Ryan White CARE Act
Amendments of 2000
Key
Similarities and Differences between House and Senate
Proposals
Legislation that would reauthorize the Ryan White CARE Act has passed
both houses of Congress. The Senate passed S. 2311 on June 6 and the House
passed H.R. 4807 on July 26. A joint Conference Committee (comprised of
Congress Members and Senators who sit on the House and Senate Committees
that oversee this legislation) will resolve differences between the two
versions. Conference staffers will meet during the August recess to begin
the process and to prepare for a meeting of the Conference Committee
members to be held in September.
This document provides a general overview of both pieces of
legislation, focusing on their significant similarities and differences.
The complete text and additional legislative information regarding both
bills can be found on "Thomas, Legislative Information on the Internet" at
thomas.loc.gov. If you
would like additional information regarding reauthorization of the CARE
Act, please contact the San Francisco AIDS Foundation Public Policy
Department at 415-487-3080 or email policy@sfaf.org.
Areas of Agreement/Common Themes of
the House and Senate Bills
Both the House and the Senate have agreed on certain key themes and
goals that are reflected in both S. 2311 and H.R. 4807. These include the
following:
- Improving Quality of
Care: Both bills attempt to ensure that medical
services funded by the CARE Act are consistent with the most recent U.S.
Public Health Service (PHS) HIV treatment guidelines and that grantees
implement improvements in access to and quality of medical services.
- Improving Collaboration
between Medicaid and State Children’s Health Improvement Programs
(SCHIPs): Both bills require States and
eligible metropolitan areas (EMAs) to establish formal linkages with
these programs.
- Enhancing Access to
Early Intervention Services: Both bills support closer
linkages and co-location of HIV testing and counseling services and
CARE-funded medical care in an effort to reduce the time between HIV
diagnosis and entry into care.
- Reaching the
Underserved and Individuals not Receiving Care: Both bills
require States and Title I planning councils to identify underserved
communities as well as individuals living with HIV currently not
receiving care and to prioritize funding for services to these targeted
individuals.
- Enhancing Existing
Quality Management: Both bills share requirements that States
and Title I grantees establish or enhance quality management systems for
CARE Act funded programs. These systems must include quality of care
standards (PHS HIV treatment guidelines as a minimum). Both bills allow
grantees to expend 5% but no more than $3 million of the annual grant on
such efforts.
- Linking Support
Services to Medical Care: Both bills require that support
services funded under the CARE Act must facilitate, enhance, support, or
sustain the delivery, continuity, or benefits of health services for
individuals or families with HIV. All CARE providers would be required
to have formal medical health care referral relationships, regardless of
the service they provide.
- Increasing Minimum
State Grants: Both bills raise the minimum allotment to
$200,000 for States with less than 90 living AIDS cases and to $500,000
for States with 90 or more cases.
- Establishing New Title
III Capacity Development Grants: Both
bills create new capacity development grants up to $150,000 for
underserved, low income and/or rural areas to expand capacity,
preparedness, and expertise to deliver primary care in these areas.
These grants are not to exceed three years in duration.
- Increasing the
Allowable Administrative Costs for Title III: Both bills
increase the administrative costs allowed for Title III grants from 7.5%
to 10% to more accurately reflect the actual administrative costs
associated with service provision.
- Removing the
"Significant Enrollment" Requirement in Research Involving Women,
Children and Infants: Both bills remove language that
requires Title IV grantees to enroll a "significant number" of patients
in clinical pharmaceutical drug trials. The bills further require
documentation of the linkages between care and research as well as the
implementation of a quality management program of research conducted
with grants under Title IV.
- Authorizing
Appropriations for Expanded Dental Reimbursement
Program: Both bills expand the definition of
eligible dental entities to include accredited schools of dental
hygiene. In addition, the House bill expands grants to dental schools to
include those dental schools and dental hygiene programs that partner
with community-based dentists in underserved areas.
Key Differences between the Senate
and House Bills
The following guide highlights the key differences in bill language
between the Senate and House versions of the Ryan White CARE Act
reauthorization amendments.
