HIV/AIDS: Use of Ryan White CARE Act and Other Assistance Grant Funds
(Letter Report, 03/01/2000, GAO/HEHS-00-54).
This report discusses the following three programs: the Ryan White
Comprehensive AIDS Resources Emergency Act (CARE) of 1990 run by the
Department of Housing and Human Services, the Centers for Disease
Control and Prevention's (CDC) HIV/AIDS prevention grants, and the
Department of Housing and Urban Development's Housing Opportunities for
Persons Living With AIDS. GAO found that funds provided by the CARE Act
serve vulnerable groups in higher proportions than their representation
in the AIDS population and that its drug assistance services are
reaching the rural AIDS population in proportion to the AIDS cases in
rural areas. Most CARE Act funds go to medical treatment and
medications. About two-thirds of CDC's fiscal year 1998 HIV prevention
funds to states, localities, schools, and organizations were used for
health education and risk reduction, public information, evaluation
research, capacity building and infrastructure development, and
community planning. About two-thirds of the HUD program's funds were
used in 1994-98 for housing assistance. Urban areas generally receive
higher funding per AIDS case when an area is designated as an eligible
metropolitan area. GAO found that the compensation for administrators of
organizations that received federal HIV/AIDS funds was generally
comparable to that of administrators of similar nonprofit organizations.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-00-54
TITLE: HIV/AIDS: Use of Ryan White CARE Act and Other Assistance
Grant Funds
DATE: 03/01/2000
SUBJECT: Acquired immunodeficiency syndrome
Blacks
Women
Disadvantaged persons
Federal aid programs
Health care services
Health services administration
Health insurance
Health resources utilization
Federal grants
IDENTIFIER: HUD Housing Opportunities for Persons with AIDS Program
Medicaid Program
Supplemental Security Income Program
SSI
AIDS
CDC HIV/AIDS Prevention Grants Program
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GAO/HEHS-00-54
Appendix I: CARE Act Criteria for Counseling and HUD Policies
on Illicit Drug Use in Housing
34
Appendix II: Methodology and Information on Administrators' Compensation
36
Appendix III: Dates When States and Territories Began Reporting HIV
Infection
42
Appendix IV: CARE Act Title I Awards, Fiscal Year 1999
43
Appendix V: CARE Act Title II HIV Grants, Fiscal Year 1999
46
Appendix VI: HOPWA Formula Grantees, Fiscal Year 1999
48
Appendix VII: Characteristics of CARE Act Clients and Persons Living With
AIDS at Seven Locations
51
Table 1: The Ryan White CARE Act's Programs Described 9
Table 2: Selected CDC HIV Prevention Program Funding,
Fiscal Year 1998 10
Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act 13
Table 4: Average Percentage of CARE Act Title I and Title II Funds
Spent on Services, Fiscal Year 1998 18
Table 5: Available CARE Act Title I and Title II Funds per AIDS Case
in Six States, Fiscal Year 1997 23
Table 6: Distribution of HOPWA Funds in Six States and Their
EMSAs, Fiscal Year 1997 25
Table 7: Compensation Characteristics at Nonprofit Organizations 31
Table 8: Organizations in Five Locations Funded by CARE Act Title I,
Fiscal Year 1998 39
Table 9: Compensation by Type of Nonprofit Organization 41
Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999 6
Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998 16
Figure 3: Distribution of Selected CDC HIV Prevention Program
Funds, Fiscal Year 1998 20
Figure 4: Distribution of HOPWA Funds, 1994-98 22
Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99 28
Figure 6: Distribution of AIDS Cases and CARE Act Clients in
Michigan, 1998 29
Figure 7: Distribution of AIDS Cases and CARE Act Clients in
Virginia, 1998 30
ADAP AIDS Drug Assistance Program
AHRQ Agency for Healthcare Research and Quality
AIDS acquired immunodeficiency syndrome
CARE Act Ryan White Comprehensive AIDS Resources Emergency Act of 1990
CBC Congressional Black Caucus
CBO Congressional Budget Office
CDC Centers for Disease Control and Prevention
EMA eligible metropolitan area
EMSA eligible metropolitan statistical area
HCSUS HIV Cost and Services Utilization Study
HHS Department of Health and Human Services
HIV human immunodeficiency virus
HOPWA Housing Opportunities for Persons Living With AIDS
HRSA Health Resources and Services Administration
HUD Department of Housing and Urban Development
IRS Internal Revenue Service
MSA metropolitan statistical area
NCCS National Center for Charitable Statistics
SSI Supplemental Security Income
Health, Education, and
Human Services Division
B-282771
March 1, 2000
The Honorable Dick Armey, Majority Leader
House of Representatives
The Honorable Thomas J. Bliley, Jr., Chairman
Committee on Commerce
House of Representatives
The Honorable Tom Coburn, Vice Chairman
Subcommittee on Health and Environment
Committee on Commerce
House of Representatives
Since the first cases of acquired immunodeficiency syndrome (AIDS) were
identified in 1981, more than 700,000 persons in the United States have been
diagnosed with AIDS. Recent developments in medical and pharmacological
therapies have improved the survival of AIDS patients. At the end of 1998,
an estimated 300,000 persons were living with AIDS. In addition, it is
estimated that hundreds of thousands of people are infected with the human
immunodeficiency virus (HIV) but have not progressed to AIDS.
In addition to increasing, the AIDS population has changed over time, with
minorities and women representing a larger proportion of cases. For example,
for the 12 months ending June 1993, African Americans accounted for 35
percent of reported AIDS cases, women 15 percent. For the 12 months ending
June 1999, the figures were 46 percent African Americans and 23 percent
women. The AIDS population by exposure category, or how HIV was contracted,
has also changed. Men who have sex with men accounted for 48 percent of the
reported AIDS cases during the 12 months ending June 1993. This group,
however, accounted for only 34 percent of the reported AIDS cases for the
period ending June 1999.
A number of federal HIV/AIDS programs provide for research, prevention,
health care, and support services to reduce the risk of contracting the
disease and to assist those who are infected with the virus. You asked us to
provide information on three programs that fund prevention activities,
health care, and other assistance: the Ryan White Comprehensive AIDS
Resources Emergency Act of 1990 (P.L. 101-381) (CARE Act), which is
administered by the Department of Health and Human Services' (HHS) Health
Resources and Services Administration (HRSA); the Centers for Disease
Control and Prevention's (CDC) HIV/AIDS prevention grants; and the
Department of Housing and Urban Development's (HUD) Housing Opportunities
for Persons Living With AIDS (HOPWA). You asked us to determine (1) the
characteristics of the persons who are served under the CARE Act; (2) how
CARE Act, CDC prevention, and HOPWA funds are distributed to treatment,
support services, housing, prevention, and program administration; (3)
whether the current approach to funding under the CARE Act leads to
advantages or disadvantages in particular areas; (4) whether CARE Act
services are reaching rural areas; and (5) how the salaries of
administrators of organizations providing HIV/AIDS services compare with the
salaries of administrators of other similar nonprofit organizations. We also
provide information related to your questions about CARE Act requirements
for counseling and HUD's policies regarding illicit drug use in HUD-funded
housing (see app. I).
To conduct our work, we interviewed officials at HUD and at HHS, including
HRSA, CDC, and the Agency for Healthcare Research and Quality (AHRQ). We
obtained and analyzed data from these federal agencies. We obtained funding
and other data from six states and public tax records on a sample of
nonprofit organizations. We reviewed federal legislation and regulations and
relevant HIV/AIDS literature. We conducted our work between June 1999 and
January 2000 in accordance with generally accepted government auditing
standards. Appendix II provides detailed information on our methodology for
comparing administrators' compensation for AIDS service organizations and
similar nonprofit organizations.
The CARE Act funds appear to be reaching groups of infected individuals that
have generally been found to be underserved, including the uninsured and the
poor. African Americans, Hispanics, and women are served by the CARE Act in
higher proportions than their representation in the AIDS population. These
vulnerable groups make up the majority of CARE Act clients.
The CARE Act funds both health care and support services, such as case
management, housing, transportation, and nutrition. Most of the funds,
however, are used for medical treatment and medications. CDC supports a wide
range of state and local HIV prevention activities. About two-thirds of
CDC's fiscal year 1998 HIV prevention funds to states, localities, schools,
and organizations were used for health education and risk reduction, public
information, evaluation and research, capacity building and infrastructure
development, and community planning. About one-third was used for counseling
about the risks of contracting HIV and the need to notify partners about
potential HIV infection, testing for the virus, and referring persons who
test positive to appropriate care. HOPWA helps low-income people with
HIV/AIDS and their families secure housing and provides other services.
HOPWA funds may be used for a variety of housing-related expenses, social
services, and program development. Between 1994 and 1998, about two-thirds
of HOPWA funds were used for housing assistance. All the programs have
limitations on how program funds can be used for administrative purposes.
The levels of funding differ in different areas, with urban areas generally
receiving higher funding per AIDS case when an area is designated as an
eligible metropolitan area (EMA). EMAs receive funds directly from the
federal government under title I of the CARE Act, in addition to the funds
provided through the states under title II. While HOPWA funds also vary
between states and their eligible metropolitan statistical areas (EMSA),
HOPWA state awards are allocated to provide assistance in areas of the state
that are outside any qualifying metropolitan area that receives a HOPWA
allocation.
