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August
1, 2000
Update on Ryan White Reauthorization
This
page will be updated as legislative action occurs on
the
Ryan White Reauthorization. Please check back for updates.
Ryan
White Bill Passes House and Senate;
Differences Will be Reconciled in
House-Senate Conference
S.
2311, Ryan White Care Amendments of 2000, a bill to
reauthorize
the Ryan White CARE Act for 5 years, was
introduced on March 29th
and voted unanimously out of the
Senate Health, Education, Labor and Pensions Committee on
April 12th. A bipartisan effort of Committee Chair Senator Jim
Jeffords (R-Vt.) and Ranking Minority Member, Senator Ted
Kennedy (D-Mass.), the reauthorization maintains the
fundamental structure of the current CARE Act program, and
appears to be modeled largely on the recommendations of
leading national AIDS organizations.
The Bill was passed by the Senate on June 7th. The full text of the bill
is available on the Congressional website: http://thomas.loc.gov.
Enter bill number, S. 2311, and click on search.
On
June 29, 2000 Rep. Tom Coburn (R-OK) and Rep. Henry Waxman
(D-CA) introduced their reauthorization bill, H.R. 4807. Coburn and Waxman negotiated over a period of weeks on the
development of the bipartisan bill. Hearings were held
on the measure on July 11, 2000 and the House Commerce
Committee voted to approve the bill with several
amendments. The bill passed the House on July 26th.
After the August recess, House and Senate members will meet to
reconcile the differences between the two versions of Ryan
White Reauthorization Legislation. A compromise version
in the form of a conference report must then be voted on in
both the House and the Senate before being sent to the
President for his signature. Time is short, but Ryan
White advocates are hopeful that a reauthorization bill can be
signed into law before Congress adjourns for the session in
early October.
The
House bill resembles the Senate measures in many respects, but
there are also key differences, including the House bill's
focus on prevention services like reducing perinatal
transmission and partner notification services. Another
major issue of contention is the hold harmless provision under
Title I, that would allow an eligible metropolitan area (EMA)
to potentially experience a loss of funding over 25 percent
over the five-year life of the program based on diminishing
number of cases. Congressional and community advocates
for San Francisco believe that this provision will primarily
affect funding for their city. The comparable provision
in the Senate passed bill would allow only a 10 percent loss
of funding for any given EMA over the five-year period.
This issue ultimately will be decided in the House-Senate
conference to reconcile the two different bills. The full text of the bill
is available on the Congressional website: http://thomas.loc.gov.
Enter bill number, H.R.
4807, and click on search.
Key
provisions of S. 2311 that
modify the existing
Care Act programs include:
Title
I
- Duties
of the Planning Council
Requires the development of priorities for allocations of
resources to include the availability of other funding
sources such as Medicaid and State Children's Health
Insurance Program (SCHIP) and capacity development needs
resulting from gaps in the availability of HIV services in
historically underserved low-income communities.
Requires, not later than 2 years after enactment, planning
for individuals with HIV disease not currently in care.
- Hold
harmless provisions
Title I grantees are limited to a funding loss of no more
than 2 percent a year per year over the 5 year period of
the law‹ no more than a 10 percent loss over 5 years,
notwithstanding greater fluctuations in AIDS case loads.
Title
I and Title II
- Establishment
of a Quality Management Program
Requires the
establishment of a quality management program to ensure
that medical services provided to patients are consistent
with the most recent PHS guidelines for the treatment of
HIV disease and related opportunistic infections and that
improvement in the access to and quality of care are
addressed.
Up to 5 percent of Title I grants or $3 million, which
ever is less, may be used for these purposes. Up to $3
million of Title II grants may be used for these purposes,
except in states that receive a Title II award of $1.5
million or less where expenditures for this purpose cannot
exceed 20 percent of the grant award.
- Funded
entities must have relationships with points of access to
health care.
Organizations receiving Title I and Title II subgrants are
required to maintain referral relationships for points of
entry to the health care system for the purpose of
facilitating early intervention for individuals newly
diagnosed with HIV disease and individuals knowledgeable
about their HIV status. Entry points identified in the
bill include: emergency rooms, substance abuse treatment
programs, detoxification centers, adult and juvenile
detention facilities, sexually transmitted disease
clinics, HIV counseling and testing sites, and homeless
shelters.
- Support
services funded under Title I and Title II must be
health-related.
All funded outpatient and ambulatory support services,
including case management, must facilitate, enhance,
support, or sustain the delivery, continuity, or benefits
of health services for individuals and families with HIV
disease.
