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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act (2004)

Chapter: Appendix B: Financial Resources of States for HIV/AIDS Reporting

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Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

B
Financial Resources of States for HIV/AIDS Reporting

Several of the factors determining system accuracy, such as the ability to follow up on a backlog of cases, depend on the capacity to conduct surveillance. As one indicator of capacity, the Committee examined federal and state funding for HIV/AIDS case reporting. The Committee heard testimony from a small number of states, from the Centers for Disease Control and Prevention (CDC) staff, and from select Eligible Metropolitan Areas (EMAs) regarding surveillance capacity and funding. The Committee also reviewed information provided by state AIDS programs and from the CDC regarding state and federal contributions to HIV/AIDS surveillance for fiscal years 1999–2002.

With the exception of very large county or city health departments, state surveillance programs provide the HIV/AIDS surveillance data for Ryan White CARE Act (RWCA) planning and evaluation. While HIV reporting has been implemented in all states and cities, except Georgia and Philadelphia (as of October 2003), most states did not see a concurrent increase in financial resources to assist with the implementation of HIV reporting. Although the RWCA Amendments of 2000 authorized limited additional funds to assist states with the implementation of HIV reporting systems (Ryan White CARE Act. Sec. 300ff-13), that funding has yet to be appropriated. Even though HIV and AIDS data are perceived to be readily available for RWCA purposes at no additional cost, states must often provide specialized reports for RWCA planning that include different or more-detailed data than are provided in standard epidemiologic reports.1 Such efforts can be costly.

1  

Subcommittee site visit to the CDC, April 4, 2002.

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

When considering the question of surveillance capacity, there are at least two levels of system cost: one associated with the implementation of HIV reporting, and the other associated with RWCA planning efforts at state and local levels. Cost issues are relevant to the question of capacity, particularly given the pervasive fiscal austerity of states and localities.

DATA EXAMINED

Financial resources clearly affect reporting capacity. In the absence of models to estimate surveillance costs, the Committee attempted to understand more about surveillance capacity by studying the distribution of federal and state funding for surveillance programs. The Committee reviewed two sources of funding for state HIV/AIDS surveillance programs for the years 1999 through 2002: (1) self-reported state general revenue contributions for HIV and AIDS surveillance, and (2) federal core surveillance funding to states through cooperative agreements with the CDC.2

The National Alliance of State and Territorial AIDS Directors (NASTAD) administered a request for information to state AIDS directors regarding states’ general revenue contributions to their HIV/AIDS surveillance programs during fiscal years 1999–2002. Forty-one states responded to that request for information.3 States were also asked to identify expected changes in general revenue (remain constant, decrease, increase). The CDC provided data to the Committee on federal funding to states for core surveillance and for other surveillance activities for corresponding fiscal years 1999 through 2002 (CDC, 2003).

The Committee reviewed data for 1999 through 2002 for three reasons: (1) approximately one-third of states implemented HIV reporting during this time period (see Table 3-1 in chapter 3), (2) state fiscal austerity was emerging during this time period, and (3) these data were readily available from most states.

2  

CDC provides “core funding” to states for their HIV/AIDS reporting systems. CDC provides additional funds to states, based on a competitive grant application process, for supplemental surveillance activities.

3  

States were asked not to include state general revenue contributions to the six cities/counties in their jurisdiction that receive direct funding from CDC for HIV/AIDS reporting (Chicago, Houston, New York, Los Angeles, Philadelphia, and San Francisco). A separate request for information was made to those areas. States were also asked to exclude in-kind contributions (e.g., staff on loan from another division) and funding for general communicable disease or sexually transmitted disease surveillance.

