Ryan White CARE Act
Implementation of the New Minority AIDS Initiative Provisions Gao ID: GAO-09-315 March 27, 2009The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) makes federal funds available to assist individuals affected by HIV/AIDS. The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) awards CARE Act funding to grantees that include states, territories, and metropolitan areas. Because minorities have been disproportionately affected by HIV/AIDS, the CARE Act's Minority AIDS Initiative (MAI) provides funding through five parts (A, B, C, D, and F) of the act with the goal of reducing HIV-related health care disparities among minorities. The reauthorization of CARE Act programs changed the process by which HRSA awards MAI grants under Part A (funding for metropolitan areas) and Part B (for states and territories) from a formula based solely on demographics of the metropolitan area, state, or territory to a competitive process. The CARE Act requires GAO to report on MAI and related issues. This report provides information on (1) the effect on grantees and service providers of the new competitive process for awarding Part A and B MAI funds, (2) the types of services grantees funded under MAI, and (3) barriers to minorities obtaining services from HIV/AIDS programs that were identified by grantees. GAO surveyed CARE Act grantees and interviewed selected grantee and HRSA officials. GAO also reviewed Part A and B MAI applications.
The new competitive process for Parts A and B altered MAI funding amounts from what they would have been under the old formula-based process, increased administrative requirements for grantees, and resulted in continued funding for existing initiatives to reduce health disparities for minorities. In determining the award amounts under the new process, HRSA considered the number of minorities with HIV/AIDS living in the grantee metropolitan area, state, or territory, along with the MAI applications grantees were required to file. The quality of the grant applications sometimes resulted in considerable differences in grantees' share of MAI funds from what they would have received under the old process. Part A and B grantees that received MAI funding told us that the administrative requirements increased significantly because of the new process. All Part A and B grantees that applied for MAI funding received it, but some Part B grantees decided that the administrative requirements, including a separate application for MAI funds, were not worth the amount of funds that they expected to receive and therefore chose not to apply. Grantees generally funded the same service providers and initiatives to reduce minority health disparities as they had in prior years. After the reauthorization of CARE Act programs, MAI grantees continued to fund a range of core medical services, which include essential medical care services, and support services, which are services needed for individuals with HIV/AIDS to achieve their medical outcomes. Consistent with HRSA guidance, the types of services funded under MAI generally did not differ from services provided with other CARE Act funds. The five services Part A grantees funded most frequently were medical case management, outpatient and ambulatory health services, outreach services, substance abuse outpatient care, and mental health services--outreach services being the only support service among these. Part B grantees used MAI funds for efforts associated with the CARE Act-funded HIV/AIDS drug program, Part C and D grantees funded a range of core medical and support services with MAI funds, and Part F grantees used MAI funds for education efforts targeting health care professionals who are from, or primarily serve, minority communities. Grantees identified many barriers that make it more difficult for minorities to obtain services from HIV/AIDS programs, including those funded by the CARE Act. Barriers to HIV/AIDS care can delay or prevent individuals' timely entrance into, or continuation of, core medical or support services, thus reducing the likely success of care. The barriers grantees identified included the presence of other diseases that impact immune systems, housing issues, and poverty. In commenting on this report, HHS suggested that we identify the law authorizing Ryan White programs as either Title XXVI of the Public Health Service Act (PHSA) or the Ryan White HIV/AIDS program. We continue to refer to the law authorizing Ryan White programs as the CARE Act, but have clarified that it refers to Title XXVI of PHSA.
GAO-09-315, Ryan White CARE Act: Implementation of the New Minority AIDS Initiative Provisions
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
March 2009:
Ryan White Care Act:
Implementation of the New Minority AIDS Initiative Provisions:
GAO-09-315:
GAO Highlights:
Highlights of GAO-09-315, a report to congressional committees.
Why GAO Did This Study:
The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE
Act) makes federal funds available to assist individuals affected by
HIV/AIDS. The Department of Health and Human Services‘ (HHS) Health
Resources and Services Administration (HRSA) awards CARE Act funding to
grantees that include states, territories, and metropolitan areas.
Because minorities have been disproportionately affected by HIV/AIDS,
the CARE Act‘s Minority AIDS Initiative (MAI) provides funding through
five parts (A, B, C, D, and F) of the act with the goal of reducing HIV-
related health care disparities among minorities.
The reauthorization of CARE Act programs changed the process by which
HRSA awards MAI grants under Part A (funding for metropolitan areas)
and Part B (for states and territories) from a formula based solely on
demographics of the metropolitan area, state, or territory to a
competitive process. The CARE Act requires GAO to report on MAI and
related issues. This report provides information on (1) the effect on
grantees and service providers of the new competitive process for
awarding Part A and B MAI funds, (2) the types of services grantees
funded under MAI, and (3) barriers to minorities obtaining services
from HIV/AIDS programs that were identified by grantees. GAO surveyed
CARE Act grantees and interviewed selected grantee and HRSA officials.
GAO also reviewed Part A and B MAI applications.
What GAO Found:
The new competitive process for Parts A and B altered MAI funding
amounts from what they would have been under the old formula-based
process, increased administrative requirements for grantees, and
resulted in continued funding for existing initiatives to reduce health
disparities for minorities. In determining the award amounts under the
new process, HRSA considered the number of minorities with HIV/AIDS
living in the grantee metropolitan area, state, or territory, along
with the MAI applications grantees were required to file. The quality
of the grant applications sometimes resulted in considerable
differences in grantees‘ share of MAI funds from what they would have
received under the old process. Part A and B grantees that received MAI
funding told us that the administrative requirements increased
significantly because of the new process. All Part A and B grantees
that applied for MAI funding received it, but some Part B grantees
decided that the administrative requirements, including a separate
application for MAI funds, were not worth the amount of funds that they
expected to receive and therefore chose not to apply. Grantees
generally funded the same service providers and initiatives to reduce
minority health disparities as they had in prior years.
After the reauthorization of CARE Act programs, MAI grantees continued
to fund a range of core medical services, which include essential
medical care services, and support services, which are services needed
for individuals with HIV/AIDS to achieve their medical outcomes.
Consistent with HRSA guidance, the types of services funded under MAI
generally did not differ from services provided with other CARE Act
funds. The five services Part A grantees funded most frequently were
medical case management, outpatient and ambulatory health services,
outreach services, substance abuse outpatient care, and mental health
services”outreach services being the only support service among these.
Part B grantees used MAI funds for efforts associated with the CARE Act-
funded HIV/AIDS drug program, Part C and D grantees funded a range of
core medical and support services with MAI funds, and Part F grantees
used MAI funds for education efforts targeting health care
professionals who are from, or primarily serve, minority communities.
Grantees identified many barriers that make it more difficult for
minorities to obtain services from HIV/AIDS programs, including those
funded by the CARE Act. Barriers to HIV/AIDS care can delay or prevent
individuals‘ timely entrance into, or continuation of, core medical or
support services, thus reducing the likely success of care. The
barriers grantees identified included the presence of other diseases
that impact immune systems, housing issues, and poverty.
In commenting on this report, HHS suggested that we identify the law
authorizing Ryan White programs as either Title XXVI of the Public
Health Service Act (PHSA) or the Ryan White HIV/AIDS program. We
continue to refer to the law authorizing Ryan White programs as the
CARE Act, but have clarified that it refers to Title XXVI of PHSA.
View [hyperlink, http://www.gao.gov/products/GAO-09-315] or key
components. For more information, contact Marcia Crosse at (202) 512-
7114 or crossem@gao.gov.
[End of section]
Contents:
Letter:
Background:
The New Competitive Process for Parts A and B Altered MAI Funding
Amounts, Increased Administrative Requirements for Grantees, and
Generally Funded the Same Initiatives:
Grantees Fund a Range of Core Medical and Support Services under MAI:
MAI Grantees Identified Multiple Barriers to Minorities' Access to the
Services Provided by HIV/AIDS Programs:
Agency Comments and Our Evaluation:
Appendix I: Grantees Reported Few Challenges to Program Integration:
Appendix II: Objectives, Scope, and Methodology:
Appendix III: Ryan White CARE Act Title I and II Funding for Fiscal
Year 2006 and Part A and B Funding for Fiscal Year 2007:
Appendix IV: Explanation of Barriers to Minorities Obtaining HIV/AIDS
Services:
Appendix V: Comments from the Department of Health and Human Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Core Medical and Support Services Categories:
Table 2: Ryan White CARE Act Part A MAI Grant Awards for Fiscal Year
2007: Award Amounts Received under the New Competitive Process Compared
to Estimates of What Award Amounts Would Have Been under the Old
Formula-Based Process:
Table 3: Ryan White CARE Act Part B MAI Grant Awards for Fiscal Year
2007: Award Amounts Received under the New Competitive Process Compared
to Estimates of What Award Amounts Would Have Been under the Old
Formula-Based Process:
Table 4: Core Medical and Support Services Funded by Ryan White CARE
Act Part A Grantees in Fiscal Year 2007 under the Minority AIDS
Initiative:
Table 5: Ten Barriers to Minorities in Obtaining HIV/AIDS Services Most
Frequently Identified by Ryan White CARE Act Part A and B Minority AIDS
Initiative Grantees:
Table 6: Ryan White CARE Act Title I Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards, Fiscal Year 2006:
Table 7: Ryan White CARE Act Part A Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards for Fiscal Year 2007, Including
Percentage Change from Fiscal Year 2006:
Table 8: Ryan White CARE Act Title II Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards, Fiscal Year 2006:
Table 9: Ryan White CARE Act Part B Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards for Fiscal Year 2007, Including
Percentage Change from Fiscal Year 2006:
Table 10: Barriers to Minorities in Obtaining HIV/AIDS Services
Identified by Ryan White CARE Act Part A and B Minority AIDS Initiative
(MAI) Grantees:
Figure:
Figure 1: Administration and Oversight of Ryan White CARE Act Minority
AIDS Initiative (MAI) Funds:
Abbreviations:
ADAP: AIDS Drug Assistance Program:
AETC: AIDS education and training center:
AIDS: acquired immunodeficiency syndrome:
CARE Act: Ryan White Comprehensive AIDS Resources Emergency Act of
1990:
CBO: community-based organizations:
CDC: Centers for Disease Control and Prevention:
EMA: eligible metropolitan area:
HHS: Department of Health and Human Services:
HIV: human immunodeficiency virus:
HRSA: Health Resources and Services Administration:
MAI: Minority AIDS Initiative:
PHSA: Public Health Service Act:
RFP: request for proposal:
RWTMA: Ryan White HIV/AIDS Treatment Modernization Act of 2006:
SAMHSA: Substance Abuse and Mental Health Services Administration:
TGA: transitional grant area:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
March 27, 2009:
The Honorable Edward M. Kennedy:
Chairman:
The Honorable Michael B. Enzi:
Ranking Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Henry A. Waxman:
Chairman:
The Honorable Joe Barton:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
Racial and ethnic minorities in the United States have been
disproportionately affected by acquired immunodeficiency syndrome
(AIDS) and human immunodeficiency virus (HIV) since the beginning of
the HIV/AIDS epidemic.[Footnote 1] According to the most recent Centers
for Disease Control and Prevention (CDC) data, 60 percent of all
estimated AIDS cases since the beginning of the HIV/AIDS epidemic have
been among racial and ethnic minorities and in 2006 racial and ethnic
minorities represented 69 percent of AIDS cases and 67 percent of
estimated new HIV infections. Since the first U.S. cases of what would
become known as AIDS were reported in June 1981, over 1 million people
in the United States have been infected with HIV, including almost
550,000 who have already died and over 1 million living with HIV/AIDS
today. 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 HIV/AIDS and their family members.[Footnote
2] Total CARE Act grant funding was approximately $2.1 billion in
fiscal year 2007.[Footnote 3] The Minority AIDS Initiative (MAI), first
known as the Congressional Black Caucus Initiative, originated in
fiscal year 1999 and it included the provision of funds to CARE Act
grantees to reduce HIV-related disparities in access to health care and
to improve health-related outcomes among racial and ethnic minority
populations. Total MAI grant funding in fiscal year 2007 was
approximately $131.2 million, representing 6 percent of overall CARE
Act grant funding. Organizations that provide care to minorities living
with HIV/AIDS have suggested that barriers exist for minorities in
accessing HIV/AIDS services, which often make it more difficult for
minorities living with HIV/AIDS to receive treatment and other HIV/AIDS
services. Barriers to HIV/AIDS care can delay or prevent minorities‘
timely entrance into, or continuation of, HIV/AIDS services, thus
reducing the likely success of those services.[Footnote 4]
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWTMA)
reauthorized CARE Act programs for fiscal year 2007 through fiscal year
2009 and included new provisions on MAI.[Footnote 5] There are five
primary sections of the CARE Act under which HRSA awards grants”Parts
A, B, C, D, and F.[Footnote 6] Together, grants made under these
provisions annually fund services for approximately 500,000 people
living with or affected by HIV/AIDS. CARE Act Part A provides for
grants to selected metropolitan areas”known as eligible metropolitan
areas (EMA) and transitional grant areas (TGA)”that have been
disproportionately affected by the HIV/AIDS epidemic.[Footnote 7] Part
B provides for grants to states and territories to improve quality,
availability, and organization of HIV/AIDS services. Part C provides
for grants to public and private nonprofit entities to provide early
intervention services, such as HIV testing and ambulatory care. Part D
provides for grants to programs for family-centered comprehensive care
to children, youth, and women and their families. Part F provides for
grants for demonstration and evaluation of innovative models of
HIV/AIDS care delivery for hard-to-reach populations and training of
health care providers. Part E does not provide for funding for HIV/AIDS
services but rather includes provisions to address various
administrative functions. To be eligible for MAI funds, grantees must
also have received CARE Act Part A, B, C, D, or F funds.
Grantees can arrange with service providers to offer essential medical
care, referred to as core medical services, as well as support services
needed to achieve positive medical outcomes. Grantees may also provide
these services themselves. Grantees and service providers can include
states, territories and associated jurisdictions, metropolitan areas,
community-based organizations, and academic medical centers.[Footnote
8]
Prior to the enactment of RWTMA, HRSA awarded Part A and B MAI funds to
Part A and B grantees according to a formula that was solely based on
the demographic characteristics of the grantees‘ jurisdictions out of
funds otherwise available for Parts A and B;[Footnote 9] those that
received other Part A and Part B funds received MAI funds without
having to file separate applications.[Footnote 10] The CARE Act now
requires HRSA to award MAI funds under Parts A and B according to a
competitive process. Under this new process, HRSA evaluates grantee
applications for MAI funds in addition to the demographic
characteristics of the jurisdictions.[Footnote 11]
The CARE Act requires us to report on MAI and related issues. In this
report, we provide information on (1) the effect on grantees and
service providers of the new competitive process for awarding Part A
and B MAI funds, (2) the types of services grantees funded under MAI,
and (3) barriers to minorities obtaining services from HIV/AIDS
programs that were identified by grantees. The CARE Act also requires
us to report on the challenges of integrating CARE Act–funded programs
with HIV/AIDS programs funded from other sources, such as Medicaid,
Medicare, CDC, and the Substance Abuse and Mental Health Services
Administration. (See app. I for information on the challenges of
HIV/AIDS program integration experienced by CARE Act grantees.)
To determine the effect on grantees and service providers of the new
competitive process for awarding Part A and B MAI funds, we conducted a
Web-based survey of CARE Act fiscal year 2007 Part A and B grantees to
learn how the grantees applied for funds, distributed funds to service
providers, and provided oversight, and what services they provided
prior to and after the enactment of RWTMA.[Footnote 12] The survey
response rates were about 77 percent (43 of 56) for Part A and about 81
percent (48 of 59) for Part B. Also, we created estimated funding
amounts for Part A and B grantees based on the old formula-based
process and analyzed the difference between these amounts and the
actual funding for fiscal year 2007. To create these estimated funding
amounts, we reviewed CARE Act MAI funding data for fiscal years 2006
and 2007, case counts of minorities living with AIDS for fiscal year
2006, and case counts of minorities living with HIV/AIDS for fiscal
year 2007, all of which were provided by HRSA. We used this information
to assess the effect of the new competitive process on MAI funding.
(See app. II for more information on the survey and how estimated
funding amounts were determined.) To assess the validity of the funding
amounts, we compared data we received from HRSA to previously published
funding amounts. We provided HRSA officials with a copy of our tables,
and they agreed with our methodology. We determined that the funding
data and case count data were sufficiently reliable for the purposes of
this report.
Additionally, we reviewed HRSA‘s policies and reporting requirements
under MAI for Part A and B grantees. We interviewed HRSA officials and
staff from selected grantees for Parts A and B to determine how funds
were distributed and how grantees provided oversight. We selected
grantees to interview based on the amount of MAI funding they received
and their location to ensure geographic diversity. We also interviewed
staff from national organizations with HIV/AIDS expertise, including
the National Minority AIDS Council, Kaiser Family Foundation, the
National Alliance of State and Territorial AIDS Directors, and the
Communities Advocating Emergency AIDS Relief Coalition.
To identify the types of services funded under MAI, we conducted a Web-
based survey of Part A grantees, as described above, and interviewed
selected Part A, B, C, D, and F grantees about services they provided
under MAI prior to and after the enactment of RWTMA. There was no
change in the process for awarding MAI funds under Parts C, D, and F,
but we interviewed these grantees to learn about the services they
funded. We reviewed HRSA‘s policies, reporting requirements, and
guidance for Parts A, B, C, D, and F, and we interviewed HRSA officials
about implementation of MAI. Additionally, we reviewed Part A and B MAI
competitive grant applications for fiscal year 2007.
To identify the barriers to minorities obtaining services from HIV/AIDS
programs that were identified by grantees, we reviewed Part A MAI and
Part B MAI competitive grant applications for fiscal year 2007, which
included grantees‘ responses regarding barriers minorities face in
accessing HIV/AIDS services. We interviewed staff from selected Part A,
B, C, D, and F grantees to better understand the barriers. We also
interviewed staff from the organizations listed above.
We conducted our work from January 2008 to February 2009 in accordance
with all sections of GAO‘s Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
Background:
MAI, a component of the CARE Act, provides for funds to eligible
grantees with the goal of reducing HIV-related health disparities among
minority populations. HRSA awards MAI grants to Part A, B, C, D, and F
grantees through a competitive process. HRSA provides oversight of
these grantees, while the grantees provide oversight of their service
providers.
