HIV/AIDS: Changes Needed to Improve the Distribution of Ryan
White CARE Act and Housing Funds (28-FEB-06, GAO-06-332).
Among federal efforts to address the HIV/AIDS epidemic are the
CARE Act of 1990 and the Housing Opportunities for Persons with
AIDS program (HOPWA) administered by the Departments of Health
and Human Services (HHS) and Housing and Urban Development (HUD),
respectively. Both use formulas based upon a grantee's number of
AIDS cases, rather than HIV and AIDS cases, to distribute funds
to metropolitan areas, states, and territories. HIV cases must be
incorporated with AIDS cases in CARE Act formulas not later than
fiscal year 2007. GAO was asked to examine (1) how CARE Act and
HOPWA funds are allocated among types of services, (2) the extent
of funding distribution differences among CARE Act and HOPWA
grantees, and how funding formula provisions contribute to these
differences, and (3) what distribution differences could result
from incorporating HIV case counts in CARE Act and HOPWA funding
formulas.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-332
ACCNO: A47957
TITLE: HIV/AIDS: Changes Needed to Improve the Distribution of
Ryan White CARE Act and Housing Funds
DATE: 02/28/2006
SUBJECT: Acquired immunodeficiency syndrome
Allocation (Government accounting)
Data collection
Data integrity
Eligibility determinations
Federal funds
Federal grants
Formula grants
Funds management
Health care programs
Health care services
Infectious diseases
HIV/AIDS
HUD Housing Opportunities for Persons
with AIDS Program
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GAO-06-332
* HIV/AIDS
* Changes Needed to Improve the Distribution of Ryan White CARE Act and
Housing Funds
* Background
* HIV/AIDS in the United States
* The CARE Act
* CARE Act Amendments
* Metropolitan Statistical Areas
* HIV Case Counts
* HOPWA
* Results in Brief
* CARE Act and HOPWA Funds Allocated for Health Care, Housing
Assistance, and a Variety of Other Services
* More Than Half of Title I Fiscal Year 2003 Funding Was
Allocated for Health Care Services
* Over Two-thirds of Title II Fiscal Year 2003 Funding
Was Allocated for Medications
* Over Three-quarters of Title III Fiscal Year 2002
Funding Was Allocated for Health Care Services
* CARE Act Grants Funded Other Activities in Fiscal Year
2003
* Two-thirds of HOPWA Fiscal Year 2003 Funds Were Spent
on Housing Costs
* Multiple Provisions Contribute to Disproportionate
Distribution of CARE Act and HOPWA Formula Funding
* CARE Act and HOPWA Grants Are Not Distributed Solely in
Proportion to Number of Persons Living with AIDS
* Provisions in HOPWA and CARE Act Funding Formulas
Incorporate Measures of AIDS Cases That Do Not Reflect
an Accurate Count of Persons Living with AIDS
* HOPWA Grants
* CARE Act Grants
* CARE Act Funding Provisions for Metropolitan Areas
Result in Disproportionate Funding
* Counting ELCs within EMAs Twice Results in
Disproportionate Funding per ELC across States and
Puerto Rico
* The Two-tiered Division of Emerging Communities
Results in Funding Disparities Among Metropolitan
Areas
* Hold-harmless Provisions and Grandfather Clause Protect
Funding of Certain CARE Act Grantees
* One EMA Has Been the Primary Recipient of Title I
Hold-harmless Funding
* Grandfathering Maintains Eligibility for EMAs That
No Longer Meet Certain Eligibility Criteria
* Title II Hold-harmless Funding Could Diminish ADAP
Severe Need Grants in the Future
* HOPWA Provision Restricts Bonus Grant Eligibility for
Some Grantees
* The Use of Revised OMB Metropolitan Area Definitions
Would Change Most EMA Boundaries, but Increase in ELCs
within EMAs Would Be Minimal
* Funding Effect of Using HIV Case Counts Would Depend on
Multiple Factors
* Current HIV Case-reporting Systems Have Limitations for
Providing Case Counts for Funding Allocations
* The Use of HIV Case Counts in Funding Formulas Would
Have Changed the Distribution of Fiscal Year 2004 CARE
Act and HOPWA Funds
* Methodological Approaches Used
* Changes in CARE Act Funding Using HIV Cases and
Hold-harmless and Minimum-grant Provisions
* Title I Base Funding
* Title II Base Funding
* ADAP Base Funding
* Changes in CARE Act Formula Funding Would Be Larger If
Hold-harmless and Minimum-grant Provisions Were Not in
Effect
* Title I Base Funding
* Title II Base Funding
* ADAP Base Funding
* HOPWA Base Funding Would Generally Shift If HIV Cases
Were Used in Formula Allocations
* Differences in Case-reporting Systems Would Affect
Allocations
* Conclusions
* Matters for Congressional Consideration
* Agency Comments and Our Evaluation
* Appendix I: Objectives, Scope, and Methodology
* Objectives
* Scope and Methodology
* Allocation of CARE Act and HOPWA Funds among Service
Categories
* Funding-formula Provisions
* Use of HIV Cases in Formulas
* Appendix II: CARE Act Title I Awards, Fiscal Year 2004
* Appendix III: CARE Act Title II Awards, Fiscal Year 2004
* Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal
Year 2004
* Appendix V: HOPWA Base Funding Allocations Using Cumulative and
Living AIDS Cases, Fiscal Year 2004
* Appendix VI: Total CARE Act Title I and Title II Funding by State
and Territory, Fiscal Year 2004
* Appendix VII: HRSA's Title I EMAs, GAO-Identified Set of
Comparable 2004 OMB-Defined Metropolitan Areas, and Changes
* Appendix VIII: Estimated CARE Act Title I Funding Changes from
Use of HIV Case Counts and ELCs with Hold-harmless
* Appendix IX: Estimated CARE Act Title II Base Funding Changes
from Use of HIV Case Counts and ELCs with Hold-harmless
* Appendix X: Estimated CARE Act ADAP Base Funding Changes from Use
of HIV Case Counts and ELCs with Hold-harmless
* Appendix XI: Estimated CARE Act Title I Base Funding Changes from
Use of HIV Case Counts and ELCs without Hold-harmless
* Appendix XII: Estimated CARE Act Title II Base Funding Changes
from Use of HIV Case Counts and ELCs without Hold-harmless
* Appendix XIII: Estimated CARE Act ADAP Base Funding Changes from
Use of HIV Case Counts and ELCs without Hold-harmless
* Appendix XIV: Estimated HOPWA Base Funding Changes from Use of
HIV and Living AIDS Case Counts, Fiscal Year 2004
* Appendix XV: Comments from the Department of Health and Human
Services
* Appendix XVI: Comments from the Department of Housing and Urban
Development
* Appendix XVII: GAO Contact and Staff Acknowledgments
* GAO Contact
* Acknowledgments
* Related GAO Products
* Order by Mail or Phone
Report to Congressional Requesters
United States Government Accountability Office
GAO
February 2006
HIV/AIDS
Changes Needed to Improve the Distribution of Ryan White CARE Act and
Housing Funds
HIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
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GAO-06-332
Contents
Letter 1
Background 6
Results in Brief 14
CARE Act and HOPWA Funds Allocated for Health Care, Housing Assistance,
and a Variety of Other Services 17
Multiple Provisions Contribute to Disproportionate Distribution of CARE
Act and HOPWA Formula Funding 21
Funding Effect of Using HIV Case Counts Would Depend on Multiple Factors
45
Conclusions 63
Matters for Congressional Consideration 64
Agency Comments and Our Evaluation 65
Appendix I Objectives, Scope, and Methodology 69
Objectives 69
Scope and Methodology 69
Appendix II CARE Act Title I Awards, Fiscal Year 2004 80
Appendix III CARE Act Title II Awards, Fiscal Year 2004 82
Appendix IV HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004 84
Appendix V HOPWA Base Funding Allocations Using Cumulative and Living AIDS
Cases, Fiscal Year 2004 88
Appendix VI Total CARE Act Title I and Title II Funding by State and
Territory, Fiscal Year 2004 92
Appendix VII HRSA's Title I EMAs, GAO-Identified Set of Comparable 2004
OMB-Defined Metropolitan Areas, and Changes 94
Appendix VIII Estimated CARE Act Title I Funding Changes from Use of HIV
Case Counts and ELCs with Hold-harmless 99
Appendix IX Estimated CARE Act Title II Base Funding Changes from Use of
HIV Case Counts and ELCs with Hold-harmless 101
Appendix X Estimated CARE Act ADAP Base Funding Changes from Use of HIV
Case Counts and ELCs with Hold-harmless 103
Appendix XI Estimated CARE Act Title I Base Funding Changes from Use of
HIV Case Counts and ELCs without Hold-harmless 105
Appendix XII Estimated CARE Act Title II Base Funding Changes from Use of
HIV Case Counts and ELCs without Hold-harmless 107
Appendix XIII Estimated CARE Act ADAP Base Funding Changes from Use of HIV
Case Counts and ELCs without Hold-harmless 109
Appendix XIV Estimated HOPWA Base Funding Changes from Use of HIV and
Living AIDS Case Counts, Fiscal Year 2004 111
Appendix XV Comments from the Department of Health and Human Services 115
Appendix XVI Comments from the Department of Housing and Urban Development
120
Appendix XVII GAO Contact and Staff Acknowledgments 127
Related GAO Products 128
Tables
Table 1: CARE Act Programs, 2004 9
Table 2: Description of CARE Act Title I and Title II Formula Grants 11
Table 3: Relationship between ELCs in EMAs and Total CARE Act Title I and
II Funding per ELC, Fiscal Year 2004 28
Table 4: Title II Emerging Communities in Fiscal Year 2004 30
Table 5: Title I Hold-harmless Funding, Fiscal Year 2004 33
Table 6: Grandfathered EMAs, Fiscal Year 2004 36
Table 7: States That Received Title II Hold-harmless Funding from Severe
Need Set-aside, Fiscal Year 2004 39
Table 8: Fiscal Year 2004 HOPWA Formula Funding 40
Table 9: CDC Acceptance of HIV Case Counts and Year of Establishment of
HIV-reporting Systems, December 2005 48
Table 10: Reported HIV Cases and ELCs as of June 2003 61
Table 11: U.S. Census Bureau Regions 78
Table 12: EMAs with Service Area Changes 94
Table 13: EMAs with No Service Area Changes 97
Figures
Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004 8
Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003 18
Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003 19
Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002 20
Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003 21
Abbreviations
ADAP AIDS Drug Assistance Program AIDS acquired immunodeficiency syndrome
CARE Act Ryan White Comprehensive AIDS Resources Emergency Act CDC Centers
for Disease Control and Prevention ELC estimated living AIDS case EMA
eligible metropolitan area EMSA eligible metropolitan statistical area HHS
Department of Health and Human Services HIV human immunodeficiency virus
HOPWA Housing Opportunities for Persons with AIDS program HRSA Health
Resources and Services Administration HUD Department of Housing and Urban
Development IOM Institute of Medicine MSA metropolitan statistical area
OMB Office of Management and Budget
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.
United States Government Accountability Office
Washington, DC 20548
February 28, 2006
The Honorable Michael B. Enzi Chairman Committee on Health, Education,
Labor, and Pensions United States Senate
The Honorable Mark E. Souder Chairman Subcommittee on Criminal Justice,
Drug Policy and Human Resources Committee on Government Reform House of
Representatives
The Honorable Tom A. Coburn United States Senate
The Honorable Judd Gregg United States Senate
It has been nearly 25 years since the first cases of acquired
immunodeficiency syndrome (AIDS) in the United States were identified.
Treatment advances in combination antiretroviral therapy during the 1990s
have significantly reduced AIDS mortality and slowed the progression from
a positive human immunodeficiency virus (HIV) diagnosis to AIDS. 1 Yet the
number of new HIV infections, which is estimated at 40,000 annually, has
not decreased. The Centers for Disease Control and Prevention (CDC)
estimate that between 1,039,000 and 1,185,000 people in the United States
were living with HIV/AIDS at the end of 2003. The number of people
infected with HIV/AIDS is likely to have risen since then, and CDC
estimates that, as of December 2004, it included 415,193 individuals with
AIDS.
Among the federal government's efforts to address the HIV/AIDS epidemic
are the Ryan White Comprehensive AIDS Resources Emergency Act of 1990
(CARE Act) 2 and the Housing Opportunities for Persons with AIDS program
(HOPWA). The CARE Act, which is administered by the Department of Health
and Human Services's (HHS) Health Resources and Services Administration
(HRSA), established a number of grant programs through which funds are
made available to states-including the District of Columbia-territories, 3
and metropolitan areas to provide health care, medications, and support
services to individuals and families affected by HIV/AIDS. The AIDS
Housing Opportunity Act, which was enacted in 1990 and is administered by
the Department of Housing and Urban Development (HUD), established HOPWA.
4 HOPWA provides housing assistance for low-income persons with HIV/AIDS
and their families. In fiscal year 2004, over $2 billion was distributed
through the CARE Act and $295 million was distributed through HOPWA.
1HIV is the virus that causes AIDS. Throughout this report, we use the
common term "HIV/AIDS" to refer to HIV disease, inclusive of cases that
have progressed to AIDS. When we use these terms alone, HIV refers to the
disease without the presence of AIDS, and AIDS refers exclusively to HIV
disease that has progressed to AIDS.
2Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. S:S:
300ff-300ff-111 (2000)). Unless otherwise indicated, references to the
CARE Act are to current law.
3In addition to the 50 states, the CARE Act authorizes grants to the
District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin
Islands, American Samoa, the Commonwealth of the Northern Mariana Islands,
the Republic of the Marshall Islands, the Federated States of Micronesia,
and the Republic of Palau. Throughout this report, the term state refers
to the 50 states and the District of Columbia, and territory refers to
these listed territories.
4Pub. L. No. 101-625, tit. VIII, subtit. D, 104 Stat. 4079, 4375 (codified
as amended at 42 U.S.C. S:S: 12901-12912 (2000)). Unless otherwise
indicated, references to HOPWA are to the program as administered under
current law.
5Pub. L. No. 106-345, S: 206(b), 114 Stat. 1319, 1334-35.
6GAO, Ryan White CARE Act: Opportunities to Enhance Funding Equity,
GAO/T-HEHS-00-150 (Washington, D.C.: July 11, 2000), 6.
7Our analyses of CARE Act and HOPWA funding-formula provisions and the use
of HIV cases in making CARE Act and HOPWA funding allocations include the
states, Puerto Rico, and metropolitan areas eligible for funding.
8In this report, cumulative AIDS cases are the total number of AIDS cases,
both living and dead, reported in a jurisdiction in a given period.
9The 1990 CARE Act added a new title XXVI to the Public Health Service
Act. In general, because Part A of that new title, which authorizes grants
to metropolitan areas, was established by Title I of the CARE Act, it is
commonly referred to as Title I, and because part B, which authorizes
grants to states and territories, was established by Title II of the CARE
Act, it is commonly referred to as Title II. Titles III and IV of the Act
established Parts C and D, respectively, authorizing grants for early
intervention services as well as grants for services to women and
children, among other things. Under Title I, a metropolitan area with a
population of at least 500,000 and more than 2,000 reported AIDS cases in
the last 5 calendar years is eligible to receive Title I funding, and is
defined as an EMA.
10Under HOPWA, cumulative AIDS cases are the total AIDS cases reported in
a jurisdiction since the beginning of the epidemic in 1981.
11Under HOPWA there is a single formula grant for each grantee. It
consists of funding determined using a base factor and funding determined
using a bonus factor (which may be zero). In this report, we use the terms
base grants and bonus grants to differentiate between funding determined
using these factors.
12Bonus grants are awarded to EMSAs that have a higher-than-average per
capita incidence of AIDS over the previous year. Allocations are based on
the number of cases in excess of the average AIDS incidence rates of
EMSAs.
13In our November 1995 report, we showed that differences under the CARE
Act in funding per living AIDS case were not related to cost differences.
For a discussion of this issue as well as criteria for distributing funds,
see GAO, Ryan White CARE Act of 1990: Opportunities to Enhance Funding
Equity, GAO/HEHS-96-26 (Washington, D.C.: Nov. 13, 1995).
14For our CARE Act analyses, we used ELCs as our measure of living AIDS
cases. For HOPWA we used a measure of living AIDS cases calculated by
subtracting the number of reported deaths among AIDS cases in a
jurisdiction from the number of reported cases. In our analysis of HOPWA,
we used living AIDS cases instead of cumulative AIDS cases, which is the
measure currently required by law to be used to determine HOPWA base
funding. Consequently, our analyses of HOPWA funding reflect the effect of
using HIV and living AIDS cases instead of cumulative AIDS cases. We do
not compare how allocations could be affected if HIV cases and cumulative
cases were used to determine funding.
15Prevalence reflects the number of people living with the disease.
16In addition to the 50 states, these grants are authorized to the
District of Columbia, the Commonwealth of Puerto Rico, Guam, and the
Virgin Islands.
17All EMAs received a supplemental grant in fiscal year 2004.
18Pub. L. No. 104-146, 110 Stat. 136.
19Pub. L. No. 106-345, 114 Stat. 1319.
20HRSA calculates a jurisdiction's ELCs by using data from CDC 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 measure as
our estimate of living AIDS cases in our analyses of CARE Act
funding-formula provisions and the use of HIV cases in CARE Act funding
formulas.
21See GAO, Ryan White CARE Act of 1990: Opportunities Are Available to
Improve Funding Equity, GAO/T-HEHS-95-126 (Washington, D.C.: Apr. 5,
1995).
22In 2005, OMB issued 2004 MSA definitions using fundamentally revised
standards issued in 2000 and data from the 2000 census. In an attempt to
make the classification of areas simpler and more transparent than the
previous standards, OMB's 2000 standards introduced new terminology and
employed new criteria for identifying central counties and their outlying
counties, and did not seek to conform with past standards nor to preserve
past metropolitan status.
2342 U.S.C. S:S: 300 ff-13(a)(3)(D)(i) and 300ff-28(a)(2)(D)(i) (2000).
24Institute of Medicine of the National Academies, Measuring What Matters:
Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
(Washington, D.C.: The National Academies Press, 2004).
25Fiscal year 2002 allocations were the most recent funding data available
for Title III.
26The CARE Act requires that grantees' administrative costs not exceed 5
percent of the Title I funds awarded. Each EMA must establish a planning
council, which sets spending priorities according to local unmet needs.
27The CARE Act requires that grantees not use more than 10 percent of
Title II funds for administration. The combined funding for
administration, planning, and program evaluation may not exceed 15 percent
of a Title II grantee's award.
28The CARE Act requires that grantees not use more than 10 percent of
Title III funds for administration costs, including planning and
evaluation.
29Unless otherwise indicated, we use the term grantees to indicate the
jurisdictions on which our analyses are based, that is, the states, Puerto
Rico, and metropolitan areas.
30ELCs are the 10-year weighted estimate of living AIDS cases as specified
in the CARE Act. HRSA calculates a jurisdiction's ELCs by using data from
CDC on the reported AIDS case counts for the last 10 years. Data for each
of the 10 years are adjusted to take into account the number of deaths in
each year. However, rather that simply subtracting the number of deceased
cases in each jurisdiction, the number of reported cases is adjusted by
the national average death rate among AIDS cases.
31In this report, cumulative AIDS cases are the total number of AIDS
cases, both living and dead, reported in a jurisdiction in a given period.
Under HOPWA, cumulative AIDS cases encompass all reported cases since the
beginning of the epidemic in 1981. By statute, 75 percent of HOPWA formula
funding is allocated on the basis of cumulative AIDS cases.
32In the absence of a measure of living AIDS cases used for HOPWA funding,
we used a measure of living AIDS cases calculated by subtracting the
number of reported deaths among AIDS cases in a jurisdiction from the
number of reported cases. This measure of living AIDS cases is used for
illustrative purposes only.
33Until fiscal year 2006, bonus funding was based on the per capita
incidence of AIDS over a 1-year period. As a result, the amount of bonus
funding a grantee received could vary significantly from year to year.
With respect to fiscal year 2006 funding, HUD's appropriation act included
a provision to help mitigate this variability by changing to the use of
data reported over a 3-year period. Pub. L. No. 109-115, S: 303(d), 119
Stat. 2396, 2460 (2005).
34Eligibility for Minority AIDS Initiative grants and grant amounts are
determined using the last 2 years of reported AIDS cases.
35GAO/HEHS-96-26, 6.
36We used living AIDS case counts as of March 31, 2003, because this date
was the cutoff for reporting AIDS cases to be used for determining fiscal
year 2004 HOPWA formula funding.
37When determining CARE Act funding for fiscal year 2004, HRSA used a
survival weight of .28 for AIDS cases that had been reported 10 years
earlier. This figure represents the proportion of persons who had been
reported with AIDS 10 years earlier and were known to be alive.
38The estimate of reported living AIDS cases was calculated by subtracting
the number of reported deaths among AIDS cases from the number of reported
AIDS cases since the beginning of the epidemic.
39For an assessment of three methods for estimating the number of persons
living with AIDS, including the method used for the CARE Act, see Centers
for Disease Control and Prevention, "AIDS Cases and Persons Living with
AIDS," HIV/AIDS Surveillance Supplemental Report, vol. 8, no. 3 (2002).
40There are three EMAs in Puerto Rico: Caguas, Ponce, and San Juan.
41For 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 ELCs from each state in these EMAs. We then calculated the
percentage of ELCs in each state and allocated the EMA funding to each
state according to this percentage. For example, approximately 96 percent
of the ELCs 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.
42Approximately 80 percent of Puerto Rico's ELCs are in EMAs.
43Under Title I, a metropolitan area with a population of at least 500,000
and more than 2,000 reported AIDS cases in the last 5 calendar years is
eligible to receive funding.
44We excluded from our analyses the nine states that received minimum
Title II base grant awards.
45HRSA provides Minority AIDS Initiative grants according to the number of
nonwhite reported AIDS cases in the most recent 2-year period.
46The hold-harmless provision is triggered when, because of its current
number of ELCs, an EMA would not receive at least a specified level of
base funding. Hold-harmless funding under Title I is calculated using a
base year. The base year is the year preceding the fiscal year in which
the hold-harmless provision is triggered for a particular EMA. Because the
hold-harmless provision can first be triggered in different years in
different EMAs, the base year can differ among EMAs. Under the CARE Act
Amendments of 2000, an EMA is guaranteed not less than 98 percent of its
base grant in the first year the hold-harmless is triggered, 95 percent in
the second year, 92 percent in the third year, 89 percent in the fourth
year, and 85 percent in the fifth or subsequent years.
47The funds used to meet the Title I hold-harmless requirement are
deducted from the funds otherwise available for supplemental grants before
these grants are awarded. Supplemental grants are awarded by HRSA to EMAs
using a competitive process based on the demonstration of severe need and
other criteria.
48San Francisco was the only EMA that received hold-harmless funding from
fiscal year 1999 through fiscal year 2002. In fiscal year 2003, 19
additional EMAs qualified for hold-harmless funding. Twenty-one EMAs
received hold-harmless funding in fiscal year 2004. Eleven EMAs qualified
in both fiscal years 2003 and 2004.
49This analysis shows how the hold-harmless funding would have been
distributed if it had been allocated in the same proportions as the
supplemental grant funding. For example, Newark received about 2.5 percent
of the funds available for supplemental grants and, consequently, we
allocated 2.5 percent of the $8,033,563 hold-harmless funding to Newark.
It is not possible to determine the exact effect of the hold-harmless
provision on the amount of supplemental funding for each EMA because it is
not known how the funds would have been distributed in the absence of the
hold-harmless awards.
50The CARE Act Amendments of 1996 guaranteed amounts ranging from 95 to
100 percent of the 1995 base grant. The CARE Act Amendments of 2000
guaranteed amounts ranging from 85 to 98 percent of the grant received in
a base year. The base year varies by EMA.
51The guaranteed amount is calculated by multiplying the two percentages
(89 and 95) together. 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.
52To be eligible for Title I funding, a metropolitan area must have
reported a cumulative total of 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 base grant funding
allocations, which are determined using the number of ELCs.
53The AIDS case eligibility thresholds contained in the 1990 statute were
either that an area had a cumulative total of more than 2,000 AIDS cases
(that is, more than 2,000 cases living or deceased) or greater than 25
AIDS cases per 100,000 population reported to CDC. This standard was
changed in 1996 to the current threshold of more than 2,000 reported AIDS
cases during the most recent 5 calendar years and a population of 500,000
or more.
54Both EMA eligibility and Emerging Community funding are based on the
number of AIDS cases reported in the most recent 5 calendar years.
55To be eligible for a Severe Need grant, a jurisdiction must have met one
of four eligibility criteria as of January 1, 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 fewer 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.) In addition, a
jurisdiction must also have agreed to provide a 25 percent match and not
impose eligibility requirements more restrictive than those in place on
January 1, 2000. According to HRSA, grantees have provided funds or
in-kind services to meet the matching requirement.
5642 U.S.C. S: 300ff-28(a)(2)(I)(ii)(VI) (2000). Title II also contains a
hold-harmless provision that requires HRSA to consider separately Title II
base grants and ADAP base grants. For the Title II base grants, this
hold-harmless provision is funded by proportionately reducing the size of
the Title II base grants made to other jurisdictions that did not qualify
for this hold-harmless funding or receive a minimum grant . The ADAP
portion would be funded by reducing the size of the ADAP base grants made
to those grantees that did not qualify for ADAP base grant hold-harmless
funding. 42 U.S.C. S: 300ff-28(a)(2)(H) (2000).
57States and Puerto Rico, as well as EMSAs, receive HOPWA base grants that
are determined by the grantee's proportion of the total number of
cumulative AIDS cases. CDC reported that there were 5.4 AIDS cases per
100,000 people in nonmetropolitan areas in 2000 and 6.2 cases per 100,000
people in these areas in 2004.
58Twenty-five percent of HOPWA formula funding is distributed through
bonus grants. Until fiscal year 2006, bonus funding was based on the per
capita incidence of AIDS over a one-year period. As a result, the amount
of bonus funding a grantee received could vary significantly from year to
year. With respect to fiscal year 2006 funding, HUD's appropriation act
included a provision to help mitigate this variability by changing to the
use of data reported over a 3-year period.
59These funding levels were calculated by dividing a grantee's fiscal year
2004 formula allocation by the number of living cases in the jurisdiction.
If the funding had been allocated proportionally on the basis of living
AIDS cases, each grantee would have received $716 per case.
60OMB's new MSA standards and definitions represent a major break with the
classification scheme used in the past. In some instances OMB retained a
term that was used in the past, such as MSA, but OMB has altered the
meaning. As a result, 2004 MSA boundaries of some EMAs are very different
from those in 1993.
61We use the term "metropolitan area" here in a generic sense to refer to
both the MSA (metropolitan statistical area) and the metropolitan division
(OMB's newly defined term for a subdivision of the very largest MSAs).
62If Title I EMA boundaries were reconfigured to conform with new OMB
definitions, those areas outside of EMAs that are currently served by
governments under Title II would also be changed. Though the effect on
areas outside EMAs can be inferred from the changes to EMAs, we do not
explicitly report those results here.
63While we focus on Title I of the CARE Act, the Title II Emerging
Communities program also uses metropolitan area definitions and it would
also be affected if the new OMB definitions were applied. We also exclude
HOPWA from this subsection because these new OMB definitions have already
been used to determine fiscal year 2004 HOPWA grant funding. For HOPWA,
HUD implemented a different method than we use for the analysis here. HUD
provided no grandfathering of eligibility for previously designated EMSAs
and instead, among all newly defined metropolitan areas, HUD selected
those whose data qualified them to be eligible for HOPWA funding. In
contrast, in our method we assume a policy whereby the 51 current EMAs
would retain their eligibility for CARE Act Title I grants without needing
to qualify on the basis of their number of ELCs or population size, and we
selected only those new metropolitan areas (or combinations of those
areas) that most closely correspond to the geographic area of each of the
51 existing Title I EMAs.
64App. I provides further explanation of the methodology we used for
selecting those combinations of metropolitan areas that would minimize
changes to current EMAs. As shown in the tables in app. VII, our
conversion method would equate some EMAs with more than one newly defined
metropolitan area in order to minimize any change in boundaries that would
occur. For example, we equate the New Haven EMA with two newly defined
units (the New Haven MSA and the Bridgeport MSA) because the two units
together have boundaries identical to the New Haven EMA.
65The Bergen-Passaic, Jersey City, and New York City EMAs would be
consolidated into the new New York City EMA (with no change to the
geographic area encompassed and no change to the numbers of ELCs served).
The Caguas and San Juan EMAs would be consolidated into the new San Juan
EMA (with a net increase of 6 counties and 4 percent in ELCs.) Increases
or decreases in the number of outlying counties included in metropolitan
area boundaries would mostly have small effect on the numbers of ELCs
because such outlying counties have many fewer ELCs than the more populous
central counties. In those instances where EMAs would be consolidated, the
changes to boundaries would be substantial, though there would be little
or no net change in numbers of ELCs within those boundaries.
66Institute of Medicine, Measuring What Matters, 87-134. While IOM
examined only the CARE Act, its findings regarding the use of HIV data for
determining funding allocations are also relevant for HOPWA.
67In our analyses, we considered the Title I hold-harmless provision and
the Title II hold-harmless provisions that are funded by proportional
reductions in Title II base grants and ADAP base grants. We did not
include the Title II hold-harmless provision funded by amounts otherwise
available for Severe Need grants.
68See app. I for a listing of the four U.S. Census Bureau regions and the
jurisdictions that constitute each region. Because Puerto Rico is not
included in any of these four regions, we excluded it from our regional
analyses.
69HIV case-reporting systems are generally either name- or code-based. In
name-based systems, cases are collected by name while in a code-based
system cases are collected using a coded identifier. Currently, 38 states
and Puerto Rico have name-based systems while 8 states have code-based
systems. In the remaining 5 states, names are collected and converted to
codes by public health authorities.
70 GAO/T-HEHS-00-150 .
71Name-based HIV reporting has been established in all parts of
Pennsylvania except Philadelphia since 2002. Philadelphia was given
permission by the state to establish code-based HIV reporting, and the
system began in 2004. However, in August 2005, the Philadelphia Board of
Health voted to implement a name-based HIV-reporting system. This system
went into effect in October 2005. Philadelphia is in the process of having
its HIV surveillance data certified by CDC; once certified, its data will
be accepted by CDC.
72HRSA uses AIDS case counts provided by CDC for determining CARE Act
formula funding. All states and territories report AIDS cases by name.
73CDC 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 must result in accurate case counts (less
than or equal to 5 percent of reported cases are duplicates). 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. In July 2005, CDC began recommending that all states and
territories adopt confidential name-based surveillance systems to report
HIV infections.
74Two of the 13 states, Illinois and Maine, established name-based HIV
reporting in January 2006.
75CDC 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 with providers to resolve potential duplicate reports on the
same person.
