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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.107573
RESEARCH AND PRACTICE |
Robert J. Buchanan is with the Department of Political Science and Public Administration at Mississippi State University, Mississippi State. William Hatcher is a doctoral student in the Department of Political Science and Public Administration, Mississippi State University, Mississippi State.
Correspondence: Requests for reprints should be sent to Robert J. Buchanan, PhD, Department of Political Science and Public Administration, PO Box PC, Mississippi State University, Mississippi State, MS 39762 (e-mail: rjb161{at}ps.msstate.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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President George W. Bush has proposed modest increases, when he has proposed any at all, in funding for the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act during his administration, and Congress has appropriated little funding increase since fiscal year 2004. Growing numbers of Americans living with HIV or AIDS, 40 000 people newly infected with HIV each year, and Centers for Disease Control and Prevention–recommended efforts to identify people with undiagnosed HIV infection indicate an increasing need for services funded by CARE Act programs. Inadequate CARE Act funding harms the most vulnerable people with HIV.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in 1990 to improve health care for low-income, uninsured, and underinsured people and families affected by HIV.1 CARE Act programs reach more than 500 000 people annually.1 Part A (formerly called Title I) of the CARE Act provides funds to metropolitan areas disproportionately affected by HIV and AIDS.1–3 Part B (formerly Title II) assists the states and territories with improving the quality, availability, and organization of health care and support services to people and families with HIV, including medications through the AIDS Drug Assistance Programs. Part C (formerly Title III) provides funding for early intervention and primary care services for people with HIV or AIDS. Part D (formerly Title IV) enhances access to family-centered, comprehensive care for children, youths, and women living with HIV and their families. Part F provides funding for the development of innovative HIV and AIDS service delivery models, the AIDS Education and Training Centers Program, and the Dental Reimbursement Program.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The CARE Act appropriations data utilized in this study are available from the Health Resources and Services Administration for fiscal years 2002 through 20064 and from the Henry J. Kaiser Family Foundation for fiscal year 2007.5 Data for President Bush’s 2000–2008 annual budget requests for CARE Act programs were obtained from National Alliance of State and Territorial AIDS Directors.6–8 The percentage changes in Bush Administration funding requests for the CARE Act programs presented in Table 1
are changes in the amount of the Bush budget request for each CARE act program from the previous fiscal year’s appropriation. The percentage changes in CARE Act appropriations presented in Table 2 are the changes in the amount of spending for that CARE Act program from the previous fiscal year’s appropriation.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Table 1
presents funding requests from the Bush administration for CARE Act programs, illustrating that the president rarely requested increases to the previous year’s appropriation. Bush administration requests for increases in CARE Act funding during fiscal years 2002 through 2008 were mainly for the AIDS Drug Assistance Programs, with requests for most other CARE Act programs either at or below the previous year’s appropriations. When we analyzed the first 6 federal budgets approved by Congress during the Bush administration, total CARE Act funding increased from $1.910 billion in fiscal year 2002 to $2.113 billion in fiscal year 2007, an increase of less than 11% (see Table 2).4,5 By contrast, CARE Act funding more than doubled from the first to the sixth federal budgets approved during the Clinton administration, increasing from about $579 million in fiscal year 1994 to $1.411 billion in fiscal year 1999.4 Table 2 shows final congressional appropriations for CARE Act programs during the Bush administration; annual cuts have been made in most of these programs since fiscal year 2004. Total CARE Act funding approved by Congress and signed into law by President Bush during fiscal year 2007 increased only about 3% from fiscal year 2004 levels. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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During 2005, about 1.1 million Americans were living with HIV,10 with about 40000 new infections each year.11 Half of the new HIV or AIDS diagnoses occurred among African American people during 2004, whereas 18% occurred among Hispanic people and 30% among White people.11,12 Almost 2 in 3 women living with HIV or AIDS during 2004 were African American, with another 15% being Hispanic.11–13 About 70% of new HIV infections among men in the United States during 2004 occurred among men who have sex with men.14 In addition, evidence suggests a resurgence of HIV among men who have sex with men, with the number of HIV and AIDS diagnoses increasing 8% in 2004.14
