As CARE Act Reauthorization Heats Up, Congress Calls for Audit of Federal AIDS Programs

On April 20th, House Majority Leader Dick Armey (R-TX), Commerce Committee Chairman Thomas Bliley (R-VA), and Vice Chair of the Commerce Health Subcommittee Tom Coburn (R-OK) wrote to the General Accounting Office (GAO) requesting an audit of all federally-funded HIV/AIDS programs. While supportive of legitimate efforts to ensure that federal funds are used appropriately, AIDS advocates are concerned that the call for a GAO audit is primarily a political ploy to undermine Congressional support for HIV/AIDS programs on the eve of reauthorization.

House members' questions to the GAO include:

• Do funding disparities exist between different groups affected by HIV/AIDS?
• What is the average cost per CARE Act client served nationally, regionally and in urban versus rural areas?
• Is there evidence of abuse or misuse of federal AIDS funds?
• How much CARE Act funding is used directly or indirectly on housing?
• How do salary levels of top administrators in large AIDS service organizations compare with state and federal civil service compensation in corresponding areas?
• Is there any evidence of failure to enforce federal laws regarding spousal notification and against tolerating drug abuse in housing programs?

The GAO's response to these questions will probably take many months to complete. Other Members of Congress are also expected to submit questions, which will broaden the scope of the audit.

In the interim, the Congress is expected to hold hearings on the status of the federal response to HIV/AIDS sometime in the fall. Hearings specific to reauthorization would then be held in the winter of 1999 in hopes of legislation being introduced by January 2000.

Concurrent to Congressional action, the Health Resources and Services Administration (HRSA) AIDS Advisory Committee (HAAC) met on May 13-14th to develop a series of recommendations related to CARE reauthorization.

During its two-day meeting, the HAAC voted on nearly 30 proposals, including several that pertain to the Title I formula. The HAAC voted to maintain the existing hold harmless provision in the Title I formula, a move strongly supported by the San Francisco AIDS Foundation. The HAAC also called on the Secretary of Health and Human Services to commission a study to assess the eventual use of data on HIV prevalence and on the cost of care in the Title I funding formula.

The HAAC also proposed several changes in the AIDS Drug Assistance Program (ADAP), including adding a provision that would allow states to use a portion of their ADAP funds for other HIV-related care services. A state could only do so as long as it first demonstrated that all eligible ADAP clients had access to the full array of drugs identified in the federal HIV treatment guidelines. The HAAC also voted to use 10% of ADAP funds to create a competitive grant program to target ADAP resources to states that continue to face barriers to providing care due to funding shortfalls.

Barbara Garcia from San Francisco's Health Department (SFDPH) is a member of the HAAC. SFAF was also represented at the meeting and provided public testimony on these and other proposals. The final HAAC report will be available later this summer.

Finally, on May 22nd-23rd, Cities Advocating Emergency AIDS Relief (CAEAR Coalition), whose members represent Titles I and III nationwide, met in Washington to finalize its position statement on reauthorization. The Coalition also adopted a position in support of a hold harmless provision in Title I, but increased the annual allowable decrease in the amount of formula funding a city could receive from one to two percent. Representing San Francisco at the meeting were SFAF policy staff, the Community Clinic Consortium, Mayor Brown's office and the SFDPH.

Congressional Action on Work Incentives Improvement Act Shows Strong Bi-Partisan Support

Despite continued efforts to block Senate consideration of the bill by Majority Leader Trent Lott (R-MS), the Work Incentives Improvements Act (S. 331) continues to enjoy strong bi-partisan support with 74 Senate co-sponsors. The House companion bill, H.R. 1180, was approved by the Commerce Committee on May 19th with 157 co-sponsors. The Work Incentives Improvement Act is strongly supported by many national disability advocacy organizations, including many in the HIV/AIDS community.

The bill would provide important health care coverage in several ways. It would allow uninsured individuals who earn over 250 percent of poverty to buy into Medicaid and would also allow individuals whose health disability improves sufficiently such that they receive cuts to their Social Security Disability Insurance (SSDI) cash benefits to continue to receive health care through Medicaid. State run job training and employment aid services would also be supported by a "ticket to work" provision in the legislation.

Both Senators Feinstein and Boxer are co-sponsors of this legislation and the San Francisco AIDS Foundation has written to the entire Northern California Congressional delegation requesting support.

S. 331/H.R. 1180 would also allow states to create Medicaid Expansion Demonstration Programs that would allow individuals who currently work to purchase Medicaid coverage if they have disabilities that could become severe enough to prevent them from working without health care coverage. This would allow individuals to continue to work, maintaining their productivity and independence, while at the same time reducing reliance on government benefits, such as SSDI.

This $9.2 million corresponds to the total amount of state AIDS Drug Assistance Program (ADAP) funds that were shifted away from program. Even with the reduction in the state's contribution to the program, due to increased federal funds and pharmaceutical rebates, ADAP's proposed budget of $136.6 million represents an overall increase in spending and will ensure access for all Californians who are eligible.

• $1.9 M to expand access to the Early Intervention Program (EIP)
• $1.0 M for Residential Care Facilities for the Chronically Ill (RCFCIs)
• $3.0 M for HIV prevention programs, including
• $1.5 M to support psychosocial support groups and HIV counseling and testing for high risk men who have sex with men (MSM), particularly African American and Latino MSMs, and $1.5 M to develop a prevention program for high risk youth living in counties with the highest occurrence of HIV infection among youth
• $1.3 M to provide HIV/AIDS services in communities of color, including $650,000 for targeted prevention and $650,000 for outreach and care
• $2.0 M for HIV/AIDS prevention program evaluation and behavioral surveillance research

Following the release of the Governor's revised budget, the Assembly and Senate Budget Subcommittees reviewed the HIV/AIDS items and provided even more funding than the Governor proposed in several areas. As these items are debated in Conference Committee in the weeks ahead, CHAC will advocate for maximum funding for each of the programs.