76Unlike the CARE Act, there is currently no law requiring the use of HIV
cases in determining HOPWA funding. In our analysis of HOPWA, we used
living AIDS cases instead of cumulative AIDS cases, which is the measure
currently required by law to be used to determine HOPWA base funding. As
we reported in 1995, we believe that cumulative AIDS cases is an
inappropriate measure for allocating funds ( GAO/HEHS-96-26 , 6).
Consequently, our analyses of HOPWA funding reflect the effect of using
HIV and living AIDS cases instead of cumulative AIDS cases. This measure
of living AIDS cases is used for illustrative purposes only.
77We used ELCs in our analyses of CARE Act programs, which is the measure
of AIDS cases used by HRSA in determining funding for the grants we
examined: Title I, Title II, and ADAP base grants. HUD does not have a
measure of living AIDS cases that it uses to determine HOPWA funding.
Because ELCs are specific to the CARE Act and because of shortcomings in
this measure discussed earlier, we calculated an alternative measure of
living AIDS cases in our examination of HOPWA funding. For the HOPWA
analyses, the living AIDS case counts were calculated by subtracting the
number of reported deaths among AIDS cases from the number of reported
AIDS cases.
78Because HIV-reporting systems in some jurisdictions are changing to
name-based systems, CDC now accepts HIV case counts from some
jurisdictions from which it did not accept HIV case counts earlier. For
our analyses, we classified Connecticut, Kentucky, and New Hampshire as
having HIV case counts that are not accepted by CDC. Our analyses were
conducted using fiscal year 2004 allocations, which were based on case
reports as of June 30, 2003, for the CARE Act and as of March 31, 2003,
for HOPWA. At those times, 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. A fourth state, Georgia, had not
established any HIV case reporting as of June 30, 2003, but did so in
2004. Consequently, the HIV case count for Georgia is zero in our
analyses. Pennsylvania is classified as having its HIV case counts
accepted by CDC. However, these counts do not include any cases from
Philadelphia, which established its code-based system in 2004.
Philadelphia established a name-base HIV-reporting system in October 2005
and is in the process of having its HIV surveillance data certified by
CDC; once certified, its data will be accepted by CDC. Illinois and Maine
established name-based HIV-reporting systems in January 2006 and are also
in the process of having their HIV data certified by CDC; once certified,
their data will be accepted by CDC.
79CDC receives, reviews, and processes name-based HIV case reports on
individual cases. Potential duplicate reports across jurisdictions are
reviewed through a CDC-coordinated process to remove duplicate reports
from the national database. Code-based reports cannot be included in this
de-duplication process because name-based and code-based systems do not
have comparable patient identifiers. Because the name- and code-based case
counts are not comparable, in its comments on a draft of this report HHS
stated that it would not be appropriate to use the code-based case counts
in monitoring HIV/AIDS nationally. Our purpose in using both the name- and
code-based case counts was to provide a general indication of how funding
would be affected by using HIV and AIDS cases to distribute CARE Act and
HOPWA funds in light of the statutory requirement that HIV cases be used
in CARE Act funding formulas not later than fiscal year 2007. Our use of
the code-based case counts should not be taken as endorsement for their
use in monitoring HIV/AIDS or distributing funds. An assessment of the
feasibility of using code-based case counts was beyond the scope of our
report.
80HIV case counts for three states-Georgia, Kentucky, and the District of
Columbia-were unavailable. Consequently, their HIV case counts are zero
under both approaches. HIV case counts were also unavailable for
Philadelphia, and as a consequence HIV counts were incomplete for
Pennsylvania.
81For example, for CARE Act Title I base funding, we calculated the EMA's
percentage of the total number of HIV/AIDS cases in all EMAs.
82Under the CARE Act, there is a minimum-grant provision for Title II base
grants, but not for Title I and ADAP base funding. However, there are
hold-harmless provisions for Title I, Title II, and ADAP base funding.
There is no comparable hold-harmless provision in HOPWA and minimum-grant
requirements have been effectively waived in recent years. Consequently,
the analyses in which the hold-harmless and minimum-grant provisions are
maintained are limited to the CARE Act. For purposes of this analysis, we
considered the Title I hold-harmless provision and the Title II
hold-harmless provision that is funded by proportional reductions in Title
II base grants and ADAP base grants. We did not include the Title II
hold-harmless provision funded by amounts otherwise available for Severe
Need grants. The effect on HOPWA allocations are discussed later.
83There is no minimum funding provision for Title I base grants.
84See app. I for a listing of the four U.S. Census Bureau regions and the
jurisdictions that constitute each region.
85We assume that the case threshold for determining the size of minimum
grants would remain at 90 even if HIV cases were included in the case
counts. Currently, states with fewer than 90 ELCs are guaranteed a minimum
Title II base grant of $200,000 while states with 90 or more cases are
guaranteed at least $500,000. Our analyses assume that the threshold would
be a total of 90 HIV cases and ELCs.
86There is no minimum funding provision for ADAP base grants.
87The ADAP base grant funding reported to us included any hold-harmless
funding taken from funds otherwise set aside for the ADAP Severe Need
grants. This hold-harmless funding results from a different Title II
hold-harmless provision than that which requires HRSA to consider
separately Title II base grants and ADAP base grants. In our analyses, we
excluded hold-harmless funding taken from the ADAP Severe Need grants when
we estimated the dollar and percent changes in the ADAP base grants.
88For a description of features in funding formulas, see National Research
Council, Statistical Issues in Allocating Funds by Formula: Panel on
Formula Allocations (Washington, D.C.: The National Academies Press,
2003).
89In these analyses we considered the Title I hold-harmless provision and
the Title II hold-harmless provisions that are funded by proportional
reductions in Title II base grants and ADAP base grants. We did not
include the Title II hold-harmless provision funded by amounts otherwise
available for Severe Need grants.
90There is no minimum funding provision for Title I base funding.
91The amount of base grant funding would have been about $8 million less
without the hold-harmless provision. This money would have been
distributed to EMAs in supplemental grants.
92EMAs in the West would gain funding under both approaches if the
hold-harmless was maintained but would receive less funding under both
approaches if it was not maintained.
93Grantees in the West would gain funding under both approaches if the
hold-harmless and minimum-grant provisions were maintained but would
receive less funding under both approaches if they were not maintained.
94There is no minimum funding provision for ADAP base funding.
95For the HOPWA analyses, the living AIDS case counts were calculated by
subtracting the number of reported deaths among AIDS cases from the number
of reported AIDS cases.
96This analysis indicates how HOPWA base funding would have changed if
living AIDS cases and HIV cases had been used to distribute funding rather
than cumulative case counts. The effect of using living AIDS cases but not
HIV cases on HOPWA base funding is shown in app. V.
97These six grantees are the state of Alabama; Birmingham, Alabama;
Charlotte, North Carolina; Memphis, Tennessee; the state of North
Carolina; and Wake County, North Carolina.
98In those cases in which an EMSA included both southern and nonsouthern
jurisdictions, we classified the EMSA as not being in the South.
99In this instance, AIDS cases refers to ELCs for the CARE Act and
cumulative AIDS cases for HOPWA.
100Other factors may also affect the ratio of HIV to AIDS cases in a
reporting system. For example, some jurisdictions with newer HIV-reporting
systems were among the first to be affected by the HIV epidemic. This
factor could mean that in those jurisdictions there are relatively more
AIDS cases and the ratio of HIV to AIDS cases would be lower than in
jurisdictions more recently experiencing an HIV epidemic.
101Institute of Medicine, Measuring What Matters, 92.
1Grantees are those entities that receive CARE and HOPWA funding. Grantees
vary by program and can include states, territories, metropolitan areas,
and primary-care providers.
2HRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
3Title II also contains a hold-harmless provision that requires HRSA to
consider separately Title II base grants and ADAP base grants. For the
Title II base grants, this hold-harmless provision is funded by
proportionately reducing the size of the Title II base grants made to
other jurisdictions that did not qualify for this hold-harmless funding or
receive a minimum grant. The ADAP portion would be funded by reducing the
size of the ADAP base grants made to those grantees that did not qualify
for ADAP base grant hold-harmless funding.
4Unlike the CARE Act in which ELCs in EMAs are counted once for
determining Title I funding and a second time for determining Title II
funding, under HOPWA AIDS cases in EMSAs are counted only for determining
funding for EMSAs. These cases are not counted a second time for
determining HOPWA base funding allocations for states and territories.
Funding for states and territories is based on the number of cumulative
AIDS cases outside of EMSAs. For example, HOPWA base funding for Colorado
is based on the number of cumulative AIDS cases in the state minus the
number of cumulative cases in the Denver EMSA.
5The AIDS case count used in the analyses varied by program (e.g., ELCs
and cumulative AIDS cases).
6In our November 1995 report, we showed under the CARE Act that
differences in funding per living AIDS case were not related to cost
differences. For a discussion of this issue as well as criteria for
distributing funding per case, see GAO, Ryan White CARE Act of 1990:
Opportunities to Enhance Funding Equity, GAO/HEHS-96-26 (Washington, D.C.:
Nov. 13, 1995).
7GAO, Metropolitan Statistical Areas: New Standards and Their Impact on
Selected Federal Programs, GAO-04-758 (Washington, D.C.: June 14, 2004).
8There is no straightforward way to equate EMAs based on OMB's 1993
metropolitan areas with OMB's 2004 metropolitan areas. In developing its
2000 metropolitan area standards and its 2004 metropolitan area boundary
definitions, OMB did not seek to make them conform to past standards and
definitions. Moreover, even where OMB employed the same terminology (e.g.,
the term "metropolitan statistical area" was retained), the terms were
given new meanings.
9These include combinations of adjoining MSAs or adjoining MSAs and
metropolitan divisions. We exclude the use of the smaller micropolitan
statistical areas (a new OMB designation for less-populated areas) and
also exclude combined statistical areas (a new OMB designation for
groupings of adjacent metropolitan and micropolitan areas).
10Unlike the CARE Act, there are no requirements regarding the use of HIV
cases in determining HOPWA funding.
11In our analysis of HOPWA, we used living AIDS cases instead of
cumulative AIDS cases, which is the measure currently required by law to
be used to determine HOPWA base grant funding. Therefore, our analyses
reflect the effect of using HIV cases and living AIDS cases instead of
cumulative AIDS case counts on fiscal year 2004 HOPWA base grant funding.
12These 35 include 34 states and Puerto Rico.
13Some HIV case-reporting systems are name-based while others are
code-based. Currently, CDC will only accept name-based case counts as no
code-based system has yet met CDC's quality criteria. CDC 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 must result in accurate case counts (less than or equal to 5
percent of reported cases are duplicates). CDC has determined that the
only systems that 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. In July
2005, CDC began recommending that all states and territories adopt
confidential, name-based surveillance systems to report HIV infections.
14Because HIV-reporting systems in some jurisdictions are changing to
name-based systems, CDC now accepts HIV case counts from some
jurisdictions from which it did not accept HIV case counts earlier. For
our analyses, we classified Connecticut, Kentucky, and New Hampshire as
having HIV case counts that are not accepted by CDC. Our analyses were
conducted using fiscal year 2004 allocations, which were based on case
reports as of June 30, 2003, for the CARE Act and as of March 31, 2003,
for HOPWA. At those times, 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. A fourth state, Georgia, had not
established any HIV case reporting as of June 30, 2003, but did so in
2004. Consequently, the HIV case count for Georgia is zero in our
analyses. Pennsylvania is classified as having its HIV case counts
accepted by CDC. However, these counts do not include any cases from
Philadelphia, which established its code-based system in 2004.
Philadelphia establsihed a name-based system in October 2005. Philadelphia
is in the process of having its HIV surveillance data certified by CDC;
once certified, its data will be accepted by CDC. Illinois and Maine
established name-based HIV-reporting systems in January 2006 and are also
in the process of having their HIV data certified by CDC; once certified,
their data will be accepted by CDC.
15HIV case counts for three of these jurisdictions, Georgia, Kentucky, and
the District of Columbia, were unavailable. Consequently, their HIV case
counts are zero under both approaches. HIV case counts were also
unavailable for Philadelphia, and as a consequence HIV counts were
incomplete for Pennsylvania.
16CDC receives, reviews, and processes name-based HIV case reports on
individual cases. Potential duplicate reports across jurisdictions are
reviewed through a CDC-coordinated process to remove duplicate reports
from the national database. Code-based reports cannot be included in this
de-duplication process because name-based and code-based systems do not
have comparable patient identifiers. Because the name- and code-based case
counts are not comparable, in its comments on a draft of this report HHS
stated that it would not be appropriate to use the code-based case counts
in monitoring HIV/AIDS nationally. Our purpose in using both the name- and
code-based case counts was to provide a general indication of how funding
would be affected by using HIV and AIDS cases to distribute CARE Act and
HOPWA funds. Our use of the code-based case counts should not be taken as
endorsement for their use in monitoring HIV/AIDS or distributing funds. An
assessment of the feasibility of using code-based case counts was beyond
the scope of our report.
17For example, for CARE Act Title I base funding, we calculated the EMA's
percentage of the total number of HIV cases and ELCs across all EMAs.
18Under the CARE Act, there is a minimum-grant provision for Title II base
grants, but not for Title I and ADAP base grants. However, there are
hold-harmless provisions for Title I, Title II, and ADAP base grants.
There are no comparable hold-harmless provisions in HOPWA and
minimum-grant requirements have been effectively waived in recent years.
Consequently, the analyses in which the hold-harmless and minimum-grant
provisions are maintained are limited to the CARE Act.
19Puerto Rico is not included in any of these regions and is, therefore,
excluded from these analyses.
20Michael Saag (paper presented at the XIV International AIDS Conference:
Plenary Session, HIV/AIDS Treatment and Care in the New Century,
Barcelona, July 2002); "UAB Announces Results of First HIV Patient Care
Cost Analysis," UAB Media Relations (Birmingham, Ala.: University of
Alabama at Birmingham, July 2002),
http://main.uab.edu/show.asp?durki=51750 (downloaded March 30, 2005).
Under the CARE Act and HOPWA, funding is distributed through a combination
of competitive grants and, in accordance with CDC data on the number of
individuals diagnosed with AIDS, formula grants. Approximately 68 percent
of CARE Act funding and 90 percent of HOPWA funding were distributed
through formula grants in fiscal year 2004. The use of AIDS cases in the
distribution of formula grants was prescribed because most jurisdictions
tracked and reported AIDS cases instead of HIV cases when the grant
programs were established. Because of concerns that a jurisdiction's
disease burden is not adequately reflected by only counting cases that
have progressed to AIDS, the Ryan White CARE Act Amendments of 2000
required the use of HIV/AIDS case counts in the distribution of formula
grants not later than fiscal year 2007. 5 We have reported that because
CARE Act grants serve persons who have been diagnosed with HIV that has
not progressed to AIDS as well as those for whom it has, it would be
reasonable to distribute funds on the basis of the total number of persons
living with HIV/AIDS. 6 Incorporating HIV data along with AIDS data would
result in targeting funds more accurately according to need. However,
because there is a lack of HIV data that are sufficiently adequate and
reliable to serve as a basis for CARE Act formula grant allocations, as of
December 2005, HIV cases have not been used in the distribution of formula
grants under the CARE Act.
Various provisions governing CARE Act and HOPWA grants affect the
distribution of funds. As Congress prepares to reauthorize CARE Act
programs, you asked us to examine how funds are distributed under the CARE
Act and HOPWA. We are reporting on (1) how CARE Act and HOPWA funds are
allocated by grantees among the types of services each program supports;
(2) the extent of funding differences among CARE Act and HOPWA grantees,
and how specific CARE Act and HOPWA funding-formula provisions contribute
to these differences; and (3) what distribution differences could result
from using HIV cases in CARE Act and HOPWA funding formulas.
To report on these issues, we reviewed the CARE Act of 1990, as well as
the 1996 and 2000 CARE Act amendments, the AIDS Housing Opportunity Act of
1990, HRSA and HUD documents on CARE Act and HOPWA funding, HUD memoranda,
Institute of Medicine (IOM) reports on the CARE Act, and other related
reports. We analyzed data, spanning from 2002 through 2004, obtained from
HRSA, HUD, and CDC. 7 We also collected data on HIV case counts from state
and local HIV/AIDS officials. We interviewed CDC, HRSA, HUD, and state
officials, as well as officials from the National Alliance of State and
Territorial AIDS Directors.
To determine how grantees allocate CARE Act and HOPWA funds by type of
service, we obtained information from HRSA and HUD on grantees' use of
funds. We analyzed these data and, where available, calculated the
percentage of total spending represented by each category of service. To
assess the reliability of HRSA and HUD data on allocations of CARE Act and
HOPWA grant funds, we interviewed agency officials about the data and
reviewed relevant documentation. We determined that the data were
sufficiently reliable for the purposes of our report.
In order to examine the effect of specific funding-formula provisions on
the distribution of fiscal year 2004 funds by HRSA and HUD under the CARE
Act and HOPWA to grantees, we first assessed the use of 2- and 5-year
cumulative AIDS case counts 8 and the use of estimated living AIDS cases
(ELC) in CARE Act programs by comparing these measures with living AIDS
case counts received from CDC. HRSA calculates a jurisdiction's ELCs by
using data from CDC on the reported AIDS case counts for the last 10 years
and weighting those numbers to account for the likelihood of deaths. We
then examined the effect of the following CARE Act formula provisions: the
counting of ELCs in eligible metropolitan areas (EMA) for both Title I and
Title II funding, 9 the dividing of Emerging Communities into two tiers
for determining funding, the Title I hold-harmless provision, the Title I
grandfather clause, and the Title II hold-harmless provision that is
funded from amounts that would otherwise be available for states with
severe need in their drug programs. To examine the effect of each
provision on the distribution of CARE Act and HOPWA funds, we measured
differences either on a per case basis, by the amount of funding received,
or both. To determine the effects of adopting the Office of Management and
Budget's (OMB) 2004 definitions of metropolitan statistical areas (MSA) on
EMAs, we compared the boundaries of existing EMAs with those that would be
created, and we determined the change in the number of ELCs that would be
counted under Title I. In addition, we examined the effect of using living
AIDS cases instead of cumulative AIDS cases 10 in making HOPWA base grant
distributions by comparing the actual funding distributions with simulated
distributions using living AIDS cases. 11 We also assessed the effect of
HOPWA bonus grants on funding for eligible metropolitan statistical areas
(EMSA) by examining the size of these grants and which EMSAs received
them. 12
In our analyses we used funding per AIDS case to illustrate the effect of
certain funding-formula provisions on the distribution of CARE Act and
HOPWA funds. There are other considerations that could be included in
funding formulas that could justify deviations from equal funding per
case. For example, differing health care and housing costs across regions
and differences in grantees' capacities to fund services from local
resources could be used as bases for distributing program funds and could
justify such deviations. 13 Currently, these considerations are not taken
into account when distributing formula grants under either the CARE Act or
HOPWA, and are not considered here. To assess the reliability of the HRSA
and HUD data on the distribution of funds under the CARE Act and HOPWA, we
asked agency officials about how the data were developed and reported. We
also reviewed relevant documentation. We determined the data were
sufficiently reliable for the purposes of our report.
To show how CARE Act and HOPWA funding could be affected by including HIV
cases in funding formulas, we examined how CARE Act and HOPWA fiscal year
2004 formula grants would have been affected by using HIV cases in
addition to living AIDS cases to determine formula funding. 14 We
undertook our analyses in light of the statutory requirement that HIV
cases be used in CARE Act funding formulas not later than fiscal year
2007. Our analyses, however, rely on data whose reliability has been
questioned. The Secretary of Health and Human Services has determined that
because of the problems associated with these data, they should not
currently be used in determining CARE Act funding. We used these data in
our analyses to give a general indication of the effect of using HIV cases
in future formula allocations as required by the CARE Act. The extent to
which the use of HIV cases could affect formula allocations cannot be
determined by these analyses because jurisdictions use different methods
to identify HIV cases, and it is unclear to what degree the resulting case
counts are comparable. However, we think our approaches in these analyses
are informative given the required incorporation of HIV cases into CARE
Act funding formulas. To assess the reliability of the case-count data, we
asked HRSA, HUD, CDC, state, and local officials a series of questions
about how the data were collected and the methods used to ensure their
accuracy. On the basis of the information provided regarding the
verification of these data, we determined these data to be sufficiently
reliable for the purposes of our analyses. Appendix I provides a more
detailed explanation of the scope and methodology for this report. We
performed our work from July 2004 through February 2006, in accordance
with generally accepted government auditing standards.
Background
In 1990, Congress passed the CARE Act and HOPWA legislation to address the
needs of jurisdictions, health care providers, and people with HIV/AIDS
and their family members. Within the CARE Act and HOPWA legislation, there
are provisions for determining the distribution of program funding.
Furthermore, amendments in 1996 and 2000 changed some CARE Act provisions,
and public debate continues on how best to measure the effect of HIV/AIDS
within the United States, and how to distribute funding accordingly.
HIV/AIDS in the United States
Over the course of the last quarter century, the HIV/AIDS epidemic has
spread to every region of the country. CDC has estimated that in the 50
states approximately 40,000 persons become infected with HIV annually.
While AIDS cases remained concentrated in metropolitan areas through 2004,
AIDS prevalence rates in nonmetropolitan areas rose. 15
The United States population living with HIV/AIDS is diverse. Racial and
ethnic minorities have been disproportionately affected by HIV/AIDS since
the beginning of the epidemic, but in 2004 African Americans accounted for
more new AIDS cases, more of those estimated to be living with AIDS, and
more of those who died with AIDS than any other racial or ethnic group.
Latinos also account for a greater proportion of AIDS cases and deaths
than their representation in the overall population.
Despite the number of deaths from AIDS and the steady increase of AIDS
prevalence, there have been successes in the fight against HIV/AIDS.
Developments in treatment have enhanced care options and can extend the
lives of those living with HIV/AIDS. The introduction of highly active
antiretroviral therapy in 1996 was followed by a decline in the number of
deaths and new AIDS cases in the United States for the first time since
the beginning of the epidemic.
The federal government's efforts to address the domestic HIV/AIDS epidemic
include providing federal funding for the following categories of
activities-treatment and income support for individuals with HIV/AIDS,
prevention efforts, and research. In fiscal year 2004, federal funding for
domestic HIV/AIDS programs was nearly $16.3 billion. Of this total, about
$2.1 billion was distributed through CARE Act programs, and $295 million
was distributed through the HOPWA program. Medicaid was the largest source
of federal assistance for HIV/AIDS health care, with $5.4 billion in
federal funding. Other large sources of federal funding for HIV/AIDS are
Medicare-$2.6 billion-and the National Institutes of Health-about $2.5
billion. Funding from other federal sources ranged from $1 million from
the Department of Labor to more than $1 billion from the Social Security
Disability Insurance Program. Figure 1 provides a breakdown of federal
HIV/AIDS funding by category.
Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004
The CARE Act
The majority of CARE Act funds are distributed through four different
programs, each contained in a separate title, to the states, EMAs, and
other entities. Titles I and II of the act provide for formula grants
(base grants) to EMAs and states according to each jurisdiction's number
of ELCs relative to all EMAs and states. These titles also provide for
other grants to subsets of eligible jurisdictions either by formula or by
a competitive process. For example, in addition to AIDS Drug Assistance
Program (ADAP) base grants, Title II also authorizes grants for states and
certain territories with demonstrated need for additional funding to
support their ADAPs. 16 These grants, known as Severe Need Grants, are
funded through a set-aside of funds otherwise available for ADAP grants.
Title II also authorizes funding for "Emerging Communities," which are
communities affected by AIDS that have not had a sufficient number of AIDS
cases reported in the last 5 calendar years to be eligible for Title I
grants as EMAs. In order to address the effect of the disease on racial
and ethnic minorities, HRSA has used funds otherwise available under Title
I and Title II for Minority AIDS Initiative grants to EMAs, states, and
territories. EMAs may also receive Title I supplemental grants, which are
awarded using a competitive application process based on the demonstration
of severe need and other criteria. 17 Table 1 describes the purposes and
the grantees of each title.
Table 1: CARE Act Programs, 2004
CARE Act program Grantees Purpose
Title I. Grants to 51 EMAsa Support primary health care,
Eligible medications, and a range of
Metropolitan Areas services, such as case
(EMAs) management, substance abuse
treatment, housing, mental
health treatment, and
nutritional counseling.
Title II. Grants to States and territories Support primary and
States and home-based health care,
Territories insurance coverage,
medications, support
services, and early
intervention services, such
as HIV counseling, testing,
and referral. Funding for
AIDS Drug Assistance Programs
provides medications,
treatment adherence and
support, and health insurance
with prescription drug
benefits.
Title III. Early Primary care providers, Support comprehensive
Intervention including health services including HIV
Services, Capacity centers, city and county counseling, testing,
Development, and health departments, and outpatient medical care, and
Planning Grants outpatient medical case management; funds also
centers go toward developing HIV
service delivery systems and
building capacity to provide
services.
Title IV. Services Health care facilities, Support family-centered and
for Women, Infants, public health agencies, coordinated health care and
Children, Youth, and community-based support services that benefit
and Their Affected organizations that serve children, youth, and women
Family Members Title IV target living with HIV, and their
populations families. Also support
initiatives to help identify
HIV-positive pregnant women
and ensure access to prenatal
care that could prevent
perinatal transmission.
Special Projects of University and community Support the development of
National clinics, evaluation innovative models of HIV/AIDS
Significance centers,b local and care that can be replicated,
state health such as interventions for
departments, HIV-positive substance
community-based abusers.
organizations, and
nonprofit agencies
AIDS Education and 4 national centers and Conduct education and
Training Center 11 regional centers with training programs for health
Program 130 associated sites care providers treating
people with HIV/AIDS.
Dental Programs Dental education Improve access to oral health
institutions, hospitals, care and enhance dental
and other institutions training on caring for people
with dental education with HIV/AIDS through the
programs Dental Reimbursement Program
and Community-Based Dental
Partnership grants.
Source: HRSA.
aUnder Title I, a metropolitan area with a population of at least 500,000
and more than 2,000 reported AIDS cases in the last 5 calendar years is
eligible to receive a formula base grant. As a result of the CARE Act
Amendments of 1996, EMAs that were eligible for Title I grants in that
year are grandfathered: they will be eligible for grants under Title I
even if their number of AIDS cases drops below the threshold for
eligibility. App. II contains a list of the EMAs.
bEvaluation centers support Special Projects grantees and coordinate the
evaluation of initiatives under the Special Projects of National
Significance program.
CARE Act Amendments
The Ryan White CARE Act Amendments of 1996 18 and the Ryan White CARE Act
Amendments of 2000 19 modified the original funding formulas. For example,
prior to the 1996 amendments, the CARE Act required that for purposes of
determining grant amounts a metropolitan area's caseload be measured by a
cumulative count of AIDS cases recorded in the jurisdiction since
reporting began in 1981. The 1996 amendments required the use of ELCs
instead of cumulative AIDS cases. 20 Because this switch would have
resulted in large shifts of funding away from jurisdictions with a longer
history of the disease than other jurisdictions, due in part to a higher
proportion of deceased cases, the 1996 CARE Act amendments added a
hold-harmless provision under Title I, as well as under Title II, that
limit the extent a grantee's funding can decline from one year to the
next.
Metropolitan areas heavily affected by HIV/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. 21 To adjust for this
situation, the 1996 amendments instituted a two-part formula for Title II
base grants that takes into account the number of ELCs that reside within
a state but outside of any EMA. Under this distribution formula, 80
percent of the Title II base grant is based upon a state's proportion of
all ELCs, and 20 percent of the base grant is based on a states'
proportion of ELCs outside of EMAs relative to all such ELCs. A second
provision included in 1996 protected the eligibility of EMAs. The 1996
amendments provided that a jurisdiction designated as an EMA for that
fiscal year would be "grandfathered" so it would continue to receive Title
I funding even if its reported number of AIDS cases dropped below the
threshold for eligibility. Table 2 describes CARE Act formula grants for
Titles I and II.
Table 2: Description of CARE Act Title I and Title II Formula Grants
Formula Eligible Distribution Minimum Hold-harmless
grant grantees grant provisiona
Title I Base Metropolitan Distributed among No Grant annually
Grant areas with EMAs according to declines to
500,000 or each EMA's 98%, 95%, 92%,
more in proportion of ELCs and 89% of the
population relative to all base year
and with more EMAs. grant,
than 2,000 respectively.c
reported AIDS In the fifth
cases in the and all
most recent 5 subsequent
calendar years, EMA
yearsb receives 85%
of base year
grant. The
funds
necessary to
meet the
hold-harmless
requirement
are deducted
from funds
available for
supplemental
grants under
Title I.d
Title II States and Eighty percent of For states Grant declines
Base Grant territoriese base grant funding with fewer by 1% per year
divided among than 90 from the
states/territories ELCs, fiscal year
according to each $200,000; 2000 grant. In
grantee's states with fifth year,
proportion of all 90 or more grant is 95%
ELCs. Twenty ELCs, of 2000 grant.
percent of base $500,000;
grant funding for
divided among territories,
states/territories $50,000
according to each
grantee's ELCs
located outside the
EMAs within the
state's/territory's
borders relative to
such ELCs in all
states/territories.
Title II States and Distributed No Grant declines
ADAP Base certain according to each by 1% per year
Grant territoriesf grantee's from the
proportion of all fiscal year
ELCs. 2000 grant. In
fifth year
grant is 95%
of 2000 grant.
Title II States and Distributed No No
ADAP Severe certain according to each
Need Grantg territoriesf grantee's
with a severe proportion of all
need for a ELCs: grantees must
grant to agree to match 25
increase percent of their
access to severe need grant
medications and not to impose
eligibility
requirements
stricter than those
in place on January
1, 2000.
Title II States and Funds are divided Minimum of No
Emerging territories into two tiers: 50% $5 million
Communities with distributed among for each
Grant metropolitan communities with tier
areas that 1,000-1,999 AIDS
are not cases, and 50%
eligible for distributed among
Title I, and communities with
that have 500-999 AIDS cases.
500-1,999 Funding is
reported AIDS distributed
cases in the according to each
most recent 5 community's
calendar proportion of AIDS
years cases (reported in
the most recent 5
calendar years) in
Emerging
Communities within
the tier.
Source: HRSA.