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

RESULTS

The Committee examined data provided by the CDC and NASTAD on federal and state contributions for HIV surveillance. The Committee converted the total spending to spending per capita, using data from the 2000 Census (U.S. Census Bureau, 2000). During 1999–2002, the majority of funds for AIDS and HIV surveillance programs came from the federal government, and in 32 states, funding was entirely from the federal government. Average federal and state funding was flat from 1999–2002. Relative state contributions were flat during the period with less than 10 percent of the total average $0.09–$0.10 spent per capita. Moreover, 33 of the 41 states that responded reported $0 of state general revenue funding for HIV/AIDS surveillance programs for fiscal years 1999, 2000, and 2002. Thirty-two states reported $0 state contributions in fiscal year 2001.

State-by-state comparisons of federal and state HIV/AIDS surveillance funding for 1999–2002 in dollar terms is found in Table B-1. State contributions to HIV/AIDS surveillance funding are only provided for the 41 states that responded to NASTAD’s request for information. Federal contributions are provided for all 50 states and the District of Columbia.

The funding picture for state HIV/AIDS surveillance programs did not change appreciably during FY1999–2002 for the 41 states that responded to the request for information.4

Table B-2 shows state general revenue contributions for HIV/AIDS surveillance as a percentage of total surveillance budgets. The aggregate reliance on federal resources for HIV/AIDS surveillance does not change greatly from year to year.

Table B-3 presents data from the 11 states that implemented HIV reporting during the analysis period. These data show that for the majority of these states, there was little change in the amount of state or federal funding for surveillance during the period when they were implementing HIV reporting. Only California substantially increased funding in the years just prior to implementation of HIV reporting. Pennsylvania began general revenue contributions prior to implementing HIV reporting, but Kansas discontinued general revenue contributions the year following implementation of HIV reporting. Federal funding increased for Vermont, Hawaii, Alaska, and Kansas during this period, but was essentially flat for other states.

4  

Financial data were adjusted for inflation using the All Items Consumer Price Index. U.S. City average, nonseasonally adjusted, All Urban Consumers. (U.S. Department of Labor, Bureau of Labor Statistics). [Online] http://data.bls.gov.SeriesID:CUUS0000SA0.

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

TABLE B-1 State and Federal Contributions for HIV/AIDS Surveillance for FY1999–2002, in Dollars (N=51)

 

FY1999

FY2000

State

State General Revenue (in $)

Federal Revenue (in $)

State General Revenue (in $)

Federal Revenue (in $)

Alabama

Not Available*

572,603

Not Available

786,712

Alaska

0

115,000

0

115,000

Arizona

125,000

340,573

125,000

398,133

Arkansas

0

238,727

0

207,653

Californiaa

5,116,200

3,914,875

7,746,000

4,058,017

Colorado

0

537,822

0

467,772

Connecticut

Not Available

346,444

Not Available

298,319

Delaware

0

112,664

0

113,005

District of Columbia

Not Available

388,336

Not Available

485,865

Florida

634,227

1,806,242

634,227

1,760,761

Georgia

0

196,816

0

297,909

Hawaii

0

31,505

0

135,989

Idaho

0

75,000

0

75,000

Illinois

Not Available

1,010,508b

Not Available

1,409,531b

Indiana

0

274,633

0

280,708

Iowa

0

29,476

0

129,151

Kansas

42,900

90,200

42,900

127,301

Kentucky

0

109,852

0

117,000

Louisiana

7,500

772,966

7,500

774,042

Maine

0

112,947

0

72,319

Maryland

Not Available

956,359

Not Available

956,359

Massachusetts

0

226,901

0

483,925

Michigan

0

851,426

0

881,745

Minnesota

0

189,568

0

232,345

Mississippi

0

243,071

0

220,000

Missouri

0

550,203

0

577,455

Montana

0

68,105

0

67,124

Nebraska

0

83,635

0

120,000

Nevada

Not Available

310,600

Not Available

327,494

New Hampshire

Not Available

83,200

Not Available

77,985

New Jersey

616,000

2,202,177

553,000

2,089,025

New Mexico

Not Available

163,320

Not Available

213,479

New York

1,607,028

4,525,303c

1,809,183

4,394,123c

North Carolina

0

406,125

0

1,292d

North Dakota

0

59,675

0

59,251

Ohio

0

176,228

0

399,052

Oklahoma

0

286,509

0

286,509

Oregon

Not Available

330,108

Not Available

320,108

Pennsylvania

0

1,079,110e

0

1,092,184e

Rhode Island

Not Available

213,218

Not Available

214,304

South Carolina

0

446,217

0

486,314

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

FY2001

FY2002

State General Revenue (in $)

