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Subject: Ryan White Care Act: Impact of Legislative Funding Proposal on Urban Areas: 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 human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and their family members.[Footnote 1] In December 2006 the Ryan White HIV/AIDS Treatment Modernization Act of 2006 reauthorized CARE Act programs for fiscal years 2007 through 2009.[Footnote 2] In July 2007, the House of Representatives passed H.R. 3043, the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act for fiscal year 2008, which contains a hold-harmless provision covering funding for urban areas that receive funding under the CARE Act.[Footnote 3] This bill has not been passed by the Senate. Under the CARE Act, funding for Eligible Metropolitan Areas (EMA) and Transitional Grant Areas (TGA) is primarily provided through three categories of grants:[Footnote 4] (1) formula grants that are awarded based on the case counts of people with HIV/AIDS living in an urban area; (2) supplemental grants that are awarded on a competitive basis based on an urban area's demonstration of need, including criteria such as HIV/AIDS prevalence; and (3) Minority AIDS Initiative (MAI) grants, which are supplemental grants awarded on a competitive basis for urban areas to address disparities in access, treatment, care, and health outcomes. The CARE Act includes a hold-harmless provision that limited the decrease that an EMA could receive in its formula funding for fiscal year 2007 to 5 percent of the fiscal year 2006 formula funding it would have received if the revised urban area allocations required by the Modernization Act of 2006 had been in place in fiscal year 2006.[Footnote 5] For fiscal years 2008 and 2009, the hold- harmless provision provides that an EMA will receive at least 100 percent of the amount of its formula funding for fiscal year 2007. However, no limitation applies to the decrease in total formula, supplemental, and MAI funding that an EMA can receive. The hold- harmless provision does not apply to TGAs. H.R. 3043, which was passed by the House of Representatives on July 19, 2007, would include funds for fiscal year 2008 to ensure that decreases in total 2007 Part A funding for EMAs and TGAs would not exceed levels specified in the bill.[Footnote 6] It would limit the total funding decrease for an EMA for the 2007 program year to no more than 8.4 percent of what the EMA received for the 2006 program year. Decreases for TGAs for the program year 2007 would be limited to 13.4 percent of their total funding from program year 2006.[Footnote 7] This hold- harmless provision would not apply to funding for any program year other than 2007. The bill does not characterize the hold-harmless funding as formula, supplemental, or MAI funding for purposes of the CARE Act nor does it indicate when such funds would be provided to EMAs and TGAs entitled to receive it. Finally, it does not state how long the eligible EMAs and TGAs would have to spend the funds they would receive. As Congress considers appropriations for CARE Act programs for fiscal year 2008, on July 27, 2007, and September 11, 2007, you asked us to (1) provide historical information on the funding levels identified during the appropriations process for CARE Act grants to urban areas as compared to fiscal year 2008 CARE Act funding levels proposed as part of the fiscal year 2008 appropriations process in the House of Representatives; (2) examine how the proposed hold-harmless provision from H.R. 3043 would impact funding for urban areas under the proposed funding levels; (3) determine whether any urban areas receive funding based on the number of both living and deceased HIV/AIDS cases; (4) provide sources that address the amount of CARE Act funding unobligated by urban areas, states, and territories; and (5) provide sources that address the number of people on AIDS Drug Assistance Program (ADAP) waiting lists.[Footnote 8] To provide information on the funding levels for CARE Act grants to urban areas identified during the appropriations process, we examined appropriations acts and related reports and HHS data for fiscal years 2001 through 2007, the proposed funding for fiscal year 2008 contained in H.R. 3043, and the report of the House Committee on Appropriations on that bill.[Footnote 9] To assess the impact of the proposed hold- harmless provision on urban areas, we examined funding for fiscal years 2006 and 2007, determined the amounts needed to fund the proposed hold- harmless provision, and estimated funding for fiscal year 2008 for EMAs and TGAs. To conduct this work, we reviewed data provided by HHS on fiscal years 2006 and 2007 CARE Act funding and case counts of people living with HIV/AIDS. We used this information to determine which urban areas would receive the hold-harmless funding, the amount each would receive, and the total needed to fund the hold-harmless provision. We also used the HHS data to estimate the fiscal year 2008 funding levels for urban areas with and without the proposed hold-harmless provision; that is, we determined (1) the projected funding levels for urban areas if all fiscal year 2008 funding for urban areas were used for program year 2008 formula, supplemental, and MAI grants and (2) the projected funding levels for urban areas if the amounts needed to fund the hold- harmless provision contained in H.R. 3043 were taken out of the funding to be used for program year 2008 grants.[Footnote 10] We conducted analyses with different funding levels to examine the impact of the proposed hold-harmless provision because the amount in H.R. 3043 and the amount in the report of the House Committee on Appropriations differ. At the time we conducted our analyses, fiscal year 2008 appropriations for CARE Act programs had not been enacted and, consequently, we used the amounts in H.R. 3043 and the report of the House Committee on Appropriations. However, the amount for urban areas and states and territories in H.R. 3043, that is Parts A and B, as passed by the House of Representatives is $10 million less than the amount obtained by adding together the amounts identified for urban areas and states and territories in the report of the House Committee on Appropriations. We have therefore conducted separate analyses using each amount. Each analysis requires different assumptions. The amount specified in H.R. 3043 for urban areas and states and territories as passed by the House of Representatives is $1,865,800,000, which according to HRSA is approximately a 3.68 percent increase over the fiscal year 2007 total funding for Parts A and B. We had to make several assumptions to estimate the fiscal year 2008 funding for urban areas. First, we assumed that the percentage of funding for Part A (approximately 33.56 percent) out of the total funding for Parts A and B would be the same in fiscal year 2008 as it was in fiscal year 2007. By applying this percentage to the $1,865,800,000 specified in H.R. 3043, we estimated that approximately $626,248,693 would be the total funding for Part A in fiscal year 2008. Second, we assumed that MAI funding for each urban area would increase by the same percentage that total MAI funding allocated to urban areas is scheduled to increase under the CARE Act, which is approximately 3.65 percent. Third, we assumed that the amount of funds set aside by HRSA prior to awarding grants to urban areas would be the same in fiscal year 2008 as it was in fiscal year 2007.[Footnote 11] Fourth, we subtracted the funding for MAI and set asides from the estimated Part A funding for fiscal year 2008, $626,248,693. The resulting funding, $557,300,597 would therefore be used for formula and supplemental grants. This represents an estimated increase of 3.8 percent in overall formula and supplemental funding for urban areas. Fifth, because updated HIV/AIDS case counts were not available, we used the HIV/AIDS case counts that HRSA used to determine fiscal year 2007 funding. We estimated the fiscal year 2008 formula funding for each urban area using these case counts. Sixth, we assumed that each urban area would receive the same percentage of the available supplemental funding in fiscal year 2008 that it received in fiscal year 2007. For the alternative analysis on the proposed hold-harmless provision based on the report of the House Committee on Appropriations, we used the amount specified in the report for urban areas, $636,300,000.[Footnote 12] We then made the same assumptions as for the previous analysis regarding MAI grants, amounts set aside by HRSA prior to awarding grants to urban areas, case counts, and supplemental grants. To determine whether any urban areas received funding based on both living and deceased HIV/AIDS cases, we used the funding formula data for fiscal years 2006 and 2007.[Footnote 13] In addition, we identified sources where information is available on the unobligated funding and waiting list issues by discussing these issues respectively with the HHS Office of Inspector General and the National Alliance of State & Territorial AIDS Directors. The objective of this work was to provide pertinent and timely information from readily available sources that Congress can use in determining funding for CARE Act programs. Because of time constraints, we did not conduct extensive testing and analysis of the reliability and validity of the data that were used for the analyses, nor did we conduct any additional analysis of the proposed provision. We performed our work from August 2007 through September 2007. CARE Act Funding for Urban Areas: CARE Act funding for urban areas would increase under the funding level identified in the report of the House Committee on Appropriations for CARE Act grants to these areas.[Footnote 14] Since fiscal year 2001, CARE Act funding for urban areas specified in conference reports accompanying the appropriations acts has ranged from a high of $622,741,000 in fiscal year 2003 to a low of $604,200,000 in fiscal year 2001.[Footnote 15] For fiscal year 2008, the report of the House Committee on Appropriations specifies $636,300,000 for urban areas,[Footnote 16] an increase of approximately 4.3 percent over the amount specified in the conference report for fiscal year 2006 funding.[Footnote 17] However, this amount includes the funding that would be used to address the funding decreases that certain EMAs and TGAs experienced in fiscal year 2007, a total of approximately $9.4 million.[Footnote 18] This would reduce the amount available for fiscal year 2008 grants as described by the Committee to approximately $626,900,000. This represents an increase of approximately 2.8 percent over the amount specified in the conference report for fiscal year 2006.