CARE Act programs and services vary across the country because of local flexibility in program design, different levels of CARE Act funding, and access to other programs such as Medicaid (see Table 3-2). All states receive Title II HIV Care formula grants for ADAP and health care and support services, but some states receive additional CARE Act funding through other CARE Act programs. Nearly all states also receive some Title III Early Intervention Services (EIS) discretionary grants to expand the service capacity of organizations providing primary care services, but some states have more than one grantee (New York, 41 grantees; California, 30; Florida, 19; Texas, 9; Michigan, 4). Twenty-eight states/territories have a number of Eligible Metropolitan Areas (EMAs) and receive additional funding under the Title I Emergency Relief Grant program. Some states are home to some of the 90 grantees who receive funding under Title IV for coordinated services and access to research for women, infants, children, and youth (not shown in Table 3-2). Furthermore, residents with HIV in 37 states have an opportunity to continue health coverage that otherwise might be terminated under the Ryan White Health Insurance Continuation Program (Kates, 2004).

Available CARE Act funds vary in different areas of the country; thus, there is wide variation in the state per capita allocation of CARE Act dollars, a variation that has raised important issues about funding equity. In 2000, a General Accounting Office study found substantial differences in funding among states. In particular, per capita allocations differed significantly between states with an EMA and those without one. States with no eligible EMA received an average of $3,340 per capita for persons with HIV. States with more than 75 percent of their AIDS cases in an EMA averaged $4,954 per AIDS case, nearly 50 percent more than those states without an EMA (GAO, 2000). States with even higher numbers of AIDS cases (more than 90 percent) in EMAs, such as California and New York, received nearly $5,240 per case. States with EMAs receive more funding because AIDS cases are counted twice under Title I and Title II formulas. GAO called for Congress to phase out the “double counting” of EMA AIDS cases to improve equity in the distribution of CARE Act funds. Subsequent changes in the formula have reduced these inequities, but others remain.8


In allocating CARE Act funds, the Health Resources and Services Administration (HRSA) currently uses a “hold harmless” provision that curtails the extent to which CARE Act funds can decline from one period to the next within an EMA. Note that all funds retained by EMAs under such provisions are in effect funds denied to other EMAs and their HIV-infected populations. According to a recent Institute of Medicine (IOM, 2003) report, EMAs would observe a 2.6 percent increase in their allocation if the “hold-harmless” provision currently in effect for San Francisco was removed.

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement