HIV/AIDS:

Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds

GAO-06-332: Published: Feb 28, 2006. Publicly Released: Feb 28, 2006.

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Among federal efforts to address the HIV/AIDS epidemic are the CARE Act of 1990 and the Housing Opportunities for Persons with AIDS program (HOPWA) administered by the Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD), respectively. Both use formulas based upon a grantee's number of AIDS cases, rather than HIV and AIDS cases, to distribute funds to metropolitan areas, states, and territories. HIV cases must be incorporated with AIDS cases in CARE Act formulas not later than fiscal year 2007. GAO was asked to examine (1) how CARE Act and HOPWA funds are allocated among types of services, (2) the extent of funding distribution differences among CARE Act and HOPWA grantees, and how funding formula provisions contribute to these differences, and (3) what distribution differences could result from incorporating HIV case counts in CARE Act and HOPWA funding formulas.

CARE Act and HOPWA grants are allocated by grantees for health care, housing assistance, and a variety of services for people with HIV/AIDS. These grants provide services for persons who have been diagnosed with HIV that has not progressed to AIDS as well as those for whom it has. In fiscal year 2003, more than half of Title I CARE Act funds awarded to eligible metropolitan areas (EMAs) were allocated for health care services such as outpatient care and home health services, and over two-thirds of Title II CARE Act funds awarded to states and territories were allocated for medications. Two-thirds of HOPWA funds were used for direct housing costs for people with HIV/AIDS and their families. Multiple provisions in the CARE Act and HOPWA grant funding formulas as enacted result in funding not being comparable per AIDS case across grantees. First, both the CARE Act and HOPWA use measures of AIDS cases that do not accurately reflect the number of persons living with AIDS. For example, the statutory funding formulas require the use of cumulative AIDS case counts, which could include deceased cases. Second, AIDS cases within EMAs are counted once for determining funding under Title I of the CARE Act for EMAs and again under Title II for determining funding for the states and territories in which those EMAs are located. As a result, states with EMAs receive more total funding per case than states without EMAs. Third, CARE Act hold-harmless provisions under Titles I and II and the grandfather clause for EMAs under Title I sustain the funding and eligibility of CARE Act grantees on the basis of a previous year's measurements of the number of AIDS cases in these jurisdictions. For example, under Title I's hold-harmless provision, one EMA continues to have deceased AIDS cases factored into its allocation because its hold-harmless funding dates back to the mid-1990s when formula funding was based on a count of AIDS cases from the beginning of the epidemic. If HIV case counts had been incorporated along with AIDS case counts in allocating fiscal year 2004 CARE Act and HOPWA grants, funding would have shifted among jurisdictions. Grantees in the South and the Midwest generally would have received more funding, although there would have been grantees that would have received increased funding and grantees that would have received decreased funding in every region of the country. Although CARE Act and HOPWA grantees have established HIV case reporting systems, differences between these systems--in their maturity and reporting methods, for instance--would impact the appropriateness of using HIV case counts in distributing CARE Act and HOPWA funding. GAO found that CARE Act and HOPWA fiscal year 2004 funding would have shifted to jurisdictions with more mature HIV reporting systems.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Matters for Congressional Consideration

    Matter: If Congress wishes to preserve funding for the ADAP Severe Need grants, it may wish to consider revising the Title II hold-harmless provision that is funded with amounts set aside for ADAP Severe Need Grants.

    Status: Closed - Implemented

    Comments: In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the provision that funded hold-harmless payments with amounts set aside for AIDS Drug Assistance Program severe need grants was eliminated. Instead, funding for hold-harmless payments would be come from a different source.

    Matter: While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider eliminating the two-tiered structure of the Emerging Communities program.

    Status: Closed - Implemented

    Comments: In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the Emerging Communities provision was changed so that there was only one group of emerging communities rather than two.

    Matter: While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider modifying the Title I grandfather clause, which protects the eligibility of metropolitan areas that no longer meet the eligibility criteria.

    Status: Closed - Implemented

    Comments: In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the grandfather clause which protected the eligibility of metropolitan areas that no longer met the eligibility criteria was modified so that funding eligibility would end if for three consecutive years a metropolitan area does not meet specified criteria.

    Matter: While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider modifying the hold-harmless provisions for Title I, Title II, and AIDS Drug Assistance Program base grants to reduce the extent to which they prevent funding from shifting to areas where the epidemic has been increasing.

    Status: Closed - Implemented

    Comments: In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, Congress eliminated the hold-harmless provision for one set of metropolitan areas, eliminated two hold-harmless provisions for states, territories, and the District of Columbia, and modified a third hold-harmless provision for states, territories, and the District of Columbia.

    Matter: While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider eliminating the counting of cases in EMAs for Title I base grants and again for Title II base grants.

    Status: Closed - Implemented

    Comments: In this report, we stated that if Congress wanted the Ryan White CARE Act funding to more closely reflect the distribution of persons living with AIDS, it should eliminate the counting of cases for both Title I grants to metropolitan areas and for Title II grants to states, the District of Columbia, and territories. This is referred to as double counting. In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby reauthorizing the CARE Act. In the reauthorization, Congress addressed double counting in two ways. First, Congress stipulated a new funding formula for CARE Act grants to states, the District of Columbia, and territories. This change partially reduced the impact of double counting by altering how funding was allocated among grantees. Second, Congress stated that the Secretary of Health and Human Services should develop a Severity of Need Index that, when ready, would replace the formula for determining funding to states, the District of Columbia, and territories.

    Matter: While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider revising the funding formulas used to determine grantee eligibility and grant amounts using a measure of living AIDS cases that does not include deceased cases and reflects the longer lives of persons living with AIDS.

    Status: Closed - Not Implemented

    Comments: In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, Congress implemented part of our suggestion regarding how AIDS cases are counted. Congress changed how the number of living AIDS cases was counted for determining grantee amounts and, therefore, grant amount are now based on a better measure of the number of AIDS cases living in a jurisdiction. However, Congress retained or implemented new eligibility criteria for grants that do not necessarily reflect the number of persons living with AIDS in a jurisdiction. In October 2009, Congress again reauthorized the Ryan White CARE Act (Public Law 111-87). It did not make any additional changes in the methods used to determine eligibility for CARE Act grants.

    Matter: If Congress wishes HOPWA funding to more closely reflect the distribution of persons living with AIDS, it may wish to consider changing the program so that HOPWA formula grant eligibility, including for bonus grants, and base grant funding allocations are based on a measure of living AIDS cases.

    Status: Closed - Not Implemented

    Comments: Congress has not taken action to change how AIDS cases are counted in the Department of Housing and Urban Development's Housing Opportunities for Persons with AIDS program.

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