The Department of Health and Human Services (HHS) provides funding under numerous grant programs to address the needs of individuals affected by the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the United States. The Minority AIDS Initiative (MAI) was established in 1998 in response to growing concern about the impact of HIV/AIDS on racial and ethnic minorities in the United States. The Health Resources and Services Administration’s (HRSA) MAI program was codified into law as part of the 2006 reauthorization of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act), which was enacted to address the treatment needs of uninsured and underinsured persons living with HIV/AIDS. Other HHS agencies and offices carry out MAI grant programs separate from the statutory MAI program that HRSA implements under the CARE Act. Congress has not enacted specific appropriations provisions applicable to all of these agencies’ and offices’ MAI grant programs. As a result, where a specific appropriation is absent, HHS exercises discretion in allocating this funding to numerous agencies and offices to implement separate MAI grant programs, which may be influenced by any applicable committee report language accompanying their annual appropriations acts.
According to data from the Centers for Disease Control and Prevention (CDC), racial and ethnic minorities in the United States have been disproportionately affected by AIDS, representing 72 percent of new HIV infections and 74 percent of all AIDS diagnoses in 2011. HHS awards MAI grants to provide services for communities disproportionally affected by HIV/AIDS. MAI grantees include health departments, state and local governments, tribal governments, community health centers, hospitals and medical centers, community-based organizations, colleges and universities, AIDS Education and Training Centers, and national HIV/AIDS organizations such as the National Minority AIDS Council. In fiscal year 2011, 10 agencies and offices within HHS allocated a total of $416.5 million to MAI programs.
In addition to MAI funds, two agencies within HHS—HRSA and CDC—administer grant programs that provide core HIV/AIDS funding for HIV/AIDS services to all qualifying individuals affected by HIV/AIDS. HRSA awards core HIV/AIDS grants pursuant to the CARE Act. CDC awards core HIV/AIDS grants for prevention programs, research and evaluation, surveillance, and policy development to reduce the impact of HIV/AIDS. In fiscal year 2011, CDC’s and HRSA’s combined budget for core HIV/AIDS funding was $2.76 billion. Similar to MAI grants, core HIV/AIDS grants are awarded to health departments, state governments, community health centers, hospitals, community-based organizations, universities, and AIDS Education and Training Centers. Many grantees are awarded both MAI and core HIV/AIDS grants.
Pub. L. No. 101-381, 104 Stat. 576 (1990), codified, as amended, at 42 U.S.C. §§ 300ff through 300ff-121. The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless otherwise indicated, references to the CARE Act refer to current title XXVI. The CARE Act programs have been reauthorized by the Ryan White CARE Act Amendments of 1996 (Pub. L. No. 104-146, 110 Stat. 1346 (1996)), the Ryan White CARE Act Amendments of 2000 (Pub. L. No. 106-345, 114 Stat. 1319 (2000)), the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767 (2006)), and the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885 (2009)).
In addition to grants, some agencies may have awarded MAI funding to recipients through other mechanisms such as cooperative agreements, contracts, or interagency agreements. GAO treated all recipients as “grantees” regardless of the funding mechanism by which they received their funds.
Sixteen AIDS Education and Training Centers provide HIV/AIDS education to health professionals such as nurses and physicians.
We use the term “core funding” to refer to those funding programs administered by CDC and HRSA that are intended to provide services to all qualifying individuals affected by HIV/AIDS, as opposed to HHS’s Minority AIDS Initiative’s targeted funding programs.
In November 2013, GAO reported that MAI and core HIV/AIDS funding is fragmented across numerous agencies and offices in HHS and that all grantees provide similar services to respond to the same national need. Ten different HHS agencies and offices awarded HIV/AIDS grants through multiple funding streams. In fiscal year 2011, 56 percent (596) of the 1,067 MAI grantees received several HIV/AIDS grants, including at least one MAI grant and one core HIV/AIDS grant. For these 596 grantees, the average MAI grant was $391,225, while the average core HIV/AIDS grant was $3,823,102.
In addition to fragmentation, GAO found that the services provided by MAI grantees overlapped, meaning that they were similar to those provided by grantees awarded HRSA’s and CDC’s core HIV/AIDS funding and that those services were being provided to similar populations. GAO found that MAI grantees were providing mostly support services with their MAI grants, similar to the types of support services grantees provided with core HIV/AIDS funding from CDC and HRSA. These support services included community outreach and education for the purpose of recruiting and retaining clients to HIV/AIDS services; client assistance, which included care coordination, case management, or referrals to care; and staff or provider training such as training to keep providers informed about HIV-related clinical service guidelines. The demographic information available from HHS agencies and offices, while limited, suggested that the majority of those served with both MAI and core HIV/AIDS grants are racial and ethnic minorities. This is consistent with the current distribution of HIV/AIDS in the United States.
GAO’s work on duplication and fragmentation has found that the presence of fragmentation can lead to instances of overlap and duplication among government agencies or programs that have similar goals or activities. Similarly, the National HIV/AIDS Strategy of 2010 noted the issue of multiple funding streams as one that could complicate the coordination of HIV/AIDS programs. The Strategy stated that “HIV service providers often receive funding from multiple sources with different grant application processes and funding schedules, and varied reporting requirements.” GAO also has identified approaches that agencies can take to improve efficiency, such as streamlining or consolidating management or operational processes to make them more cost-effective.