Notes: HRSA has also awarded Minority AIDS Initiative grants to EMAs,
states, and territories. HRSA characterizes Minority AIDS Initiative
grants to EMAs as Title I grants and Minority AIDS Initiative grants to
states and territories as Title II grants. These funds are allocated by
formula. Title I funds have been used for grants to EMAs with greater than
zero reported nonwhite AIDS cases in the most recent 2 calendar years. The
funds are distributed among all EMAs according to each EMA's proportion of
nonwhite AIDS cases reported over the most recent 2 calendar years. Title
II funds have been used for grants to states and territories with greater
than zero reported nonwhite AIDS cases in the most recent 2 calendar
years. The funds are distributed among all grantees according to each
grantee's proportion of nonwhite AIDS cases reported over the most recent
2 calendar years. There are no minimum-grant or hold-harmless provisions
for these grants.
aIf the distribution formula would otherwise result in a funding decrease
from a prior year, a hold-harmless provision may be triggered to mitigate
the decrease in funding.
bA grandfather clause added in 1996 provides that areas eligible at that
time continue to be eligible even if they no longer meet the eligibility
critieria.
cThe base year is the fiscal year prior to that in which the EMA first
becomes eligible for hold-harmless funding.
dTitle I also includes supplemental grants, which are awarded to EMAs
using a competitive application process based on the demonstration of
severe need and other criteria.
eIn addition to the 50 states, Title II base grants are authorized for the
District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin
Islands, American Samoa, the Commonwealth of the Northern Mariana Islands,
the Federated States of Micronesia, the Republic of Palau, and the
Republic of the Marshall Islands.
fIn addition to the 50 states, these grants are authorized for the
District of Columbia, the Commonwealth of Puerto Rico, Guam, and the
Virgin Islands.
gFunding for Severe Need grants may be reduced to maintain funding for
some states under a Title II hold-harmless provision. Severe Need grants
are funded by setting aside 3 percent of the funds earmarked specifically
for ADAPs.
Metropolitan Statistical Areas
In determining a metropolitan area's eligibility for Title I funding and
for purposes of defining areas served under Title I, the CARE Act uses the
OMB 1993 definitions of MSAs. OMB's 1993 definitions were based on
applying OMB's 1990 standards for defining an MSA to data from the 1990
census. OMB's standards create a metropolitan classification scheme that
includes rules for determining which counties (the basic building block of
MSAs) would be designated as the central counties of metropolitan areas
and which outlying counties would be associated with particular central
counties. The 1996 CARE Act amendments froze the metropolitan areas to
those specified in the 1993 OMB definitions. 22
HIV Case Counts
The 2000 amendments provided for HIV case counts to be incorporated in the
Title I and Title II funding formulas 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. 23 They also required that HIV
data be used no later than the beginning of fiscal year 2007. In June 2004
the Secretary of Health and Human Services determined that HIV data were
not yet ready to be used for the purposes of distributing formula funding
under Title I and Title II of the CARE Act. The Secretary cited a 2004 IOM
report, which identified several limitations in the ability of states to
provide adequate and reliable HIV case counts for use in distributing CARE
Act grants. 24
HOPWA
HOPWA is the only federal program dedicated to providing housing
assistance to persons living with HIV/AIDS and their families. Funding
under HOPWA supports a variety of services, including rental assistance
and the acquisition, rehabilitation, and construction of housing units.
HOPWA funds also provide for supportive services, such as health care,
substance abuse treatment, and case management. In fiscal year 2004, $295
million was distributed through HOPWA.
Ninety percent of HOPWA funds are distributed through formula grants to
states, Puerto Rico, and metropolitan areas. The remaining 10 percent of
HOPWA funds are provided through competitive grants to states, Puerto
Rico, local governments, and nonprofit organizations. Formula grants under
HOPWA incorporate cumulative AIDS case counts, rather than an estimate of
persons living with AIDS, such as ELCs as used in the CARE Act.
Seventy-five percent of HOPWA formula funding is awarded through base
grants to EMSAs, which are jurisdictions with more than 500,000 people and
more than 1,500 cumulative AIDS cases, and to states and Puerto Rico that
have more than 1,500 cumulative AIDS cases outside EMSAs. The remaining 25
percent of HOPWA formula funding is awarded through bonus grants for EMSAs
that meet the eligibility threshold but also demonstrate a
higher-than-average per capita incidence of AIDS. These grants are based
on the number of cases in excess of the average AIDS incidence rates of
EMSAs. HUD first used OMB's new MSA definitions in determining EMSAs for
fiscal year 2004 funding.
Results in Brief
CARE Act and HOPWA grants are used for health care, housing assistance,
and a variety of services for people with HIV/AIDS. In fiscal year 2003,
more than half of the approximately $600 million in Title I CARE Act funds
were allocated by grantees for health care services such as outpatient
care and home health services, and over two-thirds of the approximately $1
billion in Title II funds were allocated by states and territories for
medications. Over three-quarters of the approximately $194 million in
Title III fiscal year 2002 funds were allocated for health care services.
In fiscal year 2003, about $68 million in Title IV grants was provided for
health care and support services for children, youth, and women with
HIV/AIDS and their families. Also in fiscal year 2003, about $74 million
in funding was provided in total for dental programs, projects that
support innovative models of HIV/AIDS care, and AIDS Education and
Training Centers for health care providers. HOPWA funds were used for a
variety of housing-related expenses, such as rental assistance, and
support services. In fiscal year 2003, two-thirds of the approximately
$249 million in HOPWA funds were used for direct housing costs, such as
rental assistance, for people with HIV/AIDS and their families.
Multiple provisions in the CARE Act and HOPWA grant funding formulas
result in funding not being distributed according to the current
distribution of the disease. Grantees do not receive the same level of
CARE Act or HOPWA funding per person living with AIDS because various
formula provisions affect the proportional allocation of funding.
o We found that both the CARE Act and HOPWA use measures of AIDS
cases that do not accurately reflect the number of persons living
with AIDS. Some CARE Act grants and HOPWA base grant funding are
based on case counts that could include deceased cases because the
eligibility and allocations are determined using cumulative case
counts. In addition, the CARE Act's use of ELCs, which are
determined using the most recent 10 years of reported AIDS cases,
to distribute the majority of formula funding does not take into
account that many AIDS patients now live longer than 10 years
after their disease is reported.
o We found that certain CARE Act Title I and II provisions
related to metropolitan areas result in variability in the amounts
of funding per ELC among grantees. For instance, the counting of
ELCs within EMAs once for determining Title I base grants and once
again for determining Title II base grants results in states with
a higher proportion of ELCs in EMAs and Puerto Rico, which has a
similar percentage, receiving more total Title I and Title II
funding per ELC than states with no EMA or with comparatively few
ELCs located in EMAs. Also, the division of Emerging Communities
into two tiers based on their numbers of reported AIDS cases in
the past 5 years leads to funding disparities among grantees. This
divergence occurs because funding is divided equally between the
two tiers regardless of the number of communities or the number of
reported AIDS cases in each tier. In fiscal year 2004, the 4
communities in the first tier received $1,052 per reported case
while the 25 communities in the second tier received $313 per
reported case.
o We found that because of CARE Act hold-harmless provisions
under Titles I and II and the grandfather clause for EMAs under
Title I, the funding of certain grantees is protected. For
example, the CARE Act Title I hold-harmless provision results in
the San Francisco EMA's funding being based in part on deceased
cases in the EMA in 1995. In addition, a Title II hold-harmless
provision, which has had little effect thus far, has the potential
to reduce the amount of funding to grantees with severe need for
drug treatment funds because the hold-harmless provision is funded
from amounts set aside for ADAP Severe Need grants. The Title I
grandfather clause protected the funding of more than half of
EMAs.
The Ryan White CARE Act Amendments of 2000 required the use of
HIV/AIDS case counts in the distribution of formula grants not
later than fiscal year 2007. If case counts from HIV-reporting
systems had been used along with a measure of the number of
persons living with AIDS in distributing fiscal year 2004 CARE Act
and HOPWA grants, funding would have shifted among jurisdictions.
Although CARE Act and HOPWA grantees have established HIV
case-reporting systems, differences between these systems-in their
maturity and reporting methods, for instance-would have affected
the distribution of CARE Act and HOPWA funds based on HIV/AIDS
case counts. Recently established HIV-reporting systems might not
have captured an accurate count of a grantee's HIV cases in part
because cases diagnosed prior to the establishment of the
reporting system might not have been reported and entered into the
system. Also, because CDC does not accept case reports that are
reported using a code rather than a person's name to protect their
anonymity, those states with code-based systems would not have had
their HIV cases counted when funding distributions were made.
Accordingly, we developed two approaches to assess the effect of
using the HIV case counts, as they currently exist, on CARE Act
and HOPWA formula grants. While the extent to which funding may
have shifted cannot be determined given the different methods
jurisdictions use to identify HIV cases, we think these approaches
are informative given the required corporation of HIV cases into
CARE Act funding formulas. Using these approaches, we found that
up to 13 percent of CARE Act formula funding would have shifted
among grantees if HIV cases were included in the funding formulas
and the hold-harmless provisions analyzed and minimum-grant
provision were maintained. Larger changes for individual grantees
would have occurred with some grantees more than doubling their
funding. Grantees in the South and Midwest would generally have
received more funding from using HIV cases in funding formulas.
However, there would have been grantees that would have received
increased funding and grantees that would have received decreased
funding in every region of the country. If, in addition to using
HIV data, the hold-harmless provisions we analyzed and
minimum-grant provisions were eliminated, the redistribution of
program funds would have been more dramatic. Up to 24 percent of
funding would have shifted. HOPWA base funding would also have
shifted if HIV and living AIDS cases were used to distribute
funding. In fiscal year 2004, up to 15 percent of HOPWA base
funding would have shifted among grantees, with six grantees more
than doubling their funding. Differences in HIV case-reporting
systems would affect the distribution of funding, and we found
that funding would have tended to shift to jurisdictions with
older HIV-reporting systems. Jurisdictions with older
HIV-reporting systems tend to have more reported HIV cases
compared with their number of AIDS cases than do jurisdictions
with newer reporting systems.
If Congress wishes CARE Act and HOPWA funding to more closely
reflect the distribution of persons living with AIDS, it should
take actions that lead to more-comparable funding per case by
revising the funding formulas. In accordance with achieving
more-comparable funding per AIDS case, we raise a number of
matters for consideration when Congress reviews the CARE Act and
HOPWA.
We provided a draft of this report to HHS and HUD. HHS and HUD
generally agreed with our identification of issues in the funding
formulas. While HHS also generally agreed with our matters for
congressional consideration, it expressed concern that our
discussion of the Title I grandfather provision in the CARE Act
could be interpreted as suggesting that the metropolitan areas
that continue to receive grants because of this provision need not
be funded. However, these areas could still receive funding
through their respective states or territories, which receive
funds under Title II. HUD concurred with our matter for
congressional consideration that HOPWA formula grant eligibility
and base grant funding be based on a measure of living AIDS cases.
CARE Act and HOPWA Funds Allocated for Health Care, Housing Assistance,
and a Variety of Other Services
The CARE Act and HOPWA grants fund a variety of treatment and support
services for people with HIV/AIDS. For fiscal year 2003, Title I grantees
allocated more than half of the approximately $600 million in Title I
grants for health care services such as outpatient care and home health
care, and over 70 percent of the approximately $1 billion in Title II
funds were allocated for medications. Almost 80 percent of the
approximately $194 million in Title III fiscal year 2002 funds were
allocated for health care services such as physician office visits and HIV
counseling and testing. 25 In fiscal year 2003, there was also about $68
million in funding for Title IV grantees and about $74 million for other
programs, such as Special Projects of National Significance. Two-thirds of
the approximately $249 million in HOPWA fiscal year 2003 funds were used
to assist with housing costs for people with HIV/AIDS and their families.
More Than Half of Title I Fiscal Year 2003 Funding Was Allocated for
Health Care Services
For fiscal year 2003, HRSA provided about $600 million in grants to EMAs
under Title I of the CARE Act to support services for people with
HIV/AIDS. Grantees allocated the largest portion of these funds, about 52
percent, for health care services such as outpatient care, home health
care, rehabilitation care, and medications. About 12 percent of these
Title I health care services funds were allocated for substance abuse
treatment and counseling services. For the same year, Title I grantees
allocated about 36 percent of those funds for case management and support
services. Support services include child care, client advocacy, and
emergency financial assistance, among others. The remaining 12 percent of
Title I funding was allocated for administration, planning councils, and
program support. 26 (See fig. 2.)
Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003
Note: About $600 million was allocated under Title I.
Over Two-thirds of Title II Fiscal Year 2003 Funding Was Allocated for
Medications
HRSA provided approximately $1 billion to states and territories under
Title II in fiscal year 2003. Title II grantees allocated the majority of
these funds, about 71 percent, for medications, which includes ADAP
medications, non-ADAP medications, and pharmacy assistance for CARE Act
clients. Ten percent of Title II funds were allocated for health care
services, similar to those provided under Title I. Grantees allocated
about 3 percent of Title II health care services funds for substance abuse
treatment services. Case management and support services similar to those
provided under Title I accounted for approximately 10 percent of the Title
II funds. The remainder of Title II funds, about 9 percent, was allocated
for program administration, planning, and evaluation. 27 (See fig. 3.)
Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003
Notes: Approximately $1 billion was allocated under Title II.
aMedications includes ADAP medications, non-ADAP medications, and pharmacy
assistance.
Over Three-quarters of Title III Fiscal Year 2002 Funding Was Allocated
for Health Care Services
Under Title III of the CARE Act, HRSA provided about $194 million in
grants to certain public and nonprofit primary care providers in support
of early intervention services for people with HIV/AIDS for fiscal year
2002. Title III grantees allocated about 79 percent of these funds for
health care services such as physician office visits, HIV counseling and
testing, and employing primary care personnel. Health care services also
included outpatient mental health care and substance abuse treatment.
Title III grantees allocated another 13 percent for other activities,
including case management and HIV patient education. The remaining 8
percent was allocated for administration. 28 (See fig. 4.)
Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002
Note: About $194 million was allocated under Title III.
CARE Act Grants Funded Other Activities in Fiscal Year 2003
Grants made under Title IV of the CARE Act address the specific needs of
women, infants, children, and youth living with HIV/AIDS. The funds cover
primary and specialty medical care, psychosocial services, case
management, and other activities. For fiscal year 2003, HRSA provided
about $68 million for Title IV programs. Other CARE Act programs include
the Special Projects of National Significance Program, funded at about $25
million for fiscal year 2003; the AIDS Education and Training Centers
Program, funded at about $36 million for fiscal year 2003; and the
HIV/AIDS Dental Reimbursement Program and Community-Based Dental
Partnership program funded at nearly $10 million and $3 million
respectively for fiscal year 2003.
Two-thirds of HOPWA Fiscal Year 2003 Funds Were Spent on Housing Costs
For fiscal year 2003, HOPWA grantees spent about $249 million to support
housing services for people with HIV/AIDS. The largest portion of these
funds, about 66 percent, was spent on direct housing costs, such as rental
assistance, and housing facility operating costs. Support services
accounted for 25 percent of the funds. HOPWA-funded support services
include case management, health care, alcohol and drug abuse treatment,
and child care, among others. Housing information services and permanent
housing placement costs accounted for 4 percent of HOPWA funds, while
grant administration was 5 percent of the total. (See fig. 5.)
Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003
Notes: About $249 million was spent under HOPWA.
Multiple Provisions Contribute to Disproportionate Distribution of CARE
Act and HOPWA Formula Funding
Provisions in the CARE Act and HOPWA funding formulas result in a
distribution of funds among grantees that does not reflect the relative
distribution of AIDS cases in these jurisdictions. 29 CARE Act grantees do
not receive the same amount of funding per ELC, and HOPWA grantees do not
receive the same amount of funding per living AIDS case. We found that
provisions affected the proportional allocation of funding as follows: (1)
the AIDS case-count provisions in the CARE Act and HOPWA each result in a
distribution of funding that is not reflective of the distribution of
persons living with AIDS, (2) CARE Act provisions related to metropolitan
areas result in variability in the amounts of funding per ELC among
grantees, (3) the CARE Act hold-harmless provisions and grandfather clause
protect the funding of certain grantees, and (4) the ineligibility of
grantees other than EMSAs for HOPWA bonus funding restricts the
distribution of these funds and limits HUD's ability to fund areas outside
of EMSAs with high rates of new AIDS cases. We also considered the
provision in the 1996 CARE Act amendments that froze the EMA boundaries to
1993 OMB definitions. We found that the boundaries for more than half of
current EMAs would change if OMB's 2004 MSA definitions were adopted for
purposes of CARE Act funding.
CARE Act and HOPWA Grants Are Not Distributed Solely in Proportion to
Number of Persons Living with AIDS
Funds distributed under Title I of the CARE Act are not distributed
proportionally per ELC across EMAs. 30 In fiscal year 2004, the total
funding for all Title I grants to EMAs was about $595 million. If this
funding had been distributed solely by a grantee's proportion of ELCs,
each EMA would have received $2,443 per ELC. However, Title I provisions
affect the grant awards so that funding is not distributed strictly on a
proportional basis, but instead is allocated in part according to the
number of ELCs and in part on other bases, such as the amounts awarded in
a prior year, as reflected in the hold-harmless funding. Total funding for
EMAs also reflects Minority AIDS Initiative grants and supplemental
grants. In fiscal year 2004, total Title I funding for the 51 EMAs ranged
from $2,130 per ELC case in Riverside-San Bernardino to $4,137 in San
Francisco, with an average of $2,380. Excluding San Francisco, West Palm
Beach had the highest Title I funding per ELC at $2,515. Appendix II lists
the EMAs and amounts awarded under Title I for fiscal year 2004.
CARE Act Title II funding is also not distributed proportionally per ELC.
In fiscal year 2004, the total funding for all Title II grants was about
$1.051 billion. If this funding had been distributed solely according to
the proportion of ELCs, each grantee would have received $3,053 per ELC.
However, minimum-award requirements and hold-harmless provisions affect
the distribution of Title II funds. In addition, grants for Emerging
Communities as well as the Minority AIDS Initiative are not determined
proportionally by the number of ELCs. Total Title II funding for fiscal
year 2004 ranged from $2,793 for the District of Columbia to $7,275 for
South Dakota, with an average of $3,559. Appendix III shows the grantees
and amounts awarded under Title II for fiscal year 2004.
HOPWA formula funding is also disproportionate across grantees. In fiscal
year 2004, about $263 million was allocated by formula to 117 grantees.
Seventy-five percent of this funding was distributed according to the
number of cumulative AIDS cases 31 in a jurisdiction and 25 percent was
distributed based on the rate of new AIDS cases in EMSAs. If this funding
had been distributed proportionally by the number of cumulative AIDS cases
across jurisdictions each grantee would have received $306 per cumulative
case. However, 26 grantees received bonus grants that are based on the
rate of new AIDS cases in an EMSA, not the number of cumulative AIDS
cases. Therefore, the actual amounts grantees received ranged from $230
per cumulative AIDS case for 91 grantees to $626 per case in Baton Rouge,
with an average of $260. We also determined how much funding each grantee
received per living AIDS case. 32 We found that grantees received an
average of $573 per living AIDS case, with funding ranging from $387 per
case in Nashville to $1,290 per case in Baton Rouge. These funding
differences are due to the use of cumulative AIDS cases to distribute base
grant funding and because bonus grants are distributed according to the
rate of new cases in EMSAs. 33 Appendix IV identifies the fiscal year 2004
HOPWA formula grantees and award amounts.
Provisions in HOPWA and CARE Act Funding Formulas Incorporate Measures of
AIDS Cases That Do Not Reflect an Accurate Count of Persons Living with
AIDS
HOPWA and the CARE Act both use measurements of AIDS cases that do not
reflect an accurate count of people currently living with AIDS. To
determine eligibility for HOPWA formula grants and to distribute base
funding, allocations are determined using a measure of AIDS cases that is
based on the number of living and deceased AIDS cases reported in the
jurisdiction since the beginning of the AIDS epidemic in 1981. Also,
eligibility and distribution of certain CARE Act grants are based on the
number of reported AIDS cases over either the last 2- or 5-year period, 34
which likely does not reflect all live cases and could include deceased
AIDS cases. In addition, Title I, Title II, and ADAP base grants are
calculated using ELCs, which can underestimate the number of living cases
because many persons with AIDS now live longer than 10 years after their
cases are reported.
HOPWA Grants
Eligibility for HOPWA formula grants is determined by the number of
cumulative AIDS cases in a metropolitan area, state, and Puerto Rico, and
base funding allocations (which represent 75 percent of total HOPWA
formula funding) to grantees are determined by the grantee's proportion of
the total number of cumulative AIDS cases. As we reported in 1995, the use
of cumulative case counts is an inappropriate caseload measure because it
includes all AIDS cases, living and dead, reported to CDC for the
jurisdiction since the beginning of the epidemic in 1981. 35
Because the HOPWA funding formula includes deceased persons, the
distribution of funds does not reflect the current distribution of people
living with AIDS. Using estimates of living AIDS cases obtained from CDC,
we calculated how base funding for grantees would have changed in fiscal
year 2004 if these estimates had been used instead of the cumulative case
counts. Each of the 117 grantees would have received approximately $537
per living AIDS case. We found that 25 grantees received more funding in
fiscal year 2004 using cumulative case counts than they would have
received if the number of living AIDS cases had been used. The additional
funding received by the grantees ranged from approximately $2,000 in San
Jose to $4,020,000 in New York City. Conversely, if the number of living
cases had been used, 92 grantees would have received increased funding.
The funding increases would have ranged from $1,000 in Springfield,
Massachusetts, to $1,120,000 in the District of Columbia. Areas that
receive more funding from the use of cumulative case counts include
jurisdictions in California, Michigan, New Jersey, and New York. (App. V
contains information on funding using cumulative AIDS counts and living
AIDS cases.)
Use of cumulative case counts rather than living cases can lead to areas
with similar numbers of living AIDS cases receiving markedly different
amounts of funding. For example, as of March 31, 2003, Oakland and New
Orleans both reported 3,374 living AIDS cases. 36 However, in fiscal year
2004 Oakland received $221,000 more ($66 more per living AIDS case) in
HOPWA base funding than did New Orleans. Atlanta and Houston also have
similar numbers of living AIDS cases (8,557 and 8,579 respectively).
However, in fiscal year 2004 Houston received $806,000 more ($93 more per
case) in HOPWA base funding than did Atlanta.
CARE Act Grants
The use of cumulative case counts is not limited to the HOPWA program.
Deceased cases can also be included when determining eligibility for CARE
Act funding. Eligibility for Title I funding and Title II Emerging
Communities grants is based on cumulative totals of AIDS cases reported in
the most recent 5-year period, not on the number of ELCs. Funding amounts
for Emerging Communities grants are also determined using the most recent
5 years of reported cases. In addition, HRSA determines eligibility and
funding amounts of Minority AIDS Initiative grants according to the number
of reported AIDS cases in the most recent 2-year period.
The use of the cumulative number of reported cases over a certain period
to determine eligibility and allocate funding results in funding not being
distributed according to the current distribution of the disease. For
example, because Emerging Communities funding is determined by using
5-year cumulative case counts, allocations could be based in part on
deceased cases, that is, people for whom AIDS was reported in the past 5
years but who have since died. In addition, these case counts do not take
into account living cases in which AIDS was diagnosed more than 5 years
earlier. Consequently, 5-year cumulative case counts can substantially
misrepresent the number of AIDS patients in these communities. For
example, while the 5-year cumulative case count in Buffalo for determining
fiscal year 2004 Emerging Communities eligibility and funding was 581
cases, the number of ELCs was 956. Similarly, the 5-year cumulative case
count in Charleston, South Carolina, was 538, but the number of ELCs was
758.
The use of ELCs as provided for in the CARE Act can also lead to
inaccurate estimates of living AIDS cases. Currently, Title I, Title II,
and ADAP base funding, which constitute the majority of formula funding,
are distributed according to ELCs. ELCs are an estimate of living AIDS
cases calculated by applying annual national survival weights to the most
recent 10 years of reported AIDS cases and adding the totals from each
year. This method for estimating cases was first included in the CARE Act
Amendments of 1996. At that time, this approach captured the vast majority
of living AIDS cases. However, some persons with AIDS now live more than
10 years after their case is first reported, and they are not accounted
for by this formula. 37 Thus, like the 2- and 5-year reported case counts,
ELCs can misrepresent the number of living AIDS cases in an area in part
by not taking into account those persons living with AIDS whose cases were
reported more than 10 years earlier. For example, fiscal year 2004 Title I
base funding for the Atlanta EMA was based on 7,589 ELCs, but CDC
estimated that there were 8,560 reported living AIDS cases in the EMA. 38
Similarly, funding for the Seattle EMA was based on 2,468 ELCs while CDC
estimated that there were 3,273 reported living cases. 39
CARE Act Funding Provisions for Metropolitan Areas Result in
Disproportionate Funding
The counting of ELCs within EMAs once to determine the amount of the base
grant under Title I and once again to determine the amount of the Title II
base grant results in states with EMAs and Puerto Rico receiving more
total Title I and Title II funding per ELC than states without EMAs. 40 In
addition, the formula for awarding Title II Emerging Communities grants
results in different levels of funding per AIDS case across grantees.
Counting ELCs within EMAs Twice Results in Disproportionate Funding per
ELC across States and Puerto Rico
When total Title I and Title II funding is considered, states with EMAs
and Puerto Rico receive more funding per ELC than states without EMAs
because cases within EMAs are counted twice, once in connection with Title
I base grants and once for Title II base grants. Eighty percent of Title
II base grants is determined by the total number of ELCs in the state or
territory. The remaining 20 percent is based on the number of ELCs in each
jurisdiction outside of any EMA. This 80/20 split was established by the
1996 CARE Act amendments to address the concern that grantees with EMAs
received more total Title I and Title II funding per case than grantees
without EMAs. However, even with the 80/20 split, states with EMAs and
Puerto Rico receive more total Title I and Title II funding per ELC than
states without EMAs. States without EMAs receive no funding under Title I,
and thus, when total Title I and Title II funds are considered, states
with EMAs and Puerto Rico receive more funding per ELC. 41 Appendix VI
shows the combined Title I and Title II fiscal year 2004 funding received
by each state and Puerto Rico.
Table 3 illustrates the effect of counting EMA cases twice by comparing
the relationship between the percentage of a state's and Puerto Rico's
ELCs that are within EMAs and the amount of total Title I and Title II
funding they receive per ELC. Table 3 shows that as the percentage of a
state's or Puerto Rico's ELCs within EMAs increases, the total Title I and
II funding per ELC also increases. For example, states with no ELCs in
EMAs received on average $3,592 per ELC. States with 75 percent or more of
their cases in EMAs and Puerto Rico 42 received on average $4,955 per ELC,
or 38 percent more funding than states with no EMA. If the total Title I
and Title II funding had been distributed proportionally per ELC among all
states and Puerto Rico, each grantee would have received $4,782 per ELC.
Table 3: Relationship between ELCs in EMAs and Total CARE Act Title I and
II Funding per ELC, Fiscal Year 2004
Percentage of states' and Puerto Rico's ELCs in Average funding per ELCa
EMAs
None $3,592
Less than 50 percent 3,954
50 to 75 percent 4,717
More than 75 percent 4,955
Source: GAO analysis of HRSA data.
aWe excluded from our analyses the nine states that received the minimum
Title II base grant awards. Under Title II, states with fewer 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 effect of counting EMA cases twice is that grantees with similar
numbers of ELCs can receive different levels of combined Title I and Title
II funding. For example, for fiscal year 2004 funding, Connecticut had
5,363 ELCs while South Carolina had 5,563 ELCs. However, Connecticut had
two EMAs that accounted for 91.3 percent of its ELCs while South Carolina
had none. Connecticut received $26,797,308 ($4,997 per ELC) in combined
Title I and Title II funding while South Carolina, with 200 more cases,
received $20,705,328 ($3,722 per ELC). Connecticut received 29 percent
more funding than South Carolina, a difference of $6,091,980, or $1,275
per ELC. (See app. VI.)
The Two-tiered Division of Emerging Communities Results in Funding
Disparities Among Metropolitan Areas
The two-tiered division of Emerging Communities results in disparities in
funding among metropolitan areas. Title II provides for a minimum of $10
million to states with metropolitan areas that have 500 to 1,999 AIDS
cases reported in the last 5 calendar years but do not qualify for funding
under Title I as EMAs. 43 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
for 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. The two tiers and the 50/50 split were meant to ensure that a
significant portion of the Emerging Communities funding was allocated to
the communities with the largest number of new cases.
In fiscal year 2004, the two-tiered structure of Emerging Communities
funding led to large differences in funding per reported AIDS case in the
last 5 calendar years among the Emerging Communities because the total
number of AIDS cases in each tier was not equal. Twenty-nine communities
qualified for Emerging Communities funds in fiscal year 2004. Four of
these communities had 1,000 to 1,999 reported AIDS cases in the last 5
calendar years and 25 communities had 500 to 999 cases. This distribution
meant that the 4 communities with a total of 4,754 reported cases in the
last 5 calendar years split $5 million while the remaining 25 communities
with a total of 15,994 reported cases in the last 5 calendar years also
split $5 million. These case counts 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
reported case than the other 25. If the total $10 million funding for
Emerging Communities grants had been distributed equally per reported case
among the communities, each would have received $482 per reported case.
Table 4 lists the 29 Emerging Communities along with their reported AIDS
case counts over the most recent 5 years and their funding.
Table 4: Title II Emerging Communities in Fiscal Year 2004
Emerging Community AIDS cases Emerging Communities
reported in the funding per AIDS case
most recent 5 reported in the most
calendar years recent 5 calendar years
Memphis, Tenn. 1,588 $1,052
Nashville, Tenn. 1,123 1,052
Baton Rouge, La. 1,038 1,052
Indianapolis, Ind. 1,005 1,052
Columbia, S.C. 972 313
Charlotte, N.C. 875 313
Wilmington, Del. 801 313
Richmond, Va. 783 313
Raleigh-Durham-Chapel Hill, N.C. 775 313
Jackson, Miss. 722 313
Louisville, Ky. 705 313
Rochester, N.Y. 681 313
Fort Pierce-Port St. Lucie, Fla. 636 313
Greensboro-Winston-Salem, N.C. 617 313
Birmingham, Ala. 615 313
Oklahoma City, Okla. 608 313
Pittsburgh, Pa. 602 313
Springfield, Mass. 588 313
Monmouth-Ocean, N.J. 582 313
Buffalo-Niagara Falls, N.Y. 581 313
Greenville, S.C. 560 313
Columbus, Ohio 558 313
Milwaukee, Wis. 558 313
Salt Lake City, Utah 555 313
Sarasota, Fla. 539 313
Charleston, S.C. 538 313
Cincinnati, Ohio 517 313
Daytona Beach, Fla. 514 313
Providence, R.I. 512 313
Total 20,748
Source: GAO analysis of HRSA data.
Note: Emerging Communities are metropolitan areas not eligible for Title I
grants and that have 500-1,999 reported AIDS cases in the most recent 5
calendar years. The 5 most recent calendar years are 1998-2002.
Similar to the counting of ELCs in EMAs for both Title I and Title II base
grant funding, AIDS cases reported in the past 5 calendar years in
Emerging Communities are counted more than once for determining Title II
funding. For example, these cases are counted once for determining Title
II base funding and again for Emerging Communities grants. Title II
grantees with Emerging Communities receive an average of $3,443 per ELC
while grantees without an Emerging Community receive about $3,089. 44 The
Emerging Communities funding accounted for about $125 per ELC of this
difference. Other Title II funds that are also not distributed
proportionally by the number of ELCs, such as the Minority AIDS Initiative
grants, account for the rest of the difference. 45
Hold-harmless Provisions and Grandfather Clause Protect Funding of Certain
CARE Act Grantees
Titles I and II of the CARE Act both contain provisions that protect
certain grantees' funding levels. Title I has a hold-harmless provision
that guarantees that the Title I base grant to an EMA will be at least as
large as a statutorily specified percentage of a previous year's funding.
The Title I hold-harmless provision has primarily protected the funding of
one EMA. Title I also contains a grandfather clause that has resulted in a
large number of EMAs maintaining their eligibility for grants despite no
longer meeting the eligibility criteria. Title II has a hold-harmless
provision that ensures that the total of Title II and ADAP base grants
awarded to a grantee will be at least as large as the total of these
grants a grantee received the previous year. This provision has the
potential of reducing the amount of funding to grantees that had
demonstrated severe need for drug treatment funds because it is funded out
of amounts that would otherwise be used for that purpose.
One EMA Has Been the Primary Recipient of Title I Hold-harmless Funding
The San Francisco EMA has been the primary recipient of Title I
hold-harmless funding. An EMA's base funding is determined according to
its proportion of ELCs. The hold-harmless provision guarantees each EMA a
statutorily specified percentage of the base grant it received in a
previous year regardless of how much its proportion of the number of ELCs
in all EMAs may have decreased in the current year. 46 If an EMA qualifies
for hold-harmless funding, that amount is added to the base funding and
distributed together as the base grant. In fiscal year 2004, the San
Francisco EMA received $7,358,239 in hold-harmless funding, or 91.6
percent of the hold-harmless funding that was distributed. 47 The second
largest recipient was Kansas City, which received $134,485, or 1.7 percent
of the hold-harmless funding under Title I. Table 5 lists the EMAs that
received hold-harmless funding in fiscal year 2004. 48
Table 5: Title I Hold-harmless Funding, Fiscal Year 2004
EMA Hold-harmless Percent of Hold-harmless Base Hold-harmless
funding hold-harmless funding per grant as a percent
funding ELC per of base grant
ELCa
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, 8,315 0.1 7 1,228 0.5
N.J.
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%b
Source: GAO analysis of HRSA data.
Notes: An EMA's base funding is determined according to its proportion of
ELCs. If an EMA qualifies for hold-harmless funding, that amount is added
to the base funding and distributed together as the base grant.
aThis amount was calculated by dividing the base grant, including any
hold-harmless funding, received by each EMA by the number of ELCs in the
EMA.
bIndividual entries do not sum to total because of rounding.
The effect of the hold-harmless provision varies among the EMAs that
receive hold-harmless funding, 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 ELC in fiscal year 2004. Fiscal year 2004
base grant funding per ELC in EMAs that received hold-harmless funding
ranged from $1,223 (Newark) to $2,241 (San Francisco). Thus, the San
Francisco EMA received $1,020 more in base grant funding per ELC 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 ELCs
in fiscal year 2004, received a base grant equivalent to what an EMA with
approximately 13,245 ELCs (84 percent more) would have received. Kansas
City, the second largest hold-harmless grantee, received about what an EMA
with 9 percent more ELCs would have received.
Forty-eight of the 51 EMAs would have received more funding if there had
been no hold-harmless provision and if the $8 million that was actually
used for hold-harmless funding had been distributed in the same
proportions as the supplemental grants. 49 Although 21 EMAs received
hold-harmless funding in fiscal year 2004, only 3 (San Francisco, Kansas
City, and Santa Rosa) received more funding because of the hold-harmless
provision than they would have received through supplemental grants in the
absence of the hold-harmless provision. Without the hold-harmless funding,
San Francisco would have received $960 less per ELC, Kansas City $70 less,
and Santa Rosa $15 less.
In fiscal year 2004 the San Francisco EMA was guaranteed to receive 89
percent of its fiscal year 2000 Title I base grant under the hold-harmless
provision. However, the amount of San Francisco's 2000 Title I base grant
had been determined by formulas specified in the CARE Act Amendments of
1996, which guaranteed EMAs 95 percent of their 1995 base grant in fiscal
year 2000. 50 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. Taken together, the
hold-harmless provisions mean that in fiscal year 2004 San Francisco was
guaranteed approximately 85 percent of its fiscal year 1995 base grant of
$19,126,679. 51 Prior to the CARE Act Amendments of 1996, 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 San Francisco's
Title I funding reflects the application of hold-harmless provisions under
the 1996 amendments, as well as under current law, San Francisco's Title I
base grant is determined in part by the number of deceased cases in the
San Francisco EMA as of 1995.
Grandfathering Maintains Eligibility for EMAs That No Longer Meet Certain
Eligibility Criteria
More than half of the EMAs received Title I funding in fiscal year 2004
even though they were below Title I eligibility thresholds. 52 The
eligibility of these EMAs was protected based on a CARE Act grandfather
clause. Under a grandfather clause established by the CARE Act Amendments
of 1996, metropolitan areas eligible for funding for fiscal year 1996
remain 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 threshold of more than 2,000 reported AIDS cases during the
most recent 5 calendar years but nonetheless retained their status as EMAs
(see table 6). 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.
Table 6: Grandfathered EMAs, Fiscal Year 2004
EMA Number of AIDS cases Total Title I
reported in the most funding
recent 5 calendar years
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 1998-2002.
The number of EMAs ineligible for Title I funds in the absence of the
grandfather clause reflects the combination of the decline in the number
of new AIDS cases following the advent of more effective therapies and the
more restrictive eligibility standards adopted in the CARE Act Amendments
of 1996. 53 No metropolitan areas have become eligible for Title I funding
since 1999, when Las Vegas and Norfolk received their initial funding,
because no additional metropolitan areas have reported enough new cases to
meet the AIDS case-count-eligibility threshold. This decline in the number
of new cases reflects the general pattern of AIDS case counts in the
country. While the number of people living with AIDS has been increasing
as persons with AIDS live longer, the number of new AIDS cases reported
each year throughout the country decreased from about 1993 until about
1999 and has since leveled off. In addition, six of the EMAs not meeting
the current eligibility threshold became eligible on the basis of their
case rates, under the 1990 thresholds, rather than their number of cases.
These include Caguas, Dutchess County, Santa Rosa, and
Vineland-Millville-Bridgeton, the four EMAs with the fewest reported
cases. In addition, the Jersey City and Ponce EMAs also became eligible on
the basis of their case rates.
As discussed earlier, some metropolitan areas are designated as Emerging
Communities under Title II because their numbers of reported AIDS cases in
the most recent 5 calendar years 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 EMAs that were
eligible for Title I funding because of the grandfather clause. 54 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. The overall
effect is that Emerging Communities received less funding than EMAs with
comparable numbers of reported AIDS cases in the most recent 5 calendar
years. For example, Baton Rouge, with 1,038 reported cases, received
$1,091,976 in Emerging Communities funding while the San Antonio EMA, with
1,034 reported cases, received $3,833,443 in Title I funding.
Title II Hold-harmless Funding Could Diminish ADAP Severe Need Grants in
the Future
A Title II hold-harmless provision established by the CARE Act Amendments
of 2000 could diminish ADAP Severe Need grant amounts in the future
because the hold-harmless payments and the grants are funded from the same
3 percent set-aside of Title II funds available for drug treatment
programs. If larger amounts are needed to meet this hold-harmless
provision in the future, grantees that have demonstrated a severe need for
drug treatment funds could get less than the amounts they would otherwise
receive. 55
Fiscal year 2004 was the first time that any grantees triggered the Title
II hold-harmless provision funded with amounts that would otherwise be
used for Severe Need grants. Severe Need grants are funded with a 3
percent set-aside of the funds appropriated specifically for ADAPs. 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 grantee will be at least as large as the total the
previous year. 56 Eight states became eligible for this hold-harmless
funding in fiscal year 2004. 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 7.)
The remaining $20.8 million, or 93 percent of the set-aside amount, was
distributed in Severe Need grants.
Table 7: 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 further in the future if larger amounts are
needed to fund this hold-harmless protection. The total amount of Severe
Need grant funds available in fiscal year 2004 to distribute among the
eligible grantees was less than it would have been without the
hold-harmless payments. However, in fiscal year 2004 not all 25 of the
Title II grantees eligible for Severe Need grants made the required match.
Consequently, the Severe Need grants were not as small as they would
otherwise have been because of the application of the hold-harmless
provision. In future years, if all of the eligible Title II grantees make
the match, and if there are also grantees that qualify to receive
hold-harmless funds under this provision, grantees with severe need for
ADAP funding would get less than the amounts they would otherwise receive.
HOPWA Provision Restricts Bonus Grant Eligibility for Some Grantees
The structure of the HOPWA program restricts states and Puerto Rico from
receiving HOPWA bonus grant funding for areas outside EMSAs. 57 Bonus
grants, which totaled about $66 million in fiscal year 2004, are awarded
only to the EMSAs in which the AIDS epidemic is spreading most rapidly. 58
In fiscal year 2004, EMSAs with more than 19.5 new AIDS cases per 100,000
people over the past year qualified for bonus grants. In fiscal year 2004,
26 EMSAs qualified for bonus grants (see table 8).
Table 8: Fiscal Year 2004 HOPWA Formula Funding
EMSA Base Bonus Bonus Total HOPWA Total HOPWA
funding funding funding formula funding formula
as a when calculated funding when
percent per cumulative calculated
of base AIDS casea per living
funding AIDS case
Atlanta, Ga. $4,262,000 $637,000 15% $264 $573
Baltimore, Md. 3,940,000 3,996,000 101 463 1,039
Baton Rouge, 666,000 1,147,000 172 626 1,290
La.
Bridgeport, 752,000 27,000 4 238 476
Conn.
Charleston, 411,000 7,000 2 234 480
S.C.
Chicago, Ill. 5,622,000 2,716,000 48 341 805
Columbia, S.C. 626,000 644,000 103 466 824
Detroit, Mich. 1,624,000 355,000 22 280 749
District of 5,626,000 6,176,000 110 482 939
Columbia
Fort 3,337,000 2,903,000 87 430 954
Lauderdale,
Fla.
Jackson, Miss. 449,000 275,000 61 371 728
Jacksonville, 1,195,000 369,000 31 301 623
Fla.
Memphis, Tenn. 920,000 1,214,000 132 533 1,000
Miami, Fla. 6,149,000 4,566,000 74 400 934
New Haven, 937,000 295,000 31 302 605
Conn.
New Orleans, 1,785,000 1,207,000 68 385 887
La.
New York, N.Y. 33,487,000 26,868,000 80 414 1,099
Newark, N.J. 4,297,000 885,000 21 277 828
Philadelphia, 4,340,000 3,292,000 76 404 799
Pa.
Orlando, Fla. 1,660,000 1,529,000 92 441 913
Wake County, 345,000 7,000 2 234 408
N.C.
San Francisco, 6,698,000 1,864,000 28 294 1,130
Calif.
San Juan, P.R. 4,585,000 2,555,000 56 358 1,000
Tampa, Fla. 2,221,000 168,000 8 247 569
West Palm 2,019,000 1,817,000 90 436 933
Beach, Fla.
Wilmington, 566,000 232,000 41 325 624
Del.
All other b 0 0 230 c
grantees
Source: GAO analysis of CDC and HUD data.
aCumulative AIDS cases are the total number of AIDS cases, both living and
dead, reported in the jurisdiction since the beginning of the epidemic in
1981.
bVaries by number of cumulative AIDS cases.
cVaries by number of living AIDS cases.
Bonus funding can be an important component of an EMSA's HOPWA formula
funding. Bonus grants exceeded base funding amounts in five EMSAs
(Baltimore, Maryland; Baton Rouge, Louisiana; Columbia, South Carolina;
Memphis, Tennessee; and the District of Columbia), and were more than 50
percent of base funding in another nine. EMSAs that did not receive bonus
funding received approximately $230 per cumulative AIDS case in fiscal
year 2004 formula funding. Because grantees other than EMSAs were not
eligible for the bonus funding, they also received $230 per cumulative
case. However, the 26 EMSAs that received bonus funding were allocated an
average of $367 per cumulative case in total formula funding, ranging from
$234 to $626 per case. If all of the formula funding had been allocated on
the basis of cumulative AIDS cases, instead of allocating base grants by
cumulative cases and bonus grants by incidence rates, each grantee would
have received $306 per case. The last column in table 8 shows that EMSAs
that received bonus funding also received more funds per living AIDS case.
59 These EMSAs received an average of approximately $816 per living case,
ranging from $408 per case in Wake County, North Carolina, to $1,290 per
case in Baton Rouge, Louisiana. Those grantees that did not receive bonus
funding received about $503 per living case, ranging from $387 to $627 per
case. (See app. IV).
The Use of Revised OMB Metropolitan Area Definitions Would Change Most EMA
Boundaries, but Increase in ELCs within EMAs Would Be Minimal
Title I EMA boundaries were made permanent by the 1996 amendments to the
CARE Act, and they have not been altered to conform to OMB's 2004
definitions of metropolitan areas. 60 Since existing Title I and Title II
organizational and administrative arrangements within states and EMAs are
connected to current EMA boundaries, changing EMA boundaries to conform to
OMB 2004 metropolitan areas could disrupt those arrangements. On the other
hand, adopting the 2004 OMB definitions for EMAs would reflect the same
metropolitan areas for which statistical agencies make data available to
the public and reflect the 2000 decennial census demographic data. OMB
recommends that policymakers review and consider the appropriateness of
the new definitions of metropolitan area boundaries for program purposes.
If OMB's 2004 definitions of metropolitan area 61 boundaries were used to
establish the area to be considered when defining an EMA under Title I, 62
the service area boundaries would change for the majority of the current
EMAs. 63 To demonstrate the changes involved in reconfiguring EMA
boundaries to conform to the new metropolitan areas, we chose a method
that could be used for this conversion. As described in appendix I, the
method we chose would combine new metropolitan areas so as to minimize
changes to current EMA boundaries. 64
If our method of converting EMA boundaries to metropolitan areas using the
2004 definitions were incorporated in the CARE Act funding formulas, the
service area boundaries of more than half of current EMAs would change. In
addition, 5 EMAs would be consolidated to 2, reducing the total number of
EMAs from 51 to 48. 65 We found that 31 of the 51 current EMAs would add,
lose, or both add and lose counties in their service areas. For example,
the Atlanta EMA would add 8 counties, the Las Vegas EMA would lose 2
counties, and the Newark EMA (New Jersey) would both add 2 counties and
lose 1 other county. Overall, 17 counties would no longer be part of an
EMA and 53 counties that were not previously included in an EMA would be
added to the service area of a newly reconfigured EMA. Service area
boundaries of 20 current EMAs would not change if the new OMB metropolitan
area definitions were adopted. (See app. VII.)
Changing the service area boundaries of current Title I EMAs to reflect
the new OMB metropolitan area definitions would result in most EMAs having
a change in the number of ELCs within their boundaries, and the total net
effect would be an increase of ELCs counted under Title I of less than 1
percent. Any ELCs that would no longer be counted under Title I would
continue to be considered for purposes of Title II base grants as ELCs
outside an EMA. Our analysis of the change in ELCs resulting from a change
in EMA boundaries to the new OMB definitions shows that 19 of the 51
current EMAs would have less than a 2 percent change in their number of
ELCs, and 23 EMAs would have no change in the number of ELCs in their
service area. In total, these 42 EMAs represent about 88 percent of the
total number of Title I ELCs. Of the remaining 9 EMAs, 3 EMAs would
experience a gain or loss of more than 9 percentage points in their ELCs.
The Dutchess County EMA (New York) would have about a 93 percentage-point
increase in ELCs (a gain of 486 in the number of ELCs) as a result of
adding Orange County to its service area. In New Jersey, Middlesex would
have a 79 percentage-point increase in ELCs (a gain of 979 in the number
of ELCs) by adding Monmouth and Ocean Counties. The Boston EMA would have
about a 9 percentage-point decrease (a loss of 554 in the number of ELCs)
because Bristol County (Massachusetts) would be reassigned from the Boston
EMA to the Providence (Rhode Island) metropolitan area, which is not an
EMA. Because the overall change in the number of Title I ELCs that would
result from EMA service area boundary changes under the new OMB
definitions would be an increase of less than 1 percent (a net gain of
1,742 in the number of ELCs), a minimal overall effect on funding per ELC
would be expected.
Funding Effect of Using HIV Case Counts Would Depend on Multiple Factors
CARE Act and HOPWA funding would have shifted among grantees if HIV case
counts had been used with a measure of persons living with AIDS to
allocate fiscal year 2004 formula grants. While all states and Puerto Rico
have established HIV case-reporting systems, IOM identified
characteristics of these systems that limit their appropriateness for the
distribution of CARE Act and HOPWA funds. 66 We found that up to 13
percent of CARE Act funding would have shifted if HIV case counts had been
used with ELCs in the distribution of fiscal year 2004 funds and if the
hold-harmless and minimum-grant provisions we considered were maintained.
67 Larger changes for individual grantees would have occurred with some
grantees more than doubling their funding. Grantees in the South and
Midwest would generally have received more funding from using HIV cases in
funding formulas. 68 However, there would have been grantees that would
have received increased funding and grantees that would have received
decreased funding in every region of the country. Larger funding shifts
would have occurred without these CARE Act hold-harmless and minimum-grant
provisions. HOPWA funding would also have shifted if HIV cases along with
living AIDS cases had been used to determine funding rather than
cumulative AIDS case counts. Differences in HIV case-reporting systems
would affect funding allocations, and we found that funding would have
tended to shift to jurisdictions with older HIV-reporting systems.
Jurisdictions with older HIV-reporting systems tend to have more reported
HIV cases compared with their number of AIDS cases than do jurisdictions
with newer reporting systems.
Current HIV Case-reporting Systems Have Limitations for Providing Case
Counts for Funding Allocations
In order to monitor HIV infection, the states and Puerto Rico have
established HIV case-reporting systems under which individuals who have
been diagnosed with HIV are reported to health departments by physicians
and other practitioners. 69 In 2000 we reported that HIV cases accounted
for a much smaller percent of total HIV/AIDS cases in states with newer
HIV-reporting systems. 70 In its 2004 report, IOM updated our earlier
analysis and identified several limitations in the ability of these
jurisdictions to provide accurate HIV case counts to CDC for use in CARE
Act funding allocations. Among these limitations, IOM found that the
maturity of HIV case-reporting systems continued to vary widely across
grantees. The earliest HIV-reporting systems were established in Colorado,
Minnesota, and Wisconsin in 1985, followed by most southern and other
midwestern states prior to 1995. The newest systems were established after
2003 in six states and Philadelphia, Pennsylvania. 71 Case-reporting
systems need several years to become fully operational. Practitioners need
to be made aware of the requirement to report new HIV cases and the
methods for doing so. Existing cases also need to be reported by
practitioners and entered into the system. Grantees with newer systems may
not have collected and entered data on existing cases, and, consequently,
may underreport the number of HIV cases. Underreporting of HIV cases in
states with newer HIV-reporting systems would result in grantees receiving
less funding than they would be entitled to receive according to the
actual number of HIV/AIDS cases.
IOM also found that differences in how jurisdictions report HIV case
counts to CDC preclude HRSA's use of those case counts in the distribution
of CARE Act funds. 72 While some HIV case-reporting systems are
code-based, CDC will only accept name-based case counts as no code-based
system has met its quality criteria as of January 2006. 73 Therefore, HIV
cases reported using codes rather than names would not be counted in
distributing CARE Act funds, if HIV case counts were used in funding
formulas. As of December 2005, thirteen states have some form of a
code-based system rather than a name-based system. 74 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. 75 Table 9 shows the 39 jurisdictions
where HIV case counts are accepted by CDC and the 13 jurisdictions where
they are not accepted, and the year in which each jurisdiction established
its HIV-reporting system.
Table 9: CDC Acceptance of HIV Case Counts and Year of Establishment of
HIV-reporting Systems, December 2005
Accepted Not accepted
Colorado (1985) Maryland (1994)
Minnesota (1985) Massachusetts (1999)
Wisconsin (1985) Illinois (1999)d
Idaho (1986) Maine (1999)e
South Carolina (1986) Washington (1999)
Arizona (1987) Montana (2000)
Missouri (1987) Rhode Island (2000)
Alabama (1988) Vermont (2000)
Indiana (1988) Delaware (2001)
Mississippi (1988) District of Columbia (2001)
North Dakota (1988) Hawaii (2001)
Oklahoma (1988) Oregon (2001)
South Dakota (1988) California (2002)
Arkansas (1989)
Utah (1989)
Virginia (1989)
West Virginia (1989)
Wyoming (1989)
North Carolina (1990)
Ohio (1990)
Michigan (1992)
Nevada (1992)
New Jersey (1992)
Tennessee (1992)
Louisiana (1993)
Nebraska (1995)
Florida (1997)
Iowa (1998)
New Mexico (1998)
Alaska (1999)
Kansas (1999)
Texas (1999)
New York (2000)
Pennsylvania (2002)a
Georgia (2003)
Puerto Rico (2003)
Kentucky (2004)
Connecticut (2005)b
New Hampshire (2005)c
Sources: CDC, IOM, Connecticut, Kentucky, and Philadelphia. Connecticut,
Kentucky, and Philadelphia provided us with updated information about
their HIV case-reporting systems.
Notes: Currently, CDC will only accept name-based case counts.
aName-based HIV reporting has been established in all parts of
Pennsylvania except Philadelphia since 2002. Philadelphia was given
permission by the state to establish code-based HIV reporting, and the
system began in 2004. However, in August 2005, the Philadelphia Board of
Health voted to implement a name-based HIV-reporting system. This system
went into effect in October 2005. Philadelphia is in the process of having
its HIV surveillance data certified by CDC; once certified, its data will
be accepted by CDC.
bConnecticut established mandatory name-based HIV reporting in 2005.
Previously, name-based reporting was only required for pediatric cases.
cNew 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.
dIllinois established name-based HIV reporting in January 2006. It is in
the process of having its HIV surveillance data certified by CDC and, once
certified, its data will be accepted by CDC.
eMaine established name-based HIV reporting in January 2006. It is in the
process of having its HIV surveillance data certified by CDC and, once
certified, its data will be accepted by CDC.
The Use of HIV Case Counts in Funding Formulas Would Have Changed the
Distribution of Fiscal Year 2004 CARE Act and HOPWA Funds
While we are aware of differences in the HIV data across jurisdictions, 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
not later than fiscal year 2007. We used two approaches to examine the
potential effect of including HIV cases in addition to persons living with
AIDS in fiscal year 2004 CARE Act and HOPWA funding formulas. We found
that some CARE Act fiscal year 2004 funding would have shifted among
grantees if HIV case counts and ELCs had been used to allocate the funds.
While our analyses indicate that up to 13 percent of CARE Act funding
would have shifted, larger changes for individual grantees would have
occurred. Southern and midwestern grantees would generally have received
more funding, but there would have been grantees that would have received
increased funding and grantees that would have received decreased funding
in every region of the country. Funding changes in our model would have
been larger without the hold-harmless and minimum-grant provisions that we
included. There would also have been at most a 15 percent shift in HOPWA
funding if HIV cases were used to allocate funding, although there would
have been larger changes for some grantees. 76 CARE Act and HOPWA funding
changes could have resulted from the number of people living with HIV/AIDS
in each jurisdiction or differences in HIV case-reporting systems.
Methodological Approaches Used
We used two approaches to examine the effect of using HIV cases in
addition to AIDS cases 77 in funding formulas for CARE Act Title I and
Title II base grants, ADAP base grants, and HOPWA base funding in the
states and Puerto Rico. Under the first approach, we used HIV and AIDS
case counts for the 35 grantees from which CDC accepted HIV data. 78
Because CDC did not receive HIV case counts from the other 17 grantees, we
used only the AIDS case counts received by CDC for these grantees.
Consequently, for some grantees we used HIV and AIDS case counts, but for
others we used only AIDS case counts. This approach reflects the data that
would have been used if funding allocations were based on the HIV and AIDS
case counts received by CDC in time for determining fiscal year 2004
formula grants. Under the second approach, we used the same HIV and AIDS
case counts as our first approach, but supplemented these data with the
code-based HIV case counts collected by the grantees from which CDC did
not receive HIV data. 79 We obtained these HIV case counts directly from
these jurisdictions. 80
For both approaches, we calculated the grantee's percentage of the total
number of HIV/AIDS cases in each jurisdiction 81 and estimated the fiscal
year 2004 formula grants that each would have received. Under each
approach, CARE Act formula grants were calculated both with certain
hold-harmless and minimum-grant provisions and again without those
provisions. 82 Eliminating hold-harmless and minimum-grant provisions was
done to reveal the full effect of distributing fiscal year 2004 funding
solely according to HIV/AIDS data available at that time. We also
estimated the effect of using HIV cases and living AIDS cases for HOPWA
base funding. Although there are limitations associated with the
underlying data, the results of our analyses indicate the general effect
of using HIV and AIDS cases to distribute CARE Act and HOPWA formula
funding. (See app. I for a discussion of the limitations in the data.)
Changes in CARE Act Funding Using HIV Cases and Hold-harmless and
Minimum-grant Provisions
Our analyses indicate that for fiscal year 2004 as much as 13 percent of
Title I, Title II, and ADAP base grants would have shifted, with southern
and midwestern grantees being the primary beneficiaries, if hold-harmless
and minimum-grant provisions were maintained. However, there would have
been grantees that would have received increased funding and grantees that
would have received decreased funding in every region of the country.
Changes in funding could have resulted from the actual number of HIV/AIDS
cases living in each jurisdiction or from differences across jurisdictions
in HIV case-reporting systems. The funding changes under each of our
approaches would have been larger if we had not applied the hold-harmless
and minimum-grant provisions.
Title I Base Funding
Title I base grant funding would have shifted among grantees under both
our approaches, but because the funds necessary to meet the hold-harmless
provision are taken from funds that would otherwise be used for
supplemental grants, the overall effect on Title I EMAs is unclear. 83 The
Title I base grant includes (1) funding amounts determined by the number
of ELCs and (2) the hold-harmless amounts, if applicable. In fiscal year
2004, a total of about $8.0 million was needed to fund the hold-harmless
payments for EMAs. The amount of Title I hold-harmless funding for all
EMAs would have increased from $8.0 million to $43.3 million under our
first approach in which we used only HIV data received by CDC and ELCs. It
would have increased to $29.4 million under our second approach in which
we used the HIV case counts collected by CDC, the code-based HIV counts we
collected from the grantees, and ELCs. In order to meet the hold-harmless
levels, funds would have to be deducted from the amounts otherwise
available for Title I supplemental grants. Supplemental grants are divided
among all EMAs using a competitive application process based on the
demonstration of severe need and other criteria. Because these awards are
made competitively, it is unclear how the reduction in funding for
supplemental grants would have affected individual EMAs and, therefore,
what the overall effect on funding for each EMA would have been under our
two approaches.
Under the first approach-using ELCs and HIV cases when accepted by CDC and
only ELCs elsewhere-13 EMAs would have received a total of $2.8 million
less in fiscal year 2004 Title I base grants, about 1 percent of the total
Title I base grants. Twenty-nine grantees would have received $38.1
million in additional Title I base grant funding, about 13 percent of
total Title I base grants, if HIV cases and ELCs had been used to allocate
funding instead of just ELCs. The other 9 EMAs would have had no change in
their funding. The effect on certain EMAs would have been large, with the
Denver EMA more than doubling its Title I base funding and 16 others
receiving at least a 25 percent increase in funding. Of the 29 that would
have received more funding, 13 are in the South. In addition, 5 of the 6
EMAs in the Midwest and 8 of 12 EMAs in the Northeast would have received
increased funding. However, only 3 of 14 EMAs in the West would have
received increased funding. 84
Under the second approach-using the HIV case counts collected by CDC, the
code-based HIV counts we collected from the grantees, and ELCs- 15 EMAs
would have received a total of $1.9 million less in fiscal year 2004 Title
I base grants, about 1 percent of the total Title I base grants.
Twenty-eight grantees would have received $23.3 million more in fiscal
year 2004 Title I base grants, about 8 percent of total Title I base
grants. Eight EMAs would have had no change in their funding. Some EMAs
would have received large increases in funding, with the Denver EMA more
than doubling its Title I base grant funding and 9 others receiving at
least a 25 percent increase in funding. Of the 28 EMAs that would have
received additional funding, 10 are in the South. All 6 midwestern EMAs
would have received additional funding. Seven of 12 EMAs in the Northeast
and 5 of 14 EMAs in the West would have received increased funding.
Appendix VIII shows the results of the analyses for each EMA under each
approach.
Title II Base Funding
There would be some shifting of funds if HIV cases and ELCs had been used
to allocate CARE Act Title II base grants while maintaining the
hold-harmless and minimum-grant provisions. 85 Most southern and
midwestern grantees would receive increased funding under either approach
we used for analysis. Under the first approach-using ELCs and HIV cases
when accepted by CDC and only ELCs elsewhere-about 5 percent or $14.3
million of Title II base grants would have shifted among grantees. Unlike
funding for the Title I hold-harmless provision, the amounts necessary to
fund the Title II base grant hold-harmless and minimum-grant provisions
are subtracted from the base grants of those states that did not qualify
for funding under these provisions. Consequently, the total amount of
funding increases received by some Title II grantees would have to be
equal to the total decreases received by other grantees. Twenty-one
grantees would have received additional funding in their Title II base
grants, and 22 would have received less. Nine grantees would have had no
change in their funding. Of the 21 that would have received more funding,
9 are in the South and 7 in the Midwest. Of the 22 that would have
received less funding, 6 are in the Northeast and 5 are in the West.
Changes in funding for individual grantees would have ranged from a 150
percent increase in North Dakota and Wyoming to a 22 percent decrease in
Delaware and the District of Columbia.
The second approach-using the HIV case counts accepted by CDC, the
code-based HIV counts we collected from the grantees, and ELCs-would yield
a smaller shift in funding. Under this approach, approximately 4 percent
or $12.6 million of fiscal year 2004 Title II base grants would have
shifted. Of the 22 grantees that would have received additional funding,
10 are in the South and 7 in the Midwest. Among those that would have
received less funding, 4 are in the Northeast and 4 are in the West.
Twenty grantees would have received less funding and 10 would have
received the same amount. Funding changes for individual grantees would
have ranged from a 150 percent increase in North Dakota and Wyoming to a
22 percent decrease in Delaware and the District of Columbia. Appendix IX
shows the results of these analyses for each grantee under each approach.
While a majority of southern grantees would have received increased
funding under both approaches, the amount of the increase would have been
relatively small. Southern grantees would have received a total of about
$430,000 more funding under our first approach and about $640,000 under
the second approach. This relatively small shift can be attributed to the
fact that southern states generally would not benefit from the
minimum-grant and hold-harmless provisions. For example, many southern
states would have their grants reduced in order to fund the hold-harmless
provision. Midwestern grantees would have received larger dollar and
percent increases in funding than the southern grantees under both
approaches.
