Ryan White Comprehensive AIDS
Resources Emergency (CARE)
Act of 1990
Technical Information Specialist
Education and Public Welfare Division
March 16 1994
RYAN WHITE COMPREHENSIVE AIDS RESOURCES
EMERGENCY(CARE) ACT OF 1990
This report provides an overview of the Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act of 1990 (P.L. 101-381) a four part Federal grant program
designed to provide emergency relief and essential health care services to persons afflicted
with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome
(AIDS). The Act administered by the Health Resources and Services Administration
(HRSA) focuses primarily on treatment and treatment-related services and authorizes
appropriations through FY 1995 .
Programs authorized under the Ryan White Act provide emergency assistance to
localities disproportionately affected by the HIV epidemic . Grants are made to States
metropolitan areas and other public or private nonprofit entities to provide for the
development organization coordination and operation of more effective and cost efficient
services for individuals and families with HIV disease .
Title I of the Act provides emergency formula and supplemental grants to
disproportionately affected eligible metropolitan areas (EMAs) . Thirty-four EMAs
received funds for FY 1994 and an estimated three to seven new EMAs could be added
for FY 1995 . Title I funds are directed to the chief elected official administering the
public health agency providing outpatient and ambulatory services to the greatest number
of persons with AIDS in the designated area . The official must establish an HIV Health
Services Planning Council which further sets priorities for care delivery in accord with
Federal guidelines .
Title II provides formula grants to States and Territories for comprehensive care
services including home and community-based care continuity of health insurance
coverage treatments to prevent deterioration of health and other services . States
reporting 1 percent or more of the national AIDS caseload are required to match Federal
funds ($1 State for every $2 Federal in 1994) and must use 50 percent or more of their
grant toward establishing an HIV health and support services consortium . Title II grants
also support Special Projects of National Significance (SPNS) a program which promotes
advancements in the delivery of health care and support services to the HIV population .
Title III(b) provides early intervention categorical grants to public and private
nonprofit entities already providing primary care services to populations at risk of HIV .
Services allowed under title III(b) include counseling and testing case management
outreach medical evaluation transmission prevention and risk reduction strategies .
Title IV pediatric demonstration grants were funded under the CARE Act for the first
time in FY 1994 . These grants foster collaboration and coordination between clinical
research and health care providers and target HIV infected children pregnant women and
their families .
Appropriations for all titles under the Act increased from $220 .5 million in FY 1991
to $579 .4 million in FY 1994 . The President's FY 1995 budget includes an appropriation
request of $672 million which if approved would constitute a 16 percent or $92 million
increase over FY 1994 . Several HRSA evaluations of CARE Act programs were complete
or underway during 1993 and the Office of Inspector General (01G) recently published a
draft report evaluating the Act's funding formulas .
TABLE OF CONTENTS
Title I : HIV Emergency Relief Grant
Title II : HIV CARE Grant
Title 111(b) : Early Intervention Services
Title IV : General Provisions
FY 1995 BUDGET REQUEST
EVALUATION OF THE PROGRAM
FOR RELATED INFORMATION
LIST OF TABLES
FY 1994 Title I Formula Grant Appropriations 2
FY 1994 Title II Formula Grant Appropriations 4
Title III(b) HIV Early Intervention FY 1992 5
Authorization and Appropriations Ryan White CARE Act 7
COMPREHENSIVE AIDS RESOURCES
EMERGENCY (CARE) ACT OF 1990
The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990'
is a four part Federal grant program designed to provide emergency relief and essential
health care services to persons afflicted with human immunodeficiency virus (HIV) and
acquired immune deficiency syndrome (AIDS) . The Act focuses primarily on treatment
and treatment-related services and authorizes appropriations through 1995 . Appropriations
for FY 1994 were $579 .4 million .'
According to one estimate between 800 000 and 1 .2 million individuals are infected
with HIV in the United States . As of September 1993 over 339 000 cases of AIDS had
been reported to the Centers for Disease Control (CDC) . 3 The HIV infection is now the
leading cause of death among males aged 25-44 and the fourth leading cause among
females of the same group .' The average annual cost of treating a person with AIDS has
been estimated as $38 3005 and the number of persons with AIDS who were without health
insurance has been estimated at 29 percent . 6
Federal response to the HIV epidemic spans several government agencies . This
report provides an overview of the Ryan White CARE Act a program administered by
the Health Resources and Services Administration (HRSA) under the Public Health
'P.L. 101-381 Aug . 18 1990 (title XXVI of the Public Health Service Act) .
