ohio (1990)                             
                                                            
Idaho (1986)     Oklahoma (1988)                         
                                                            
Indiana (1988)   Pennsylvania                            
                    (2002)c                                 
Iowa (1998)                                              
                    Puerto Rico (2003)                      
Kansas (1999)                                            
                    South Carolina                          
Kentucky (2004)  (1986)                                  
                                                            
Louisiana (1993) South Dakota                            
                    (1988)                                  
Michigan (1992)                                          
                    Tennessee (1992)                        
Minnesota (1985)                                         
                    Texas (1999)                            
Mississippi                                              
(1988)           Utah (1989)                             
                                                            
Missouri (1987)  Virginia (1989)                         
                                                            
Nebraska (1995)  West Virginia                           
                    (1989)                                  
Nevada (1992)                                            
                    Wisconsin (1985)                        
                                                            
                    Wyoming (1989)                          

Sources: CDC, IOM, Connecticut, Kentucky, and Philadelphia.

aConnecticut established mandatory name-based HIV reporting in 2005.
Previously, name-based reporting was only required for pediatric cases.

bNew Hampshire established mandatory name-based HIV reporting in 2005.
Previously, HIV cases could be reported using the patient name, a code, or
no identifier at all.

cName-based HIV reporting has been established in all parts of
Pennsylvania except Philadelphia. Philadelphia was given permission by the
state to establish code-based HIV reporting, and the system began in 2004,
but data from Philadelphia are not accepted by CDC.

The Use of HIV Case Counts in Funding Formulas Would Change the Distribution of
CARE Act Funds

While we are aware of some of the limitations of HIV data, we used two
approaches to examine the potential impact of using HIV cases in addition
to AIDS cases on fiscal year 2004 Title II base grant distributions. We
conducted this analysis in light of the CARE Act requirement that HIV case
counts be used for the distribution of Title I and Title II formula grants
no later than fiscal year 2007. Some CARE Act fiscal year 2004 funding
would have shifted if HIV and AIDS case counts had been used to allocate
the funds. Our analyses indicate that at most 14 percent of CARE Act Title
II base funding would have shifted, with southern states being the primary
beneficiaries. Changes could have resulted from the number of reported HIV
cases and AIDS cases in each jurisdiction or differences in state HIV case
reporting systems. However, many of the funding changes in our model would
have been negated if we had applied hold-harmless and minimum grant
provisions.

  Methodological Approaches Used

We used two approaches to examine the impact of using HIV cases in
addition to AIDS cases22 on funding for Title II base grants in the 50
states, the District of Columbia, and Puerto Rico. We chose Title II base
grants to illustrate the effect of using HIV case counts in funding
formulas. Under the first approach, we used HIV case counts in addition to
AIDS case counts for the 36 jurisdictions from which CDC accepted HIV
data.23 We then supplemented these data with only the AIDS case counts CDC
received from the other jurisdictions because CDC does not accept their
HIV data. Consequently, for some states and metropolitan areas we used HIV
and AIDS case counts, but for others we used only AIDS case counts. This
approach reflects the data that would be used if funding allocations were
based on the HIV and AIDS case counts currently received by CDC. Under the
second approach, we used the same HIV and AIDS case counts for the 36
jurisdictions as our first approach, but supplemented these data with the
HIV case counts collected by the other 15 states and the District of
Columbia from which CDC did not accept HIV data. We obtained these HIV
case counts directly from these jurisdictions. For both approaches, we
calculated the percentage of cases in each jurisdiction and estimated the
fiscal year 2004 Title II base grant that each would have received. Our
initial analyses assume that funding was distributed equally per AIDS case
and that there were no hold-harmless or minimum grant provisions. We then
estimated the impact of the hold-harmless and minimum grant provisions.
Although there are limitations associated with each of the approaches,
they indicate the general impact of using HIV and AIDS cases to distribute
all CARE Act formula funding.

22We used estimated living AIDS cases in these analyses, which is the
measure used by HRSA in determining Title II base grants.

23In these analyses, Connecticut, Kentucky, and New Hampshire are
classified as not having their HIV case counts accepted by CDC. Our
analyses were conducted using fiscal year 2004 allocations, which were
based on case reports as of June 30, 2003. At that time, Connecticut had
name-based HIV reporting for only pediatric cases, but established
name-based reporting for all cases in 2005. Kentucky had code-based
reporting at that time and established name-based reporting in 2004. New
Hampshire established mandatory name-based reporting in 2005, but
previously accepted reports using the patient name, a code, or no
identifier.

  Impact on Title II Base Grants

Both approaches indicated that there would be some shifting of funds if
HIV and AIDS case counts had been used to allocate CARE Act Title II base
grants, with southern jurisdictions generally being among the areas that
would have received increased funding. Under the first approach-using HIV
and AIDS cases from 36 jurisdictions and only AIDS cases from 16
jurisdictions-about 14 percent or $38.9 million of Title II base grants
would have shifted among grantees. Twenty-seven grantees would have
received additional funding in their Title II base grants if HIV and AIDS
cases had been used to allocate funding instead of just AIDS cases. Of the
27 that would have received more funding, 12 were in the South.
Jurisdictions outside the South that would have received more funding
include Colorado, New Jersey, and Ohio. All 3 would have each received
more than $2 million in additional funding. Funding increases would have
ranged from less than $50,000 in Iowa to almost $5 million in North
Carolina, or from less than 5 to almost 100 percent. Twenty-five grantees
would have received less funding. California, Georgia, and Illinois would
have received the largest decreases in Title II base grants. Decreases
would have ranged from about $100,000 in Idaho and Wyoming to almost $12
million in California. Percentage decreases would have ranged from less
than 5 percent in New York to almost 80 percent in Montana.

The second approach - including the code-based HIV counts - yields a
smaller shift in funding. Under this approach, approximately 10 percent or
$28.4 million of fiscal year 2004 Title II base grants would have shifted.
Of the 26 grantees that would have received additional funding, 11 are in
the South. Funding increases for the 26 grantees that would have received
additional funding would have ranged from less than $50,000 in Maine to
about $4 million in North Carolina, or from 5 percent in Washington to 80
percent in Colorado. Among the states benefiting from this funding
approach, Maryland, North Carolina, and Virginia would each have received
increases of more than $2 million. Twenty-six grantees would have received
less funding. California, New York, and Georgia, would have received the
largest decreases. Decreases would have ranged from less than $50,000 in
Iowa to $5 million in California. Percentage decreases would have ranged
from less than 5 percent in Florida, Illinois, New Mexico, and Utah to 65
percent in North Dakota. Appendix II shows the results of these analyses
for each state.