- Allows
use of grant funds for early intervention services
Allows grantees that serve as key points of entry to
medical care or those that are current Ryan White-funded
medical sites to include HIV early intervention activities
to support early diagnosis and provide linkages into care
among populations at high risk for HIV infection.
Title
II
- Increases
the minimum Title II base award to $500,000 for states
with 90 or more living cases of AIDS, and to $200,000 for
states with fewer than 90 living cases of AIDS.
- Set-aside
for infants, children, and women
Requires Title II grantees to provide resources for
infants, children and women proportionate to the
percentage each group represents in the state's AIDS
population.
- Use
of AIDS Drug Assistance Program (ADAP) Funds
Allows
states that provide a comprehensive formulary of HIV
medications to all eligible recipients to use up to 10
percent of their ADAP funds to provide services that
encourage, support and enhance adherence with treatment
regimens, including medical monitoring.
- Creates
a new supplemental grant program for certain states.
Funding preference will be given to "emerging
communities" defined as cities with between 1,000 and
1,999 living AIDS cases in the last 5 years. States must
demonstrate that there is a severe need for supplemental
financial assistance in areas in the state not served
under Title I. States must demonstrate that they will
maintain HIV-related activities at a level at least equal
to the year prior to the grant; must demonstrate an
existing commitment of local resources, both financial and
in-kind; and must present a planning process for funding
allocation that includes affected communities and
individuals with HIV disease. Grants will be funded out of
a reserve fund created by withholding 50 percent of any
funding increase appropriated for Title II in a given
fiscal year, or $5 million.
- Creates
a new supplemental grant program for states for the
provision of therapeutics.
Provides for the awarding of supplemental grants to enable
states to provide assistance with medications for
individuals living at or below 200 percent of the federal
poverty level (FPL). In order to be eligible, states must
demonstrate that they are unable to provide HIV
therapeutic regimens to all eligible individuals living at
or below 200 percent of FPL; and states must demonstrate
that they are unable to provide all eligible individuals
appropriate HIV regimens in approved federal guidelines.
States must make available non-federal contributions
toward this effort at an amount equal to $1 for each $4 in
federal funds provided under this grant. Grants will be
funded from a reserve created from withholding at least 2
percent, not to exceed 4 percent of ADAP appropriations.
Title
III
- Planning
and Development Grants
Provides for new capacity and development grants to assist
public and non-profit agencies to provide HIV early
intervention services or to assist agencies to expand the
capacity, preparedness, and expertise to deliver primary
care services to individuals with HIV disease in
underserved low-income communities. Funds early
intervention services grants at $50,000 and capacity
development grants at $150,000. Limits capacity
development grants to 3 years. Increases the percentage of
appropriations that can be utilized for planning and
capacity development grants from 1 percent to 5 percent.
- Increases
the administrative cap for directly funded Title III
grants from 7.5 percent to 10 percent.
- Directs
HRSA to give preference to applications from non-Title I
EMA underserved areas when awarding new grants under Title
III.
Title
IV
- Removes
requirement that Title IV grantees enroll a
"significant number" of patients in research
projects, but requires better documentation of the
linkages between care and research.
- Directs
NIH Director to examine the distribution and availability
of HIV-related research projects to existing Title IV
sites for purposes of enhancing and expanding voluntary
access to HIV-related research.
- Administrative
expenses
Establishes a process for a review of
administrative and program support expenses to determine
fiscal year 2002 limitations on allowable amounts for
administrative and program support expenses.
General
Provisions
- Institute
of Medicine (IOM) Study
Requires an IOM study, within 2 years of enactment, of the
financing and delivery of primary care and support
services for low income, uninsured and underinsured
individuals with HIV disease. The study shall consider:
- Availability and utility of health outcomes measures and
data for HIV primary care and support services and whether
those measures and data could be used to measure the
quality of services.
- Effectiveness and efficiency of service delivery with the
context of a changing health care and therapeutic
environment as well as the changing epidemiology of the
epidemic.
- Existing and needed data for resource planning and
allocation decisions, specifically for estimating severity
of a community's need and the relationship to the
allocations process.
- Other factors deemed relevant to assessing an
individual's or a community's ability to gain and sustain
access to quality HIV services.
Key
provisions of H.R. 4807 that
modify
the existing Care Act programs include:
Title I
- Composition
of the Title I Planning Council
Requires that
at least one-third of the membership shall be individuals
receiving HIV-related services under Title I who do not have a
financial relationship with any subgrantee.
Adds representatives of incarcerated or formerly
incarcerated persons, HIV prevention providers, and providers
of housing and homeless services. There must be public notice
about meetings and meetings must be public.