HRSA Administration of CARE Act Funding:
HRSA primarily awards CARE Act funds to grantees for core medical
services, support services, and education through five primary sections
of the legislation”Parts A, B, C, D, and F. In fiscal year 2007, 22
EMAs and 34 TGAs received grants under Part A; all 50 states, the
District of Columbia, Puerto Rico, and 7 U.S. territories received
grants under Part B;[Footnote 13] 354 public and private organizations
that provide services directly to individuals with HIV received grants
under Part C; and 90 public and private organizations that provide
services to families in which at least one member is HIV positive
received grants under Part D. For Parts A, B, C, and D, programs funded
by the CARE Act are the payers of last resort for care.[Footnote 14] In
addition, some Part B funds are used to provide medication for HIV/AIDS
treatment through the AIDS Drug Assistance Program (ADAP) when annual
appropriation laws provide funds exclusively for this purpose.[Footnote
15] Fifteen AIDS education and training centers (AETC), which provide
HIV/AIDS education to health professionals such as nurses and
physicians, received funding under Part F.[Footnote 16] For all parts
of the CARE Act, grantees may use CARE Act funds to engage service
providers that provide HIV/AIDS services to individuals.
CARE Act funding for metropolitan areas, states, and territories is
distributed in the form of base, supplemental, and MAI grants.[Footnote
17] CARE Act grant funding totaled approximately $2.1 billion in fiscal
year 2007; $131.2 million of that amount was MAI grants, representing 6
percent of overall CARE Act grants. Grantees under Parts A, B, and C
must spend at least 75 percent of their grants for core medical
services, while no more than 25 percent of these funds can be spent for
support services.[Footnote 18] Table 1 lists core medical service and
support service categories.
Table 1: Core Medical and Support Services Categories:
Core medical service category: Outpatient and ambulatory health
services;
Support service category: Respite care for persons caring for persons
living with HIV/AIDS.
Core medical service category: ADAP treatments;
Support service category: Outreach services.
Core medical service category: AIDS pharmaceutical assistance;
Support service category: Medical transportation.
Core medical service category: Oral health care;
Support service category: Linguistics services.
Core medical service category: Early intervention services;
Support service category: Referrals for health care and supportive
services.
Core medical service category: Health insurance premium and cost-
sharing assistance.
Core medical service category: Home health care.
Core medical service category: Medical nutrition therapy.
Core medical service category: Hospice services.
Core medical service category: Home and community-based health
services.
Core medical service category: Mental health services.
Core medical service category: Substance abuse outpatient care.
Core medical service category: Medical case management.
Source: HRSA guidance.
Note: According to HRSA officials, HRSA guidance does not provide an
exhaustive list of the core medical and support services that can be
provided using CARE Act funds.
[End of table]
In administering the CARE Act, HRSA issues guidance for applying for
and spending MAI grants. HRSA requires MAI grantees to submit reports
as a condition of their grant awards. The reports MAI grantees submit
to HRSA summarize grantees‘ MAI activities and include data on
individuals served, services offered, budget allocations, and
expenditures. For all parts of the CARE Act, HRSA provides oversight of
grantees but expects grantees to provide oversight of service
providers. (See figure 1 for HRSA‘s role in the administration and
oversight of MAI funds.)
Figure 1: Administration and Oversight of Ryan White CARE Act Minority
AIDS Initiative (MAI) Funds:
CARE Act[A] Part A:
MAI funds;
MAI grantees: EMAs and TGAs[B];
MAI funds;
MAI-Funded service providers[C]: Core medical and support services
providers;
Service providers can be funded through multiple CARE Act parts.
CARE Act Part B:
MAI funds;
MAI grantees: States and territories;
MAI funds;
MAI-Funded service providers[C]: Outreach providers;
Service providers can be funded through multiple CARE Act parts.
CARE Act Part C:
MAI funds;
MAI grantees: Community Organizations;
MAI funds;
MAI-Funded service providers[C]: Core medical and support services
providers;
Service providers can be funded through multiple CARE Act parts.
CARE Act Part D:
MAI funds;
MAI grantees: Community organizations focused on women, children, and
youth;
MAI funds;
MAI-Funded service providers[C]: Core medical and support services
providers;
Service providers can be funded through multiple CARE Act parts.
CARE Act Part F:
MAI funds;
MAI grantees: Academic and medical institutions;
MAI funds;
MAI-Funded service providers[C]: Training and education providers;
Sometimes MAI grantees also function as service providers.
Care Act Parts and MAI grantees are part of the General area of HRSA[D]
oversight.
Source: GAO analysis of HRSA guidance.
[A] Ryan White Comprehensive AIDS Resources Emergency Act of 1990, as
amended.
[B] EMAs are eligible metropolitan areas, TGAs are transitional grant
areas.
[C] Service providers are organizations with which grantees contract or
award subgrants to provide services or arrange to have another
organization to provide services.
[D] Health Resources and Services Administration.
[End of figure]
Reporting Requirements for CARE Act Grantees:
Federal grantees are required to comply with certain audit requirements
based upon their total expenditures of federal funding and to submit
certain reports at a frequency determined by the agency awarding the
grant. HRSA requires CARE Act grantees to submit the following reports:
* quarterly payment management reports, which include grantee spending
for the previous 3-month period, and;
* a financial status report, which is required within 90 days of the
end of each grant year and accounts for expenditures under the project
that year.
Additionally, HRSA has grant-specific reporting requirements. For
example, Part A and B grantees are required to submit the annual Ryan
White HIV/AIDS Program Data Report, which requires grantees and their
service providers to provide information on:
* the number of clients who have received services and demographic
information about these clients,
* the services provided by the grantees‘ service providers,
* the number of clients who received HIV counseling and testing, and,
* medical information about the clients who received services.
There are also MAI-specific reporting requirements. Each MAI grantee is
required to submit the Minority AIDS Initiative Report, which includes:
* the final annual MAI plan due within 90 days of the budget start date
each year and,
* the annual progress report.
Grantees that receive Part A and B MAI grants have some additional
reporting requirements since the enactment of RWTMA. Since the
enactment of RWTMA, Part A and B MAI grantees have been required to
submit separate sets of the payment management reports and financial
status reports for their base and supplemental funding.
MAI Changes Resulting from RWTMA:
MAI grants were first distributed in conjunction with CARE Act funding
in fiscal year 1999. RWTMA added provisions on MAI funding to the CARE
Act, authorizing specific amounts for the purpose of carrying out
activities to evaluate and address the disproportionate impact of
HIV/AIDS on, and the disparities in access, treatment, care, and
outcomes for, racial and ethnic minorities. The amount of CARE Act
funds used for MAI grants has increased from $24 million in fiscal year
1999 to $131 million in fiscal year 2007.
According to HRSA officials, Part A and B MAI funds are to be used to
expand the core medical and support services to minorities that might
not otherwise be provided through the base funding. Part C, D, and F
MAI funds are to be used to expand the number of individuals receiving
services as these individuals may not otherwise be served by non-MAI
funding.
Prior to the enactment of RWTMA, the MAI funds for Part A and B
grantees were awarded according to a formula that solely reflected the
number of living minority AIDS cases in the metropolitan area, state,
or territory receiving funds. These data are referred to as case
counts. RWTMA changed how case counts are defined for other CARE Act
programs to include living HIV cases. For Part A and B MAI grants, HRSA
changed the case counts from the number of living minority AIDS cases
to the number of living minorities with HIV/AIDS for the most recent
year available as reported to CDC.
The CARE Act requires HRSA to award Part A and B MAI grants using a
competitive process. The Part A and B MAI applications, which are
separate from Part A and B base and supplemental applications, require
grantees to describe their local needs and the services they would
provide using MAI funds. HRSA continues to use minority case counts in
determining MAI grant awards, but now does so in combination with
application scores. HRSA officials reported that the agency calculates
Part A and B MAI grant awards based on both the grantee‘s application
scores and the minority case count in the metropolitan area, state, or
territory. HRSA application guidance outlines the points awarded for
each section of the application,[Footnote 19] and the impact of a
grantee‘s performance in its completion of the application is
demonstrated in the MAI funding the grantee receives. The CARE Act does
not specifically require Part C, D, and F MAI grants to be awarded on a
competitive basis or to be awarded separately from base funds under
those parts. HRSA awarded MAI grants under these parts competitively,
as a component of the competitive grant award for the base Parts C, D,
and F. HRSA did this prior to the enactment of RWTMA and continues to
do so.
Barriers to Care:
Barriers to HIV/AIDS care can delay or prevent individuals‘ timely
entrance into, or continuation of, core medical or support services,
thus reducing the likely success of care. Research shows that
minorities, in general, often receive a lower quality of health care
and face barriers to obtaining health care, including services related
to cancer screening, cardiovascular disease, diabetes, and HIV/AIDS.
[Footnote 20] Barriers to HIV/AIDS care can include issues such as
histories of substance abuse disorders or domestic violence. For
example, research studies show that individuals living with HIV/AIDS
who also have substance abuse disorders and are actively using
substances are less likely to adhere to medical care.[Footnote 21]
Barriers to care, such as lack of transportation to medical care or
social stigma associated with HIV/AIDS, can also affect minority
communities. For example, we have found in previous work that lack of
transportation was found to delay, prevent, or interrupt HIV/AIDS
treatment for American Indian and Alaska Native communities.[Footnote
22] HRSA required MAI applicants to describe barriers to care for
minorities in their jurisdictions as part of their MAI applications.
Eliminating or decreasing barriers is important to the delivery of
comprehensive, integrated, quality HIV/AIDS services.
The New Competitive Process for Parts A and B Altered MAI Funding
Amounts, Increased Administrative Requirements for Grantees, and
Generally Funded the Same Initiatives:
The new competitive process for Parts A and B resulted in changes in
the amount of funding from what grantees would have received under the
old formula-based process. Grantees that received MAI funding stated
that the administrative requirements of the grant increased
significantly in fiscal year 2007, and some grantees chose not to apply
for MAI funds. Grantees continued funding existing initiatives to
reduce health disparities for minorities rather than funding new
initiatives, and grantees generally provided funding to the same
service providers as they had in prior years.
The New Competitive Process Resulted in Changes in the Amount of
Funding from What Grantees Would Have Received under the Old Formula-
Based Process:
The new MAI competitive process resulted in funding amounts that
differed from what grantees would have received under the old formula-
based process that based funding solely on minority case counts. All
Part A and B grantees that applied for MAI funds in fiscal year 2007
received MAI funding.[Footnote 23] However, since RWTMA changed the
process by which MAI funds were awarded, some grantees‘ MAI grant
amounts differed from what they would have been awarded under the
previous formula-based process.
Prior to RWTMA, a Part A or B grantee‘s MAI funding was based on its
share of minority AIDS cases relative to the total number of minority
AIDS cases in all metropolitan areas or states and territories eligible
for funds, and a competitive application was not required. For example,
if a Part A grantee‘s minority case count accounted for 4 percent of
the total number of minority AIDS cases in all eligible metropolitan
areas, that grantee would receive 4 percent of the total available Part
A MAI funds. The new competitive MAI process, as implemented by HRSA,
considers the minority case count in determining a grantee‘s MAI award,
but does so in conjunction with the grantee‘s MAI application score.
Because a grantee‘s MAI application score is considered along with the
number of HIV/AIDS cases in the metropolitan area, state, or territory,
there is no longer a one-to-one relationship between an applicant‘s
proportion of cases and its proportion of MAI grant funding. As a
result, we found differences between the amounts many grantees would
have received under the old formula-based process and the amounts they
received under the new competitive process. For example, in fiscal year
2007, Phoenix received $127,578 (39.8 percent) less than it would have
received under the old formula, while Houston received $154,018 (10.9
percent) more. In addition, in some cases we found that grantees with a
lower number of HIV/AIDS cases received more funding under MAI than
grantees with a higher number of HIV/AIDS cases because of their
competitive scores. Table 2 shows Part A MAI grantees‘ fiscal year 2007
funding levels under the competitive process, and an estimate of what
each grantee‘s funding level would have been under the old formula-
based process. For Part A MAI, 30 of the 56 grantees received lower
funding amounts under the new competitive process than they would have
under the old formula-based process. The median difference for all Part
A grantees between the actual fiscal year 2007 funding and the
estimated funding based on the old formula-based process was a loss of
$3,053. Because of their competitive scores, 20 Part A grantees
experienced changes of greater than 10 percent of what they would have
received under the old formula-based process.
Table 2: Ryan White CARE Act Part A MAI Grant Awards for Fiscal Year
2007: Award Amounts Received under the New Competitive Process Compared
to Estimates of What Award Amounts Would Have Been under the Old
Formula-Based Process:
EMA/TGA: Atlanta, Ga.
Actual FY 2007 MAI funding: $1,050,229;
Estimated FY 2007 MAI under the formula-based process: $1,176,644;
Difference between actual and estimated: -$126,415;
Percentage difference between actual and estimated: -10.7.
EMA/TGA: Austin, Tex.
Actual FY 2007 MAI funding: $229,065;
Estimated FY 2007 MAI under the formula-based process: $208,591;
Difference between actual and estimated: $20,474;
Percentage difference between actual and estimated: 9.8.
EMA/TGA: Baltimore, Md.
Actual FY 2007 MAI funding: $2,100,038;
Estimated FY 2007 MAI under the formula-based process: $1,925,202;
Difference between actual and estimated: $174,836;
Percentage difference between actual and estimated: 9.1.
EMA/TGA: Baton Rouge, La.
Actual FY 2007 MAI funding: $249,059;
Estimated FY 2007 MAI under the formula-based process: $327,938;
Difference between actual and estimated: -$78,879;
Percentage difference between actual and estimated: -24.1.
EMA/TGA: Bergen-Passaic, N.J.
Actual FY 2007 MAI funding: $287,493;
Estimated FY 2007 MAI under the formula-based process: $310,872;
Difference between actual and estimated: -$23,379;
Percentage difference between actual and estimated: -7.5.
EMA/TGA: Boston, Mass.
Actual FY 2007 MAI funding: $814,862;
Estimated FY 2007 MAI under the formula-based process: $802,602;
Difference between actual and estimated: $12,260;
Percentage difference between actual and estimated: 1.5.
EMA/TGA: Caguas, P.R.
Actual FY 2007 MAI funding: $121,984;
Estimated FY 2007 MAI under the formula-based process: $125,629;
Difference between actual and estimated: $3,645;
Percentage difference between actual and estimated: -2.9.
EMA/TGA: Charlotte-Gastonia-Concord, N.C.-S.C.
Actual FY 2007 MAI funding: $371,535;
Estimated FY 2007 MAI under the formula-based process: $391,582;
Difference between actual and estimated: -$20,047;
Percentage difference between actual and estimated: -5.1.
EMA/TGA: Chicago, Ill.
Actual FY 2007 MAI funding: $1,787,310;
Estimated FY 2007 MAI under the formula-based process: $1,983,038;
Difference between actual and estimated: -$195,728;
Percentage difference between actual and estimated: -9.9.
EMA/TGA: Cleveland, Ohio;
Actual FY 2007 MAI funding: $316,520;
Estimated FY 2007 MAI under the formula-based process: $298,191;
Difference between actual and estimated: $18,329;
Percentage difference between actual and estimated: 6.1.
EMA/TGA: Dallas, Tex.
Actual FY 2007 MAI funding: $772,577;
Estimated FY 2007 MAI under the formula-based process: $833,772;
Difference between actual and estimated: -$61,195;
Percentage difference between actual and estimated: -7.3.
EMA/TGA: Denver, Colo.
Actual FY 2007 MAI funding: $275,492;
Estimated FY 2007 MAI under the formula-based process: $282,665;
Difference between actual and estimated: -$7,173;
Percentage difference between actual and estimated: -2.5.
EMA/TGA: Detroit, Mich.
Actual FY 2007 MAI funding: $644,567;
Estimated FY 2007 MAI under the formula-based process: $662,988;
Difference between actual and estimated: -$18,421;
Percentage difference between actual and estimated: -2.8.
EMA/TGA: Dutchess County, N.Y.
Actual FY 2007 MAI funding: $103,571;
Estimated FY 2007 MAI under the formula-based process: $96,710;
Difference between actual and estimated: $6,861;
Percentage difference between actual and estimated: 7.1.
EMA/TGA: Fort Lauderdale, Fla.
Actual FY 2007 MAI funding: $1,113,452;
Estimated FY 2007 MAI under the formula-based process: $1,055,045;
Difference between actual and estimated: $58,407;
Percentage difference between actual and estimated: 5.5.
EMA/TGA: Fort Worth, Tex.
Actual FY 2007 MAI funding: $204,310;
Estimated FY 2007 MAI under the formula-based process: $217,243;
Difference between actual and estimated: -$12,933;
Percentage difference between actual and estimated: -6.0.
EMA/TGA: Hartford, Conn.
Actual FY 2007 MAI funding: $252,944;
Estimated FY 2007 MAI under the formula-based process: $255,406;
Difference between actual and estimated: -$2,462;
Percentage difference between actual and estimated: -1.0.
EMA/TGA: Houston, Tex.
Actual FY 2007 MAI funding: $1,571,727;
Estimated FY 2007 MAI under the formula-based process: $1,417,709;
Difference between actual and estimated: $154,018;
Percentage difference between actual and estimated: 10.9.
EMA/TGA: Indianapolis, Ind.
Actual FY 2007 MAI funding: $189,079;
Estimated FY 2007 MAI under the formula-based process: $180,858;
Difference between actual and estimated: $8,221;
Percentage difference between actual and estimated: 4.5.
EMA/TGA: Jacksonville, Fla.
Actual FY 2007 MAI funding: $393,745;
Estimated FY 2007 MAI under the formula-based process: $387,434;
Difference between actual and estimated: $6,311;
Percentage difference between actual and estimated: 1.6.
EMA/TGA: Jersey City, N.J.
Actual FY 2007 MAI funding: $417,858;
Estimated FY 2007 MAI under the formula-based process: $394,308;
Difference between actual and estimated: $23,550;
Percentage difference between actual and estimated: 6.0.
EMA/TGA: Kansas City, Mo.
Actual FY 2007 MAI funding: $187,284;
Estimated FY 2007 MAI under the formula-based process: $194,251;
Difference between actual and estimated: -$6,967;
Percentage difference between actual and estimated: -3.6.
EMA/TGA: Las Vegas, Nev.
Actual FY 2007 MAI funding: $225,918;
Estimated FY 2007 MAI under the formula-based process: $266,546;
Difference between actual and estimated: -$40,628;
Percentage difference between actual and estimated: -15.2.
EMA/TGA: Los Angeles, Calif.
Actual FY 2007 MAI funding: $2,528,561;
Estimated FY 2007 MAI under the formula-based process: $2,441,109;
Difference between actual and estimated: $87,452;
Percentage difference between actual and estimated: 3.6.
EMA/TGA: Memphis, Tenn.
Actual FY 2007 MAI funding: $556,225;
Estimated FY 2007 MAI under the formula-based process: $533,330;
Difference between actual and estimated: $22,895;
Percentage difference between actual and estimated: 4.3.
EMA/TGA: Miami, Fla.
Actual FY 2007 MAI funding: $2,565,107;
Estimated FY 2007 MAI under the formula-based process: $2,374,858;
Difference between actual and estimated: $190,249;
Percentage difference between actual and estimated: 8.0.
EMA/TGA: Middlesex-Somerset-Hunterdon, N.J.
Actual FY 2007 MAI funding: $165,169;
Estimated FY 2007 MAI under the formula-based process: $189,154;
Difference between actual and estimated: -$23,985;
Percentage difference between actual and estimated: -12.7.
EMA/TGA: Minneapolis-St. Paul, Minn.
Actual FY 2007 MAI funding: $264,702;
Estimated FY 2007 MAI under the formula-based process: $237,865;
Difference between actual and estimated: $26,837;
Percentage difference between actual and estimated: 11.3.
EMA/TGA: Nashville, Tenn.
Actual FY 2007 MAI funding: $207,441;
Estimated FY 2007 MAI under the formula-based process: $234,902;
Difference between actual and estimated: -$27,461;
Percentage difference between actual and estimated: -11.7.
EMA/TGA: Nassau-Suffolk, N.Y.
Actual FY 2007 MAI funding: $325,286;
Estimated FY 2007 MAI under the formula-based process: $341,568;
Difference between actual and estimated: -$16,282;
Percentage difference between actual and estimated: -4.8.
EMA/TGA: New Haven, Conn.
Actual FY 2007 MAI funding: $321,657;
Estimated FY 2007 MAI under the formula-based process: $385,657;
Difference between actual and estimated: -$64,000;
Percentage difference between actual and estimated: -16.6.
EMA/TGA: New Orleans, La.
Actual FY 2007 MAI funding: $541,807;
Estimated FY 2007 MAI under the formula-based process: $559,522;
Difference between actual and estimated: -$17,715;
Percentage difference between actual and estimated: -3.2.
EMA/TGA: New York, N.Y.
Actual FY 2007 MAI funding: $9,347,777;
Estimated FY 2007 MAI under the formula-based process: $8,494,045;
Difference between actual and estimated: $853,732;
Percentage difference between actual and estimated: 10.1.
EMA/TGA: Newark, N.J.
Actual FY 2007 MAI funding: $1,284,886;
Estimated FY 2007 MAI under the formula-based process: $1,267,191;
Difference between actual and estimated: -$17,695;
Percentage difference between actual and estimated: -1.4.
EMA/TGA: Norfolk, Va.
Actual FY 2007 MAI funding: $379,699;
Estimated FY 2007 MAI under the formula-based process: $459,967;
Difference between actual and estimated: -$80,268;
Percentage difference between actual and estimated: -17.5.
EMA/TGA: Oakland, Calif.
Actual FY 2007 MAI funding: $392,080;
Estimated FY 2007 MAI under the formula-based process: $421,923;
Difference between actual and estimated: -$29,843;
Percentage difference between actual and estimated: -7.1.
EMA/TGA: Orange County, Calif.
Actual FY 2007 MAI funding: $292,945;
Estimated FY 2007 MAI under the formula-based process: $282,902;
Difference between actual and estimated: $10,043;
Percentage difference between actual and estimated: 3.6.
EMA/TGA: Orlando, Fla.
Actual FY 2007 MAI funding: $578,713;
Estimated FY 2007 MAI under the formula-based process: $551,937;
Difference between actual and estimated: $26,776;
Percentage difference between actual and estimated: 4.9.
EMA/TGA: Philadelphia, Pa.
Actual FY 2007 MAI funding: $1,682,127;
Estimated FY 2007 MAI under the formula-based process: $1,627,841;
Difference between actual and estimated: $54,286;
Percentage difference between actual and estimated: 3.3.
EMA/TGA: Phoenix, Ariz.
Actual FY 2007 MAI funding: $193,368;
Estimated FY 2007 MAI under the formula-based process: $320,946;
Difference between actual and estimated: -$127,578;
Percentage difference between actual and estimated: -39.8.
EMA/TGA: Ponce, P.R.
Actual FY 2007 MAI funding: $153,098;
Estimated FY 2007 MAI under the formula-based process: $200,176;
Difference between actual and estimated: -$47,078;
Percentage difference between actual and estimated: -23.5.
EMA/TGA: Portland, Oreg.
Actual FY 2007 MAI funding: $78,536;
Estimated FY 2007 MAI under the formula-based process: $77,155;
Difference between actual and estimated: $1,381;
Percentage difference between actual and estimated: 1.8.
EMA/TGA: Riverside-San Bernadino, Calif.
Actual FY 2007 MAI funding: $255,733;
Estimated FY 2007 MAI under the formula-based process: $326,398;
Difference between actual and estimated: -$70,665;
Percentage difference between actual and estimated: -21.6.
EMA/TGA: Sacramento, Calif.
Actual FY 2007 MAI funding: $97,469;
Estimated FY 2007 MAI under the formula-based process: $98,488;
Difference between actual and estimated: -$1,019;
Percentage difference between actual and estimated: -1.0.
EMA/TGA: San Antonio, Tex.
Actual FY 2007 MAI funding: $264,661;
Estimated FY 2007 MAI under the formula-based process: $303,050;
Difference between actual and estimated: -$38,389;
Percentage difference between actual and estimated: -12.7.
EMA/TGA: San Diego, Calif.
Actual FY 2007 MAI funding: $543,389;
Estimated FY 2007 MAI under the formula-based process: $514,248;
Difference between actual and estimated: $29,141;
Percentage difference between actual and estimated: 5.7.
EMA/TGA: San Francisco, Calif.
Actual FY 2007 MAI funding: $652,491;
Estimated FY 2007 MAI under the formula-based process: $608,114;
Difference between actual and estimated: $44,377;
Percentage difference between actual and estimated: 7.3.
EMA/TGA: San Jose, Calif.
Actual FY 2007 MAI funding: $137,156;
Estimated FY 2007 MAI under the formula-based process: $147,436;
Difference between actual and estimated: -$10,280;
Percentage difference between actual and estimated: -7.0.
EMA/TGA: San Juan, P.R.
Actual FY 2007 MAI funding: $741,100;
Estimated FY 2007 MAI under the formula-based process: $1,086,333;
Difference between actual and estimated: -$345,233;
Percentage difference between actual and estimated: -31.8.
EMA/TGA: Santa Rosa, Calif.
Actual FY 2007 MAI funding: $50,000[A];
Estimated FY 2007 MAI under the formula-based process: $25,244;
Difference between actual and estimated: $24,756;
Percentage difference between actual and estimated: 98.1.
EMA/TGA: Seattle, Wash.
Actual FY 2007 MAI funding: $234,009;
Estimated FY 2007 MAI under the formula-based process: $212,384;
Difference between actual and estimated: $21,625;
Percentage difference between actual and estimated: 10.2.
EMA/TGA: St. Louis., Mo.
Actual FY 2007 MAI funding: $378,174;
Estimated FY 2007 MAI under the formula-based process: $352,353;
Difference between actual and estimated: $25,821;
Percentage difference between actual and estimated: 7.3.
EMA/TGA: Tampa-St. Petersburg, Fla.
Actual FY 2007 MAI funding: $525,592;
Estimated FY 2007 MAI under the formula-based process: $498,367;
Difference between actual and estimated: $27,225;
Percentage difference between actual and estimated: 5.5.
EMA/TGA: Vineland-Millville-Bridgeton, N.J.
Actual FY 2007 MAI funding: $68,510;
Estimated FY 2007 MAI under the formula-based process: $79,762;
Difference between actual and estimated: -$11,252;
Percentage difference between actual and estimated: -14.1.
EMA/TGA: Washington, D.C.
Actual FY 2007 MAI funding: $1,976,712;
Estimated FY 2007 MAI under the formula-based process: $2,345,939;
Difference between actual and estimated: -$369,227;
Percentage difference between actual and estimated: -15.7.
EMA/TGA: West Palm Beach, Fla.
Actual FY 2007 MAI funding: $576,631;
Estimated FY 2007 MAI under the formula-based process: $646,040;
Difference between actual and estimated: -$69,409;
Percentage difference between actual and estimated: -10.7.
EMA/TGA: Total:
Actual FY 2007 MAI funding: $42,041,430.
Sources: HRSA and GAO analysis of HRSA data.
Note: In calculating the estimated funding amounts, we held the total
funding allocated for fiscal year 2007, $42,041,430, constant. We did
not adjust funding amounts to reflect the minimum grant awards set in
fiscal year 2007 because these were not in place when the formula
grants were awarded.
[A] Santa Rosa, California, received the minimum grant award of
$50,000. The maximum grant award was set at $10,750,000; however, no
grantee qualified for the maximum.
[End of table]
Table 3 shows Part B MAI grantees‘ fiscal year 2007 funding levels
under the competitive process and an estimate of what each grantee‘s
funding level would have been under the old formula-based process. For
Part B MAI, 20 of the 29 grantees that applied for funding received
higher funding amounts under the new competitive process than they
would have under the old formula-based process. For these Part B
grantees, the median difference between the actual fiscal year 2007
funding and the estimated funding based on the old formula-based
process was a gain of $2,779. (See app. III for a comparison of the
fiscal year 2006 and fiscal year 2007 Part A and B MAI funding amounts
and MAI as a proportion of total funding.) Because of their competitive
scores, 20 Part B grantees experienced changes of greater than 10
percent of what they would have received under the old formula-based
process.
Table 3: Ryan White CARE Act Part B MAI Grant Awards for Fiscal Year
2007: Award Amounts Received under the New Competitive Process Compared
to Estimates of What Award Amounts Would Have Been under the Old
Formula-Based Process:
State/territory: Alabama;
Actual FY 2007 MAI funding[A]: $109,917;
Estimated FY 2007 MAI under the formula-based process: $87,480;
Difference between actual and estimated: $22,437;
Percentage difference between actual and estimated: 25.6.
State/territory: Alaska;
Actual FY 2007 MAI funding[A]: $4,412;
Estimated FY 2007 MAI under the formula-based process: $3,390;
Difference between actual and estimated: $1,022;
Percentage difference between actual and estimated: 30.1.
State/territory: Arizona;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $53,634;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Arkansas;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $27,664;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: California;
Actual FY 2007 MAI funding[A]: $856,348;
Estimated FY 2007 MAI under the formula-based process: $658,233;
Difference between actual and estimated: $198,115;
Percentage difference between actual and estimated: 30.1.
State/territory: Colorado;
Actual FY 2007 MAI funding[A]: $36,113;
Estimated FY 2007 MAI under the formula-based process: $43,562;
Difference between actual and estimated: -$7,449;
Percentage difference between actual and estimated: -17.1.
State/territory: Connecticut;
Actual FY 2007 MAI funding[A]: $83,285;
Estimated FY 2007 MAI under the formula-based process: $81,697;
Difference between actual and estimated: $1,588;
Percentage difference between actual and estimated: 1.9.
State/territory: Delaware;
Actual FY 2007 MAI funding[A]: $4,360;
Estimated FY 2007 MAI under the formula-based process: $28,134;
Difference between actual and estimated: -$23,774;
Percentage difference between actual and estimated: -84.5.
State/territory: District of Columbia;
Actual FY 2007 MAI funding[A]: $204,224;
Estimated FY 2007 MAI under the formula-based process: $157,311;
Difference between actual and estimated: $46,913;
Percentage difference between actual and estimated: 29.8.
State/territory: Florida;
Actual FY 2007 MAI funding[A]: $1,087,726;
Estimated FY 2007 MAI under the formula-based process: $811,755;
Difference between actual and estimated: $275,971;
Percentage difference between actual and estimated: 34.0.
State/territory: Georgia;
Actual FY 2007 MAI funding[A]: $267,205;
Estimated FY 2007 MAI under the formula-based process: $225,945;
Difference between actual and estimated: $41,260;
Percentage difference between actual and estimated: 18.3.
State/territory: Hawaii;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $7,465;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Idaho;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $1,610;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Illinois;
Actual FY 2007 MAI funding[A]: $72,966;
Estimated FY 2007 MAI under the formula-based process: $270,518;
Difference between actual and estimated: -$197,552;
Percentage difference between actual and estimated: -73.0.
State/territory: Indiana;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $44,260;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated:[Empty].
State/territory: Iowa;
Actual FY 2007 MAI funding[A]: $8,377;
Estimated FY 2007 MAI under the formula-based process: $5,598;
Difference between actual and estimated: $2,779;
Percentage difference between actual and estimated: 49.6.
State/territory: Kansas;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $12,564;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Kentucky;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $17,693;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated:[Empty].
State/territory: Louisiana;
Actual FY 2007 MAI funding[A]: $140,731;
Estimated FY 2007 MAI under the formula-based process: $149,946;
Difference between actual and estimated: -$9,215;
Percentage difference between actual and estimated: -6.1.
State/territory: Maine;
Actual FY 2007 MAI funding[A]: $2,500;
Estimated FY 2007 MAI under the formula-based process: $1,553;
Difference between actual and estimated: $947;
Percentage difference between actual and estimated: 61.0.
State/territory: Maryland;
Actual FY 2007 MAI funding[A]: $304,838;
Estimated FY 2007 MAI under the formula-based process: $323,141;
Difference between actual and estimated: -$18,303;
Percentage difference between actual and estimated: -5.7.
State/territory: Massachusetts;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $113,893;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Michigan;
Actual FY 2007 MAI funding[A]: $141,887;
Estimated FY 2007 MAI under the formula-based process: $106,968;
Difference between actual and estimated: $34,919;
Percentage difference between actual and estimated: 32.6.
State/territory: Minnesota;
Actual FY 2007 MAI funding[A]: $26,875;
Estimated FY 2007 MAI under the formula-based process: $32,679;
Difference between actual and estimated: -$5,804;
Percentage difference between actual and estimated: -17.8.
State/territory: Mississippi;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $78,762;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Missouri;
Actual FY 2007 MAI funding[A]: $69,743;
Estimated FY 2007 MAI under the formula-based process: $65,899;
Difference between actual and estimated: $3,844;
Percentage difference between actual and estimated: 5.8.
State/territory: Montana;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $399;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Nebraska;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $7,564;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Nevada;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $36,283;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: New Hampshire;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $3,390;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: New Jersey;
Actual FY 2007 MAI funding[A]: $414,015;
Estimated FY 2007 MAI under the formula-based process: $350,235;
Difference between actual and estimated: $63,780;
Percentage difference between actual and estimated: 18.2.
State/territory: New Mexico;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $15,955;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: New York;
Actual FY 2007 MAI funding[A]: $1,476,866;
Estimated FY 2007 MAI under the formula-based process: $1,216,350;
Difference between actual and estimated: $260,516;
Percentage difference between actual and estimated: 21.4.
State/territory: North Carolina;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $200,047;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: North Dakota;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $556;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Ohio;
Actual FY 2007 MAI funding[A]: $62,201;
Estimated FY 2007 MAI under the formula-based process: $99,461;
Difference between actual and estimated: -$37,260;
Percentage difference between actual and estimated: -37.5.
State/territory: Oklahoma;
Actual FY 2007 MAI funding[A]: $20,313;
Estimated FY 2007 MAI under the formula-based process: $21,610;
Difference between actual and estimated: -$1,297;
Percentage difference between actual and estimated: -6.0.
State/territory: Oregon;
Actual FY 2007 MAI funding[A]: $14,031;
Estimated FY 2007 MAI under the formula-based process: $10,898;
Difference between actual and estimated: $3,133;
Percentage difference between actual and estimated: 28.8.
State/territory: Pennsylvania;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $152,311;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Puerto Rico;
Actual FY 2007 MAI funding[A]: $142,792;
Estimated FY 2007 MAI under the formula-based process: $213,509;
Difference between actual and estimated: -$70,717;
Percentage difference between actual and estimated: -33.1.
State/territory: Rhode Island;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $8,832;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: South Carolina;
Actual FY 2007 MAI funding[A]: $177,810;
Estimated FY 2007 MAI under the formula-based process: $146,185;
Difference between actual and estimated: $31,625;
Percentage difference between actual and estimated: 21.6.
State/territory: South Dakota;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $1,567;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Tennessee;
Actual FY 2007 MAI funding[A]: $130,743;
Estimated FY 2007 MAI under the formula-based process: $106,925;
Difference between actual and estimated: $23,818;
Percentage difference between actual and estimated: 22.3.
State/territory: Texas;
Actual FY 2007 MAI funding[A]: $597,547;
Estimated FY 2007 MAI under the formula-based process: $480,622;
Difference between actual and estimated: $116,925;
Percentage difference between actual and estimated: 24.3.
State/territory: Utah;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $7,664;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Vermont;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $527;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Virginia;
Actual FY 2007 MAI funding[A]: $203,896;
Estimated FY 2007 MAI under the formula-based process: $164,590;
Difference between actual and estimated: $39,306;
Percentage difference between actual and estimated: 23.9.
State/territory: Washington;
Actual FY 2007 MAI funding[A]: $34,333;
Estimated FY 2007 MAI under the formula-based process: $36,240;
Difference between actual and estimated: -$1,907;
Percentage difference between actual and estimated: -5.3.
State/territory: West Virginia;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $6,211;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Wisconsin;
Actual FY 2007 MAI funding[A]: $41,046;
Estimated FY 2007 MAI under the formula-based process: $31,767;
Difference between actual and estimated: $9,279;
Percentage difference between actual and estimated: 29.2.
State/territory: Wyoming;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $541;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Guam;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $1,097;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Virgin Islands;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $6,738;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: American Samoa;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $28;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Marshall Islands;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $14;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: North Marianas;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: $57;
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Republic of Palau;
Actual FY 2007 MAI funding[A]: [Empty];
Estimated FY 2007 MAI under the formula-based process: [Empty];
Difference between actual and estimated: [Empty];
Percentage difference between actual and estimated: [Empty].
State/territory: Federated States of Micronesia;
Actual FY 2007 MAI funding[A]: $2,500[B];
Estimated FY 2007 MAI under the formula-based process: $71;
Difference between actual and estimated: $2,429;
Percentage difference between actual and estimated: 3409.9.
State/territory: Total;
Actual FY 2007 MAI funding[A]: $$6,739,600.
Sources: HRSA and GAO analysis of HRSA data.
Note: In calculating the estimated funding amounts, we held the total
funding allocated for fiscal year 2007, $6,739,600, constant. We did
not adjust funding amounts to reflect the minimum grant awards set in
fiscal year 2007 because these were not in when the formula grants were
awarded.
[A] States that did not apply for funding in fiscal year 2007 have a
dash. No difference between actual and estimated or percentage
difference between actual and estimated was calculated for these
states.