Growing Need for CARE Act Programs
The use of highly active antiretroviral therapy resulted in dramatic declines in AIDS-related deaths15 and slowed the progression of HIV infection to AIDS.16 Better treatment resulted in increasing numbers of people with AIDS in the United States; 433 760 Americans were living with AIDS in 2005, compared with 341 302 in 2001.9 The Centers for Disease Control and Prevention (CDC) estimates that 1 in 4 Americans living with HIV infection does not know that he or she is infected,17 or between 252 000 and 312 000 Americans are unaware of their HIV infection.18 In September 2006, the CDC released recommendations to make HIV testing a routine part of medical care to reduce the number of Americans with undetected HIV infection.18 However, these newly diagnosed Americans with HIV need treatment, which adds patients to the HIV/AIDS care network.19
The growing number of Americans living with AIDS, 40 000 new HIV infections each year, CDC-recommended efforts to identify undiagnosed HIV infection, and the possible resurgence of HIV among men who have sex with men increase the need for HIV prevention, treatment, and care-related services.
This increasing need for HIV-related treatment and care indicates a growing demand for services funded by the CARE Act. The slower progression from HIV infection to AIDS because of the effectiveness of highly active antiretroviral therapy can make it more difficult to meet eligibility criteria for Medicaid coverage, which also increases the need for CARE Act programs. HIV infection does not automatically qualify a person as meeting disability status for Medicaid eligibility; most low-income people with HIV do not become eligible for Medicaid until they become disabled by AIDS.20 In addition, an estimated 42% to 59% of patients with HIV or AIDS did not receive regular care during 200021,22; such patients are typically underserved and may have the greatest need for CARE Act programs.23
Despite the increasing number of people living with HIV who could benefit from these programs, Table 1 shows that President Bush proposed modest increases, when he proposed any, in funding for the CARE Act programs during his administration, and Table 2 documents that Congress appropriated little increase in funding since fiscal year 2004. CARE Act funding has not kept pace with increases in the cost of medical services since 1998.24 Minimal or no increase in appropriations for the CARE Act programs during the Bush administration essentially resulted in a decrease in funds available for patient services because of cost increases, new medications and treatments, and increases in the number of people with HIV who benefited from these programs.
CARE Act Analyses
Studies by the Institute of Medicine (IOM) found inequities in CARE Act funding by state.25,26 In addition, the US Government Accountability Office (GAO) recommended revising CARE Act funding formulas if Congress wanted spending for CARE Act programs to reflect more accurately the distribution of people living with AIDS.27 An IOM study concluded that the focus of the CARE Act should be expanded to include the entire population of people infected with HIV, identifying those who are infected but not diagnosed or receiving care.26 Members of Congress and the Bush administration expressed concern that CARE Act funding varies among the states because of funding formulas.28 States receiving Part A funding averaged more CARE Act funding per estimated living AIDS patient than did states not receiving Part A funds.28
Another GAO study found variation among the states and territories in AIDS Drug Assistance Program eligibility criteria and drug formularies, with some AIDS Drug Assistance Programs paying higher prices for medications than necessary.29 In addition, members of Congress expressed concern that some states use less than 25% of Ryan White funding to provide core medical services.28 The Bush administration proposed requiring states to use 75% of CARE Act funding to provide core medical services to foster health among people with HIV and establish uniformity of HIV-related services across the nation.28
2006 CARE Act Reauthorization