[Footnote 19] Table 1 shows the funding specified in congressional reports and the actual amounts awarded to urban areas for fiscal years 2001 through 2007 and the proposed funding for fiscal year 2008 in the report of the House Committee on Appropriations. Table 1: CARE Act Funding for Urban Areas: Fiscal year: 2001; Funding identified in congressional report: $604,200,000[B]; Actual funding awarded[A]: $582,727,700. Fiscal year: 2002; Funding identified in congressional report: 619,585,000[B]; Actual funding awarded[A]: 597,256,000. Fiscal year: 2003; Funding identified in congressional report: 622,741,000[B]; Actual funding awarded[A]: 599,513,000. Fiscal year: 2004; Funding identified in congressional report: 618,693,000[B]; Actual funding awarded[A]: 595,342,000. Fiscal year: 2005; Funding identified in congressional report: 615,023,000[B]; Actual funding awarded[A]: 587,425,500. Fiscal year: 2006; Funding identified in congressional report: 610,094,000[B]; Actual funding awarded[A]: 579,686,392. Fiscal year: 2007; Funding identified in congressional report: [C]; Actual funding awarded[A]: 578,686,334. Fiscal year: 2008; Funding identified in congressional report: 636,300,000[D]; Actual funding awarded[A]: [E]. Sources: Conference reports accompanying annual appropriations laws, report of the House Committee on Appropriations (110-231), and HHS. [A] The actual funding awarded to urban areas differs from the amounts specified in the congressional reports for a variety of reasons. For example, rescissions may have reduced the total appropriations available for CARE Act programs. [B] Each appropriations act provided a lump sum covering the CARE Act and other programs and did not specify funding amounts for urban areas. The conference reports accompanying each act, while not legally binding, specified a separate amount to be used for grants to urban areas. [C] Fiscal year 2007 funds were appropriated for HRSA in a continuing resolution which contained a lump sum amount for all HRSA programs and did not specify a particular amount for grants to urban areas. See Pub. L. No. 110-5, 121 Stat. 8, 31-32. There were no conference or committee reports for this law. According to HHS, $603,993,000 was the funding level for grants to urban areas; that is, the amount available before subtracting for annual set asides. HRSA refers to this amount as the "final appropriation amount" for fiscal year 2007. [D] The $636,300,000 amount for urban areas is taken from the report of House Committee on Appropriations (No. 110-231) for H.R. 3043. According to the committee report, this amount is $32,307,000 above the fiscal year 2007 funding level and the administration's budget request for fiscal year 2007. If the proposed hold-harmless provision is enacted, the amount available to fund fiscal year 2008 grants would be reduced by approximately $9.4 million to $626,900,000. In addition, H.R. 3043 as reported by the Committee and passed by the House identifies an amount for CARE Act grants for urban areas and states and territories. However, this amount is $10 million less than the amount obtained by adding the amount identified in the House report for urban areas to the amount identified in the House report for states and territories. [E] No funding for fiscal year 2008 has been awarded yet. [End of table] CARE Act funding for urban areas is awarded to EMAs and TGAs through formula, supplemental, and MAI grants. Table 2 shows the grants awarded in fiscal years 2006 and 2007 to each EMA categorized by funding type. Table 3 shows the grants awarded in fiscal years 2006 and 2007 to each TGA categorized by funding type. Table 2: Grants Awarded to EMAs, Fiscal Years 2006 and 2007: EMA: Atlanta, Ga; Fiscal year 2006 grants: Formula: $9,634,687; Fiscal year 2006 grants: Supplemental: $7,625,341; Fiscal year 2006 grants: MAI: $1,609,533; Fiscal year 2006 grants: Total: $18,869,561; Fiscal year 2007 grants: Formula: $12,223,780; Fiscal year 2007 grants: Supplemental: $3,850,505; Fiscal year 2007 grants: MAI: $1,050,229; Fiscal year 2007 grants: Total: $17,124,514. EMA: Baltimore, Md; Fiscal year 2006 grants: Formula: 10,125,086; Fiscal year 2006 grants: Supplemental: 8,850,824; Fiscal year 2006 grants: MAI: 1,652,985; Fiscal year 2006 grants: Total: 20,628,895; Fiscal year 2007 grants: Formula: 13,101,233; Fiscal year 2007 grants: Supplemental: 5,186,790; Fiscal year 2007 grants: MAI: 2,100,038; Fiscal year 2007 grants: Total: 20,388,061. EMA: Boston, Mass; Fiscal year 2006 grants: Formula: 6,979,687; Fiscal year 2006 grants: Supplemental: 5,814,962; Fiscal year 2006 grants: MAI: 544,492; Fiscal year 2006 grants: Total: 13,339,141; Fiscal year 2007 grants: Formula: 9,091,554; Fiscal year 2007 grants: Supplemental: 3,769,583; Fiscal year 2007 grants: MAI: 814,862; Fiscal year 2007 grants: Total: 13,675,999. EMA: Chicago, Ill; Fiscal year 2006 grants: Formula: 12,891,725; Fiscal year 2006 grants: Supplemental: 10,274,677; Fiscal year 2006 grants: MAI: 1,878,231; Fiscal year 2006 grants: Total: 25,044,633; Fiscal year 2007 grants: Formula: 16,477,405; Fiscal year 2007 grants: Supplemental: 6,888,727; Fiscal year 2007 grants: MAI: 1,787,310; Fiscal year 2007 grants: Total: 25,153,442. EMA: Dallas, Tex; Fiscal year 2006 grants: Formula: 6,509,160; Fiscal year 2006 grants: Supplemental: 5,615,969; Fiscal year 2006 grants: MAI: 1,071,248; Fiscal year 2006 grants: Total: 13,196,377; Fiscal year 2007 grants: Formula: 9,137,396; Fiscal year 2007 grants: Supplemental: 3,640,608; Fiscal year 2007 grants: MAI: 772,577; Fiscal year 2007 grants: Total: 13,550,581. EMA: Detroit, Mich; Fiscal year 2006 grants: Formula: 4,450,466; Fiscal year 2006 grants: Supplemental: 3,380,311; Fiscal year 2006 grants: MAI: 597,700; Fiscal year 2006 grants: Total: 8,428,477; Fiscal year 2007 grants: Formula: 5,648,743; Fiscal year 2007 grants: Supplemental: 2,073,152; Fiscal year 2007 grants: MAI: 644,567; Fiscal year 2007 grants: Total: 8,366,462. EMA: Fort Lauderdale, Fla; Fiscal year 2006 grants: Formula: 7,390,404; Fiscal year 2006 grants: Supplemental: 6,514,401; Fiscal year 2006 grants: MAI: 1,058,833; Fiscal year 2006 grants: Total: 14,963,638; Fiscal year 2007 grants: Formula: 9,444,098; Fiscal year 2007 grants: Supplemental: 3,727,245; Fiscal year 2007 grants: MAI: 1,113,452; Fiscal year 2007 grants: Total: 14,284,795. EMA: Houston, Tex; Fiscal year 2006 grants: Formula: 10,069,778; Fiscal year 2006 grants: Supplemental: 8,252,040; Fiscal year 2006 grants: MAI: 1,631,702; Fiscal year 2006 grants: Total: 19,953,520; Fiscal year 2007 grants: Formula: 12,780,890; Fiscal year 2007 grants: Supplemental: 5,120,182; Fiscal year 2007 grants: MAI: 1,571,727; Fiscal year 2007 grants: Total: 19,472,799. EMA: Los Angeles, Calif; Fiscal year 2006 grants: Formula: 18,302,095; Fiscal year 2006 grants: Supplemental: 14,085,426; Fiscal year 2006 grants: MAI: 2,507,856; Fiscal year 2006 grants: Total: 34,895,377; Fiscal year 2007 grants: Formula: 23,182,654; Fiscal year 2007 grants: Supplemental: 9,552,345; Fiscal year 2007 grants: MAI: 2,528,561; Fiscal year 2007 grants: Total: 35,263,560. EMA: Miami, Fla; Fiscal year 2006 grants: Formula: 12,178,882; Fiscal year 2006 grants: Supplemental: 9,772,536; Fiscal year 2006 grants: MAI: 2,048,496; Fiscal year 2006 grants: Total: 23,999,914; Fiscal year 2007 grants: Formula: 16,014,327; Fiscal year 2007 grants: Supplemental: 6,481,882; Fiscal year 2007 grants: MAI: 2,565,107; Fiscal year 2007 grants: Total: 25,061,316. EMA: New Orleans, La; Fiscal year 2006 grants: Formula: 3,894,926; Fiscal year 2006 grants: Supplemental: 2,946,620; Fiscal year 2006 grants: MAI: 593,266; Fiscal year 2006 grants: Total: 7,434,812; Fiscal year 2007 grants: Formula: 4,944,054; Fiscal year 2007 grants: Supplemental: 1,770,338; Fiscal year 2007 grants: MAI: 541,807; Fiscal year 2007 grants: Total: 7,256,199. EMA: New York, N.Y; Fiscal year 2006 grants: Formula: 59,000,321; Fiscal year 2006 grants: Supplemental: 49,486,747; Fiscal year 2006 grants: MAI: 11,936,258; Fiscal year 2006 grants: Total: 120,423,326; Fiscal year 2007 grants: Formula: 74,867,223; Fiscal year 2007 grants: Supplemental: 25,998,357; Fiscal year 2007 grants: MAI: 9,347,777; Fiscal year 2007 grants: Total: 110,213,357. EMA: Newark, N.J; Fiscal year 2006 grants: Formula: 7,636,547; Fiscal year 2006 grants: Supplemental: 6,304,290; Fiscal year 2006 grants: MAI: 811,417; Fiscal year 2006 grants: Total: 14,752,254; Fiscal year 2007 grants: Formula: 9,089,812; Fiscal year 2007 grants: Supplemental: 3,552,687; Fiscal year 2007 grants: MAI: 1,284,886; Fiscal year 2007 grants: Total: 13,927,385. EMA: Orlando, Fla; Fiscal year 2006 grants: Formula: 4,336,162; Fiscal year 2006 grants: Supplemental: 3,555,581; Fiscal year 2006 grants: MAI: 669,530; Fiscal year 2006 grants: Total: 8,561,273; Fiscal year 2007 grants: Formula: 5,503,524; Fiscal year 2007 grants: Supplemental: 1,980,246; Fiscal year 2007 grants: MAI: 578,713; Fiscal year 2007 grants: Total: 8,062,483. EMA: Philadelphia, Pa; Fiscal year 2006 grants: Formula: 11,798,212; Fiscal year 2006 grants: Supplemental: 9,000,750; Fiscal year 2006 grants: MAI: 1,585,589; Fiscal year 2006 grants: Total: 22,384,551; Fiscal year 2007 grants: Formula: 14,920,594; Fiscal year 2007 grants: Supplemental: 5,037,001; Fiscal year 2007 grants: MAI: 1,682,127; Fiscal year 2007 grants: Total: 21,639,722. EMA: Phoenix, Ariz; Fiscal year 2006 grants: Formula: 3,701,962; Fiscal year 2006 grants: Supplemental: 2,489,262; Fiscal year 2006 grants: MAI: 328,114; Fiscal year 2006 grants: Total: 6,519,338; Fiscal year 2007 grants: Formula: 4,970,250; Fiscal year 2007 grants: Supplemental: 1,811,234; Fiscal year 2007 grants: MAI: 193,368; Fiscal year 2007 grants: Total: 6,974,852. EMA: San Diego, Calif; Fiscal year 2006 grants: Formula: 4,917,200; Fiscal year 2006 grants: Supplemental: 3,901,564; Fiscal year 2006 grants: MAI: 450,492; Fiscal year 2006 grants: Total: 9,269,256; Fiscal year 2007 grants: Formula: 6,769,231; Fiscal year 2007 grants: Supplemental: 2,912,131; Fiscal year 2007 grants: MAI: 543,389; Fiscal year 2007 grants: Total: 10,224,751. EMA: San Francisco, Calif; Fiscal year 2006 grants: Formula: 15,444,793; Fiscal year 2006 grants: Supplemental: 11,985,334; Fiscal year 2006 grants: MAI: 534,737; Fiscal year 2006 grants: Total: 27,964,864; Fiscal year 2007 grants: Formula: 14,672,553; Fiscal year 2007 grants: Supplemental: 4,134,300; Fiscal year 2007 grants: MAI: 652,491; Fiscal year 2007 grants: Total: 19,459,344. EMA: San Juan, P.R; Fiscal year 2006 grants: Formula: 7,641,520; Fiscal year 2006 grants: Supplemental: 4,636,975; Fiscal year 2006 grants: MAI: 1,191,852; Fiscal year 2006 grants: Total: 13,470,347; Fiscal year 2007 grants: Formula: 9,415,282; Fiscal year 2007 grants: Supplemental: 2,553,297; Fiscal year 2007 grants: MAI: 741,100; Fiscal year 2007 grants: Total: 12,709,679. EMA: Tampa-St. Petersburg, Fla; Fiscal year 2006 grants: Formula: 4,987,570; Fiscal year 2006 grants: Supplemental: 4,016,711; Fiscal year 2006 grants: MAI: 567,549; Fiscal year 2006 grants: Total: 9,571,830; Fiscal year 2007 grants: Formula: 6,330,047; Fiscal year 2007 grants: Supplemental: 2,345,441; Fiscal year 2007 grants: MAI: 525,592; Fiscal year 2007 grants: Total: 9,201,080. EMA: Washington, D.C; Fiscal year 2006 grants: Formula: 14,810,305; Fiscal year 2006 grants: Supplemental: 9,445,282; Fiscal year 2006 grants: MAI: 2,667,479; Fiscal year 2006 grants: Total: 26,923,066; Fiscal year 2007 grants: Formula: 18,759,719; Fiscal year 2007 grants: Supplemental: 6,895,292; Fiscal year 2007 grants: MAI: 1,976,712; Fiscal year 2007 grants: Total: 27,631,723. EMA: West Palm Beach, Fla; Fiscal year 2006 grants: Formula: 4,546,333; Fiscal year 2006 grants: Supplemental: 3,055,721; Fiscal year 2006 grants: MAI: 673,964; Fiscal year 2006 grants: Total: 8,276,018; Fiscal year 2007 grants: Formula: 5,769,416; Fiscal year 2007 grants: Supplemental: 1,949,450; Fiscal year 2007 grants: MAI: 576,631; Fiscal year 2007 grants: Total: 8,295,497. EMA: Total; Fiscal year 2006 grants: Formula: $241,247,821; Fiscal year 2006 grants: Supplemental: $191,011,324; Fiscal year 2006 grants: MAI: $36,611,323; Fiscal year 2006 grants: Total: $468,870,468; Fiscal year 2007 grants: Formula: $303,113,785; Fiscal year 2007 grants: Supplemental: $111,230,793; Fiscal year 2007 grants: MAI: $33,593,023; Fiscal year 2007 grants: Total: $447,937,601. Source: HHS. [End of table] Table 3: Grants Awarded to TGAs, Fiscal Years 2006 and 2007: TGA: Austin, Tex; Fiscal year 2006 grants: Formula: $1,932,460; Fiscal year 2006 grants: Supplemental: $1,572,898; Fiscal year 2006 grants: MAI: $213,718; Fiscal year 2006 grants: Total: $3,719,076; Fiscal year 2007 grants: Formula: $2,311,513; Fiscal year 2007 grants: Supplemental: $1,073,557; Fiscal year 2007 grants: MAI: $229,065; Fiscal year 2007 grants: Total: $3,614,135. TGA: Baton Rouge, La; Fiscal year 2006 grants: Formula: 0; Fiscal year 2006 grants: Supplemental: 0; Fiscal year 2006 grants: MAI: 0; Fiscal year 2006 grants: Total: 0; Fiscal year 2007 grants: Formula: 2,179,184; Fiscal year 2007 grants: Supplemental: 831,337; Fiscal year 2007 grants: MAI: 249,059; Fiscal year 2007 grants: Total: 3,259,580. TGA: Bergen-Passaic, N.J; Fiscal year 2006 grants: Formula: 2,440,939; Fiscal year 2006 grants: Supplemental: 1,834,541; Fiscal year 2006 grants: MAI: 210,170; Fiscal year 2006 grants: Total: 4,485,650; Fiscal year 2007 grants: Formula: 2,480,997; Fiscal year 2007 grants: Supplemental: 1,101,476; Fiscal year 2007 grants: MAI: 287,493; Fiscal year 2007 grants: Total: 3,869,966. TGA: Caguas, P.R; Fiscal year 2006 grants: Formula: 872,640; Fiscal year 2006 grants: Supplemental: 567,319; Fiscal year 2006 grants: MAI: 208,397; Fiscal year 2006 grants: Total: 1,648,356; Fiscal year 2007 grants: Formula: 690,977; Fiscal year 2007 grants: Supplemental: 269,503; Fiscal year 2007 grants: MAI: 121,984; Fiscal year 2007 grants: Total: 1,082,464. TGA: Charlotte-Gastonia, N.C.