[B] The Federated States of Micronesia received the minimum grant award
of $2,500. No maximum grant award was set.
[End of table]
The New Competitive Process Increased the Administrative Requirements
for Grantees, and Some Grantees Chose Not to Apply for MAI Funds:
Many MAI grantees said that the new competitive process increased their
administrative requirements. Part A and B grantees that applied for MAI
grants in fiscal year 2007 reported that the new MAI grant application
and reporting requirements are time-consuming and duplicative of the
requirements for the Part A and Part B base and supplemental funding.
Prior to the implementation of the MAI competitive process, grantees
answered a few MAI-related questions on their base and supplemental
applications. However, the amount of funding a grantee received was
based on the grantee‘s number of AIDS cases relative to the overall
number of AIDS cases among all grantees, not its responses to these
questions.
Several grantees we interviewed that did apply and received MAI grants
stated that the administrative requirements increased significantly
with the new competitive process. Grantees explained that integrating
the Part A and Part B base funding program activities with MAI
activities has become difficult because under the new process, these
activities must be reported separately. Reporting on MAI activities has
also been made substantially more difficult because of HRSA‘s
designation of different fiscal years for different CARE Act grant
programs. The fiscal year for Part A base and supplemental funding is
March 1 to February 28. For Part B base and supplemental funding the
fiscal year is April 1 to March 31. The Part A and Part B MAI fiscal
year is August 1 to July 31.[Footnote 24] Some grantees said that the
separate fiscal years increased their administrative requirements. For
example, one grantee told us that the separate reporting and different
fiscal years act as an ’artificial separation“ of funding for services
to the same client population. While grant guidance states that ’HRSA
expects grantees to implement and administer MAI-funded services and
activities in a manner that is consistent with the Part A and Part B
programs,“[Footnote 25] some grantees stated that the different funding
cycles make such integration difficult. Many grantees also explained
that the separate applications and different funding cycles complicated
the contracting process, thus requiring them to write more contracts,
file more reports, and conduct additional monitoring without extra
funding for this added administration.
In addition, HRSA officials explained that some states and territories
did not apply for MAI funding because in past years they had received
relatively small amounts of funding, and would have to undergo
increased requirements because of the new competitive application
process to receive that funding in fiscal year 2007. In total, 22
states and territories that were Part B grantees in fiscal year 2006
chose not to apply for MAI in fiscal year 2007. Grantees that chose to
apply in fiscal year 2007 received MAI funding that amounted to less
than 1 percent of their total Part B funding (see app. III for funding
tables for total CARE Act awards for Part B grantees). Moreover, some
grantees explained that they only had about a month to complete the MAI
application after new application guidance was issued, which they did
not consider to be enough time to prepare the application. In addition,
one grantee we interviewed also explained that the narrow scope of Part
B MAI funding, that is, that it could only be used for ADAP-related
outreach and education services, also made it less likely to apply. As
indicated in table 3, because there was a fixed amount of funding and
fewer applications were received, there were more MAI funds available
to each grantee that submitted an application.
The New Competitive Process Generally Resulted in the Funding of the
Same Initiatives:
Some Part A and B grantees reported that they have continued to fund
the same initiatives to reduce minority health disparities that they
did prior to the implementation of the new MAI competitive process.
Grantees we interviewed whose fiscal year 2007 MAI funding increased
from the previous year stated that they funded their service providers
to continue funding existing initiatives to reduce health disparities
for minorities. Some grantees whose fiscal year 2007 MAI funding
decreased from the prior year reported to us that they reduced or
eliminated the amount of funding they awarded to service providers. One
grantee reported that a service provider the grantee had intended to
fund declined to provide services because the service provider lacked
the resources needed to comply with MAI reporting requirements.
Part A grantees generally used the same request for proposal (RFP)
process to select service providers under the new MAI competitive
process as they had used before.[Footnote 26] Of the 43 Part A grantees
that responded to our survey, 33 stated that they used an RFP selection
process to choose service providers in the first year under the new
competitive process, and 35 stated that they used an RFP prior to
RWTMA. Of the 8 grantees that did not use an RFP process, 5 generally
stated that they did not need RFPs in the first year of the change to
the new competitive process because they used an RFP process in an
earlier year to select service providers and awarded multiple-year
contracts.
Most of the Part B grantees that responded to our survey changed how
they selected service providers after the switch to a competitive
process. While 20 out of 44 Part B survey respondents that received MAI
funding before the change to the new competitive process used an RFP to
select service providers, only 7 out of 26 Part B survey respondents
that received MAI funding after the change used an RFP process to
select service providers. Some grantees stated that they provided
funding to one or two organizations with which they were familiar,
applied the funds to existing contracts, or used the funds themselves,
instead of issuing an RFP.
Grantees Fund a Range of Core Medical and Support Services under MAI:
MAI grantees under all parts of the CARE Act reported funding a range
of core medical and support services using MAI funds. These services
can be provided either directly by the grantees or through service
providers. We found that Part A grantees generally used MAI funds to
fund services similar to those funded through base or supplemental
grants. This is in accordance with HRSA‘s guidance, which states that
it is appropriate to implement similar types of services using MAI and
base and supplemental Part A funds. Only rarely did Part A grantees use
MAI funds exclusively to fund a specific type of service, such as
outreach to minority individuals or nonmedical case management not
otherwise supported with CARE Act funds. Some Part A grantees reported
that they take a coordinated approach to the prioritization and
expenditure of base, supplemental, and MAI funds.
Part A grantees reported funding a range of core medical and support
services under MAI. According to our survey, four of the top five
services most commonly funded in fiscal year 2007 were categorized as
core medical services”medical case management, outpatient and
ambulatory health services, substance abuse outpatient care, and mental
health services. (See table 4.) Outreach was the only support service
among the top five most commonly funded services.[Footnote 27] In
addition, nine Part A grantees responded that they funded a range of
services other than those listed in our survey, including early
intervention services, residential substance abuse treatment, and
psychosocial support.
Table 4: Core Medical and Support Services Funded by Ryan White CARE
Act Part A Grantees in Fiscal Year 2007 under the Minority AIDS
Initiative:
Core medical:
Service: Medical case management;
Grantees providing services (of 43): 29.
Service: Outpatient and ambulatory health services;
Grantees providing services (of 43): 24.
Service: Substance abuse outpatient care;
Grantees providing services (of 43): 12.
Service: Mental health services;
Grantees providing services (of 43): 12.
Service: AIDS pharmaceutical assistance;
Grantees providing services (of 43): 8.
Service: HIV counseling and testing;
Grantees providing services (of 43): 5.
Service: Oral health;
Grantees providing services (of 43): 5.
Service: Medical nutrition therapy;
Grantees providing services (of 43): 4.
Service: Home health care;
Grantees providing services (of 43): 1.
Support:
Service: Outreach services;
Grantees providing services (of 43): 16.
Service: Case management (nonmedical);
Grantees providing services (of 43): 10.
Service: Medical transportation;
Grantees providing services (of 43): 7.
Service: Housing services;
Grantees providing services (of 43): 6.
Service: Referrals to health care/supportive services;
Grantees providing services (of 43): 4.
Service: Emergency financial assistance;
Grantees providing services (of 43): 2.
Service: Food bank;
Grantees providing services (of 43): 2.
Service: Legal services;
Grantees providing services (of 43): 2.
Service: Child care;
Grantees providing services (of 43): 1.
Service: Family advocacy;
Grantees providing services (of 43): 1.
Service: Health insurance premium and cost-sharing assistance;
Grantees providing services (of 43): 1.
Service: Home and community-based health services;
Grantees providing services (of 43): 1.
Service: Linguistic services;
Grantees providing services (of 43): 1.
Source: GAO analysis of survey data.
Note: In our survey, the list of services that a grantee could
potentially provide was based on information obtained from grantee
applications.
[End of table]
Similar to Part A grantees, Part C and D grantees used MAI funding for
a range of core medical and support services, while Part B and F
grantees used MAI funding for specific services designated by the MAI
provisions in the CARE Act. In interviews, Part C and D MAI grantees
generally reported funding core medical and support services based on
their clients‘ needs as well as their organizational missions. For
example, five Part D MAI grantees reported focusing their services on
the needs of women and youth, including offering child care services
and targeted case management. The CARE Act restricts the use of Part B
MAI funds to efforts related to increasing the number of minorities in
ADAP. Part F MAI grantees told us that they use MAI funds for education
efforts targeting health care professionals who are from, or primarily
serve, minority communities. These education efforts are similar to
services they fund using other CARE Act grants.
Some MAI grantees reported changing the mix of services they funded
from fiscal year 2005 through fiscal year 2007. Grantees we interviewed
said that they changed the mix of services they funded to comply with
the requirement added by RWTMA that at least 75 percent of grant
funding be spent for core medical services. Among the 43 respondents to
our survey of Part A grantees, the number of MAI grantees funding
medical case management more than doubled from fiscal year 2005 through
fiscal year 2007, while the number funding nonmedical case management
decreased by a third.[Footnote 28] In addition, Part A grantees
indicated changes in the types of support services they funded from
fiscal year 2005 through fiscal year 2007. Survey results showed
increases in the number of grantees providing referrals to health care
services and transportation services and a decrease in the number
providing outreach services. Some Part A grantees reported that since
the enactment of RWTMA, they have had to curtail support services such
as housing, emergency financial assistance, and client advocacy as well
as capacity building in historically underrepresented communities.
Furthermore, in interviews, some grantees reported changing the types
of services they funded as a result of RWTMA‘s enactment. For example,
two grantees, one Part A and one Part B, reported changing existing
case management services to fit within the medical case management
definition, which includes, for example, the coordination and follow-up
of medical treatments.
MAI Grantees Identified Multiple Barriers to Minorities‘ Access to the
Services Provided by HIV/AIDS Programs:
MAI grantees identified multiple barriers that make it difficult for
minorities to obtain services through HIV/AIDS programs.[Footnote 29]
Similar to the barriers minorities face, in general, in obtaining
health care, these barriers present challenges for individuals in
obtaining HIV/AIDS services that may not only prevent or delay entry
into care but could also decrease adherence to treatment.[Footnote 30]
Barriers to minorities‘ access to HIV/AIDS services are often
interconnected and include issues such as a lack of transportation to
HIV/AIDS services, mistrust of service providers, lacking or
insufficient insurance, homelessness, poverty, and language issues.
Language issues, for example, suggest the need for the linguistic
services of an interpreter or translated materials to receive HIV/AIDS
services. If a minority must overcome language issues in order to
receive HIV/AIDS services and cannot do so, then these issues become a
barrier to obtaining HIV/AIDS services. Complications for care, such as
co-morbidities, also were reported as barriers to minorities obtaining
HIV/AIDS services.[Footnote 31]
We found that Part A and B grantees generally identified similar
barriers in their MAI applications. Table 5 shows the 10 barriers to
minorities obtaining HIV/AIDS services most frequently identified by
Part A and B MAI grantees. They identified co-morbidities, housing
issues, and poverty as the top three barriers to care, with at least 8
out of 10 grantees identifying each barrier. Co-morbidities can include
hypertension, mental illness, sexually transmitted infections/diseases,
and tuberculosis. Unstable housing can prevent minorities with HIV/AIDS
from accessing health care and adhering to complex HIV/AIDS treatments
because they often must attend to more immediate needs, such as
obtaining food and shelter. Poverty, defined by the federal government
according to income thresholds that vary by family size and
composition, can have similar implications. Appendix IV provides
descriptions and a more complete list of barriers identified by Part A
and B grantees in their fiscal year 2007 MAI competitive grant
applications.
Table 5: Ten Barriers to Minorities in Obtaining HIV/AIDS Services Most
Frequently Identified by Ryan White CARE Act Part A and B Minority AIDS
Initiative Grantees:
Barrier: Co-morbidities;
Number of Part A grantees reporting this barrier (of 56): 56;
Number of Part B grantees reporting this barrier (of 30): 23;
Total number of grantees reporting this barrier (of 86): 79.
Barrier: Housing issues;
Number of Part A grantees reporting this barrier (of 56): 55;
Number of Part B grantees reporting this barrier (of 30): 21;
Total number of grantees reporting this barrier (of 86): 76.
Barrier: Poverty;
Number of Part A grantees reporting this barrier (of 56): 54;
Number of Part B grantees reporting this barrier (of 30): 19;
Total number of grantees reporting this barrier (of 86): 73.
Barrier: Lack of insurance;
Number of Part A grantees reporting this barrier (of 56): 56;
Number of Part B grantees reporting this barrier (of 30): 12;
Total number of grantees reporting this barrier (of 86): 68.
Barrier: Substance abuse;
Number of Part A grantees reporting this barrier (of 56): 47;
Number of Part B grantees reporting this barrier (of 30): 20;
Total number of grantees reporting this barrier (of 86): 67.
Barrier: Lack of transportation;
Number of Part A grantees reporting this barrier (of 56): 51;
Number of Part B grantees reporting this barrier (of 30): 14;
Total number of grantees reporting this barrier (of 86): 65.
Barrier: Language issues;
Number of Part A grantees reporting this barrier (of 56): 42;
Number of Part B grantees reporting this barrier (of 30): 18;
Total number of grantees reporting this barrier (of 86): 60.
Barrier: Prison population issues;
Number of Part A grantees reporting this barrier (of 56): 45;
Number of Part B grantees reporting this barrier (of 30): 15;
Total number of grantees reporting this barrier (of 86): 60.
Barrier: Stigma/fear;
Number of Part A grantees reporting this barrier (of 56): 45;
Number of Part B grantees reporting this barrier (of 30): 14;
Total number of grantees reporting this barrier (of 86): 59.
Barrier: Lack of health information;
Number of Part A grantees reporting this barrier (of 56): 41;
Number of Part B grantees reporting this barrier (of 30): 12;
Total number of grantees reporting this barrier (of 86): 53.
Source: GAO analysis of HRSA applications.
[End of table]
In our interviews, grantees under Parts C, D, and F also described many
of the issues in table 5 as barriers to minorities obtaining HIV/AIDS
services. Grantees explained that HIV/AIDS care may not be the primary
issue on an individual‘s list of needs or concerns. Without overall
programs to support these competing needs, minorities will experience
barriers to obtaining HIV/AIDS medical services. For example, some
grantees discussed barriers related to language issues within some
minority communities. A Part C grantee identified the lack of bilingual
health care providers as a major barrier to care for minorities served
by the grantee. The director of a Part C grantee explained that stigma
associated with HIV/AIDS is a barrier for some minorities because they
are less likely to seek services within their communities for fear of
revealing that they have HIV/AIDS. Part F grantees we interviewed
stated that the barriers to care included the lack of specialty care,
mistrust of health systems by patients, and the lack of insurance.
Agency Comments and Our Evaluation:
HHS provided comments on a draft of this report. The comments are
reprinted in appendix V. In its comments, HHS suggested that we
identify the law authorizing Ryan White programs as either Title XXVI
of the Public Health Service Act or the Ryan White HIV/AIDS program.
Consistent with our previous work, we continue to refer to the law
authorizing Ryan White programs as the CARE Act. As noted in the
report, the current program is authorized under the CARE Act, as
amended. We have added the Public Health Service Act title to our
footnote providing the legal citation to the statute. In addition, HHS
provided technical comments on the report draft, which we have
incorporated as appropriate.
We are sending a copy of this report to the Acting Secretary of Health
and Human Services. The report is also available at no charge on GAO‘s
Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Other staff who made major contributions
to this report are listed in appendix VI.
Signed by:
Marcia Crosse:
Director, Health Care:
[End of section]
Appendix I: Grantees Reported Few Challenges to Program Integration:
The Ryan White Comprehensive AIDS Resources Emergency Act (CARE Act)
requires us to report information on the challenges to human
immunodeficiency virus (HIV) and acquired immunodeficiency syndrome
(AIDS) program integration experienced by CARE Act grantees. Challenges
to program integration are issues that can prevent grantees and service
providers from working together to coordinate HIV/AIDS service
provision and can prevent clear communication between these
organizations regarding funding and program requirements. To identify
the challenges to HIV/AIDS program integration experienced by CARE Act
grantees, we interviewed staff from selected Part A, B, C, D, and F
grantees.[Footnote 32] To gather background information about the
challenges to HIV/AIDS program integration experienced by CARE Act
grantees, we interviewed officials from the Health Resources and
Services Administration (HRSA) of the Department of Health and Human
Services and staff of the National Minority AIDS Council, Kaiser Family
Foundation, the National Alliance of State and Territorial AIDS
Directors, and the Communities Advocating Emergency AIDS Relief
Coalition.
Grantees reported that few challenges exist to HIV/AIDS program
integration. Many grantees and service providers funded under different
parts of the CARE Act interact with other grantees, service providers,
and federal and state HIV/AIDS programs to provide services. However,
few problems were identified. For example, an official from a grantee
told us that the organization promotes program integration by designing
its services to create a ’seamless flow“ of care for individuals. This
includes using targeted outreach programs to bring minorities into care
and providing case management services. The service provider then
follows up with minority individuals through case management services
as well as mental health, substance abuse, and psychosocial support
services, as needed.
Grantees reported few challenges to HIV/AIDS program integration even
though they receive funding from multiple sources to provide HIV/AIDS
services. Funding for HIV/AIDS programs to provide services can come
from Medicaid, Medicare, Centers for Disease Control and Prevention
(CDC) grants, Substance Abuse and Mental Health Services Administration
(SAMHSA) grants, and state programs. Grantees we interviewed may
receive funding from a variety of federal and state sources. However,
CARE Act grants are designated as the ’payer of last resort“ and
therefore pay for HIV/AIDS services that are not covered by other
resources, such as Medicaid, Medicare, or private insurance.[Footnote
33] Some grantees reported in interviews that they have mechanisms in
place to ensure that these CARE Act programs are the payers of last
resort, which usually consists of closely tracking funding and
expenditures on services rendered for individuals, and to identify the
appropriate program to pay for HIV/AIDS services for individuals,
including those with specific needs.
One challenge some grantees identified was a lack of uniform data
collection and reporting requirements across the multiple parts of the
CARE Act, even though the required data are similar. Some grantees we
interviewed told us that differences in data collection and reporting
systems are challenges to program integration across the multiple parts
of the CARE Act.
Another challenge to achieving program integration is that definitions
of services may differ between the CARE Act and other federal and state
funding sources. Officials from a Part B grantee told us that differing
definitions present challenges to collaboration and integration because
grantees and service providers may be referencing different services
despite using the same term. For example, the definition of ’case
management“ is different depending on whether one uses the term in
reference to the CARE Act or to another federally funded program, such
as the Housing Opportunities for Persons with AIDS program.