  Differences in Case Reporting Systems Would Affect Distributions

One explanation for the changes in funding allocations when HIV and AIDS
cases are used instead of only AIDS cases is the maturity of state HIV
case reporting systems. We found that those states that would benefit from
the use of HIV cases tend to be those with the oldest HIV case reporting
systems. Those states with the oldest reporting systems include 11
southern states whose HIV reporting systems were implemented prior to
1995. As shown in table 8, states with long histories of collecting HIV
case counts tend to have many more HIV cases compared with their number of
AIDS cases than do states with less mature reporting systems. This is
likely because states with newer systems do not have reports on many cases
of HIV diagnosed before their reporting systems were established.24 This
can be illustrated by comparing Wisconsin and Delaware, 2 states with
similar numbers of AIDS cases. Wisconsin began reporting HIV cases in 1985
while Delaware began in 2001. As of June 2003, the 909 reported HIV cases
in Delaware was about 40 percent less than the 1,518 reported AIDS cases.
In Wisconsin, there were about 50 percent more reported HIV cases and AIDS
cases, or 2,287 HIV cases and 1,507 AIDS cases. This variability could be
reduced as Delaware identifies more preexisting HIV cases. However, the
variability between HIV cases and AIDS cases would remain if there was a
difference in the actual number of HIV cases.

Table 8: Comparison of Reported HIV and AIDS Cases as of June 2003

HIV case reporting system start                      Ratio of HIV cases to 
date                               Number of statesa            AIDS cases 
1985-1991                                         21                  1.42 
1992-1998                                         11                  1.01 
1999-2002                                         17                   .68 

Source: GAO analysis of CDC, HRSA, and state data.

aGeorgia and Puerto Rico implemented their HIV reporting systems after
2002. Kentucky changed from a code-based to a name-based system in 2004
and was unable to provide HIV case data. In this table, Connecticut is
classified as having established its reporting system in 2001 (and so is
included in the 1999-2002 time period) since state officials provided us
HIV case counts based on the system in operation as of June 2003. In this
table, New Hampshire is classified as having established its reporting
system in 1990 (and so is included in the 1985-1991 time period) because
state officials provided us HIV case counts based on the system in
operation as of June 2003.

24Other factors may also affect the ratio of HIV to AIDS cases in a
reporting system. For example, some states with newer reporting systems
were among the first to be affected by the HIV epidemic. This could mean
that in those states there are relatively more AIDS cases and the ratio of
HIV to AIDS cases would be lower than in states more recently experiencing
an HIV epidemic.

Under either approach, jurisdictions that would receive increased funding
allocations because of the use of HIV and AIDS case counts might do so
because other jurisdictions did not yet have an accurate measure of HIV
case counts. The larger the proportion of HIV cases within the total
number of HIV and AIDS cases in a jurisdiction, the more a jurisdiction
would benefit from the use of HIV cases in funding allocations. However,
this increased funding could simply be the effect of a state's older
reporting system, and not necessarily due to actual differences in the
number of HIV cases. IOM has reported that it could take from 18 months to
several years after the implementation of an HIV reporting system before
there would be valid estimates of the number of people living with HIV.
However, table 8 suggests that it could take even longer to get accurate
case counts. The data in table 8 suggest that as an HIV case reporting
system matures, it will record a higher ratio of HIV cases to AIDS cases.
One state official we spoke with said that it could take 5 to 6 years
before a reporting system's HIV case counts were complete.

Changes in Funding Would be Limited Initially if Certain Formula Provisions Were
Maintained

Changes in funding caused by shifting to HIV cases and AIDS cases would be
negated, at least initially, if the current hold-harmless or minimum grant
amounts were maintained. Consider the situation in which a state received
$2 million in its Title II CARE Act base grant award based on its AIDS
case count. In the following year, the formula is changed so that HIV and
AIDS cases are used to determine funding allocations, and the state is
then only entitled to $1 million. However, there is a hold-harmless
provision that guarantees the state 98 percent of what it received the
previous year. The state would receive 98 percent of its $2 million
allocation, or $1.96 million, largely offsetting the reduction in funding
due to the shift to HIV and AIDS cases. Minimum award amounts could also
affect the impact of using HIV and AIDS counts. If a jurisdiction
qualified for $100,000 formula funding using HIV and AIDS case counts, but
the minimum award was $500,000, the jurisdiction would not receive less
funding because of the change to HIV and AIDS counts.

Under our first approach, 5 percent of Title II base grants would shift
among grantees if the hold-harmless and minimum grant provisions were
maintained while 14 percent would shift if they were not included. Under
our second approach, 4 percent would shift instead of 10 percent.
California, which would have had large reductions under both approaches if
the hold-harmless provision was not maintained, would have had no change
in funding under either approach if the current hold-harmless provisions
were maintained. Appendix III shows the results of these analyses for each
state.

        State ADAP Eligibility Criteria and Funding Sources Vary Widely

Among state ADAP programs, there is wide variation in the eligibility
criteria used to determine who is covered for ADAP services and in the
funding sources available beyond each state's Title II ADAP base grant.
States have flexibility in determining their ADAP program eligibility
standards, including the income eligibility ceilings for ADAP clients,
caps on spending per client, and the HIV and AIDS drugs included in their
formulary. As a result, an individual eligible for ADAP services in one
state may not be eligible in another. There is also wide variability in
the additional funding sources that ADAPs may receive to help fund their
programs. Beyond each state's Title II ADAP base grant for providing HIV
and AIDS medications and related services, additional ADAP funding sources
may include Title II Severe Need grants, non-federal transfers of Title II
state or Title I EMA funds, state contributions, and other funding
sources. States with waiting lists for ADAP services do not fit any
particular pattern of eligibility criteria and funding sources.

Eligibility Criteria Contribute to Coverage Differences Among States

States set different eligibility criteria for their ADAP programs, so a
person with HIV or AIDS at a certain income level and needing medication
assistance may be an eligible ADAP client in one state, but not in
another. Eligibility also varies among state Medicaid programs, which may
provide HIV and AIDS services and drug assistance. The interaction between
these two programs can affect which clients are eligible for ADAP
services, and many individuals seeking ADAP coverage may not be aware that
they are eligible for drug assistance through Medicaid.

One eligibility requirement where there is considerable variation among
state ADAPs is the client income ceiling. The income ceilings among 52
state ADAPs for fiscal year 2004 ranged from the most restrictive at 125
percent of the federal poverty level,25 or $11,638, in North Carolina to
the most generous at 556 percent, or $51,764, in Massachusetts. Eleven
states had eligibility ceilings at 200 percent or less of the poverty
level.

