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Ryan White Reauthorization Headed to President

The House on October 5 unanimously passed, 411-0, a compromise bill (S. 2311) to reauthorize the Ryan White CARE Act (P.L. 101-381). The same day, the Senate approved the measure by unanimous consent, sending it to the President. Both the House and Senate approved separate versions earlier this year, with the Senate approving the bill on June 6 and the House passing it on July 25 (see The Source, 6/9/00, p. 1; 7/31/00, p. 3).

Sponsored by Reps. Tom Coburn (R-OK) and Henry Waxman (D-CA) and Sen. James Jeffords (R-VT), the bill represents a compromise among the cosponsors. “The Ryan White CARE Act has made an enormous difference….Today’s overwhelming bipartisan support for the CARE Act demonstrates that Congress understands how crucial it is to the health and welfare of our country,” stated Rep. Waxman.

Detailing the bill’s provisions, Rep. Coburn stated, “All of these changes, while long overdue, will do much to improve our Nation’s responsibilities to HIV and AIDS by ensuring medical access to all of those who are infected and by providing the proper care for all.”

The CARE Act provides emergency assistance to those cities with the largest number of AIDS cases. In order to qualify for funding, cities must have a population of 500,000 as well as 2,000 newly diagnosed AIDS cases in the previous two years. Cities may use the funds to increase and improve the quality and availability of health and support services for HIV-infected individuals and their families, including outpatient services, substance abuse and mental health treatment, and drug therapy; to provide early intervention services, including HIV testing for high-risk individuals; and to hire and train health care personnel and support staff. Funding streams for the Act are divided into five Titles.

Under the compromise measure, the funding formula for Titles I and II would be changed—the number of HIV infections would be added to the criteria for determining grant assistance. However, the bill would not implement this change until FY2005. Currently, cities receive funding based solely on the number of reported AIDS cases, not on the number of HIV infections. The provision is identical to the House-passed version.

Additionally, the bill would authorize $30 million in additional grants to states that have enacted laws requiring mandatory newborn testing. Another $30 million would be authorized for partner notification programs. The Institute of Medicine also would be required to study the number of infants born with HIV and the barriers that may prevent obstetricians from routinely screening pregnant women and infants for HIV. These provisions were included in the House-passed version.

The bill would expand the Title I and II set-aside for infants, children, and women to include adolescents and give priority to this population in the provision of health and support services.

The final measure makes another change to the funding formula in an effort to ensure a more equitable distribution of funding. Under the original 1990 Act, funding was distributed to eligible metropolitan areas (EMAs) based on the number of cumulative AIDS cases, which included individuals living with AIDS as well as those who had died from AIDS. However, the 1996 authorization changed the funding distribution so that it was based on the estimated number of people living with AIDS. Noting that this shift would cause a burden on certain EMAs, authorizers included a “hold harmless” provision that gradually implemented the funding change over a five-year period. Under the 1996 hold harmless provision, EMAs were guaranteed to receive at least 95 percent of the funds they received in the previous fiscal year (FY1999).

The House-passed bill (H.R. 4807) would have phased-in a change to the current hold harmless provision to ease the transition to the new funding formula. EMAs would have been guaranteed to receive 98 percent of funds the first year, 95.7 percent the second year, 91.1 percent the third year, 84.2 percent the fourth year, and 75 percent the fifth year. The Senate-passed bill (S. 2311) would have limited the formula reductions to an EMA to no more than 2 percent a year for a maximum of 10 percent over 5 years.

Under the final version, EMAs would be guaranteed 98 percent the first year, 95 percent the second year, 92 percent the third year, 89 percent the fourth year, and 85 percent the fifth year. Additionally, if the Department of Health and Human Services determines that there is enough data on the number of HIV infections to change the funding formula, then beginning in FY2005 cities could lose no more than 2 percent of their FY2004 allocation.

The final bill also would allow Title I and II funds to be used for early intervention services. Currently, only Title II funds may be used for those services. Additionally, under current law, Title IV funds may be used for clinical research on drug therapies for infants, children, and pregnant women. Programs are required to ensure “significant enrollment” of clients; however, many rural areas are unable to do so. As a result, S. 2311 would remove this requirement.

S. 2311 also includes language from the House-passed bill to ensure that the membership of the HIV Health Services Planning Councils reflects the demographics of the population of individuals infected with HIV. Another House-passed provision that would authorize training on prenatal and gynecological care for women at HIV/AIDS Education and Training Centers was included in the final measure.

Pointing to the need for reauthorization, Rep. Connie Morella (R-MD) stated, “The HIV/AIDS epidemic thus remains an enormous health emergency in the United States, and it will remain so into this century. The state of the epidemic points to an increase rather than a decrease in the overall need for health care, drug treatment, and social services. As a Nation, we must continue our effort to expand access to these services for people living with HIV/AIDS, particularly in communities of color and women.”

Del. Eleanor Holmes Norton (D-DC) agreed, saying, “This week, the surgeon general was quoted as saying the epidemic has evolved to become increasingly an epidemic of people of color, of women and of the young. We have got to get rid of this epidemic, not let it evolve; and what we are doing here this morning will have a great deal to do with getting rid of it.”

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