'Table 4 on page 7 shows annual authorizations and appropriations for all titles under the program .
3U . S . Department of Health and Human Services . Centers for Disease Control and Prevention . HIVIAIDS
Surveillance Report v . 5 no . 3 Oct . 1993 .
4U . S . Department of Health and Human Services . Centers for Disease Control and Prevention . Current
Trends Update : Mortality Attributable to HIV Infection among Persons Aged 25-44 U.S. 1991 and 1992.
Morbidity and Mortality Weekly Report Nov . 11 1993 .
'Hellinger F .J . Forecasts of the Costs ofMedical Care for Persons with HIV: 1992-1995 Inquiry v . 29
no . 3 fall 1992 . p . 356-365 .
6National Commission on Acquired Immune Deficiency Syndrome . America Living with AIDS . 1991 . p.
The CARE Act provides emergency assistance
to localities disproportionately affected by the HIV
epidemic . Grants are made to States metropolitan
areas and other public or private nonprofit entities
to provide for the development organization
coordination and operation of more effective and
cost efficient systems for the delivery of essential
services to individuals and families with HIV
Currently four programs under the Act have
been funded . Title I provides emergency assistance
to disproportionately affected eligible metropolitan
areas (EMAs) title II provides comprehensive care
grants to States and territories title III(b) provides
direct grants to public and private nonprofit entities
for early intervention services and title IV provides
for pediatric AIDS demonstration projects .'
Title I : HIV Emergency Relief Grant
Title I provides emergency relief in the form
of formula and supplemental grants for case
management and comprehensive treatment services
to EMAs disproportionately affected by the
epidemic . Areas with more than 2 000 cases of
AIDS or where the cumulative per capita incidence
exceeds one quarter of I percent ( .0025) may apply
for title I funds . The grants are intended to
"supplement " not "supplant" State funds and have
the express purpose of enhancing HIV-related
ambulatory health and support services at the
outpatient level and case management services that
prevent unnecessary hospitalization at the inpatient
level of services . Fifty percent of title I funds are
TABLE 1 . FY 1994
Title I Formula Giant
EMAs Appoved FY 1991
Adan6 GA $4 066 100
Boston MA 3 091 900
Cldcago IL 4 706 700
Dallas TX 3 445 200
Fort La deniale FL 3 555 400
Houston TX 5 676 800
kney City NJ 2 306 300
Los Angeles CA 12 617 300
Miand FL 6 875 100
New Yodc NY 45 835 400
Newadc NJ 5 166 300
PhIIadelphia PA 3 479 500
San Diego CA 2 696 900
San Fnarisco CA 19 057 000
San Jm. PR 4 561 200
Washington D.C 5 225 900
EMAs Added FY 1992
Baldneow MD 2 232 400
Oakland CA 2 379 500
EMAs Added FY 1993
Detoit MI 1 623
Nassau-Sufrolk NY 1 403
New Odeam LA 1 691
Omge Co CA 1 426
Pounce PR 976
Sendle WA 1 617
TampaStPete FL 1 955
EMAs Added FY 1994
Bergen-Passek NJ 1 277
Denver CO 1 626
Kaman City MO 1 251
New Haven CN 1 235
Odando FL 1 319
Phoenix AZ 1 176
idvenideSar Beamsdino CA 1 299
St Louis MO 1 178
W. Palm Beach FL 1 959
Title III(a) early intervention formula grants have never received appropriations . Congress has continued
to fund related activities under general authority of the Public Health Service Act . Provisions under title IV not
receiving appropriations pertain to the research evaluation assessment and coordination of HIV-related health
and support services and model curriculum for emergency response employees . Some of the activities authorized
are being carried out by PHS agencies under general appropriations .
allocated by formula the remaining 50 percent is awarded competitively in the form of
There are currently 34 EMAs approved for title I funds . Sixteen EMAs received
grants originally . Baltimore MD and Oakland CA were added for FY 1992 and seven
more areas became eligible for FY 1993 . Nine EMAs have been added for this year
bringing the total to 34 . Table 1 shows FY 1994 title I allocations to EMAs and the year
each EMA became eligible under the program . An estimated three to seven new EMAs
could be added for FY 1995 .