Another eligibility criterion where there is wide variation among state
ADAPs is the number of HIV and AIDS drugs covered under a state program's
drug formulary. The number of drugs included in ADAP formularies in fiscal
year 2004 varied widely from Colorado with 20 drugs to four state
ADAPs-Massachusetts, New Hampshire, New Jersey, and Washington-with open
drug formularies.26 Thirty-nine ADAPs had 100 or fewer drugs, including 15
with fewer than 50 drugs on their formularies. The CARE Act allows states
to purchase health insurance to cover HIV and AIDS drugs for their
clients. HRSA requires an ADAP to demonstrate that the insurance includes
coverage for drugs comparable to those on the state's ADAP formulary.27

25The 2004 Department of Health and Human Services' federal poverty level
for a single person was $9,310; the poverty levels are higher for Alaska
($11,630) and Hawaii ($10,700). Poverty level is not defined for Puerto
Rico.

Determining whether an individual is eligible for state ADAP or state
Medicaid services is important because the ADAPs serve as the individual's
HIV and AIDS drug assistance program of last resort. Medicaid programs
provide HIV and AIDS health care services, including medications, to
eligible disabled individuals with low incomes. If an individual is
eligible for a state's Medicaid drug assistance, the state ADAP should not
provide the same services under its program. Twenty-three ADAPs reported
requiring clients to have been denied Medicaid eligibility before the ADAP
will cover them. To ensure that a prospective or current ADAP client is
not eligible to be served by Medicaid, 42 of the 52 state ADAPs reported
in ADAP grant year 200428 that they used a case manager review process to
monitor an ADAP client's Medicaid eligibility, and 40 of the 52 ADAPs also
reported using computer access to eligibility determinations to verify a
client's Medicaid and ADAP eligibility.

Because it is important to ensure continuing therapy for HIV and AIDS
clients once they begin taking medications, states may limit the number of
ADAP clients they serve to prevent a budget shortfall. This could result
in eligible clients being on an ADAP waiting list. States also use a
variety of ADAP eligibility restrictions to limit the number of clients
they serve. Of the 52 state ADAPs, 36 reported eligibility restrictions
for ADAP grant year 2004, and 20 of the 36 used more than one. The
restrictions most used were (1) an annual cap on individual incomes by 20
ADAPs, (2) a limitation on an individual's assets by 16 ADAPs, (3) capping
ADAP enrollment by 7 ADAPs, (4) sliding scale copayments paid by
individuals by 7 ADAPs, and (5) capping the amount expended per client for
all HIV and AIDS drugs by 6 ADAPs. Appendix IV provides a state-by-state
summary of the reported restrictions.

26In the state ADAP profile reports for ADAP grant year 2004,
Massachusetts, New Hampshire, and New Jersey each reported having 1,000
drugs on their ADAP formularies, and Washington reported it had 125 drugs
on its formulary.

27In fiscal year 2003, 20 states reported that they used either funds from
their Title II base ($3 million) or ADAP ($23.5 million) grants to
purchase health care insurance.

28ADAP grant year 2004 covers the period April 1, 2004 through March 31,
2005.

A Large Percentage of ADAPs' Funds Received from Sources Other than the ADAP
Base Grant

In addition to their Title II ADAP base grants, 46 of the 52 states ADAPs
received funding from other sources for their programs in fiscal year
2004. There were five sources of additional funding across these 46 state
ADAPs: (1) $20.8 million in Title II Severe Need grants (including $4.5
million in state match funds), (2) $26.9 million from Title II state
funding transfers, (3) $10.9 million from Title I EMA funding transfers,
(4) $194.8 million in state contributions, and (5) $169.3 million in other
funds. When the additional funding source totals are compared among states
as a percentage of the ADAP's CARE Act base grant, and as an amount per
AIDS case, there is a significant range among the states. Appendix V
provides a state-by-state summary of additional ADAP funding and the base
grant and per AIDS case comparisons.

State ADAPs that received funding from sources other than their Title II
base grant award include

           o  Sixteen of the 25 states eligible for ADAP Severe Need grants
           received grant amounts ranging from about $37,000 in Montana to
           about $6 million in Texas. States eligible for these grants must
           agree to match 25 percent of the funds.29 
           o  Eighteen ADAPs reported receiving transfers from their states'
           Title II base grants ranging from about $65,000 in Maryland to
           $12.2 million in California.
           o  Nine of the 24 states with EMAs reported receiving Title I fund
           transfers from their EMAs for their ADAPs ranging from more than
           $65,000 for Nevada to about $6 million for New York.
           o  Thirty-five ADAPs reported receiving state contributions from
           their states ranging from about $8,000 in Ohio to about $64
           million in California.
           o  Thirty-two ADAPs reported other funding sources ranging from
           about $7,000 in Montana to $64.5 million in New York. Other
           funding sources include additional funds from drug rebates30 and
           HRSA approved carryover of ADAP CARE Act funds from one year to
           the next.

           Among states with additional funding sources, there is a
           significant range in amounts per AIDS case and percentages of the
           ADAP base grants. The highest amount of additional funding
           received per AIDS case was $3,604, or 171 percent of the base
           grant in Idaho and the lowest was $61 per AIDS case, or 3 percent
           of the base grant in the District of Columbia. ADAPs in six states
           did not receive any additional funding-Iowa, New Hampshire, New
           Mexico, Tennessee, Utah, and Wyoming.

           During fiscal years 2002 through 2004, some states had people
           eligible for their ADAPs' services on waiting lists and the states
           with ADAP waiting lists have remained relatively static in fiscal
           years 2002 through 2004. Sixteen, or about one-third, of the 52
           states had ADAP waiting lists for at least 1 month during these 3
           years. Seven of the 16 states had ADAP waiting lists in all 3
           years. (See table 9.)

           Table 9: States with ADAP Waiting Lists in at Least 1 Month of a
           Fiscal Year, Fiscal Years 2002-04

           Source: HRSA and GAO analysis.