[End of section]
Appendix II: Objectives, Scope, and Methodology:
The CARE Act requires us to report on the Minority AIDS Initiative
(MAI) and related issues. In this report, we are providing information
on (1) the effect on grantees and service providers of the new
competitive process for awarding Part A and B MAI funds, (2) the types
of services grantees funded under MAI, and (3) barriers to minorities
obtaining services from HIV/AIDS programs that were identified by
grantees. The CARE Act also requires us to report on the challenges of
integrating CARE Act–funded programs with HIV/AIDS programs funded from
other sources such as Medicaid, Medicare, the Centers for Disease,
Control and Prevention and SAMHSA. (See app. I for information on the
challenges of HIV/AIDS program integration experienced by CARE Act
grantees.)
To determine the effect of the new competitive process for awarding MAI
funds on grantees and service providers, we conducted a Web-based
survey of CARE Act grantees under Parts A and B. We obtained contact
information for Part A and Part B grantee officials, including names
and e-mail addresses, from HRSA. The survey questions focused on how
grantees applied for MAI funds, distributed funds to service providers,
and provided oversight, and what services they provided prior to and
after the passage of the Ryan White HIV/AIDS Treatment Modernization
Act of 2006 (RWTMA). We included in the survey Part B grantees that did
not apply for MAI funding for fiscal year 2007 in order to obtain their
reasons for not applying. The survey response rates were about 77
percent (43 out of 56) for Part A grantees and about 81 percent (48 out
of 59) for Part B grantees.
During the development of our survey, we conducted pretests with two
Part A grantees (in Washington, D.C., and Baltimore, Maryland) and two
Part B grantees (in Georgia and Pennsylvania). We opened the survey on
May 15, 2008, and closed it on June 27, 2008. While the survey was
open, we contacted each nonrespondent by e-mail to follow up and
subsequently contacted any remaining nonrespondents by telephone to
follow up as a way to address any problems and to encourage
nonrespondents to complete the survey. Because this survey was
conducted with all of the Part A and B grantees, it is not subject to
sampling error. However, there are practical difficulties in conducting
any survey that may introduce other types of errors, such as
nonsampling errors. For example, nonsampling error may introduce
unwanted variability or bias in the survey results and can result when
survey respondents inconsistently interpret particular survey
questions. We took steps to minimize nonsampling errors in developing
the questionnaire and in data collection and analysis. While the
response rates of 77 and 81 percent are high, if those not responding
differed materially from those responding on any particular question we
analyzed, our analysis may not accurately represent the group surveyed.
Therefore, our results are representative only of those responding to
our survey and are not generalizable to a larger population.
In addition, we reviewed HRSA‘s policies and reporting requirements for
Parts A, B, C, D, and F. We interviewed HRSA officials and staff from
selected grantees for Parts A and B to determine how funds were
distributed to service providers.
We estimated funding amounts for Part A and B grantees based on the old
formula-based process and analyzed the difference between these amounts
and the actual funding for fiscal year 2007. To create these estimated
funding amounts, we reviewed CARE Act MAI funding data for fiscal years
2006 and 2007, case counts of minorities living with AIDS for fiscal
year 2006, and case counts of minorities living with HIV/AIDS for
fiscal year 2007, all of which were provided by HRSA. To estimate
funding amounts for each Part A and Part B grantee, we followed the old
formula-based process, which used a proportion that represented the
relationship between a grantee‘s minority HIV/AIDS case count for
fiscal year 2007 and the total minority HIV/AIDS case count for all
jurisdictions, and then multiplied that proportion by the total amount
of MAI funding available. This gave us the estimated amount of funding
for each grantee. We then determined the difference between the actual
funding the grantee received under the new competitive process for 2007
and our estimated funding amount to establish the impact of the change
to the new competitive process. To assess the validity of the funding
amounts, we compared data we received from HRSA to previously published
funding amounts. To assess the reliability and validity of the computer-
generated estimated funding amounts, we provided HRSA officials with a
copy of our tables. They agreed with our methodology and were able to
duplicate our funding amounts. We determined that the funding data and
case count data were sufficiently reliable for the purposes of this
report.
To identify the types of services grantees funded under MAI, we
conducted a Web-based survey of Part A and B grantees, as described
above, and interviewed selected Part A, B, C, D, and F grantees about
services they provided under MAI prior to and after the passage of
RWTMA. We interviewed HRSA officials and staff from six Part A and six
Part B grantees to determine how funds were distributed. Although there
was no change in the process for awarding funds under Parts C, D, and
F, we interviewed grantees under those parts to learn about the
services they funded. We interviewed staff from six Part C, six Part D,
and three Part F grantees. We selected grantees to interview based on
the amount of MAI funding they received and to ensure geographic
diversity. All interviews were conducted over the telephone using a
structured interview guide that was provided to the interviewees in
advance. Question topics included the relationship between HRSA and the
grantee and between the grantee and service providers, the services
grantees funded, evaluation of services funded by grantees, barriers
minorities with HIV/AIDS face in obtaining services through HIV/AIDS
programs, and program integration barriers. We also interviewed staff
of the National Minority AIDS Council, Kaiser Family Foundation, the
National Alliance of State and Territorial AIDS Directors, and the
Communities Advocating Emergency AIDS Relief Coalition.
To identify the barriers to minorities obtaining services from HIV/AIDS
programs that were identified by grantees, we reviewed Part A MAI and
Part B MAI competitive grant applications for fiscal year 2007, which
included grantees‘ responses regarding barriers minorities face in
accessing HIV/AIDS services. We interviewed staff from selected Part A,
B, C, D, and F grantees about barriers minorities with HIV/AIDS face in
obtaining services through HIV/AIDS programs and budget allocations to
different HIV/AIDS services. We requested and received from HRSA fiscal
year 2007 MAI grant applications from all Part A and Part B applicants.
We conducted content analyses on selected sections of the MAI
applications in which grantees described barriers, co-morbidities,
unmet needs, coordination of services, implementation plans, and impact
of MAI services. During the content analyses, we collected information
from the fiscal year 2007 Part A MAI and Part B MAI applications
regarding barriers to HIV/AIDS services, co-morbidities for individuals
with HIV/AIDS, and factors that were complications for care. We also
interviewed staff from the organizations listed above.
We conducted our work from January 2008 to February 2009 in accordance
with all sections of GAO‘s Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
[End of section]
Appendix III: Ryan White CARE Act Title I and II Funding for Fiscal
Year 2006 and Part A and B Funding for Fiscal Year 2007:
Table 6 shows funding for Title I grant awards for fiscal year 2006.
Since the enactment of RWTMA, CARE Act Title I has been referred to as
Part A. In fiscal year 2006, 51 Title I grantees received MAI funding,
and the grant amounts ranged from $29,264 to $11,936,248. Overall, MAI
grants accounted for 13 percent or less of a Title I grantee‘s total
CARE Act funding.
Table 6: Ryan White CARE Act Title I Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards, Fiscal Year 2006:
EMA/TGA: Atlanta, Ga.
Total Title I grant: $18,869,561;
MAI grant: $1,609,533;
MAI as percentage of total Title I funding: 8.5.
EMA/TGA: Austin, Tex.
Total Title I grant: $3,719,076;
MAI grant: $213,718;
MAI as percentage of total Title I funding: 5.7.
EMA/TGA: Baltimore, Md.
Total Title I grant: $20,628,895;
MAI grant: $1,652,985;
MAI as percentage of total Title I funding: 8.0.
EMA/TGA: Baton Rouge, La.[A];
Total Title I grant: [Empty];
MAI grant: [Empty];
MAI as percentage of total Title I funding: [Empty].
EMA/TGA: Bergen-Passaic, N.J.
Total Title I grant: $4,485,650;
MAI grant: $210,170;
MAI as percentage of total Title I funding: 4.7.
EMA/TGA: Boston, Mass.
Total Title I grant: $13,339,141;
MAI grant: $544,492;
MAI as percentage of total Title I funding: 4.1.
EMA/TGA: Caguas, P.R.
Total Title I grant: $1,648,356;
MAI grant: $208,397;
MAI as percentage of total Title I funding: 12.6.
EMA/TGA: Charlotte-Gastonia-Concord, N.C.-S.C.[A];
Total Title I grant: [Empty];
MAI grant: [Empty];
MAI as percentage of total Title I funding: [Empty].
EMA/TGA: Chicago, Ill.
Total Title I grant: $25,044,633;
MAI grant: $1,878,231;
MAI as percentage of total Title I funding: 7.5.
EMA/TGA: Cleveland, Ohio;
Total Title I grant: $3,349,096;
MAI grant: $241,208;
MAI as percentage of total Title I funding: 7.2.
EMA/TGA: Dallas, Tex.
Total Title I grant: $13,196,377;
MAI grant: $1,071,248;
MAI as percentage of total Title I funding: 8.1.
EMA/TGA: Denver, Colo.
Total Title I grant: $4,283,042;
MAI grant: $186,227;
MAI as percentage of total Title I funding: 4.3.
EMA/TGA: Detroit, Mich.
Total Title I grant: $8,428,477;
MAI grant: $597,700;
MAI as percentage of total Title I funding: 7.1.
EMA/TGA: Dutchess County, N.Y.
Total Title I grant: $1,367,584;
MAI grant: $112,623;
MAI as percentage of total Title I funding: 8.2.
EMA/TGA: Fort Lauderdale, Fla.
Total Title I grant: $14,963,638;
MAI grant: $1,058,833;
MAI as percentage of total Title I funding: 7.1.
EMA/TGA: Fort Worth, Tex.
Total Title I grant: $3,409,819;
MAI grant: $219,925;
MAI as percentage of total Title I funding: 6.4.
EMA/TGA: Hartford, Conn.
Total Title I grant: $4,666,281;
MAI grant: $266,925;
MAI as percentage of total Title I funding: 5.7.
EMA/TGA: Houston, Tex.
Total Title I grant: $19,953,520;
MAI grant: $1,631,702;
MAI as percentage of total Title I funding: 8.2.
EMA/TGA: Indianapolis, Ind.[A];
Total Title I grant: [Empty];
MAI grant: [Empty];
MAI as percentage of total Title I funding: [Empty].
EMA/TGA: Jacksonville, Fla.
Total Title I grant: $4,913,816;
MAI grant: $409,699;
MAI as percentage of total Title I funding: 8.3.
EMA/TGA: Jersey City, N.J.
Total Title I grant: $5,145,142;
MAI grant: $265,152;
MAI as percentage of total Title I funding: 5.2.
EMA/TGA: Kansas City, Mo.
Total Title I grant: $2,916,485;
MAI grant: $125,038;
MAI as percentage of total Title I funding: 4.3.
EMA/TGA: Las Vegas, Nev.
Total Title I grant: $4,323,627;
MAI grant: $253,623;
MAI as percentage of total Title I funding: 5.9.
EMA/TGA: Los Angeles, Calif.
Total Title I grant: $34,895,377;
MAI grant: $2,507,856;
MAI as percentage of total Title I funding: 7.2.
EMA/TGA: Memphis, Tenn.[A];
Total Title I grant: [Empty];
MAI grant: [Empty];
MAI as percentage of total Title I funding: [Empty].
EMA/TGA: Miami, Fla.
Total Title I grant: $23,999,914;
MAI grant: $2,048,496;
MAI as percentage of total Title I funding: 8.5.
EMA/TGA: Middlesex-Somerset-Hunterdon, N.J.
Total Title I grant: $2,595,663;
MAI grant: $135,680;
MAI as percentage of total Title I funding: 5.2.
EMA/TGA: Minneapolis-St. Paul, Minn.
Total Title I grant: $3,046,512;
MAI grant: $197,755;
MAI as percentage of total Title I funding: 6.5.
EMA/TGA: Nashville-Davidson-Murfeesboro, Tenn.[A];
Total Title I grant: [Empty];
MAI grant: [Empty];
MAI as percentage of total Title I funding: [Empty].
EMA/TGA: Nassau-Suffolk, N.Y.
Total Title I grant: $6,148,307;
MAI grant: $464,680;
MAI as percentage of total Title I funding: 7.6.
EMA/TGA: New Haven, Conn.
Total Title I grant: $6,684,594;
MAI grant: $342,303;
MAI as percentage of total Title I funding: 5.1.
EMA/TGA: New Orleans, La.
Total Title I grant: $7,434,812;
MAI grant: $593,266;
MAI as percentage of total Title I funding: 8.0.
EMA/TGA: New York, N.Y.
Total Title I grant: $120,423,326;
MAI grant: $11,936,258;
MAI as percentage of total Title I funding: 9.9.
EMA/TGA: Newark, N.J.
Total Title I grant: $14,752,254;
MAI grant: $811,417;
MAI as percentage of total Title I funding: 5.5.
EMA/TGA: Norfolk, Va.
Total Title I grant: $4,414,760;
MAI grant: $235,887;
MAI as percentage of total Title I funding: 5.3.
EMA/TGA: Oakland, Calif.
Total Title I grant: $5,735,837;
MAI grant: $352,944;
MAI as percentage of total Title I funding: 6.2.
EMA/TGA: Orange County, Calif.
Total Title I grant: $4,858,579;
MAI grant: $214,604;
MAI as percentage of total Title I funding: 4.4.
EMA/TGA: Orlando, Fla.
Total Title I grant: $8,561,273;
MAI grant: $669,530;
MAI as percentage of total Title I funding: 7.8.
EMA/TGA: Philadelphia, Pa.
Total Title I grant: $22,384,551;
MAI grant: $1,585,589;
MAI as percentage of total Title I funding: 7.1.
EMA/TGA: Phoenix, Ariz.
Total Title I grant: $6,519,338;
MAI grant: $328,114;
MAI as percentage of total Title I funding: 5.0.
EMA/TGA: Ponce, P.R.
Total Title I grant: $2,391,444;
MAI grant: $246,529;
MAI as percentage of total Title I funding: 10.3.
EMA/TGA: Portland, Oregon;
Total Title I grant: $3,401,956;
MAI grant: $94,887;
MAI as percentage of total Title I funding: 2.8.
EMA/TGA: Riverside-San Bernadino, Calif.
Total Title I grant: $7,074,521;
MAI grant: $274,906;
MAI as percentage of total Title I funding: 3.9.
EMA/TGA: Sacramento, Calif.
Total Title I grant: $2,778,729;
MAI grant: $55,868;
MAI as percentage of total Title I funding: 2.0.
EMA/TGA: San Antonio, Tex.
Total Title I grant: $3,325,881;
MAI grant: $305,057;
MAI as percentage of total Title I funding: 9.2.
EMA/TGA: San Diego, Calif.
Total Title I grant: $9,269,256;
MAI grant: $450,492;
MAI as percentage of total Title I funding: 4.9.
EMA/TGA: San Francisco, Calif.
Total Title I grant: $27,964,864;
MAI grant: $534,737;
MAI as percentage of total Title I funding: 1.9.
EMA/TGA: San Jose, Calif.
Total Title I grant: $2,304,762;
MAI grant: $110,849;
MAI as percentage of total Title I funding: 4.8.
EMA/TGA: San Juan, P.R.
Total Title I grant: $13,470,347;
MAI grant: $1,191,852;
MAI as percentage of total Title I funding: 8.8.
EMA/TGA: Santa Rosa, Calif.
Total Title I grant: $1,028,634;
MAI grant: $29,264;
MAI as percentage of total Title I funding: 2.8.
EMA/TGA: Seattle, Wash.
Total Title I grant: $5,445,484;
MAI grant: $204,850;
MAI as percentage of total Title I funding: 3.8.
EMA/TGA: St. Louis. Mo.
Total Title I grant: $4,502,572;
MAI grant: $250,076;
MAI as percentage of total Title I funding: 5.6.
EMA/TGA: Tampa-St. Petersburg, Fla.
Total Title I grant: $9,571,830;
MAI grant: $567,549;
MAI as percentage of total Title I funding: 5.9.
EMA/TGA: Vineland-Millville-Bridgeton, N.J.
Total Title I grant: $849,715;
MAI grant: $71,833;
MAI as percentage of total Title I funding: 8.5.
EMA/TGA: Washington, D.C.
Total Title I grant: $26,923,066;
MAI grant: $2,667,479;
MAI as percentage of total Title I funding: 9.9.
EMA/TGA: West Palm Beach, Fla.
Total Title I grant: $8,276,018;
MAI grant: $673,964;
MAI as percentage of total Title I funding: 8.1.
EMA/TGA: Total;
Total Title I grant: $579,686,392;
MAI grant: $42,912,000;
MAI as percentage of total Title I funding: 7.4.
Sources: HRSA and GAO analysis of HRSA data.
Note: Since the enactment of RWTMA, CARE Act Title I has been referred
to as Part A. EMAs are eligible metropolitan areas; TGAs are
transitional grant areas.
[A] Baton Rouge, Louisiana; Charlotte-Gastonia-Concord, North
Carolina/South Carolina; Indianapolis, Indiana; Memphis, Tennessee; and
Nashville-Davidson-Murfreesboro, Tennessee, were newly designated as
TGAs in fiscal year 2007 and, therefore, did not receive Part A funding
in fiscal year 2006.
[End of table]
Table 7 shows Part A grant awards for fiscal year 2007. In addition, we
provide information on the percentage change from fiscal year 2006
through fiscal year 2007 in Part A MAI grant awards. This change is
based on several factors in addition to the new competitive process.
(See pages 13-19 for our analysis of fiscal year 2007 funding that
isolates the effect of this change.) The reasons for the changes in
funding from fiscal year 2006 through fiscal year 2007 include the
following:
* The addition of five Part A TGAs, which decreased the amount of
individual funding for all Part A grantees.
* Increases or decreases in grantees‘ proportion of the total number of
living minority HIV/AIDS cases, which is used as part of the
determination of the demonstrated need for funding. From fiscal year
2006 through fiscal year 2007, HRSA changed the case count method from
using the number of living minority AIDS cases to using the number of
living minorities with HIV/AIDS for the most recent year available as
reported to CDC.
* Scoring of grantees‘ competitive applications. The competitive
process determines the funding level of each grantee partly by the
score of its application.
In fiscal year 2007, 56 Part A grantees received MAI funding, and the
grant amounts ranged from $50,000 to $9,347,777. Overall, MAI grants
accounted for 10 percent or less of a Part A grantee‘s total CARE Act
funding in fiscal year 2007.
Table 7: Ryan White CARE Act Part A Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards for Fiscal Year 2007, Including
Percentage Change from Fiscal Year 2006:
EMA/TGA: Atlanta, Ga.
Total Part A grant: $17,124,514;
MAI grant: $1,050,229;
MAI as percentage of total Part A funding: 6.1;
Percentage change in MAI funding from FY 2006 to FY 2007: -35.
