more than a set percent each year in order to help sustain needed health care infrastructure and continuity of services, seemed to accomplish their purpose at the expense of states and local areas believed to have younger epidemics and rising need (U.S. Congress, 2000a).

Congress asked the General Accounting Office (GAO) to examine opportunities to enhance the equity of funding to RWCA grantees prior to the 1996 and 2000 reauthorizations. The GAO’s 1995 study found that CARE Act funding formulas led to disparities in per AIDS case funding that could not be completely explained by variations in service costs or the fiscal capacity of states and EMAs.

In a 2000 report, the GAO again found large disparities across Eligible Metropolitan Areas (EMAs) and states in allocations per ELC. The GAO concluded that two formula features in particular, the hold-harmless provision and the “double-counting” of EMA cases in Title I and II formulas,3 contributed to these funding inequities. In particular, states with an EMA had up to 60 percent higher per case allocations than states without an EMA and the hold-harmless provision instituted in the 1996 reauthorization benefited only San Francisco (GAO, 2000).

The GAO report further concluded that the formulas, which were based on living AIDS cases, did not reflect the changing nature of the HIV/AIDS epidemic and recommended the inclusion of HIV case data in the Title I and II formulas to more effectively target and deliver funding to persons in need of care. The GAO noted that, at a minimum, all states would have to report HIV cases to provide an equitable distribution of funds. At the time, only 60 percent of states had HIV reporting systems in place (GAO, 2000).

Congress began the 2000 reauthorization with the expectation that HIV case-reporting data would be of value to the RWCA formula allocations, as well as to planning and evaluation efforts. The 2000 legislation specifies that, if appropriate, the Secretary of Health and Human Services (HHS) should incorporate cases of HIV disease in RWCA Title I and II funding formulas as early as FY2005 but no later than FY2007 (Ryan White CARE Act. 42 U.S.C. § 300ff-28 [2003]). The reauthorization legislation authorized the Institute of Medicine (IOM) to assist the Secretary of HHS in assessing the readiness of states to produce accurate and reliable HIV case-reporting data, determine the accuracy of using HIV cases within the existing allocation formulas, and establish recommendations regarding the manner in which states could improve their HIV case-reporting systems (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]).4


EMA cases are counted in both Title I and II formulas.


See Chapter 1 for legislative language relating to the Committee’s charge.

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