PI Action alerts & updates ... 2006

PROJECT INFORM STATEMENT:
Senator Coburn’s Ryan White CARE Act
Reauthorization Bill

March 3, 2006

For more information, contact:
Ryan Clary: 415-558-8669 x224, rclary@projectinform.org
Anne Donnelly: 415-558-8669 x208, adonnelly@projectinform.org

On February 28th, Senator Tom Coburn (R-OK) introduced legislation to reauthorize the Ryan White CARE Act. The CARE Act, which provides care, treatment, and support services to thousands of low-income people with HIV/AIDS nationwide, expired on September 30, 2005 (although it continues to be funded).

Project Inform appreciates Senator Coburn’s support for the CARE Act and his effort to move the reauthorization process forward. However, his legislation contains several provisions of grave concern that would result in loss of access to vital health care and support services, particularly in urban areas and larger states. We therefore oppose many components of this legislation, and look forward to the release of the reauthorization bill being crafted by bipartisan group of staff members of House Energy and Commerce and Senate HELP committees, which have jurisdiction over the CARE Act.

Our overall concern with the legislation is the inherent assumption that the CARE Act is severely flawed and that structural changes will adequately address gaps in providing care and treatment in certain areas. While there are certainly improvements that should be made in the reauthorized bill, the CARE Act continues to serve as a model program of providing life-saving and life-enhancing services in a fractured and crumbling health care system. It also empowers local health officials, service providers, and people with HIV to prioritize funding based on the identified needs in the community, allowing the flexibility needed to address a complex and changing epidemic.

Senator Coburn is correct that many people with HIV are unable to access care and treatment services across the country, particularly in rural areas. This is not the result, however, of major structural problems within the CARE Act, rather of years of highly inadequate funding from the federal government. The Bush Administration and many in Congress have prioritized tax cuts for the wealthy, while restricting the amount of money available for discretionary health and social service programs, such as the CARE Act. Furthermore, at the same time that rates of the uninsured have risen dramatically, state Medicaid programs have been restricted by inadequate funding and need for health and social services has grown.

Outside of some small increases to the AIDS Drug Assistance Program (ADAP), the CARE Act has suffered from five years of flat-funding and mandatory rescissions. Title I, for example, has only grown by 1% since Fiscal Year 2001 (from $604 million to $610 million), despite over 40,000 new infections per year and rising health care costs. Title II base funding is only $9 million more than 2001.

This has led to reductions in services and restricted access to care and treatment programs all over the country. Cuts to Medicaid contained in the recently passed budget bill will only make the problem worse: as people begin to lose access to care through Medicaid, the largest federal payer of HIV care, they will look to the CARE Act for services.

Many of the proposals included in Senator Coburn’s bill will simply shift money around, taking large sums of funding from certain geographical areas—causing loss of care, treatment, and support services—to give to other areas. As advocates for people with HIV/AIDS, we can not accept what we see as a short-sighted solution.

We recognize that there is severe need in many parts of the country, particularly in rural areas, and this need must get addressed. Rather than support a massive redistribution of funds, however, we first and foremost urge Congress to provide adequate funding for all Titles of the CARE Act. We also support proposals that will provide fiscal relief to areas in need without causing great harm to people with HIV/AIDS in other states and localities that have their own needs.

Below are some of our most significant concerns with Senator Coburn’s bill, along with the proposals we believe will strengthen the CARE Act and provide relief to people with HIV/AIDS in areas that are struggling to provide treatment, care and support services

Title II Formula Allocations:
Senator Coburn is proposing to eliminate what he calls “double counting” that he states results in people being counted twice for funding: once for Title I funding and again for Title II funding. This is an inaccurate description of the process. People with AIDS who are living in Title I EMAs are counted for the Title I funding formula, and partially counted in the Title II base funding formula. For Title II, the overall number of statewide AIDS cases is given a weight of 80%, and the number of cases in the state outside of Title I EMAs is given a weight of 20%. Under Senator Coburn’s proposal, none of the cases in Title I EMAs would be counted to determine how much Title II funding a state should get.

Project Inform opposes this proposal, as it fails to recognize the extreme burden facing high prevalence areas. States need the partial credit given for people who live in Title I EMAs in order to receive sufficient Title II funding to support not only the health care systems in their EMAs, which can’t be fully supported solely with Title I funds, but to provide adequate services to people outside of EMAs. For example, under Senator Coburn’s proposal, California would lose $19 million in Title II funding. The result of such a dramatic shift of funding could be major cutbacks in the state’s ADAP, and/or reduced access to care and support services both inside and outside the state’s EMAs. There is little purpose to causing a health care crisis in one area in an attempt to alleviate a crisis in another area.