EMA/TGA: Austin, Tex.
Total Part A grant: $3,614,135;
MAI grant: $229,065;
MAI as percentage of total Part A funding: 6.3;
Percentage change in MAI funding from FY 2006 to FY 2007: 7.
EMA/TGA: Baltimore, Md.
Total Part A grant: $20,388,061;
MAI grant: $2,100,038;
MAI as percentage of total Part A funding: 10.3;
Percentage change in MAI funding from FY 2006 to FY 2007: 27.
EMA/TGA: Baton Rouge, La.[A];
Total Part A grant: $3,259,580;
MAI grant: $249,059;
MAI as percentage of total Part A funding: 7.6;
Percentage change in MAI funding from FY 2006 to FY 2007: [Empty].
EMA/TGA: Bergen-Passaic, N.J.
Total Part A grant: $3,869,966;
MAI grant: $287,493;
MAI as percentage of total Part A funding: 7.4;
Percentage change in MAI funding from FY 2006 to FY 2007: 37.
EMA/TGA: Boston, Mass.
Total Part A grant: $13,675,999;
MAI grant: $814,862;
MAI as percentage of total Part A funding: 6.0;
Percentage change in MAI funding from FY 2006 to FY 2007: 50.
EMA/TGA: Caguas, P.R.
Total Part A grant: $1,082,464;
MAI grant: $121,984;
MAI as percentage of total Part A funding: 11.3;
Percentage change in MAI funding from FY 2006 to FY 2007: -41.
EMA/TGA: Charlotte-Gastonia-Concord, N.C.-S.C.[A];
Total Part A grant: $4,200,378;
MAI grant: $371,535;
MAI as percentage of total Part A funding: 8.8;
Percentage change in MAI funding from FY 2006 to FY 2007: [Empty].
EMA/TGA: Chicago, Ill.
Total Part A grant: $25,153,442;
MAI grant: $1,787,310;
MAI as percentage of total Part A funding: 7.1;
Percentage change in MAI funding from FY 2006 to FY 2007: -5.
EMA/TGA: Cleveland, Ohio
Total Part A grant: $3,983,088;
MAI grant: $316,520;
MAI as percentage of total Part A funding: 7.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 31.
EMA/TGA: Dallas, Tex.
Total Part A grant: $13,550,581;
MAI grant: $772,577;
MAI as percentage of total Part A funding: 5.7;
Percentage change in MAI funding from FY 2006 to FY 2007: -28.
EMA/TGA: Denver, Colo.
Total Part A grant: $7,061,342;
MAI grant: $275,492;
MAI as percentage of total Part A funding: 3.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 48.
EMA/TGA: Detroit, Mich.
Total Part A grant: $8,366,462;
MAI grant: $644,567;
MAI as percentage of total Part A funding: 7.7;
Percentage change in MAI funding from FY 2006 to FY 2007: 8.
EMA/TGA: Dutchess County, N.Y.
Total Part A grant: $1,162,194;
MAI grant: $103,571;
MAI as percentage of total Part A funding: 8.9;
Percentage change in MAI funding from FY 2006 to FY 2007: -8.
EMA/TGA: Fort Lauderdale, Fla.
Total Part A grant: $14,284,795;
MAI grant: $1,113,452;
MAI as percentage of total Part A funding: 7.8;
Percentage change in MAI funding from FY 2006 to FY 2007: 5.
EMA/TGA: Fort Worth, Tex.
Total Part A grant: $3,443,293;
MAI grant: $204,310;
MAI as percentage of total Part A funding: 5.9;
Percentage change in MAI funding from FY 2006 to FY 2007: -7.
EMA/TGA: Hartford, Conn.
Total Part A grant: $3,170,527;
MAI grant: $252,944;
MAI as percentage of total Part A funding: 8.0;
Percentage change in MAI funding from FY 2006 to FY 2007: -5.
EMA/TGA: Houston, Tex.
Total Part A grant: $19,472,799;
MAI grant: $1,571,727;
MAI as percentage of total Part A funding: 8.1;
Percentage change in MAI funding from FY 2006 to FY 2007: -4.
EMA/TGA: Indianapolis, Ind.[A];
Total Part A grant: $3,230,389;
MAI grant: $189,079;
MAI as percentage of total Part A funding: 5.9;
Percentage change in MAI funding from FY 2006 to FY 2007: [Empty].
EMA/TGA: Jacksonville, Fla.
Total Part A grant: $4,886,573;
MAI grant: $393,745;
MAI as percentage of total Part A funding: 8.1;
Percentage change in MAI funding from FY 2006 to FY 2007: -4.
EMA/TGA: Jersey City, N.J.
Total Part A grant: $4,535,846;
MAI grant: $417,858;
MAI as percentage of total Part A funding: 9.2;
Percentage change in MAI funding from FY 2006 to FY 2007: 58.
EMA/TGA: Kansas City, Mo.
Total Part A grant: $3,724,815;
MAI grant: $187,284;
MAI as percentage of total Part A funding: 5.0;
Percentage change in MAI funding from FY 2006 to FY 2007: 50.
EMA/TGA: Las Vegas, Nev.
Total Part A grant: $4,670,529;
MAI grant: $225,918;
MAI as percentage of total Part A funding: 4.8;
Percentage change in MAI funding from FY 2006 to FY 2007: -11.
EMA/TGA: Los Angeles, Calif.
Total Part A grant: $35,263,560;
MAI grant: $2,528,561;
MAI as percentage of total Part A funding: 7.2;
Percentage change in MAI funding from FY 2006 to FY 2007: 1.
EMA/TGA: Memphis, Tenn.[A];
Total Part A grant: $5,574,9285;
MAI grant: $56,225;
MAI as percentage of total Part A funding: 10.0;
Percentage change in MAI funding from FY 2006 to FY 2007: [Empty].
EMA/TGA: Miami, Fla.
Total Part A grant: $25,061,316;
MAI grant: $2,565,107;
MAI as percentage of total Part A funding: 10.2;
Percentage change in MAI funding from FY 2006 to FY 2007: 25.
EMA/TGA: Middlesex-Somerset-Hunterdon, N.J.
Total Part A grant: $2,465,279;
MAI grant: $165,169;
MAI as percentage of total Part A funding: 6.7;
Percentage change in MAI funding from FY 2006 to FY 2007: 22.
EMA/TGA: Minneapolis-St. Paul, Minn.
Total Part A grant: $4,468,112;
MAI grant: $264,702;
MAI as percentage of total Part A funding: 5.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 34.
EMA/TGA: Nashville-Davidson-Murfeesboro, Tenn.[A]
Total Part A grant: $3,688,043;
MAI grant: $207,441;
MAI as percentage of total Part A funding: 5.6;
Percentage change in MAI funding from FY 2006 to FY 2007: [Empty].
EMA/TGA: Nassau-Suffolk, N.Y.
Total Part A grant: $4,814,937;
MAI grant: $325,286;
MAI as percentage of total Part A funding: 6.8;
Percentage change in MAI funding from FY 2006 to FY 2007: -30.
EMA/TGA: New Haven, Conn.
Total Part A grant: $5,101,747;
MAI grant: $321,657;
MAI as percentage of total Part A funding: 6.3;
Percentage change in MAI funding from FY 2006 to FY 2007: -6.
EMA/TGA: New Orleans, La.
Total Part A grant: $7,256,199;
MAI grant: $541,807;
MAI as percentage of total Part A funding: 7.5;
Percentage change in MAI funding from FY 2006 to FY 2007: -9.
EMA/TGA: New York, N.Y.
Total Part A grant: $110,213,357;
MAI grant: $9,347,777;
MAI as percentage of total Part A funding: 8.5;
Percentage change in MAI funding from FY 2006 to FY 2007: -22.
EMA/TGA: Newark, N.J.
Total Part A grant: $13,927,385;
MAI grant: $1,284,886;
MAI as percentage of total Part A funding: 9.2;
Percentage change in MAI funding from FY 2006 to FY 2007: 58.
EMA/TGA: Norfolk, Va.
Total Part A grant: $5,054,931;
MAI grant: $379,699;
MAI as percentage of total Part A funding: 7.5;
Percentage change in MAI funding from FY 2006 to FY 2007: 61.
EMA/TGA: Oakland, Calif.
Total Part A grant: $5,837,061;
MAI grant: $392,080;
MAI as percentage of total Part A funding: 6.7;
Percentage change in MAI funding from FY 2006 to FY 2007: 11.
EMA/TGA: Orange County, Calif.
Total Part A grant: $4,966,678;
MAI grant: $292,945;
MAI as percentage of total Part A funding: 5.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 37.
EMA/TGA: Orlando, Fla.
Total Part A grant: $8,062,483;
MAI grant: $578,713;
MAI as percentage of total Part A funding: 7.2;
Percentage change in MAI funding from FY 2006 to FY 2007: -14.
EMA/TGA: Philadelphia, Pa.
Total Part A grant: $21,639,722;
MAI grant: $1,682,127;
MAI as percentage of total Part A funding: 7.8;
Percentage change in MAI funding from FY 2006 to FY 2007: 6.
EMA/TGA: Phoenix, Ariz.
Total Part A grant: $6,974,852;
MAI grant: $193,368;
MAI as percentage of total Part A funding: 2.8;
Percentage change in MAI funding from FY 2006 to FY 2007: -41.
EMA/TGA: Ponce, P.R.
Total Part A grant: $1,699,838;
MAI grant: $153,098;
MAI as percentage of total Part A funding: 9.0;
Percentage change in MAI funding from FY 2006 to FY 2007: -38.
EMA/TGA: Portland, Oregon
Total Part A grant: $3,156,465;
MAI grant: $78,536;
MAI as percentage of total Part A funding: 2.5;
Percentage change in MAI funding from FY 2006 to FY 2007: -17.
EMA/TGA: Riverside-San Bernadino, Calif.
Total Part A grant: $6,720,094;
MAI grant: $255,733;
MAI as percentage of total Part A funding: 3.8;
Percentage change in MAI funding from FY 2006 to FY 2007: -7.
EMA/TGA: Sacramento, Calif.
Total Part A grant: $2,259,806;
MAI grant: $97,469;
MAI as percentage of total Part A funding: 4.3;
Percentage change in MAI funding from FY 2006 to FY 2007: 74.
EMA/TGA: St. Louis. Mo.
Total Part A grant: $5,273,629;
MAI grant: $378,174;
MAI as percentage of total Part A funding: 7.2;
Percentage change in MAI funding from FY 2006 to FY 2007: 51.
EMA/TGA: San Antonio, Tex.
Total Part A grant: $3,655,732;
MAI grant: $264,661;
MAI as percentage of total Part A funding: 7.2;
Percentage change in MAI funding from FY 2006 to FY 2007: -13.
EMA/TGA: San Diego, Calif.
Total Part A grant: $10,224,751;
MAI grant: $543,389;
MAI as percentage of total Part A funding: 5.3;
Percentage change in MAI funding from FY 2006 to FY 2007: 21.
EMA/TGA: San Francisco, Calif.
Total Part A grant: $19,459,344;
MAI grant: $652,491;
MAI as percentage of total Part A funding: 3.4;
Percentage change in MAI funding from FY 2006 to FY 2007: 22.
EMA/TGA: San Jose, Calif.
Total Part A grant: $2,338,369;
MAI grant: $137,156;
MAI as percentage of total Part A funding: 5.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 24.
EMA/TGA: San Juan, P.R.
Total Part A grant: $12,709,679;
MAI grant: $741,100;
MAI as percentage of total Part A funding: 5.8;
Percentage change in MAI funding from FY 2006 to FY 2007: -38.
EMA/TGA: Santa Rosa, Calif.[B];
Total Part A grant: $1,040,934;
MAI grant: $50,000;
MAI as percentage of total Part A funding: 4.8;
Percentage change in MAI funding from FY 2006 to FY 2007: 71.
EMA/TGA: Seattle, Wash.
Total Part A grant: $5,953,167;
MAI grant: $234,009;
MAI as percentage of total Part A funding: 3.9;
Percentage change in MAI funding from FY 2006 to FY 2007: 14.
EMA/TGA: Tampa-St. Petersburg, Fla.
Total Part A grant: $9,201,080;
MAI grant: $525,592;
MAI as percentage of total Part A funding: 5.7;
Percentage change in MAI funding from FY 2006 to FY 2007: -7.
EMA/TGA: Vineland-Millville-Bridgeton, N.J.
Total Part A grant: $783,864;
MAI grant: $68,510;
MAI as percentage of total Part A funding: 8.7;
Percentage change in MAI funding from FY 2006 to FY 2007: -5.
EMA/TGA: Washington, D.C.
Total Part A grant: $27,631,723;
MAI grant: $1,976,712;
MAI as percentage of total Part A funding: 7.2;
Percentage change in MAI funding from FY 2006 to FY 2007: -26.
EMA/TGA: West Palm Beach, Fla.
Total Part A grant: $8,295,497;
MAI grant: $576,631;
MAI as percentage of total Part A funding: 7.0;
Percentage change in MAI funding from FY 2006 to FY 2007: -14.
EMA/TGA: Total
Total Part A grant: $578,686,334;
MAI grant: $42,041,430;
MAI as percentage of total Part A funding: 7.3;
Percentage change in MAI funding from FY 2006 to FY 2007: -2.
Sources: HRSA and GAO analysis of HRSA data.
[A] Baton Rouge, Louisiana; Charlotte-Gastonia-Concord, North
Carolina/South Carolina; Indianapolis, Indiana; Memphis, Tennessee; and
Nashville-Davidson-Murfreesboro, Tennessee, were newly designated as
TGAs in fiscal year 2007 and, therefore, did not receive Part A funding
in fiscal year 2006.
[B] Santa Rosa, California, received the minimum grant award of
$50,000. The maximum grant award was set at $10,750,000; however, no
one qualified for the maximum.
End of table]
Table 8 shows funding for Title II grant awards for fiscal year 2006.
Since the enactment of RWTMA, CARE Act Title II has been referred to as
Part B. In fiscal year 2006, 51 Title II grantees received MAI funding,
and funding amounts ranged from $415 to $1,606,289. Overall, MAI grants
accounted for 1 percent or less of a Part B grantee‘s total CARE Act
funding.[Footnote 34]
Table 8: Ryan White CARE Act Title II Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards, Fiscal Year 2006:
State/territory: Alabama;
Total Title II grant: $12,379,760;
MAI grant[A]: $71,621;
MAI as percentage of total Part B funding: 0.58.
State/territory: Alaska;
Total Title II grant: $1,038,349;
MAI grant[A]: $3,425;
MAI as percentage of total Part B funding: 0.33.
State/territory: Arizona;
Total Title II grant: $12,732,077;
MAI grant[A]: $53,353;
MAI as percentage of total Part B funding: 0.42.
State/territory: Arkansas;
Total Title II grant: $5,161,119;
MAI grant[A]: $18,580;
MAI as percentage of total Part B funding: 0.36.
State/territory: California;
Total Title II grant: $121,734,064;
MAI grant[A]: $587,814;
MAI as percentage of total Part B funding: 0.48.
State/territory: Colorado;
Total Title II grant: $8,042,203;
MAI grant[A]: $28,960;
MAI as percentage of total Part B funding: 0.36.
State/territory: Connecticut;
Total Title II grant: $15,824,810;
MAI grant[A]: $76,604;
MAI as percentage of total Part B funding: 0.48.
State/territory: Delaware;
Total Title II grant: $5,432,326;
MAI grant[A]: $26,676;
MAI as percentage of total Part B funding: 0.49.
State/territory: District of Columbia;
Total Title II grant: $19,495,237;
MAI grant[A]: $180,403;
MAI as percentage of total Part B funding: 0.93.
State/territory: Florida;
Total Title II grant: $116,883,905;
MAI grant[A]: $798,318;
MAI as percentage of total Part B funding: 0.68.
State/territory: Georgia;
Total Title II grant: $37,822,590;
MAI grant[A]: $294,166;
MAI as percentage of total Part B funding: 0.78.
State/territory: Hawaii;
Total Title II grant: $3,298,130;
MAI grant[A]: $8,719;
MAI as percentage of total Part B funding: 0.26.
State/territory: Idaho;
Total Title II grant: $987,627;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Illinois;
Total Title II grant: $36,322,297;
MAI grant[A]: $244,239;
MAI as percentage of total Part B funding: 0.67.
State/territory: Indiana;
Total Title II grant: $11,631,445;
MAI grant[A]: $42,454;
MAI as percentage of total Part B funding: 0.36.
State/territory: Iowa;
Total Title II grant: $2,181,764;
MAI grant[A]: $6,124;
MAI as percentage of total Part B funding: 0.28.
State/territory: Kansas;
Total Title II grant: $3,130,712;
MAI grant[A]: $10,587;
MAI as percentage of total Part B funding: 0.34.
State/territory: Kentucky;
Total Title II grant: $7,190,340;
MAI grant[A]: $19,514;
MAI as percentage of total Part B funding: 0.27.
State/territory: Louisiana;
Total Title II grant: $23,891,181;
MAI grant[A]: $167,947;
MAI as percentage of total Part B funding: 0.70.
State/territory: Maine;
Total Title II grant: $1,333,909;
MAI grant[A]: $1,972;
MAI as percentage of total Part B funding: 0.15.
State/territory: Maryland;
Total Title II grant: $36,055,252;
MAI grant[A]: $303,301;
MAI as percentage of total Part B funding: 0.84.
State/territory: Massachusetts;
Total Title II grant: $20,190,874;
MAI grant[A]: $73,697;
MAI as percentage of total Part B funding: 0.37.
State/territory: Michigan;
Total Title II grant: $15,983,050;
MAI grant[A]: $85,842;
MAI as percentage of total Part B funding: 0.54.
State/territory: Minnesota;
Total Title II grant: $4,318,987;
MAI grant[A]: $25,742;
MAI as percentage of total Part B funding: 0.60.
State/territory: Mississippi;
Total Title II grant: $10,679,221;
MAI grant[A]: $77,642;
MAI as percentage of total Part B funding: 0.73.
State/territory: Missouri;
Total Title II grant: $10,500,632;
MAI grant[A]: $44,011;
MAI as percentage of total Part B funding: 0.42.
State/territory: Montana;
Total Title II grant: $824,817;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Nebraska;
Total Title II grant: $1,815,394;
MAI grant[A]: $7,162;
MAI as percentage of total Part B funding: 0.39.
State/territory: Nevada;
Total Title II grant: $6,654,115;
MAI grant[A]: $32,593;
MAI as percentage of total Part B funding: 0.49.
State/territory: New Hampshire;
Total Title II grant: $1,281,115;
MAI grant[A]: $2,595;
MAI as percentage of total Part B funding: 0.20.