Title I funds are directed to the chief elected official administering the public health
agency providing outpatient and ambulatory services to the greatest number of persons
with AIDS in the designated area . The official must establish an HIV Health Services
Planning Council which further sets priorities for care delivery in accord with Federal
guidelines . The Council must consist of representatives from a minimum of 11 specific
groups . Included among the groups are health care providers community-based and AIDS
service organizations social service providers mental health care providers local public
health agencies hospital and health care planning agencies representatives of State
government affected community members (including persons infected with HIV) nonelected community leaders entities receiving grants under the early intervention
component (title III) of the Act and the lead agency from any HRSA demonstration grant
operating in the area .
Title II : HIV CARE Grant
Title II formula grants are made to States and territories . The funds are designed to
improve the quality availability and organization of health care and support services . In
FY 1994 50 States 3 territories and the District of Columbia will receive funds under
the program .
Allocation of funds is based on the number of AIDS cases reported to CDC for the
2 most recent fiscal years and the average per capita income of the State relative to
national per capita income with the minimum grant set at $100 000 .
The focus of title II is comprehensive care and essential services . The grants provide
for home and community-based care continuity of health insurance coverage and
treatments to prolong life or prevent the deterioration of health (e.g. pharmaceuticals) .
States are required to use 15 percent of their grant to provide health and support services
to infants children women and families with HIV disease. Eligible areas excluding
Puerto Rico that report more than 1 percent of total AIDS cases during the 2 fiscal years
preceding the grant must match Federal contributions at a rate of $1 State for $2 Federal
during fiscal 1994 and must use 50 percent of their CARE grant toward an HIV health and
support services consortium in areas where the greatest number of HIV patients live .
sApplications are received and awards are made annually for all titles under the program . Additional
information on the grants process can be obtained from the Bureau of Health Resources Development HRSA .
TABLE 2 . FY 1994 Title 11 Formula Grant Appropriations
Alabama $ 1 421 700
1 855 500
California 28 174 800
Colorado 1 794 700
Connecticut 2 246 300
District of Columbia 2 155 900
16 362 900
4 527 800
5 364 300
1 395 000
Maryland 3 626
Massachusetts 3 502
Michigan 2 874
New Hampahire 160 100
New Jersey 6 651 100
New Mexico 485 800
New York 26 128 000
North Carolina 1 996 200
North Dakota . . . . . . . . . . . . . . . 100 000
2 288 900
Oklahoma 1 133 800
1 171 000
Pennsylvania 4 422 300
Rhode Island 452 600
South Carolina 2 092 000
Sco h Dakota 100 000
Tennessee 1 675 500
11 814 700
Virginia 2 622 600
Washington 2 262 800
West Virginia 173 900
Wisconsin 1 069 800
Puerto Rico 7 522 200
Virgin Islands 68 700
Source : Health Resources and Services Administration
Nineteen States currently fall under this requirement . Other States may choose to establish
and operate an HIV consortium defined as "an association of one or more public and one
or more nonprofit private health care and support service providers and community-based
organizations" that delivers care to areas most affected by the disease .'
According to HHS 41 States or territories supported HIV care consortia in FY 1992 .
Forty-eight used title II funds for AIDS/HIV treatments 27 supported home and
community-based care and 17 assisted with the continuation of health care insurance
The Secretary is authorized to withhold 10 percent of title II appropriations before
allocation to States in order to fund Special Projects of National Significance (SPNS) .
Any public or private non-profit organization including community-based organizations
can become eligible and grants are usually awarded for a 3-year cycle .
The program supports projects contributing to the advancement of health care and
support services delivery for the HIV population . In the first 2 years of the program
9P.L. 101-381 sec . 2b13(a)(1) .
priority was given to projects that improved access to care and/or addressed problems such
as advocacy social isolation quality of life and mental health ."
Table 2 shows FY 1994 title II formula grants by State or territory .
Title 111(b) : Early Intervention Services
Title 111(b)" provides categorical grants for
outpatient early intervention services . Grants are
made to certain organizations already providing
comprehensive primary care to populations at risk
of HIV . Migrant health centers community health
centers health care for the homeless grantees
family planning grantees comprehensive hemophilia
diagnostic and treatment centers federally qualified
and other private nonprofit
organizations can become eligible .