Title I: Funding to High-Incidence Eligible Metropolitan
Areas (EMAs)
1.
Planning Councils
Senate: Requires addition of housing and homeless service
providers to planning council representation.
House: Requires addition of prevention providers as well
as HIV positive prisoners, former prisoners or their representatives to
planning council representation. Adds language requiring planning councils
to comply with federal laws governing open meetings, also known as FACA or
Sunshine laws. Mandates that one-third of planning council members be
unaffiliated recipients of Title I funding (i.e., consumers of CARE
services who cannot be an officer, employee, or consultant for a Title I
grant recipient). The U.S. Secretary of Health and Human Services (HHS) is
required to assist EMAs in providing training materials and guidance to
planning council members.
2.
Allowable Reductions in Formula Funding
Senate: Doubles the existing "hold harmless" provision from 1%
per year (or 5% total reduction over the five years the legislation is
reauthorized) to 2% per year (for a total allowable reduction over the
five years the legislation is reauthorized of 10%). This provision is
intended to protect jurisdictions from experiencing dramatic reductions in
funding from year to year.
House: Adopts "hold harmless" language that allows a graduated
reduction of Title I formula funding as follows: 2% in the first year the
hold harmless is needed, a total of 4.3% in the second year, a total of
8.9% in the third year, a total of 15.8% in the fourth year, and a maximum
total reduction of 25% by the fifth year. Reductions are calculated using
the total of Title I formula funding from the fiscal year immediately
prior to the year the hold harmless provision is first used. The graduated
reduction begins anew if there is an intervening year in which an EMA does
not need the hold harmless provision.
3. Use of HIV/AIDS Data in Formula Funding
Senate: Retains existing 10-year weighted AIDS case band count
(the current method used to estimate the number of people living with AIDS
in a given area).
House: Maintains existing 10-year weighted AIDS case
count through 2004. Requires addition of HIV case data in 10-year weighted
case count beginning in 2005 unless the Secretary of HHS determines that
HIV case data are insufficient. Requires Institute of Medicine study of
HIV case surveillance to identify if it is adequate for use in formula
funding.
4.
Administrative Costs and Compensation
Senate: No related provisions.
House: Requires planning councils to review existing, available
data to determine administrative costs associated per client served and to
indicate growth in administrative costs per client. Planning councils must
also make a determination of whether the compensation of any officers or
employees of Title I recipients exceed that of the chief elected official
in the EMA.
Title II: Funding to States for Medical and Support Services
(including the AIDS Drug Assistance Program)
1.
Use of HIV/AIDS Data in Formula Funding
The differences between the Senate and House version related to the use
of HIV data to determine Title II awards are identical to the differences
included in Title I (see #3 above).
2.
Supplemental Grants for "Emerging Communities"
Senate: Creates a new supplemental grant to States to provide
services to "emerging communities" that are not currently eligible for
Title I funding. Fifty percent of new Title II funds would be set aside to
fund the new supplemental grants. To be eligible, communities must
have had between 500 and 1,999 cases of AIDS in the past five years
(cities with more than 2,000 cases are eligible for Title I funds). The
amount provided would be 25% or $5 million (whichever is greater) to
States that report between 1,000 and 1,999 AIDS cases during the previous
five years; and 25% or $5 million (whichever is greater) to States that
report between 500 and 999 AIDS cases. This provision would not take
effect until Title II appropriations (exclusive of ADAP-specific funds)
exceed FY 2000 funding levels by at least $20 million. Once this funding
is provided, HHS is required to ensure that at least $10 million is made
available for these "emerging communities" every year.
House: Adds a competitive supplemental component to Title II,
which would support grants to States that have one or more "eligible
communities" (communities outside of Title I that demonstrate a severe
need for services). Fifty percent of the new Title II base funds would be
used for these grants and would be awarded competitively. Like the Senate
version, this provision would not take effect unless there is an increase
in Title II funding of $20 million over the FY 2000 appropriation
(exclusive of ADAP funds).