-S.C; Fiscal year 2006 grants: Formula: 0; Fiscal year 2006 grants: Supplemental: 0; Fiscal year 2006 grants: MAI: 0; Fiscal year 2006 grants: Total: 0; Fiscal year 2007 grants: Formula: 2,854,516; Fiscal year 2007 grants: Supplemental: 974,327; Fiscal year 2007 grants: MAI: 371,535; Fiscal year 2007 grants: Total: 4,200,378. TGA: Cleveland, Ohio; Fiscal year 2006 grants: Formula: 1,793,462; Fiscal year 2006 grants: Supplemental: 1,314,426; Fiscal year 2006 grants: MAI: 241,208; Fiscal year 2006 grants: Total: 3,349,096; Fiscal year 2007 grants: Formula: 2,606,155; Fiscal year 2007 grants: Supplemental: 1,060,413; Fiscal year 2007 grants: MAI: 316,520; Fiscal year 2007 grants: Total: 3,983,088. TGA: Denver, Colo; Fiscal year 2006 grants: Formula: 2,286,509; Fiscal year 2006 grants: Supplemental: 1,810,306; Fiscal year 2006 grants: MAI: 186,227; Fiscal year 2006 grants: Total: 4,283,042; Fiscal year 2007 grants: Formula: 4,860,304; Fiscal year 2007 grants: Supplemental: 1,925,546; Fiscal year 2007 grants: MAI: 275,492; Fiscal year 2007 grants: Total: 7,061,342. TGA: Dutchess County, N.Y; Fiscal year 2006 grants: Formula: 698,112; Fiscal year 2006 grants: Supplemental: 556,849; Fiscal year 2006 grants: MAI: 112,623; Fiscal year 2006 grants: Total: 1,367,584; Fiscal year 2007 grants: Formula: 719,007; Fiscal year 2007 grants: Supplemental: 339,616; Fiscal year 2007 grants: MAI: 103,571; Fiscal year 2007 grants: Total: 1,162,194. TGA: Fort Worth, Tex; Fiscal year 2006 grants: Formula: 1,726,845; Fiscal year 2006 grants: Supplemental: 1,463,049; Fiscal year 2006 grants: MAI: 219,925; Fiscal year 2006 grants: Total: 3,409,819; Fiscal year 2007 grants: Formula: 2,298,475; Fiscal year 2007 grants: Supplemental: 940,508; Fiscal year 2007 grants: MAI: 204,310; Fiscal year 2007 grants: Total: 3,443,293. TGA: Hartford, Conn; Fiscal year 2006 grants: Formula: 2,374,565; Fiscal year 2006 grants: Supplemental: 2,024,791; Fiscal year 2006 grants: MAI: 266,925; Fiscal year 2006 grants: Total: 4,666,281; Fiscal year 2007 grants: Formula: 2,003,833; Fiscal year 2007 grants: Supplemental: 913,750; Fiscal year 2007 grants: MAI: 252,944; Fiscal year 2007 grants: Total: 3,170,527. TGA: Indianapolis, Ind; Fiscal year 2006 grants: Formula: 0; Fiscal year 2006 grants: Supplemental: 0; Fiscal year 2006 grants: MAI: 0; Fiscal year 2006 grants: Total: 0; Fiscal year 2007 grants: Formula: 2,277,616; Fiscal year 2007 grants: Supplemental: 763,694; Fiscal year 2007 grants: MAI: 189,079; Fiscal year 2007 grants: Total: 3,230,389. TGA: Jacksonville, Fla; Fiscal year 2006 grants: Formula: 2,631,441; Fiscal year 2006 grants: Supplemental: 1,872,676; Fiscal year 2006 grants: MAI: 409,699; Fiscal year 2006 grants: Total: 4,913,816; Fiscal year 2007 grants: Formula: 3,078,757; Fiscal year 2007 grants: Supplemental: 1,414,071; Fiscal year 2007 grants: MAI: 393,745; Fiscal year 2007 grants: Total: 4,886,573. TGA: Jersey City, N.J; Fiscal year 2006 grants: Formula: 2,831,663; Fiscal year 2006 grants: Supplemental: 2,048,327; Fiscal year 2006 grants: MAI: 265,152; Fiscal year 2006 grants: Total: 5,145,142; Fiscal year 2007 grants: Formula: 2,831,049; Fiscal year 2007 grants: Supplemental: 1,286,939; Fiscal year 2007 grants: MAI: 417,858; Fiscal year 2007 grants: Total: 4,535,846. TGA: Kansas City, Mo; Fiscal year 2006 grants: Formula: 1,607,764; Fiscal year 2006 grants: Supplemental: 1,183,683; Fiscal year 2006 grants: MAI: 125,038; Fiscal year 2006 grants: Total: 2,916,485; Fiscal year 2007 grants: Formula: 2,524,021; Fiscal year 2007 grants: Supplemental: 1,013,510; Fiscal year 2007 grants: MAI: 187,284; Fiscal year 2007 grants: Total: 3,724,815. TGA: Las Vegas, Nev; Fiscal year 2006 grants: Formula: 2,422,499; Fiscal year 2006 grants: Supplemental: 1,647,505; Fiscal year 2006 grants: MAI: 253,623; Fiscal year 2006 grants: Total: 4,323,627; Fiscal year 2007 grants: Formula: 3,251,501; Fiscal year 2007 grants: Supplemental: 1,193,110; Fiscal year 2007 grants: MAI: 225,918; Fiscal year 2007 grants: Total: 4,670,529. TGA: Memphis, Tenn; Fiscal year 2006 grants: Formula: 0; Fiscal year 2006 grants: Supplemental: 0; Fiscal year 2006 grants: MAI: 0; Fiscal year 2006 grants: Total: 0; Fiscal year 2007 grants: Formula: 3,585,906; Fiscal year 2007 grants: Supplemental: 1,432,797; Fiscal year 2007 grants: MAI: 556,225; Fiscal year 2007 grants: Total: 5,574,928. TGA: Middlesex-Somerset-Hunterdon, N.J; Fiscal year 2006 grants: Formula: 1,427,281; Fiscal year 2006 grants: Supplemental: 1,032,702; Fiscal year 2006 grants: MAI: 135,680; Fiscal year 2006 grants: Total: 2,595,663; Fiscal year 2007 grants: Formula: 1,599,025; Fiscal year 2007 grants: Supplemental: 701,085; Fiscal year 2007 grants: MAI: 165,169; Fiscal year 2007 grants: Total: 2,465,279. TGA: Minneapolis-St. Paul, Minn; Fiscal year 2006 grants: Formula: 1,569,524; Fiscal year 2006 grants: Supplemental: 1,279,233; Fiscal year 2006 grants: MAI: 197,755; Fiscal year 2006 grants: Total: 3,046,512; Fiscal year 2007 grants: Formula: 2,963,378; Fiscal year 2007 grants: Supplemental: 1,240,032; Fiscal year 2007 grants: MAI: 264,702; Fiscal year 2007 grants: Total: 4,468,112. TGA: Nashville, Tenn; Fiscal year 2006 grants: Formula: 0; Fiscal year 2006 grants: Supplemental: 0; Fiscal year 2006 grants: MAI: 0; Fiscal year 2006 grants: Total: 0; Fiscal year 2007 grants: Formula: 2,541,621; Fiscal year 2007 grants: Supplemental: 938,981; Fiscal year 2007 grants: MAI: 207,441; Fiscal year 2007 grants: Total: 3,688,043. TGA: Nassau-Suffolk, N.Y; Fiscal year 2006 grants: Formula: 3,227,540; Fiscal year 2006 grants: Supplemental: 2,456,087; Fiscal year 2006 grants: MAI: 464,680; Fiscal year 2006 grants: Total: 6,148,307; Fiscal year 2007 grants: Formula: 3,130,907; Fiscal year 2007 grants: Supplemental: 1,358,744; Fiscal year 2007 grants: MAI: 325,286; Fiscal year 2007 grants: Total: 4,814,937. TGA: New Haven, Conn; Fiscal year 2006 grants: Formula: 3,631,905; Fiscal year 2006 grants: Supplemental: 2,710,386; Fiscal year 2006 grants: MAI: 342,303; Fiscal year 2006 grants: Total: 6,684,594; Fiscal year 2007 grants: Formula: 3,278,228; Fiscal year 2007 grants: Supplemental: 1,501,862; Fiscal year 2007 grants: MAI: 321,657; Fiscal year 2007 grants: Total: 5,101,747. TGA: Norfolk, Va; Fiscal year 2006 grants: Formula: 2,543,672; Fiscal year 2006 grants: Supplemental: 1,635,201; Fiscal year 2006 grants: MAI: 235,887; Fiscal year 2006 grants: Total: 4,414,760; Fiscal year 2007 grants: Formula: 3,390,349; Fiscal year 2007 grants: Supplemental: 1,284,883; Fiscal year 2007 grants: MAI: 379,699; Fiscal year 2007 grants: Total: 5,054,931. TGA: Oakland, Calif; Fiscal year 2006 grants: Formula: 3,310,871; Fiscal year 2006 grants: Supplemental: 2,072,022; Fiscal year 2006 grants: MAI: 352,944; Fiscal year 2006 grants: Total: 5,735,837; Fiscal year 2007 grants: Formula: 3,781,868; Fiscal year 2007 grants: Supplemental: 1,663,113; Fiscal year 2007 grants: MAI: 392,080; Fiscal year 2007 grants: Total: 5,837,061. TGA: Orange County, Calif; Fiscal year 2006 grants: Formula: 2,552,176; Fiscal year 2006 grants: Supplemental: 2,091,799; Fiscal year 2006 grants: MAI: 214,604; Fiscal year 2006 grants: Total: 4,858,579; Fiscal year 2007 grants: Formula: 3,328,279; Fiscal year 2007 grants: Supplemental: 1,345,454; Fiscal year 2007 grants: MAI: 292,945; Fiscal year 2007 grants: Total: 4,966,678. TGA: Ponce, P.R; Fiscal year 2006 grants: Formula: 1,338,048; Fiscal year 2006 grants: Supplemental: 806,867; Fiscal year 2006 grants: MAI: 246,529; Fiscal year 2006 grants: Total: 2,391,444; Fiscal year 2007 grants: Formula: 1,101,000; Fiscal year 2007 grants: Supplemental: 445,740; Fiscal year 2007 grants: MAI: 153,098; Fiscal year 2007 grants: Total: 1,699,838. TGA: Portland, Oreg; Fiscal year 2006 grants: Formula: 1,790,756; Fiscal year 2006 grants: Supplemental: 1,516,313; Fiscal year 2006 grants: MAI: 94,887; Fiscal year 2006 grants: Total: 3,401,956; Fiscal year 2007 grants: Formula: 2,120,010; Fiscal year 2007 grants: Supplemental: 957,919; Fiscal year 2007 grants: MAI: 78,536; Fiscal year 2007 grants: Total: 3,156,465. TGA: Riverside-San Bernadino, Calif; Fiscal year 2006 grants: Formula: 3,643,238; Fiscal year 2006 grants: Supplemental: 3,156,377; Fiscal year 2006 grants: MAI: 274,906; Fiscal year 2006 grants: Total: 7,074,521; Fiscal year 2007 grants: Formula: 4,389,913; Fiscal year 2007 grants: Supplemental: 2,074,448; Fiscal year 2007 grants: MAI: 255,733; Fiscal year 2007 grants: Total: 6,720,094. TGA: Sacramento, Calif; Fiscal year 2006 grants: Formula: 1,459,858; Fiscal year 2006 grants: Supplemental: 1,263,003; Fiscal year 2006 grants: MAI: 55,868; Fiscal year 2006 grants: Total: 2,778,729; Fiscal year 2007 grants: Formula: 1,472,863; Fiscal year 2007 grants: Supplemental: 689,474; Fiscal year 2007 grants: MAI: 97,469; Fiscal year 2007 grants: Total: 2,259,806. TGA: St. Louis. Mo; Fiscal year 2006 grants: Formula: 2,377,264; Fiscal year 2006 grants: Supplemental: 1,875,232; Fiscal year 2006 grants: MAI: 250,076; Fiscal year 2006 grants: Total: 4,502,572; Fiscal year 2007 grants: Formula: 3,471,180; Fiscal year 2007 grants: Supplemental: 1,424,275; Fiscal year 2007 grants: MAI: 378,174; Fiscal year 2007 grants: Total: 5,273,629. TGA: San Antonio, Tex; Fiscal year 2006 grants: Formula: 1,952,384; Fiscal year 2006 grants: Supplemental: 1,068,440; Fiscal year 2006 grants: MAI: 305,057; Fiscal year 2006 grants: Total: 3,325,881; Fiscal year 2007 grants: Formula: 2,441,234; Fiscal year 2007 grants: Supplemental: 949,837; Fiscal year 2007 grants: MAI: 264,661; Fiscal year 2007 grants: Total: 3,655,732. TGA: San Jose, Calif; Fiscal year 2006 grants: Formula: 1,322,616; Fiscal year 2006 grants: Supplemental: 871,297; Fiscal year 2006 grants: MAI: 110,849; Fiscal year 2006 grants: Total: 2,304,762; Fiscal year 2007 grants: Formula: 1,596,809; Fiscal year 2007 grants: Supplemental: 604,404; Fiscal year 2007 grants: MAI: 137,156; Fiscal year 2007 grants: Total: 2,338,369. TGA: Santa Rosa, Calif; Fiscal year 2006 grants: Formula: 572,703; Fiscal year 2006 grants: Supplemental: 426,667; Fiscal year 2006 grants: MAI: 29,264; Fiscal year 2006 grants: Total: 1,028,634; Fiscal year 2007 grants: Formula: 725,352; Fiscal year 2007 grants: Supplemental: 265,582; Fiscal year 2007 grants: MAI: 50,000; Fiscal year 2007 grants: Total: 1,040,934. TGA: Seattle, Wash; Fiscal year 2006 grants: Formula: 2,931,596; Fiscal year 2006 grants: Supplemental: 2,309,038; Fiscal year 2006 grants: MAI: 204,850; Fiscal year 2006 grants: Total: 5,445,484; Fiscal year 2007 grants: Formula: 4,051,676; Fiscal year 2007 grants: Supplemental: 1,667,482; Fiscal year 2007 grants: MAI: 234,009; Fiscal year 2007 grants: Total: 5,953,167. TGA: Vineland-Millville-Bridgeton, N.J; Fiscal year 2006 grants: Formula: 464,590; Fiscal year 2006 grants: Supplemental: 313,292; Fiscal year 2006 grants: MAI: 71,833; Fiscal year 2006 grants: Total: 849,715; Fiscal year 2007 grants: Formula: 518,884; Fiscal year 2007 grants: Supplemental: 196,470; Fiscal year 2007 grants: MAI: 68,510; Fiscal year 2007 grants: Total: 783,864. TGA: Total; Fiscal year 2006 grants: Formula: $59,734,921; Fiscal year 2006 grants: Supplemental: $44,780,326; Fiscal year 2006 grants: MAI: $6,300,677; Fiscal year 2006 grants: Total: $110,815,924; Fiscal year 2007 grants: Formula: $86,456,387; Fiscal year 2007 grants: Supplemental: $35,843,939; Fiscal year 2007 grants: MAI: $8,448,407; Fiscal year 2007 grants: Total: $130,748,733. Source: HHS. Note: The 2006 Modernization Act created a new category of urban areas called TGAs. TGAs that received Part A funding in 2006 were classified at that time as EMAs. [End of table] Projected CARE Act Funding for Urban Areas Would be Impacted by the Proposed Hold-Harmless Provision: The funding for both EMAs and TGAs would be impacted by the proposed hold-harmless provision in H.R. 3043. Some EMAs and TGAs would receive additional funding for the 2007 program year under the provision, but the amounts needed to fund the hold-harmless provision would be taken from the amount that could otherwise be available for fiscal year 2008 funding. A total of $9,377,444 would be needed to fund the proposed hold-harmless provision, with $6,410,885 needed for EMAs and $2,966,559 for TGAs. Projected EMA Funding: We found that the impact of the proposed hold-harmless provision in H.R. 3043 on EMAs would be to increase funding for 3 of 22 EMAs by a total of $6,410,885 for the 2007 program year, which runs from April 1, 2007, to March 31, 2008. The San Francisco EMA would receive the largest increase, $6,156,471, while the Atlanta and New York EMAs would receive an additional $160,004 and $94,410, respectively. We found that under funding as identified in the report of the House Committee on Appropriations and under our assumptions, funding would be impacted for all EMAs. Sixteen of 22 EMAs would receive an increase in funding over fiscal year 2007 if the proposed hold-harmless provision is enacted. However, regardless of whether an EMA would receive an increase over fiscal year 2007 or not, all EMAs would be awarded less fiscal year 2008 funding with the hold-harmless provision in place than if the entire amount was awarded as fiscal year 2008 funding without the hold harmless because less funding would be available to be awarded. Less funding would be available for fiscal year 2008 because funds would be taken from fiscal year 2008 funding to cover the proposed hold-harmless provision in H.R. 3043 that protects funds for the 2007 program year, which ends March 31, 2008. The size of the difference in the amount of funding with and without the proposed hold- harmless provision would vary by EMA with differences ranging from approximately 0.7 percent to 2.1 percent.[Footnote 20] However, it is not possible to determine exactly how each EMA would be affected by the proposed 8.4 percent hold-harmless provision because it is not known how HRSA will award fiscal year 2008 funding. Table 4 lists EMA funding for fiscal years 2006 and 2007, and the projected funding for fiscal year 2008 with and without the proposed hold-harmless provision, assuming funding amounts as identified in the report of the House Committee on Appropriations. Table 4: Total EMA Formula, Supplemental, and MAI Grants for Fiscal Years 2006 and 2007 and Projected Funding for Fiscal Year 2008 Under Funding Levels as Identified in the Report of the House Committee on Appropriations: EMA: Atlanta, Ga; Fiscal year 2006 grants: $18,869,561; Fiscal year 2007 grants: $17,124,514; Estimated hold-harmless funding under H.R. 3043: $160,004; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: $17,112,815; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: $16,982,259. EMA: Baltimore, Md; Fiscal year 2006 grants: 20,628,895; Fiscal year 2007 grants: 20,388,061; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 22,732,883; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 22,301,873. EMA: Boston, Mass; Fiscal year 2006 grants: 13,339,141; Fiscal year 2007 grants: 13,675,999; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 15,277,498; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,972,628. EMA: Chicago, Ill; Fiscal year 2006 grants: 25,044,633; Fiscal year 2007 grants: 25,153,442; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 28,066,579; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 27,512,113. EMA: Dallas, Tex; Fiscal year 2006 grants: 13,196,377; Fiscal year 2007 grants: 13,550,581; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 15,137,303; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,836,295. EMA: Detroit, Mich; Fiscal year 2006 grants: 8,428,477; Fiscal year 2007 grants: 8,366,462; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 9,013,890; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,839,476. EMA: Fort Lauderdale, Fla; Fiscal year 2006 grants: 14,963,638; Fiscal year 2007 grants: 14,284,795; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 15,936,744; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 15,626,839. EMA: Houston, Tex; Fiscal year 2006 grants: 19,953,520; Fiscal year 2007 grants: 19,472,799; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 20,852,940; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 20,445,124. EMA: Los Angeles, Calif; Fiscal year 2006 grants: 34,895,377; Fiscal year 2007 grants: 35,263,560; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 38,631,203; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 37,867,959. EMA: Miami, Fla; Fiscal year 2006 grants: 23,999,914; Fiscal year 2007 grants: 25,061,316; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 27,885,150; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 27,354,166. EMA: New Orleans, La; Fiscal year 2006 grants: 7,434,812; Fiscal year 2007 grants: 7,256,199; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,056,604; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 7,901,579. EMA: New York, N.Y; Fiscal year 2006 grants: 120,423,326; Fiscal year 2007 grants: 110,213,357; Estimated hold-harmless funding under H.R. 3043: 94,410; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 110,216,803; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 109,335,299. EMA: Newark, N.J; Fiscal year 2006 grants: 14,752,254; Fiscal year 2007 grants: 13,927,385; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 14,821,268; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,535,807. EMA: Orlando, Fla; Fiscal year 2006 grants: 8,561,273; Fiscal year 2007 grants: 8,062,483; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,614,615; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,447,306. EMA: Philadelphia, Pa; Fiscal year 2006 grants: 22,384,551; Fiscal year 2007 grants: 21,639,722; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 21,765,212; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 21,464,894. EMA: Phoenix, Ariz; Fiscal year 2006 grants: 6,519,338; Fiscal year 2007 grants: 6,974,852; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 7,831,853; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 7,673,854. EMA: San Diego, Calif; Fiscal year 2006 grants: 9,269,256; Fiscal year 2007 grants: 10,224,751; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 11,828,264; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 11,590,839. EMA: San Francisco, Calif; Fiscal year 2006 grants: 27,964,864; Fiscal year 2007 grants: 19,459,344; Estimated hold-harmless funding under H.R. 3043: 6,156,471; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 19,429,426; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 19,289,248. EMA: San Juan, P.R; Fiscal year 2006 grants: 13,470,347; Fiscal year 2007 grants: 12,709,679; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 12,703,554; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 12,616,981. EMA: Tampa-St. Petersburg, Fla; Fiscal year 2006 grants: 9,571,830; Fiscal year 2007 grants: 9,201,080; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 9,692,491; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 9,500,031. EMA: Washington, D.C; Fiscal year 2006 grants: 26,923,066; Fiscal year 2007 grants: 27,631,723; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 28,861,975; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 28,297,491. EMA: West Palm Beach, Fla; Fiscal year 2006 grants: 8,276,018; Fiscal year 2007 grants: 8,295,497; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,404,609; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,241,277. EMA: Total; Fiscal year 2006 grants: $468,870,468; Fiscal year 2007 grants: $447,937,601; Estimated hold-harmless funding under H.R. 3043: $6,410,885; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: $472,873,680; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: $465,633,338. Sources: GAO analysis of HHS data, H.R. 3043, and report of the House of Committee on Appropriations (110-231). Notes: The projected fiscal year 2008 funding in this table is based on the funding amount for urban areas identified in the report of the House Committee on Appropriations (110-231). Before estimating the funding allocations, we reduced the amount to be allocated by subtracting out the amounts set aside by HRSA before awarding grants to urban areas. We used the same amounts for these reductions as were used in fiscal year 2007, $23,548,096. We cannot determine the exact impact on total funding for each EMA for fiscal year 2008. It is not possible to determine exactly how each EMA would be affected by the proposed 8.4 percent hold-harmless provision for EMAs because it is not known how HRSA will award fiscal year 2008 supplemental and MAI grants and because the case counts on which formula grants will be based are not yet available. [A] The projected funding amounts in this column include the CARE Act hold-harmless provision that protects formula funding for EMAs. [B] Under the proposed hold-harmless provision in H.R. 3043, the maximum decrease in formula, supplemental, and MAI grants in total that an EMA could receive for program year 2007 would be no more than 8.4 percent of what it received for program year 2006. Funds would be taken from fiscal year 2008 funding to cover this proposed hold-harmless provision. The projected funding amounts in this column include the CARE Act hold-harmless provision that protects formula funding for EMAs. [End of table] Under funding identified in H.R. 3043 and under our assumptions, funding for each EMA would be similarly impacted if the proposed hold- harmless provision is enacted. Sixteen of 22 EMAs would receive an increase in funding over fiscal year 2007 if the proposed hold-harmless provision