           The funding sources and eligibility criteria for states with
           waiting lists have varied just as considerably as for states
           without waiting lists, and there is no clear pattern between a
           state's funding sources or eligibility criteria and the existence
           of a waiting list. While 33 states that received additional funds
           did not have an ADAP waiting list in 2004, 13 of the 14 states
           with waiting lists also received additional funding beyond their
           ADAP base grant. For example, for

           o  Title II Severe Need grants: Eight of the 16 states that
           received Severe Need grants had waiting lists. Three of the 9
           eligible states that did not apply for Severe Need grants in
           2004-Alaska, Iowa, and South Dakota-also had ADAP waiting lists.
           o  Title I EMA transfers: One state ADAP of the nine that received
           a Title I transfer-Colorado-had an ADAP waiting list.
           o  Title II state transfers: Eight of the 18 ADAPs receiving Title
           II transfers had waiting lists.
           o  State funds: Nine of the 35 ADAPs that received state funds had
           waiting lists.
           o  Other funding: Of the 32 ADAPs reporting other funding sources,
           10 had ADAP waiting lists.

           Of the 14 states with ADAP waiting lists, 5 were among the top 10
           for additional funding per AIDS case received-Idaho (1), South
           Dakota (2), Oregon (3), North Carolina (7), and Colorado (8). The
           remaining 9 states with waiting lists and their per AIDS case
           ranks were Montana (12), Alabama (18), Nebraska (23), Indiana
           (24), West Virginia (28), Kentucky (33), Arkansas (34), Alaska
           (42), and Iowa with no additional funds.

           There also seems to be no clear pattern between eligibility
           criteria-such as a low income eligibility ceiling or a limited
           drug formulary-and a waiting list of clients that a state ADAP
           deems eligible but is unable to serve. For example, for

           o  Client income eligibility levels: North Carolina with the most
           restrictive level at 125 percent of the poverty level had a
           waiting list, and Massachusetts with the most generous level at
           556 percent had no waiting list.
           o  Eligibility restrictions: Among the seven ADAPs that capped
           their ADAP enrollment, six had waiting lists. Five ADAPs that
           capped the amount they expend per client for all HIV and AIDS
           drugs included two states with waiting lists.
           o  Drug formularies: Among the 39 ADAPs with 100 or fewer drugs on
           their formularies, 13 had waiting lists.

           When eligible clients are on state ADAP waiting lists, there are
           limited medication assistance options available to help them until
           they can be served by the ADAP. HRSA officials told us that case
           managers, who are not ADAP employees, are to assist ADAP-eligible
           clients in accessing options to act as stopgaps until clients can
           be provided ADAP services. Among the options are pharmaceutical
           manufacturers' patient assistance programs that provide free or
           cost-reduced drugs and non-ADAP pharmacy assistance programs
           provided by some EMAs using their Title I funds.31

           The services provided under the Care Act have filled important
           gaps in communities throughout the country, but as Congress
           reviews this act, we believe it is important to understand how
           variable this funding can be. Today I have highlighted a few of
           the issues that are relevant to this review. For each of these
           issues, we found that the provisions of the CARE Act have impacted
           the extent to which funds have been distributed in proportion to
           the incidence of HIV and AIDS. It is clear that the level of
           funding available per case is quite variable depending upon where
           an individual lives. The way cases from EMAs are counted twice,
           the tiered allocation of funds to Emerging Communities, the
           hold-harmless provisions, and the grandfathering of EMAs have all
           resulted in considerably more funding going to some communities
           than others with equivalent numbers of cases. The inclusion of HIV
           cases in the funding formulas, while improving on the basis for
           funding allocations by reflecting cases that have not progressed
           to AIDS, would also result in variable funding depending upon the
           type and maturity of the reporting system used in each state. In
           addition, the flexibility given to states to shift funds,
           establish eligibility criteria, place limits on the medications
           covered, and cap enrollment, has resulted in great variability for
           ADAP services depending upon where an individual lives.

           Mr. Chairman, this completes my prepared statement. I would be
           happy to respond to any questions you or other members of the
           subcommittee may have at this time.

           For future contacts regarding this testimony, please call Marcia
           Crosse at (202) 512-7118. Other individuals who made key
           contributions include Robert Copeland, Louise Duhamel, Cathy
           Hamann, James McClyde, Opal Winebrenner, and Craig Winslow.

           Sources: GAO analysis of HRSA data.

           aState received a Title II base award of $500,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           bState received a Title II base award of $200,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           Sources: GAO analysis of CDC and HRSA data for fiscal year 2004.

           Notes: Rounded to nearest $10,000. For this testimony, we chose
           Title II base grants to illustrate the effect of using HIV case
           counts in funding formulas.

           aState received a Title II base award of $500,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           bState received a Title II base award of $200,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           Sources: GAO analysis of CDC and HRSA data for fiscal year 2004.

           Notes: Rounded to nearest $10,000. For this testimony, we chose
           Title II base grants to illustrate the effect of using HIV case
           counts in funding formulas.

           aState received a Title II base award of $500,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           bState received a Title II base award of $200,000, the minimum it
           could receive based on the number of AIDS cases in the state.

           Source: HRSA and state ADAP profile reports.

           Note: The ADAP 2004 grant year covers April 1, 2004, through March
           31, 2005.

29According to HRSA, Puerto Rico is not required to provide matching funds
for Severe Need grants.

30ADAPs can receive drug rebates through (1) the federal Section 340B drug
discount program, (2) their states' negotiated rebates, or (3) the
National Alliance of State and Territorial AIDS Directors' negotiated
rebates.

Eligibility Criteria and Funding Sources Also Vary Among States with Waiting
Lists

         State          FY2002 FY2003 FY2004 
1     Alabama          o      o      o    
2     Alaska                  o      o    
3     Arkansas                       o    
4     Colorado                o      o    
5     Georgia          o           
6     Idaho                   o      o    
7     Indiana          o      o      o    
8     Iowa                           o    
9     Kentucky         o      o      o    
10    Montana          o      o      o    
11    Nebraska                o      o    
12    North Carolina   o      o      o    
13    Oregon           o      o      o    
14    South Dakota     o      o      o    
15    West Virginia           o      o    
16    Wyoming                 o    
Total                  8      13     14   

                            Concluding Observations

31In fiscal year 2003, 33 EMAs in 16 states used $33.3 million of their
Title I funds to provide HIV and AIDS pharmaceutical assistance.