3.
Competitive Grants for ADAP Funds
Senate: Sets aside three percent of all Title II ADAP-specific
funds to be used for a competitive grant program to increase access to HIV
drugs for individuals living at or below 200% of the federal poverty
level. Requires that no State can receive a reduction in ADAP funds as a
result of this new set-aside (i.e., holds States harmless from reduction
that could occur due to this program). Eligible States must match the
award at a rate of one dollar for every four dollars they receive. States
must also agree not to impose limitations on eligibility requirements or
scope of benefits that are more restrictive than such requirements that
were in effect on January 1, 2000. The criteria for awarding of grants
will be developed by the Secretary of HHS.
House: Sets aside two percent of all Title II ADAP-specific
funds to be used for a competitive grant program to assist States that
have severe unmet need in providing HIV drugs to their populations. Like
the Senate bill, the criteria for awarding of grants will be developed by
HHS. States are required to provide a 25% match. This provision takes
effect only if the amount appropriated to ADAP is greater than the
amount in the preceding year.
4.
Allowable Reductions in Title II Funding
Senate: Does not have a Title II "hold harmless"
provision.
House: Provides for a 1% per year "hold harmless," meaning that
any State receiving funds would receive no less than 99% of their base
year award in the first year. It would continue to allow only an
additional 1% reduction per year in the following years (for a maximum
total reduction of 5% over the five years of the reauthorized Act).
5.
Partner Notification Programs
Senate: Senate version contains no language on partner
notification programs or counseling requirements.
House: Creates a new $30 million annual authorization to provide
States with funding to create or enhance existing partner notification,
counseling and referral service programs. States must follow certain
conditions to be eligible for these grants, including State implementation
of a partner notification program and reporting of those who test
HIV-positive to the State public health officer in a manner recommended
and approved by the CDC. Prior to FY 2004, preference in making grants
would be given to States with HIV reporting systems that are "sufficiently
accurate and reliable" for Title I and Title II formula allocation. After
2004, a State may not receive a grant under this program unless the
State’s HIV reporting system produces data that have been deemed reliable
by HHS.
6.
Pregnancy and Perinatal Transmission of HIV -- Mandatory Testing of
Newborns
Senate: Contains no new language or funding relating to HIV
testing of pregnant women and/or newborns.
House: Authorizes $30 million to address the issue of perinatal
HIV transmission. Ten million of this funding is to be authorized and
appropriated through the CDC (this is identical to current law). Each year
in which the appropriation for this program exceeds $10 million, an
increasing percentage of the remaining balance would be distributed to
States with mandatory HIV testing requirements for either all newborns or
those newborns in which the mother’s HIV status is unknown. The percentage
used to allocate these funds to States with such policies is as follows:
25% in FY 01, 50% in FY 02 and FY 03, 75% in FY 04 and 05.
The House bill also requires an Institute of Medicine study to examine
the number of HIV-positive infants born in each State, the possible
barriers that exist in each State that might prevent the mother’s
obstetrician from offering her an HIV test, and recommendations to each
State in reducing the incidence of perinatal HIV transmission. In response
to these recommendations, each State must submit a report to HHS by 2004
that describes the actions it has taken toward meeting the
recommendations.
Title III: Direct Grants to Organizations for Early
Intervention and Primary Care Services
1.
Preferences in Awarding New Funds
Senate: Includes new language giving preference in new Title III
funding to areas that are "rural and underserved."
House: Includes new language giving preference in new Title III
funding to "rural areas or in areas that are underserved."
2.
Partner Notification & Counseling
Senate: Senate version contains no new language on partner
notification programs or counseling requirements.
House: Adds new HIV counseling component "that emphasizes it is
the duty of infected individuals to disclose their status" to partners and
"emphasize that it is the continuing duty of the individual to avoid any
behaviors that would expose others to HIV."
Title IV: Programs for Women, Infants, Children and Youth
1.
