Ryan White Care Act

The distribution of federal resources needs to reflect the changing nature of the HIV/AIDS epidemic. New medicines and treatments have lengthened the life expectancy of infected persons. Before the 1996 reauthorization of the Ryan White CARE Act, which replaced cumulative AIDS case counts with estimates of living AIDS cases, the areas of the country with the longest experience with the disease benefited most from using cumulative case counts. HIV counts have not been considered in the funding formulas. Today, only about 60 percent of the states include HIV cases that have not progressed to AIDS. To ensure that the formulas provide an equitable distribution of funds, all states would need to report HIV cases. All states are expected to be reporting new HIV cases by 2003. Currently, states with an eligible metropolitan area (EMA) receive more funds than those who do not have an EMA. States such as California and New York, for example, received $5,240 per case, or 60 percent more than states without an EMA. Finally, a hold-harmless provision in the 1996 reauthorization that would help states transition from a cumulative AIDS cases to living AIDS cases has been very gradual; however, only San Francisco has benefited from the hold-harmless provision as of 1999. GAO recommends changing the Ryan White funding formulas to enhance comparable funding across the states. GAO believes that including living HIV case data will improve the ability of the Ryan White CARE Act to effectively deliver funding to needy persons.

GAO noted that: (1) only about 60 percent of the states include HIV cases that have not progressed to AIDS in their reports and have been approved by the Centers for Disease Control and Prevention (CDC); (2) to ensure that the formulas provide an equitable distribution, all states would need to report HIV cases; (3) CDC officials told GAO that they expect all states to be reporting new HIV cases by 2003 and that an additional 1 to 3 years may be needed to allow cases that existed before then to be entered into their reporting systems; (4) however, the states' ability to completely identify past cases is not known; (5) GAO also found substantial differences in funding between states with an EMA and those without one; (6) for example, in fiscal year (FY) 2000 states that had no eligible EMA received on average of $3,340 per person suffering from AIDS; (7) in contrast, the states with more than 75 percent of their AIDS cases in an EMA received nearly 50 percent more, averaging $4,954 per AIDS case; (8) states such as California and New York with more than 90 percent of their cases in EMAs received $5,240 per case or almost 60 percent more than states without an EMA; (9) GAO has in the past recommended changes to the Ryan White Funding Formulas that would result in more comparable funding across states; (10) a hold-harmless provision was included in the 1996 reauthorization to help EMAs that would receive less funding under the revised funding formulas adopted in FY 1996; (11) the transition has been very gradual and has had the effect of providing some EMAs with more funding on a per-person-with-AIDS basis than other similarly situated EMAs; (12) only one EMA, San Francisco, continues to benefit from the hold-harmless provision, and it received substantially more aid than other similarly situated EMAs; (13) for example, San Francisco received more than 80 percent greater title I funding per person with AIDS than other EMAs; (14) Oakland, across the bay from San Francisco, and all other EMAs received $1,289 per person in FY 2000 title I funding compared with San Francisco's $2,359 per person; and (15) San Francisco continues to benefit from the hold-harmless provision because a large proportion of its cumulative AIDs cases were deceased under the formula used before FY 1996 and because there have been smaller increases in new AIDS cases compared with other EMAs.