Ryan White HIV/AIDS Program, Part B HIV Care Grants to States

Authorizing Legislation: Title XXVI, Sections 2611-2631 of the Public Health Service Act, as amended.

Program Description and Accomplishments
Part B of the Ryan White HIV/AIDS Program provides grants to all 50 states, the District of Columbia, Puerto Rico and the U.S. territories to provide services for people living with HIV/AIDS, including outpatient medical care, oral health care, home- and community-based services, continuation of health insurance coverage, prescription drugs, HIV care consortia, and supportive services. Part B includes the AIDS Drug Assistance Program (ADAP), which supports the provision of HIV medications and related services. Seventy-five percent of Part B funds must be used to support core medical services. Part B funds are distributed through base and supplemental grants, ADAP and ADAP supplemental grants, and Emerging Communities (ECs) grants. The base awards are distributed by a formula based on a state or territory’s living HIV/AIDS cases weighted for cases outside of Part A-funded jurisdictions. Supplemental awards are available to states with demonstrated need. Congress designates a portion of the Part B award to support ADAP. The majority of ADAP funds are also distributed by a formula based on living HIV/AIDS cases, though 5% of the funds are set aside for states with severe need. A state’s combined Part B base award and ADAP allocation cannot decrease by more than five percent per year. Most states provide some services directly, while others work through subcontracts with Part B HIV Care Consortia. A consortium is an association of public and nonprofit health care and support service providers and community-based organizations that plans, develops, and delivers services for people living with HIV/AIDS. Emerging communities are metropolitan areas that do not qualify as EMAs or TGAs but have 500-999 cumulative reported AIDS cases over the last five years and apply for supplemental funding through a grant application. The AIDS Drug Assistance Programs (ADAPs) provides FDA-approved prescription medications for people with HIV/AIDS with limited or no prescription drug coverage. ADAP funds also may be used to purchase health insurance for eligible clients or to pay for services that enhance access, adherence, and monitoring of drug treatments.

The Part B programs have been successful in helping to ensure that people living with HIV/AIDS can get the care and services they need to stay healthy longer. The number of visits for health-related services demonstrates the effectiveness of the Part B program in delivering primary care and related services for individuals infected with HIV/AIDS by increasing the availability and accessibility of care. Part B programs provided 2.28 million visits in 2004 and 2.34 million visits in 2005. In FY 2006, Part B provided 1.88 million visits. The actual performance for FY 2006 exceeded the target by 320,000 visits. This however was a decrease from FY 2005. This is most likely a result of the decline in Program resources available for funding service provision, which resulted in fewer providers and clients, and the impact of healthcare inflation. ADAP served 147,187 clients in 2005. In FY 2006, 157,988 clients were served annually through State ADAPs exceeding the target. Sixty-five percent of those served by ADAPS are people of color. Nationally, more than 78 percent of ADAP clients have incomes at 200 percent or less of the federal poverty level (FPL). Individual ADAPs operate in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, and the Republic of the Marshall Islands.

Program Assessment Rating Tool: Part B was included in the combined PART reassessment conducted in 2007 for the Ryan White HIV/AIDS Program. The Program received an Effective rating. See Summary of Request for more details.

External Evaluation: The Part B program is regularly evaluated by independent agencies, such as OIG and GAO. In the past year an OIG Audit was conducted entitled “Review of the Management of Unobligated Funds Provided by Part B of the Ryan White Comprehensive AIDS Resources Emergency Act” (A-06-04-00060) (Final Report - May 2007). The findings of these Audits indicate that HRSA did not always comply with Departmental policy that limit the carryover of unobligated grant balances to the next budget year only. These funds were originally awarded to provide services during a specific budget year were instead carried over for use in subsequent budget periods. Departmental policy guidance issued after the audit period now permits the carryover of unobligated grant funds into either of the next two budget periods. HAB has taken appropriate steps and follows current Departmental policy regarding the approval of carryover requests from Part B (Title II) grantees. Additionally, the Part B program examines the reasons for some States’ large unobligated balances and monitors compliance to obligate 75 percent of grant award with in 120 days.

A GAO evaluation conducted in the past year was entitled “Oversight of Drug Pricing in Federal Programs” (GAO-07-481T) (Final Report - February 2007). The Legislative Funding Proposal found that prior to the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (enacted December 19, 2006), the Part A funding amounts were evenly split between formula and supplemental grants. The new legislation changes the distribution whereas; two-thirds of Part A funds will be distributed as formula grants and one-third as supplemental grants. The finding showed how the proposed hold-harmless provision from H.R. 3043 would impact funding for urban areas under the proposed funding levels. The Oversight of Drug Pricing in Federal Programs provided information related to the oversight of prescription drug pricing practices, especially 340B drug pricing programs which provide discounted drug prices to some State ADAPs. HRSAs Healthcare Systems Bureau, Office of Pharmacy Affairs administers the 340B Program which GAO found lacks transparency in 340B prices, lacks oversight, and provides overpayments to drug manufactures.

Funding includes costs associated with grant reviews, processing of grants through the Grants Administration Tracking and Evaluation System (GATES) and HRSA’s electronic handbook, and follow-up performance reviews.

Funding History

Budget Request
The FY 2009 Request of $1,209,487,000 is an increase of $14,239,000 over the FY 2008 Enacted level. The request supports current program activities and includes an increase to provide life-saving medications to people living with HIV. Of this amount $394,941,000 which is $8,193,000 above the FY 2008 Enacted level will be used for base formula HIV grants for the provision of services in the fifty States, the District of Columbia, Puerto Rico, the Virgin Islands and six Pacific jurisdictions. This request also includes $814,546,000 for State ADAP which is $6,046,000 above the FY 2008 Enacted level.

HRSA has developed a model for estimating the marginal cost of serving ADAP clients. The model takes into account many of the factors affecting purchasing power, such as increases in cost of HIV/AIDS drugs; the legislative requirement that all State ADAPs maintain a minimum drug formulary, including new drug classes; and the impact of Medicare Part D, rebates, and insurance coverage. The FY 2009 ADAP Request of $814,546,000 will support providing ADAP services to 158,887 persons. This represents an increase of 148 individuals over the estimated number that might be served at the FY 2008 level. The marginal cost model corroborates the Program’s projected target for number of ADAP clients is by 2009. Part B funding will also contribute to achieving the FY 2009 targets for the Ryan White Program’s over-arching performance measures, including proportion of racial/ethnic minorities and women served, number of ADAP clients, persons tested for CD4 count and viral load, and providers implementing a quality management program. (See Summary of Request for targets and for strategies and challenges.)

Notes:

State Table

FY 2009 Ryan White HIV/AIDS Treatment Modernization Act Part B CARE Grants

*Total includes AIDS Drug Assistance Program (ADAP) and Base Formula awards, and Competitive ADAP Supplemental and Minority AIDS Initiative (MAI) award amounts
**Fiscal Year 2008 grant amounts pending award calculations in March 2008
***Fiscal Year 2009 grant amounts pending award calculations in March 2009
****Total State Grants include or would include amounts for AIDS Drug Assistance Programs as follows:
FY 2007 $789,546,000 (excludes 5% setaside for severe need supplemental)
FY 2008 $808,500,000 (excludes 5% setaside for severe need supplemental)
*****Includes amount for technical assistance to Ryan White Program grantees and program evaluation