Overview of CARE Act Allocation Formulas1
Most allocation formulasinclude ameasure ofneed, while some include measures of costs, fiscal capacity, and effort. Some formulas also contain special features such as floors and ceilings (minimum and maximum awards), “hold-harmless” provisions that prevent an area’s funding from declining too rapidly from year to year, or eligibility thresholds (NRC, 2001, 2003).
Most formulas for Titles I and II of the Ryan White CARE Act (CARE Act) allocate funds based on a jurisdiction’s disease burden, often defined as estimated living AIDS cases (ELCs). ELCs are calculated by applying annual national survival weights to 10 years of reported AIDS cases and summing the totals.2 Most of these formulas also contain one or more features like hold-harmless provisions or thresholds.
TITLE I AWARDS TO ELIGIBLE METROPOLITAN AREAS
A metropolitan area becomes eligible for Title I if it has a population of 500,000 or more and has reported a cumulative total of more than 2,000
cases of AIDS during the most recent five calendar years for which data are available from the CDC (HRSA, 2002a). A type of hold-harmless provision applies to Eligible Metropolitan Areas (EMAs) in that once a metropolitan area’s eligibility is established, the area remains eligible even if the number of cases drops below the threshold in later years.
An EMA’s base award is determined by a formula based on its proportion of the total number of estimated living cases in all EMAs. The formula also includes a hold-harmless provision that limits the amount an EMA’s funding can fall from year to year, according to a schedule specified in the legislation.3 San Francisco is the only EMA that now benefits from the hold-harmless provision (HRSA, 2002c).
Supplemental awards are determined by a competitive application process, rather than by a formula. Reviewers score the application according to criteria laid out by HRSA. Either HRSA staff or external reviewers score applications. The supplemental award is divided among all EMAs, taking into account the score as well as the proportion of all ELCs that an EMA has. Three different “smoothing” algorithms are applied to see which distributes the money most appropriately. In general, no grantee is given less than 80 percent of its base formula award (HRSA, 2001).
Title I Minority AIDS Initiative
Minority AIDS Initiative (MAI) grant awards are divided among all EMAs according to a formula based on their proportion of racial and ethnic minorities AIDS cases—including African Americans, Hispanics, Asian/Pacific Islanders, and Native Americans/Alaska Natives—diagnosed during the most recent two years for which data are available, and adjusted for reporting delays. For instance, data from 1998 and 1999 were used to calculate the Fiscal Year 2001 MAI award (HRSA, 2001).
TITLE II AWARDS TO STATES AND TERRITORIES
Title II base awards are determined by a formula. Eighty percent of the base grant is based on each state’s proportion of the total number of ELCs. The remaining 20 percent is based on the number of ELCs in each state outside any EMAs, in proportion to the total number of such cases nationwide4 (HRSA, 2001). The base award also includes a minimum award: $200,000 for states with fewer than 90 ELCs, $500,000 for states with more than 90 ELCs, and $50,000 for all United States territories, regardless of the number of AIDS cases (HRSA, 2001). The base award formula includes a hold-harmless provision that declines annually according to a schedule established in the legislation.
States must match a portion of the Title II base award if they report more than 1 percent of the total number of AIDS cases for the two preceding fiscal years. The number of years that a state has been matching determines the percentage that it must match (20 percent the first year, 25 percent the second year, 33 percent the third year, and 50 percent in the fourth year). Puerto Rico is exempt from this requirement (HRSA, 2001).
AIDS Drug Assistance Program Award
The AIDS Drug Assistance Program (ADAP) award is based on a state’s proportion of the total ELCs in all states and territories. Unlike the Title II base award, this award does not include an 80–20 split. The formula includes a hold-harmless provision that declines annually according to a schedule established in the legislation (HRSA, 2001).
ADAP Supplemental Award
Before the ADAP award is calculated, 3 percent of the appropriated earmark is set aside for the ADAP Supplemental Award, given to states in severe need (HRSA, 2002b). A state’s supplemental ADAP award is based on its proportion of the total ELCs in qualifying states and territories. A state must match 25 percent of these federal funds to receive the award. If a qualifying state does not agree to do so, HRSA runs the formula again after deleting the nonparticipating states (HRSA, 2001).
Title II Minority AIDS Initiative
This award is based on each state’s proportion of all African Americans, Hispanics, Asian/Pacific Islanders, and Native Americans/Alaska Natives diagnosed during the previous two calendar years, adjusted for reporting delays. If a state or territory has no diagnosed non-white AIDS cases during the past two years, it does not receive an award (HRSA, 2001). Montana, North Dakota, American Samoa, Marshall Islands, Northern Marianas, Republic of Palau, and the Federated States of Micronesia did not qualify for this award in Fiscal Year 2002 (HRSA, 2002d).
Emerging Communities Award
Emerging communities are Metropolitan Statistical Areas (MSA—a community with a population greater than 50,000) that do not meet the eligibility criteria to qualify as a Title I EMA, but that have 500–1,999 reported AIDS cases in the most recent five-year period. Half the available funding goes to MSAs with 1,000–1,999 AIDS cases, while the other half is divided among MSAs with 500–999 AIDS cases. Each award is based on the area’s proportion of the total number of AIDS cases among all qualifying MSAs (HRSA, 2001).
HRSA (Health Resources and Services Administration). 2001. A Primer on Title I and Title II Formula Allocation Calculations. Unpublished document. (Email communication, Steven Young, HRSA, November 11, 2001).
HRSA. 2002a. Title I: Grants to Eligible Metropolitan Areas. [Online]. Available: http://ftp.hrsa.gov/hab/titleifact.pdf [accessed May 22, 2003].
HRSA. 2002b. Title II: AIDS Drug Assistance Program. [Online]. Available: ftp://ftp.hrsa.gov/hab/adap1.pdf [accessed May 22, 2003].
HRSA. 2002c. FY2002 Ryan White CARE Act Title I Emergency Relief Grants. (Email communication, Steven Young, HRSA, July 22, 2002).
HRSA. 2002d. FY2002 Ryan White CARE Act Title II Emergency Relief Grants. )Email communication, Steven Young, HRSA, July 22, 2002.
NRC (National Research Council). 2001. Choosing the Right Formula. Washington, DC: National Academy Press.
NRC. 2003. Statistical Issues in Allocating Funds by Formulas. Louis TA, Jabine TB, Gerstein MA, Eds. Washington, DC: The National Academies Press.