While the vast majority of people with AIDS reside in urban areas, the
number of AIDS cases is growing in rural areas, which may offer more limited
medical and social services. CARE Act drug assistance services are reaching
the rural AIDS population in proportion to the AIDS cases in rural areas.
Other services under the CARE Act are being provided to individuals who
reside in rural areas, although data do not exist to show where the
individuals receive the services.
The compensation for administrators of organizations that received federal
HIV/AIDS funds was generally comparable to that of administrators of similar
nonprofit organizations. The median compensation for administrators at
organizations that received CARE Act or CDC HIV prevention funds was
$78,000, and the median at organizations that serve only HIV/AIDS clients
was $64,878. The median for other nonprofit organizations providing such
services as health care, family planning, and substance abuse prevention and
treatment services was $74,203.
The CARE Act, CDC HIV prevention programs, and HOPWA accounted for about 20
percent of the estimated $10 billion in federal spending on HIV/AIDS
programs for fiscal year 1999. For that period, estimated federal spending
for HIV/AIDS included $2 billion for research, $0.8 billion for prevention
activities, $5.8 billion for treatment, and $1.4 billion for income and
support. (See fig. 1.)
Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999
Note: CARE Act funds are assigned to "Treatment." Some funds are used for
support services. "Other" includes primarily Medicaid, Medicare, Social
Security Disability Insurance, Supplemental Security Income, and National
Institutes of Health research.
Source: Congressional Research Service.
Medicaid is the largest source of federal assistance for health care for
AIDS patients.1 In 1998, Medicaid was estimated to cover 50 percent of adult
AIDS patients and about 90 percent of pediatric AIDS patients. States vary
in their Medicaid eligibility requirements. Most adults with AIDS or HIV
infection become eligible for Medicaid by meeting the disability criteria of
the federal Supplemental Security Income (SSI) program but usually not until
they have developed AIDS and have become too disabled by their disease to
work.2 Within broad federal guidelines, states have flexibility in
developing their Medicaid programs, including eligibility, services to be
covered by the program, and the scope of the prescription drug benefit, if
any.
The incidence of AIDS varies from state to state. AIDS cases reported for
the 12 months ending June 1999 ranged from less than one case per 100,000
people in North Dakota to 143.4 cases per 100,000 people in the District of
Columbia. The rates of AIDS cases also vary within states. For example, for
the 12 months ending June 1999, the rate of AIDS cases reported in New York
was 42.1 per 100,000 people. A large portion of this was accounted for by
the New York City metropolitan area, where the rate was 74.9 per 100,000
people for the same period. A comparison of Florida and Miami shows similar
differences. The rate of reported cases in Florida was 38.1 per 100,000
people while in Miami it was 72.5.
Rural areas still account for only a small portion of AIDS cases, according
to CDC information. AIDS rates have increased in nonmetropolitan statistical
areas but do not indicate that the epidemic is increasing rapidly there.3 Of
the reported cases, 83 percent were from large metropolitan statistical
areas (MSA), where 62 percent of the population lived. Medium-sized MSAs
accounted for 10 percent of the AIDS cases and 18 percent of the population.
Non-MSAs accounted for 7 percent of the AIDS cases and 20 percent of the
population.4
The pattern of HIV cases is not as clear as the pattern of AIDS cases
because not all states report HIV cases. While information on people with
HIV is important in planning for surveillance purposes, only 33 states had
implemented HIV reporting as of June 30, 1999. Additionally, the states'
reporting practices vary. For example, states began HIV reporting on
different dates, and some states reported previously diagnosed cases along
with new cases, while others reported only newly diagnosed cases. Two states
report only pediatric cases. Appendix III lists the states that have
initiated HIV reporting.
The CARE Act was enacted to improve the quality and availability of medical
and support services for individuals with HIV disease and their families.
The act was reauthorized in 1996. HRSA administers it. Appropriations for
fiscal year 1999 were $1.4 billion. Title I provides funds to EMAs with
substantial numbers of AIDS cases. Title II provides funds to states and
territories by formula, including for the AIDS Drug Assistance Program
(ADAP). Discretionary grants to community health centers and other related
entities are available under title III for providing primary medical care,
HIV counseling and testing, and a variety of support services. Other
discretionary grants are available under title IV for services for women,
children, and families. (See table 1.)
Table 1: The Ryan White CARE Act's Programs Described
Continued from Previous Page
Program Grantee Fiscal year Purpose and
1999 funding requirements
Title
Provides HIV/AIDS
outpatient health
care, including
medications, and a
range of support
services, including
case management,
substance abuse
treatment, housing,
mental health
treatment,
51 EMAs in fiscal transportation, and
I. HIV Emergency year 1999 with at nutritional
Relief Grant least 500,000 $485.8 services, among
Program (formula population and milliona others. Each EMA has
and supplemental 2,000 AIDS cases to establish a
grants) reported in the planning council of
most recent 5 years representatives of
health care
agencies,
community-based
providers, health
care planning
agencies, and
persons with HIV
disease, among
others. The planning
councils establish
priorities for
allocating funds.
In addition to ADAP,
services include
home and
community-based
health care and
support and health
insurance
continuation. States
provide the services
II. HIV Care 50 states, the $710 million, directly or through
Grants (formula District of of which $461 consortia of service
grants) Columbia, and U.S. million was providers. States
territories for ADAP are required to
periodically convene
people living with
HIV disease,
grantees, providers,
and public health
agencies to develop
a statewide
coordinated
statement of need.
198 grantees,
III. Early including community Services include
Intervention and migrant health risk reduction,
Services centers, hospital $94.3 million counseling, testing,
(discretionary or university-based clinical care,
grants) medical centers, medications, and
and city and county case management.
health departments
IV. Coordinated 55 grantees and
Services and projects in fiscal Health care and
Access to Research year 1998, social services that
for Women, including health benefit children,
Infants, Children, care facilities, $46 million youths, and women
and Youth public health living with HIV and
(discretionary agencies, and their families.
grants) community-based
organizations
Other
Funded by
set-asides Supports the
Special Projects from titles development and
of National I-IV not to evaluation of
Significance exceed $25 innovative models of
million HIV/AIDS care.
annually
A national network
of 15 centers that
AIDS Education and conduct training and
Training Centers $20 million education for health
Program care providers in
designated
geographic areas.
Assists accredited
dental schools and
postdoctoral dental
Dental programs with
Reimbursement $7.8 million uncompensated costs
Program incurred in
providing oral
health treatment to
HIV- positive
patients.
aAdditional funds were available to some EMAs. HHS in collaboration with the
Congressional Black Caucus (CBC) provided funds to target and enhance
effective HIV/AIDS efforts that directly benefit racial and ethnic minority
communities: technical assistance and infrastructure support, increasing
access to prevention and care, and building stronger linkages to address the
needs of specific populations. For fiscal year 1999, CBC funds to the EMAs
totaled $5 million.
Appendix IV lists the EMAs for fiscal year 1999 and title I award amounts;
appendix V shows the title II awards to the states, the District of
Columbia, and the territories.
CDC's role includes vaccine research, research on HIV infection and disease
progression, surveillance programs, prevention research, prevention program
evaluations, state and local prevention activities, school-based prevention
activities, and prevention in occupational settings. In this report, we
focus on CDC-funded HIV prevention programs through state and local health
departments; national and regional minority organizations; national
business, labor, and faith partnerships; and other community-based
organizations. State, territory, District of Columbia, and local education
agencies also receive funding for prevention activities. The major grantees
received $289.8 million in fiscal year 1998, as shown in table 2.
Table 2: Selected CDC HIV Prevention Program Funding, Fiscal Year 1998
Type of grantee Number of grantees Funding
State, territorial, and local health
departments 65 $252,824,319a
State and local education agencies 75 19,414,850
Community-based organizations 93 17,553,983
aExcludes funding for surveillance activities.
HOPWA provides housing assistance and supportive services for low-income
persons with HIV/AIDS and their families. Formula grants to states and
metropolitan areas that exceed thresholds for population and AIDS cases
constitute 90 percent of the funding. The remaining 10 percent of funds are
awarded competitively. Fiscal year 1999 funding of $200.5 million was
distributed to 63 metropolitan areas and 34 states, and $24.5 million in
competitive awards went to 24 projects. States, localities, and other
grantees provide emergency shelter, shared housing, apartments, single room
occupancy units, group homes, and housing combined with support services.
Grantees can also use HOPWA funds for a variety of housing-related expenses,
social services, and program development costs such as housing information
and resource identification, purchase, repair, and construction. HOPWA funds
are also used for health care, mental health services, substance abuse
treatment, nutritional services, case management, and help with daily
living.5 Appendix VI identifies grantees and fiscal year 1999 award amounts.
African Americans, Hispanics, and women are served by the CARE Act in higher
proportions than their representation in the AIDS population. These
vulnerable groups, including the uninsured and poor, are the majority of
CARE Act clients. According to a recent HIV study, they generally receive
less appropriate health care for their disease when assessed in terms of
physician visits, emergency room visits, hospitalizations, and
antiretroviral and prophylactic drug therapies.
