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. 

  • Hold harmless provisions

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 

  • Funding formula

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.

  • Authorizes a $30 million grant program to states for efforts to prevent perinatal transmission

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.

  • Institute of Medicine Report on Perinatal Transmission

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

  • Preference for funding is given to agencies applying from rural areas and areas that are underserved with respect to such services and are located in states without Title I grants.

  • 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. 

  • AIDS Dental Reimbursement Program

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.

  • 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:

 



Key provisions of
S. 2311

Key provisions of 
H.R. 4807

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