ADAP Base Funding
Our analyses indicate that there would have been some shifting of funding
for ADAP base grants if HIV and AIDS case counts had been used to
determine allocations while maintaining the hold-harmless provision, 86
with southern and midwestern grantees generally being among the areas that
would have received increased funding. 87 Under the first approach-using
ELCs and HIV cases when accepted by CDC and only ELCs elsewhere-about 12
percent or $85.2 million of fiscal year 2004 ADAP base grants would have
shifted among grantees. The amounts necessary to fund the ADAP base grant
hold-harmless provision are subtracted from the ADAP base grants of those
states that did not qualify for hold-harmless funding. Consequently, the
total amount of funding increases received by some Title II grantees must
be equal to the total decreases received by other grantees. Thirty-one of
the 52 grantees would have received additional funding in their ADAP base
grants if HIV cases and ELCs had been used to allocate funding instead of
just ELCs. Of the 31 that would have received more funding, 12 are in the
South and 11 in the Midwest. The funding changes for some grantees would
have been large. For example, Colorado's allocation would have doubled and
South Dakota's would have increased by 84 percent while funding would be
reduced by 38 percent in Delaware, the District of Columbia, Illinois,
Kentucky, and Maryland.
The second approach-using the HIV case counts accepted by CDC, the
code-based HIV counts we collected from the grantees, and ELCs-yields a
smaller shift in funding. Under this approach, approximately 9 percent or
$65.2 million of fiscal year 2004 ADAP base grants would have shifted. Of
the 35 grantees that would have received additional funding, 12 are in the
South and 10 are in the Midwest. Funding changes for some grantees would
have been large. For example, the allocation for Montana would have
increased 93 percent and the allocation for Colorado 84 percent, while
funding would have declined by 40 percent in the District of Columbia and
by 38 percent in Kentucky. Appendix X shows the results of these analyses
for each grantee under both approaches.
Changes in CARE Act Formula Funding Would Be Larger If Hold-harmless and
Minimum-grant Provisions Were Not in Effect
Hold-harmless provisions limit how much funding can decline from one grant
period to the next. However, while these provisions limit changes in
funding they also reduce a program's ability to respond to changing need.
Minimum-grant provisions guarantee that no grantee will receive less than
a specified funding amount. These provisions also limit how funding can be
distributed. 88
Changes in CARE Act funding levels for Title I base grants, Title II base
grants, and ADAP base grants caused by shifting to HIV cases and AIDS
cases would be larger-up to 24 percent-if the current hold-harmless or
minimum-grant amounts were not in effect than if they were in effect. 89
Consider the hypothetical situation in which an EMA or Title II grantee
received a $2 million base grant award according to its number of ELCs.
Assume that in the following year, the formula is changed so that HIV
cases and ELCs are used to determine funding allocations, and the grantee
is then only entitled to $1 million. However, there is a hold-harmless
provision that guarantees the grantee 98 percent of what it received the
previous year. The grantee 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 cases and ELCs. The change in funding with the
hold-harmless provision would be a decrease of $40,000, but the loss would
grow to $1,000,000 without the hold-harmless provision. If a grantee
qualified for $100,000 in formula funding using HIV case counts and ELCs,
but the minimum award was $500,000, the grantee would receive $500,000
because of the minimum-grant provision, thereby offsetting the changes due
to using HIV cases and ELCs.
Title I Base Funding
Under both our methodological approaches, Title I funding would have been
affected by eliminating the Title I base grant hold-harmless provision. 90
If the hold-harmless provision had been eliminated, the number of EMAs
that would have received less Title I base grant funding would have
increased from 13 to 23 under our first approach-using ELCs and HIV cases
when accepted by CDC and only ELCs elsewhere-and from 15 to 24 under our
second approach-using the HIV case counts collected by CDC, the code-based
HIV counts we collected from the grantees, and ELCs. 91 The effect of the
hold-harmless provision on an individual grantee can be illustrated with
the New Haven EMA. New Haven, which would have had no change in base grant
funding if the hold-harmless provision was maintained would have had Title
I base grant funding reductions of 31 and 35 percent under the first and
second approaches, respectively, without the hold-harmless provision.
Overall, southern and midwestern EMAs would gain funding under both
approaches whether or not the hold-harmless provision was maintained while
northeastern EMAs would lose funding only under our second approach and
only if the hold-harmless provision was not maintained. 92 However, in all
four regions of the country, there would have been EMAs that would have
received increased funding and EMAs that would have received decreased
funding. Appendix XI shows the results of our analyses for Title I base
grants if the hold-harmless provision was not maintained.
Title II Base Funding
The hold-harmless and minimum-grant provisions have a large effect on
funding shifts in Title II base grants. Under our first approach-using
ELCs and HIV cases when accepted by CDC and only ELCs elsewhere- 14
percent of Title II base grants would have shifted among grantees if the
hold-harmless and minimum-grant provisions had been eliminated, while 5
percent would have shifted if they had been maintained. Under our second
approach-using the HIV case counts collected by CDC, the code-based HIV
counts we collected from the grantees, and ELCs-10 percent would have
shifted if the provisions were eliminated and 4 percent if they had been
maintained. The importance of these provisions can be illustrated by
examining individual grantees. For example, Vermont, which received a
minimum grant of $500,000 in fiscal year 2004, would have had a decrease
of 74 percent under approach one and 52 percent under approach two if the
hold-harmless and minimum-grant provisions had not been maintained.
However, it would have had no change in funding if these provisions had
been maintained. California would have received decreases of $11.8 million
under our first approach and $5.0 million under our second approach if the
provisions had been eliminated, but the state would have had no change in
funding if the provisions had been maintained. Conversely, North Carolina
would have received $5.0 million in additional funding under our first
approach and $4.0 million under our second approach if the hold-harmless
and minimum-grant provisions had not been maintained. It would have
received $2.4 million and $2.1 million additional under each approach
respectively if the provision had been maintained. Southern and midwestern
grantees would gain funding under both approaches whether or not the
hold-harmless and minimum-grant provisions had been maintained, while
northeastern grantees would lose funding. 93 However, in all four regions
of the country, there would have been grantees that would have received
increased funding and grantees that would have received decreased funding.
Appendix XII shows the results of our analyses for Title II base grants if
the hold-harmless and minimum-grant provisions were not maintained.
ADAP Base Funding
The overall effect of the hold-harmless provision is smaller on funding
shifts for the ADAP base grants. 94 Under our first approach-using ELCs
and HIV cases when accepted by CDC and only ELCs elsewhere- 14 percent
instead of 12 percent of ADAP base funding would have shifted among
grantees if the hold-harmless provision was eliminated. Ten percent
instead of 9 percent of the funding would have shifted under our second
approach-using the HIV case counts collected by CDC, the code-based HIV
counts we collected from the grantees, and ELCs. The reason for the
smaller effect on the ADAP base grants than on the Title I and Title II
base grants is the increase in ADAP base funding since fiscal year 2000.
In fiscal year 2000, $528 million was distributed to grantees while $728
million was distributed in fiscal year 2004. Because of these increases,
the hold-harmless provision had less effect in our analyses. However,
under all our scenarios grantees in the Northeast and West would have
received less total funding while grantees in the Midwest and South would
have received more. In all four regions of the country, there would have
been grantees that would have received increased funding and grantees that
would have received decreased funding. For example, in the Northeast, New
Jersey would have gained funding and New York would have lost funding
under both our approaches. In the South, Alabama would gain funding and
Georgia would lose funding under both our approaches. Appendix XIII shows
the results of our analyses for ADAP base grants if the hold-harmless
provision had not been in effect.
HOPWA Base Funding Would Generally Shift If HIV Cases Were Used in Formula
Allocations
There would have been some shifting of funds if HIV and living AIDS case
counts 95 had been used to allocate HOPWA base grants instead of
cumulative AIDS cases under either of our methodological approaches-with
or without the code-based HIV case counts-with southern and midwestern
grantees generally being among the jurisdictions that would have received
increased funding. 96 Under the first approach-using living AIDS cases and
HIV cases when accepted by CDC and only living AIDS cases elsewhere-about
15 percent or $30.0 million of fiscal year 2004 HOPWA base grants would
have shifted among grantees. Seventy of 117 grantees would have received
additional funding in their HOPWA base grants if living HIV and AIDS cases
had been used to allocate funding. Six grantees would have more than
doubled their funding. 97 Thirty-five of 47 southern grantees 98 and 18 of
the 20 midwestern grantees would have received more funding. Southern
grantees would have received an additional $15.8 million (22 percent) in
funding while those in the Midwest would have received an additional $3.3
million (17 percent). Seventeen of the 24 northeastern grantees and 14 of
the 24 western grantees would have received less funding. The northeastern
and western grantees would have received $6.3 million (10 percent) and
$9.7 million (24 percent) less in funding respectively.
The second approach-using the HIV case counts accepted by CDC, the
code-based HIV counts we collected from the grantees, and living AIDS
cases-yields an overall smaller shift in funding although changes would
have been larger in the Midwest and Northeast. Under this approach,
approximately 13 percent or $25.6 million of fiscal year 2004 HOPWA base
grants would have shifted, with Maryland and Charlotte, North Carolina,
more than doubling their funding. Of the 82 grantees that would have
received additional funding, 39 are in the South, 19 in the Midwest, 14 in
the West, and 10 in the Northeast. Overall, the South would have received
$13.7 million (19 percent) in additional funding and the Midwest would
have received an additional $4.0 million (21 percent). The Northeast would
have received $8.5 million (14 percent) less in funding and the West $5.8
million (15 percent) less. Appendix XIV shows the results of these
analyses for each jurisdiction under both approaches.
Differences in Case-reporting Systems Would Affect Allocations
One explanation for the changes in funding allocations when HIV cases and
either ELCs or living AIDS cases are used-whether or not the code-based
HIV case counts are included-instead of only AIDS cases 99 is the maturity
of HIV case-reporting systems. We found that those grantees that would
receive increased funding from the use of HIV cases tend to be those with
the oldest HIV case-reporting systems. Those grantees with the oldest
reporting systems include 11 southern and 8 midwestern states whose
HIV-reporting systems were implemented prior to 1995. As shown in table
10, jurisdictions with long histories of counting HIV cases tend to have
many more reported HIV cases compared with their number of ELCs than do
jurisdictions with less-mature reporting systems. This difference is
likely because jurisdictions with newer systems do not have reports on
many cases of HIV that were diagnosed before their reporting systems were
established. 100 This divergence can be illustrated by comparing Wisconsin
and Delaware, two states with similar numbers of AIDS cases. Wisconsin
began reporting HIV cases in 1985 while Delaware began in 2001. In
Wisconsin, as of June 2003, there were about 50 percent more reported HIV
cases than AIDS cases, or 2,287 HIV cases and 1,507 AIDS cases. As of June
2003, the 909 reported HIV cases in Delaware were about 40 percent less
than the 1,518 ELCs. This variability could be reduced as Delaware
identifies more preexisting HIV cases. However, the variability between
HIV cases and ELCs would remain if there was a difference in the actual
number of HIV cases.
Table 10: Reported HIV Cases and ELCs as of June 2003
HIV case-reporting system Number of jurisdictionsa Ratio of HIV cases
start date to ELCs
1985-1991 21 1.42
1992-1998 11 1.01
1999-2002 17 0.68
Source: GAO analysis of CDC, HRSA, and state data.
aGeorgia, Kentucky, and Puerto Rico are not included in this table because
they established their HIV-reporting systems after 2002. Connecticut and
New Hampshire established their name-based HIV-reporting system in 2005.
However, 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. 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.
Under either approach, grantees might receive increased funding because
other grantees did not yet have an accurate measure of HIV case counts.
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. 101
The maturity of the HIV-reporting systems can be linked to whether a
jurisdiction has a name- or code-based system. As discussed earlier, CDC
does not currently accept HIV case reports from code-based systems.
However, even if code-based data were incorporated into the CDC case
counts, the age of the code-based systems could still be a factor since
the code-based systems tend to be newer than the name-based systems. As of
December 2005, twelve of the 13 code-based systems were implemented in
1999 or later, compared with 10 of the 39 name-based systems. The effect
of the maturity of the code-based systems could be increased if, as CDC
believes, name-based systems can be executed with more complete coverage
of cases in much less time than code-based systems. As a result,
jurisdictions with code-based systems could find themselves with
undercounts of HIV cases for longer periods of time than jurisdictions
with name-based systems.
The use of HIV cases in CARE Act funding formulas could result in
fluctuations in funding over time because of newly identified preexisting
HIV cases. Grantees with more mature HIV-reporting systems have generally
identified more of their HIV cases. Therefore, if HIV cases were used to
distribute funding, these grantees would tend to receive more funds. As
grantees with newer systems identify and report a higher percentage of
their HIV cases, their proportion of the total number of ELCs and HIV
cases in the country would increase and funding that had shifted away from
states with newer HIV-reporting systems would shift back, creating
potentially significant additional shifts in program funding. Without
corresponding increases in CARE Act funding, this increase in identified
HIV cases could cause grantees with more mature systems to experience
funding decreases. Hold-harmless provisions would protect grantees with
older reporting systems from funding losses. However, grantees with newer
systems could receive less funding per case because funds would be needed
to cover hold-harmless provisions.
Conclusions
The funding provided under the CARE Act and HOPWA has filled important
gaps in communities throughout the country, but as Congress reviews these
programs, it is important to understand how much funding can vary across
communities with comparable numbers of persons living with AIDS. While
provisions in the formulas have served specific purposes, such as
maintaining consistent funding from year to year, it is clear that the
level of funding available per AIDS case is quite variable because of
these provisions:
o The use of ELCs-AIDS cases reported over the past 10 years
weighted by survival rates-and the use of 2- and 5-year cumulative
reported AIDS cases for CARE Act funding results in AIDS case
counts that do not reflect the number of persons who could be
served by the program because many persons with AIDS live longer
than 10 years after their disease is reported, deceased cases are
included in the case counts, and cases diagnosed prior to the
reporting period are not included.
o Considerably more CARE Act funding has gone to some grantees
than others even though they have similar numbers of cases because
of the counting of ELCs in EMAs for both Title I base funding and
Title II base funding, hold-harmless provisions that protect Title
I, Title II, and ADAP base grant funding levels, the
grandfathering of EMAs so that metropolitan areas designated as
EMAs for fiscal year 1996 continue to be eligible for Title I
funding, and the division of Emerging Communities into two tiers
with equal funding of each tier without regard to the number of
communities or the number of reported AIDS cases in each tier.
o The use of cumulative AIDS cases to determine eligibility for
HOPWA formula grants, including for bonus grants, and the amount
of HOPWA base grants has led to disproportionate funding per
living AIDS case because the formula counts deceased cases in
addition to living cases, thereby resulting in increased funding
for areas with early outbreaks.
The CARE Act Title II hold-harmless provision that is funded from
amounts that would otherwise be available for ADAP Severe Need
grants has had little effect so far as the amounts needed to fund
this provision have been comparatively small. However, reducing
funds to be made available for qualifying states could adversely
affect the states with severe need in the future if the amounts
needed to fund the hold-harmless provision increase.
Congress recognized in the 2000 CARE Act amendments that the CARE
Act benefits many people whose HIV infection has not progressed to
AIDS when it required that HIV case counts be used in the
distribution of funds. The inclusion of HIV cases in the CARE Act
funding formulas by fiscal year 2007 could eventually improve the
targeting of funding to needy individuals with HIV disease.
However, it could result in significant shifts in program funding
that may not be related to the geographic distribution of HIV/AIDS
cases because of differences in the type and maturity of the
reporting system used in each state.
Matters for Congressional Consideration
While only AIDS case counts are currently used for determining CARE Act
formula funding, Congress has required that HIV case counts be
incorporated into the funding formulas not later than fiscal year 2007.
Regardless of when HIV case counts are incorporated, issues will still
exist regarding how AIDS cases are used in the formulas and the effect
various provisions have on funding. If Congress wishes CARE Act funding to
more closely reflect the distribution of persons living with AIDS, and to
more closely reflect the distribution of persons living with HIV/AIDS when
HIV cases are incorporated into the funding formulas, it should take the
following five actions:
o revising the funding formulas used to determine grantee
eligibility and grant amounts using a measure of living AIDS cases
that does not include deceased cases and reflects the longer lives
of persons living with AIDS,
o eliminating the counting of cases in EMAs for Title I base
grants and again for Title II base grants,
o modifying the hold-harmless provisions for Title I, Title II,
and ADAP base grants to reduce the extent to which they prevent
funding from shifting to areas where the epidemic has been
increasing,
o modifying the Title I grandfather clause, which protects the
eligibility of metropolitan areas that no longer meet the
eligibility criteria, and
o eliminating the two-tiered structure of the Emerging
Communities program.
If Congress wishes to preserve funding for the ADAP Severe Need
grants, it should revise the Title II hold-harmless provision that
is funded with amounts set aside for ADAP Severe Need Grants.
If Congress wishes HOPWA funding to more closely reflect the
distribution of persons living with AIDS, it should change the
program so that HOPWA formula grant eligibility, including for
bonus grants, and base grant funding allocations are based on a
measure of living AIDS cases.
Agency Comments and Our Evaluation
HHS and HUD provided written comments on a draft of this report. HHS and
HUD generally agreed with our identification of issues in the funding
formulas. Their comments are reprinted in appendixes XV and XVI. HHS
commended us for its comprehensive approach and ambitious analysis that
pulled together data from many disparate sources. HUD noted that it
appreciated that the report seeks to improve the targeting of federal
resources to better assist those with HIV/AIDS.
HHS noted that we identified various deficiencies in the current HIV data.
However, HHS suggested that we did not examine the distribution
differences that would result from incorporating HIV cases into the CARE
Act funding formulas. HHS noted that we did not assess the potential
usefulness of HIV data in funding formulas if all jurisdictions
participated in the national reporting system coordinated by CDC using
standardized methods of reporting. Such a determination was beyond the
scope of our work. However, as noted in the draft report, we present
analyses showing the impact of using HIV cases on fiscal year 2004 funding
for Title I, Title II, and ADAP base grants, which comprise the bulk of
CARE Act funding.
While HHS generally agreed with our matters for congressional
consideration, HHS made several comments on the issues these matters
address. HHS noted that our matters for congressional consideration focus
only on potential changes to the use of AIDS cases in formulas but not to
the use of HIV cases. The matters for consideration are based on current
funding formula provisions that require the use of AIDS cases. Our
discussion should not be interpreted as endorsing the superiority of using
living AIDS cases instead of HIV/AIDS cases.
Regardless of whether HIV case counts are used, the funding formula
provisions we identified will continue to affect proportional funding per
case if they are maintained. We believe that the use of AIDS case counts
that include deceased cases and do not reflect the current life spans of
persons living with AIDS will continue to be of concern. Also, various
provisions, such as allocating funding for Emerging Communities by tier
and hold-harmless provisions, will affect the distribution of funding
regardless of whether HIV cases are used in the formulas.
HHS pointed out that our assessment of the impact of hold-harmless
provisions on CARE Act formula funding appears accurate. HHS noted
disparities in funding per AIDS case that can result from counting cases
in EMAs once for Title I funding, and once again for Title II funding. HHS
also agreed with our analysis of the Emerging Communities provision; we
deleted our reference to a population threshold as an eligibility
requirement for Emerging Communities in response to its comment on this
issue. HHS concurred with our suggestion that the Title II hold-harmless
provision should be revised to preserve funding for ADAP Severe Need
grants.
HHS raised concerns that our discussion of the Title I grandfather clause
in the CARE Act could be interpreted as suggesting EMAs that continue to
receive grants because of this provision need not be funded. HHS noted
that a cessation of funding could lead to a decline in these areas'
systems of care and, by extension, a decline in the progress made in
fighting the epidemic. However, we note that these areas could receive
funding through their respective states or territories, which receive
funds under Title II. In addition, much of the improvement in care for
those with HIV/AIDS is due to the improvement in drugs, which, as
indicated in Appendix III, are primarily provided through Title II ADAP
grants. HHS noted that without Title II minimum grant amounts for states
and territories, the number of reported AIDS cases in low prevalence areas
would not be sufficient to sustain state-of-the-art HIV/AIDS care and
treatment services.
HHS also noted that we do not have a specific matter for congressional
consideration regarding the use of OMB's revised definitions of
metropolitan boundaries for determining Title I EMAs. HHS stated that the
report suggests that the revised definitions be accepted for determining
such boundaries. In the report, we discuss the methods used in our
analysis and the results of this analysis, but take no position on whether
the new definitions should be used in determining the EMA boundaries.
HHS commented that the draft report lacked specificity regarding the
process by which CDC receives HIV case counts from the states. We have
modified our report to include a discussion of this process. HHS also
stated in its comments that it would not be appropriate to use the
code-based case counts in monitoring HIV/AIDS nationally. An assessment of
whether code-based data should be used for monitoring HIV/AIDS is beyond
the scope of our work. Our purpose was to provide Congress with an
indication of the impact of using HIV cases in the CARE Act and HOPWA
funding formulas in light of the statutory requirement that HIV cases be
used in CARE Act funding formulas not later than fiscal year 2007. We have
added text to the report discussing HHS's concerns about code-based data.
HUD concurred with our matter for congressional consideration that
cumulative AIDS cases no longer be used in the HOPWA formula. HUD pointed
out that incorporation of a more current estimate of persons living with
HIV/AIDS would be more effective in targeting these HOPWA funds to
grantees. HUD stated in its comments that we did not take into account
differing housing costs across jurisdictions in the draft report. In
response to this comment, we revised the report to note that housing costs
are not currently part of the HOPWA funding formula, and consideration of
housing costs was not within the scope of our work. However, we have
clarified the draft report to note that if housing costs were included in
the funding formulas, they could justify deviations from proportional
funding per case.
HUD suggested that we not use the terms base grant and bonus grant. We
have added a note to our report to reflect that our terminology differs
from HUD's, but retained the use of bonus and base grants in order to
differentiate between the two formula funding components.
HUD expressed concern that the full effect of incorporating HIV case
counts may not be apparent by only stating the amount of funding that
would shift among grantees. We have added text to note that the changes
could result in some grantees more than doubling their funding. HUD
suggested that these analyses could be done based solely on data from
jurisdictions with CDC-accepted HIV case counts, or those jurisdictions
with mature HIV-reporting systems. However, as noted in the draft report,
we present analyses showing the impact of using only CDC-accepted HIV data
on fiscal year 2004 HOPWA base grants. We do not include an analysis using
only jurisdictions with mature HIV-reporting systems because it would
exclude many jurisdictions and we determined that such an analysis would
not be appropriate. HUD also pointed out that the draft report did not
describe the incremental effect on HOPWA allocations of using HIV cases
with living AIDS cases rather than living AIDS cases only. The draft
report provided information on this in appendix V, and we have added text
to the report to refer the reader to this appendix. HUD suggested that we
expand a footnote to further describe our analysis of HIV cases in funding
formulas. However, this information is already presented in detail in
appendix I and is also described in the text of the report.
In its comments HUD noted bonus funding can provide a significant amount
of resources to those eligible and that this funding can have a large
effect on formula funding per AIDS case. As noted in the draft report, we
show the amount of base funding and bonus funding that each grantee
received in fiscal year 2004 and state that funding differences per case
are due in part to the bonus grants. HUD suggested that we revise our
conclusion to reflect the importance of the bonus grants. However, our
conclusion focuses on the base grants because of the use of cumulative
AIDS cases in determining these grants. HUD also noted that not all
grantees that receive bonus grants sustain the funding from year to year.
We have added text to note the instability of the bonus funding and that,
with respect to fiscal year 2006 funding, HUD's appropriation act included
a provision to mitigate the variability of incidence data by using data
reported over a 3-year period.
HUD also suggested that we use different terms to categorize how HOPWA
funding was allocated by grantees and provided us with updated information
on how grantees allocated fiscal year 2003 HOPWA grants. We have revised
the report based on this information.
HHS and HUD also provided technical comments, which we have incorporated
where appropriate.
We are sending copies of this report to the Secretary of Health and Human
Services, the Secretary of Housing and Urban Development, the Director of
the Centers for Disease Control and Prevention, the Administrator of the
Health Resources and Services Administration, and to interested
congressional committees. We will also make copies available to others
upon request. In addition, the report will be available on GAO's Web site
at http://www.gao.gov .
If you or your staff have any questions about this report, please contact
me at (202) 512-7119 or [email protected] . Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this report
are listed in appendix XVII.
Marcia Crosse Director, Health Care
Appendix I: Objectives, Scope, and Methodology
Objectives
We assessed the distribution of funding for human immunodeficiency virus
(HIV) and acquired immunodeficiency syndrome (AIDS) under the Ryan White
Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) and the AIDS
Housing Opportunity Act's Housing Opportunities for Persons with AIDS
program (HOPWA). Specifically, we are reporting on (1) how CARE Act and
HOPWA funds are allocated by grantees among the types of services each
program supports; (2) the extent of funding distribution differences among
CARE Act and HOPWA grantees, and how CARE Act and HOPWA funding-formula
provisions contribute to these difference; and (3) what distribution
differences would result from using HIV cases in CARE Act and HOPWA
funding formulas.
Scope and Methodology
To report on these three objectives, we reviewed the CARE Act of 1990, as
well as the 1996 and 2000 CARE Act amendments, the AIDS Housing
Opportunity Act, Health Resources and Services Administration (HRSA) and
Department of Housing and Urban Development (HUD) documents on CARE Act
and HOPWA funding, HUD memoranda, Institute of Medicine reports on the
CARE Act, and other related reports. We interviewed officials from HRSA,
the Centers for Disease Control and Prevention (CDC), HUD, and the
National Alliance of State and Territorial AIDS Directors. We received
information from state government officials regarding their HIV
case-reporting systems. Details on the scope of our work and the methods
to address each objective follow.
Allocation of CARE Act and HOPWA Funds among Service Categories
To determine how grantees allocate CARE Act and HOPWA funds by types of
service, we obtained information on the allocation of these funds from
HRSA and HUD. 1 HRSA provided information on grantees' allocation of CARE
Act Titles I and II funds for fiscal year 2003, and Title III allocations
for fiscal year 2002. HRSA also provided funding amounts for its HIV/AIDS
Dental Reimbursement Program, Community-Based Dental Partnership grants,
Special Projects of National Significance, and AIDS Education and Training
Centers program for fiscal year 2003. HUD provided HOPWA allocation data
for fiscal year 2003, these being the most recently available data. We
analyzed these data and, where available, calculated the percentage of the
total amount each service category represented. To assess the reliability
of HRSA and HUD data on the allocations of CARE Act and HOPWA grant funds,
we interviewed agency officials about the data and reviewed relevant
documentation. We determined that the data were sufficiently reliable for
the purposes of our report.
Funding-formula Provisions
We examined the effect of specific funding-formula provisions on CARE Act
and HOPWA grants. We first assessed the use of 2- and 5-year cumulative
counts of AIDS cases and the use of estimated living AIDS cases (ELC) in
CARE Act programs by comparing these measures with living AIDS case counts
received from CDC. 2 We then examined the following CARE Act formula
provisions: the counting of ELCs in eligible metropolitan areas (EMA) for
both Title I and Title II funding, the tiered allocation of Emerging
Communities funding, the Title I hold-harmless provision, the Title I
grandfathering clause, and the Title II hold-harmless provision funded
from amounts available for Severe Need grants. 3 To examine the effect of
each provision on the CARE Act and HOPWA grant amounts, we measured
differences on a per case basis, by the amount of funding received, or
both. We calculated each grantee's percentage of the total number of AIDS
cases in all relevant jurisdictions, and we used these percentages to
determine the funding each grantee would have received. We then compared
these amounts with what was actually received to show the effect of a
provision in the formula. In addition, we examined the effect of using
living AIDS cases instead of cumulative cases in making HOPWA base grant
distributions by comparing the actual funding distributions with simulated
distributions using living AIDS cases. We also assessed the effect of
HOPWA bonus grants on funding for eligible metropolitan statistical areas
(EMSA) by examining the size of these grants and which EMSAs received
them.
To conduct our analyses of the effect of funding-formula provisions on
CARE Act and HOPWA funding and programs in the states, including the
District of Columbia, Puerto Rico, and metropolitan areas, we obtained
fiscal year 2004 funding data and AIDS case counts from HRSA and HUD, and
supplemented this information with additional AIDS case-count data from
CDC. Fiscal year 2004 data were the latest data available at the time of
our review. We limited our CARE Act analyses to Titles I and II because
grants under other parts of the Act are not formula-driven. Similarly, our
HOPWA analyses are also limited to the parts of the program that are
formula-based, namely, the base and bonus grants.
Our analyses of funding provisions take into consideration that CARE Act
and HOPWA formula grants use different measures of the number of AIDS
cases to determine grant amounts. There are three measures used for CARE
Act grants-reported AIDS cases over 2 years, reported AIDS cases over 5
years, and ELCs. HRSA calculates a jurisdiction's ELCs by using data from
CDC on the reported AIDS case counts for the last 10 years and weighting
those numbers to account for the likelihood of deaths. HOPWA uses two
measures-total AIDS cases reported in the jurisdiction since the beginning
of the epidemic in 1981 and AIDS incidence rates.
In our analyses of the funding formulas, we used the measure of AIDS cases
that is used to determine funding in a particular grant program in order
to show the effect of different formula provisions on fund distribution.
We also compared the AIDS data used for funding formulas with data on
living AIDS cases to assess the effect of not using living AIDS cases on
funding allocations. For the CARE Act, we used the measure of living AIDS
cases that is required by law to be used by the program when distributing
Title I, Title II, and ADAP base grants, that is, the number of ELCs based
on 10 years of reported cases and survival rates. In the absence of a
measure of living AIDS cases for HOPWA funding, we used a measure of
living AIDS cases calculated by subtracting the number of reported deaths
among AIDS cases in a jurisdiction from the number of reported cases. This
measure of living AIDS cases is used for illustrative purposes only.
In our analysis of counting ELCs in EMAs for both Title I and Title II
CARE Act funding, we aggregated Title I and Title II funding received by
each of the states and Puerto Rico. Because some EMAs cross state
boundaries, we apportioned Title I funding among states according to the
proportionate share of an EMA's ELCs in each state. For example,
approximately 96 percent of the ELCs 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. We then compared the combined total Title I and
Title II funding received by all Title II grantees.
To examine the effect of using living AIDS case counts on funding for
HOPWA base grants, we estimated the amount of funding grantees would have
received by determining the number of living AIDS cases in each
jurisdiction. CDC provided us with living AIDS cases counts for states,
Puerto Rico, and EMSAs. To determine each grantee's number of living AIDS
cases, we subtracted the number of living AIDS cases in EMSAs in a state
from the total number of living AIDS cases in the state. 4 When an EMSA
crossed state boundaries, we used information from CDC to determine the
number of living AIDS cases in each state within the EMSA. For example,
the Memphis EMSA covers parts of Arkansas, Mississippi, and Tennessee. We
obtained the living AIDS case counts for each of the states in the Memphis
EMSA. We then subtracted the number of living AIDS cases from Arkansas in
the Memphis EMSA from the Arkansas state total, and did comparable
calculations for the cases from the other two states. After doing similar
calculations for all EMSAs that crossed state boundaries, we had living
AIDS case counts for all HOPWA grantees. We then calculated each grantee's
percentage of the total number of living AIDS cases in all jurisdictions
and simulated the HOPWA base grant funding allocations according to this
percentage. We then compared the base funding received using cumulative
AIDS case counts with the simulated funding allocations using living AIDS
cases.
The dates of the AIDS case counts used in our analyses varied by program.
Depending on the grant, formula allocations under the CARE Act are based
on the number of ELCs in a jurisdiction as of June 30 preceding the start
of the fiscal year for which the award is to be made or on the number of
reported AIDS cases in either the most recent 2 or 5 calendar years. HOPWA
eligibility is based on the number of cumulative AIDS cases as of March 31
preceding the start of the fiscal year. Where appropriate, we used ELCs as
of June 30, 2003, to estimate the effect of formula provisions on CARE Act
funding for fiscal year 2004, which began on October 1, 2003. For other
CARE Act grants, we used reported cases for the appropriate calendar-year
period. We used AIDS case counts as of March 31, 2003, to estimate the
effect of formula provisions on HOPWA funding for fiscal year 2004.
We used funding per AIDS case 5 to illustrate the effect of certain
funding-formula provisions on the distribution of CARE Act and HOPWA
funds. There are other considerations that could be included in funding
formulas. For example, differing health care and housing costs across
regions and differences in grantees' capacities to fund services from
local resources could be used as bases for distributing program funds and
to justify deviations from proportional funding per case. 6 Without such
considerations, regions with the same funding and the same number of AIDS
cases could not treat the same number of patients. Currently, these
considerations are not taken into account when awarding formula grants
under either the CARE Act or HOPWA.
To analyze the effect of retaining the current EMA boundaries, we reviewed
documents pertaining to the Office of Management and Budget's (OMB) 2004
metropolitan boundary definitions. In particular, we relied on information
generated in our June 2004 report on metropolitan statistical areas (MSA)
that reported on the process used to develop the 2000 standards and how
the 2000 standards differ from the 1990 standards. 7 Before each decennial
census, OMB reviews the standards used in defining the boundaries of these
statistical areas to ensure their continued usefulness and relevance and,
if warranted, revises them. OMB had determined that a more fundamental
examination of the standards was required for 2000, and advisory groups
were formed to look at the standards. These groups suggested OMB consider
defining less-populated areas, which had been statistically unrecognized.
The 2000 standards differ from the 1990 standards in many ways, and the
Census Bureau and OMB have stated that the new standards are simpler and
more transparent.
To demonstrate the effect on the current boundaries of the 51 CARE Act
Title I EMAs if OMB's 2004 definitions of MSAs were used to establish EMA
boundaries, we compared the boundaries of existing EMAs with the new MSA
boundaries that could be created using the new definitions. Because most
EMA boundaries include portions of more than one new metropolitan area,
for our analysis we chose two decision rules to serve as a basis for
selecting new metropolitan areas to be compared with the existing EMAs. 8
First, we assumed there would be no change in eligibility of the current
51 Title I EMAs. Second, since the number of ELCs within an EMA would
change if its boundaries were revised, we chose whatever combination of
the newly defined metropolitan areas 9 would result in the least change to
the numbers of ELCs within the EMA's boundaries. The results of our method
are shown in appendix VII, which lists each of the existing EMAs together
with the corresponding new areas, the number of counties constituting the
metropolitan areas, and the number of ELCs contained within those areas.
To assess the reliability of the data on HRSA's and HUD's distribution of
CARE Act and HOPWA funds, we asked agency officials about how the data
were developed and reported. We also reviewed relevant documentation. We
determined the data were sufficiently reliable for the purposes of our
report.
Use of HIV Cases in Formulas
We examined how CARE Act and HOPWA fiscal year 2004 allocations would have
been affected by using HIV cases in addition to living AIDS cases to
determine funding. We undertook our analyses in light of the statutory
requirement that HIV cases be used in CARE Act funding formulas not later
than fiscal year 2007. 10 We examined the effect of using HIV cases in
addition to living AIDS cases on formula funding for CARE Act Title I,
Title II, and ADAP base grants, and HOPWA base grants in the states,
Puerto Rico, and metropolitan areas. 11 We limited our analyses to these
grants because they constitute the majority of the CARE Act and HOPWA
formula funding. For the CARE Act, we used the measure of living AIDS
cases that is required by law to be used by the program when distributing
Title I, Title II, and ADAP base grants, that is, the number of ELCs based
on 10 years of reported cases and survival rates. In the absence of a
measure of living AIDS cases for HOPWA funding, we used a measure of
living AIDS cases calculated by subtracting the number of reported deaths
among AIDS cases in a jurisdiction from the number of reported cases. This
measure of living AIDS cases is used for illustrative purposes only. We
used fiscal year 2004 allocations, which were based on case counts
reported as of June 30, 2003, for the CARE Act and as of March 31, 2003,
for HOPWA. As of these dates there were 35 jurisdictions 12 from which CDC
accepted HIV data and 17 without CDC-approved HIV data. CDC will only
accept name-based case counts as no code-based system has yet met CDC's
quality criteria. 13
Because CDC did not accept HIV case counts from 17 jurisdictions, we
conducted our analysis using two approaches to measure total HIV/AIDS
cases for purposes of formula calculations. Under the first approach, we
used HIV and live AIDS case counts for the 35 jurisdictions from which CDC
accepted HIV data. 14 Because CDC did not accept the HIV case counts from
the other 17 jurisdictions, we used only the live AIDS case counts
received by CDC for these grantees. Consequently, for some grantees we
used HIV and AIDS case counts, but for others we used only AIDS case
counts. This approach reflects the data that would have been used if
funding allocations were based on the HIV and AIDS case counts received by
CDC in time for determining fiscal year 2004 allocations. Under the second
approach, we used the same HIV and AIDS case counts as our first approach,
but supplemented these data with the code-based HIV case counts collected
by the grantees from which CDC did not receive HIV data. 15 We obtained
these HIV case counts directly from these jurisdictions. 16 These case
counts were collected and reported to us by public health authorities. We
also received information from them regarding their HIV case-reporting
systems.
For both approaches, we calculated the grantee's percentage of the total
number of HIV/AIDS cases relative to all grantees for that program and
estimated the fiscal year 2004 grants that each would have received. 17
CARE Act formula allocations were calculated both with certain
hold-harmless and minimum-grant provisions and again without those
provisions. 18 Eliminating hold-harmless and minimum-grant provisions was
done to show the full effect of distributing fiscal year 2004 funding
solely according to HIV/AIDS data available at that time. We also
estimated the effect of using HIV cases and living AIDS cases for HOPWA
base funding.
In our analyses of how the use of HIV cases would affect funding by
region, we use U.S. Census Bureau definitions to define regions of the
country. The Census Bureau divides the country into four regions:
Northeast, Midwest, South, and West. 19 Table 11 lists the four regions
and the jurisdictions that constitute them.
Table 11: U.S. Census Bureau Regions
Northeast
Connecticut New York
Maine Pennsylvania
Massachusetts Rhode Island
New Hampshire Vermont
New Jersey
Midwest
Illinois Missouri
Indiana Nebraska
Iowa North Dakota
Kansas Ohio
Michigan South Dakota
Minnesota Wisconsin
South
Alabama Mississippi
Arkansas North Carolina
Delaware Oklahoma
District of Columbia South Carolina
Florida Tennessee
Georgia Texas
Kentucky Virginia
Louisiana West Virginia
Maryland
West
Alaska Nevada
Arizona New Mexico
California Oregon
Colorado Utah
Hawaii Washington
Idaho Wyoming
Montana
Source: U.S. Census Bureau.
Our analyses of the effect of using HIV case counts for determining CARE
Act and HOPWA funding rely on data whose reliability has been questioned.
In June 2004, the Secretary of Health and Human Services determined that
because of the problems associated with these data, they should not
currently be used in determining CARE Act funding. We used these data in
our analyses to give a general indication of the effect of using HIV cases
in future formula allocations as required by the CARE Act. By using
HIV/AIDS counts in determining CARE Act and HOPWA funding, the number of
persons on which funding is based would increase. The effect on individual
grantees would depend on the number of reported HIV cases in the
jurisdiction compared with the number reported in other jurisdictions. The
extent to which the use of HIV cases could affect formula allocations
cannot be determined by these analyses because jurisdictions use different
methods to identify HIV cases, and it is unclear to what degree the
resulting case counts are comparable. However, we think our approaches in
these analyses are informative in light of the statutory requirement that
HIV cases be used in CARE Act funding formulas not later than fiscal year
2007.
To assess the reliability of the HIV and AIDS case-count data, we asked
HRSA, HUD, CDC, state, and local officials a series of questions about how
the data were collected and the methods used to ensure their accuracy. We
asked state and local officials about their HIV data only when they were
not accepted by CDC. On the basis of the information provided regarding
the verification of the reliability of these data, we determined these
data to be sufficiently reliable for the purposes of our analyses.
Our analyses do not include the different costs of treating patients with
HIV and AIDS. The cost of serving persons who have HIV and AIDS can vary
substantially, depending on the stage of the disease. Patients whose
disease has progressed to AIDS often require more expensive drug therapies
and more intensive care than those whose disease has not progressed to
AIDS. One study found that the average annual cost of treating an HIV
patient was about $18,000 per year. However, the cost ranged from about
$14,000 per year for well patients with HIV to $34,000 per year for
patients with advanced-stage AIDS. 20
We performed our work from July 2004 through February 2006, in accordance
with generally accepted government auditing standards.
Appendix II: CARE Act Title I Awards, Fiscal Year 2004 Appendix II: CARE
Act Title I Awards, Fiscal Year 2004
Eligible metropolitan area Base award Supplemental award Minority AIDS Total Title I award Total Title I
Initiative award award per ELCa
Atlanta, Ga. $9,268,937 $7,518,391 $1,552,404 $18,339,732 $2,417
Austin, Tex. 2,016,473 1,559,617 224,430 3,800,520 2,302
Baltimore, Md. 10,195,952 7,615,994 1,898,933 19,710,879 2,361
Bergen-Passaic, N.J.b 2,605,497 2,002,220 206,987 4,814,704 2,306
Boston, Mass.b, c 7,434,884 6,630,052 783,761 14,848,697 2,459
Caguas, P.R. 935,565 735,726 145,356 1,816,647 2,372
Chicago, Ill. 12,801,123 10,363,895 2,261,742 25,426,760 2,426
Cleveland, Ohiob 1,850,098 1,379,848 256,990 3,486,936 2,308
Dallas, Tex 6,425,600 5,378,653 1,016,330 12,820,583 2,437
Denver, Colo.b 2,440,655 1,843,081 245,361 4,529,097 2,273
Detroit, Mich. 4,382,256 3,427,753 780,272 8,590,281 2,394
District of Columbiac 14,431,645 9,840,164 2,679,205 26,951,014 2,281
Dutchess County, N.Y. 639,995 512,173 79,074 1,231,242 2,350
Fort Lauderdale, Fla. 7,330,631 6,349,097 1,069,822 14,749,550 2,457
Fort Worth, Tex. 1,805,177 1,386,868 181,405 3,373,450 2,282
Hartford, Conn. 2,386,547 1,899,397 266,293 4,552,237 2,330
Houston, Tex. 9,416,722 8,472,252 1,239,598 19,128,572 2,481
Jacksonville, Fla.b 2,517,844 1,873,132 472,117 4,863,093 2,371
Jersey City, N.J.b 3,022,562 2,548,825 312,807 5,884,194 2,424
Kansas City, Mo.b, c 1,716,152 1,358,374 166,287 3,240,813 2,503
Las Vegas, Nev.c 2,375,554 1,832,717 265,130 4,473,401 2,300
Los Angeles, Calif. 18,540,316 16,153,706 1,950,099 36,644,121 2,414
Miami, Fla. 12,806,009 10,268,761 2,465,241 25,540,011 2,436
Middlesex-Somerset-Hunterdon, 1,520,364 988,206 215,127 2,723,697 2,200
N.J.b
Minneapolis-St. Paul, Minn.b, 1,587,346 1,328,653 177,916 3,093,915 2,432
c
Nassau-Suffolk, N.Y.b 3,182,104 2,402,225 367,460 5,951,789 2,300
New Haven, Conn.b 3,639,492 3,012,393 417,463 7,069,348 2,400
New Orleans, La. 3,852,184 2,239,460 695,384 6,787,028 2,152
New York, N.Y. 60,276,790 52,106,068 9,720,259 122,103,117 2,474
Newark, N.J.b 8,151,371 6,076,957 1,083,776 15,312,104 2,297
Norfolk, Va.c 2,732,193 1,639,148 448,860 4,820,201 2,155
Oakland, Calif.b 3,534,076 2,614,717 462,814 6,611,607 2,318
Orange County, Calif. 2,666,239 2,282,192 284,898 5,233,329 2,397
Orlando, Fla. 4,021,954 3,028,863 770,969 7,821,786 2,375
Philadelphia, Pa.c 12,038,992 10,407,066 2,002,427 24,448,485 2,480
Phoenix, Ariz. 3,480,889 2,975,380 358,158 6,814,427 2,391
Ponce, P.R. 1,414,340 1,002,813 301,178 2,718,331 2,347
Portland, Oreg.c 1,889,451 1,572,205 105,819 3,567,475 2,306
Riverside-San Bernardino, 3,913,252 2,613,404 296,527 6,823,183 2,130
Calif.
Sacramento, Calif.b 1,558,276 1,328,376 81,399 2,968,051 2,382
St. Louis, Mo.c 2,412,195 1,646,152 312,807 4,371,154Appendix 2,213
VI: Total CARE Act
Title I and Title II
Funding by State and
Territory, Fiscal
Year 2004
San Antonio, Tex. Total Title 2,097,083ELCsaELCsa 1,400,297Percent of 336,063Total 3,833,443 2,233Alabama
I and Title II awards Total ELCs in EMAs Percent Title I and Title
Title I and Title II awards of ELCs in EMAs II awards per
ELCTotal Title I
and Title II
awards per ELC
San Diego, Calif. 3,320 5,201,7920% 4,554,583$3,657 531,422 10,287,797Alaskab 2,416974,705
San Francisco, Calif.b0 16,171,6074,351 13,199,079 479,094Arizona 29,849,78018,635,537 4,1373,978
San Jose, Calif.b4,685 1,411,781 1,069,179Arkansas 175,5904,933,831 2,656,5501,466 2,3180
San Juan, P.R.b 8,139,880California 5,255,408223,607,373 1,337,27742,479 14,732,56588.9 2,2225,264
Santa Rosa, Calif.bColorado 611,31212,949,158 469,3702,658 26,74675.0 1,107,4284,872 2,298
Seattle, Wash.b26,797,308 3,024,1725,363 2,605,64291.4 212,8014,997 5,842,615 2,367Delaware
Tampa-St. Petersburg, 4,777,6960 3,348,9203,518 593,053 8,719,669District of 2,25033,288,417
Fla.b1,518 Columbia
Vineland-Millville-Bridgeton, 473,8895,074 297,261 76,748Florida 847,898182,771,752 2,18538,101
N.J. 100.0
West Palm Beach, Fla.b4,797 4,577,648 3,964,724Georgia 866,32354,483,301 9,408,69511,226 2,51567.6
Totald $305,704,561Hawaii $246,379,4373,298,130 $43,258,002988 $595,342,0000 3,338
Source: GAO analysis of HRSA data. Idahob
Notes: HRSA has awarded Minority AIDS Initiative grants to EMAs. HRSA
characterizes Minority AIDS Initiative grants to EMAs as Title I grants.
1,019,352
aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death. The average total Title I
award per ELC was $2,380. 220
bEMA received hold-harmless funding that is included in base award. 0
cEMA boundaries include jurisdictions in more than one state. 4,633
dIndividual entries may not sum to totals because of rounding.
State/territory State/territory
$12,142,447
224
73.5
3,366
Connecticut
5,340,795
6,561
77.3
4,853
Illinois
Appendix III: CARE Act Title II Awards, Fiscal Year 2004 Appendix III:
CARE Act Title II Awards, Fiscal Year 2004 60,837,359
12,203
Grantee Base grant award ADAP base grant award Minority AIDS Initiative award Emerging ADAP Severe Need award Total Title II award Total Title II award per ELCa
Communities award
Alabama Iowa $4,042,811 2,067,375 $7,004,635619 $77,8280 $192,2603,340 $824,913 $12,142,447Kansas $3,6573,881,999
Alaskab34.2 500,000 4,048 472,602 2,103Kentucky 1,937 974,7050 4,3513,702 7,170,005
Arizona Louisiana 3,201,547 29,740,454 8,392,9036,555 54,16448.1 11,648,614Maineb 2,9281,333,909 4,537
Arkansas 0 1,785,169 3,377 3,116,716 31,946Maryland 12,203 4,933,83193.6 3,3665,018 61,230,030
California 31,236,233 34,432,147 89,623,4656,960 565,82983.2 121,425,527Michigan 2,85824,046,130 4,947
Massachusetts
Colorado 68.8 2,117,525 4,611 5,607,928 34,181Minnesota 660,427 1,427 8,420,06188.7 3,1685,003 7,139,028
Connecticut 3,779,591 9,454,950 11,315,0182,747 81,1140 15,175,723Missouri 2,83016,501,234 3,442
Mississippi
Delaware 76.8 1,848,490 4,699 3,202,722 39,177Montanab 250,406847,196 147 5,340,7950 3,5185,763
District of Columbia 4,305,124 1,887,660 13,842,594525 175,7700 18,323,488Nevada 2,79310,757,214 3,596
Nebraska
Florida 83.3 29,860,865 4,789 80,386,630 893,442New Hampshireb 528,0111,864,452 358 111,668,94869.0 2,9315,208
Georgia New Jersey 9,408,492 80,222,837 23,684,95116,531 260,82884.8 2,789,298 36,143,569New Mexico 3,2203,338,463 4,853
Hawaii 0 1,203,101 3,400 2,084,512 10,517New York 59,226 3,298,13088.6 3,3385,041 298,549,361
IdahobNorth Carolina 500,000 22,668,734 464,1636,083 5260.1 54,663 1,019,352North Dakotac 4,633292,543 3,727
Illinois 0 8,837,193 6,803 25,746,254 287,121Ohio 5,171 34,870,56829.2 2,8583,916 20,249,202
Indiana Oklahoma 3,768,825 6,343,022 6,529,9241,687 47,1960 1,057,0053,760 11,402,950Oregon 3,6849,084,990
Iowa 68.9 753,765 4,536 1,305,985 7,625Pennsylvania 12,840 2,067,37567.4 3,3404,655 59,766,256
Kansas Puerto Rico 1,007,120 53,026,882 2,045,49510,711 8,54579.9 3,061,160Rhode Island 3,1923,189,276 4,951
Kentucky 0 2,358,712 3,520 4,086,741 22,875South Carolina 220,39520,705,328 481,282 5,563 7,170,0050 3,7023,722
Louisiana South 6,211,002 705,706 13,829,93597 192,0720 1,091,7127,275 1,628,705 22,953,426Tennessee 3,50221,178,234
Dakotab
Maineb0 500,000 4,169 833,383 526Texas 36,525 23,922 1,370,43474.5 3,4694,973 118,965,938
Maryland Utah 8,446,358 3,235,191 25,746,254882 317,3590 34,509,971Vermontb 2,828883,059 3,668
Massachusetts 0 5,223,382 4,879 14,684,416 99,257Virginia 183,81932,149,863 6,872 20,190,87463.2 2,9014,678
Michigan Washington 4,335,555 17,349,313 11,002,7633,776 117,53169.8 15,455,849West Virginia 2,9642,335,062 4,595
Minnesota 11.3 1,026,762 3,778 3,010,727 22,218Wisconsin 1,507 4,059,7070.4 2,8453,718 5,603,506
Mississippi Wyomingc 3,345,060 360,347 5,795,70376 88,4770 225,7104,741 9,454,950Source: GAO analysis of HRSA 3,442Notes: Our analysis is limited to
data. the states and Puerto Rico.
Missouri bState 2,783,489 cState 7,409,723 56,925 Table 12: EMAs 10,250,137HRSA 2004 EMA HRSA 2004 2,919GAO-identified comparable OMB Appendix VII: HRSA's Title I EMAs,
received a Title II received a Title II base with Service Area EMA newly defined 2004 MSA(s) or GAO-Identified Set of Comparable 2004
base award of award of $200,000, the Changes MDIV(s)aGAO-identified comparable OMB OMB-Defined Metropolitan Areas, and
$500,000, the minimum it could receive newly defined 2004 MSA(s) or MDIV(s)a Changes Appendix VII: HRSA's Title I
minimum it could based on the number of EMAs, GAO-Identified Set of Comparable
receive based on the ELCs in the state. 2004 OMB-Defined Metropolitan Areas,
number of ELCs in and Changes
the state.
Montanab 500,000 OMB's 1993 full 310,145Number of counties in 526ELCs in EMAs ELCs in EMAs Number of 810,671ELCs in EMAs ELCs in EMAs 5,515Decrease in counties Decrease in OMB's 2004 full title of metropolitan
title of metropolitan EMA Number of counties in EMA counties in EMA counties area(s) OMB's 2004 full title of
area OMB's 1993 full Number of metropolitan area(s)
title of metropolitan counties in EMA
area
Nebraska Change in 639,300 1,107,661Atlanta, Ga. MSA 10,25420 130,445 1,887,66028 3,5967,663 7,589
ELCs (percent)Change Atlanta-Sandy
in ELCs (percent) Springs-Ga.
Marietta, Ga. MSA
Nevada 8 1,684,896 1% 4,738,678 32,735Boston-Worcester-Lawrence-Lowell-Brockton, 6,038 6,456,309Boston-Cambridge-Quincy, 2,8759 10
Mass.-N.H. NECMA Mass-N.H. MSA; Worcester, Mass.
MSA; and Manchester-Nashua, N.H.
MSA
New Hampshireb1 500,000 0 755,319-9 1,709 9 1,257,02810,481 3,511Chicago-Naperville-Joliet, Ill. Chicago, Ill. PMSA
MDIV; and Lake County-Kenosha County,
Ill.-Wis. MDIV
New Jersey 10,534 12,302,631 0 34,877,5981 279,3651 181,943 Cleveland-Lorain-Elyria, Ohio 47,641,5376 2,8821,511
PMSA
New Mexico 5 1,195,795 1,484 2,127,0241 15,6440 3,338,463Dallas, Tex. PMSA 3,4008 -2
New York 42,659,431 8 124,956,7845,229 1,252,4751 394,5231 -1 169,263,213 2,858Denver, Colo. PMSA
Dallas-Plano-Irving,
Tex. MDIV
North Carolina 1,993 7,403,985 Denver-Aurora, 12,834,09510 197,5932,017 708,7030 1,511,429 5 22,655,8051 3,724
Colo./ MSA
North Dakotac6 200,000 3,588 92,543Detroit-Warren-Livonia, 07 3,601 0 292,5431 6,8030b
Mich. MSA and Monroe, Mich.
MSA
Ohio Dutchess 5,448,305 1 10,909,930524 67,968Poughkeepsie-Newburgh-Middletown, N.Y. MSA 336,0632 1,010 16,762,2660 3,2421
County, N.Y. PMSA
Oklahoma 2,054,284 Fort 3,655,7074 23,7951,478 190,071Fort 419,165 4 6,343,0221,475 3,7601
Worth-Arlington, Tex. Worth-Arlington,
PMSA Tex. MDIV
Oregon 0b 1,664,149 4,225,989Houston, Tex. PMSA 12,4896 7,710 Houston-Sugar Land-Baytown, Tex. 5,902,62710 2,9478,106
MSA
Pennsylvania 4 10,779,206 5 27,090,216 258,856Jacksonville, Fla. MSA 188,1964 2,051 38,316,474Jacksonville, Fla. MSA 2,9845
Puerto Rico 0 8,238,917 1 22,598,3881 260,697 Kansas City, 2,661,337 11 33,759,3391,295 3,152Kansas City, Mo.-Kans. MSA
Mo.-Kans. MSA
Rhode Island 1,305 1,103,249 0 1,911,5064 14,4611 160,060 Las Vegas, Nev.-Ariz. MSA 3,189,2763 3,5201,945
South Carolina 1 6,774,143 1,857 11,736,9842 164,8580 647,118-5 1,382,225 20,705,328Middlesex-Somerset-Hunterdon, 3,7223
N.J. PMSA
South DakotabEdison, 500,000 4 204,6542,217 1,0521 2 79 705,706 7,275New Orleans, La. MSA
N.J. MDIV
Tennessee 3,154 6,185,987 New 12,018,4387 122,5263,130 2,851,2831 0 21,178,234-1 4,169
Orleans-Metairie-Kenner,
La. MSA
Texas 5 19,125,106 6,665 50,471,351Newark-Union, 469,0706 6,735 5,943,843 1 76,009,3702 3,1771
N.J.-Pa. MDIV
Utah 1,074,024 15 1,980,5652,237 7,099Virginia Beach-Norfolk-Newport News, 173,50316 2,240 3,235,1910 3,6681
Norfolk-Virginia Va.-N.C. MSA
Beach-Newport News,
VA-N.C. MSA
Vermontb 500,000 Philadelphia, 382,0079 1,0529,857 Philadelphia, Pa. 8 883,0599,782 4,8791
Pa.-N.J. PMSA MDIV and Camden,
N.J. MDIV
Virginia -1 5,929,341 14,498,751Ponce, P.R. MSA 145,0076 244,7791,158 1,707,470 Ponce, P.R. MSA and 22,525,3487 3,2781,202
Yauco, P.R. MSA
Washington 1 3,118,978 4 7,966,718 35,890Portland-Vancouver, Oreg.-Wash. PMSA 6 1,547 11,121,586Portland-Vancouver-Beaverton, 2,9457
Oreg.-Wash. MSA
West Virginia 0 713,239 1 1,303,8750b 4,733 Sacramento, 153,553 3 2,175,4001,246 3,520Sacramento-Arden-Arcade-Roseville,
Calif. PMSA Calif. MSA
Wisconsin 1,321 1,831,726 0 3,179,5141 28,7916 174,440 374,441 St. Louis, Mo.-Ill. MSA 5,588,91212 3,7091,975
Wyomingc16 200,000 1,993 160,3470 04 1 360,347San Antonio, Tex. MSA 4,7414
Total San Antonio, $284,712,863 8 $727,320,9291,750 $6,903,7970 $10,000,0004 $20,759,721 2 $1,049,697,310 San Jose, Calif. PMSA
Tex. MSA
Source: GAO analysis of HRSA data. 1,146
Notes: HRSA has awarded grants for Minority AIDS Initiative grants to
states and territories. HRSA characterizes Minority AIDS Initiative grants
to states and territories as Title II grants. San Jose-Sunnyvale-Santa
Clara, Calif. MSA
In addition to the grantees listed, American Samoa, the Federated States
of Micronesia, Guam, the Republic of the Marshall Islands, the
Commonwealth of the Northern Mariana Islands, the Republic of Palau, and
the Virgin Islands also received Title II funding ranging from a total of
$50,000 to $1,048,657. 2
aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death. The average total Title II
award per ELC was $3,559. 1,163
bState received a Title II base award of $500,000, the minimum it could
receive based on the number of ELCs in the state. 0
cState received a Title II base award of $200,000, the minimum it could
receive based on the number of ELCs in the state. 1
959
395
5,215
3,512
2,246
982
43
2,003
906
5,080
181
618
aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
Changes Changes
Increase in countiesIncrease in counties
0
5,484
10
Cleveland-Elyria-Mentor, Ohio MSA
5,261
5
Detroit, Mich. PMSA
93
1
0
2,080
15
Las Vegas-Paradise, Nev. MSA
1,238
8
Newark, N.J. PMSA
0b
0
0
1,548
4
St. Louis, Mo.-Ill. MSA
1,717
1
1
Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004
Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004
Seattle-Bellevue-Everett, Wash. PMSA
Grantee Base funding Bonus fundinga Total formula Total formula funding per cumulative Total formula
funding AIDS caseb funding per
living AIDS casec
Alabama -1 $1,139,000 $1,139,00025 $230 11,816 $444Washington-Arlington-Alexandria, Washington,
D.C.-Va.-Md. MSA D.C.-Md.-Va-W.Va.
PMSA
Albany, N.Y. 429,000 3 429,000-1 230 497Bergen-Passaic, N.J. PMSA 0
11,732
Arizona 2,088 164,000 New 164,00053,867 230 0 4740 11
York-White
Plains-Wayne,
N.Y.-N.J.
MDIV
Arkansas 752,000 752,0002,427 230 418 1
Jersey City,
N.J. PMSA
Atlanta, Ga. 4,262,000 $637,000 4,899,000 264 New York City, N.Y. PMSA 5738
Augusta, Ga. 373,000 373,000 230 455
Austin, Tex. 988,000 5 988,000San 230 41 5207,724 766
Caguas, P.R. Juan-Caguas-Guaynabo,
PMSA P.R. MSA
Baltimore, 3,940,000 4 3,996,000 7,936,000San 463 30 1,0396,631
Md. 9 Juan-Bayamon,
P.R. PMSA
Baton Rouge, 666,000 1,147,000 1,813,000 626 1,290
La.
Birmingham, 520,000 520,000275 230 160,694 46117 Not applicable
Ala. 239 158,952
Boston, Mass. 1,829,000 1,829,00057 230 84,768 563Not applicable Subtotal of
1 unchanged areas
(see table 13)
Bridgeport, 752,000 0 27,0000 779,0000 238 476Total
Conn. 84,768
Buffalo, N.Y. 472,000 Not 472,000245,462 230 17 52353 332
243,720 applicable
California 3,042,000 3,042,000aWe chose 230 bPercent 518 Notes: HRSA's
Sources: GAO whatever combination change that Title I EMAs are
analysis of of the newly defined rounds to based on OMB's
CDC, HRSA, metropolitan areas zero, but 1993 metropolitan
and OMB data. that would result in does not area
the least change to equal zero definitions.This
the numbers of ELCs percent. table uses OMB's
within the EMA's terminology for
boundaries. classifying types
of metropolitan
areas.
Specifically, it
includes
metropolitan
statistical area
(MSA), primary
metropolitan
statistical area
(PMSA), New
England county
metropolitan area
(NECMA), and
metropolitan
division (MDIV).
The terms used
and meaning of
those terms
differ
between1993 and
2004 because of
OMB's fundamental
revisions of
metropolitan
concepts. For
further
explanation, see
GAO-04-758.
Cambridge, 659,000 659,000 230 518
Mass.
Camden, N.J. 657,000 657,000 230 567
Charleston, 411,000 7,000 418,000 234 480
S.C.
Charlotte, 571,000 571,000 230 450
N.C.
Chicago, Ill. 5,622,000 2,716,000 8,338,000 341 805
Cincinnati, 550,000 550,000 230 523
Ohio
Cleveland, 854,000 854,000 230 479
Ohio
Colorado 366,000 366,000 230 462
Columbia, 626,000 644,000 1,270,000 466 824
S.C.