According to the HIV Cost and Services Utilization Study (HCSUS)--a study of
a nationally representative sample of HIV/AIDS patients--African Americans,
Hispanics, women, the uninsured, and people insured by Medicaid are likely
to visit physicians less frequently and to take fewer anti-HIV medications
for their HIV disease than other HIV-infected people.6 HCSUS analyzed usage
patterns for six measures of health care: physician visits, emergency room
visits, hospitalizations, prophylaxis against Pneumocystis carinii
pneumonia, antiretroviral medication, and new classes of pharmaceuticals
that include protease inhibitors and nonnucleoside reverse transcriptase
inhibitors. The analysis showed that compared with whites, African Americans
and Hispanics received less appropriate care for their HIV disease. Types of
public and private health insurance coverage also affected care. People who
lacked health insurance fared worse on most measures. Also, Medicaid
recipients received less care than privately insured persons. Women also did
not fare as well as men on most of the measures. Finally, exposure category
was a significant factor; those who had acquired their infection by
injecting drugs or through heterosexual sex had less favorable patterns of
care than did men who had sex with men.7
of Minorities, Uninsured, and Poor
Analyses of the HCSUS data to determine the characteristics of persons
served under the CARE Act show that CARE Act clients are more likely to be
African American, have no insurance or rely on public insurance, and have a
lower income than other HIV/AIDS patients.8 (See table 3.)
Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act
Characteristic Funded Not funded
Gender
Male 74% 82%
Female 26 18
Race
White 40 62
African American 42 19
Hispanic 15 16
Other 3 3
Exposure category
Men who have sex with men 44 55
Persons who inject drugs 17 14
Men who have sex with men and inject drugs 8 8
Persons who have heterosexual contact 22 13
Other 3 4
Insurance status
No insurance 30 6
Medicaid only 33 23
Medicare and Medicaid 19 18
Private insurance 19 54
Income (highest income ever, in 1996 dollars)
$0−$5,000 25 12
$5,001−$10,000 30 20
$10,001−$25,000 27 23
More than $25,000 18 45
Also, a greater percentage of women (26 percent) are served under the CARE
Act than are not (18 percent). A greater percentage of persons contracting
the disease by injecting drugs or through heterosexual contact were seen by
providers funded by the CARE Act. A greater percentage of men who contracted
the disease through sexual contact with other men were seen by providers not
funded by the CARE Act.
Representation in the AIDS Population
Using separate data, we also compared the estimated number of people living
with AIDS and people receiving CARE Act-funded services in two states and
five metropolitan areas: Los Angeles, San Francisco, and Orange County,
California; Middlesex, New Jersey; Michigan; Virginia; and Washington, D.C.
These locations were selected because HRSA was able to provide data on the
unduplicated population of persons served under the CARE Act.9 We compared
the AIDS population as of June 30, 1998, with the client population
receiving services under the CARE Act in 1998.10
We found that women were receiving services funded by the CARE Act at rates
greater than their representation in the AIDS population as a whole. At all
seven locations, a greater percentage of women received such services than
their percentage in the AIDS population. Analyses also indicate that
minorities and individuals contracting the virus through heterosexual
contact are represented at higher rates among those served under the CARE
Act than in the AIDS population as a whole. While there is variation across
locations in the proportion of African Americans and Hispanics in both the
AIDS and client populations, at all seven locations a greater percentage of
African Americans are among the CARE Act clients than in the AIDS
population. This is also true for Hispanics at two of the seven locations.
In three locations, the percentages of Hispanics among CARE Act clients were
slightly higher than their representation in the AIDS population. In two
locations, they were slightly lower.
We also found that persons who contracted the HIV virus through heterosexual
contact were more likely to receive services funded by the CARE Act.11 In
the HCSUS data, we saw that a greater percentage of people who injected
drugs receive their services from providers funded under the CARE Act.
However, individuals who contracted HIV by injecting drugs had less
representation among individuals served under the CARE Act than in the AIDS
population at five of the locations. (See app. VII for detailed results for
each location.)
Services
While the CARE Act funds both health care and support services, most of the
funds are used for medical treatment and medications. Included in CDC
prevention activities are counseling about the risks of contracting HIV and
the need to notify partners about potential HIV infection, testing for the
virus, and referring those who test positive to appropriate care. About
one-third of fiscal year 1998 funds were used for these purposes. HOPWA
funds are used primarily for housing assistance; about two-thirds of the
funds between 1994 and 1998 were used for this purpose. All the programs
have limitations on the administrative use of program funds.
To determine the distribution of CARE Act funds, we focused on titles I-III.
These titles accounted for 95 percent of the act's fiscal year 1999
appropriations.12 About 56 percent of title I funds were used for health
care and medications in fiscal year 1998. For the same year, 34 percent of
the funds were used for case management and support services and 10 percent
were used for administration, planning councils, and program support. (See
fig. 2.)
Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998
Most title II funds are also used for medications and medical services.
About 66 percent of title II funds were devoted to ADAP services in fiscal
year 1998. Health services other than ADAP accounted for 12 percent of the
funds in the same year. Case management and support services accounted for
12 percent of the funds. Grantees used 10 percent of the funds for
administration as well as planning and evaluation.
Most title III funds were also used for health care. In fiscal year 1998,
health care services, including medications and laboratory services,
accounted for 74 percent of the funds. Another 12 percent were used for case
management and other services. About 8 percent were used for testing and
counseling, referral, and outreach. The remaining 6 percent went to
administration activities.
The Distribution of Funds Has Changed With New Treatment Approaches
Decreases in the number of new AIDS diagnoses and death rates have been
greatly influenced by new drug therapies generally administered in
combinations of three or more agents. These medications, however, are
expensive, with estimated annual costs of $10,000 and more per patient.
While the distribution of title I funds among various services has remained
relatively constant, title II money is increasingly supporting
pharmaceuticals.
Title II's ADAP component provides funds to the states for providing
medications to HIV-infected individuals. In response to these expensive
therapies, federal funding for ADAP increased from $52 million in fiscal
year 1996 to about $461 million in fiscal year 1999, accounting for an
increasing proportion of the title II funds. ADAP represented 20 percent of
title II funding in fiscal year 1996 and 65 percent in fiscal year 1999.
Title II funds used for other health care services remained about the
same--$59.3 million in fiscal year 1996 and $60.4 million in fiscal year
1998--but represented a decreasing proportion of title II spending.
States With EMAs Spend Proportionately Less on Medications
The proportions of CARE Act funds spent on services for their HIV-infected
populations vary from state to state. For example, the percentage of CARE
Act funds devoted to health care services other than medications ranged from
5 percent in one state to 41 percent in another for fiscal year 1998. One
state did not use any of its CARE Act funds for health care services. With
the majority of title II funds earmarked for ADAPs, states without EMAs have
most of their CARE Act funding allocated for medications. In states with
EMAs, and therefore title I funding, greater proportions of CARE Act funds
are spent, on average, for other services such as health care and support
services. Table 4 shows the average percentage of title I and title II funds
spent on different services for fiscal year 1998.
Table 4: Average Percentage of CARE Act Title I and Title II Funds Spent on
Services, Fiscal Year 1998
Service All states States with States without
EMAs EMAs
Medications 49.9% 38.5% 58.4%
Health care 20.4 24.4 17.6
Administration, planning, and
evaluation 9.4 9.7 8.6
Case management 8.9 12.3 6.5
Support services 8.6 14.2 4.5
Health insurance continuation 2.4 0.9 3.5
Source: HHS, HRSA, Ryan White CARE Act State Profiles (Washington, D.C.:
HHS, 1999).
The CARE Act Limits the Use of Funds That Can Be Used for Administrative
Purposes
As shown in figure 2, under each title, not more than 10 percent was used
for administrative purposes. Each title contains limitations on the use of
funds for administrative activities. The portion of fiscal year 1998 title
I-III funds used for administrative purposes was within these limitations.
The CARE Act defines administrative activities as routine grant
administration and monitoring, including the development of applications for
funds, the receipt and disbursal of program funds, the development and
establishment of reimbursement and accounting systems, the preparation of
routine program and financial reports, and compliance with grant conditions
and audit requirements. Also considered administrative activities are all
activities associated with a grantee's contract award procedures, including
the development of requests for proposals, contract proposal review
activities, the negotiation and awarding of contracts, monitoring contracts
through telephone consultation, written documentation of onsite visits,
reporting on contracts, and funding reallocation activities.
Grantees may not use more than 5 percent of awarded title I funds for
administrative activities. In addition, title I EMAs may use funds for
carrying out planning council support, program support, and service-related
activities that are subject to a 10 percent aggregate administrative cost
cap. While subcontractors are not included in the 10 percent aggregate cap,
HRSA strongly recommends that all subcontractors include a cap on
administrative expenses.
The states may use title II funds to conduct administrative activities
similar to those under title I. The combined costs for administration,
planning, and evaluation cannot exceed 15 percent of a state's award.13 For
title III, grantees may not use more than 7.5 percent of the grant amount
for administrative costs, including planning and evaluation.
In fiscal year 1998, CDC provided $289.8 million to state and local health
departments and education agencies and community-based organizations for HIV
prevention activities. Major HIV prevention interventions include
counseling, testing, referral, and partner notification; health education
and risk reduction; school health; and public information. Evaluation and
research, capacity building and infrastructure development, and community
planning are support activities. About 62 percent of the fiscal year 1998
funds were used for health education and risk reduction, school health,
public information, and support activities. Another 31 percent was devoted
to counseling and testing and partner counseling and referral services.
Grantees' administrative expenses or indirect costs averaged 7 percent for
fiscal year 1998.14 (See fig. 3.)