is enacted. However, regardless of whether an EMA would receive an increase over fiscal year 2007 or not, all EMAs would receive less funding awarded as fiscal year 2008 funding with the hold- harmless provision in place than if the entire amount was awarded as fiscal year 2008 funding without the hold harmless because less funding would be available to be awarded. Less funding would be available for fiscal year 2008 because funds would be taken from fiscal year 2008 funding to cover the proposed hold-harmless provision in H.R. 3043 that protects funds for the 2007 program year, which ends March 31, 2008. The size of the difference in the amount of funding with and without the hold-harmless provision would vary by EMA with differences ranging from approximately 0.7 percent to 2.2 percent. However, it is not possible to determine exactly how each EMA would be affected by the proposed 8.4 percent hold-harmless provision because it is not known how HRSA will award fiscal year 2008 funding. Table 5 lists EMA funding for fiscal years 2006 and 2007, and the projected funding for fiscal year 2008 with and without the proposed hold-harmless provision, assuming funding levels identified in H.R. 3043. Table 5: Total EMA Formula, Supplemental, and MAI Funding for Fiscal Years 2006 and 2007 and Projected Funding for Fiscal Year 2008 Under Funding Levels as Identified in H.R. 3043: EMA: Atlanta, Ga; Fiscal year 2006 grants: $18,869,561; Fiscal year 2007 grants: $17,124,514; Estimated hold-harmless funding under H.R. 3043: $160,004; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: $16,972,555; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: $16,834,467. EMA: Baltimore, Md; Fiscal year 2006 grants: 20,628,895; Fiscal year 2007 grants: 20,388,061; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 22,270,467; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 21,829,310. EMA: Boston, Mass; Fiscal year 2006 grants: 13,339,141; Fiscal year 2007 grants: 13,675,999; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 14,950,405; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,638,161. EMA: Chicago, Ill; Fiscal year 2006 grants: 25,044,633; Fiscal year 2007 grants: 25,153,442; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 27,471,692; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 26,903,749. EMA: Dallas, Tex; Fiscal year 2006 grants: 13,196,377; Fiscal year 2007 grants: 13,550,581; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 14,814,360; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,506,230. EMA: Detroit, Mich; Fiscal year 2006 grants: 8,428,477; Fiscal year 2007 grants: 8,366,462; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,826,768; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,648,298. EMA: Fort Lauderdale, Fla; Fiscal year 2006 grants: 14,963,638; Fiscal year 2007 grants: 14,284,795; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 15,604,256; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 15,287,060. EMA: Houston, Tex; Fiscal year 2006 grants: 19,953,520; Fiscal year 2007 grants: 19,472,799; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 20,415,390; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 19,997,556. EMA: Los Angeles, Calif; Fiscal year 2006 grants: 34,895,377; Fiscal year 2007 grants: 35,263,560; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 37,812,312; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 37,030,382. EMA: Miami, Fla; Fiscal year 2006 grants: 23,999,914; Fiscal year 2007 grants: 25,061,316; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 27,315,466; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 26,771,801. EMA: New Orleans, La; Fiscal year 2006 grants: 7,434,812; Fiscal year 2007 grants: 7,256,199; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 7,890,291; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 7,731,802. EMA: New York, N.Y; Fiscal year 2006 grants: 120,423,326; Fiscal year 2007 grants: 110,213,357; Estimated hold-harmless funding under H.R. 3043: 94,410; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 109,269,779; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 108,337,417. EMA: Newark, N.J; Fiscal year 2006 grants: 14,752,254; Fiscal year 2007 grants: 13,927,385; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 14,514,997; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 14,222,586. EMA: Orlando, Fla; Fiscal year 2006 grants: 8,561,273; Fiscal year 2007 grants: 8,062,483; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,435,117; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,263,934. EMA: Philadelphia, Pa; Fiscal year 2006 grants: 22,384,551; Fiscal year 2007 grants: 21,639,722; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 21,452,200; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 21,271,561. EMA: Phoenix, Ariz; Fiscal year 2006 grants: 6,519,338; Fiscal year 2007 grants: 6,974,852; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 7,662,349; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 7,500,806. EMA: San Diego, Calif; Fiscal year 2006 grants: 9,269,256; Fiscal year 2007 grants: 10,224,751; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 11,573,534; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 11,330,412. EMA: San Francisco, Calif; Fiscal year 2006 grants: 27,964,864; Fiscal year 2007 grants: 19,459,344; Estimated hold-harmless funding under H.R. 3043: 6,156,471; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 19,278,829; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 19,130,563. EMA: San Juan, P.R; Fiscal year 2006 grants: 13,470,347; Fiscal year 2007 grants: 12,709,679; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 12,610,547; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 12,518,979. EMA: Tampa-St. Petersburg, Fla; Fiscal year 2006 grants: 9,571,830; Fiscal year 2007 grants: 9,201,080; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision[A]: 9,486,004; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 9,288,957. EMA: Washington, D.C; Fiscal year 2006 grants: 26,923,066; Fiscal year 2007 grants: 27,631,723; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 28,256,351; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 27,678,377. EMA: West Palm Beach, Fla; Fiscal year 2006 grants: 8,276,018; Fiscal year 2007 grants: 8,295,497; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: 8,229,377; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: 8,150,292. EMA: Total; Fiscal year 2006 grants: $468,870,468; Fiscal year 2007 grants: $447,937,601; Estimated hold-harmless funding under H.R. 3043: $6,410,885; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision[A]: $465,113,045; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[B]: $457,872,699. Sources: GAO analysis of HHS data and H.R. 3043. Notes: The projected fiscal year 2008 funding in this table is based on the funding amount identified in H.R. 3043 and our assumption that the percentage of funding for Part A out of the total funding for Parts A and B will be the same in fiscal year 2008 as it was in fiscal year 2007. Before estimating the funding allocations, we reduced the amount to be allocated by subtracting out the amounts set aside by HRSA before awarding grants to urban areas. We used the same amounts for these reductions as were used in fiscal year 2007, $23,548,096. We cannot determine the exact impact on total funding for each EMA for fiscal year 2008. It is not possible to determine exactly how each EMA would be affected by the proposed 8.4 percent hold-harmless provision for EMAs because it is not known how HRSA will award fiscal year 2008 supplemental and MAI grants and because the case counts on which formula grants will be based are not yet available. [A] The projected funding amounts in this column include the CARE Act hold-harmless provision that protects formula funding for EMAs. [B] Under the proposed hold-harmless provision in H.R. 3043, the maximum decrease in formula, supplemental, and MAI grants in total that an EMA could receive for program year 2007 would be no more than 8.4 percent of what it received for program year 2006. Funds would be taken from fiscal year 2008 funding to cover this proposed hold-harmless provision. The projected funding amounts in this column include the CARE Act hold-harmless provision that protects formula funding for EMAs. [End of table] Projected TGA Funding: We found that the impact of the proposed hold-harmless provision in H.R. 3043 on TGAs would be to increase the 2007 program year funding for 8 of 34 TGAs--Bergen-Passaic, New Jersey; Caguas, Puerto Rico; Dutchess County, New York; Hartford, Connecticut; Nassau-Suffolk, New York; New Haven, Connecticut; Ponce, Puerto Rico; and Sacramento, California--by a total of $2,966,559.[Footnote 21] We found that under funding identified in the report of the House Committee on Appropriations and under our assumptions, funding would be impacted for all TGAs. If the proposed hold-harmless provision is enacted, each TGA would receive an increase in funding over fiscal year 2007, but the increase would be less than if the entire amount was awarded as fiscal year 2008 funding without the hold harmless because less funding would be available to be awarded. Less funding would be available for fiscal year 2008 because funds would be taken from fiscal year 2008 funding to cover the proposed hold-harmless provision in H.R. 3043 that protects funds for the 2007 program year, which ends March 31, 2008. The size of the difference in the amount of funding with and without the proposed hold-harmless provision would vary by TGA with differences ranging from approximately 1.5 to 1.6 percent.[Footnote 22] However, it is not possible to determine exactly how each TGA would be affected by the proposed 13.4 percent hold-harmless provision because it is not known how HRSA will award fiscal year 2008 funding. Table 6 lists TGA funding for fiscal years 2006 and 2007, and the projected funding for fiscal year 2008 with and without the proposed hold- harmless provision, assuming funding amounts identified in the report of the House Committee on Appropriations. Table 6: Total TGA Formula, Supplemental, and MAI Funding for Fiscal Years 2006 and 2007 and Projected Funding for Fiscal Year 2008 Under Funding Levels as Identified in the Report of the House Committee on Appropriations: TGA: Austin, Tex; Fiscal year 2006 grants: $3,719,076; Fiscal year 2007 grants: $3,614,135; Estimated hold-harmless funding under H.R. 3043: $0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: $3,815,614; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: $3,756,472. TGA: Baton Rouge, La; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,259,580; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,440,391; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,387,794. TGA: Bergen-Passaic, N.J; Fiscal year 2006 grants: 4,485,650; Fiscal year 2007 grants: 3,869,966; Estimated hold-harmless funding under H.R. 3043: 14,607; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,084,832; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,022,242. TGA: Caguas, P.R; Fiscal year 2006 grants: 1,648,356; Fiscal year 2007 grants: 1,082,464; Estimated hold-harmless funding under H.R. 3043: 345,012; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,141,704; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,124,924. TGA: Charlotte-Gastonia, N.C.