96-293 SPR Updated March 31, 1998 CRS Report for Congress Received through the CRS Web AIDS Funding for Federal Government Programs: FY1981-FY1999 Judith A. Johnson Specialist in Life Sciences Science Policy Research Division Summary This report provides a synopsis of the budget activity related to AIDS from the discovery of the disease in 1981 through FY1999. Funding for AIDS research, prevention and treatment programs within the Department of Health and Human Services (HHS) discretionary budget has increased from $200,000 in FY1981 to an estimated $3.85 billion in FY1999. Background Acquired immune deficiency syndrome (AIDS) impairs the immune system and leaves affected individuals susceptible to Figure 1: HHS Funding for AIDS, FY1999 certain opportunistic infections and CDC cancer. Since 1981, over 600,000 9% AIDS cases have been reported to the NIH HRSA 23% 18% Centers for Disease Control and Prevention (CDC). The vast majority of federal AIDS research, prevention Other HHS 2% and treatment programs are administered by four HHS agencies: HCFA-Medicare 20% CDC; the National Institutes of HCFA-Medicaid 28% Health (NIH); the Health Resources and Services Administration (HRSA); and the Health Care Financing Other HHS: FDA, SAMHSA, AHCPR, OS, and IHS; see Table 3. Administration (HCFA), which manages Medicaid and Medicare. AIDS programs within HHS account for over 75% of the total amount spent on AIDS by the federal government (see figure 2). Government-wide AIDS spending is estimated at $9.67 billion in FY1999. NIH is the principal agency of the federal government charged with the conduct and support of biomedical and behavioral research. NIH conducts research at its own 20 Congressional Research Service ˜ The Library of Congress CRS-2 institutes and centers and supports over 50,000 scientists at 1,700 U.S. institutions. For FY1998, NIH is allocating a total of $1.61 billion for AIDS research, or 12% of the $13.6 billion total NIH budget. Funding for research on AIDS in FY1998 is second only to the National Cancer Institute ($2.3 billion non-AIDS funds) and more than that for the next highest funded institute, the National Heart, Lung, and Blood Institute ($1.5 billion non-AIDS funds). Figure 2: HIV/AIDS, FY1999 Total Federal Government Spending HHS Entitlement 37% (Medicaid & Medicare) Other Federal 2% HUD 2% HHS Discretionary 40% (NIH, HRSA, CDC, FDA, SAMHSA, AHCPR, OS, IHS) OPM-FEHB 3% Veterans 4% Social Security 12% OPM-FEHB: Office of Personnel Management-Federal Employees Health Benefits; HUD: Department of Housing and Urban Development . See Tables 4 and 5. The President's FY1999 request of $1.73 billion for AIDS research at NIH is an increase of $124 million or 7.7% over the FY1998 level. The FY1999 includes all NIH AIDS funds in a single account for the Office of AIDS Research (OAR). This is consistent with provisions in the NIH Revitalization Act of 1993 (P.L. 103-43) which gave OAR the overall responsibility to plan, coordinate, evaluate and fund the AIDS research program at NIH. Although for FY1995 NIH AIDS research funds were appropriated to OAR, in subsequent fiscal years the funding mechanism for NIH AIDS research has been contentious. FY1996 AIDS funds bypassed OAR and went directly to each NIH institute as specified in a continuing resolution (P.L. 104-91). The House rejected a separate OAR account in order "to enhance NIH's flexibility to allocate funding based on scientific opportunity." For FY1997, the House again did not provide a separate appropriation for OAR; funding for NIH was provided in an omnibus bill (P.L. 104-208). The conference report (H.Rept. 104-863) stated that AIDS funding was "included within the appropriation for each institute ... as proposed by the House." However, a compromise was reached in that the conference report "directs that the funding for AIDS research as determined by the Directors of NIH and OAR be allocated directly to OAR for distribution to the institutes consistent with the AIDS research plan." The heated debate over allocating NIH funds among various diseases received increased scrutiny during the 105th Congress. House and Senate hearings were held in the spring and summer of 1997 on how NIH determines its research priorities. NIH contends