Figure 3: Distribution of Selected CDC HIV Prevention Program Funds, Fiscal
Year 1998
CDC places several requirements on its grantees, including requirements
related to counseling and testing, and partner counseling and referral
services. Public health agencies that receive CDC HIV/AIDS prevention funds
are required to offer HIV prevention counseling and testing services to
persons potentially infected with HIV, their partners, and others who have
high-risk behaviors. CDC criteria require HIV prevention program managers to
ensure the confidentiality of the persons who use HIV counseling and testing
services. Additionally, persons who seek HIV testing and others who have
been determined to be at risk of infection are offered counseling services,
regardless of their ability to pay.
These programs must also refer clients who test either positive or negative
for HIV to appropriate services that may include medical care, drug
treatment, and support. Additionally, the grantees' counselors are to assist
the client in developing a plan that ensures that all partners are counseled
about their exposure to HIV.
According to reports filed with HUD between 1994 and 1998 that accounted for
more than $302 million in HOPWA funds, most HOPWA money (64 percent) was
spent on housing assistance. Support services accounted for 22 percent of
the funds in those years. Support services include case management, adult
care and personal assistance, health care, alcohol and drug abuse treatment,
and child care, among others. Housing information services accounted for 4
percent of the funds, while program development services and administration
expenses were 10 percent of the total. (See fig. 4.) Administrative costs
may not exceed 3 percent of the grant amount for grantees and 7 percent for
program sponsors.15 HOPWA grantees reported that 3 percent of grant funds
were spent for their administrative expenses and 5 percent were spent for
program sponsors' administrative expenses.
Figure 4: Distribution of HOPWA Funds, 1994-98
In general, metropolitan areas designated EMAs and therefore receiving title
I funds receive more money per person living with AIDS than non-EMA areas.
While we are examining funding formulas in greater detail for you, we
include here some analyses of fiscal year 1997 title I and title II funding
for EMAs and states.16
The level of funding per person living with AIDS differs among states, among
EMAs, and between EMAs and states. In general, EMAs, with about
three-fourths of all AIDS cases, receive more funding per case. For those
areas, the additional money provided through title I is the primary
component of the greater availability of funds. (See table 5.)
Table 5: Available CARE Act Title I and Title II Funds per AIDS Case in Six
States, Fiscal Year 1997
Funds per person
Location Estimated number living with AIDS at
the end of 1997 living with
AIDSa
Arizona 2,430 $2,830
Phoenixb 1,670 3,133
Rest of Arizona 760 2,164
Georgia 8,776 2,846
Atlantab 6,119 3,081
Rest of Georgia 2,657 2,303
Michigan 4,050 2,939
Detroitb 2,765 3,296
Rest of Michigan 1,285 2,170
Texas 20,685 2,555
Austinb 1,408 3,462
Dallasb 4,639 2,769
Fort Worthb 1,347 2,514
Houstonb 7,258 2,457
San Antoniob 1,626 2,940
Rest of Texas 4,407 2,072
Virginiac 4,710 1,723
Washington 3,562 2,914
Seattleb 2,463 3,053
Rest of Washington 1,099 2,603
aFunds do not include state match.
b Designated an EMA as of 1997.
cParts of Northern Virginia are included in the Washington, D.C., EMA. Those
funds are not reflected in the Virginia totals.
Sources: CDC, HIV/AIDS Surveillance Supplemental Report No. 1 (Atlanta: CDC,
1999); HHS, HRSA, Ryan White CARE Act State Profiles (Washington, D.C.: HHS,
1999); HHS, HRSA, Division of HIV Services, data on title I contributions to
state ADAPs.
The states have discretion in how they distribute their title II funds.
States with EMAs may elect to give more title II money to non-EMA areas or
may choose to distribute title II funds without regard to title I funding.
Depending on how the title II funds are distributed, this can increase or
decrease the disparity in funding per case between EMA and non-EMA areas.
Also, EMAs may contribute a portion of their title I funds to their state
ADAP to fund drug assistance services.
For example, in Michigan, some title II money is set aside for consortia
while the ADAP and nonconsortia funds are available statewide. Detroit,
which has about two-thirds of the estimated persons living with AIDS in the
state, got $950,000, or about 37 percent, of the title II money Michigan
earmarked for its consortia in fiscal year 1997. However, Detroit is an EMA,
so this title II funding was in addition to the title I money of $6 million
for the same year. The Detroit EMA transferred $300,000 of its title I funds
to the state ADAP in fiscal year 1997. Thus, with the 2,765 people estimated
to be living with AIDS at the end of 1997 in the Detroit metropolitan area,
the title I and title II money going to Detroit amounts to about $3,296 per
AIDS case. This compares with funding of about $2,170 per case for the
non-EMA areas in Michigan for fiscal year 1997.
Georgia also has one EMA, Atlanta, that received $12.6 million in title I
funds. Unlike Detroit, only 2.5 percent of the title II consortium money
went to Atlanta, although 70 percent of the state's persons living with AIDS
are in the Atlanta area. Georgia thus allocated its title II consortium
funds to areas that do not receive title I funding. In addition, the Atlanta
EMA transferred $1.2 million to the state ADAP in fiscal year 1997. However,
funding for persons outside the metropolitan area was still below
metropolitan area funding. In Georgia, fiscal year funding per AIDS case was
estimated at $3,081 for Atlanta and $2,303 for the rest of the state.
Virginia, which did not have a designated EMA in 1997, had only title II
money to distribute. The funding per person living with AIDS in Virginia was
$1,723.
This comparison does not consider the state's rationale for distributing its
title II money among EMA and non-EMA areas. States' funding decisions may
take into account the incidence of HIV infection as well as AIDS prevalence
and the degree of unmet need. Such factors as a state's Medicaid benefit
package and the infrastructure investment required for some types of
services may also play a role. Further, individuals living outside the EMA
may travel to the EMA to receive certain services that would be paid for out
of title I funds.
An analysis of the distribution of HOPWA funds in the same six states shows
that HOPWA funds also generally vary by AIDS case among EMSAs and the rest
of the state. Table 6 shows HOPWA awards per person living with AIDS at the
end of 1997.
Table 6: Distribution of HOPWA Funds in Six States and Their EMSAs, Fiscal
Year 1997
Estimated number living
Location with AIDS at the end of Awarda Funds per person
1997 living with AIDS
Arizona
Phoenix 1,670 $851,000 $510
Rest of Arizona 222 0 0
Georgia
Atlanta 6,119 4,090,000 668
Rest of Georgia 2,657 1,106,000 416
Michigan
Detroit 2,765 1,374,000 497
Rest of Michigan 861 603,000 700
Texas
Austin 1,408 704,000 500
Dallas 4,639 2,640,000 569
Fort Worth 1,347 582,000 432
Houston 7,258 3,316,000 457
San Antonio 1,626 709,000 436
Rest of Texas 3,856 1,709,000 443
Virginia
Richmond 930 429,000 461
Virginia
Beach-Norfolk 1,496 556,000 372
Rest of Virginia 2,284 0 0
Washington
Seattle 2,463 1,317,000 535
Rest of Washington 789 434,000 550
aWe assume that the HOPWA awards for the EMSAs and states were spent in the
award year.
Sources: CDC, HIV/AIDS Surveillance Supplemental Report No. 1 (Atlanta: CDC,
1999), and HUD data on HOPWA formula awards for fiscal year 1997.
Awards per AIDS case in Texas ranged from $432 in Fort Worth to $569 in
Dallas. The average award in Texas was $443 per AIDS case. Washington and
Seattle were very similar, at $550 and $535, respectively. Other states had
a wider range of awards per case--for example, Michigan at $700 and Detroit
at $497. However, unlike the CARE Act title II funds, the HOPWA state awards
are allocated to provide assistance in areas of the state that are outside
any qualifying metropolitan area that receives a HOPWA allocation.
While the vast majority of people with AIDS reside in urban areas, HIV
infection and AIDS are growing in rural areas, especially in the southern
states. The CARE Act is assisting in providing services for HIV-infected
populations living in rural areas. Although data on HIV/AIDS services in
rural areas are limited, it appears that both drug assistance services and
other services are reaching rural residents.
Rural areas, with smaller populations, may offer more limited medical and
social services, although access to medical care and support services is
critical for the well-being of both the HIV-infected populations and
individuals with other medical conditions in these areas. In some instances,
rural residents may be traveling to urban areas to receive services.
Our analysis of Arizona, Georgia, Michigan, Texas, Virginia, and Washington
showed that the incidence of AIDS cases in rural areas was proportionately
smaller than in metropolitan areas. In three of these states, 4 percent of
the AIDS cases were in non-MSA areas as of June 30, 1998. The 1990 non-MSA
populations for these states ranged from about 13 percent to 16 percent of
the states' populations. In the three other states, AIDS cases in non-MSAs
accounted for 7, 10, and 14 percent, and their 1990 non-MSA populations were
about 16, 25, and 33 percent.
Coverage for expensive combination drug therapies under the CARE Act is
available primarily through the ADAPs. Our analysis of AIDS cases and ADAP
clients in the six states shows that CARE Act drug assistance services are
reaching the rural AIDS population generally in proportion to AIDS cases. We
found that in five states the percentages of ADAP clients in non-MSA areas
were the same as or greater than the percentages of people living with AIDS
in non-MSA areas. In one state, there were 1 percent fewer ADAP clients than
the estimated number of people living with AIDS, while in another state
there were 8 percent more.17 (See fig. 5.)
Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99
We were able to take a closer look at Michigan and Virginia because
client-level data (unduplicated counts of clients) exist for them. We
compared individuals receiving CARE Act services in 1998 with the estimated
numbers of persons living with AIDS as of June 30, 1998. As figures 6 and 7
show, the distributions of the AIDS populations and CARE Act clients appear
to be reasonably similar.18 However, these data show where the clients lived
and do not necessarily reflect where the services were provided. Rural
clients may be traveling to urban areas to receive certain services.
Figure 6: Distribution of AIDS Cases and CARE Act Clients in Michigan, 1998
Figure 7: Distribution of AIDS Cases and CARE Act Clients in Virginia, 1998
Our analysis shows that compensation to administrators of organizations
serving persons with HIV/AIDS is generally comparable in similar nonprofit
organizations. The median compensation for administrators for all
organizations that received CARE Act or CDC funds was $78,000, and the
median at organizations that serve only HIV/AIDS clients was $64,878. The
median for other nonprofit organizations was $74,203.
The organizations vary by services provided, funds available to provide
these services, and the salaries and benefits provided to their
administrators. These nonprofit organizations provided health care, drug
treatment services, counseling, nutritional services, and legal and other
assistance to a diverse group of clients, including people with HIV/AIDS.
Revenues, as an indicator of organization size, varied from $206,000 to more
than $30 million. Compensation also varied, ranging from $23,434 to
$527,807.19 The average compensation among organizations that received
federal HIV/AIDS funds and other nonprofit organizations also varied. (See
table 7.)
Table 7: Compensation Characteristics at Nonprofit Organizations
Receiving CARE Act and CDC funds
Serving HIV/AIDS Not receiving
Item All Serving HIV/AIDS and other CARE Act or CDC
organizations clients only
clients funds
Revenue $15,312-$27.7 $415,312-$17.6 $1.4 $206,142a -$30.9
range million million million-$27.7 million
million
Compensation
as
percentage 0.4−13 1−13 0.4−5 0.3−20
of revenue
Compensation
range $37,450-$223,804 $37,450-$197,014 $56,663-$223,804 $23,434-$527,807
Compensation
median $78,000 $64,878 $89,783 $74,203
Compensation
mean $92,490 $72,871 $104,751 $89,996
aWe limited our analysis to organizations with revenues of $300,000 or more.
However, in some cases, the Internal Revenue Service (IRS) file used to
identify the organizations had revenue amounts different from those in the
file used for the analysis.
Organizations that received CARE Act or CDC funds and served only HIV/AIDS
clients compensated their administrators $72,871 on average, while
organizations that served persons with HIV/AIDS and other clients paid their
administrators an average of $104,751. However, the average compensation at
all organizations that received either CARE Act or CDC funds was $92,490.
This compares with an average compensation of $89,996 for other nonprofit
organizations that did not receive CARE Act or CDC funds. A more complete
description of our analysis is in appendix II.
We provided HHS and HUD the opportunity to comment on a draft of this
report. HHS said that it agreed with most aspects of the report but thought
it should provide more information on the role of Medicare, Medicaid, and
State Children's Health Insurance in meeting the needs of HIV/AIDS patients.
We agree that these programs, especially Medicaid, do play important roles
in the care of HIV/AIDS patients. Our emphasis was on the CARE Act program,
however, although we do include some information on other programs that also
serve HIV/AIDS patients.
HUD provided technical comments, as did HHS, and we incorporated them where
appropriate.
As we agreed with your offices, unless you publicly announce the report's
contents earlier, we plan no further distribution of it until 30 days from
the date of this letter. We will then send copies to the Honorable Donna E.
Shalala, Secretary of Health and Human Services; the Honorable Claude Earl
Fox, Administrator of the Health Services and Resources Administration; the
Honorable Jeffrey P. Koplan, Director of the Centers for Disease Control and
Prevention; the Honorable Andrew M. Cuomo, Secretary of Housing and Urban
Development; and others who are interested. If you have any questions or
would like additional information, please call me at (202) 512-7114. Marcia
Crosse, Roy Hogberg, and Donna Bulvin made major contributions to this
report.
Janet Heinrich
Associate Director, Health Financing and
Public Health Issues
CARE Act Criteria for Counseling and HUD Policies on Illicit Drug Use in
Housing
This appendix briefly describes the Ryan White Comprehensive AIDS Resources
Emergency Act of 1990 (CARE Act) criteria for counseling people with human
immunodeficiency virus (HIV) and referring them to appropriate care and
federal policies related to substance abuse in federally subsidized housing.
Grantees receiving title III (early intervention services) money are
statutorily required to provide certain counseling services for persons who
test positive and negative for HIV. As stated earlier in this report, about
8 percent of fiscal year 1998 title III money was spent on counseling,
testing, referral, and outreach.
Counseling and testing services include pretest counseling and counseling
individuals with either negative or positive test results. Before testing
for HIV, counselors are to provide information on preventing HIV as well as
on how the virus is transmitted. They are also to convey information on the
accuracy and reliability of test results. Other information includes the
benefits of testing, the significance of test results, and encouragement to
undergo testing. Counselors should also stress the confidentiality of
receiving early intervention services, the availability of anonymous
testing, and laws related to discrimination against individuals with HIV
disease.
Post-test counseling for individuals who test negative for HIV should
contain information about reducing the risk of contracting the virus, the
accuracy and reliability of test results, and their significance. The
counseling should also include information on the appropriateness of further
HIV counseling, testing, and education and referral to HIV prevention
services.
People who test positive for the virus need counseling in addition to the
information on risk reduction and significance and the reliability of HIV
test results. Important information that should be conveyed is the
availability of appropriate health care, including antiretroviral therapies,
mental health care, and social and support services. In addition to telling
them about the availability of early intervention services and primary care,
counselors should make them aware of the benefits of counseling others whom
they may have exposed to HIV and assist them in locating those persons.
Federal law authorizes the secretary of the Department of Housing and Urban
Development (HUD) to make grants to public housing agencies, for-profit and
nonprofit owners of federally assisted low-income housing, and others for
use in eliminating drug related and violent crime (42 U.S.C. 11902(a)). The
grants may be used to employ security personnel, reimburse local law
enforcement agencies for additional security, make physical improvements for
security, conduct training and buy equipment for volunteer tenant patrols,
among other things (42 U.S.C. 11903(a)). The secretary is required to
establish a clearinghouse to respond to inquiries from the public requesting
assistance in investigating, studying, and working on substance abuse
problems. The clearinghouse is also to collect and disseminate information
on programs to assist the public in this area. Federal law also requires the
secretary to establish regional training programs to educate and prepare
officials to confront drug abuse in housing.
In addition, HUD has a zero tolerance policy regarding illegal activities in
HUD-funded programs. Housing Opportunities for Persons Living With AIDS
(HOPWA) is subject to all federal criminal statutes and procedures regarding
the sale, possession, and use of illegal substances. Grantees, project
sponsors, and other contracted agents are required to comply with them and
have no ability to waive or modify them in order to condone on-site use of
illegal substances. HUD may use established remedies to enforce compliance
on these matters, such as suspending grant awards. According to an Office of
HIV/AIDS Housing official, HUD has not taken any enforcement actions against
HOPWA-funded housing grantees.
Methodology and Information on Administrators' Compensation
To compare the compensation of top administrators of organizations receiving
CARE Act and Centers for Disease Control and Prevention (CDC) HIV prevention
funds with those of other nonprofit organizations, we first randomly
selected five eligible metropolitan areas (EMA)--Dallas, Kansas City,
Philadelphia, St. Louis, and San Francisco--that received title I CARE Act
funds for fiscal year 1999.20 We identified grantees that received at least
$250,000 in title I fiscal year 1998 funds from a list of grant recipients
in each of the five EMAs that the Health Resources and Services
Administration (HRSA) provided. We excluded hospitals, state and county
health departments, and universities from our sample because their size,
types of services, and range of clients would not have been comparable to
those of most of the organizations that receive CARE Act funds or CDC HIV
prevention funds. Through an EMA representative, we requested copies of the
latest tax filing, Internal Revenue Service (IRS) Form 990, for the 49
organizations that met our selection criteria. We could not obtain the form
for seven. In addition, because of incomplete or insufficient information,
we excluded eight more organizations from our analysis. As a result, our
analysis includes 34 organizations that received title I CARE Act funds in
fiscal year 1998.
We identified seven additional organizations that received $250,000 or more
in CDC HIV prevention grants for fiscal year 1998.21 We were able to obtain
a Form 990 for six of these grantees, but we eliminated one because of
incomplete information. In total, we identified 39 organizations that
received more than $250,000 in CARE Act or CDC prevention funds in fiscal
year 1998. Of the 39 organizations, 15 served only HIV/AIDS clients, and 24
served both HIV/AIDS and other clients.
To select nonprofit organizations for comparison, we contracted with the
Urban Institute's National Center for Charitable Statistics (NCCS). NCCS
identified and provided data for 273 nonprofit organizations whose annual
revenue was at least $300,000, located in the same five cities, that
provided health care, family planning services, and drug abuse prevention
and treatment services.22 We eliminated 24 organizations that serve HIV/AIDS
clients. We also eliminated 121 because of incomplete or questionable
information. Therefore, we used 128 organizations in our analysis.