Columbus, 584,000 584,000 230 619
Ohio
Connecticut 251,000 251,000 230 479
Dallas, Tex. 3,192,000 3,192,000 230 496
Delaware 164,000 164,000 230 463
Denver, Colo. 1,424,000 1,424,000 230 547
Detroit, 1,624,000 355,000 1,979,000 280 749
Mich.
District of 5,626,000 6,176,000 11,802,000 482 939
Columbia
Florida 4,063,000 4,063,000 230 489
Fort 3,337,000 2,903,000 6,240,000 430 954
Lauderdale,
Fla.
Fort Worth, 835,000 835,000 230 500
Tex.
Gaithersburg, 535,000 535,000 230 467
Md.
Georgia 1,515,000 HIV/AIDS 1,515,000 230 469
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
Funding
Hartford, 1,023,000 1,023,000 230 460
Conn.
Hawaii 181,000 181,000 230 439
Honolulu, 452,000 452,000 230 571
Hawaii
Houston, Tex. 5,068,000 5,068,000 230 591
Illinois 864,000 864,000 230 466
Indiana 836,000 836,000 230 500
Indianapolis, 759,000 759,000 230 476
Ind.
Iowa 347,000 347,000 230 511
Islip, N.Y. 1,660,000 1,660,000 230 577
Jackson, 449,000 275,000 724,000 371 728
Miss.
Jacksonville, 1,195,000 369,000 1,564,000 301 623
Fla.
Kansas 363,000 363,000 230 562
Kansas City, 978,000 978,000 230 506
Mo.
Kentucky 423,000 423,000 230 418
Las Vegas, 916,000 916,000 230 455
Nev.
Los Angeles, 10,476,000 10,476,000 230 622
Calif.
Louisiana 940,000 940,000 230 488
Louisville, 462,000 462,000 230 443
Ky.
Maryland 345,000 345,000 230 453
Massachusetts 525,000 525,000 230 521
Memphis, 920,000 1,214,000 2,134,000 533 1,000
Tenn.
Miami, Fla. 6,149,000 4,566,000 10,715,000 400 934
Michigan 911,000 911,000 230 546
Milwaukee, 512,000 512,000 230 511
Wis.
Minneapolis, 839,000 839,000 230 508
Minn.
Minnesota 110,000 110,000 230 529
Mississippi 756,000 756,000 230 484
Missouri 496,000 496,000 230 471
Nashville, 737,000 737,000 230 387
Tenn.
Nevada 238,000 238,000 230 499
New Haven, 937,000 295,000 1,232,000 302 605
Conn.
New Jersey 1,106,000 1,106,000 230 593
New Mexico 533,000 533,000 230 501
New Orleans, 1,785,000 1,207,000 2,992,000 385 887
La.
New York 1,776,000 1,776,000 230 500
New York, 33,487,000 26,868,000 60,355,000 414 1,099
N.Y.
Newark, N.J. 4,297,000 885,000 5,182,000 277 828
North 2,082,000 2,082,000 230 437
Carolina
Oakland, 2,006,000 2,006,000 230 595
Calif.
Ohio 1,041,000 1,041,000 230 524
Oklahoma 518,000 518,000 230 521
Oklahoma 466,000 466,000 230 509
City, Okla.
Orlando, Fla. 1,660,000 1,529,000 3,189,000 441 913
Pennsylvania 1,540,000 1,540,000 230 445
Philadelphia, 4,340,000 3,292,000 7,632,000 404 799
Pa.
Phoenix, 1,434,000 1,434,000 230 490
Ariz.
Pittsburgh, 626,000 626,000 230 568
Pa.
Portland, 1,006,000 1,006,000 230 523
Oreg.
Poughkeepsie, 604,000 604,000 230 556
N.Y.
Providence, 807,000 807,000 230 498
R.I.
Puerto Rico 1,748,000 1,748,000 230 584
Richmond, Va. 692,000 692,000 230 527
Riverside, 1,772,000 1,772,000 230 462
Calif.
Rochester, 597,000 597,000 230 460
N.Y.
Sacramento, 844,000 844,000 230 574
Calif.
St. Louis, 1,217,000 1,217,000 230 491
Mo.
Salt Lake 386,000 386,000 230 455
City, Utah
San Antonio, 1,027,000 1,027,000 230 480
Tex.
San Diego, 2,683,000 2,683,000 230 522
Calif.
San 6,698,000 1,864,000 8,562,000 294 1,130
Francisco,
Calif.
San Jose, 792,000 792,000 230 538
Calif.
San Juan, 4,585,000 2,555,000 7,140,000 358 1,000
P.R.
Santa Ana, 1,436,000 1,436,000 230 489
Calif.
Sarasota, 397,000 397,000 230 501
Fla.
Seattle, 1,688,000 1,688,000 230 524
Wash.
South 1,387,000 1,387,000 230 446
Carolina
Springfield, 461,000 461,000 230 535
Mass.
Tampa, Fla. 2,221,000 168,000 2,389,000 247 569
Tennessee 739,000 739,000 230 438
Texas 2,736,000 2,736,000 230 454
Tucson, Ariz. 402,000 402,000 230 515
Utah 120,000 120,000 230 467
Virginia 640,000 640,000 230 499
Virginia 1,022,000 1,022,000 230 505
Beach, Va.
Wake County, 345,000 7,000 352,000 234 408
N.C.
Warren, Mich. 405,000 405,000 230 571
Washington 652,000 652,000 230 480
West Palm 2,019,000 1,817,000 3,836,000 436 933
Beach, Fla.
Wilmington, 566,000 232,000 798,000 325 624
Del.
Wisconsin 405,000 405,000 230 509
Woodbridge, 1,462,000 1,462,000 230 627
N.J.
Worcester, 369,000 369,000 230 480
Mass.
Total $197,288,000 $65,751,000 $263,039,000
Sources: GAO analysis of CDC and HUD data.
aBonus grants were awarded to EMSAs that have a higher-than-average per
capita incidence of AIDS over the previous year.
bThe average formula funding per cumulative AIDS case was $260.
cThe number of living AIDS cases was calculated by subtracting the number
of reported deaths among AIDS cases in a jurisdiction from the number of
reported cases. The average formula funding per living AIDS case was $573.
0
22
2
0
49,352
3
Subtotal of changed areas
53
57
296
1
Appendix V: HOPWA Base Funding Allocations Using Cumulative and Living
AIDS Cases, Fiscal Year 2004 Appendix V: HOPWA Base Funding Allocations
Using Cumulative and Living AIDS Cases, Fiscal Year 2004
Grantee Base funding Cumulative Percent of Living AIDS casesa Percent Funding if Difference in
AIDS cases cumulative AIDS of allocated using fundingb
cases living living AIDS cases
AIDS
cases
Alabama $1,139,000 4,969 0.58% 2,568 0.70% $1,378,278 -$239,278
Albany, N.Y. 429,000 1,867 0.22 864 0.24 463,720 -34,720
Arizona 164,000 712 0.08 346 0.09 185,703 -21,703
Arkansas 752,000 3,274 0.38 1,799 0.49 965,546 -213,546
Atlanta, Ga. 4,262,000 18,554 2.16 8,557 2.33 4,592,649 -330,649
Augusta, Ga. 373,000 1,623 0.19 819 0.22 439,568 -66,568
Austin, Tex. 988,000 4,302 0.50 1,899 0.52 1,019,217 -31,217
Baltimore, 3,940,000 17,150 2.00 7,641 2.08 4,101,020 -161,020
Md.
Baton Rouge, 666,000 2,898 0.34 1,405 0.38 754,081 -88,081
La.
Birmingham, 520,000 2,265 0.26 1,127 0.31 604,875 -84,875
Ala.
Boston, Mass. 1,829,000 7,960 0.93 3,248 0.88 1,743,242 85,758
Bridgeport, 752,000 3,275 0.38 1,637 0.45 878,598 -126,598
Conn.
Buffalo, N.Y. 472,000 2,053 0.24 902 0.25 484,115 -12,115
California 3,042,000 13,240 1.54 5,870 1.60 3,150,502 -108,502
Cambridge, 659,000 2,868 0.33 1,271 0.35 682,162 -23,162
Mass.
Camden, N.J. 657,000 2,861 0.33 1,159 0.32 622,050 34,950
Charleston, 411,000 1,788 0.21 870 0.24 466,940 -55,940
S.C.
Charlotte, 571,000 2,486 0.29 1,269 0.35 681,088 -110,088
N.C.
Chicago, Ill. 5,622,000 24,471 2.85 10,362 2.82 5,561,415 60,585
Cincinnati, 550,000 2,394 0.28 1,051 0.29 564,085 -14,085
Ohio
Cleveland, 854,000 3,718 0.43 1,784 0.49 957,495 -103,495
Ohio
Colorado 366,000 1,595 0.19 792 0.22 425,076 -59,076
Columbia, 626,000 2,727 0.32 1,541 0.42 827,074 -201,074
S.C.
Columbus, 584,000 2,542 0.30 944 0.26 506,657 77,343
Ohio
Connecticut 251,000 1,092 0.13 524 0.14 281,237 -30,237
Dallas, Tex. 3,192,000 13,895 1.62 6,436 1.75 3,454,282 -262,282
Delaware 164,000 716 0.08 354 0.10 189,996 -25,996
Denver, Colo. 1,424,000 6,200 0.72 2,602 0.71 1,396,526 27,474
Detroit, 1,624,000 7,068 0.82 2,641 0.72 1,417,458 206,542
Mich.
District of 5,626,000 24,490 2.85 12,570 3.42 6,746,476 -1,120,476
Columbia
Florida 4,063,000 17,686 2.06 8,306 2.26 4,457,934 -394,934
Fort 3,337,000 14,527 1.69 6,541 1.78 3,510,636 -173,636
Lauderdale,
Fla.
Fort Worth, 835,000 3,635 0.42 1,670 0.45 896,310 -61,310
Tex.
Gaithersburg, 535,000 2,328 0.27 1,146 0.31 615,073 -80,073
Md.
Georgia 1,515,000 6,593 0.77 3,233 0.88 1,735,192 -220,192
Hartford, 1,023,000 4,455 0.52 2,222 0.60 1,192,575 -169,575
Conn.
Hawaii 181,000 786 0.09 412 0.11 221,126 -40,126
Honolulu, 452,000 1,966 0.23 791 0.22 424,540 27,460
Hawaii
Houston, Tex. 5,068,000 22,063 2.57 8,579 2.33 4,604,457 463,543
Illinois 864,000 3,761 0.44 1,855 0.50 995,602 -131,602
Indiana 836,000 3,638 0.42 1,673 0.46 897,920 -61,920
Indianapolis, 759,000 3,302 0.38 1,595 0.43 856,056 -97,056
Ind.
Iowa 347,000 1,509 0.18 679 0.18 364,428 -17,428
Islip, N.Y. 1,660,000 7,226 0.84 2,877 0.78 1,544,122 115,878
Jackson, 449,000 1,953 0.23 994 0.27 533,492 -84,492
Miss.
Jacksonville, 1,195,000 5,202 0.61 2,509 0.68 1,346,612 -151,612
Fla.
Kansas 363,000 1,582 0.18 646 0.18 346,716 16,284
Kansas City, 978,000 4,256 0.50 1,933 0.53 1,037,465 -59,465
Mo.
Kentucky 423,000 1,841 0.21 1,011 0.28 542,616 -119,616
Las Vegas, 916,000 3,986 0.46 2,014 0.55 1,080,939 -164,939
Nev.
Los Angeles, 10,476,000 45,601 5.31 16,834 4.58 9,035,018 1,440,982
Calif.
Louisiana 940,000 4,091 0.48 1,926 0.52 1,033,708 -93,708
Louisville, 462,000 2,011 0.23 1,044 0.28 560,328 -98,328
Ky.
Maryland 345,000 1,501 0.17 762 0.21 408,975 -63,975
Massachusetts 525,000 2,287 0.27 1,007 0.27 540,469 -15,469
Memphis, 920,000 4,006 0.47 2,133 0.58 1,144,808 -224,808
Tenn.
Miami, Fla. 6,149,000 26,766 3.12 11,477 3.12 6,159,849 -10,849
Michigan 911,000 3,966 0.46 1,669 0.45 895,773 15,227
Milwaukee, 512,000 2,228 0.26 1,001 0.27 537,249 -25,249
Wis.
Minneapolis, 839,000 3,654 0.43 1,650 0.45 885,576 -46,576
Minn.
Minnesota 110,000 480 0.06 208 0.06 111,636 -1,636
Mississippi 756,000 3,291 0.38 1,563 0.43 838,882 -82,882
Missouri 496,000 2,157 0.25 1,053 0.29 565,158 -69,158
Nashville, 737,000 3,208 0.37 1,902 0.52 1,020,827 -283,827
Tenn.
Nevada 238,000 1,034 0.12 477 0.13 256,012 -18,012
New Haven, 937,000 4,077 0.47 2,036 0.55 1,092,747 -155,747
Conn.
New Jersey 1,106,000 4,778 0.56 1,864 0.51 1,000,432 105,568
New Mexico 533,000 2,319 0.27 1,064 0.29 571,062 -38,062
New Orleans, 1,785,000 7,769 0.90 3,374 0.92 1,810,868 -25,868
La.
New York 1,776,000 7,730 0.90 3,553 0.97 1,906,940 -130,940
New York, 33,487,000 145,769 16.97 54,900 14.94 29,465,516 4,021,484
N.Y.
Newark, N.J. 4,297,000 18,704 2.18 6,262 1.70 3,360,894 936,106
North 2,082,000 9,065 1.06 4,761 1.30 2,555,288 -473,288
Carolina
Oakland, 2,006,000 8,731 1.02 3,374 0.92 1,810,868 195,132
Calif.
Ohio 1,041,000 4,533 0.53 1,985 0.54 1,065,374 -24,374
Oklahoma 518,000 2,254 0.26 995 0.27 534,029 -16,029
Oklahoma 466,000 2,027 0.24 916 0.25 491,629 -25,629
City, Okla.
Orlando, Fla. 1,660,000 7,228 0.84 3,494 0.95 1,875,273 -215,273
Pennsylvania 1,540,000 6,702 0.78 3,463 0.94 1,858,635 -318,635
Philadelphia, 4,340,000 18,890 2.20 9,546 2.60 5,123,457 -783,457
Pa.
Phoenix, 1,434,000 6,244 0.73 2,924 0.80 1,569,347 -135,347
Ariz.
Pittsburgh, 626,000 2,723 0.32 1,103 0.30 591,994 34,006
Pa.
Portland, 1,006,000 4,378 0.51 1,925 0.52 1,033,172 -27,172
Oreg.
Poughkeepsie, 604,000 2,630 0.31 1,087 0.30 583,406 20,594
N.Y.
Providence, 807,000 3,514 0.41 1,622 0.44 870,548 -63,548
R.I.
Puerto Rico 1,748,000 7,608 0.89 2,995 0.81 1,607,454 140,546
Richmond, Va. 692,000 3,012 0.35 1,312 0.36 704,167 -12,167
Riverside, 1,772,000 7,714 0.90 3,834 1.04 2,057,756 -285,756
Calif.
Rochester, 597,000 2,599 0.30 1,297 0.35 696,116 -99,116
N.Y.
Sacramento, 844,000 3,676 0.43 1,470 0.40 788,967 55,033
Calif.
St. Louis, 1,217,000 5,297 0.62 2,481 0.67 1,331,584 -114,584
Mo.
Salt Lake 386,000 1,680 0.20 849 0.23 455,669 -69,669
City, Utah
San Antonio, 1,027,000 4,469 0.52Change in 2,138Change in 0.58 1,147,491Grantee -120,491Dollar
Tex. Appendix Title II base Title I base Grantee changebDollar
XII: funding if funding if HIV case changeb
Estimated CDC-accepted HIV counts from all
CARE Act case counts and grantees and ELCs
Title II Base ELCs were used to were used to
Funding distribute distribute funding
Changes from funding without without
Use of HIV hold-harmless and hold-harmless and
Case Counts minimum-grant minimum-grant
and ELCs provisions Change provisionsaChange
without in Title II base in Title I base
Hold-harmless funding if funding if HIV case
CDC-accepted HIV counts from all
case counts and grantees and ELCs
ELCs were used to were used to
distribute distribute funding
funding without without
hold-harmless and hold-harmless and
minimum-grant minimum-grant
provisions provisionsa
San Diego, 2,683,000 11,677 1.36Alabama 5,136$2,550,000 1.4063% 2,756,555$2,010,000 -73,55550%
Calif. Dollar Percent
changebDollar changePercent
changeb change
San 6,698,000 29,156-54 3.40-290,000 7,577-58 2.06 4,066,671Arizona 2,631,3291,220,000
Francisco, -270,000
Calif.
Alaskac
San Jose, 792,000 25 3,446 0.40Arkansas 1,472870,000 0.4049 790,041650,000 1,95937
Calif.
810,000
San Juan, 4,585,000 19,960-38 2.32-4,980,000 7,141-16 1.94 3,832,664Colorado 752,3362,100,000
P.R. -11,750,000
California
Santa Ana, 1,436,000 81 6,250 0.73Connecticut 2,939-1,360,000 0.80-36 1,577,398-1,410,000 -141,398-37
Calif.
1,700,000
Sarasota, 397,000 1,730-40 0.20-220,000 792-12 0.22 425,076District of -28,076-1,520,000
Fla. Delaware -740,000 Columbia
Seattle, 1,688,000 -42 7,347 0.86Florida 3,2212,970,000 0.8810 1,728,751-110,000 -40,7510d
Wash.
-1,800,000
South 1,387,000 6,039-38 0.70-4,060,000 3,108-43 0.85 1,668,102Hawaii -281,102-480,000
Carolina -3,530,000
Georgia
Springfield, 461,000 -14 2,005 0.23Idahoc 861-80,000 0.23-16 462,109-110,000 -1,109-23
Mass.
-170,000
Tampa, Fla. 2,221,000 9,670-36 1.13-60,000 4,201-1 1.14 2,254,729Indiana -33,7291,210,000
Illinois -3,200,000
Tennessee 739,000 21 3,218 0.37Iowa 1,68930,000 0.463 906,507-40,000 -167,507-5
810,000
Texas Kansas 2,736,000 11,91121 1.39110,000 6,02411 1.64 3,233,156Kentucky -497,156-940,000
210,000
Tucson, Ariz. 402,000 -45 1,749 0.20Louisiana 7802,110,000 0.2134 418,6361,380,000 -16,63622
-1,060,000
Utah Mainec 120,000 524-42 0.0650,000 25710 0.07 137,935Maryland -17,935-3,020,000
-210,000
Virginia 640,000 35 2,788 0.32Massachusetts 1,282-1,910,000 0.35-37 688,065530,000 -48,06510
2,980,000
Virginia 1,022,000 4,45027 0.52680,000 2,02416 0.55 1,086,306Minnesota -64,306650,000
Beach, Va. 1,180,000
Michigan
Wake County, 345,000 48 1,502 0.17Mississippi 8631,630,000 0.2349 463,1831,220,000 -118,18337
N.C. 490,000
Warren, Mich. 405,000 1,76345 0.21880,000 70932 0.19 380,529Montanac 24,471-390,000
Missouri 1,260,000
Washington 652,000 -33 2,839 0.33Nebraska 1,357150,000 0.3724 728,31990,000 -76,31914
-170,000
West Palm 2,019,000 8,78950 1.02600,000 4,11236 1.12 2,206,962New -187,962-310,000
Beach, Fla. 840,000 Hampshirec
Nevada
Wilmington, 566,000 -24 2,459 0.29New Jersey 1,2782,140,000 0.3517 685,919760,000 -119,9196
Del. -120,000
Wisconsin New 405,000 1,7615 0.21-50,000 795-4 0.22 426,686New York -21,686-600,000
Mexico 60,000
Woodbridge, 1,462,000 -11 6,363 0.74North 2,3325,030,000 0.6368 1,251,6144,020,000 210,38654
N.J. Carolina
-4,640,000
Worcester, 369,000 1,607-62 0.19-130,000 768-65 0.21 412,195Ohio -43,1952,420,000
Mass. North -120,000
Dakotae
Total $197,288,000 858,752 367,5861,010,000 $197,288,000760,000 Oklahoma 49 37
1,750,00 32
Sources: GAO analysis of CDC and HUD data. Oregon
Notes: By law HOPWA base grants are distributed according to cumulative
AIDS case counts. -620,000
aThe number of living AIDS cases was calculated by subtracting the number
of reported deaths among AIDS cases in a jurisdiction from the number of
reported cases. -37
bThis was calculated by subtracting the amount that would have been
received if living AIDS cases had been used from the amount that was
received using cumulative AIDS cases. A positive value indicates that the
jurisdiction received more funding using cumulative AIDS cases than it
would have received if living AIDS cases had been used. A negative value
indicates that the jurisdiction would have received more funding if living
AIDS cases had been used. -280,000
Percent changePercent change
38
99
-35
-40
32
-40
-36
64
-79
-63
-1
45
-17
Appendix VI: Total CARE Act Title I and Title II Funding by State and
Territory, Fiscal Year 2004
Pennsylvania
-2,320,000 -22 -3,080,000 -29
-2,950,000 -36 -3,450,000 -42
-440,000 -40 -170,000 -15
2,370,000 35 1,620,000 24
-290,000 -58 -310,000 -62
2,250,000 36 1,550,000 25
870,000 5 -990,000 -5
110,000 10 10,000 1
-370,000 -74 -260,000 -52
2,370,000 40 1,620,000 27
-1,170,000 -37 170,000 5
150,000 21 80,000 11
940,000 51 710,000 39
-90,000 -46 -100,000 -51
Notes: HRSA aIn some bRounded to cState received dPercent
calculates a jurisdictions, nearest a Title II base change
jurisdiction's HIV cases are $10,000. award of that
ELCs by using collected by $500,000, the rounds to
data from CDC on name while in minimum it could zero, but
the reported others HIV cases receive based on does not
AIDS case counts are collected the number of equal
for the last 10 using a coded ELCs in the zero
years and identifier. We state. The percent.
weighting those used both name- estimated
numbers to and code-based changes compare
account for the case counts for this amount with
likelihood of this estimate. what the state
death. CDC only accepts would have
name-based case received if HIV
counts as no case counts and
code-based ELCs had been
system has yet used to
met its quality determine
criteria. funding and if
there had been
no hold-harmless
and
minimum-grant
provisions.
Appendix XIII: Change in ADAP
Estimated CARE base funding if
Act ADAP Base CDC-accepted HIV
Funding Changes case counts and
from Use of HIV ELCs were used
Case Counts and to distribute
ELCs without funding without
Hold-harmless hold-harmless
Appendix XIII: provision Change
Estimated CARE in ADAP base
Act ADAP Base funding if
Funding Changes CDC-accepted HIV
from Use of HIV case counts and
Case Counts and ELCs were used
ELCs without to distribute
Hold-harmless funding without
hold-harmless
provision
Grantee Grantee Dollar Percent Dollar
changebDollar changePercent changebDollar
changeb change changeb
Alabama $5,190,000 74% $3,970,000
Alaska -50,000 -10 -90,000
Arizona 3,550,000 42 2,370,000
Arkansas 1,820,000 59 1,330,000
California -32,150,000 -36 -12,590,000
Colorado 5,970,000 106 4,820,000
Connecticut -4,060,000 -36 -4,240,000
Delaware -1,150,000 -36 -250,000
District of -4,970,000 -36 -5,850,000
Columbia
Florida 10,400,000 13 1,390,000
Georgia -8,500,000 -36 -10,010,000
Hawaii -750,000 -36 -210,000
Idaho 310,000 68 240,000
Illinois -9,240,000 -36 -250,000
Indiana 2,690,000 41 1,770,000
Iowa 140,000 10 -10,000
Kansas 650,000 32 390,000
Kentucky -1,470,000 -36 -1,730,000
Louisiana 5,440,000 39 3,530,000
Maine -300,000 -36 160,000
Maryland -9,240,000 -36 7,700,000
Massachusetts -5,270,000 -36 1,530,000
Michigan 3,150,000 29 1,740,000
Minnesota 1,910,000 63 1,420,000
Mississippi 3,410,000 60 2,490,000
Missouri 3,600,000 49 2,510,000
Montana -110,000 -36 300,000
Nebraska 360,000 32 210,000
Nevada 2,400,000 51 1,700,000
New Hampshire -270,000 -36 210,000
New Jersey 6,500,000 19 2,390,000
New Mexico 250,000 12 20,000
New York -1,110,000 -1 -13,400,000
North Carolina 10,190,000 79 7,900,000
North Dakota 50,000 57 40,000
Ohio 5,520,000 51 3,890,000
Puerto Rico
Rhode Island
South Carolina
South Dakotac
Tennessee
Texas
Utah
Vermontc
Virginia
Washington
West Virginia
Wisconsin
Wyominge
Sources: GAO analysis of CDC, HRSA, state, and local data.
eState received a Title II base award of $200,000, the minimum it could
receive based on the number of ELCs in the state. The estimated changes
compare this amount with what the state would have received if HIV case
counts and ELCs had been used to determine funding and if there had been
no hold-harmless and minimum-grant provisions.
Change in ADAP base funding if HIV case counts from all grantees and ELCs
were used to distribute funding without hold-harmless provisionaChange in
ADAP base funding if HIV case counts from all grantees and ELCs were used
to distribute funding without hold-harmless provisiona
Percent changePercent change
57%
-19
28
43
-14
86
-38
-8
-42
2
-42
-10
51
-1
27
-1
19
-42
26
19
30
10
16
47
43
34
95
19
36
28
7
1
-11
62
41
36
Oklahoma
2,100,000
59
1,540,000
43
Table 13: EMAs with No Service Area Changes
HRSA 2004 EMA GAO-identified comparable OMB Changes
newly defined 2004 MSA(s) or
MDIV(s)a
OMB's 1993 full title of metropolitan area Number ELCs OMB's 2004 full title of Number ELCs Decrease Increase Change in
of in metropolitan area(s) of in in in ELCs
counties EMAs counties EMAs counties counties (percent)
in EMA in EMA
Austin-San Marcos, Tex. MSA 5 1,651 Austin-Round Rock, Tex. MSA 5 1,651 0 0 0%
Baltimore, Md. PMSA 7 8,348 Baltimore-Towson, Md. MSA 7 8,348 0 0 0
Fort Lauderdale, Fla. PMSA 1 6,002 Fort Lauderdale-Pompano 1 6,002 0 0 0
Beach-Deerfield Beach, Fla.
MDIV
Hartford, Conn. NECMA 3 1,954 Hartford-West Hartford-East 3 1,954 0 0 0
Hartford, Conn. MSA
Los Angeles-Long Beach, Calif. PMSA 1 15,180 Los Angeles-Long 1 15,180 0 0 0
Beach-Glendale, Calif. MDIV
Miami, Fla. PMSA 1 10,485 Miami-Miami Beach-Kendall, 1 10,485 0 0 0
Fla. MDIV
Minneapolis-St. Paul, Minn.-Wis. MSA 13 1,272 Minneapolis-St. 13 1,272 0 0 0
Paul-Bloomington, Minn.-Wis.
MSA
Nassau-Suffolk, N.Y. PMSA 2 2,588 Nassau-Suffolk, N.Y. MDIV 2 2,588 0 0 0
New 2 2,945 Bridgeport-Stamford-Norwalk, 2 2,945 0 0 0
Haven-Bridgeport-Stamford-Waterbury-Danbury, Conn. MSA and New
Conn. NECMA Haven-Milford, Conn. MSA
Oakland, Calif. PMSA 2 2,852 Oakland-Fremont-Hayward, 2 2,852 0 0 0
Calif. MDIV
Orange County, Calif. PMSA 1 2,183 Santa Ana-Anaheim-Irvine, 1 2,183 0 0 0
Calif. MDIV
Orlando, Fla. MSA 4 3,293 Orlando-Kissimmee, Fla. MSA 4 3,293 0 0 0
Phoenix-Mesa, Ariz. MSA 2 2,850 Phoenix-Mesa-Scottsdale, 2 2,850 0 0 0
Ariz. MSA
Riverside-San Bernardino, Calif. PMSA 2 3,204 Riverside-San 2 3,204 0 0 0
Bernardino-Ontario, Calif.
MSA
San Diego, Calif. MSA 1 4,259 San Diego-Carlsbad San 1 4,259 0 0 0
Marcos, CA MSA
San Francisco, Calif. PMSA 3 7,216 San Francisco-San 3 7,216 0 0 0
Mateo-Redwood City, Calif.
MDIV
Santa Rosa, Calif. PMSA 1 482 Santa Rosa-Petaluma, Calif. 1 482 0 0 0
MSA
Tampa-St. Petersburg-Clearwater, Fla. MSA 4 3,875 Tampa-St. 4 3,875 0 0 0
Petersburg-Clearwater, Fla.
MSA
Vineland-Millville-Bridgeton, N.J. PMSA 1 388 Vineland-Millville-Bridgeton, 1 388 0 0 0
N.J. MSA
West Palm Beach-Boca Raton, Fla. MSA 1 3,741 West Palm Beach-Boca 1 3,741 0 0 0
Raton-Boynton Beach, Fla.
MDIV
Total 57 84,768 Not applicable 57 84,768 0 0 0
HIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
FundingHIV/AIDS FundingHIV/AIDS Funding
Sources: GAO analysis of CDC, HRSA, and OMB data.
Notes: This table uses OMB's terminology for classifying types of
metropolitan areas. Specifically, it includes metropolitan statistical
area (MSA), primary metropolitan statistical area (PMSA), New England
county metropolitan area (NECMA), and metropolitan division (MDIV). The
terms used and meaning of those terms differs between1993 and 2004 because
of OMB's fundamental revisions of metropolitan concepts. For further
explanation, see GAO-04-758 .
aWe chose whatever combination of the newly defined metropolitan areas
that would result in the least change to the numbers of ELCs within the
EMA's boundaries.
Oregon
-1,520,000
-36 -600,000 -14
Pennsylvania -6,540,000 -24 -8,540,000 -32 Puerto Rico -7,890,000 -35
-41 Rhode -690,000 -36 -210,000 -11 South Carolina
Island
44 3,510,000 30 South Dakota 180,000 90 150,000 71
Tennessee 4,880,000 46 3,330,000 31 Texas 3,440,000 7
-4 Utah 330,000 18 110,000 6 Vermont
-36 50,000 14 Virginia 6,260,000 43 4,200,000 29
Washington -2,860,000 -36 720,000 9 West Virginia 380,000 29
16 Wisconsin 1,950,000 61 1,440,000 45 Wyoming
24 20,000 12 Sources: GAO Notes: The HRSA aIn some bRounded
analysis of ADAP base calculates a jurisdictions, to
CDC, HRSA, grant funding jurisdiction's HIV cases are nearest
state, and levels ELCs by using collected by $10,000.
local data. reported to data from CDC name while in
us included on the others HIV
any reported AIDS cases are
hold-harmless case counts collected
funding that for the last using a coded
would 10 years and identifier. We
otherwise be weighting used both
used for ADAP those numbers name- and
Severe Need to account for code-based
grants. The the likelihood case counts
estimated of death. for this
dollar and estimate. CDC
percent only accepts
changes name-based
presented case counts as
here are no code-based
based on what system has yet
grantees met its
received in quality
their ADAP criteria.
base grants
without this
hold-harmless
funding.