State/territory: New Jersey;
Total Title II grant: $47,641,537;
MAI grant[A]: $234,586;
MAI as percentage of total Part B funding: 0.49.
State/territory: New Mexico;
Total Title II grant: $3,489,677;
MAI grant[A]: $16,400;
MAI as percentage of total Part B funding: 0.47.
State/territory: New York;
Total Title II grant: $175,602,454;
MAI grant[A]: $1,606,289;
MAI as percentage of total Part B funding: 0.91.
State/territory: North Carolina;
Total Title II grant: $24,681,830;
MAI grant[A]: $175,005;
MAI as percentage of total Part B funding: 0.71.
State/territory: North Dakota;
Total Title II grant: $320,858;
MAI grant[A]: $727;
MAI as percentage of total Part B funding: 0.23.
State/territory: Ohio;
Total Title II grant: $16,858,517;
MAI grant[A]: $82,001;
MAI as percentage of total Part B funding: 0.49.
State/territory: Oklahoma;
Total Title II grant: $6,121,483;
MAI grant[A]: $16,712;
MAI as percentage of total Part B funding: 0.27.
State/territory: Oregon;
Total Title II grant: $5,943,054;
MAI grant[A]: $13,079;
MAI as percentage of total Part B funding: 0.22.
State/territory: Pennsylvania;
Total Title II grant: $39,891,047;
MAI grant[A]: $217,355;
MAI as percentage of total Part B funding: 0.54.
State/territory: Puerto Rico;
Total Title II grant: $33,850,327;
MAI grant[A]: $242,163;
MAI as percentage of total Part B funding: 0.72.
State/territory: Rhode Island;
Total Title II grant: $3,189,276;
MAI grant[A]: $15,985;
MAI as percentage of total Part B funding: 0.50.
State/territory: South Carolina;
Total Title II grant: $21,163,384;
MAI grant[A]: $128,607;
MAI as percentage of total Part B funding: 0.61.
State/territory: South Dakota;
Total Title II grant: $734,916;
MAI grant[A]: $1,453;
MAI as percentage of total Part B funding: 0.20.
State/territory: Tennessee;
Total Title II grant: $21,178,234;
MAI grant[A]: $102,969;
MAI as percentage of total Part B funding: 0.49.
State/territory: Texas;
Total Title II grant: $76,656,747;
MAI grant[A]: $533,838;
MAI as percentage of total Part B funding: 0.70.
State/territory: Utah;
Total Title II grant: $3,329,533;
MAI grant[A]: $4,463;
MAI as percentage of total Part B funding: 0.13.
State/territory: Vermont;
Total Title II grant: $883,059;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Virginia;
Total Title II grant: $21,832,964;
MAI grant[A]: $106,913;
MAI as percentage of total Part B funding: 0.49.
State/territory: Washington;
Total Title II grant: $11,198,763;
MAI grant[A]: $33,631;
MAI as percentage of total Part B funding: 0.30.
State/territory: West Virginia;
Total Title II grant: $2,167,287;
MAI grant[A]: $5,190;
MAI as percentage of total Part B funding: 0.24.
State/territory: Wisconsin;
Total Title II grant: $5,404,657;
MAI grant[A]: $20,137;
MAI as percentage of total Part B funding: 0.37.
State/territory: Wyoming;
Total Title II grant: $372,887;
MAI grant[A]: $623;
MAI as percentage of total Part B funding: 0.17.
State/territory: Guam;
Total Title II grant: $147,415;
MAI grant[A]: $415;
MAI as percentage of total Part B funding: 0.28.
State/territory: Virgin Islands;
Total Title II grant: $1,007,176;
MAI grant[A]: $5,398;
MAI as percentage of total Part B funding: 0.54.
State/territory: American Samoa;
Total Title II grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Marshall Islands;
Total Title II grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Northern Marianas Islands;
Total Title II grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Republic of Palau;
Total Title II grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Federated States of Micronesia;
Total Title II grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty].
State/territory: Total;
Total Title II grant: $1,078,734,384;
MAI grant[A]: $6,858,000;
MAI as percentage of total Part B funding: 0.64.
Sources: HRSA and GAO analysis of HRSA data.
Note: Since the enactment of RWTMA, CARE Act Title II has been referred
to as Part B.
[A] States and territories that did not receive MAI funding in fiscal
year 2006 have a dash.
[End of table]
Table 9 shows funding for Part B grant awards for fiscal year 2007. In
addition, we provide information on the percentage change from fiscal
year 2006 through fiscal year 2007 in Part B MAI grant awards. This
change is based on several factors in addition to the new competitive
process. (See pages 13-19 for our analysis of fiscal year 2007 funding
that isolates the effect of this change.) The reasons for the changes
in funding include the following:
* A decreased number of Part B MAI grantees applying for and accepting
MAI funding, which increased the funds available to all Part B MAI
grantees.
* Increases or decreases in grantees‘ proportion of the total number of
living minority HIV/AIDS cases, which is a factor used as part of the
determination of the demonstrated need for funding. From fiscal year
2006 through fiscal year 2007, HRSA changed the case count method from
using the number of living minority AIDS cases to using the number of
living minorities with HIV/AIDS for the most recent year available as
reported to CDC.
* Scoring of grantees‘ competitive applications. The competitive
process determines the funding level of each grantee partly by the
score of its application.
In fiscal year 2007, 30 Part B grantees received MAI funding, and grant
amounts ranged from $2,500 to $1,476,866. Overall, MAI grants accounted
for 1 percent or less of a Part B grantee‘s total CARE Act funding.
Table 9: Ryan White CARE Act Part B Grant Awards and Minority AIDS
Initiative (MAI) Grant Awards for Fiscal Year 2007, Including
Percentage Change from Fiscal Year 2006:
State/Territory: Alabama;
Total Part B grant: $19,791,847;
MAI grant[A]: $109,917;
MAI as percentage of total Part B funding: 0.56;
Percentage Change in MAI funding from FY 2006 to FY 2007: 53.
State/Territory: Alaska;
Total Part B grant: $1,129,894;
MAI grant[A]: $4,412;
MAI as percentage of total Part B funding: 0.39;
Percentage Change in MAI funding from FY 2006 to FY 2007: 29.
State/Territory: Arizona;
Total Part B grant: $13,543,748;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Arkansas;
Total Part B grant: $7,901,902;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: California;
Total Part B grant: $122,936,034;
MAI grant[A]: $856,348;
MAI as percentage of total Part B funding: 0.70;
Percentage Change in MAI funding from FY 2006 to FY 2007: 46.
State/Territory: Colorado;
Total Part B grant: $13,396,954;
MAI grant[A]: $36,113;
MAI as percentage of total Part B funding: 0.27;
Percentage Change in MAI funding from FY 2006 to FY 2007: 25.
State/Territory: Connecticut;
Total Part B grant: $15,044,081;
MAI grant[A]: $83,285;
MAI as percentage of total Part B funding: 0.55;
Percentage Change in MAI funding from FY 2006 to FY 2007: 9.
State/Territory: Delaware;
Total Part B grant: $5,270,515;
MAI grant[A]: $4,360;
MAI as percentage of total Part B funding: 0.08;
Percentage Change in MAI funding from FY 2006 to FY 2007: -84.
State/Territory: District of Columbia;
Total Part B grant: $18,834,754;
MAI grant[A]: $204,224;
MAI as percentage of total Part B funding: 1.08;
Percentage Change in MAI funding from FY 2006 to FY 2007: 13.
State/Territory: Florida;
Total Part B grant: $117,413,102;
MAI grant[A]: $1,087,726;
MAI as percentage of total Part B funding: 0.93;
Percentage Change in MAI funding from FY 2006 to FY 2007: 36.
State/Territory: Georgia;
Total Part B grant: $40,350,086;
MAI grant[A]: $267,205;
MAI as percentage of total Part B funding: 0.66;
Percentage Change in MAI funding from FY 2006 to FY 2007: -9.
State/Territory: Hawaii;
Total Part B grant: $3,237,348;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Idaho;
Total Part B grant: $1,105,364;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Illinois;
Total Part B grant: $36,392,873;
MAI grant[A]: $72,966;
MAI as percentage of total Part B funding: 0.20;
Percentage Change in MAI funding from FY 2006 to FY 2007: -70.
State/Territory: Indiana;
Total Part B grant: $12,996,706;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Iowa;
Total Part B grant: $2,874,145;
MAI grant[A]: $8,377;
MAI as percentage of total Part B funding: 0.29;
Percentage Change in MAI funding from FY 2006 to FY 2007: 37.
State/Territory: Kansas;
Total Part B grant: $3,434,675;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Kentucky;
Total Part B grant: $7,608,908;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Louisiana;
Total Part B grant: $21,542,485;
MAI grant[A]: $140,731
MAI as percentage of total Part B funding: 0.65;
Percentage Change in MAI funding from FY 2006 to FY 2007: -16.
State/Territory: Maine;
Total Part B grant: $1,399,166;
MAI grant[A]: $2,500;
MAI as percentage of total Part B funding: 0.18;
Percentage Change in MAI funding from FY 2006 to FY 2007: 27.
State/Territory: Maryland;
Total Part B grant: $35,050,493;
MAI grant[A]: $304,838;
MAI as percentage of total Part B funding: 0.8;
Percentage Change in MAI funding from FY 2006 to FY 2007: 71.
State/Territory: Massachusetts;
Total Part B grant: $19,567,006;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Michigan;
Total Part B grant: $16,950,334;
MAI grant[A]: $141,887;
MAI as percentage of total Part B funding: 0.84;
Percentage Change in MAI funding from FY 2006 to FY 2007: 65.
State/Territory: Minnesota;
Total Part B grant: $7,088,148;
MAI grant[A]: $26,875;
MAI as percentage of total Part B funding: 0.3;
Percentage Change in MAI funding from FY 2006 to FY 2007: 84.
State/Territory: Mississippi;
Total Part B grant: $13,997,861;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Missouri;
Total Part B grant: $13,786,156;
MAI grant[A]: $69,743;
MAI as percentage of total Part B funding: 0.51;
Percentage Change in MAI funding from FY 2006 to FY 2007: 58.
State/Territory: Montana;
Total Part B grant: $866,238;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Nebraska;
Total Part B grant: $2,381,505;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Nevada;
Total Part B grant: $8,010,232;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: New Hampshire;
Total Part B grant: $1,502,980;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: New Jersey;
Total Part B grant: $45,995,066;
MAI grant[A]: $414,015;
MAI as percentage of total Part B funding: 0.90;
Percentage Change in MAI funding from FY 2006 to FY 2007: 76.
State/Territory: New Mexico;
Total Part B grant: $4,065,724;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: New York;
Total Part B grant: $169,488,721;
MAI grant[A]: $1,476,866;
MAI as percentage of total Part B funding: 0.87;
Percentage Change in MAI funding from FY 2006 to FY 2007: -8.
State/Territory: North Carolina;
Total Part B grant: $34,000,911;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: North Dakota;
Total Part B grant: $343,556;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Ohio;
Total Part B grant: $23,352,802;
MAI grant[A]: $62,201;
MAI as percentage of total Part B funding: 0.27;
Percentage Change in MAI funding from FY 2006 to FY 2007: -24.
State/Territory: Oklahoma;
Total Part B grant: $9,110,963;
MAI grant[A]: $20,313;
MAI as percentage of total Part B funding: 0.22;
Percentage Change in MAI funding from FY 2006 to FY 2007: 22.
State/Territory: Oregon;
Total Part B grant: $6,709,281;
MAI grant[A]: $14,031;
MAI as percentage of total Part B funding: 0.2;
Percentage Change in MAI funding from FY 2006 to FY 2007: 17.
State/Territory: Pennsylvania;
Total Part B grant: $38,649,989;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Puerto Rico;
Total Part B grant: $32,563,575;
MAI grant[A]: $142,792;
MAI as percentage of total Part B funding: 0.44;
Percentage Change in MAI funding from FY 2006 to FY 2007: -41.
State/Territory: Rhode Island;
Total Part B grant: $3,348,666;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: South Carolina;
Total Part B grant: $29,068,516;
MAI grant[A]: $177,810;
MAI as percentage of total Part B funding: 0.61;
Percentage Change in MAI funding from FY 2006 to FY 2007: 38.
State/Territory: South Dakota;
Total Part B grant: $805,924;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Tennessee;
Total Part B grant: $18,374,749;
MAI grant[A]: $130,743;
MAI as percentage of total Part B funding: 0.71;
Percentage Change in MAI funding from FY 2006 to FY 2007: 27.
State/Territory: Texas;
Total Part B grant: $89,342,110;
MAI grant[A]: $597,547;
MAI as percentage of total Part B funding: 0.67;
Percentage Change in MAI funding from FY 2006 to FY 2007: 12.
State/Territory: Utah;
Total Part B grant: $4,275,389;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Vermont;
Total Part B grant: $902,212;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Virginia;
Total Part B grant: $28,922,603;
MAI grant[A]: $203,896;
MAI as percentage of total Part B funding: 0.70;
Percentage Change in MAI funding from FY 2006 to FY 2007: 91.
State/Territory: Washington;
Total Part B grant: $11,757,722;
MAI grant[A]: $34,333;
MAI as percentage of total Part B funding: 0.29;
Percentage Change in MAI funding from FY 2006 to FY 2007: 2.
State/Territory: West Virginia;
Total Part B grant: $2,457,104;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Wisconsin;
Total Part B grant: $9,475,779;
MAI grant[A]: $41,046;
MAI as percentage of total Part B funding: 0.43;
Percentage Change in MAI funding from FY 2006 to FY 2007: 104.
State/Territory: Wyoming;
Total Part B grant: $680,188;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Guam;
Total Part B grant: $291,084;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Virgin Islands;
Total Part B grant: $1,272,874;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: American Samoa;
Total Part B grant: $51,979;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Marshall Islands;
Total Part B grant: $52,968;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Northern Mariana Islands;
Total Part B grant: $53,958;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Republic of Palau;
Total Part B grant: $50,000;
MAI grant[A]: [Empty];
MAI as percentage of total Part B funding: [Empty];
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Federated States of Micronesia[B];
Total Part B grant: $57,447;
MAI grant[A]: $2,500;
MAI as percentage of total Part B funding: 4.35;
Percentage Change in MAI funding from FY 2006 to FY 2007: [Empty].
State/Territory: Total;
Total Part B grant: $1,150,927,400;
MAI grant[A]: $6,739,600;
MAI as percentage of total Part B funding: 0.59.
Sources: HRSA and GAO analysis of HRSA data.
[A] States and territories that did not apply for funding in fiscal
year 2007 have a dash.
[B] Federated States of Micronesia received the minimum grant award of
$2,500. No maximum grant award was set.
[End of table]
[End of section]
Appendix IV: Explanation of Barriers to Minorities Obtaining HIV/AIDS
Services:
We analyzed fiscal year 2007 Part A MAI and Part B MAI grant
applications to identify the barriers to minorities obtaining HIV/AIDS
services identified most frequently by grantees. Barriers are issues
that can delay or prevent clients from receiving HIV/AIDS services on a
timely basis, thus reducing the likely success of those services. Table
10 provides definitions for each barrier identified by Part A and B MAI
grantees in their fiscal year 2007 MAI grant applications and the
number of grantees from each part that identified the barrier.
Table 10: Barriers to Minorities in Obtaining HIV/AIDS Services
Identified by Ryan White CARE Act Part A and B Minority AIDS Initiative
(MAI) Grantees:
Barrier: The 75/25 core medical/support services split;
Description: Parts A, B, and C grantees may not use less than 75
percent of funding to provide core medical services that are needed in
the eligible area for individuals with HIV/AIDS. This requirement could
be a barrier to obtaining services because it may limit the ability of
grantees to provide services that are responsive to the needs of
individuals they serve.
Number of Part A MAI grantees identifying this barrier (of 56): 5;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Co-morbidities;
Description: Co-morbidities are other diseases or conditions that an
individual with a primary condition, such as HIV/AIDS, may also have,
including hypertension, mental illness, sexually transmitted
infections/diseases, and tuberculosis. Co-morbidities may complicate
the delivery of or access to medical care.
Number of Part A MAI grantees identifying this barrier (of 56): 56;
Number of Part B MAI grantees identifying this barrier (of 30): 23.
Barrier: Cultural or religious barriers;
Description: Culture and religion influence health beliefs and
behaviors, which may affect compliance with medical treatment. For
example, an individual may have an aversion to revealing personal
information, which could hamper provider-patient communication. In
addition, prior adverse experiences may make some individuals
distrustful of the health care system.
Number of Part A MAI grantees identifying this barrier (of 56): 40;
Number of Part B MAI grantees identifying this barrier (of 30): 18.
Barrier: Data collection and reporting;
Description: CARE Act grantees and service providers report information
on programs and the individuals they serve to HRSA. These efforts may
divert resources from the delivery of HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 16;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Discrimination;
Description: Prejudicial and unequal treatment of individuals living
with HIV/AIDS may occur because HIV/AIDS is a life-threatening disease,
people are afraid of contracting HIV, and some believe that HIV/AIDS
has been contracted because of unacceptable lifestyle choices.
Number of Part A MAI grantees identifying this barrier (of 56): 12;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Familial responsibilities;
Description: Responsibilities involving children, partners,
grandparents, and other family members may present competing needs that
potentially compromise access to and continuing in HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 10;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Geographic factors;
Description: The geographic variation in the availability of HIV/AIDS
services can limit individuals‘ access to those services. This is
especially true in rural areas that lack health care providers or
services, thus requiring individuals to travel long distances to access
HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 21;
Number of Part B MAI grantees identifying this barrier (of 30): 9.
Barrier: Housing issues;
Description: Persons living with HIV/AIDS may lose their housing
because of compounding factors, such as increased medical costs and
limited incomes or reduced ability to keep working because of HIV/AIDS
and related illnesses. The instability that stems from homelessness can
compromise access to and continuing in HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 55;
Number of Part B MAI grantees identifying this barrier (of 30): 21.
Barrier: Immigrant issues;
Description: Undocumented workers and other immigrants may face
barriers to accessing and maintaining continuity of care for HIV and
other health care because these individuals may lack proper
documentation, fear legal action, or lack insurance or other means to
pay for care. This population is also vulnerable to barriers caused by
limited English proficiency.
Number of Part A MAI grantees identifying this barrier (of 56): 31;
Number of Part B MAI grantees identifying this barrier (of 30): 10.
Barrier: Increasing cost to treat HIV/AIDS;
Description: The increasing cost to treat HIV/AIDS is usually borne by
the grantee and could result in the grantee being unable to serve all
those in need.