Senate Committee Defeats Name-Based HIV Reporting Legislation

On Wednesday, May 12th, SB 1029, the bill authored by Senator Ray Haynes (R-Riverside) that would have required HIV name reporting in California, was defeated in the Senate Health and Human Services Committee. AIDS advocates praised committee members for recognizing what many health officials and HIV advocates argued -- that such a policy should be rejected based on studies demonstrating that name reporting would deter individuals from seeking HIV testing and treatment.

During the hearing, there was an attempt made by the supporters of the bill to amend it to include a so-called "county option," which would have allowed individual counties to decide whether to implement a name or non-name based HIV reporting system. However, advocates opposing SB 1029 successfully argued that, if name reporting is bad public health policy for the state, it is equally inappropriate for individual counties.

SB 1029 ultimately failed by a vote of 3-4. Senator Martha Escutia (D-Los Angeles), Chair of the Health and Human Services Committee, deserves the AIDS community's gratitude for recognizing -- and pointing out during the hearing -- the negative consequences of a name-based reporting system.

After the bill was defeated, Senator Haynes requested "reconsideration" (asking that the bill be taken up for a vote again in the future). The request for reconsideration is almost always granted by legislative committees and was in this case, as well. However, because of legislative deadlines, Senator Haynes will not be able to seek a new vote on SB 1029 until next year (the bill will therefore become a "two year" bill). As a result, SB 1029 is still technically alive until early 2000, when it may be voted on once again.

For this reason, the AIDS community must now re-double its efforts to pass AB 103, the non-name based HIV reporting bill introduced by Assemblywoman Carole Migden. If AB 103 is enacted, it is far less likely that SB 1029, or similar name reporting bills, would re-surface or gain much ground in the Legislature next year. The Assembly passed AB 103 on May 27th by a vote of 57 to 18.

For more information on AB 103, or to join the California HIV Surveillance Coalition, please call the SFAF policy department at 415/487-3080 or email policy@sfaf.org.

Assembly Passes Needle Exchange Bill

AIDS advocates applauded the California State Assembly's recent passage of the Mazzoni/Shelley needle exchange bill (AB 518), calling the bill crucial to California's efforts to stem the tide of new HIV infections. On May 13th, by a vote of 43-31, the Assembly sent the bill to the State Senate for consideration.

"AB 518 puts sound public health policy above politics," noted Pat Christen, Executive Director of the SF AIDS Foundation. "Given the number of HIV infections directly and indirectly associated with injection drug use and the proven effectiveness of needle exchange programs, California cannot afford to ignore this vital prevention tool."

Numerous scientific studies, including six major federally-funded reports, confirm that needle exchange programs can reduce new HIV infections by at least one third and reduce risk behavior by as much as 80%. These studies also confirm that needle exchange does not increase drug use or criminal activity. In California, nearly a third of new AIDS cases reported in 1998 were associated with injection drug use.

California is home to more than a dozen local needle exchange programs, including the SF AIDS Foundation HIV Prevention Project (SFAF/HPP), the nation's largest exchange program. Although SFAF/HPP operates legally under a local state of emergency supported by S.F. Mayor Willie Brown, Jr. and the S.F. Board of Supervisors, many local programs are looking to AB 518 to guarantee their legal protection.

Under AB 518, needle exchange programs would be established only in jurisdictions that choose to enact them and would be designed with input from the communities in which they operate.

The California Medical Association, the California Nurses Association and the Health Officers of California all support AB 518. The bill is sponsored by the City of Los Angeles.
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State Office of AIDS Hosts Meeting on Health Insurance Expansion

On April 22, the California Department of Health Services' Office of AIDS convened a meeting to begin identifying ways to expand health benefits and services available to persons living with HIV/AIDS. Attendees included AIDS service organization representatives, benefits counselors, legal experts, pharmaceutical company representatives, insurance program representatives, and state and local public health officials.

The topics discussed included using Title II ADAP dollars to purchase health insurance, expansion of the Comprehensive AIDS Resources Emergency Act 1990 Health Insurance Premium Payment Continuation Program (CARE/HIPP), and use of the Managed Risk Medical Insurance Program (MRMIP) by persons living with HIV and AIDS. Additionally, representatives from both Oregon and Minnesota spoke about health insurance expansion programs for high risk individuals in their states.

The afternoon session was devoted to a discussion among all participants of the insurance needs and options for people living with HIV and AIDS in California. These programs deserve attention because they may provide comprehensive coverage (including access to drug therapies) to large numbers of HIV-infected individuals. The meeting concluded with discussion of plans for future action, including convening working groups to explore the many options on the table.

A New Attitude Welcomes 9^th AIDS Lobby Day Participants

Among those addressing the crowd were Assembly Speaker Villaraigosa (D-Los Angeles) and Assemblywomen Migden (D-San Francisco) and Mazzoni (D-Marin), as well as Senators Murray (Chair of the Black Caucus) and Burton (President pro Tempore). Several community leaders also spoke, including Juan Ledesma (Executive Director, Being Alive) Christopher Smith (Director, AIDS Prevention Team), Emani Harrington (Oakland) and Pearl Jemison-Smith (Republican Mothers in Orange County). Speaking for the dozens of people living with HIV/AIDS who joined him on stage at the conclusion of the rally, HAN Director Randy Allgaier said, "We stand here as a reminder that this epidemic is raging. And we stand for the thousands who have died and for those who are afraid to speak out."