Congress reauthorized the Ryan White CARE Act in December 2006, and President Bush signed the bill into law on December 19, 2006.30 This reauthorization provided more flexibility to direct funding to areas of greatest need, required more oversight of CARE Act programs, standardized minimum requirements for the AIDS Drug Assistance Programs, and counted all persons who were HIV positive for funding regardless of where they lived or how data were reported.30–33 Specifically, the reauthorization statute requires that states spend 75% of CARE Act funding from Parts A, B, and C on core medical services and requires the secretary of the Department of Health and Human Services to develop a list of core antiretroviral medications that must be included on the AIDS Drug Assistance Program formulary in each state.32,33
The CARE Act reauthorization legislation defines core medical services as (1) outpatient and ambulatory health services, (2) medications, (3) pharmaceutical assistance, (4) oral health care, (5) early intervention services, (6) health insurance premium and cost-sharing assistance for low-income individuals, (7) home health care, (8) medical nutrition therapy, (9) hospice services, (10) home- and community-based health services, (11) mental health services, (12) substance abuse outpatient care, and (13) medical case management, including treatment adherence services.30,32,33 This 2006 reauthorization extends the Ryan White CARE Act for only 3 years, however. Congress must address the CARE Act’s structural challenges in a new law if the program is to be extended beyond September 30, 2009.31
Conclusions
IOM noted that the number of people with HIV and AIDS continues to grow, with the cost of care and the need for CARE Act services also increasing.25 This IOM study concluded that CARE Act appropriations do not necessarily match the need for services, with many CARE Act programs unable to serve all who could benefit.25 The National Alliance of State and Territorial AIDS Directors reported that the "HIV/AIDS Community Request" for CARE Act funding for fiscal year 2007 was about $2.6 billion, $577 million (or 27%) more than the $2.1 billion that President Bush included in his fiscal year 2007 budget request for CARE Act programs.7 The "HIV/AIDS Community Request" for CARE Act programs includes assessments of funding needs from national HIV/AIDS organizations compiled by National Alliance of State and Territorial AIDS Directors. Because of inadequate CARE Act funding, as of January 2007, 3 states and Puerto Rico had implemented waiting lists for medications provided by AIDS Drug Assistance Programs, with other cost-containment strategies for AIDS Drug Assistance Programs implemented or anticipated in 6 states and Puerto Rico.34
CARE Act programs are serving the uninsured, underinsured, women, and minorities.35,36 Growing numbers of Americans living with HIV or AIDS, 40000 people newly infected with HIV each year, and CDC-recommended efforts to identify people with undiagnosed HIV infection indicate a growing need for services funded by CARE Act programs. Inadequate funding for the Ryan White CARE Act harms the most vulnerable people living with HIV in the United States. However, IOM concluded that even though CARE Act programs face many challenges, it has been "an extraordinarily successful health care policy."26
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Acknowledgments |
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Ann Lefert and Beth Crutsinger-Perry at the National Alliance of State and Territorial AIDS Directors provided essential assistance with this research, including access to data for annual Bush administration funding requests for the Comprehensive AIDS Resources Emergency Act.
Human Participant Protection
No review or approval by the institutional review board was required because all data presented in the research are publicly available.
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Footnotes |
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Peer Reviewed
Contributors
R. J. Buchanan originated the study, synthesized analyses, and led the writing of the article. W. Hatcher assisted with the study and analyses.
Accepted for publication April 19, 2007.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. Ryan White CARE Act, CARE Act overview. July 2006. Available at: http://hab.hrsa.gov/programs/CareActOverview. Accessed September 9, 2007.
2. The Henry J. Kaiser Family Foundation. Ryan White Comprehensive AIDS Resources Emergency Act. November 2006. Available at: http://www.kff.org/hivaids/upload/7582.pdf. Accessed September 9, 2007.
3. Buchanan RJ. Ryan White CARE Act and eligible metropolitan areas. Health Care Financ Rev. 2002;23: 149–157.[Medline]
4. US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. CARE Act appropriations history, by program: FY 1991 to FY 2006. Available at: ftp://ftp.hrsa.gov/hab/fundinghis06.xls. Accessed September 9, 2007.
5. The Henry J. Kaiser Family Foundation. HIV/AIDS policy fact sheet: the Ryan White Program. March 2007. Available at: http://www.kff.org/hivaids/upload/7582_03.pdf. Accessed September 8, 2007.
