Ryan White Care Act:

Impact of Legislative Funding Proposal on Urban Areas

GAO-08-137R: Published: Oct 5, 2007. Publicly Released: Oct 5, 2007.

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The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act), administered by the Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA), was enacted to address the needs of jurisdictions, health care providers, and people with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and their family members. In December 2006 the Ryan White HIV/AIDS Treatment Modernization Act of 2006 reauthorized CARE Act programs for fiscal years 2007 through 2009. In July 2007, the House of Representatives passed H.R. 3043, the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act for fiscal year 2008, which contains a hold-harmless provision covering funding for urban areas that receive funding under the CARE Act. This bill has not been passed by the Senate. Under the CARE Act, funding for Eligible Metropolitan Areas (EMA) and Transitional Grant Areas (TGA) is primarily provided through three categories of grants: (1) formula grants that are awarded based on the case counts of people with HIV/AIDS living in an urban area; (2) supplemental grants that are awarded on a competitive basis based on an urban area's demonstration of need, including criteria such as HIV/AIDS prevalence; and (3) Minority AIDS Initiative (MAI) grants, which are supplemental grants awarded on a competitive basis for urban areas to address disparities in access, treatment, care, and health outcomes. The CARE Act includes a hold-harmless provision that limited the decrease that an EMA could receive in its formula funding for fiscal year 2007 to 5 percent of the fiscal year 2006 formula funding it would have received if the revised urban area allocations required by the Modernization Act of 2006 had been in place in fiscal year 2006. For fiscal years 2008 and 2009, the hold-harmless provision provides that an EMA will receive at least 100 percent of the amount of its formula funding for fiscal year 2007. However, no limitation applies to the decrease in total formula, supplemental, and MAI funding that an EMA can receive. As Congress considers appropriations for CARE Act programs for fiscal year 2008, on July 27, 2007, and September 11, 2007, Congress asked us to (1) provide historical information on the funding levels identified during the appropriations process for CARE Act grants to urban areas as compared to fiscal year 2008 CARE Act funding levels proposed as part of the fiscal year 2008 appropriations process in the House of Representatives; (2) examine how the proposed hold-harmless provision from H.R. 3043 would impact funding for urban areas under the proposed funding levels; (3) determine whether any urban areas receive funding based on the number of both living and deceased HIV/AIDS cases; (4) provide sources that address the amount of CARE Act funding unobligated by urban areas, states, and territories; and (5) provide sources that address the number of people on AIDS Drug Assistance Program (ADAP) waiting lists.

CARE Act funding for urban areas would increase under the funding level identified in the report of the House Committee on Appropriations for CARE Act grants to these areas. Since fiscal year 2001, CARE Act funding for urban areas specified in conference reports accompanying the appropriations acts has ranged from a high of $622,741,000 in fiscal year 2003 to a low of $604,200,000 in fiscal year 2001. For fiscal year 2008, the report of the House Committee on Appropriations specifies $636,300,000 for urban areas, an increase of approximately 4.3 percent over the amount specified in the conference report for fiscal year 2006 funding. This would reduce the amount available for fiscal year 2008 grants as described by the Committee to approximately $626,900,000. This represents an increase of approximately 2.8 percent over the amount specified in the conference report for fiscal year 2006. The funding for both EMAs and TGAs would be impacted by the proposed hold-harmless provision in H.R. 3043. Some EMAs and TGAs would receive additional funding for the 2007 program year under the provision, but the amounts needed to fund the hold-harmless provision would be taken from the amount that could otherwise be available for fiscal year 2008 funding. A total of $9,377,444 would be needed to fund the proposed hold-harmless provision, with $6,410,885 needed for EMAs and $2,966,559 for TGAs.

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