Ryan White Care Act:

Opportunities to Enhance Funding Equity

T-HEHS-00-150: Published: Jul 11, 2000. Publicly Released: Jul 11, 2000.

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Pursuant to a congressional request, GAO discussed ways to distribute Ryan White Comprehensive AIDS Resources Emergency (CARE) Act funds to states and localities, focusing on the: (1) potential for distributing funds on the basis of counts of persons with human immunodeficiency virus (HIV) infection in each geographic area rather than on counts of only persons whose disease has progressed to acquired immunodeficiency syndrome (AIDS); (2) differences in funding for states with and without an eligible metropolitan area (EMA); and (3) current effect of the hold-harmless provision adopted in the 1996 reauthorization, when the method of counting living AIDS cases replaced the practice of counting cumulative AID cases.

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

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