-S.C; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 4,200,378; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,432,317; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,365,423. TGA: Cleveland, Ohio; Fiscal year 2006 grants: 3,349,096; Fiscal year 2007 grants: 3,983,088; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,203,795; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,139,736. TGA: Denver, Colo; Fiscal year 2006 grants: 4,283,042; Fiscal year 2007 grants: 7,061,342; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 7,458,467; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 7,339,910. TGA: Dutchess County, N.Y; Fiscal year 2006 grants: 1,367,584; Fiscal year 2007 grants: 1,162,194; Estimated hold-harmless funding under H.R. 3043: 22,134; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,226,371; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,207,875. TGA: Fort Worth, Tex; Fiscal year 2006 grants: 3,409,819; Fiscal year 2007 grants: 3,443,293; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,635,512; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,578,923. TGA: Hartford, Conn; Fiscal year 2006 grants: 4,666,281; Fiscal year 2007 grants: 3,170,527; Estimated hold-harmless funding under H.R. 3043: 870,472; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,346,206; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,295,231. TGA: Indianapolis, Ind; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,230,389; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,410,745; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,357,610. TGA: Jacksonville, Fla; Fiscal year 2006 grants: 4,913,816; Fiscal year 2007 grants: 4,886,573; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,157,261; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,078,765. TGA: Jersey City, N.J; Fiscal year 2006 grants: 5,145,142; Fiscal year 2007 grants: 4,535,846; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,786,028; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,714,081. TGA: Kansas City, Mo; Fiscal year 2006 grants: 2,916,485; Fiscal year 2007 grants: 3,724,815; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,933,437; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,871,632. TGA: Las Vegas, Nev; Fiscal year 2006 grants: 4,323,627; Fiscal year 2007 grants: 4,670,529; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,932,284; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,854,631. TGA: Memphis, Tenn; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 5,574,928; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,881,516; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,793,833. TGA: Middlesex-Somerset-Hunterdon, N.J; Fiscal year 2006 grants: 2,595,663; Fiscal year 2007 grants: 2,465,279; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 2,602,521; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,562,335. TGA: Minneapolis-St. Paul, Minn; Fiscal year 2006 grants: 3,046,512; Fiscal year 2007 grants: 4,468,112; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 4,717,553; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,644,114. TGA: Nashville, Tenn; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,688,043; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,894,140; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,833,330. TGA: Nassau-Suffolk, N.Y; Fiscal year 2006 grants: 6,148,307; Fiscal year 2007 grants: 4,814,937; Estimated hold-harmless funding under H.R. 3043: 509,497; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,082,928; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,004,488. TGA: New Haven, Conn; Fiscal year 2006 grants: 6,684,594; Fiscal year 2007 grants: 5,101,747; Estimated hold-harmless funding under H.R. 3043: 687,111; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,386,188; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,302,673. TGA: Norfolk, Va; Fiscal year 2006 grants: 4,414,760; Fiscal year 2007 grants: 5,054,931; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,335,464; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,253,782. TGA: Oakland, Calif; Fiscal year 2006 grants: 5,735,837; Fiscal year 2007 grants: 5,837,061; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 6,162,947; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 6,067,801. TGA: Orange County, Calif; Fiscal year 2006 grants: 4,858,579; Fiscal year 2007 grants: 4,966,678; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,244,811; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,163,142. TGA: Ponce, P.R; Fiscal year 2006 grants: 2,391,444; Fiscal year 2007 grants: 1,699,838; Estimated hold-harmless funding under H.R. 3043: 371,153; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,793,657; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,766,634. TGA: Portland, Oreg; Fiscal year 2006 grants: 3,401,956; Fiscal year 2007 grants: 3,156,465; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,335,454; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,281,669. TGA: Riverside-San Bernadino, Calif; Fiscal year 2006 grants: 7,074,521; Fiscal year 2007 grants: 6,720,094; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 7,099,329; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 6,986,369. TGA: Sacramento, Calif; Fiscal year 2006 grants: 2,778,729; Fiscal year 2007 grants: 2,259,806; Estimated hold-harmless funding under H.R. 3043: 146,573; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 2,387,096; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,349,311. TGA: St. Louis. Mo; Fiscal year 2006 grants: 4,502,572; Fiscal year 2007 grants: 5,273,629; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,566,687; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,481,157. TGA: San Antonio, Tex; Fiscal year 2006 grants: 3,325,881; Fiscal year 2007 grants: 3,655,732; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,858,822; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,799,575. TGA: San Jose, Calif; Fiscal year 2006 grants: 2,304,762; Fiscal year 2007 grants: 2,338,369; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 2,485,741; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,447,005. TGA: Santa Rosa, Calif; Fiscal year 2006 grants: 1,028,634; Fiscal year 2007 grants: 1,040,934; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,099,462; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,082,147. TGA: Seattle, Wash; Fiscal year 2006 grants: 5,445,484; Fiscal year 2007 grants: 5,953,167; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 6,288,967; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 6,189,029. TGA: Vineland-Millville-Bridgeton, N.J; Fiscal year 2006 grants: 849,715; Fiscal year 2007 grants: 783,864; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 827,169; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 814,671. TGA: Total; Fiscal year 2006 grants: $110,815,924; Fiscal year 2007 grants: $130,748,733; Estimated hold-harmless funding under H.R. 3043: $2,966,559; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: $138,055,416; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: $135,918,315. Sources: GAO analysis of HHS data, H.R. 3043, and report of the House of Committee on Appropriations (110-231). Notes: The projected fiscal year 2008 funding in this table is based on the funding amount for urban areas identified in the report of the House Committee on Appropriations (110-231). Before estimating the funding allocations, we reduced the amount to be allocated by subtracting out the amounts set aside by HRSA before awarding grants to urban areas. We used the same amounts for these reductions as were used in fiscal year 2007, $23,548,096. We cannot determine the exact impact on total funding for each TGA for fiscal year 2008. It is not possible to determine exactly how each TGA would be affected by the proposed 13.4 percent hold-harmless provision for TGAs because it is not known how HRSA will award fiscal year 2008 supplemental and MAI grants and because the case counts on which formula grants will be based are not yet available. [A] Under the proposed hold-harmless provision in H.R. 3043, the maximum decrease in formula, supplemental, and MAI grants in total that a TGA could receive for program year 2007 would be no more than 13.4 percent of what it received for program year 2006. Funds would be taken from fiscal year 2008 funding to cover this proposed hold-harmless provision. [End of table] Under funding identified in H.R. 3043 and under our assumptions, funding for each TGA would be impacted if the proposed hold-harmless provision is enacted. Each TGA would receive an increase in funding over fiscal year 2007 if the proposed hold-harmless provision is enacted, but the amount would be less than if the entire amount was awarded as fiscal year 2008 funding without the hold harmless because less funding would be available to be awarded. Less funding would be available for fiscal year 2008 because funds would be taken from fiscal year 2008 funding to cover the proposed hold-harmless provision in H.R. 3043 that protects funds for the 2007 program year, which ends March 31, 2008. The size of the difference in the amount of funding with and without the hold-harmless provision would vary by TGA with differences ranging from approximately 1.5 percent to 1.7 percent. However, it is not possible to determine exactly how each TGA would be affected by the proposed 13.4 percent hold-harmless provision because it is not known how HRSA will award fiscal year 2008 funding. Table 7 lists TGA funding for fiscal years 2006 and 2007, and the projected funding for fiscal year 2008 with and without the proposed hold-harmless provision, assuming funding amounts identified in H.R. 3043. Table 7: Total TGA Formula, Supplemental, and MAI Funding for Fiscal Years 2006 and 2007 and Projected Funding for Fiscal Year 2008 Under Funding Levels as Identified in the H.R. 3043: TGA: Austin, Tex; Fiscal year 2006 grants: $3,719,076; Fiscal year 2007 grants: $3,614,135; Estimated hold-harmless funding under H.R. 3043: $0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: $3,752,222; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: $3,693,080. TGA: Baton Rouge, La; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,259,580; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,384,014; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,331,417. TGA: Bergen-Passaic, N.J; Fiscal year 2006 grants: 4,485,650; Fiscal year 2007 grants: 3,869,966; Estimated hold-harmless funding under H.R. 3043: 14,607; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,017,744; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,955,154. TGA: Caguas, P.R; Fiscal year 2006 grants: 1,648,356; Fiscal year 2007 grants: 1,082,464; Estimated hold-harmless funding under H.R. 3043: 345,012; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,123,718; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,106,937. TGA: Charlotte-Gastonia, N.C.