                          Contact and Acknowledgments

Appendix I: Combined CARE Act Title I and Title II Funding by State,
Fiscal Year 2004 Appendix I: Combined CARE Act Title I and Title II
Funding by State, Fiscal Year 2004

                        Combined Title I        Percent of  Total Title I and 
                            and Title II   AIDS AIDS cases    Title II awards 
State/territory                awards  cases    in EMAs      per AIDS case 
Alabama                   $12,142,447  3,320         0%             $3,657 
Alaskaa                       974,705    224          0              4,351 
Arizona                    18,635,537  3,978       73.5              4,685 
Arkansas                    4,933,831  1,466          0              3,366 
California                223,607,373 42,479       88.9              5,264 
Colorado                   12,949,158  2,658       75.0              4,872 
Connecticut                26,797,308  5,363       91.4              4,997 
Delaware                    5,340,795  1,518          0              3,518 
District of Columbia       33,288,417  6,561      100.0              5,074 
Florida                   182,771,752 38,101       77.3              4,797 
Georgia                    54,483,301 11,226       67.6              4,853 
Hawaii                      3,298,130    988          0              3,338 
Idahoa                      1,019,352    220          0              4,633 
Illinois                   60,837,359 12,203       87.9              4,985 
Indiana                    11,402,950  3,095          0              3,684 
Iowa                        2,067,375    619          0              3,340 
Kansas                      3,881,999    959       34.2              4,048 
Kentucky                    7,170,005  1,937          0              3,702 
Louisiana                  29,740,454  6,555       48.1              4,537 
Mainea                      1,333,909    395          0              3,377 
Maryland                   61,230,030 12,203       93.6              5,018 
Massachusetts              34,432,147  6,960       83.2              4,947 
Michigan                   24,046,130  5,215       68.8              4,611 
Minnesota                   7,139,028  1,427       88.7              5,003 
Mississippi                 9,454,950  2,747          0              3,442 
Missouri                   16,501,234  3,512       76.8              4,699 
Montanaa                      847,196    147          0              5,763 
Nebraska                    1,887,660    525          0              3,596 
Nevada                     10,757,214  2,246       83.3              4,789 
New Hampshirea              1,864,452    358       69.0              5,208 
New Jersey                 80,222,837 16,531       84.8              4,853 
New Mexico                  3,338,463    982          0              3,400 
New York                  298,549,361 59,226       88.6              5,041 
North Carolina             22,668,734  6,083        0.1              3,727 
North Dakotab                 292,543     43          0              6,803 
Ohio                       20,249,202  5,171       29.2              3,916 
Oklahoma                    6,343,022  1,687          0              3,760 
Oregon                      9,084,990  2,003       68.9              4,536 
Pennsylvania               59,766,256 12,840       67.4              4,655 
Puerto Rico                53,026,882 10,711       79.9              4,951 
Rhode Island                3,189,276    906          0              3,520 
South Carolina             20,705,328  5,563          0              3,722 
South Dakotaa                 705,706     97          0              7,275 
Tennessee                  21,178,234  5,080          0              4,169 
Texas                     118,965,938 23,922       74.5              4,973 
Utah                        3,235,191    882          0              3,668 
Vermonta                      883,059    181          0              4,879 
Virginia                   32,149,863  6,872       63.2              4,678 
Washington                 17,349,313  3,776       69.8              4,595 
West Virginia               2,335,062    618       11.3              3,778 
Wisconsin                   5,603,506  1,507        0.4              3,718 
Wyomingb                      360,347     76          0              4,741 

Appendix II: Estimated Funding Changes Using HIV and AIDS Cases without
Hold-Harmless and Minimum Grant Provisions Appendix II: Estimated Funding
Changes Using HIV and AIDS Cases without Hold-Harmless and Minimum Grant
Provisions

                     Change in Title II case       Change in Title II base
                   funding if CDC-accepted HIV   funding if HIV case counts
                    case counts and AIDS case   from all states and AIDS case
                       counts were used to           counts were used to
                       distribute funding            distribute funding
                                       Percent                        Percent 
State/territory    Dollar change     change        Dollar change    change 
Alabama               $2,480,000         61           $1,950,000        48 
Alaskaa                 -270,000        -55             -290,000       -58 
Arizona                1,220,000         38              810,000        25 
Arkansas                 840,000         47              630,000        35 
California           -11,790,000        -38           -5,020,000       -16 
Colorado               2,090,000         99            1,700,000        80 
Connecticut           -1,360,000        -36           -1,420,000       -38 
Delaware                -750,000        -41             -230,000       -13 
District of           -1,520,000        -35           -1,800,000       -42 
Columbia                                                         
Florida                2,920,000         10             -150,000        -1 
Georgia               -3,550,000        -38           -4,090,000       -43 
Hawaii                  -490,000        -41             -180,000       -15 
Idahoa                   -80,000        -17             -120,000       -24 
Illinois              -3,210,000        -36              -70,000        -1 
Indiana                1,170,000         31              760,000        20 
Iowa                      20,000          2               40,000         6 
Kansas                   210,000         21             -110,000       -11 
Kentucky                -960,000        -41           -1,070,000       -45 
Louisiana              2,070,000         33            1,340,000        22 
Mainea                  -210,000        -43               40,000         9 
Maryland              -3,030,000        -36            3,000,000        35 
Massachusetts         -1,920,000        -37              510,000        10 
Michigan               1,160,000         27              660,000        15 
Minnesota                660,000         64              500,000        49 
Mississippi            1,580,000         47            1,180,000        35 
Missouri               1,260,000         45              880,000        32 
Montanaa                -390,000        -79             -170,000       -34 
Nebraska                 140,000         23               80,000        13 
Nevada                   830,000         50              600,000        35 
New Hampshirea          -310,000        -63             -122,000       -24 
New Jersey             2,510,000         20            1,120,000         9 
New Mexico                50,000          4              -60,000        -5 
New York                -600,000         -1           -4,640,000       -11 
North Carolina         4,910,000         66            3,910,000        53 
North Dakotab           -124,000        -62             -130,000       -65 
Ohio                   2,360,000         43             1,700,00        31 
Oklahoma                 980,000         48              730,000        36 
Oregon                  -630,000        -38             -290,000       -17 
Pennsylvania          -2,370,000        -22           -3,120,000       -29 
Puerto Rico           -2,970,000        -36           -3,460,000       -42 
Rhode Island            -450,000        -41             -180,000       -16 
South Carolina         2,280,000         34            1,540,000        23 
South Dakotaa           -290,000        -58             -310,000       -62 
Tennessee              2,160,000         35            1,480,000        24 
Texas                    840,000          4           -1,010,000        -5 
Utah                      40,000          4              -50,000        -5 
Vermonta                -370,000        -74             -260,000       -53 
Virginia               3,040,000         51            2,260,000        38 
Washington            -1,170,000        -38              160,000         5 
West Virginia            170,000         24               90,000        13 
Wisconsin                910,000         50              690,000        37 
Wyomingb                 -90,000        -47             -100,000       -51 

Appendix III: Estimated Funding Changes Using HIV and AIDS Cases with
Hold-Harmless and Minimum Grant Provisions Appendix III: Estimated Funding
Changes Using HIV and AIDS Cases with Hold-Harmless and Minimum Grant
Provisions

