There are a number of changes that have come with the passage of the Ryan White HIV/AIDS Treatment Modernization Act of 2006. . The structure of the legislation has not been altered. Title I is the funding that goes directly to urban areas – eligible metropolitan areas (EMAs). Title I awards are based on both formula funding, based on the prevalence of HIV in the jurisdictions, and a “supplemental” award which is based on scores received on the grant application.. Title II is funding that goes to the states and territories. The “base” award of Title II operates nearly identical to what was outlined for Title I. In addition to this “base” award is additional funding for the AIDS Drug Assistance Program (ADAP). Some states add their own funds to ADAP. This causes the program to be very different in each state in terms of formulary and eligibility requirements. Titles I and II have “hold harmless” provisions. “Hold harmless” is in place to ensure that any formula changes that may negatively impact a jurisdiction do not happen suddenly and cause such a large cut that it could easily destabilize the jurisdiction’s system of care. Instead decreases occur gradually with a cap on the percentage a jurisdiction can lose each year. Title III directly funds community health clinics. Title IV directly funds programs for women family and children. There are also sections of the bill that establish dental reimbursement programs (mostly dental schools); the Minority AIDS Initiative (MAI) funding for Title I and II jurisdictions specifically targeting communities of color; and demonstration projects known as Special Projects of National Significance (SPNS).
1. Sunset of legislation: Most importantly is that this bill is authorized for only 3 years (as opposed to the past – which was 5 years) and even more significantly- this bill sunsets on September 30, 2009. This was a deal made in the Senate to thwart some of the problems that were holding up the passage of this bill. So everything is on the table and there is no bill that will provide the same sort of framework we had in the 1996, 2000 and 2006 reauthorizations. Senator Kennedy’s staff is already beginning to have conversations with key organizations in the HIV/AIDS community to begin an assessment of how best to craft a new bill to be responsive to the current realities of the epidemic. This may open up an opportunity to bring employment issues into a new piece of HIV/AIDS funding legislation.
2: Core Medical Services: The bill now has language that requires Title I, II and III grantees to spend 75% of their award on core medical services. These services are defined as outpatient and ambulatory health services; medications; pharmaceutical assistance; oral health care; early intervention services; health insurance premium and cost sharing assistance for low-income individuals; home health care; medical nutrition therapy; hospice services; home and community based health services; mental health services; substance abuse outpatient care; and medical case management, including treatment adherence services. Significantly – housing and in-patient substance use are excluded from core service funding. The use of the term “medical case management, including treatment adherence services” was a concern to advocates because this could be interpreted conservatively to exclude peer based case management. However there have been assurances that the bill’s report language will clearly include peer-based case management. The 75% core services requirement can be waived if there is no ADAP waiting list and core medical services are otherwise available to all those identified and eligible. Advocates are concerned that applying for a waiver could jeopardize Title I and II jurisdictions’ ability to effectively write a grant application for the supplemental/competitive award that is part of Title I and Title II grant process and based on demonstrated need of the applicant.
3: Change in formula/supplemental funding: In the past the division of monies available for Titles I and II was split 50-50 between formula funding and the competitive application supplemental. This bill changes that split to 66% formula based and 33% available for supplemental. Hold harmless monies for eligible jurisdictions are taken out of the 33% supplemental pot and the remainder is available for distribution among all jurisdictions through the general competitive/ supplemental grant.
4: Requirement for ADAP Formulary: ADAP has never had a formulary requirement imposed on the states. There will now be a requirement for a formulary core HIV drugs and drugs for HIV related symptoms to be established by the Secretary of HHS and imposed on the states. This may require some states to increase their commitment of state funds for ADAP and this may have consequences for state funds available for other HIV specific programs in those states.
5: HIV data use for funding: Currently “formula” funding is determined by an obtuse formula that results in “estimated living AIDS cases” however the 2000 bill did require HIV case data to be used by FY 2007. The new legislation affirms current law (switch to HIV cases by FY 2007). The bill specifies that formula funding will use living HIV/AIDS cases from names-based reporting states only, after being reported to and confirmed by the CDC. A second “track” of states and Title I EMAs that do not have mature names-based HIV reporting or certified names-based HIV cases with the CDC, but use code-based systems, will have their code-based HIV cases used for funding distribution purposes after an adjustment that will reduce the count by 5%.
6: Change in structure of Title I: Title I is now divided into 2 subparts Subpart 1 = EMAs (eligibility redefined)Subpart 2 = TGAs, a new program for “transitional grant areas.” This incudes some metropolitan areas previously eligible as Title I EMAs, “grandfathered” EMAs, and some areas previously eligible as Title II Emerging Community funding. Planning Councils are not mandatory for TGAs (unless TGA was an EMA in FY2006).
7: New Title I Jurisdictions: There are currently 51 EMAs that receive Title I funding. There has been a redefinition of Title I eligibility which has added 5 new EMAs to the existing 51. These are-
Baton Rouge LA, Charlotte-Gastonia-Rock Hill NC/SC, Nashville TN, Indianapolis IN and Memphis TN/AR/MS. If appropriations for 2007 are not increased for Title I (which is unlikely) there will be more jurisdictions that must share the already inadequate funding for Title I. Current jurisdictions that no longer fall into the Title I definition (e.g. Santa Rosa CA) will not be eliminated during the term of this 3-year bill but will drop off at that time (of course there will be no legislation based on the current configuration at that time due to it’s sunset in 2009). 8: Miscellaneous other funding changes: There are a number of other funding issues in the new bill that will have an impact. The current formula for Title II funding for states that have Title I EMAs is changed that will give more weight to areas outside of EMAs.
There is a provision that extends hold harmless protection for Title I EMAs throughout the term of this legislation.
Title II no longer has a separate hold harmless for ADAP funding and Title II base.
There are new restrictions for the use of unspent funds for carryover between fiscal years.
Appropriations increases and amounts are specified in this legislation as opposed to the previous language which stated “such sums as may be necessary”.
There are a host of other changes to the legislation, but these are the 7 points that I have outlined here are, in my opinion, the most significant and will have the most impact on funding for HIV/AIDS services .
Currently Ryan White grantees and advocates are addressing issues and concerns about implementing these changes with HRSA – such as the timeline for altering allocations to be compliant with the 75% core services provision since grant applications and allocation decisions were made for FY 2007 before this legislation was signed into law.