If any
eligible area should experience a reduction in its Title I
allocation, its losses would be held to the following
percentages of the amount allocated in the previous year:
2 percent in year 1; 4.3 percent in year 2; 8.9 percent
in year 3, 15.8 percent in year 4; and 25 percent in year 5.
Should a Title I area experience a decline in its
formula allocation followed by an intervening year in which
there is no decline, losses in any subsequent, nonconsecutive
year of decline would once again be limited to 2 percent.
- Supplemental
Grant Program
Places
greater weight on demonstrating “severe need” to qualify
for additional resources.
The Secretary shall take into consideration both HIV
and AIDS prevalence, increasing need for services and the
level of unmet needs. Requires
the Secretary to develop national, quantitative data and a
mechanism to use such data in awarding supplemental grants.
- Review
of Administrative Costs and Compensation
Requires
eligible areas to conduct a review of existing data on the
growth and proportion of administrative costs, including
compensation, expended by Title I service providers.
Review shall include average client cost data on all
expenditures and on expenditures on services, and a
determination of whether the employees of such providers
receive greater compensation than the chief elected official
of the eligible areas.
Title I and Title II
Revises
formula to count living cases of HIV disease instead of just
AIDS cases. Because
a number of states do not have HIV reporting systems in place,
HIV disease would be the funding formula by fiscal year 2005
if the Secretary determines that there is data from HIV cases
from all areas. If
the Secretary determines that such data is not available, only
AIDS data will be used in FY 2005 allocations, and the
Secretary shall provide grants and technical assistance to
states and EMAs to ensure that reliable HIV case data is
available no later than FY 2007.
- Allows
use of Title I and Title II funds for early intervention
services and outreach activities necessary to identify
individuals with HIV/AIDS who are not receiving care.
Identifies
public health departments, emergency rooms, substance abuse
treatment programs, detoxification centers, detention
facilities, sexually transmitted diseases clinics, homeless
shelters, and HIV counseling and testing sites as potential
grantees under this section. Funds utilized for early
intervention must supplement and not supplant other funds
available for this purpose.
- Establishment
of a quality management program
Title I and
Title II grantees must establish a quality management program
to assess the extent to which health services being provided
under the grant are consistent with most recent PHS guidelines
and develop strategies to ensure that services are consistent
with the guidelines. Funds
utilized for this purpose cannot be more than 5 percent of the
grant or $3 million, whichever is less.
- Requires
that funded support services, including case management,
directly support or sustain the delivery or benefits of
health care for individuals with HIV disease.
- Requires
Title I and II grantees, within 2 years of enactment, to
develop and implement a plan to ensure that HIV-related
health services are coordinated with programs that provide
drug abuse prevention and treatment services.
- Requires
the HHS Secretary to submit a plan to Congress, not more
than 18 months after enactment, for coordinating funding
for grants under Title I and Title II.
Two years after submission of the plan, the
Secretary shall complete implementation.
- Within
2 years of enactment, the Secretary shall make a
determination whether efficiency would be improved by
requiring that applications for grants under Titles I and
II be submitted biennially rather than annually.
- Within
18 months of enactment, the Secretary submits a plan to
Congress to simplify the process for applications under
Titles I and II. Not later than 2 years after plan
submission, the plan shall be implemented.
Title II
- Increases
the minimum Title II base award to $500,000 for states
with 90 or more living cases of AIDS, and to $200,000 for
states with fewer than 90 living cases of AIDS.
- Creates
supplemental grant program for certain states
Creates a
supplemental competitive grant program for states with one or
more rural or underserved communities that are not eligible
for Title I funding. The
Secretary will take into consideration factors including
evidence of disparities in access and services and
historically underserved communities. Funding for this program is triggered only when funding for
Title II care programs is at least $20 million more than Title
II care funding for FY 2000.
- Creates
AIDS Drug Assistance Program (ADAP) supplemental fund
Reserves
2 percent of overall ADAP allocation for making grants to
states with ADAP funding shortfalls.
States must make available non-federal contributions
toward this effort at an amount equal to $1 for each $4 in
federal funds provided under this grant.
- Authorizes
a $30 million grant program to states for partner
notification activities
States
that satisfy a series of requirements could apply for funding
for partner notification programs under the CARE Act.
Those requirements include offering counseling, testing
and treatment, social services and legal referrals to
partners, annually reporting the number of individuals from
whom names of partners have been sought to the CDC, and state
cooperation with the CDC Director in carrying out a national
program of partner notification, including the sharing of
public information between the public health officers of the
states. For FY
2001-FY 2003, the Secretary shall give preference to states
whose reporting systems for cases of HIV disease produce data
that is sufficiently accurate and reliable.