                    Change in Title II               Change in Title II base
                      base funding if                  funding if HIV case
                   CDC-accepted HIV case             counts from all states
                   counts and AIDS case             and AIDS case counts were
                    counts were used to                used to distribute
                    distribute funding                       funding 
                         Dollar  Percent                              Percent 
State/territory       change   change               Dollar change   change 
Alabama           $1,120,000       28   $960,000               24 
Alaskaa                    0        0          0                0 
Arizona              610,000       19    410,000               13 
Arkansas             290,000       17    230,000               13 
California                 0        0          0                0 
Colorado           1,530,000       72  1,340,000               63 
Connecticut         -150,000       -4   -150,000               -4 
Delaware            -410,000      -22   -410,000              -22 
District of         -940,000      -22   -940,000              -22 
Columbia                                                          
Florida           -1,380,000       -5 -2,930,000              -10 
Georgia           -1,350,000      -14 -1,350,000              -14 
Hawaii               -70,000       -6    -70,000               -6 
Idahoa                     0        0          0                0 
Illinois          -1,780,000      -20   -790,000               -9 
Indiana              130,000        4     20,000                1 
Iowa                 -90,000      -11    -90,000              -11 
Kansas                     0        0          0                0 
Kentucky            -400,000      -17   -400,000              -17 
Louisiana            660,000       11    370,000                6 
Mainea                     0        0          0                0 
Maryland          -1,650,000      -20  2,050,000               24 
Massachusetts       -620,000      -12     10,000                0 
Michigan             350,000        8    120,000                3 
Minnesota            460,000       45    370,000               36 
Mississippi          550,000       17    430,000               13 
Missouri             710,000       26    530,000               19 
Montanaa                   0        0          0                0 
Nebraska             -20,000       -3    -40,000               -6 
Nevada               520,000       31    390,000               23 
New Hampshirea             0        0          0                0 
New Jersey           600,000        5          0                0 
New Mexico           -70,000       -6    -70,000               -6 
New York          -1,730,000       -4 -1,730,000               -4 
North Carolina     2,340,000       32                   2,050,000       28 
North Dakotab        300,000      150                     300,000      150 
Ohio                 890,000       16                     660,000       12 
Oklahoma             340,000       17                     270,000       13 
Oregon              -130,000       -8                    -130,000       -8 
Pennsylvania      -1,840,000      -17                  -1,840,000      -17 
Puerto Rico         -320,000       -4                    -320,000       -4 
Rhode Island         -30,000       -2                     -30,000       -2 
South Carolina       390,000        6                     180,000        3 
South Dakotaa              0        0                           0        0 
Tennessee            420,000        7                     220,000        4 
Texas              1,140,000       -6                  -1,140,000       -6 
Utah                 -60,000       -6                     -60,000       -6 
Vermonta                   0        0                           0        0 
Virginia           1,510,000       26                   1,200,000       20 
Washington          -200,000       -7                    -180,000       -6 
West Virginia        -13,000       -2                     -40,000       -5 
Wisconsin            340,000       18                     270,000       15 
Wyomingb             300,000      150                     300,000      150 

Appendix IV: ADAP Program Eligibility Restrictions Reported by 52 ADAPs,
ADAP Grant Year 2004 Appendix IV: ADAP Program Eligibility Restrictions
Reported by 52 ADAPs, ADAP Grant Year 2004

                                             Restrictions
                                                                            Capped HIV/  
                                                                                AIDS     
                                                                            expenditures 
                                                                            or had wait  
                                                                              lists or   
                                                               Capped HIV/    both for   
                                    Sliding             Annual     AIDS       protease   
                Capped     Fixed     scale     Asset    income expenditures  inhibitor   
ADAPs         enrollment copayment copayment limitation  cap   per patient     drugs     
Alabama                                                                     
Alaska                                                                      
Arizona                                                                     
Arkansas          o                                       o                 
California                             o                  o                 
Colorado          o                              o        o                      o       
Connecticut                                                                 
Delaware                               o         o                          
District of                                      o        o                 
Columbia                                                                    
Florida                                          o        o                 
Georgia                                          o        o                 
Hawaii                                           o                          
Idaho             o                                                 o       
Illinois                                                            o       
Indiana                                                                     
Iowa                                                                        
Kansas                       o                                              
Kentucky                                         o        o                 
Louisiana                                        o                          
Maine                                                                       
Maryland                               o                  o                 
Massachusetts                                             o                 
Michigan                                                                    
Minnesota                                        o        o                 
Mississippi                                               o                 
Missouri                                                            o       
Montana           o                                                         
Nebraska                                                                    
Nevada                                           o        o                 
New Hampshire                                                               
New Jersey                                                o                 
New Mexico                                       o        o                 
New York                                         o        o                 
North             o                                                              o       
Carolina                                                                    
North Dakota                                              o                 
Ohio                                                      o                 
Oklahoma          o                                                 o       
Oregon                                 o         o        o                 
Pennsylvania                                              o                 
Puerto Rico                                                                 
Rhode Island                                              o                 
South                                  o                                    
Carolina                                                                    
South Dakota      o                                                 o       
Tennessee                                        o                          
Texas                        o                                              
Utah                                   o         o                          
Vermont                                                                     
Virginia                                                                    
Washington                             o         o                          
West Virginia                                                               
Wisconsin                                                                   
Wyoming                                                                     
Total             7          2         7         16       20        5            2       

Appendix V: Additional ADAP Funding and its Percentage of the CARE ACT
Title II ADAP Base Grants and per AIDS Case by State Appendix V:
Additional ADAP Funding and its Percentage of the CARE Act Title II ADAP
Base Grants and per AIDS Case by State