6. National Alliance of State and Territorial AIDS Directors. Fiscal years 2002 through 2006 appropriations for federal HIV/AIDS programs. National Alliance of State and Territorial AIDS Directors.
7. National Alliance of State and Territorial AIDS Directors. FY2007 appropriations for federal HIV/AIDS programs. Available at: http://www.nastad.org/Docs/Public/Publication/2006217_FY2007%20Approps%20Chart%203.doc. Accessed September 9, 2007.
8. National Alliance of State and Territorial AIDS Directors. FY 2008 appropriations for federal HIV/AIDS programs. Available at: http://www.nastad.org/Docs/Public/Resource/2007723_FY2008%20Approps%20Chart%20House%20Senate.doc. Accessed September 9, 2007.
9. Centers for Disease Control and Prevention. HIV/AIDS surveillance report, 2005, Table 10. Vol 17, 2007, Revised ed. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf. Accessed September 9, 2007.
10. The Henry J. Kaiser Family Foundation. AIDS at 25: an overview of major trends in the U.S. epidemic. June 2006. Available at: http://www.kff.org/hivaids/upload/7525.pdf. Accessed September 9, 2007.
11. Centers for Disease Control and Prevention. CDC HIV/AIDS fact sheet: a glance at the HIV/AIDS epidemic. Revised June 2007. Available at: http://www.cdc.gov/hiv/resources/factsheets/PDF/At-A-Glance.pdf. Accessed September 9, 2007.
12. Centers for Disease Control and Prevention. CDC HIV/AIDS fact sheet: HIV/AIDS among African Americans. Revised June 2007. Available at: http://www.cdc.gov/hiv/topics/aa/resources/factsheets/pdf/aa.pdf. Accessed September 9, 2007.
13. Centers for Disease Control and Prevention. CDC HIV/AIDS fact sheet: HIV/AIDS among Hispanics. August 2007. Available at: http://www.cdc.gov/hiv/resources/factsheets/PDF/hispanic.pdf. Accessed September 9, 2007.
14. Centers for Disease Control and Prevention. CDC HIV/AIDS fact sheet: HIV/AIDS among men who have sex with men. July 2006. Available at: http://www.cdc.gov/hiv/resources/factsheets/PDF/msm.pdf. Accessed September 9, 2007.
15. Centers for Disease Control and Prevention. Evolution of HIV/AIDS Prevention Programs—United States, 1981–2006. MMWR. 2006;55(21):597–603. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a4.htm?s_cid=mm5521a4_e. Accessed September 9, 2007.
16. Centers for Disease Control and Prevention. Epidemiology of HIV/AIDS—United States, 1981–2005. MMWR. 2006;55(21):589–592. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a2.htm?s_cid=mm5521a2_e. Accessed September 9, 2007.
17. Centers for Disease Control and Prevention. CDC HIV/AIDS science facts: CDC releases revised HIV testing recommendations in healthcare settings. September 2006. Available at: http://www.cdc.gov/hiv/topics/testing/resources/factsheets/healthcare.htm. Accessed September 9, 2007.
18. Centers for Disease Control and Prevention. Recommendations and reports: revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55 (RR14):1–17. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed September 9, 2007.
19. DeNoon D. Who will care for new U.S. AIDS cases? WebMD Med News. November 29, 2006. Available at: http://www.webmd.com/content/article/130/117662. Accessed September 9, 2007.
20. National Alliance of State and Territorial AIDS Directors. Medicaid and AIDS Drug Assistance Program. October 2006. Available at: http://www.nastad.org/Docs/Public/InFocus/2006124_MedicaidandADAPFS.pdf. Accessed September 9, 2007.
21. The Henry J. Kaiser Family Foundation. The HIV/AIDS epidemic in the United States. September 2005. Available at: http://www.kff.org/hivaids/upload/Fact-Sheet-The-HIV-AIDS-Epidemic-in-the-United-States-2005-Update.pdf. Accessed September 9, 2007.