that decisions are made based on scientific opportunity. Critics charge that NIH spending often follows current politics and political correctness, responding to media attention focused on diseases such as AIDS and breast cancer (see CRS Report 97-917, Disease Funding and NIH Priority Setting). HRSA administers the Ryan White CARE Act (P.L. 101-381; P.L. 104-146), a fourpart federal grant program designed to provide emergency relief and essential health care services to AIDS patients and persons infected with the human immunodeficiency virus (HIV). Funding in FY1998 is $1.16 billion. The Administration's request for FY1999 is $1.32 billion, an increase of $165 million or 14% over FY1998. A total of $385.5 million is requested for the AIDS Drug Assistance Program (ADAP) in Title II of Ryan White, a $100 million or 35% increase over FY1998. The increase will ensure that patients have CRS-3 access to combination drug therapy. For the remaining non-ADAP Ryan White activities, a total of $930 million was requested for FY1999, a $65 million increase over FY1998. Table 1: HRSA HIV/AIDS Funding ($ in thousands) Ryan White -Title I -Title II -Title III -Title IV -Other Ryan White Subtotal, Ryan White Other HRSA Total, HRSA FY1997 FY1998 FY1999 $449,772 416,954 69,739 36,000 23,787 996,252 4,996 $1,001,248 $464,800 543,000 76,300 41,000 25,100 1,150,200 4,996 $1,155,196 $489,800 670,000 86,300 44,000 25,100 1,315,200 4,996 $1,320,196 Source: HHS Budget Office, March 1998. CDC works with community, state, national, and international public health agencies to prevent HIV infection and reduce AIDS-associated morbidity and mortality through its information and education programs. CDC also supports research, surveillance, and epidemiology studies on HIV/AIDS. Funding in FY1998 for CDC's AIDS activities is $634 million. The Administration's request level for FY1999 is $642 million. The FY1999 total consists of $631.8 million for CDC's HIV prevention program (a decrease of $2.5 million below the FY1998 appropriation, reflecting savings from the Office of the Director operations) and a $10 million increase to expand HIV/STD (sexually transmitted disease) efforts. Table 2: HHS Discretionary Funding for HIV/AIDS ($ in thousands) FY1981 FY1982 FY1983 FY1984 FY1985 FY1986 FY1987 FY1988 FY1989 FY1990 FY1991 FY1992 FY1993 FY1994 FY1995 FY1996 FY1997 FY1998 est. FY1999 est. Funding $ Increase Over Prior Year % Increase Over Prior Year $200 5,555 28,736 61,460 108,618 233,793 502,455 962,018 1,304,012 1,592,756 1,891,232 1,963,414 2,079,591 2,568,682 2,700,498 2,897,923 3,267,220 3,547,838 3,852,354 --$5,355 23,181 32,724 47,158 125,175 268,662 459,563 341,994 288,744 298,476 72,182 116,639 489,091 131,816 197,425 369,297 280,618 304,516 --2,678% 417% 114% 77% 115% 115% 94% 36% 22% 19% 4% 6% 24% 5% 7% 13% 9% 9% Source: HHS budget office, March 1998. CRS-4 Table 3: HHS Discretionary Funding for HIV/AIDS, by Agency ($ in thousands) Agency FY1991 FY1992 FY1993 FY1994 FY1995 FY1996 FY1997 FY1998* FY1999* NIH $807,465 $1,047,456 $1,071,457 $1,296,471 $1,333,875 $1,410,926 $1,501,073 $1,607,053 $1,730,796 CDC 496,960 479,620 498,253 543,253 589,831 584,080 616,790 634,266 641,779 ADAMHA 236,504 --- --- --- --- --- --- --- --- SAMHSA --- 26,025 25,655 27,320 24,095 54,201 63,857 70,125 77,826 63,395 72,302 72,628 72,399 72,745 72,745 72,745 72,745 72,745 265,915 316,912 390,341 607,796 661,185 762,398 1,001,248 1,155,196 1,320,196 10,252 10,135 9,624 10,624 9,084 6,343 4,192 1,100 1,500 OASH 5,938 4,794 5,330 5,263 4,071 --- --- --- --- OS 3,000 3,000 3,000 2,000 1,975 3,754 3,811 3,813 3,972 IHS 1,803 3,170 3,303 3,556 3,637 3,476 3,503 3,540 3,540 $1,891,232 $1,963,414 $2,079,591 $2,568,682 $2,700,498 $2,897,923 $3,267,220 $3,547,838 $3,852,354 FDA HRSA AHCPR TOTAL Source: HHS budget office,March 1998. *FY1998 and FY199 are estimates. NIH: National Institutes of Health CDC: Centers for Disease Control and Prevention ADAMHA: Alcohol, Drug Abuse, and Mental Health Administration (abolished in FY1992; activities divided between NIH and SAMHSA.) SAMHSA: Substance Abuse and Mental Health Services Administration (established in FY1992, activities formerly part of ADAMHA.) FDA: Food and Drug Administration HRSA: Health Resources