Table 10: Additional ADAP Funding Sources, Fiscal Year 2004

              Title II Severe Need                                                                                                         
              grant                                                                                                                        
                               State  Title II                                                                                             
                            matching  non-ADAP                                                                                       Total 
                           funds for      base                                                                            Other additional
              ADAP Severe     Severe     grant                                                                    State funding       ADAP
State ADAP     Need grant Need grant  transfer                                             Title I EMA transfer funding sources    funding
Alabama          $824,913   $206,228                     $0           B   $2,500,000           $0   $3,531,141 
Alaska                  0          0                      0           B       50,000            0       50,000 
Arizona                 0          0                      0           0    1,000,000       78,546    1,078,546 
Arkansas                A          A                      0           B      330,810      393,000      723,810 
California              A          A             12,168,628           0   63,934,245   47,370,750  123,473,623 
Colorado          660,427    165,107                136,000     560,254      934,134    3,212,522    5,668,444 
Connecticut             A          A                      0           0      606,678            0      606,678 
Delaware                A          A                      0           B            0      832,382      832,382 
D.C.                    A          A                      0           0      400,000            0      400,000 
Florida                 A          A              1,916,336           0    9,000,000            0   10,916,336 
Georgia         2,789,298    697,324                      0   1,540,022   11,305,339            0   16,331,983 
Hawaii                  A          A                      0           B      440,535            0      440,535 
Idaho              54,663     13,666                261,150           B      163,461      300,000      792,940 
Illinois                A          A                      0           0    7,000,000    5,619,843   12,619,843 
Indiana                 A          A              2,720,419           B            0      102,331    2,822,750 
Iowa                    0          0                      0           B            0            0            0 
Kansas                  A          A                      0           B      400,000      550,000      950,000 
Kentucky          481,282    120,320                100,000           B       90,000      199,462      991,064 
Louisiana       1,628,705    407,176                      0           0            0      422,638    2,458,519 
Maine                   0          0                      0           B       57,638      125,327      182,965 
Maryland                A          A                 65,250     105,925            0    2,100,000    2,271,175 
Massachusetts           A          A                      0     104,819      747,990    1,900,000    2,788,809 
Michigan                A          A                      0           0            0    5,500,000    5,500,000 
Minnesota               A          A                      0           0    1,100,000    2,743,522    3,843,522 
Mississippi             A          A              1,093,008           B      750,000            0    1,843,008 
Missouri                A          A                771,167   1,549,422      669,000    1,913,547    4,921,136 
Montana            36,525      9,131                178,548           B            0        7,120      231,324 
Nebraska          130,445     32,611                 74,000           B      115,938      160,000      512,994 
Nevada                  A          A                      0      65,250    1,350,947            0    1,416,197 
New Hampshire           A          A                      0           B            0            0            0 
New Jersey              A          A                      0           0            0   13,050,000   13,050,000 
New Mexico              A          A                      0           B            0            0            0 
New York                A          A              2,524,145   5,870,000   33,000,000   64,500,000  105,894,145 
North           1,511,429    377,857                      0           B    8,355,195    3,338,000   13,582,481 
Carolina                                                                                                       
North Dakota            0          0                 85,400           B            0       32,000      117,400 
Ohio                    A          A                      0     300,000        7,843       20,000      327,843 
Oklahoma          419,165    104,791                486,486          NA      786,000      361,000    2,157,442 
Oregon                  A          A                      0           0      300,000    5,650,000    5,950,000 
Pennsylvania            A          A                      0           0   10,452,000    6,044,000   16,496,000 
Puerto Rico     2,661,337         0a              3,455,671           0    2,093,000            0    8,210,008 
Rhode Island            A          A                      0           B            0      700,000      700,000 
South           1,382,225    345,556                      0           B      500,000            0    2,227,781 
Carolina                                                                                                       
South Dakota            0          0                330,744           B            0            0      330,744 
Tennessee               0          0                      0           B            0            0            0 
Texas           5,943,843  1,485,961                500,000           0   28,538,504            0   36,468,308 
Utah                    0          0                      0           B            0            0            0 
Vermont                 0          0                      0           B      175,000      130,000      305,000 
Virginia        1,707,470    426,867                      0           0    2,612,200            0    4,746,537 
Washington              A          A                      0     800,487    4,842,484      925,000    6,567,971 
West Virginia     153,553     38,388                 75,000           B            0      180,000      446,941 
Wisconsin         374,441     93,610                      0           B      186,658      855,317    1,510,026 
Wyoming                 A          A                      0           B            0            0            0 
Total         $20,759,721 $4,524,593            $26,941,952 $10,932,179 $194,795,599 $169,334,307 $427,288,351 

Source: HRSA and GAO analysis.

A State was not eligible for a grant.

B State did not have an EMA.

aPuerto Rico is not required to provide match funds.

Table 11: Additional ADAP Funding as Percentage of ADAP Base Grant and per
AIDS Case, Fiscal Year 2004

                                                          Total               
                                                additional ADAP               
                                                     funding as         Total 
                            Total                 percentage of    additional 
                  additional ADAP     ADAP base   the ADAP base  ADAP funding
State ADAP             funding         grant           grant per AIDS case
Alabama             $3,531,141    $7,004,635             50%        $1,064 
Alaska                  50,000       472,602             11%           223 
Arizona              1,078,546     8,392,903             13%           271 
Arkansas               723,810     3,116,716             23%           494 
California         123,473,623    89,623,465            138%         2,907 
Colorado             5,668,444     5,607,928            101%         2,133 
Connecticut            606,678    11,315,018              5%           113 
Delaware               832,382     3,202,722             26%           548 
D.C.                   400,000    13,842,594              3%            61 
Florida             10,916,336    80,386,630             14%           287 
Georgia             16,331,983    23,684,951             69%         1,455 
Hawaii                 440,535     2,084,512             21%           446 
Idaho                  792,940       464,163            171%         3,604 
Illinois            12,619,843    25,746,254             49%         1,034 
Indiana              2,822,750     6,529,924             43%           912 
Iowa                         0     1,305,985              0%             0 
Kansas                 950,000     2,045,495             46%           991 
Kentucky               991,064     4,086,741             24%           512 
Louisiana            2,458,519    13,829,935             18%           375 
Maine                  182,965       833,383             22%           463 
Maryland             2,271,175    25,746,254              9%           186 
Massachusetts        2,788,809    14,684,416             19%           401 
Michigan             5,500,000    11,002,763             50%         1,055 
Minnesota            3,843,522     3,010,727            128%         2,693 
Mississippi          1,843,008     5,795,703             32%           671 
Missouri             4,921,136     7,409,723             66%         1,401 
Montana                231,324       310,145             75%         1,574 
Nebraska               512,994     1,107,661             46%           977 
Nevada               1,416,197     4,738,678             30%           631 
New Hampshire                0       755,319              0%             0 
New Jersey          13,050,000    34,877,598             37%           789 
New Mexico                   0     2,127,024              0%             0 
New York           105,894,145   124,956,784             85%         1,788 
North Carolina      13,582,481    12,834,095            106%         2,233 
North Dakota           117,400        92,543            127%         2,730 
Ohio                   327,843    10,909,930              3%            63 
Oklahoma             2,157,442     3,655,707             59%         1,279 
Oregon               5,950,000     4,225,989            141%         2,971 
Pennsylvania        16,496,000    27,090,216             61%         1,285 
Puerto Rico          8,210,008    22,598,388             36%           767 
Rhode Island           700,000     1,911,506             37%           773 
South Carolina       2,227,781    11,736,984             19%           400 
South Dakota           330,744       204,654            162%         3,410 
Tennessee                    0    12,018,438              0%             0 
Texas               36,468,308    50,471,351             72%         1,524 
Utah                         0     1,980,565              0%             0 
Vermont                305,000       382,007             80%         1,685 
Virginia             4,746,537    14,498,751             33%           691 
Washington           6,567,971     7,966,718             82%         1,739 
West Virginia          446,941     1,303,875             34%           723 
Wisconsin            1,510,026     3,179,514             47%         1,002 
Wyoming                      0       160,347              0%             0 
Total             $427,288,351 $ 727,320,929             59%             - 

Source: HRSA and GAO analysis.