The fragmented nature of MAI and core HIV/AIDS funding has caused administrative challenges for grantees by often forcing grantees to manage grants from several sources. These funding sources required them to complete multiple administrative requirements. For example, the city of Chicago received nine grants from HHS to provide HIV/AIDS services, including six MAI grants and three core HIV/AIDS grants. Each of these grants has administrative requirements, such as application and reporting requirements, associated with it. As a result, Chicago is required to submit a report or application for one of its HIV/AIDS grants in most months of the year and in some months, they are required to produce multiple submissions. While some of the specific services Chicago provided with the nine grants varied, all of the grants were used to provide HIV/AIDS treatment or prevention services to residents of the city of Chicago. Other cities with a similar array of grants include Philadelphia, San Francisco, Los Angeles, and New York City. Such overlap in reporting requirements increases the administrative costs associated with participating in the programs.
Because of the administrative requirements associated with managing multiple HIV/AIDS grants, some grantees decided not to apply for MAI grants. In fiscal year 2011, according to information provided by HRSA, 37 percent of state grantees chose not to apply for MAI grants. Some grantees that chose not to apply were states with sizeable minority populations. HRSA officials stated that several grantees reported that their reasons for not applying for MAI funds were that the small size of MAI grants did not provide enough funding to implement a program and justify the additional administrative requirements. The fragmented nature of the MAI and core HIV/AIDS funding and the accompanying administrative requirements could discourage some grantees from applying for this funding and divert resources from providing HIV/AIDS services.
Fragmentation occurs when one or more federal agencies or agency organizations are involved in the same broad area of national need and opportunities exist to improve service delivery. Overlap occurs when multiple agencies or programs have similar goals, engage in similar activities or strategies to achieve them, or target similar beneficiaries. Duplication occurs when two or more agencies or programs are engaged in the same activities or provide the same services to the same beneficiaries. See GAO, 2013 Annual Report: Actions Needed to Reduce Fragmentation, Overlap, and Duplication and Achieve Other Financial Benefits, GAO‑13‑279SP(Washington, D.C.: April 2013).
The White House, National HIV/AIDS Strategy for the United States, July 2010, p.42.
In order to reduce the administrative costs associated with a fragmented MAI grant structure that diminishes the effective use of HHS’s limited HIV/AIDS funding, and to enhance services to minority populations, GAO recommended in November 2013 that HHS should take the following two actions:
Implementation of these recommendations would help the government more efficiently and effectively provide HIV/AIDS services to minority populations who are disproportionally affected by HIV/AIDS. GAO did not conduct an analysis of the benefits of consolidating MAI and core HIV/AIDS funding, but consolidating these programs would likely increase the efficiency of the provision of HIV/AIDS services to minority populations with the approximately $3 billion used for this purpose.
The information contained in this analysis is based on findings from the product in the related GAO product section. To examine the types of services provided by MAI grantees, GAO reviewed services reported in fiscal year 2011 MAI grantee annual reports from a generalizable sample of 100 grantees. GAO reviewed grant administrative requirements, including application and reporting requirements for MAI and core HIV/AIDS grants in the generalizable sample. GAO also obtained, reviewed, and analyzed the core HIV/AIDS grant amounts that MAI grantees in the sample were awarded in order to understand the total amount of HIV/AIDS funding that MAI grantees received. GAO then compared the core HIV/AIDS grant amounts to their MAI grant amounts. To determine core HIV/AIDS grant amounts, GAO used CDC and HRSA funding data in addition to publicly available funding data. GAO interviewed all 10 HHS agencies and offices that awarded MAI grants in fiscal year 2011 and staff from six stakeholder organizations, including national HIV/AIDS organizations that represent MAI grantees, to obtain their perspectives on MAI. GAO also reviewed the available demographic data on the race and ethnicity of clients served with MAI grants.
Table 6 in appendix IV lists the agencies GAO identified that might have similar or overlapping objectives, provide similar services, or be fragmented across government missions. Overlap and fragmentation might not necessarily lead to actual duplication, and some degree of overlap and duplication may be justified.
In commenting on GAO’s November 2013 report, on which this analysis is based, HHS stated that GAO’s recommendations align with the National HIV/AIDS Strategy and federal program accountability goals, but also stated that any restructuring of its HIV/AIDS funding approach must ensure continued responsiveness to minorities who are disproportionately affected by HIV/AIDS. HHS said it welcomed an expanded discussion of strategies to more efficiently administer MAI, reduce duplicative requirements for grantees, and more effectively administer HIV/AIDS funding streams. HHS also described some of its efforts to make its program more efficient, responsive, and accountable since the release of the National HIV/AIDS Strategy in July 2010.
HHS noted in its comments that it has several things to consider before it moves to restructure its HIV/AIDS core funding streams and consolidate MAI within core funding streams. HHS also noted that grantees’ administrative challenges are important, but aren’t the only consideration in assessing the merits of funding streams and the programs they produce. For example, HHS noted that any restructuring of core HIV/AIDS funding must ensure that HHS continues to be responsive to the needs of communities and populations disproportionately impacted by the HIV/AIDS epidemic.
GAO provided a draft of this report section to HHS for its review and comment. HHS provided its comments in an email received on February 27, 2014. HHS stated that it concurred with the facts presented but, in contrast to its comments on the 2013 report, disagreed with the characterization of “fragmentation, overlap and duplication” in describing the administration of MAI and its impact on the jurisdictions that receive HIV/AIDS funding. HHS also stated that it does not support consolidation of MAI into core funding at this time. GAO maintains that the findings in this report support consolidation of the disparate MAI funding streams into core funding to achieve administrative savings, and, as HHS noted in its comments on the 2013 report, align with the National HIV/AIDS Strategy and federal program accountability goals.
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