Services allowed under title III(b) include
counseling and testing case management outreach
medical evaluation transmission prevention and
risk reduction strategies . One hundred thirty-six
grantees received funds during FY 1993 and 96 000
persons were expected to be served .
TABLE 3 . Title III(b)
HIV Early Intervention
IV Drug Users
IV Drug Users and
Department of Health and Human
Justification of Estimates
Table 3 shows ethnicity and client use of title
Appr priaticns Committees FY 1994 .
III(b) services based on a survey of FY 1992
grantees . Preliminary survey results for FY 1993
grantees indicate nearly 69 percent of title III(b)
clients were between the ages of 20 and 39 and 50 percent were female .
Title IV: General Provisions
Authorized for appropriations under title IV are pediatric demonstration grants and
other provisions relating to the research evaluation assessment and coordination of
HIV-related health and support services .
Pediatric Demonstration Grants under title IV target HIV infected children pregnant
women and their families . In coordination with the National Institutes of Health the
grants encourage innovative models that foster collaboration and coordination between
clinical research and health care providers . This title will be funded for the first time in
t'For more specific criteria on the SPNS or other CARE Act programs see Health Resources and Services
Administration . Bureau of Health Resources Development . The Ryan White Comprehensive AIDS Resources
Emergency Act of 1990. Aug . 1993 .
"Title 111(a) providing early intervention formula grants to States has never been funded .
FY 1994 (previous pediatric HIV demonstrations have been funded under general Public
Health Service authorizations) .
Title IV subtitle II contains provisions regarding the notification of exposure to
infectious diseases for emergency response employees and authorizes $5 000 000 for FYs
1991-1995 toward the initial implementation of model curriculum . Appropriations for this
subtitle have not been made .
P.L . 101-381 authorizes all titles of the CARE Act through FY 1995 (such sums as
necessary for titles I-IV) . The program is funded annually under the Labor HHS
Education appropriation (the FY 1994 appropriation bill H . R. 2518 became P . L. 103-112
on October 21 1993) .
FY 1995 BUDGET REQUEST
The President's FY 1995 budget includes an appropriation request of $672 million
for Ryan White programs . If appropriated the request would constitute a 16 percent or
$92 million increase over FY 1994 .
EVALUATION OF THE PROGRAM
Evaluations of the program have focused on four key areas : allocation of funds to
priority needs inclusion of relevant parties in planning and priority setting the extent to
which services have been received by targeted populations and the quality and availability
of services .
Numerous HRSA evaluations were completed or under way during FY 1993 . An
evaluation of six HIV-service consortia found approaches to be varied but effective in
building networks for service delivery . In particular progress was found in the
implementation of case management and the linking of clients with primary and home
health care services . A longitudinal assessment of community HIV/AIDS services in
Baltimore and Oakland which initially measured provider services and client perceptions
of service barriers has entered it's second phase . An evaluation of how the needs of
women with HIV are being addressed in the title I planning process and an identification
and description of HIV service delivery systems in rural areas are also in process .
HRSA has sponsored a series of HIV services access work groups concerned with
identifying barriers to care for various ethnic racial economic and gender groups . Work
groups are comprised of between 10 and 20 invited participants representative of the above
populations and include service providers people living with AIDS and health services
researchers . Strategies recommended by the work groups aid in determining the focus of
evaluation projects .
The HHS Office of the Inspector General (OIG) is conducting a series of studies
evaluating the effectiveness of Ryan White formulas . Formulas govern half of title I and
all of title II funds the preponderance of the Act's appropriation . Concerns have been
raised that distributions under the current formulas may be leading to disparities in
funding a matter that could be of importance during the reauthorization process .
TABLE 4 . Authorization and Appropriations
Ryan White CARE Act
($ in millions)
305 .0 Indefinite
20 .0 Indefinite
'Funding for pediatric demonstration grants only .
Source: Health Resources and Services Admininstration .
FOR RELATED INFORMATION :
U.S. Department of Health and Human Services . Public Health Service . Health
Resources and Services Administration . Bureau of Health Resources Development .
The Ryan white comprehensive AIDS resources emergency act of 1990 . Aug . 1993 .
U .S . Library of Congress .
Congressional Research Service . Federal funding for
AIDS research and prevention : FY 1981-FY 1994. CRS Report for Congress No.
93-340 SPR by Judith Johnson . Washington 1993 .