Appendix V: Additional APercentage of the CARE ABase Grants and per
AIDRelated GAO Products

Ryan White CARE ACT: Tie I Funding or San Francisco. GAO/HEHS-00-189R .
Washington, D.C.: August 24, 2000.

Ryan White CARE Act: Opportunities to Enhance Funding Equity.
GAO/T-HEHS-00-150 . Washington, D.C.: July 11, 2000.

HIV/AIDS: Use of Ryan Whie CARE Act and Other Asssance GrantFunds.
GAO/HEHS-00-54 . Washington, D.C.: March 1, 2000.

HIV/AIDS Drugs: Funding Impcatons o New Combnaon Therapes or Federal and
State Programs. GAO/HEHS-99-2 . Washington, D.C.: October 14, 1998.

Revisng Ryan Whie Funding Formulas. GAO/HEHS-96-116R . Washington, D.C.:
March 26, 1996.

Ryan White CARE Act o1990: Opporunities to Enhance Funding Equity.
GAO/HEHS-96-26 . Washington, D.C.: November 13, 1995.

Ryan White CARE Act: Access o Services by Mnories, Women, and Substance
Abusers. GAO/T-HEHS-95-112 . Washington, D.C.: July 17, 1995.

Ryan White CARE Act o1990: Opporunites Are Avaiabe to Improve Funding
Equiy. GAO/T-HEHS-95-126 . Washington, D.C.: April 5, 1995.

Folowup on Ryan Whe Testmony. GAO/HEHS-95-119R . Washington, D.C.: March
31, 14, 1995.

Ryan White CARE ACT of 1990: Opportunies Are Avaiabe o Improve Funding
Equiy. GAO/T-HEHS-95-91 . Washington, D.C.: February 22, 1995.

Ryan White Funding Formulas. GAO/HEHS-95-79R . Washington, D.C.: February
14, 1995.

Ryan White CARE Act: Access o Services by Mnories, Women, and Substance
Abusers. GAO/HEHS-95-94 . Washington, D.C.: January 13, 1995.

(290468)

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www.gao.gov/cgi-bin/getrpt? GAO-05-841T .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Marcia Crosse at (202) 512-7118.

Highlights of GAO-05-841T , a testimony before the Subcommittee on Federal
Financial Management, Government Information, and International Security,
Committee on Homeland Security and Governmental Affairs, U.S. Senate

June 23, 2005

RYAN WHITE CARE ACT

Factors that Impact HIV and AIDS Funding and Client Coverage

The Ryan White Comprehensive AIDS Resources Emergency Act (CARE Act) was
enacted in 1990 to respond to the needs of individuals and families living
with the Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency
Syndrome (AIDS). In fiscal year 2004, over $2 billion in funding was
provided through the CARE Act, the majority of which was distributed
through Title I grants to eligible metropolitan areas (EMA) and Title II
grants to states, the District of Columbia, and territories. Titles I and
II use formulas to distribute grants according to a jurisdiction's
reported count of AIDS cases. Title II includes grants for
state-administered AIDS Drug Assistance Programs (ADAP), which provide
medications to HIV-infected individuals.

GAO was asked to discuss the distribution of funding under the CARE Act.
This testimony presents preliminary findings on (1) the impact of CARE Act
provisions that distribute funds based upon the number of AIDS cases in
metropolitan areas, (2) the impact of CARE Act provisions that limit
annual funding decreases, (3) the potential shifts in funding among
grantees if HIV case counts were incorporated with the AIDS cases that are
currently used in funding formulas, and (4) the variation in eligibility
criteria and funding sources among state ADAPs.

Under the CARE Act, GAO's preliminary findings show that the amount of
funding per AIDS case varied among states and metropolitan areas in fiscal
year 2004. Some CARE Act provisions that distribute funds based on the
AIDS case count within metropolitan areas result in differing amounts of
funding per case. In particular, when a state or territory has an EMA
within its borders, the cases within that EMA are counted twice during the
distribution of CARE Act funds-once to determine the EMA's funding under
Title I, and once again to determine a state's Title II grant.

The hold-harmless provisions under Titles I and II guarantee a certain
percentage of a previous year's funding amount, thus sustaining the
funding levels of CARE Act grantees based upon previous years'
measurements of AIDS cases. Title I's hold-harmless provision for EMAs has
primarily benefited the San Francisco EMA, which received over 90 percent
of the fiscal year 2004 Title I hold-harmless funding. San Francisco alone
continues to have deceased cases factored in to its allocation, because it
is the only EMA with hold-harmless funding that dates back to the
mid-1990s when formula funding was based on the cumulative count of
diagnosed AIDS cases.

If HIV case counts had been incorporated with AIDS cases in allocating
Title II funding to the states in fiscal year 2004, about half of the
states would have received an increase in funding and half of the states
would have received less funding. Many of those states receiving increased
funding would have been in the South, a region that includes 7 of the 10
states with the highest estimated rates of individuals living with HIV.
However, wide variation in the maturity of states' HIV reporting systems
could limit the adequacy of their HIV case counts for the distribution of
CARE Act funding.

Among state ADAPs, there is wide variation in the criteria used to
determine who is eligible for ADAP medications and services, and in the
additional funding received beyond the Title II grant for each state ADAP.
States have flexibility to determine what drugs they will cover for their
ADAP clients and what income level will entitle a person to eligibility,
among other criteria, and the resulting variation can contribute to client
coverage differences among state ADAPs. There is similar variation in
additional funding sources and eligibility criteria among states that have
established waiting lists for eligible clients. The Centers for Disease
Control and Prevention and the Health Resources and Services
Administration provided comments on the facts contained in this testimony
and GAO made changes as appropriate.
*** End of document. ***