Limitation on Administrative Expenses
Senate: Requires the Secretary of HHS to conduct a review of the
administrative, program support, and direct service-related activities of
Title IV grantees to ensure eligible individuals have access to quality
HIV-related health, support services and research opportunities. This
review is to be completed no later than 12 months after the CARE Act is
reauthorized. No later than 180 days following the 12-month period for the
review, HHS (in consultation with Title IV grantees) would be required to
report on the relationship between the cost of service and eligible
individuals’ access to such services. After this determination is
completed, grantees would have to comply with requirements regarding
administrative expenses.
House: The House version contains no language regarding this
topic.
Part F: Miscellaneous Provisions
1.
AIDS Education and Training Centers – Prenatal and Gynecological Care
Senate: The Senate version contains no language regarding this
topic.
House: Requires the development and distribution of protocols
for women with HIV disease, including prenatal and other gynecological
care. Such treatment protocols must be developed and disseminated within
90 days of reauthorization of the CARE Act.
Subtitle B: General Provisions
1.
Plans Regarding Release of Prisoners Living with HIV
Disease
Senate: No related provision on this issue.
House: Requires HHS to develop a plan for the medical case
management and delivery of support services to individuals living with HIV
disease who are to be imminently released from either federal or state
penal systems. The plan must be submitted to Congress no later than two
years after reauthorization.
2.
Selected Audits
Senate: No related provision on this issue.
House: The Secretary of HHS may reduce the Title I or Title II
grant to any grantee if it fails, in two consecutive grant years, to
produce audits required of all federal grantees. Annually, the Secretary
of HHS will be required to select a representative sample of grantee
audits, summarize them and provide them in a report to be submitted to
Congress.
3.
Coordination of Title I and Title II Grant Years
Senate: No related provision on this issue.
House: No later than 18 months after enactment of the bill, HHS
shall develop a plan for coordinating the distribution of appropriated
Title I and Title II funding for grant making purposes. No later than two
years after the plan is submitted to Congress, the Secretary of HHS shall
implement this plan regardless of any other provision of law.
4.
Biennial Application Process
Senate: No related provision on this issue.
House: No later than two years after enactment of the bill, the
Secretary of HHS must determine whether the administration and efficiency
of Title I and Title II CARE grants would be improved by a biennial rather
than annual grant process.
Title V: General Provisions
1.
Institute of Medicine Studies
Senate: Not later than 120 days after reauthorization, the
Secretary of HHS – in conjunction with the Institute of Medicine – would
be required to conduct a study regarding epidemiological measures and
their relationship to the financing and delivery of primary care and
health-related support services for low-income, uninsured, and
under-insured individuals living with HIV. The study would consider
availability and utility of health outcomes measures, the effectiveness
and efficiency of service delivery, existing and needed epidemiological
data and other tools for resource planning and allocation decisions, and
other relevant factors.
House: Contains similar study requirement, but adds a
requirement that the study include an assessment of the financial impact
of reforming the Social Security Act to provide Medicaid eligibility to
those in earlier stages of HIV disease.
Requires an additional IOM study on State HIV surveillance systems. The
study would include a determination of whether the HIV surveillance system
of each of the States provides adequate and reliable information on the
number of HIV cases and whether such information is sufficiently accurate
to be used for formula funding purposes. Recommendations would be issued
to those States where the reporting mechanism is deemed insufficient.
2.
Development of Rapid HIV Test
Senate: The Senate version of the bill does not contain language
regarding the development of a rapid HIV test.
House: Directs the National Institutes of Health to expand,
intensify and coordinate research to develop an HIV test that can be
rapidly administered and the results rapidly obtained. Within 90 days
after the CARE Act is reauthorized, the Secretary of HHS must submit a
report to Congress on the progress made towards (and the barriers to) the
development and availability of such rapid HIV tests. As soon as
commercial distribution of a rapid HIV test occurs, the Secretary of HHS
will establish guidelines that include recommendations regarding the
availability of rapid HIV tests for administration to pregnant women who
are in labor (or in the late stages of pregnancy) and whose HIV status is
not known to her physician.
Page last updated 30 August
2000 | 