The nonprofit organizations were limited to the following IRS National
Taxonomy for Exempt Organization classifications:
� health treatment facilities, primarily outpatient;
� ambulatory health centers and community clinics;
� family planning centers;
� public health programs (includes general health and wellness promotion
services);
� alcohol, drug, substance abuse, and dependency prevention and treatment;
� alcohol and drug abuse prevention only; and
� alcohol and drug abuse treatment only.
Our analysis contains a number of qualifiers that limit drawing any
conclusions about the appropriateness of compensation among HIV/AIDS service
providers and other nonprofit organizations. First, although IRS Form 990 is
the most commonly used data source of such financial information about
nonprofit organizations, it can contain numerous errors. Several studies
have shown that a sizable number of these forms contain errors and
omissions. Also, we limited our selection of the organizations that were
funded by the CARE Act to five locations, which resulted in a sample of 34
organizations that received $250,000 or more in CARE Act funds. We obtained
data for only five of the seven organizations that received $250,000 or more
in CDC HIV prevention funds. We compared the organizations that received
CARE Act or CDC funds with 128 nonprofit organizations with total revenues
of at least $300,000 in the same locations. Further, our analysis is based
only on salary and other compensation and does not consider other factors
such as differences in job responsibilities, working conditions, and job
satisfaction that would be needed for a more complete analysis.
Additionally, because of the small number of organizations in each location,
we did not perform separate analyses by location. Therefore, we did not take
into account geographical differences in cost of living.
The 15 organizations that provided services exclusively to HIV/AIDS clients
gave their top administrators compensation ranging from $37,450 to $197,014.
However, only one organization in this group paid its administrator more
than $100,000. While the median compensation was $64,878, the average
compensation was $72,871. Revenue at these organizations ranged from
$415,312 to $17.6 million, and about 73 percent of them reported revenues
between $1 million and $4 million. The organization with the lowest revenue
($415,312) paid its top administrator the fourth lowest compensation
($54,600), while the organization with the highest revenue paid its top
administrator the highest salary ($197,014). As a portion of total revenue,
their compensation accounted for 13 and 1 percent, respectively.
In the HIV/AIDS dedicated organizations, we also found that the portion of
CARE Act or CDC funds as a percentage of total revenue ranged from 12
percent to 77 percent. At the organization with the highest revenue ($17.6
million), CARE Act or CDC funds accounted for 18 percent of total revenue,
while at the organization with the lowest revenue ($415,312), CARE Act or
CDC funds accounted for 77 percent of total revenue.
The 24 organizations that served HIV/AIDS and other clients gave their top
administrators compensation ranging from $56,663 to $223,804. Further, nine
top administrators earned $100,000 or more in compensation. The median was
$89,783, and the average compensation among these organizations was
$104,751. Revenue at these organizations ranged from $1.4 million to $27.7
million. As a percentage of total revenue, top administrator compensation
ranged from 0.4 percent to 5 percent of total revenue. The organization with
the lowest revenue ($1.4 million) paid its top administrator the lowest
compensation ($56,663), but this was not true of the organization with the
highest revenue, which paid its top administrator the fifth highest
compensation ($129,927) in the group.
At these 24 organizations, CARE Act or CDC funds accounted for from 1
percent to 51 percent of total revenue. At the organization with the highest
revenue, CARE Act or CDC funds accounted for 2 percent of total revenue,
while at the organization with the lowest total revenue, CARE Act or CDC
funds accounted for 20 percent of total revenue. Table 8 provides
information on the organizations in the five locations that received at
least $250,000 in CARE Act title I funds in fiscal year 1998.
Table 8: Organizations in Five Locations Funded by CARE Act Title I, Fiscal
Year 1998
Continued from Previous Page
Benefits Total Title I
Location Total Title I Salary and Total compensation funds as
revenue funds compensation as a % of a % of
expenses
revenue revenue
Dallas
1 $514,196 $253,433 $40,000 0 $40,000 8% 49%
2 415,312 318,723 54,600 0 54,600 13 77
3 1,691,200 282,500 54,041 $1,923 55,964 3 17
4 2,007,229 642,600 50,000 7,190 57,190 3 32
5 1,137,791 496,822 60,000 2,397 62,397 6 44
6 3,773,898 1,526,053 64,878 0 64,878 2 40
7 2,610,912 349,900 70,258 0 70,258 3 13
8 4,112,524 500,984 85,326 0 85,326 2 12
Kansas City
1 2,254,491 304,493 63,656 340 63,996 3 14
Philadelphia
1 2,331,515 433,233 52,982 0 52,982 2 19
2 1,433,529 566,863 51,896 4,767 56,663 4 20
3 1,611,038 269,863 58,266 0 58,266 4 35
4 18,509,917 363,999 74,770 0 74,770 0.4 2
5 3,400,227 1,524,141 73,798 3,567 77,356 2 45
6 4,718,978 384,607 85,750 2,315 88,065 2 8
7 4,307,284 778,872 87,063 10,560 97,623 2 18
8 22,106,787 528,252 110,250 6,951 117,201 1 3
9 27,742,432 440,993 119,657 10,270 129,927 0.5 2
10 25,480,535 287,975 169,825 31,672 201,497 1 1
San
Francisco
1 1,107,951 373,912 65,000 0 65,000 6 34
2 1,971,651 334,395 68,275 3,343 71,618 4 17
3 4,483,191 430,000 71,769 2,153 73,922 2 10
4 1,558,470 278,051 78,000 0 78,000 5 18
5 2,353,199 276,827 75,000 3,000 78,000 3 12
6 4,104,965 2,108,102 65,747 13,903 79,650 2 51
7 1,505,562 595,113 86,798 300 87,098 6 40
8 13,375,684 252,033 86,700 4,800 91,500 1 2
9 4,603,175 517,398 92,292 0 92,292 2 11
10 10,487,800 979,699 108,925 0 108,925 1 9
11 16,669,156 1,660,850 120,450 0 120,450 1 10
12 16,311,005 1,122,477 141,428 11,999 153,427 1 7
13 17,589,710 3,078,915 183,892 13,122 197,014 1 18
14 19,497,658 1,699,928 130,384 93,420 223,804 1 9
St. Louis
1 2,471,436 321,894 75,210 4,528 79,738 3 13
Compensation for top administrators in the 128 other nonprofit organizations
ranged from $23,434 to $527,807. Further, 33 organizations paid the top
administrator $100,000 or more. Total revenues of the organizations ranged
from $206,142 to $30.9 million.23 The median compensation was $74,203 and
the average was $89,996. As a percentage of total revenue, total
compensation ranged from 0.3 percent to 20 percent. The organization with
the highest revenue ($30.9 million) did not pay its administrator the
highest compensation. Nor did the organization with the lowest revenue pay
its administrator the lowest compensation. Table 9 provides information on
compensation at nonprofit organizations by type.
Table 9: Compensation by Type of Nonprofit Organization
Category Range Number of
organizations
Alcohol and drug abuse prevention
only $54,266-$125,916 7
Alcohol and drug abuse treatment
only $33,390-$135,844 30
Alcohol, drug, and substance abuse
dependency prevention and $29,500-$131,994 23
treatment
Family planning center $63,568-$267,867 8
Public health programs (includes
general health and wellness $28,577-$318,625 16
promotion services)
Ambulatory health center,
community clinic $23,434-$346,339 33
Health treatment facility,
primarily outpatient $36,000-$527,807 11
To further compare the compensation of top administrators for organizations
receiving CARE Act or CDC funds, we considered two surveys of nonprofit
organizations that show salaries. One survey by the Congressional Budget
Office includes salary and benefits. This study, which considered large
nonprofit organizations with annual revenue of $50 million or more, found
that chief executive officer salary and benefits averaged about $212,000 per
year.24 Another survey by The NonProfit Times, a publication by the NPT
Publishing Group, which conducts annual salary surveys, found that chief
executive salaries averaged $73,687.25 In comparing different types of
nonprofit organizations, The NonProfit Times reported that foundation
executives averaged $103,976, followed by chief executives at health
organizations at $89,044.
Dates When States and Territories Began Reporting HIV Infection
State and territory Date
Alaska Jan.-June 1999
Arizona Jan. 1987
Arkansas July 1989
Colorado Nov. 1985
Connecticut July 1992a
Florida July 1997
Idaho June 1986
Indiana July 1988
Iowa July 1998
Louisiana Feb. 1993
Michigan April 1992
Minnesota Oct. 1985
Mississippi Aug. 1988
Missouri Oct. 1987
Nebraska Sept. 1995
Nevada Feb. 1992
New Jersey Jan. 1992
New Mexico Jan. 1998
North Carolina Feb. 1990
North Dakota Jan. 1988
Ohio June 1990
Oklahoma June 1988
Oregon Sept. 1988b
South Carolina Feb. 1986
South Dakota Jan. 1988
Tennessee Jan. 1992
Texas Jan. 1999
Utah April 1989
Virginia July 1989
Virgin Islands Dec. 1998
West Virginia Jan. 1989
Wisconsin Nov. 1985
Wyoming June 1989
a Confidential HIV infection reporting for pediatric cases only.
bConfidential infection reporting for children younger than 6 years old.