Appendix Change in Change in Grantee Dollar changeb Percent
XIV: HOPWA base HOPWA base change
Estimated funding if funding if HIV
HOPWA Base CDC-accepted case counts
Funding HIV case from all
Changes from counts and grantees and
Use of HIV living AIDS living AIDS
and Living case counts case counts
AIDS Case were used to were used to
Counts, distribute distribute
Fiscal Year funding fundinga
2004
Appendix
XIV:
Estimated
HOPWA Base
Funding
Changes from
Use of HIV
and Living
AIDS Case
Counts,
Fiscal Year
2004
Percent Alabama $1,150,000 101% $960,000 84% Albany, N.Y.
change
18 30,000 8 Arizona 60,000 39 40,000 27
Arkansas 630,000 84 520,000 69 Atlanta, Ga. -1,160,000 -27
-33 Augusta, 10,000 3 -20,000 -6 Austin, Tex.
Ga.
7 -20,000 -2 Baltimore, -1,170,000 -30 1,770,000 45
Md.
Baton Rouge, 470,000 71 370,000 56 Birmingham, 550,000 106
La. Ala.
89 Boston, -650,000 -36 110,000 6 Bridgeport, Conn.
Mass.
-21 -180,000 -24 Buffalo, N.Y. 30,000 6 -10,000 -3
California -1,150,000 -38 -600,000 -20 Cambridge, -200,000 -30
Mass.
16 Camden, 180,000 27 110,000 16 Charleston, S.C.
N.J.
72 230,000 57 Charlotte, 900,000 158 780,000 137
N.C.
Chicago, -1,860,000 -33 -10,000 0c Cincinnati, 200,000 36
Ill. Ohio
24 Cleveland, 410,000 48 300,000 35 Colorado
Ohio
97 290,000 80 Columbia, 600,000 96 490,000 80
S.C.
Columbus, 360,000 61 280,000 48 Connecticut -60,000 -24
Ohio
-28 Dallas, 590,000 19 270,000 9 Delaware
Tex.
-22 30,000 18 Denver, Colo. 1,210,000 85 990,000 69
Detroit, 270,000 17 110,000 7 District of -230,000 -4
Mich. Columbia
0c Florida -660,000 -16 -950,000 -23 Fort
Lauderdale,
Fla.
24 460,000 14 Fort Worth, 110,000 13 30,000 3
Tex.
-9,350,000
5,190,000
-1,920,000
-140,000
210,000
40,000
Dollar changeb
80,000
-1,420,000
70,000
460,000
-160,000
110,000
290,000
130,000
350,000
-70,000
-40,000
20,000
820,000
Appendix VIII: Estimated CARE Act Title I Funding Changes from Use of HIV
Case Counts and ELCs with Hold-harmless Appendix VIII: Estimated CARE Act
Title I Funding Changes from Use of HIV Case Counts and ELCs with
Hold-harmless
Change in Title I Change in Title I
base funding if base funding if
CDC-accepted HIV HIV case counts
case counts and from all grantees
ELCs were used to and ELCs were
distribute funding used to
with hold-harmless distribute
provision funding with
hold-harmless
provisiona
Eligible metropolitan area Dollar Percent Dollar changeb Percent
changeb change change
Atlanta, Ga. -$210,000 -2% -$210,000 -2%
Austin, Tex. 260,000 13 -10,000 0c
Baltimore, Md. -240,000 -2 3,210,000 32
Bergen-Passaic, N.J. 600,000 23 210,000 8
Boston, Mass. 0 0 1,180,000 16
Caguas, P.R. -50,000 -5 -50,000 -5
Chicago, Ill. -950,000 -7 510,000 4
Cleveland, Ohio 940,000 51 610,000 33
Dallas, Tex. 1,630,000 25 660,000 10
Denver, Colo. 3,210,000 132 2,530,000 104
Detroit, Mich. 1,520,000 35 810,000 19
District of Columbia -750,000 -5 -750,000 -5
Dutchess County, N.Y. 40,000 7 -30,000 -5
Fort Lauderdale, Fla. 2,060,000 28 940,000 13
Fort Worth, Tex. 350,000 19 90,000 5
Hartford, Conn. -80,000 -3 -80,000 -3
Houston, Tex. 1,130,000 12 -20,000 0c
Jacksonville, Fla. 570,000 23 200,000 8
Jersey City, N.J. 590,000 20 160,000 5
Kansas City, Mo. 870,000 51 560,000 32
Las Vegas, Nev. 1,460,000 61 1,000,000 42
Los Angeles, Calif. -10,000 0c -10,000 0c
Miami, Fla. 3,580,000 28 1,620,000 13
Middlesex-Somerset-Hunterdon, 400,000 26 170,000 11
N.J.
Minneapolis-St. Paul, Minn. 1,130,000 71 810,000 51
Nassau-Suffolk, N.Y. 40,000 1 40,000 1
New Haven, Conn. 0 0 0 0
New Orleans, La. 1,950,000 51 1,250,000 33
New York, N.Y. 5,660,000 9 -310,000 -1
Newark, N.J. 2,360,000 29 1,100,000 14
Norfolk, Va. 1,560,000 57 1,040,000 38
Oakland, Calif. 0 0 0 0
Orange County, Calif. -30,000 -1 -30,000 -1
Orlando, Fla. 1,190,000 30 570,000 14
Philadelphia, Pa. -230,000 -2 -230,000 -2
Phoenix, Ariz. 2,020,000 58 1,360,000 39
Ponce, P.R. -30,000 -2 -30,000 -2
Portland, Oreg. -20,000 -1 -20,000 -1
Riverside-San Bernardino, -90,000 -2 -90,000 -2
Calif.
Sacramento, Calif. 0 0 0 0
St. Louis, Mo. 1,120,000 47 830,000 34
San Antonio, Tex. 180,000 8 -20,000 -1
San Diego, Calif. -120,000 -2 800,000 15
San Francisco, Calif. 0 0 0 0
San Jose, Calif. 0 0 0 0
San Juan, P.R. 0 0 0 0
Santa Rosa, Calif. 0 0 0 0
Seattle, Wash. 0 0 640,000 21
Tampa-St. Petersburg, Fla. 1,000,000 21 310,000 7
Vineland-Millville-Bridgeton, 130,000 28 60,000 12
N.J.
West Palm Beach, Fla. 530,000 12 0 0
Sources: GAO analysis of CDC, HRSA, state, and local data.
Notes: The estimated dollar and percent changes are based on what the EMAs
received in their base grants, including any hold-harmless funding, and
what they would have received if HIV cases and ELCs had been used to
allocate funding. In fiscal year 2004, the amount of hold-harmless funding
was $8,033,563. Because the amounts needed to fund the Title I
hold-harmless provision are taken from funds that would otherwise be
available for supplemental grants, the total funding actually allocated as
base grants and our estimated base grant funding differ by the amounts
necessary to fund the hold-harmless provision. The hold-harmless funding
was $43,300,968 when only CDC-accepted HIV case counts and ELCs were used
and $29,413,708 when the HIV case counts from all grantees were used.
HRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
aIn some jurisdictions, HIV cases are collected by name while in others
HIV cases are collected using a coded identifier. We used both name- and
code-based case counts for this estimate. CDC only accepts name-based case
counts as no code-based system has yet met its quality criteria.
bRounded to nearest $10,000.
cPercent change that rounds to zero, but does not equal zero percent.
Appendix IX: Estimated CARE Act Title II Base Funding Changes from Use of
HIV Case Counts and ELCs with Hold-harmless Appendix IX: Estimated CARE
Act Title II Base Funding Changes from Use of HIV Case Counts and ELCs
with Hold-harmless
Change in Title II base Change in Title II base
funding if CDC-accepted HIV funding if HIV case
case counts and ELCs were counts from all
used to distribute funding grantees and ELCs were
with hold-harmless and used to distribute
minimum-grant provisions funding with
hold-harmless and
minimum-grant
provisionsa
Grantee Dollar changeb Percent Dollar changeb Percent
change change
Alabama $1,170,000 29% $1,000,000 25%
Alaskac 0 0 0 0
Arizona 620,000 19 410,000 13
Arkansas 320,000 18 250,000 14
California 0 0 0 0
Colorado 1,540,000 73 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 -1,330,000 -4 -2,910,000 -10
Georgia -1,350,000 -14 -1,350,000 -14
Hawaii -70,000 -6 -70,000 -6
Idahoc 0 0 0 0
Illinois -1,780,000 -20 -780,000 -9
Indiana 180,000 5 50,000 1
Iowa -90,000 -11 -90,000 -11
Kansas 0 0 0 0
Kentucky -400,000 -17 -400,000 -17
Louisiana 700,000 11 390,000 6
Mainec 0 0 0 0
Maryland -1,650,000 -20 2,060,000 24
Massachusetts -620,000 -12 20,000 0d
Michigan 370,000 9 130,000 3
Minnesota 460,000 45 370,000 36
Mississippi 590,000 18 460,000 14
Missouri 720,000 26 520,000 19
Montanac 0 0 0 0
Nebraska -10,000 -2 -30,000 -5
Nevada 520,000 31 400,000 24
New Hampshirec 0 0 0 0
New Jersey 370,000 3 0 0
New Mexico -70,000 -6 -70,000 -6
New York -1,730,000 -4 -1,730,000 -4
North Carolina 2,440,000 33 2,120,000 29
North Dakotae 300,000 150 300,000 150
Ohio 940,000 17 690,000 13
Oklahoma 370,000 18 290,000 14
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 470,000 7 230,000 3
South Dakotac 0 0 0 0
Tennessee 490,000 8 270,000 4
Texas -1,140,000 -6 -1,140,000 -6
Utah -60,000 -6 -60,000 -6
Vermontc 0 0 0 0
Virginia 1,100,000 19 750,000 13
Washington -200,000 -7 -170,000 -5
West Virginia -20,000 -3 -50,000 -7
Wisconsin 360,000 20 290,000 16
Wyominge 300,000 150 300,000 150
Sources: GAO analysis of CDC, HRSA, state, and local data.
Notes: HRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
For purposes of this analysis, we considered the Title II hold-harmless
provision that is funded by proportional reductions in Title II base
grants. We did not include the Title II hold-harmless provision funded by
amounts otherwise available for Severe Need grants.
aIn some jurisdictions, HIV cases are collected by name while in others
HIV cases are collected using a coded identifier. We used both name- and
code-based case counts for this estimate. CDC only accepts name-based case
counts as no code-based system has yet met its quality criteria.
bRounded to nearest $10,000.
cState received a Title II base award of $500,000, the minimum it could
receive based on the number of AIDS cases in the state.
dPercent change that rounds to zero, but does not equal zero percent.
eState received a Title II base award of $200,000, the minimum it could
receive based on the number of AIDS cases in the state.
Appendix X: Estimated CARE Act ADAP Base Funding Changes from Use of HIV
Case Counts and ELCs with Hold-harmless Appendix X: Estimated CARE Act
ADAP Base Funding Changes from Use of HIV Case Counts and ELCs with
Hold-harmless
Change in ADAP base Change in ADAP base
funding if CDC-accepted funding if HIV case
HIV case counts and ELCs counts from all
were used to distribute grantees and ELCs were
funding with hold-harmless used to distribute
provision funding with
hold-harmless
provisiona
Grantee Dollar changeb Percent Dollar changeb Percent
change change
Alabama $4,810,000 69% $3,860,000 55%
Alaska -60,000 -13 -90,000 -20
Arizona 3,180,000 38 2,260,000 27
Arkansas 1,670,000 54 1,290,000 42
California -18,530,000 -21 -13,400,000 -15
Colorado 5,610,000 100 4,710,000 84
Connecticut -2,970,000 -26 -2,970,000 -26
Delaware -1,210,000 -38 -280,000 -9
District of -5,240,000 -38 -5,490,000 -40
Columbia
Florida 7,570,000 9 530,000 1
Georgia -8,120,000 -34 -8,120,000 -34
Hawaii -610,000 -30 -230,000 -11
Idaho 290,000 62 230,000 49
Illinois -9,750,000 -38 -520,000 -2
Indiana 2,400,000 37 1,690,000 26
Iowa 90,000 7 -20,000 -2
Kansas 570,000 28 360,000 18
Kentucky -1,550,000 -38 -1,550,000 -38
Louisiana 4,840,000 35 3,350,000 24
Maine -260,000 -32 150,000 18
Maryland -9,750,000 -38 7,340,000 29
Massachusetts -4,760,000 -32 1,360,000 9
Michigan 2,710,000 25 1,610,000 15
Minnesota 1,750,000 58 1,370,000 46
Mississippi 3,120,000 54 2,410,000 42
Missouri 3,260,000 44 2,400,000 32
Montana -80,000 -25 290,000 93
Nebraska 310,000 28 200,000 18
Nevada 2,180,000 46 1,630,000 34
New Hampshire -170,000 -22 200,000 26
New Jersey 5,210,000 15 2,000,000 6
New Mexico 170,000 8 -10,000 0c
New York -4,960,000 -4 -14,570,000 -12
North Carolina 9,470,000 74 7,680,000 60
North Dakota 50,000 52 40,000 40
Ohio 5,010,000 46 3,730,000 34
Oklahoma 1,930,000 54 1,490,000 42
Oregon -1,230,000 -29 -640,000 -15
Pennsylvania -7,180,000 -27 -8,780,000 -32
Puerto Rico -5,900,000 -26 -5,900,000 -26
Rhode Island -520,000 -27 -230,000 -12
South Carolina 4,660,000 40 3,350,000 29
South Dakota 170,000 84 140,000 69
Tennessee 4,400,000 41 3,180,000 30
Texas 1,760,000 4 -2,430,000 -5
Utah 260,000 14 90,000 5
Vermont -130,000 -35 50,000 12
Virginia 5,610,000 39 4,000,000 28
Washington -2,220,000 -28 630,000 8
West Virginia 330,000 25 200,000 15
Wisconsin 1,790,000 56 1,400,000 44
Wyoming 30,000 20 20,000 11
Sources: GAO analysis of CDC, HRSA, state, and local data.
Notes: The ADAP base grant funding levels reported to us included any
hold-harmless funding that would otherwise be used for ADAP Severe Need
grants. The estimated dollar and percent changes presented here are based
on what grantees received in their ADAP base grants without this
hold-harmless funding.
HRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
For purposes of this analysis, we considered the Title II hold-harmless
provision that is funded by proportional reductions in ADAP base grants.
We did not include the Title II hold-harmless provision funded by amounts
otherwise available for Severe Need grants.
aIn some jurisdictions, HIV cases are collected by name while in others
HIV cases are collected using a coded identifier. We used both name- and
code-based case counts for this estimate. CDC only accepts name-based case
counts as no code-based system has yet met its quality criteria.
bRounded to nearest $10,000.
cPercent change that rounds to zero, but does not equal zero percent.
Appendix XI: Estimated CARE Act Title I Base Funding Changes from Use of
HIV Case Counts and ELCs without Hold-harmless Appendix XI: Estimated CARE
Act Title I Base Funding Changes from Use of HIV Case Counts and ELCs
without Hold-harmless
Change in Title I Change in
base funding if Title I base
CDC-accepted HIV case funding if HIV
counts and ELCs were case counts
used to distribute from all
funding without grantees and
hold-harmless ELCs were used
provision to distribute
funding
without
hold-harmless
provisiona
Eligible metropolitan area Dollar Percent Dollar changeb Percent
changeb change change
Atlanta, Ga. -$2,830,000 -31% -$3,600,000 -39%
Austin, Tex. 260,000 13 -10,000 0c
Baltimore, Md. -3,110,000 -31 3,210,000 32
Bergen-Passaic, N.J. 600,000 23 210,000 8
Boston, Mass. -2,310,000 -31 1,180,000 16
Caguas, P.R. -260,000 -28 -340,000 -37
Chicago, Ill. -3,900,000 -31 510,000 4
Cleveland, Ohio 940,000 51 610,000 33
Dallas, Tex. 1,630,000 25 660,000 10
Denver, Colo. 3,210,000 132 2,530,000 104
Detroit, Mich. 1,520,000 35 810,000 19
District of Columbia -2,330,000 -16 -1,390,000 -10
Dutchess County, N.Y. 40,000 7 -40,000 -6
Fort Lauderdale, Fla. 2,060,000 28 940,000 13
Fort Worth, Tex. 350,000 19 90,000 5
Hartford, Conn. -730,000 -31 -800,000 -34
Houston, Tex. 1,130,000 12 -140,000 -1
Jacksonville, Fla. 570,000 23 200,000 8
Jersey City, N.J. 590,000 20 160,000 5
Kansas City, Mo. 870,000 51 560,000 32
Las Vegas, Nev. 1,460,000 61 1,000,000 42
Los Angeles, Calif. -5,660,000 -31 -2,660,000 -14
Miami, Fla. 3,580,000 28 1,620,000 13
Middlesex-Somerset-Hunterdon, 400,000 26 170,000 11
N.J.
Minneapolis-St. Paul, Minn. 1,130,000 71 810,000 51
Nassau-Suffolk, N.Y. -940,000 -29 -1,210,000 -38
New Haven, Conn. -1,140,000 -31 -1,270,000 -35
New Orleans, La. 1,950,000 51 1,250,000 33
New York, N.Y. 5,660,000 9 -2,240,000 -4
Newark, N.J. 2,360,000 29 1,100,000 14
Norfolk, Va. 1,560,000 57 1,040,000 38
Oakland, Calif. -1,100,000 -32 -680,000 -19
Orange County, Calif. -810,000 -31 -190,000 -7
Orlando, Fla. 1,190,000 30 570,000 14
Philadelphia, Pa. -2,620,000 -22 -3,750,000 -31
Phoenix, Ariz. 2,020,000 58 1,360,000 39
Ponce, P.R. -420,000 -29 -540,000 -38
Portland, Oreg. -580,000 -31 -90,000 -5
Riverside-San Bernardino, -1,190,000 -31 -170,000 -4
Calif.
Sacramento, Calif. -500,000 -32 -330,000 -21
St. Louis, Mo. 1,120,000 47 830,000 34
San Antonio, Tex. 180,000 8 -100,000 -5
San Diego, Calif. -1,590,000 -31 800,000 15
San Francisco, Calif. -10,050,000 -62 -8,470,000 -52
San Jose, Calif. -440,000 -31 -30,000 -2
San Juan, P.R. -2,430,000 -30 -3,120,000 -38
Santa Rosa, Calif. -200,000 -33 -30,000 -5
Seattle, Wash. -930,000 -31 640,000 21
Tampa-St. Petersburg, Fla. 1,000,000 21 310,000 7
Vineland-Millville-Bridgeton, 130,000 28 60,000 12
N.J.
West Palm Beach, Fla. 530,000 12 -80,000 -2
Sources: GAO analysis of CDC, HRSA, state, and local data.
Notes: The estimated dollar and percent changes are based on what the EMAs
actually received in their base grants, which includes hold-harmless
funding, and what they would have received using HIV cases and ELCs if
there had been no hold-harmless provision. Because hold-harmless funding
is taken from amounts otherwise available for supplemental grants, the
total funding actually allocated as base grants and our estimated funding
differ by the amount of the hold-harmless funding ($8,033,563).
HRSA calculates a jurisdiction's ELCs by using data from CDC on the
reported AIDS case counts for the last 10 years and weighting those
numbers to account for the likelihood of death.
aIn some jurisdictions, HIV cases are collected by name while in others
HIV cases are collected using a coded identifier. We used both name- and
code-based case counts for this estimate. CDC only accepts name-based case
counts as no code-based system has yet met its quality criteria.
bRounded to nearest $10,000.
cPercent change that rounds to zero, but does not equal zero percent.
Appendix XII: Estimated CARE Act Title II Base Funding Changes from Use of
HIV Case Counts and ELCs without Hold-harmless
Change in HOPWA base Change in
funding if CDC-accepted HOPWA base
HIV case counts and living funding if HIV
AIDS case counts were used case counts
to distribute funding from all
grantees and
living AIDS
case counts
were used to
distribute
fundinga
Grantee Dollar changeb Percent Dollar changeb Percent
change change
Gaithersburg, Md. -120,000 -22 190,000 35
Georgia -340,000 -23 -440,000 -29
Hartford, Conn. -220,000 -21 -230,000 -23
Hawaii -30,000 -17 10,000 5
Honolulu, Hawaii -160,000 -37 -70,000 -16
Houston, Tex. -260,000 -5 -660,000 -13
Illinois -190,000 -22 140,000 17
Indiana 470,000 56 360,000 43
Indianapolis, Ind. 420,000 56 320,000 42
Iowa 60,000 17 30,000 8
Islip, N.Y. -300,000 -18 -410,000 -25
Jackson, Miss. 450,000 99 370,000 82
Jacksonville, Fla. 290,000 24 160,000 14
Kansas 90,000 25 50,000 15
Kentucky -60,000 -13 -90,000 -21
Kansas City, Mo. 360,000 36 240,000 25
Las Vegas, Nev. 710,000 77 570,000 62
Los Angeles, Calif. -4,370,000 -42 -3,660,000 -35
Louisiana 580,000 62 460,000 49
Louisville, Ky. -40,000 -9 -80,000 -17
Maryland -70,000 -20 710,000 204
Massachusetts -160,000 -30 60,000 12
Memphis, Tenn. 940,000 102 780,000 85
Miami, Fla. 1,140,000 19 520,000 9
Michigan 370,000 41 270,000 29
Milwaukee, Wis. 340,000 66 260,000 52
Minneapolis, Minn. 350,000 42 250,000 30
Minnesota 60,000 56 50,000 43
Mississippi 630,000 84 520,000 68
Missouri 270,000 55 210,000 42
Nashville, Tenn. 680,000 93 560,000 77
Nevada 130,000 55 100,000 41
New Haven, Conn. -200,000 -21 -220,000 -24
HIV/AIDS FundingNew -770,000 -70 -800,000 -72
Jersey HIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS
FundingHIV/AIDS Funding
New Mexico 110,000 21 60,000 11
New Orleans, La. 760,000 43 550,000 31
New York 300,000 17 130,000 7
New York, N.Y. -3,040,000 -9 -5,610,000 -17
Newark, N.J. 40,000 1 -330,000 -8
North Carolina 2,130,000 103 1,780,000 85
Oakland, Calif. -780,000 -39 -670,000 -33
Ohio 500,000 49 370,000 36
Oklahoma 430,000 83 350,000 67
Oklahoma City, Okla. 180,000 39 130,000 27
Orlando, Fla. 610,000 37 420,000 25
Pennsylvania -50,000 -4 -180,000 -12
Philadelphia, Pa. -730,000 -17 -1,040,000 -24
Phoenix, Ariz. 920,000 65 730,000 51
Pittsburgh, Pa. -120,000 -19 -160,000 -26
Portland, Oreg. -300,000 -30 -110,000 -11
Poughkeepsie, N.Y. -30,000 -5 -80,000 -13
Providence, R.I. -220,000 -27 40,000 5
Puerto Rico -1,080,000 -62 -1,130,000 -65
Richmond, Va. 490,000 71 390,000 57
Riverside, Calif. -380,000 -22 -90,000 -5
Rochester, N.Y. 170,000 29 110,000 18
Sacramento, Calif. -310,000 -37 -280,000 -33
St. Louis, Mo. 450,000 37 370,000 30
Salt Lake City, Utah 120,000 32 80,000 21
San Antonio, Tex. 100,000 10 0 d 1
San Diego, Calif. -820,000 -31 20,000 1
San Francisco, Calif. -3,950,000 -59 -3,420,000 -51
San Jose, Calif. -260,000 -33 -100,000 -13
San Juan, P.R. -1,990,000 -44 -2,210,000 -48
Santa Ana, Calif. -370,000 -26 -130,000 -9
Sarasota, Fla. 40,000 11 10,000 1
Seattle, Wash. -520,000 -31 170,000 10
South Carolina 1,040,000 75 840,000 61
Springfield, Mass. -150,000 -32 90,000 20
Tampa, Fla. 330,000 15 110,000 5
Tennessee 490,000 67 390,000 53
Texas 780,000 29 480,000 18
Tucson, Ariz. 210,000 53 160,000 40
Utah 30,000 26 20,000 15
Virginia 320,000 50 240,000 37
Virginia Beach, Va. 720,000 71 580,000 56
Wake County, N.C. 360,000 105 300,000 88
Warren, Mich. 120,000 31 80,000 20
Washington -160,000 -25 70,000 10
West Palm Beach, Fla. 270,000 14 80,000 4
Wilmington, Del. -70,000 -13 110,000 19
Wisconsin 220,000 54 170,000 41
Woodbridge, N.J. 50,000 4 -80,000 -5
Worcester, Mass. -90,000 -25 80,000 22
Sources: GAO analysis of CDC, HUD, state, and local data.
Notes: The number of living AIDS cases was calculated by subtracting the
number of reported deaths among AIDS cases in a jurisdiction from the
number of reported cases.
aIn some jurisdictions, HIV cases are collected by name while in others
HIV cases are collected using a coded identifier. We used both name- and
code-based case counts for this estimate. CDC only accepts name-based case
counts as no code-based system has yet met its quality criteria.
bRounded to nearest $10,000.
cPercent change that rounds to zero, but does not equal zero.
dDollar change that rounds to zero, but does not equal zero.
Appendix XV: Comments from the Department of Health and Human Services
Appendix XV: Comments from the Department of Health and Human Services
Appendix XVI: Comments from the Department of Housing and Urban
Development Appendix XVI: Comments from the Department of Housing and
Urban Development
Appendix XVII: GAO Contact and Staff Acknowledgments
GAO Contact
Marcia Crosse, (202) 512-7119 or [email protected]
Acknowledgments
In addition to the contact above, James McClyde, Assistant Director;
Robert Copeland; Robert Dinkelmeyer; Louise Duhamel; Cathy Hamann; Opal
Winebrenner; Craig Winslow; and Suzanne Worth made key contributions to
this report.
Related GAO Products Related GAO Products
Ryan White CARE Act: Factors that Impact HIV and AIDS Funding and Client
Coverage. GAO-05-841T . Washington, D.C.: June 23, 2005.
Ryan White CARE Act: Title I Funding for 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 White CARE Act and Other Assistance Grant Funds.
GAO/HEHS-00-54 .Washington, D.C.: March 1, 2000.
HIV/AIDS Drugs: Funding Implications of New Combination Therapies for
Federal and State Programs. GAO/HEHS-99-2 .Washington, D.C.: October 14,
1998.
Revising Ryan White Funding Formulas. GAO/HEHS-96-116R . Washington, D.C.:
March 26, 1996.
Ryan White CARE Act of 1990: Opportunities to Enhance Funding Equity.
GAO/HEHS-96-26 . Washington, D.C.: November 13, 1995.
Ryan White CARE Act: Access to Services by Minorities, Women, and
Substance Abusers. GAO/T-HEHS-95-212 . Washington, D.C.: July 17, 1995.
Ryan White CARE Act of 1990: Opportunities Are Available to Improve
Funding Equity. GAO/T-HEHS-95-126 . Washington, D.C.: April 5, 1995.
Follow-up on Ryan White Testimony. GAO/HEHS-95-119R . Washington, D.C.:
March 31, 1995.
Ryan White CARE Act of 1990: Opportunities Are Available to Improve
Funding Equity. 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 to Services by Minorities, Women, and
Substance Abusers. GAO/HEHS-95-49 . Washington, D.C.: January 13, 1995.
(290345)
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Highlights of GAO-06-332 , a report to congressional requesters
February 2006
HIV/AIDS
Changes Needed to Improve the Distribution of Ryan White CARE Act and
Housing Funds
Among federal efforts to address the HIV/AIDS epidemic are the CARE Act of
1990 and the Housing Opportunities for Persons with AIDS program (HOPWA)
administered by the Departments of Health and Human Services (HHS) and
Housing and Urban Development (HUD), respectively. Both use formulas based
upon a grantee's number of AIDS cases, rather than HIV and AIDS cases, to
distribute funds to metropolitan areas, states, and territories. HIV cases
must be incorporated with AIDS cases in CARE Act formulas not later than
fiscal year 2007.
GAO was asked to examine (1) how CARE Act and HOPWA funds are allocated
among types of services, (2) the extent of funding distribution
differences among CARE Act and HOPWA grantees, and how funding formula
provisions contribute to these differences, and (3) what distribution
differences could result from incorporating HIV case counts in CARE Act
and HOPWA funding formulas.
What GAO Recommends
If Congress wishes CARE Act and HOPWA funding to more closely reflect the
distribution of persons living with AIDS, it should consider taking
actions that lead to more comparable funding per case by revising the
funding formulas. HHS and HUD generally agreed with GAO's identification
of issues in the funding formulas.
CARE Act and HOPWA grants are allocated by grantees for health care,
housing assistance, and a variety of services for people with HIV/AIDS.
These grants provide services for persons who have been diagnosed with HIV
that has not progressed to AIDS as well as those for whom it has. In
fiscal year 2003, more than half of Title I CARE Act funds awarded to
eligible metropolitan areas (EMAs) were allocated for health care services
such as outpatient care and home health services, and over two-thirds of
Title II CARE Act funds awarded to states and territories were allocated
for medications. Two-thirds of HOPWA funds were used for direct housing
costs for people with HIV/AIDS and their families.
Multiple provisions in the CARE Act and HOPWA grant funding formulas as
enacted result in funding not being comparable per AIDS case across
grantees. First, both the CARE Act and HOPWA use measures of AIDS cases
that do not accurately reflect the number of persons living with AIDS. For
example, the statutory funding formulas require the use of cumulative AIDS
case counts, which could include deceased cases. Second, AIDS cases within
EMAs are counted once for determining funding under Title I of the CARE
Act for EMAs and again under Title II for determining funding for the
states and territories in which those EMAs are located. As a result,
states with EMAs receive more total funding per case than states without
EMAs. Third, CARE Act 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. For
example, under Title I's hold-harmless provision, one EMA continues to
have deceased AIDS cases factored into its allocation because its
hold-harmless funding dates back to the mid-1990s when formula funding was
based on a count of AIDS cases from the beginning of the epidemic.
If HIV case counts had been incorporated along with AIDS case counts in
allocating fiscal year 2004 CARE Act and HOPWA grants, funding would have
shifted among jurisdictions. Grantees in the South and the Midwest
generally would have received more funding, although there would have been
grantees that would have received increased funding and grantees that
would have received decreased funding in every region of the country.
Although CARE Act and HOPWA grantees have established HIV case reporting
systems, differences between these systems-in their maturity and reporting
methods, for instance-would impact the appropriateness of using HIV case
counts in distributing CARE Act and HOPWA funding. GAO found that CARE Act
and HOPWA fiscal year 2004 funding would have shifted to jurisdictions
with more mature HIV reporting systems.
*** End of document. ***