-S.C; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 4,200,378; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,360,616; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,293,722. TGA: Cleveland, Ohio; Fiscal year 2006 grants: 3,349,096; Fiscal year 2007 grants: 3,983,088; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,135,132; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,071,073. TGA: Denver, Colo; Fiscal year 2006 grants: 4,283,042; Fiscal year 2007 grants: 7,061,342; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 7,331,391; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 7,212,834. TGA: Dutchess County, N.Y; Fiscal year 2006 grants: 1,367,584; Fiscal year 2007 grants: 1,162,194; Estimated hold-harmless funding under H.R. 3043: 22,134; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,206,546; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,188,050. TGA: Fort Worth, Tex; Fiscal year 2006 grants: 3,409,819; Fiscal year 2007 grants: 3,443,293; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,574,857; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,518,267. TGA: Hartford, Conn; Fiscal year 2006 grants: 4,666,281; Fiscal year 2007 grants: 3,170,527; Estimated hold-harmless funding under H.R. 3043: 870,472; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,291,568; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,240,594. TGA: Indianapolis, Ind; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,230,389; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,353,792; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,300,657. TGA: Jacksonville, Fla; Fiscal year 2006 grants: 4,913,816; Fiscal year 2007 grants: 4,886,573; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,073,124; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,994,629. TGA: Jersey City, N.J; Fiscal year 2006 grants: 5,145,142; Fiscal year 2007 grants: 4,535,846; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,708,911; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,636,964. TGA: Kansas City, Mo; Fiscal year 2006 grants: 2,916,485; Fiscal year 2007 grants: 3,724,815; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,867,191; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,805,386. TGA: Las Vegas, Nev; Fiscal year 2006 grants: 4,323,627; Fiscal year 2007 grants: 4,670,529; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 4,849,051; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,771,399. TGA: Memphis, Tenn; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 5,574,928; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,787,532; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,699,849. TGA: Middlesex-Somerset-Hunterdon, N.J; Fiscal year 2006 grants: 2,595,663; Fiscal year 2007 grants: 2,465,279; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 2,559,448; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,519,262. TGA: Minneapolis-St. Paul, Minn; Fiscal year 2006 grants: 3,046,512; Fiscal year 2007 grants: 4,468,112; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 4,638,837; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,565,398. TGA: Nashville, Tenn; Fiscal year 2006 grants: 0; Fiscal year 2007 grants: 3,688,043; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 3,828,960; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,768,150. TGA: Nassau-Suffolk, N.Y; Fiscal year 2006 grants: 6,148,307; Fiscal year 2007 grants: 4,814,937; Estimated hold-harmless funding under H.R. 3043: 509,497; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 4,998,851; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 4,920,411. TGA: New Haven, Conn; Fiscal year 2006 grants: 6,684,594; Fiscal year 2007 grants: 5,101,747; Estimated hold-harmless funding under H.R. 3043: 687,111; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,296,672; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,213,157. TGA: Norfolk, Va; Fiscal year 2006 grants: 4,414,760; Fiscal year 2007 grants: 5,054,931; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 5,247,912; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,166,230. TGA: Oakland, Calif; Fiscal year 2006 grants: 5,735,837; Fiscal year 2007 grants: 5,837,061; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 6,060,963; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,965,817. TGA: Orange County, Calif; Fiscal year 2006 grants: 4,858,579; Fiscal year 2007 grants: 4,966,678; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,157,273; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,075,603. TGA: Ponce, P.R; Fiscal year 2006 grants: 2,391,444; Fiscal year 2007 grants: 1,699,838; Estimated hold-harmless funding under H.R. 3043: 371,153; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,764,692; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,737,668. TGA: Portland, Oreg; Fiscal year 2006 grants: 3,401,956; Fiscal year 2007 grants: 3,156,465; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,277,805; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,224,020. TGA: Riverside-San Bernadino, Calif; Fiscal year 2006 grants: 7,074,521; Fiscal year 2007 grants: 6,720,094; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 6,978,252; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 6,865,292. TGA: Sacramento, Calif; Fiscal year 2006 grants: 2,778,729; Fiscal year 2007 grants: 2,259,806; Estimated hold-harmless funding under H.R. 3043: 146,573; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 2,346,595; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,308,810. TGA: St. Louis. Mo; Fiscal year 2006 grants: 4,502,572; Fiscal year 2007 grants: 5,273,629; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 5,475,011; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 5,389,481. TGA: San Antonio, Tex; Fiscal year 2006 grants: 3,325,881; Fiscal year 2007 grants: 3,655,732; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 3,795,318; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 3,736,072. TGA: San Jose, Calif; Fiscal year 2006 grants: 2,304,762; Fiscal year 2007 grants: 2,338,369; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 2,444,222; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 2,405,486. TGA: Santa Rosa, Calif; Fiscal year 2006 grants: 1,028,634; Fiscal year 2007 grants: 1,040,934; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 1,080,902; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 1,063,586. TGA: Seattle, Wash; Fiscal year 2006 grants: 5,445,484; Fiscal year 2007 grants: 5,953,167; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: 6,181,848; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 6,081,910. TGA: Vineland-Millville-Bridgeton, N.J; Fiscal year 2006 grants: 849,715; Fiscal year 2007 grants: 783,864; Estimated hold-harmless funding under H.R. 3043: 0; Projected fiscal year 2008 grants without H.R. 3043 hold-harmless provision: 813,773; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: 801,275. TGA: Total; Fiscal year 2006 grants: $110,815,924; Fiscal year 2007 grants: $130,748,733; Estimated hold-harmless funding under H.R. 3043: $2,966,559; Projected fiscal year 2008 grants without H.R. 3043 hold- harmless provision: $135,764,743; Projected fiscal year 2008 grants with H.R. 3043 hold-harmless provision[A]: $133,627,642. Sources: GAO analysis of HHS data and H.R. 3043. Notes: The projected fiscal year 2008 funding in this table is based on the funding amount identified in H.R. 3043 and our assumption that the percentage of funding for Part A out of the total funding for Parts A and B will be the same in fiscal year 2008 as it was in fiscal year 2007. Before estimating the funding allocations, we reduced the amount to be allocated by subtracting out the amounts set aside by HRSA before awarding grants to urban areas. We used the same amounts for these reductions as were used in fiscal year 2007, $23,548,096. We cannot determine the exact impact on total funding for each TGA for fiscal year 2008. It is not possible to determine exactly how each TGA would be affected by the proposed 13.4 percent hold-harmless provision for TGAs because it is not known how HRSA will award fiscal year 2008 supplemental and MAI grants and because the case counts on which formula grants will be based are not yet available. [A] Under the proposed hold-harmless provision in H.R. 3043, the maximum decrease in formula, supplemental, and MAI grants in total that a TGA could receive for program year 2007 would be no more than 13.4 percent of what it received for program year 2006. Funds would be taken from fiscal year 2008 funding to cover this proposed hold-harmless provision. [End of table] San Francisco EMA Continues to Have Deceased Cases Factored into Its Funding Allocation: The San Francisco EMA continues to be the only urban area whose formula funding is based on both living and deceased AIDS cases. In February 2006, we reported that the San Francisco EMA was the only EMA still receiving CARE Act formula funding based on the number of living and deceased cases in a metropolitan area.[Footnote 23] All other EMAs received formula funding based on an estimate of the number of living AIDS cases. We showed that the fiscal year 2004 CARE Act formula funding for the San Francisco EMA was determined by its fiscal year 1995 funding, which was based on both living and deceased AIDS cases. Since the San Francisco EMA also received hold-harmless funding in fiscal years 2005, 2006, and 2007, its CARE Act formula funding continues to be based, in part, on the number of deceased cases in the San Francisco EMA as of 1995.[Footnote 24] Information on Unobligated CARE Act Funding and ADAP Waiting Lists: Information on unobligated CARE Act funding can be found in two reports by the HHS Office of the Inspector General issued in February 2007 and May 2007.[Footnote 25] Information on the number of people on ADAP waiting lists can be found in the National ADAP Monitoring Project Annual Report and The ADAP Watch.[Footnote 26] ADAPs purchase and provide HIV/AIDS drugs to people with HIV/AIDS and pay for health insurance that includes HIV/AIDS treatments. We are sending copies of this report to the Secretary of Health and Human Services, the Administrator of the Health Resources and Services Administration, and to the Committee on Appropriations, United States Senate; the Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Committee on Appropriations, United States Senate; the Committee on Health, Education, Labor, and Pensions, United States Senate; the Committee on Appropriations, House of Representatives; the Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Committee on Appropriations, House of Representatives; and the Committee on Energy and Commerce, House of Representatives. We will also make copies available to others upon request. In addition, the report will be available 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. Major contributors to this report were Martha Kelly, Assistant Director; Robert Copeland; Helen Desaulniers; Adrienne Griffin; Cathy Hamann; and Suzanne Worth. Signed by: Marcia Crosse Director, Health Care: List of Requesters: The Honorable Nancy Pelosi: The Speaker of the House of Representatives: The Honorable Michael B. Enzi: Ranking Member: Committee on Health, Education, Labor, and Pensions: United States Senate: The Honorable Barbara Boxer: The Honorable Richard Burr: The Honorable Tom A. Coburn: The Honorable Christopher J. Dodd: The Honorable Dianne Feinstein: The Honorable Jeff Sessions: United States Senate: The Honorable Rosa L. DeLauro: The Honorable Anna G. Eshoo: The Honorable Tom Lantos: The Honorable Lynn C. Woolsey: House of Representatives: Footnotes: [1] Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. �� 300ff through 300ff-121). Unless otherwise indicated, references to the CARE Act refer to current law. [2] Pub. L. No. 109-415, 120 Stat. 2767. The CARE Act programs had previously been 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). [3] H.R. 3043, 110th Cong. (2007). For purposes of this report, unless otherwise specified we use the term H.R. 3043 to refer to the bill as passed by the House of Representatives. [4] In this report, we use the term urban areas to refer to both EMAs and TGAs. An EMA is a metropolitan area with a population of 50,000 or more that had more