CARE Act Title I Awards, Fiscal Year 1999
Continued from Previous Page
Eligible metropolitan area Title I award CBCa
Arizona
Phoenix $3,865,319 $19,445
California
Los Angeles 33,540,737 261,519
Oakland 6,218,532 55,004
Orange County 4,300,690 23,586
Riverside-San Bernardino 6,463,388 36,460
Sacramento 2,578,873 12,423
San Diego 8,872,685 52,934
San Francisco 36,218,513 67,788
San Jose 2,486,136 15,214
Santa Rosa 1,127,018 0
Colorado
Denver 4,150,341 19,265
Connecticut
Hartford 4,019,409 48,703
New Haven 6,100,471 62,746
District of Columbiab 18,322,558 259,988
Florida
Fort Lauderdale 10,810,324 118,291
Jacksonville 3,683,146 41,591
Miami 21,248,387 279,163
Orlando 4,907,180 54,824
Tampa-St. Petersburg 7,236,728 48,163
West Palm Beach 6,711,944 87,953
Georgia
Atlanta 13,147,268 157,991
Illinois
Chicago 18,227,884 191,570
Louisiana
New Orleans 5,695,360 68,148
Maryland
Baltimore 13,478,549 202,463
Massachusetts
Bostonb 10,647,381 68,508
Michigan
Detroit 6,585,744 73,909
Minnesota
Minneapolis-St. Paulb 2,548,603 12,783
Missouri
Kansas Cityb 2,952,910 16,204
St. Louisb 3,664,771 33,669
Nevada
Las Vegas 3,402,697 25,747
New Jersey
Bergen-Passaic 4,320,176 48,163
Jersey City 5,015,785 63,737
Middlesex-Somerset-Hunterdon 2,555,029 26,467
Newark 14,390,269 192,110
Vineland-Millville-Bridgeton 688,648 8,732
New York
Dutchess County 1,220,662 12,153
Nassau-Suffolk 5,632,012 49,963
New York 96,961,856 1,260,780
Ohio
Cleveland 2,933,058 31,148
Oregon
Portlandb 3,115,251 0
Pennsylvania
Philadelphiab 16,011,451 205,884
Puerto Rico
Caguas 1,610,314 29,348
Ponce 2,487,768 33,849
San Juan 11,912,865 217,047
Texas
Austin 3,175,509 27,997
Dallas 10,164,078 82,552
Fort Worth 2,935,543 21,606
Houston 15,489,996 177,707
San Antonio 3,014,654 44,742
Virginia
Norfolkb 3,665,087 49,963
Washington
Seattle 5,303,343 0
Total $485,846,900 $5,000,000
aIncluded in title I award. A Department of Health and Human Services (HHS)
and Congressional Black Caucus (CBC) initiative to further address HIV/AIDS
in racial and ethnic communities.
bEMA boundaries include jurisdictions in more than one state.
CARE Act Title II HIV Grants, Fiscal Year 1999
Continued from Previous Page
State and territory Formula ADAPa Total
Alabama $3,314,520 $3,980,313 $7,294,833
Alaska 269,662 323,829 593,491
Arizona 2,224,423 4,057,517 6,281,940
Arkansas 1,505,463 1,807,868 3,313,331
California 30,669,853 65,267,693 95,937,546
Colorado 1,968,440 3,787,302 5,755,742
Connecticut 3,629,583 7,793,350 11,422,933
Delaware 1,392,956 1,672,761 3,065,717
District of Columbia 3,319,351 7,690,410 11,009,761
Florida 24,976,515 48,505,772 73,482,287
Georgia 7,658,435 13,815,288 21,473,723
Guam 8,929 10,723 19,652/
Hawaii 1,101,864 1,323,197 2,425,061
Idaho 264,304 317,396 581,700
Illinois 6,967,711 14,548,730 21,516,441
Indiana 3,253,801 3,907,398 7,161,199
Iowa 658,975 791,345 1,450,320
Kansas 981,136 1,426,136 2,407,272
Kentucky 1,851,917 2,223,914 4,075,831
Louisiana 5,010,641 8,061,420 13,072,061
Maine 441,103 529,708 970,811
Maryland 6,496,978 14,175,575 20,672,553
Massachusetts 4,213,646 8,413,129 12,626,775
Michigan 3,740,253 6,712,489 10,452,742
Minnesota 971,008 2,024,469 2,995,477
Mississippi 2,269,803 2,725,742 4,995,545
Missouri 2,683,738 5,127,655 7,811,393
Montana 250,000 227,324 477,324
Nebraska 548,253 658,381 1,206,634
Nevada 1,568,357 3,079,595 4,647,952
New Hampshire 308,492 553,298 861,790
New Jersey 12,427,002 25,275,844 37,702,846
New Mexico 1,125,079 1,351,076 2,476,155
New York 41,145,958 85,949,879 127,095,837
North Carolina 5,301,431 6,371,503 11,672,934
North Dakota 100,000 75,060 175,060
Ohio 4,920,576 6,914,078 11,834,654
Oklahoma 1,773,340 2,129,553 3,902,893
Oregon 1,543,178 2,790,079 4,333,257
Pennsylvania 8,590,475 15,041,980 23,632,455
Puerto Rico 7,895,807 15,505,206 23,401,013
Rhode Island 1,069,718 1,284,594 2,354,312
South Carolina 4,968,208 5,966,180 10,934,388
South Dakota 100,000 105,084 205,084
Tennessee 4,461,029 5,357,124 9,818,153
Texas 17,245,801 32,998,423 50,244,224
Utah 946,495 1,136,619 2,083,114
Vermont 250,000 238,047 488,047
Virginia 4,847,006 8,252,286 13,099,292
Virgin Islands 283,949 340,986 624,935
Washington 2,933,765 5,400,015 8,333,780
West Virginia 624,763 797,778 1,422,541
Wisconsin 1,730,610 2,082,373 3,812,983
Wyoming 100,000 96,506 196,506
Total $248,904,300 $461,000,000 $709,904,300
aAIDS Drug Assistance Program.
HOPWA Formula Grantees, Fiscal Year 1999
Continued from Previous Page
State and territory Grantee Amount
Alabama State of Alabama $796,000
Birmingham 365,000
Arizona State of Arizona 366,000
Phoenix 923,000
Arkansas State of Arkansas 552,000
California State of California 2,427,000
Los Angeles 8,769,000
Oakland 1,670,000
Riverside 1,372,000
Sacramento 656,000
San Diego 2,168,000
San Francisco 8,510,000
San Jose 649,000
Santa Ana (for Orange County) 1,143,000
Colorado Denver 1,164,000
State of Connecticut 920,000
Connecticut Hartford 1,413,000
New Haven 1,214,000
State of Delaware 113,000
Delaware
Wilmington 485,000
District of Columbia Washington, D.C. 6,475,000
State of Florida 3,164,000
Fort Lauderdale 4,186,000
Jacksonville 983,000
Florida Miami 8,418,000
Orlando 1,753,000
Tampa 1,661,000
West Palm Beach 2,635,000
State of Georgia 1,297,000
Georgia
Atlanta 3,407,000
State of Hawaii 132,000
Hawaii
Honolulu 364,000
State of Illinois 534,000
Illinois
Chicago 4,219,000
State of Indiana 636,000
Indiana
Indianapolis 579,000
Kentucky Commonwealth of Kentucky 561,000
State of Louisiana 1,063,000
Louisiana
New Orleans 2,031,000
Maryland Baltimore 4,689,000
Massachusetts Boston 1,890,000
State of Michigan 677,000
Michigan
Detroit, 1,526,000
State of Minnesota 92,000
Minnesota
Minneapolis 670,000
Mississippi State of Mississippi 769,000
State of Missouri 396,000
Missouri Kansas City 813,000
St. Louis 944,000
State of Nevada 190,000
Nevada
Las Vegas 1,308,000
State of New Jersey 1,430,000
Dover (for Monmouth) 595,000
Jersey City 2,271,000
New Jersey
Newark 5,777,000
Paterson (for Bergen-Passaic) 1,160,000
Woodbridge (for Middlesex) 671,000
New Mexico State of New Mexico 391,000
State of New York 2,218,000
Buffalo 352,000
New York Islip (for Nassau-Suffolk) 1,362,000
New York City 48,668,000
Rochester 542,000
State of North Carolina 1,212,000
North Carolina Charlotte 397,000
Raleigh 386,000
State of Ohio 822,000
Cincinnati 395,00
Ohio
Cleveland 670,000
Columbus 458,000
Oklahoma State of Oklahoma 723,000
Oregon Portland 803,000
Commonwealth of Pennsylvania 1,135,000
Pennsylvania Philadelphia 3,428,000
Pittsburgh 491,000
Commonwealth of Puerto Rico 1,841,000
Puerto Rico
San Juan 5,891,000
Rhode Island Providence 424,000
South Carolina State of South Carolina 1,657,000
State of Tennessee 525,000
Tennessee Memphis 538,000
Nashville 479,000
State of Texas 2,086,000
Austin 767,000
Dallas 2,505,000
Texas
Fort Worth 655,000
Houston 6,466,000
San Antonio 805,000
Utah State of Utah 368,000
Commonwealth of Virginia 463,000
Virginia Richmond 492,000
Virginia Beach (for Norfolk) 702,000
State of Washington 487,000
Washington
Seattle 1,401,000
State of Wisconsin 325,000
Wisconsin
Milwaukee 393,000
Characteristics of CARE Act Clients and Persons Living With AIDS at Seven
Locations
Orange
County, Los San Middlesex, Michigan Virginia Washington,
Calif. Angeles Francisco N.J. D.C.