Federal Revenue (in $)

State General Revenue (in $)

Federal Revenue (in $)

Not Available

551,606

Not Available

557,276

0

120,750

0

120,750

125,000

423,863

125,000

380,226

0

218,036

0

218,036

7,746,000

3,927,473

7,746,000

4,042,160

0

522,250

0

318,972

Not Available

433,988

Not Available

454,338

0

126,864

0

126,904

Not Available

487,435

Not Available

510,158

634,227

1,896,204

634,227

183,146

0

69,973

0

384,666

0

173,417

0

173,418

0

78,750

0

64,184

Not Available

750,838b

Not Available

988,642b

0

362,653

0

325,508

0

169,198

0

143,412

42,900

135,344

0

130,144

0

122,850

0

122,850

7,500

812,010

7,500

322,866

0

103,530

0

106,688

Not Available

988,653

Not Available

874,028

0

488,190

0

409,864

0

925,832

0

924,110

0

144,096

0

247,094

0

132,424

0

132,720

0

601,078

0

601,078

0

63,100

0

67,772

0

126,000

0

126,000

Not Available

343,869

Not Available

343,870

Not Available

87,681

Not Available

76,838

692,000

2,260,092

400,000

2,224,150

Not Available

179,071

Not Available

153,312

1,726,081

4,097,758c

1,590,230

4,484,826c

0

228,949

0

374,534

0

61,067

0

62,214

0

481,189

0

516,746

0

300,834

0

300,834

Not Available

326,113

Not Available

336,114

100,000

1,128,759e

100,000

966,010e

Not Available

226,169

Not Available

226,170

0

501,745

0

371,358

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

 

FY1999

FY2000

State

State General Revenue (in $)

Federal Revenue (in $)

State General Revenue (in $)

Federal Revenue (in $)

South Dakota

0

52,048

0

54,404

Tennessee

0

526,858

0

505,200

Texas

263,006

1,627,176f

263,006

1,401,897f

Utah

0

115,481

0

141,092

Vermont

0

64,294

0

75,056

Virginia

0

339,806

0

423,268

Washington

0

748,702

0

760,952

West Virginia

0

182,351

0

204,419

Wisconsin

0

342,445

0

342,445

Wyoming

0

52,690

0

52,689

aIncludes funding for Los Angeles and San Francisco.

bIncludes funding for Chicago.

cIncludes funding for New York City.

d$1,292 was allocated to North Carolina in 2000 due to unexpended and carryover funding from the previous year.

eIncludes funding for Philadelphia.

fIncludes funding for Houston.

*Not available means there was no response to NASTAD’s request for information.

NOTE: Data from states is self-reported and has not been independently verified.

SOURCE: NASTAD, 2003.

TABLE B-2 State Funding for HIV/AIDS Surveillance as a Percent of Total State HIV/AIDS Surveillance Budget, FY1999–2002 (N = 41)

Fiscal Year

Mean (%)

1999

4.48

2000

4.36

2001

4.65

2002

3.51

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

FY2001

FY2002

State General Revenue (in $)

Federal Revenue (in $)

State General Revenue (in $)

Federal Revenue (in $)

0

47,024

0

44,454

0

581,102

0

616,100

268,872

1,308,762f

268,872

1,086,330f

0

168,719

0

179,268

0

128,832

0

82,526

0

444,332

0

393,084

0

802,181

0

770,510

0

199,627

0

225,750

0

383,851

0

341,914

0

51,555

0

57,954

TABLE B-3 State and Core Federal Funding for Surveillance by States Implementing HIV Surveillance per 1,000 Adult Population, FY1999–2002, by State (N = 11)