than 2,000 AIDS cases reported in the most recent 5- year period. The 2,000 AIDS cases criterion does not include cases of HIV that have not progressed to AIDS. In fiscal year 2007, there were 22 EMAs. The Modernization Act of 2006 created a new program for TGA. A TGA is a metropolitan area with a population of 50,000 or more, which had 1,000 to 1,999 AIDS cases reported in the most recent 5-year period. Under this program urban areas that were eligible for EMA funding in fiscal year 2006 but that no longer meet the eligibility criteria for either EMAs or TGAs maintain their eligibility for funding and are considered TGAs for fiscal year 2007. In fiscal year 2007, there were 34 TGAs. [5] Prior to enactment of the Modernization Act of 2006, amounts available for formula and supplemental grants were split evenly between the two. Under the Modernization Act of 2006, two-thirds of such funding is to be distributed as formula grants and one-third as supplemental grants. [6] Part A of the CARE Act (also referred to as Title I) covers funding to urban areas. Part B (also referred to as Title II) covers funding to states, territories, and the District of Columbia. [7] The 2007 CARE Act program year began on April 1, 2007, and grants for that year were made with fiscal year 2007 appropriations. The proposed legislation states that "within the amounts provided for Part A . . ., funds are included to ensure that the amount of any funding provided under [Part A to an EMA] for the program year beginning in 2007 is not reduced by an amount that is more than 8.4 percent, and the amount of any funding provided under [Part A to a TGA] is not reduced by an amount that is more than 13.4 percent, relative to the amount of the total funding provided under such part to the [EMA or TGA] for the program year beginning in fiscal year 2006." Because the provision would apply to "any funding" provided to EMAs and TGAs under Part A, we consider the total amount subject to the hold-harmless to be formula, supplemental, and MAI grants made with Part A funds. MAI grants are authorized by 42 U.S.C. � 300ff-121, which specifically directs HHS to provide funding under Part A. [8] Funding for ADAPs is provided under Part B of the CARE Act and goes to states, territories, and the District of Columbia. Funding for ADAPs provides medications, treatment adherence and support, and health insurance with prescription drug benefits to people with HIV/AIDS. [9] H. Rep. No. 110-231 (2007). [10] In this report, we treat the proposed hold-harmless funding as if it was an addition to fiscal year 2007 supplemental funding. While not addressed in this report, the treatment of the proposed hold-harmless funding could have ramifications for funding beyond 2007. For fiscal years 2008 and 2009, hold-harmless amounts for EMAs under the CARE Act are based on the amount of formula funding (including hold-harmless funding) provided under the act for 2007. If the additional funding provided under H.R. 3043 was treated as formula funding, it would be included when the formula funding hold-harmless amounts for EMAs for fiscal years 2008 and 2009 are calculated. However, if the funding is not treated as formula funding, it would not be counted for calculations of CARE Act hold-harmless funding in future years since there is no hold-harmless provision protecting other funding categories. [11] Before awarding grants, HRSA sets aside funds from the total amount available for urban areas. These amounts are set aside for various purposes, including for possible public health emergencies. According to HRSA, the amount set aside in fiscal year 2007 was $23,548,096. Therefore, we have used this same figure for fiscal year 2008 calculations. [12] Although the difference in proposed fiscal year 2008 funding between H.R. 3043 and the report of the Committee on Appropriations for Parts A and B is $10 million, under our assumptions the difference for Part A alone would be $10,051,307. This results from our assumption that under H.R. 3043 the percentage of funding for Part A (approximately 33.56 percent) out of the total funding for Parts A and B would be the same in fiscal year 2008 as it was in fiscal year 2007. However, the amount proposed in the report of the House Committee on Appropriations for Part A ($636,300,000) is a larger percentage (33.92 percent) of the total amount specified for Parts A and B ($1,875,800,000). Therefore, the increase for Part A would actually be larger than the $10 million difference for Parts A and B combined. [13] In our February 2006 report, we found that as of fiscal year 2004, one EMA was receiving CARE Act formula funding based on both living and deceased cases. See GAO, HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds, GAO-06-332 (Washington, D.C.: Feb. 28, 2006). [14] This committee report is not binding on HHS. [15] The appropriations acts for fiscal years 2001 through 2007 covering HHS have not specified an amount of funding to be used for Part A grants for urban areas. However, when available the conference report accompanying the appropriations act has identified a total amount to be used for Part A funding for urban areas. Although these reports are not legally binding on HHS, we have used the amounts specified in them for the purposes of our analysis. [16] See H.R. Rep. No. 110-231, at 78-79 (2007). According to the committee report, this amount is $32,307,000 above the fiscal year 2007 funding level and the administration's budget request for fiscal year 2008. According to HHS, $603,993,000 was the funding level for grants to urban areas; that is, the amount available before subtracting for annual set asides. HHS refers to this amount as the "final appropriation amount" for fiscal year 2007. [17] See H.R. Conf. Rep. No. 109-337, at 137 (2005). We use funding from fiscal year 2006 because this was the last year for which there was a conference report accompanying the appropriations act for HHS. Fiscal year 2007 funds were appropriated for HRSA in a continuing resolution which contained a lump sum amount for all HRSA programs and did not specify a particular amount for grants to urban areas. See Revised Continuing Appropriations Resolution, 2007, Pub. L. No. 110-5, 121 Stat. 8, 31-32. There were no conference or committee reports for this law. [18] The analyses demonstrating that $9.4 million would be needed to fund the hold-harmless provision contained in H.R. 3043 as passed by the House are described later in this report. [19] The $636,300,000 funding level for urban areas is taken from the report of the House Committee on Appropriations (No. 110-231) for H.R. 3043. H.R. 3043 as reported by the Committee and passed by the House identifies an amount for CARE Act grants for urban areas and states and territories. However, this amount is $10 million less than the amount obtained by adding the amount identified in the House report for urban areas to the amount identified in the House report for states and territories. [20] The size of the decrease would depend on whether an EMA's formula funding would be held harmless for fiscal year 2008 under the hold- harmless provision of the CARE Act and the size of its MAI funding. Under our assumptions, those EMAs whose formula funding was held harmless would receive smaller decreases in their total funding. This would occur because those EMAs that qualified for the formula funding hold harmless could only have their supplemental funding decreased, not both formula and supplemental funding. Since we assumed that each EMA would receive the same percentage of supplemental funding in fiscal year 2008 that it received in fiscal year 2007, those EMAs that also received formula funding decreases would have larger total funding decreases. Under our assumptions, MAI funding would not be used to fund the hold-harmless provision. We assumed that the total funding for MAI grants would increase to the amount specified in the CARE Act and that each EMA would receive the same percentage of MAI funding in fiscal year 2008 funding that it received in fiscal year 2007. Consequently, those EMAs that have a larger proportion of their funding provided through MAI have smaller amounts that could be used to fund the hold- harmless provision. This results in smaller funding differences between what they would receive with and without the proposed hold-harmless provision. [21] The hold-harmless amounts for the eight TGAs would be $14,607 for Bergen-Passaic; $345,012 for Caguas; $22,134 for Dutchess County; $870,472 for Hartford; $509,497 for Nassau-Suffolk; $687,111 for New Haven; $371,153 for Ponce; and $146,573 for Sacramento. [22] Under our assumptions, MAI funding would not be used to fund the hold-harmless provision. We assumed that the total funding for MAI grants would increase to the amount specified in the CARE Act and that each TGA would receive the same percentage of MAI funding in fiscal year 2008 funding that it received in fiscal year 2007. Consequently, those EMAs that have a larger proportion of their funding provided through MAI have smaller amounts that could be used to fund the hold- harmless provision. This results in smaller funding differences between what they would receive with and without the proposed hold-harmless provision. [23] GAO-06-332, pp. 34-35. [24] Fiscal year 2007 funding for the San Francisco EMA can be traced to its fiscal year 1995 funding due to the relationship between the amount it received in fiscal year 1995 and the amounts it was guaranteed by law to receive in fiscal years 2000, 2006, and 2007 due to the operation of the hold-harmless provisions. In fiscal year 2000, the San Francisco EMA received 95 percent of the amount it received from its grant in fiscal year 1995. In fiscal year 2006, it received 85 percent of the amount it received from its grant in fiscal year 2000. In fiscal year 2007, it received 95 percent of the amount it received from its grant in fiscal year 2006. Taken together, the hold-harmless provisions meant that in fiscal year 2007 the San Francisco EMA received approximately 76.7 percent of its fiscal year 1995 grant of $19,126,679, or $14,672,553. We calculated the guaranteed percentage by multiplying the hold-harmless amounts (95, 85, and 95 percents) for each year together. See GAO-06-332 for more discussion on how the hold- harmless provision operates and how it has affected funding for the San Francisco EMA. [25] HHS, Review of the Management of Unobligated Funds Provided by Title I of the Ryan White Comprehensive AIDS Resources Emergency Act, A- 02-03-02006 (Washington, D.C.: Feb. 27, 2007), [hyperlink, http://www.oig.hhs.gov/oas/reports/region2/20302006.pdf] (downloaded September 6, 2007) and Review of the Management of Unobligated Funds Provided by Title II of the Ryan White Comprehensive AIDS Resources Emergency Act, A-06-04-00060 (Washington, D.C, May 15, 2007), [hyperlink, http://www.oig.hhs.gov/oas/reports/region6/60400060.htm] (downloaded September 6, 2007). [26] Henry J. Kaiser Family Foundation and the National Alliance of State & Territorial AIDS Directors, National ADAP Monitoring Project Annual Report (Washington, D.C.: April 2007), [hyperlink, http://www.nastad.org/Docs/highlight/2007411_2007NationalADAPMonitoringR epFINAL.pdf] (downloaded September 6, 2007) and the National Alliance of State & Territorial AIDS Directors, The ADAP Watch (Washington, D.C.: Aug. 16, 2007), [hyperlink, http://www.nastad.org/infocus/infocusresults.aspx] (downloaded September 6, 2007). GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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