Number of Part A MAI grantees identifying this barrier (of 56): 6;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Lack of adequate nutrition;
Description: Inadequate nutrition can contribute to impaired immune
response, accelerate disease progression, and impede the effectiveness
of medications.
Number of Part A MAI grantees identifying this barrier (of 56): 31;
Number of Part B MAI grantees identifying this barrier (of 30): 7.
Barrier: Lack of child care;
Description: Individuals, most often women, caring for children can
have problems securing reliable, affordable child care in order to
attend medical appointments and therefore may delay or miss such
HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 16;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Lack of funds (source not specified);
Description: Low amounts or lack of available funding challenges
grantees‘ provision of HIV/AIDS services and therefore may prevent
individuals from receiving these services.
Number of Part A MAI grantees identifying this barrier (of 56): 0;
Number of Part B MAI grantees identifying this barrier (of 30): 5.
Barrier: Lack of health information;
Description: If individuals with HIV/AIDS are not provided with
services that educate them about HIV transmission or the medical and
support services that are designed to improve health status, they might
not access or continue HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 41;
Number of Part B MAI grantees identifying this barrier (of 30): 18.
Barrier: Lack of insurance;
Description: Individuals without insurance or those who are
underinsured may delay, never seek, or not continue HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 56;
Number of Part B MAI grantees identifying this barrier (of 30): 12.
Barrier: Lack of providers with nontraditional hours;
Description: Clients who work during typical business hours may have
difficulty accessing HIV/AIDS services from medical and social service
programs that are open only during these times.
Number of Part A MAI grantees identifying this barrier (of 56): 13;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Lack of qualified organizations or physicians;
Description: Without adequately qualified organizations or physicians
to serve individuals with HIV/AIDS, individuals may not be able to
access specialized care or HIV/AIDS-specific services.
Number of Part A MAI grantees identifying this barrier (of 56): 21;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Lack of transportation;
Description: Lack of reliable transportation, including affordable and
convenient public transportation, and the need to travel long distances
to receive HIV/AIDS services can prevent minorities from accessing or
continuing HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 51;
Number of Part B MAI grantees identifying this barrier (of 30): 14.
Barrier: Language issues;
Description: Language issues include limits to understanding, speaking,
or reading English. Individuals with limited English proficiency often
require interpretation and translation to receive HIV/AIDS services,
but these may not be readily available.
Number of Part A MAI grantees identifying this barrier (of 56): 42;
Number of Part B MAI grantees identifying this barrier (of 30): 18.
Barrier: Late entry into care;
Description: Many individuals do not know their HIV status or do not
seek care immediately when they do know their status. Those who delay
care are often sicker when they do enter care, thus presenting more
complex care needs. Such needs may make it difficult for the available
HIV/AIDS services to be successful.
Number of Part A MAI grantees identifying this barrier (of 56): 25;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Limited psychosocial support;
Description: Social and emotional support includes counseling
activities, HIV support groups, pastoral care, caregiver support, and
bereavement counseling. Limited provision of these support services may
negatively affect an individual‘s adherence to HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 11;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Mental illness;
Description: Individuals with mental illness and HIV/AIDS often delay
medical treatment and require complex management of both illnesses,
which may not all be addressed by HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 36;
Number of Part B MAI grantees identifying this barrier (of 30): 13.
Barrier: Physical abuse;
Description: Some women may not seek HIV/AIDS or other medical care out
of fear of being abused by a partner.
Number of Part A MAI grantees identifying this barrier (of 56): 9;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Poverty;
Description: Poverty is defined by the federal government according to
income thresholds that vary by family size and composition. If a
family‘s total income is less than the family‘s threshold, then that
family and every individual in it is considered in poverty. Poverty
increases the likelihood of unemployment, inadequate or no health
insurance, and limited access to high quality health care.
Number of Part A MAI grantees identifying this barrier (of 56): 54;
Number of Part B MAI grantees identifying this barrier (of 30): 19.
Barrier: Prison population issues;
Description: Current and newly released inmates have increased
prevalence of HIV/AIDS. Newly released inmates may experience
difficulties accessing HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 45;
Number of Part B MAI grantees identifying this barrier (of 30): 15.
Barrier: Restrictive Medicaid[A] or Medicare[B] eligibility or benefit
reductions;
Description: Most adults are not eligible for Medicaid, though some
states have applied for a waiver to expand Medicaid eligibility for low-
income individuals with HIV prior to disability. Medicaid beneficiaries
often lose eligibility for Medicaid if they return to work as a result
of effective medical care. Those who are not eligible but cannot afford
insurance may be unlikely to access or continue HIV/AIDS care.
Eligibility criteria for Medicare are restrictive, but once an
individual becomes eligible, not all HIV/AIDS-related services may be
covered. For example, Medicare has limited support for nonmedical
services that are important for HIV/AIDS care, such as case management.
Number of Part A MAI grantees identifying this barrier (of 56): 27;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Ryan White CARE Act funding decline;
Description: A grantee‘s Ryan White Care Act funding might decline or
remain level, but if the number of HIV positive individuals to whom the
grantee must provide services increases, the grantee might not be able
to provide services to all those in need.
Number of Part A MAI grantees identifying this barrier (of 56): 25;
Number of Part B MAI grantees identifying this barrier (of 30): 1.
Barrier: Service appointment wait times;
Description: Long waits to schedule appointments may discourage
individuals from accessing or continuing HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 5;
Number of Part B MAI grantees identifying this barrier (of 30): 0.
Barrier: Staff turnover;
Description: Frequent turnover in management and staff can hinder
program implementation. Additionally, staff turnover can adversely
affect the knowledge and experience of the organization. The increased
caseload makes it more difficult for case managers to monitor their
clients and ensure that they are continuing care.
Number of Part A MAI grantees identifying this barrier (of 56): 6;
Number of Part B MAI grantees identifying this barrier (of 30): 6.
Barrier: Stigma/fear;
Description: HIV-related stigma refers to all unfavorable attitudes,
beliefs, and policies directed toward people perceived to have
HIV/AIDS. HIV/AIDS-related stigma affects individuals‘ willingness to
be tested for HIV and individuals‘ responses to testing positive, and
can lead to delays in accessing HIV/AIDS services.
Number of Part A MAI grantees identifying this barrier (of 56): 45;
Number of Part B MAI grantees identifying this barrier (of 30): 14.
Barrier: Substance abuse disorders;
Description: Substance abuse disorders are defined as dependence on or
abuse of a substance. Associated problems may include negative health
consequences, such as an increase in HIV transmission and a delay in
seeking medical care.
Number of Part A MAI grantees identifying this barrier (of 56): 47;
Number of Part B MAI grantees identifying this barrier (of 30): 20.
Barrier: Unemployment;
Description: Unemployment may result in an individual‘s loss of health
insurance or have financial consequences that may affect access to and
continuation of HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 26;
Number of Part B MAI grantees identifying this barrier (of 30): 8.
Barrier: Waiting lists for services;
Description: Individuals may not receive care because of long waits for
medical services. Additionally, not being eligible to participate in
programs such as Medicaid[A] because of income requirements may prevent
individuals from accessing or continuing HIV/AIDS care.
Number of Part A MAI grantees identifying this barrier (of 56): 12;
Number of Part B MAI grantees identifying this barrier (of 30): 5.
Source: GAO analysis of Part A and Part B MAI fiscal year 2007
competitive grant applications.
Note: Barriers reported by fewer than five Part A grantees or five Part
B grantees were not included in the table. If five or more grantees
from either part reported the barrier, the barrier is included in the
table with the number of grantees reporting the barrier for both parts.
[A] Medicaid is a jointly funded, federal-state health program that
covers certain low-income individuals, including those who are aged or
disabled, and families.
[B] Medicare is a federal health program for people 65 years of age and
older and for certain disabled adults.
[End of table]
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary
Assistant Secretary for Legislation:
Washington, DC 20201:
March 24, 2009:
Marcia G. Crosse:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Crosse:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: "Ryan White Care Act: Implementation of New
Provisions in the Minority AIDS Initiative (GAO-09-315).
The Department appreciates the opportunity to review this report before
its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Attachment:
[End of letter]
Department Of Health & Human Services:
Health Resources and Services Administration:
Rockville, MD 20857:
March 23, 2009:
To: Marcia Crosse Director, Health Care:
Government Accountability Office:
From: Administrator:
Subject: Government Accountability Office Draft Report: "Ryan White
Care Act: Implementation of New Provisions in the Minority AIDS
Initiative" (GAO-09-315):
Thank you for the opportunity to provide comments on the above subject
draft report. Attached please find the Department's comments.
Questions may be referred to Gail Lipton in HRSA's Office of Federal
Assistance Management at (301) 443-6509.
Signed by:
Mary K. Wakefield, Ph.D., R.N.
Attachment:
The Department of Health and Human Services' Comments on the Government
Accountability Office Draft Report: "Ryan White Care Act:
Implementation of New Provisions in the Minority AIDS Initiative"(GAO-
09-315):
General Comments:
The Department of Health and Human Services (DHHS) recommends using
consistent terminology to refer to the program and avoid confusion, as
either Title XXVI of the PHS Act or the Ryan White HIV/AIDS program.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia Crosse, (202) 512-7114 or crossem@gao.gov:
Acknowledgments:
In addition to the contact named above, Tom Conahan, Assistant
Director; Romonda McKinney Bumpus; Stefanie Bzdusek; Melanie Egorin;
Jill Evancho; Cathleen Hamann; Martha Kelly; Justin Mausel; Deborah
Miller; and Jennifer Whitworth made key contributions to this report.
[End of section]
Footnotes:
[1] HIV is the virus that causes AIDS. In this report, we use the
common term HIV/AIDS to refer to HIV disease, inclusive of cases that
have progressed to AIDS. When we use these terms alone, HIV refers to
the disease without the presence of AIDS, and AIDS refers exclusively
to HIV disease that has progressed to AIDS.
[2] Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42
U.S.C. §§ 300ff through 300ff-121).
[3] Unless otherwise indicated, references to the CARE Act are to
Public Health Service Act Title XXVI.
[4] We focus our discussion on how barriers to access to HIV/AIDS
services affect minorities. However, research shows that many of the
same barriers apply more generally to all individuals with HIV/AIDS.
See, for example, Institute of Medicine, Public Financing and Delivery
of HIV/AIDS Care: Securing the Legacy of Ryan White (Washington, D.C.,
2005). Under the CARE Act, as amended, racial and ethnic minority
populations include African Americans, Alaska Natives, Latinos,
American Indians, Asian Americans, Native Hawaiians, and Pacific
Islanders.
[5] Pub. L. No. 109-415, § 603, 120 Stat. 2767, 2818. There was no
specific statutory provision regarding the distribution of MAI funds
prior to RWTMA. CARE Act programs were previously reauthorized by the
Ryan White CARE Act Amendments of 1996 (Pub. L. No. 104-146, 110 Stat.
1346) and the Ryan White CARE Act Amendments of 2000 (Pub. L. No. 106-
345, 114 Stat. 1319).
[6] The 1990 CARE Act added Title XXVI to the Public Health Service
Act. Title XXVI, as enacted, contained several parts, which authorized
various HIV/AIDS-related grants. Prior to the enactment of RWTMA, Parts
A, B, C, D, and F of the CARE Act were referred to as Titles I, II,
III, IV, and the AIDS Education and Training Centers, respectively.
[7] EMAs are areas that have a population of 50,000 persons or more and
had a cumulative total of more than 2,000 new AIDS cases during the
most recent 5-year period. TGAs are areas that have a population of
50,000 persons or more and had a cumulative total of 1,000 to 1,999 new
AIDS cases during the most recent 5-year period.
[8] In this report, ’grantees“ refers to organizations or entities that
receive funding directly from HRSA for CARE Act services, and ’service
providers“ refers to organizations awarded contracts or subgrants from
grantees to provide services or arrange for another organization to
provide services. Grantees may also provide services to minorities
living with HIV/AIDS themselves. Therefore, when we use ’services,“ we
are referring to services provided by both grantees and their service
providers.
[9] In this report, ’formula-based process“ refers to the process prior
to the enactment of RWTMA when the distribution of MAI funds was based
solely on the number of minority individuals with AIDS within the
jurisdiction.
[10] Prior to RWTMA, U.S. territories and associated jurisdictions did
not receive MAI funding.
[11] The way HRSA awards MAI funds under Parts C, D, and F remains
unchanged. The Part C, D, and F MAI funds are awarded through a
competitive process as a component of the competitive grant award for
the base parts C, D, and F.
[12] Fiscal year 2007 funds were the only fiscal year funds awarded
under the new competitive application process when we began our work in
January 2008. Each part of the Care Act has its own defined fiscal
year; for example, the fiscal year for Part A funding is March 1 to
February 28, and the fiscal year for Part B funding is April 1 to March
31, but the Part A and Part B MAI fiscal year is August 1 to July 31.
[13] The seven U.S. territories and associated jurisdictions that
received Part B funding in fiscal year 2007 were American Samoa, the
Federated States of Micronesia, Guam, the Republic of the Marshall
Islands, the Commonwealth of the Northern Mariana Islands, the Republic
of Palau, and the Virgin Islands.
[14] As the ’payer of last resort,“ the CARE Act pays for HIV/AIDS
services that are not covered by other resources, such as Medicaid,
Medicare, or private insurance. U.S.C. §§ 300ff-15(a)(6), 300ff-
27(b)(7)(F), 300ff-64(f)(1). According to HRSA officials, Part D is a
payer of last resort by operation of HRSA policy.
[15] 42 U.S.C. § 300ff-28(a)(2)(F).
[16] There are 11 regional AETCs and 4 national AETCs, which are funded
under Part F. One of the national centers is the National Minority
AETC, which receives 100 percent of its funding from MAI.
[17] Base funding, also known as formula funding, is awarded based on
the number of people with HIV/AIDS living in the grantee‘s
jurisdiction, and supplemental funding is awarded on a competitive
basis based on demonstrated need, including criteria such as HIV/AIDS
prevalence. Base and supplemental funds are awarded separately from MAI
funds.
[18] According to HRSA application guidance for the Part A Minority
AIDS Initiative Grant Program (issued April 27, 2007), the 75 percent
’core medical services“ requirement applies to MAI funds. However, an
EMA/TGA could allocate and spend up to 100 percent of its MAI funds on
support services so long as 75 percent of total Part A funding (base,
supplemental, and MAI funding) is allocated and spent on core medical
services.
[19] Application sections include demonstrated need (grantee
description of the severity of the HIV/AIDS epidemic), impact
(description of the use and success of previously funded MAI programs),
evaluation (of progress toward program goals and client-level
outcomes), resources, and administration (description of grantee
administration and accountability) and the budget.
[20] See Brian Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds.,
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health
Care (Washington, D.C.: National Academies Press, 2003), and GAO,
Health Care: Approaches to Address Racial and Ethnic Disparities,
[hyperlink, http://www.gao.gov/products/GAO-03-862R] (Washington, D.C.:
July 8, 2003).
[21] Gregory Lucas et al., ’Detrimental Effects of Continued Drug Use
on the Treatment of HIV-1 Infection.“ Journal of Acquired Immune
Deficiency Syndromes, vol. 27, no. 3 (2001); Nancy Sohler et al., ’Type
and Pattern of Illicit Drug Use and Access to Health Care Services for
HIV-Infected People,“ AIDS Patient Care and STDs, vol. 21, supplement 1
(2007) and Chinazo O. Cunningham et al., ’Type of Substance Use and
Access to HIV-Related Health Care,“ AIDS Patient Care and STDs, vol.
20, no. 6 (2006).
[22] See GAO, Indian Health Service: HIV/AIDS Prevention and Treatment
Services for American Indians and Alaska Natives, [hyperlink,
http://www.gao.gov/products/GAO-08-90] (Washington, D.C.: Dec. 14,
2007).
[23] HRSA officials informed us that one state applied for and was
allocated Part B MAI funding in fiscal year 2007 but returned the
funding.
[24] HRSA officials said that they changed the beginning and ending
dates of the MAI fiscal year for 2007 so that HRSA could complete the
new guidance necessitated by the changes made by RWTMA.
[25] Department of Health and Human Services, Health Resources and
Services Administration, Part A Minority AIDS Initiative Grant Program:
Application Guidance for New Competing Discretionary Grants, HRSA
Announcement No. 07-135 (Washington, D.C., 2007).
[26] We use ’request for proposal“ (RFP) to describe all forms of
solicitation whether they are used in conjunction with the award of
contracts or subgrants.
[27] According to HRSA, CARE Act outreach services help to identify
persons at high risk for HIV infection and to bring HIV-infected
persons into care. Outreach services include services to both HIV-
infected persons who know their status and are not in care and HIV-
infected persons who do not know their status and are not in care.
[28] According to HRSA, nonmedical case management includes the
provision of advice and assistance in obtaining medical, social,
community, legal, financial, and other needed services. It does not
involve coordination and follow-up of medical treatments as medical
case management does.
[29] We focus our discussion on barriers to minorities in obtaining
HIV/AIDS services. However, research shows that many of the same
barriers apply more generally to all individuals with HIV/AIDS.
[30] Our recent work found that barriers to access to HIV/AIDS services
may exist for American Indians and Alaska Natives. These barriers
include issues such as stigma associated with HIV/AIDS, lack of
transportation, housing issues, and the prevalence of substance abuse
disorders. These barriers and others were found to delay, prevent, or
interrupt the continuity of HIV/AIDS treatment for these minorities.
GAO-08-90.
[31] Comorbidities are conditions that exist at the same time as a
primary condition. Comorbidities for individuals with HIV/AIDS include
diabetes and tuberculosis.
[32] CARE Act Part A provides for grants to selected metropolitan areas-
-known as eligible metropolitan areas and transitional grant areas--
that have been disproportionately affected by the HIV/AIDS epidemic.
Part B provides for grants to states and territories to improve
quality, availability, and organization of HIV/AIDS services. Part C
provides for grants to public and private nonprofit entities to provide
early intervention services, such as HIV testing and ambulatory care.
Part D provides for grants to programs for family-centered
comprehensive care to children, youth, and women and their families.
Part F provides for grants for demonstration and evaluation of
innovative models of HIV/AIDS care delivery for hard-to-reach
populations and training of health care providers.
[33] As the "payer of last resort," the CARE Act pays for HIV/AIDS
services that are not covered by other resources, such as Medicaid,
Medicare or private insurance. U.S.C. §§ 300ff-15(a)(6), 300ff-
27(b)(7)(F), 300ff-64(f)(1). According to HRSA officials, Part D is a
payer of last resort by operation of HRSA policy.
[34] We did not include the Federates States of Micronesia in this
analysis because they received the minimum grant award.
[End of section]
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