 

State Funding (in $)

Federal Funding (in $)

State

1999

2000

2001

2002

1999

2000

2001

2002

Alaska

0*

0

0

0

20*

20

190

190

California

150

230

230

230*

120

120

120

120*

Delaware

0

0

0*

0

160

140

160*

160

Hawaii

0

0

0*

0

30

110

140*

140

Kansas

20

20

20

0

30*

50

50

50

Kentucky

0

0*

0

0

30

30*

30

10

Maine

0*

0

0

0

90*

60

80

80

Montana

0

0*

0

0

80

70*

70

80

New York

80

100*

90

80

80

80*

90

80

Pennsylvania

0

0

10

10*

40

40

40

40*

Vermont

0

0*

0

0

110

120*

210

140

*Year of HIV surveillance implementation

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×

As one of several potential indicators of capacity, these data imply that more financial resources might be required to accommodate the current and additional information needs or demands of the HIV/AIDS surveillance programs vis-à-vis use of information for RWCA planning, allocation, or evaluation. States are facing significant financial crises, and while several states are newly implementing HIV reporting, most programs do not anticipate additional state general revenue contributions. According to the 41 states that responded to the NASTAD request for information, 65 percent (27) reported that they expect their state’s contributions for HIV/AIDS surveillance to remain constant; 7.3 percent (3) reported that they expect a decrease; while 2.4 percent (1) reported they expect an increase. State dependence upon federal funding for HIV surveillance activity, and for the provision of HIV/AIDS data for RWCA planning, evaluation, and allocation is apparent.

The use of financial data to understand capacity has limitations. For example, some resources used for other surveillance may partially support HIV/AIDS surveillance. Furthermore, the Committee did not have the ability to calculate the incremental costs of implementing specific HIV surveillance and reporting activities. Nevertheless, it appears that states are being required to engage in additional surveillance and reporting activities without a commensurate increase in state or federal resources. Additional assessments of the incremental costs of such activities would be helpful in determining overall funding needed to support HIV/AIDS surveillance activities.

REFERENCES

CDC (Centers for Disease Control and Prevention). 2003. FY02 Surveillance by State Final. (Email communication, Patricia Sweeney, CDC, May 2, 2003).


NASTAD. 2003. Request for Information: State/Local Funding for HIV/AIDS Surveillance.


U.S. Census Bureau. 2000. Population, Housing Units, Area and Density (geographies ranked by total population). [Online]. Available: http://factfinder.census.gov/ [accessed June 25, 2003].

U.S. Department of Labor. Bureau of Labor Statistics. [Online]. Available: http://data.bls.gov. Series ID: CUUS0000SA0.

Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 239
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 240
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 241
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 242
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 243
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 244
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 245
Suggested Citation:"Appendix B: Financial Resources of States for HIV/AIDS Reporting." Institute of Medicine. 2004. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: The National Academies Press. doi: 10.17226/10855.
×
Page 246
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The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act gives funding to cities, states, and other public and private entities to provide care and support services to individuals with HIV and AIDS who have low-incomes and little or no insurance. The CARE Act is a discretionary program that relies on annual appropriations from Congress to provide care for low-income, uninsured, or underinsured individuals who have no other resources to pay for care. Despite its successes, funding has been insufficient to address all of the inequalities and gaps in coverage for people with HIV.

In response to a congressional mandate, an Institute of Medicine committee was formed to reevaluate whether CARE allocation strategies are an equitable and efficient way of distributing resources to jurisdictions with the greatest needs and to assess whether quality of care can be refined and expanded. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act proposes several types of analyses that could be used to guide the evaluation and improvement of allocation formulas, as well as a framework for assessing quality of care provided to HIV-infected persons.

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