and Services Administration AHCPR: Agency for Health Care Policy and Research (established in 1990, formerly in OASH) OASH: Office of the Assistant Secretary for Health (abolished in FY1996; activities now under OS) OS: Office of the Secretary (AIDS programs in Office for Civil Rights, Office of Minority Health, and National AIDS Program Office) IHS: Indian Health Service CRS-5 Table 4: Total Federal Government Spending on HIV/AIDS by Function ($ in millions) FY1997 FY1998 FY1999 Research Prevent Treatmt Income Support Total Research Prevent Treatmt Income Support Total Research Prevent Treatmt Income Support Total $1,702 $522 $1,044 $0 $3,267 $1,806 $541 $1,200 $0 $3,548 $1,929 $544 $1,374 $0 $3,847 -HCFA/Medicaid -- -- 1,800 -- 1,800 -- -- 1,900 -- 1,900 -- -- 2,100 -- 2,100 -HCFA/Medicare -- -- 1,300 -- 1,300 -- -- 1,400 -- 1,400 -- -- 1,500 -- 1,500 $1,702 $522 $4,144 $0 $6,367 $1,806 $541 $4,500 $0 $6,848 $1,929 $544 $4,974 $0 $7,447 Social Security - DI -- -- -- $691 $691 -- -- -- $726 $726 -- -- -- $776 $776 Social Security - SSI -- -- -- 310 310 -- -- -- 335 335 -- -- -- 360 360 Veterans Affairs 6 31 295 -- 332 6 31 306 -- 343 6 31 321 -- 358 22 12 66 -- 100 24 13 68 -- 105 25 13 69 -- 107 Agency for Int. Dev. -- 117 -- -- 117 -- 121 -- -- 121 -- 121 -- -- 121 Justice Dept. -Bureau of Prisons -- 1 6 -- 7 -- 1 7 -- 8 -- 1 8 -- 9 State Department -- -- -- -- -- -- -- -- -- 0 -- -- -- -- -- Labor Department -- 2 -- -- 2 -- 1 -- -- 1 -- 1 -- -- 1 Education Dept. -- -- -- -- -- -- -- -- -- 0 -- -- -- -- -- Housing & Urban Dev. -- -- -- 196 196 -- -- -- 204 204 -- -- -- 225 225 - -- 241 -- 241 -- -- 253 -- 253 -- -- 266 -- 266 $28 $163 $608 $1,197 $1,996 $30 $167 $634 $1,265 $2,096 $31 $167 $664 $1,361 $2,223 $1,730 $685 $4,752 $1,197 $8,363 $1,836 $708 $5,134 $1,265 $8,944 $1,960 $711 $5,638 $1,361 $9,670 $77 $50 $665 $86 $876 $106 $24 $382 $68 $581 $124 $3 $504 $96 $727 Agency/Department HHS Discretionary Subtotal, HHS Other: Defense Dept. OPM-FEHB Subtotal, Other TOTAL Chg from Previous Yr % Chg from Prev Yr 5% 8% 16% 8% 12% 6% 3% 8% 6% 7% 7% 0% 10% 8% 8% Source: HHS budget office, Mar. 30, 1998. FY1998 and FY1999 are estimates. HHS: Department of Health and Human Services; HCFA: Health Care Financing Administration; DI: Disability Insurance; SSI: Supplemental Security Income; OPM-FEHB: Office of Personnel Management-Federal Employees Health Benefits. CRS-6 Table 5: Government-wide Spending on HIV/AIDS ($ in millions) Dept./Agency FY83 FY84 FY85 FY86 FY87 FY88 FY89 FY90 FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 FY99 $29 $60 $109 $234 $502 $962 $1,304 $1,593 $1,891 $1,963 $2,080 $2,569 $2,701 $2,898 $3,267 $3548 $3,847 10 0 30 0 70 5 130 5 200 15 330 30 490 55 670 110 870 180 1,080 280 1,290 385 1,490 500 1,640 600 1,600 1,100 1,800 1,300 1,900 1,400 2,100 1,500 SS -DI -SSI 0 0 5 1 10 3 30 5 55 15 95 20 150 35 215 55 305 95 415 150 515 200 585 240 640 300 696 280 691 310 726 335 776 360 VA 5 7 8 20 51 78 136 220 258 279 299 312 317 331 332 343 358 Defense 0 0 0 79 74 53 86 125 127 129 159 129 112 98 100 105 107 AID 0 0 0 0 0 30 40 71 78 94 117 115 120 115 117 121 121 DoJ-Prisons 0 0 0 0 1 1 2 5 5 5 5 6 6 6 7 8 9 State 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 0 0 Labor 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 1 1 HUD 0 0 0 0 0 1 0 0 0 48 100 156 171 171 196 204 225 OPM-FEHB 0 0 0 5 8 13 22 37 61 103 175 193 212 226 241 253 266 Education 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 $44 $103 $205 $508 $922 $1,615 $2,322 $3,103 $3,872 $4,548 $5,327 $6,297 $6,821 $7,522 $8363 $8944 $9670 HHS -Discretionary -HCFA --Medicaid --Medicare TOTAL Source: HHS budget office, Mar. 1998. FY98 and FY99 are estimates. May not add due to rounding. In FY82, AIDS spending was $8 million: $6 million HHS discretionary and $2 million VA. HHS: HCFA SS: DI: SSI: VA: AID: DoJ-Prisons: HUD: OPM-FEHB: Department of Health and Human Services; Discretionary AIDS budget Health Care Financing Administration Social Security Disability Insurance Supplemental Security Income Veterans Affairs Agency for International Development Department of Justice, Bureau of Prisons Department of Housing and Urban Development Office of Personnel Management-Federal Employees Health Benefits