22. The Henry J. Kaiser Family Foundation. Financing HIV/AIDS care: a quilt with many holes. May 2004. Available at: http://www.kff.org/hivaids/upload/Financing-HIV-AIDS-Care-A-Quilt-with-Many-Holes.pdf. Accessed September 9, 2007.
23. Hayes C, Gambrell A, Young S, Conviser R. Using data to make decisions: planning HIV/AIDS care under the Ryan White CARE Act. AIDS Educ Prev. 2005;17(suppl B):17–25.[CrossRef][Web of Science][Medline]
24. Martin EG, Pollack HA, Pattiel AD. Fact, fiction, and fairness: resource allocation under the Ryan White CARE Act. Health Aff. 2006;25:1103–1112.
25. Institute of Medicine, National Academy of Sciences. Public Financing and Delivery of HIV Care: Securing the Legacy of Ryan White. Washington, DC: National Academies Press; 2005.
26. Institute of Medicine, National Academy of Sciences. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, DC: National Academies Press; 2004.
27. US Government Accountability Office. Report to Congressional Requesters: HIV/AIDS: changes needed to improve the distribution of Ryan White CARE Act and housing funds (GAO-06-332). February 2006. Available at: http://www.gao.gov/new.items/d06332.pdf. Accessed September 9, 2007.
28. Hearing of the Committee on Health, Education, Labor, and Pensions US Senate, 109th Cong, 2nd Sess. Fighting the AIDS Epidemic Today: Revitalizing the Ryan White CARE Act. S. Hrg. 109–409; March 1, 2006. Washington, DC: US Government Printing Office; 2006. 26-427 PDF. Available at: http://purl.access.gpo.gov/GPO/LPS71744(PDF file). Accessed September 9, 2007.
29. US Government Accountability Office. Report to Congressional Requesters: Ryan White CARE Act: improved oversight needed to ensure AIDS drug assistance programs obtain best prices for drugs. GAO-06-646. April 2006. Available at: http://www.gao.gov/new.items/d06646.pdf. Accessed September 9, 2007.
30. US Department of Health and Human Services. Ryan White HIV/AIDS Treatment Modernization Act. Available at: http://hab.hrsa.gov/treatmentmodernization. Accessed September 9, 2007.
31. The Henry J. Kaiser Family Foundation. Kaisernetwork.org: Kaiser Daily HIV/AIDS Report. President Bush signs Ryan White CARE Act reauthorization bill. December 20, 2006. Available at: http://www.kaisernetwork.org/Daily_reports/rep_index.cfm?DR_ID=41763. Accessed September 9, 2007.
32. The Henry J. Kaiser Family Foundation. The Ryan White CARE Act: a side-by-side comparison of prior law to the newly reauthorized CARE Act. Available at: http://www.kff.org/hivaids/upload/7531-03.pdf. Accessed September 9, 2007.
33. Library of Congress. Thomas. H.R. 6143 Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Enrolled as Agreed to or Passed by Both House and Senate). Available at: http://thomas.loc.gov/cgi-bin/query/z?c109:h.r.6143.enr. Accessed September 9, 2007.
34. National Alliance of State and Territorial AIDS Directors. The ADAP Watch. February 7, 2007. Available at: http://www.nastad.org/Docs/highlight/2007212_NASTAD_ADAP_Watch_2-07-07_FINAL.pdf. Accessed September 9, 2007.
35. Valverde E, Del Rio C, Metchen L, et al. Characteristics of Ryan White and non-Ryan White funded HIV medical care facilities across four metropolitan areas: results from the Antiretroviral Treatment and Access Studies site survey. AIDS Care. 2004;16:841–850.[CrossRef][Web of Science][Medline]
36. McInnes K, Landon BE, Malitz FE, et al. Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics. AIDS Care. 2004;16:851–857.[CrossRef][Web of Science][Medline]
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