For FY 2004 and subsequent years, a state may not
receive a grant unless the reporting system for cases of HIV
disease produces data that is accurate and reliable.
Expands
current grant program targeting perinatal transmission of HIV.
Adds treatment services for pregnant women with HIV to
the currently authorized uses of counseling, voluntary testing
and outreach for pregnant women with HIV.
Funding for this program at levels above $10 million
will have increasing percentages of funding reserved for
states that require HIV testing of all newborns or that
require testing of all newborns in cases in which the
attending physician does not know the HIV status of the
mother. State grants would be capped at $4 million and any
unobligated funds from the set-aside for mandatory testing
states would be made available to all states.
The
report will document the number of newborns with HIV born in
the U.S. where the attending physician did not know the HIV
status of the mother; identify state barriers to making it a
routine practice to test newborns when mother’s status is
unknown; and develop recommendations for each state to reduce
perinatal transmission.
Title
III
- Planning
and Development Grants
Provides
for grants for early intervention services and capacity and
development grants to assist public and non-profit agencies to
provide HIV-related health services, in underserved low-income
communities. Early
intervention grants will be funded at $50,000 and capacity
development grants at $150,000.
- Increases
the administrative cap for directly funded Title III
grants from 7.5 percent to 10 percent
- Requires
quality management program to assess the extent to which
medical services that are provided under the grant are
consistent with the most recent PHS guidelines, and that
improvements in the access to and quality of medical
services are addressed.
Title
IV
- Removes
requirement that Title IV grantees enroll a “significant
number" of patients in research projects, and
requires applicant to demonstrate linkages to research and
how such research is being offered to patients.
- Directs
NIH Director to examine the distribution and availability
of HIV-related research projects to existing Title IV
sites for purposes of enhancing and expanding HIV-related
research, especially within communities that are
underrepresented with respect to such projects.
- Requires
quality management program like those for other Titles.
Title V, Part F
- Special
Projects of National Significance
There
shall be one or more grant or contract award under this
section for research and other activities to develop a plan
for a system through which health care providers can readily
obtain federal treatment guidelines and protocols.
Such a system should include a toll-free line through
which health care providers can enter into discussions with
physicians and pharmacists who are experienced with respect to
the guidelines.
- AIDS
Education and Training Centers
Funding
is to be provided to train providers in gynecological care for
women with HIV disease and for the development of protocols
for the medical care of women with HIV disease, including
prenatal care.
The
Secretary is required, 90 days after enactment, to issue and
begin implementation of a strategy for the dissemination of
HIV treatment information to health care providers and
patients.
Amends
dental school grants to authorize cooperative projects
partnering dental schools and dental hygiene programs with
community-based dentists to provide care in unserved areas.
Reserves $3 million for such cooperative projects.
Authorizes dental hygiene programs to receive
reimbursement for services provided to individuals with
HIV/AIDS.
General Provisions
- Authorizes
additional funds for the CDC to collect and provide data
for Ryan White program planning and evaluation activities.
-
Requires
the Secretary to submit a plan to Congress, not later than
one year after enactment, for improving coordination of
HIV related health services funded under the CARE Act with
services provided under Medicaid, State Children’s
Health Insurance Program (SCHIP) and other federal
programs that are a significant source of funding for HIV
health services.
-
Plan
for medical case management of HIV-infected individuals
who were federal or state prisoners.
Secretary, after
consultation with Attorney General, Director of the Bureau
of Prisons, states, Title I grantees, Title II grantees,
will submit a plan to Congress within two years of
enactment.
-
Institute of
Medicine study
concerning the appropriate epidemiological measures
and their relationship to the financing and delivery of
primary care and health-related support services for
low-income, uninsured, and under-insured individuals with
HIV disease. Study will address the impact of modifying
the Medicaid program to establish Medicaid eligibility on
the basis of HIV infection rather than AIDS.
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Development of Rapid HIV
Test
Director of NIH shall expand
and coordinate research with respect to the development of
reliable and affordable tests for HIV disease that can rapidly
be administered and whose results can rapidly be obtained—and
report to Congress.
Not
later than 90 days after enactment, the Secretary in concert
with the CDC Director and the FDA Commissioner shall submit a
report to Congress regarding the premarket review and
commercial distribution of rapid HIV tests.
After
commercial distribution of a rapid HIV test begins, the CDC
Director shall establish or update guidelines that include
recommendations for states, hospitals and others regarding the
ready availability of such tests for administration to
pregnant women who are in labor or in the late stage of
pregnancy and whose HIV status is not known to the attending
physician.
For
more information, contact:
HIV Quality Care Network
Phone: 703/299-0200
Fax: 703/299-0204
Email: [email protected]
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