Instead, Project Inform strongly supports proposals that would provide badly needed fiscal relief to states without high prevalence areas while avoiding harm to other areas. Two proposals have been issued that would achieve this goal. The Ryan White Legislative Group (a coalition of CARE Act advocates that includes the CAEAR Coalition, AIDS Action, National Minority AIDS Council, National Association of People With AIDS, the AIDS Alliance for Children, Youth, and Families, and the National Association of AIDS Education and Training Centers) has drafted a legislative proposal that would establish a mechanism to fund Title II Supplemental Grants. This funding would go to states without a Title I EMA, or where more than 50% of their caseload resides outside an EMA. The National Alliance of State and Territorial AIDS Directors (NASTAD) has proposed modifying the current Emerging Communities provision in the CARE Act to direct funding to states which meet the same criteria. Both of these proposals deserve strong consideration by Congress.

AIDS Drug Assistance Program:
Project Inform appreciates Senator Coburn’s support of the AIDS Drug Assistance Program, and we agree with his desire to increase ADAP appropriations and to expand the ADAP Supplemental as a way to provide extra funding to states dealing with crises in their programs.

We do, however, disagree with many of the details in his ADAP proposal. First, the authorizing level for ADAP funding must be higher than the $70 million per fiscal year proposed in his legislation. Each year, HIV/AIDS treatment experts determine the level of ADAP funding needed from the federal government to help state ADAPs provide a basic level of service. In the past few years, the annual need has ranged from around $200 million to $300 million. The reauthorized CARE Act must include funding levels that allow for the significant increases needed in all Titles of the Act, and without ceilings that will limit the possibility of securing adequate funding.

While we agree with Senator Coburn’s proposal to expand the ADAP Supplemental to provide more resources for states in need, we oppose the provision that would tap funds from all Titles of the CARE Act should ADAP appropriations not be sufficient to provide an adequate pool of funds for the Supplemental. Shifting funds from vital care and support services to help states improve their ADAPs does nothing more than weaken one part of the health care system to bolster another, and we believe it is not a thoughtful approach to public health.

Project Inform instead strongly supports the CAEAR Coalition’s ADAP reauthorization proposal (www.caear.org). This proposal calls for getting new resources to states struggling with their ADAPs by strengthening and expanding the ADAP Supplemental, without shifting funds from other Titles. It would increase the percentage of the ADAP earmark set aside for the Supplemental from 3% to 7%, over five years. It would also eliminate barriers that currently keep some states from qualifying for supplemental funding.

Funding For Primary Care:
Senator Coburn’s legislation requires that at least 75% of all Ryan White CARE Act funding be spent on primary medical care, including doctor visits and therapeutic drugs. While we share the belief that care and treatment services should be a priority in Ryan White spending, we strongly oppose mandatory funding levels. One of the unique features of the CARE Act is the flexibility and community involvement that allows those most familiar with local needs to determine how Ryan White funds are best spent. Areas of the country that have a strong public health care system should be able to use their funds for other vital services that extend the length and quality of life for people with HIV/AIDS.

Elimination of Hold Harmless Provision in Title I:
Senator Coburn’s bill would eliminate the Title I protection-period (or “hold harmless) provision by Fiscal Year 2009. This provision keeps an EMA from drastic losses in funding from year to year, reducing the likelihood of destabilizing its system of care. Interestingly, Senator Coburn proposes keeping a hold harmless provision for Title II, with the intention of protecting against “dramatic shifts in funding”.

Project Inform supports reasonable hold harmless provisions. Without them, an EMA could lose a large percentage of its funding, while other EMAs would get only a small increase as allocated through the funding formula. It makes little sense for one area’s health care system to be destabilized causing real harm to people living with HIV/AIDS while providing little benefit to other individual areas. It also makes little sense to support the concept of hold harmless for states, through Title II, but not for cities, through Title I.

Therefore, Project Inform opposes Senator Coburn’s provision on hold harmless and strongly supports the “Protection Period” proposal from the Ryan White Legislative Group. This proposal maintains hold harmless for Title I EMA’s, allowing losses in funding of up to 21% over five years. It is a reasonable proposal that will allow cities to adjust to decreased funding over time.

We were encouraged to read a statement released on February 28th by Senators Mike Enzi (R-WY) and Ted Kennedy (D-MA), Chair and Ranking Member of the Senate HELP Committee, stating their commitment to continue working in a bipartisan manner with counterparts in the House Energy and Commerce Committee to reauthorize the CARE Act. Project Inform will continue working with our coalition partners to advocate for legislation that will strengthen the CARE Act and ensure that it provides services to everyone who needs them.