CARE
CharacteristicCARE AIDS CAREAIDS CARE AIDS CARE AIDS CARE AIDS AIDS CARE AIDS
Act Act Act Act Act Act
Act
Gender
Male 85.0 89.6 84.990.5 88.5 93.8 59.6 67.7 74.3 82.0 64.9 80.8 67.4 77.9
Female 15.0 10.4 15.19.5 11.5 6.2 40.4 32.3 25.7 18.0 35.1 19.2 32.6 22.1
Race
White 53.7 63.0 37.543.0 56.7 67.4 35.9 40.0 32.7 41.4 30.1 38.9 17.4 23.4
African
American 6.0 5.2 21.721.4 24.1 16.0 42.4 36.5 63.0 54.8 66.3 56.4 76.6 71.0
Hispanic 37.0 29.0 38.132.7 14.0 12.7 20.5 22.5 3.6 3.3 3.0 3.9 5.3 4.9
Asian Pacific
or Native 3.3 2.7 2.7 2.5 5.1 3.9 1.2 0.8 0.8 0.4 0.6 0.8 0.7 0.6
American
Exposure
category
Men who have
sex with men 56.2 71.1 66.173.6 59.7 71.8 23.3 25.3 44.7 53.2 37.3 48.9 31.5 44.8
Persons who
inject drugs 15.8 13.3 7.1 9.6 17.5 12.8 36.2 43.2 19.0 24.6 18.0 21.5 19.7 28.9
Men who have
sex with men
and inject 4.4 5.6 5.3 6.1 12.4 11.9 4.7 4.4 5.0 6.7 7.2 6.2 5.4 4.6
drugs
Persons who
have
heterosexual 22.3 7.7 14.98.1 8.7 2.7 34.9 21.4 26.6 12.1 34.8 19.2 39.8 17.9
contact
Other 1.4 2.2 6.7 2.7 1.6 0.8 0.8 5.6 4.8 3.4 2.7 4.3 3.6 3.8
Stage of
illness
HIV but not
AIDS 50.6 59.3 52.0 58.1 57.9 57.3 58.7
AIDS 49.4 40.7 48.0 41.9 42.1 42.7 41.3
Note: Numbers are percentages.
(101838)
Table 1: The Ryan White CARE Act's Programs Described 9
Table 2: Selected CDC HIV Prevention Program Funding,
Fiscal Year 1998 10
Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act 13
Table 4: Average Percentage of CARE Act Title I and Title II Funds
Spent on Services, Fiscal Year 1998 18
Table 5: Available CARE Act Title I and Title II Funds per AIDS Case
in Six States, Fiscal Year 1997 23
Table 6: Distribution of HOPWA Funds in Six States and Their
EMSAs, Fiscal Year 1997 25
Table 7: Compensation Characteristics at Nonprofit Organizations 31
Table 8: Organizations in Five Locations Funded by CARE Act Title I,
Fiscal Year 1998 39
Table 9: Compensation by Type of Nonprofit Organization 41
Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999 6
Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998 16
Figure 3: Distribution of Selected CDC HIV Prevention Program
Funds, Fiscal Year 1998 20
Figure 4: Distribution of HOPWA Funds, 1994-98 22
Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99 28
Figure 6: Distribution of AIDS Cases and CARE Act Clients in
Michigan, 1998 29
Figure 7: Distribution of AIDS Cases and CARE Act Clients in
Virginia, 1998 30
1. Medicaid is a joint federal and state program that pays for health care
services for eligible low-income or disabled individuals.
2. A disabled adult is unable to engage in any substantial gainful activity
because of a medically determined physical or mental impairment that has
lasted (or can be expected to last) at least 12 months or that is expected
to result in death. An individual with AIDS or HIV infection could also
qualify for Medicaid on the basis of eligibility under another eligibility
category such as being a pregnant woman, a child under 21, or a member of a
family with a dependent child.
3. This is based on AIDS cases in adults and adolescents 13 years of age or
older reported to CDC in 1996 from the 50 states and the District of
Columbia.
4. Large MSAs are defined as having populations larger than 500,000,
medium-sized MSAs between 50,000 and 500,000, and non-MSAs smaller than
50,000.
5. Health care services are limited to persons with HIV/AIDS and not other
family members. Further, the cost of these services is limited when payments
are made by other sources.
6. HCSUS is being conducted under a cooperative agreement between RAND and
AHRQ. Additional funding has been provided by a number of agencies within
HHS, the Robert Wood Johnson Foundation, Merck & Co., and Glaxo-Wellcome
Inc. The study is based on a sample of 2,864 respondents representing the
231,400 persons who were at least 18 years old, known to have been infected
with HIV, and receiving medical care in the 48 contiguous United States in
early 1996.
7. M. Shapiro and others, "Variations in the Care of HIV-Infected Adults in
the United States," Journal of the American Medical Association , Vol. 281
(1999), pp. 2305-15.
8. HCSUS defines CARE Act clients as all patients receiving care from a site
that has received CARE Act funds. It is possible that some individuals
received services at a CARE Act-funded site that were not funded under the
CARE Act. AHRQ performed specific analyses of the HCSUS data at our request.
9. HRSA obtains client data from service providers, and clients may seek
services from more than one provider. Therefore, an unduplicated count of
clients is typically not available. HRSA initiated "Client-Level Data
Demonstration Projects" at eight sites that can provide an unduplicated
count of clients. For California, however, limited data were available and
are therefore not included in our analysis.
10. While both HIV-infected and AIDS patients can receive services funded
under the CARE Act, we are limited to comparing CARE Act clients with
persons with AIDS because data on HIV-infected persons are not uniformly
reported. The percentage of CARE Act clients with AIDS ranged from about 41
percent at one location to about 49 percent at another. Our analysis of the
seven locations shows CARE Act client characteristics and HCSUS data to be
similar. Also, we noted that the characteristics of persons with AIDS and
CARE Act clients vary by location.
11. The proportion of AIDS cases that resulted from heterosexual contact is
increasing in the general population. Of the AIDS cases reported for the 12
months ending June 1993, exposure to HIV through heterosexual contact
accounted for 9 percent in which exposure category was known. This compares
with 15 percent of the AIDS cases reported for the 12 months ending June
1999 for the same exposure group.
12. HRSA was not able to provide data on the distribution of funds among
various services for title IV and demonstration and training programs.
13. States that receive a minimum allotment of title II funds (between
$100,000 and $250,000) may spend up to the amount required to support one
full-time equivalent employee for administration, planning, and evaluation.
14. CDC uses a grantee's federal negotiated indirect cost rate. Typical
examples of indirect costs are costs of general administrative services,
general research and technical support, security, rent, employee health and
recreation facilities, and operating and maintenance costs for buildings,
equipment, and utilities.
15. Grantees can carry out program activities themselves or by contract with
a program sponsor. Program sponsors are nonprofit organizations or
governmental housing agencies.
16. The analysis includes only title I and title II funds. We assigned all
ADAP funds, including any title I contributions, to statewide distribution.
Remaining title I funds and title II consortia funds for the EMA community
were assigned to the EMA. Other title II consortia funds were assigned to
the remainder of the state. We did not include title III grants in our
analysis because these are not distributed by formula. However, in fiscal
year 1999 half of the 26 title III grants in these six states were awarded
to organizations located within the EMAs.
17. Reporting periods for ADAP clients varied: Two states provided number of
clients receiving medications during June 1999, two states included clients
enrolled during June 1999, and two states provided the number of clients
enrolled as of June 30, 1999. The estimated number of people living with
AIDS is as of June 30, 1998. As with other comparisons in this report, we
are not including people with HIV infection who have not progressed to AIDS,
since not all states report HIV cases.
18. CARE Act client data are by zip codes; AIDS population data are by
county.
19. IRS Form 990 instructions state that compensation includes salary, fees,
bonuses, and severance payments. For this report, we included in the
computation of total compensation contributions to employee benefit plans,
deferred compensation, and expense account and other allowances.
20. The compensation line item from IRS Form 990 includes salary, fees,
bonuses, and severance pay. We also included as part of total compensation
contributions to employee benefit plans, deferred compensation, and expense
account and other allowances. These line items were also obtained from Form
990.
21. Because of the limited number of CDC prevention grantees, we included
these grantees; they are in San Antonio, Tex.; Jersey City, N.J.; New York,
N.Y.; Hartford, Conn.; and San Francisco, Calif.
22. Of the 273 organizations, 107 were in San Francisco, 31 in Dallas, 92 in
Philadelphia, 21 in Kansas City, and 22 in St. Louis.
23. We limited our analysis to organizations with revenues of $300,000 or
more. However, in some cases, the IRS file we used to identify the
orgnizations had revenue amounts different from those in the file used for
analysis.
24. Congressional Budget Office, Comparing the Pay and Benefits of Federal
and Nonfederal Executives (Washington, D.C.: CBO, Nov. 1999).
25. The NonProfit Times Online, The 1998 Salary Survey (Cedar Knolls, N.J.:
The NonProfit Times Online, Feb. 1999).
*** End of document ***