[House Report 106-788]
[From the U.S. Government Publishing Office]
106th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 106-788
======================================================================
RYAN WHITE CARE ACT AMENDMENTS OF 2000
_______
July 25, 2000.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Bliley, from the Committee on Commerce, submitted the following
R E P O R T
together with
ADDITIONAL VIEWS
[To accompany H.R. 4807]
[Including cost estimate of the Congressional Budget Office]
The Committee on Commerce, to whom was referred the bill
(H.R. 4807) to amend the Public Health Service Act to revise
and extend programs established under the Ryan White
Comprehensive AIDS Resources Emergency Act of 1990, and for
other purposes, having considered the same, report favorably
thereon with an amendment and recommend that the bill as
amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 22
Background and Need for Legislation.............................. 22
Hearings......................................................... 45
Committee Consideration.......................................... 45
Committee Votes.................................................. 45
Committee Oversight Findings..................................... 46
Committee on Government Reform Oversight Findings................ 46
New Budget Authority, Entitlement Authority, and Tax
Expenditures................................................... 46
Committee Cost Estimate.......................................... 46
Congressional Budget Office Estimate............................. 46
Federal Mandates Statement....................................... 54
Advisory Committee Statement..................................... 54
Constitutional Authority Statement............................... 54
Applicability to Legislative Branch.............................. 54
Section-by-Section Analysis of the Legislation................... 54
Changes in Existing Law Made by the Bill, as Reported............ 68
Additional Views................................................. 114
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Ryan White CARE Act Amendments of
2000''.
SEC. 2. TABLE OF CONTENTS.
The table of contents for this Act is as follows:
TITLE I--EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES
Subtitle A--HIV Health Services Planning Councils
Sec. 101. Membership of councils.
Sec. 102. Duties of councils.
Sec. 103. Open meetings; other additional provisions.
Subtitle B--Type and Distribution of Grants
Sec. 111. Formula grants.
Sec. 112. Supplemental grants.
Subtitle C--Other Provisions
Sec. 121. Use of amounts.
Sec. 122. Application.
Sec. 123. Review of administrative costs and compensation.
TITLE II--CARE GRANT PROGRAM
Subtitle A--General Grant Provisions
Sec. 201. Priority for women, infants, and children.
Sec. 202. Use of grants.
Sec. 203. Grants to establish HIV care consortia.
Sec. 204. Provision of treatments.
Sec. 205. State application.
Sec. 206. Distribution of funds.
Sec. 207. Supplemental grants for certain States.
Subtitle B--Provisions Concerning Pregnancy and Perinatal Transmission
of HIV
Sec. 211. Repeals.
Sec. 212. Grants.
Sec. 213. Study by Institute of Medicine.
Subtitle C--Certain Partner Notification Programs
Sec. 221. Grants for compliant partner notification programs.
TITLE III--EARLY INTERVENTION SERVICES
Subtitle A--Formula Grants for States
Sec. 301. Repeal of program.
Subtitle B--Categorical Grants
Sec. 311. Preferences in making grants.
Sec. 312. Planning and development grants.
Sec. 313. Authorization of appropriations.
Subtitle C--General Provisions
Sec. 321. Provision of certain counseling services.
Sec. 322. Additional required agreements.
TITLE IV--OTHER PROGRAMS AND ACTIVITIES
Subtitle A--Certain Programs for Research, Demonstrations, or Training
Sec. 401. Grants for coordinated services and access to research for
women, infants, children, and youth.
Sec. 402. AIDS education and training centers.
Subtitle B--General Provisions in Title XXVI
Sec. 411. Evaluations and reports.
Sec. 412. Data collection through Centers for Disease Control and
Prevention.
Sec. 413. Coordination.
Sec. 414. Plan regarding release of prisoners with HIV disease.
Sec. 415. Audits.
Sec. 416. Administrative simplification.
Sec. 417. Authorization of appropriations for parts A and B.
TITLE V--GENERAL PROVISIONS
Sec. 501. Studies by Institute of Medicine.
Sec. 502. Development of rapid HIV test.
TITLE VI--EFFECTIVE DATE
Sec. 601. Effective date.
TITLE I--EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES
Subtitle A--HIV Health Services Planning Councils
SEC. 101. MEMBERSHIP OF COUNCILS.
(a) In General.--Section 2602(b) of the Public Health Service Act (42
U.S.C. 300ff-12(b)) is amended--
(1) in paragraph (1), by striking ``demographics of the
epidemic in the eligible area involved,'' and inserting
``demographics of the population of individuals with HIV
disease in the eligible area involved,''; and
(2) in paragraph (2)--
(A) in subparagraph (G), by striking ``or AIDS'';
(B) in subparagraph (K), by striking ``and'' at the
end;
(C) in subparagraph (L), by striking the period and
inserting the following: ``, including but not limited
to providers of HIV prevention services; and''; and
(D) by adding at the end the following subparagraph:
``(M) representatives of individuals who formerly
were Federal, State, or local prisoners, were released
from the custody of the penal system during the
preceding three years, and had HIV disease as of the
date on which the individuals were so released.''.
(b) Conflicts of Interests.--Section 2602(b)(5) of the Public Health
Service Act (42 U.S.C. 300ff-12(b)(5)) is amended by adding at the end
the following subparagraph:
``(C) Composition of council.--The following applies
regarding the membership of a planning council under
paragraph (1):
``(i) Not less than 33 percent of the council
shall be individuals who are receiving HIV-
related services pursuant to a grant under
section 2601(a), are not officers, employees,
or consultants to any entity that receives
amounts from such a grant, and do not represent
any such entity, and reflect the demographics
of the population of individuals with HIV
disease as determined under paragraph (4)(A).
For purposes of the preceding sentence, an
individual shall be considered to be receiving
such services if the individual is a parent of,
or a caregiver for, a minor child who is
receiving such services.
``(ii) With respect to membership on the
planning council, clause (i) may not be
construed as having any effect on entities that
receive funds from grants under any of parts B
through F but do not receive funds from grants
under section 2601(a), on officers or employees
of such entities, or on individuals who
represent such entities.''.
SEC. 102. DUTIES OF COUNCILS.
(a) In General.--Section 2602(b)(4) of the Public Health Service Act
(42 U.S.C. 300ff-12(b)(4)) is amended--
(1) by redesignating subparagraphs (A) through (E) as
subparagraphs (C) through (G), respectively;
(2) by inserting before subparagraph (C) (as so redesignated)
the following subparagraphs:
``(A) determine the size and demographics of the
population of individuals with HIV disease;
``(B) determine the needs of such population, with
particular attention to--
``(i) individuals with HIV disease who are
not receiving HIV-related services; and
``(ii) disparities in access and services
among affected subpopulations and historically
underserved communities;'';
(3) in subparagraph (C) (as so redesignated), by striking
clauses (i) through (iv) and inserting the following:
``(i) size and demographics of the population
of individuals with HIV disease (as determined
under subparagraph (A)) and the needs of such
population (as determined under subparagraph
(B));
``(ii) demonstrated (or probable) cost
effectiveness and outcome effectiveness of
proposed strategies and interventions, to the
extent that data are reasonably available;
``(iii) priorities of the communities with
HIV disease for whom the services are intended;
``(iv) availability of other governmental and
nongovernmental resources to provide HIV-
related services to individuals and families
with HIV disease, including the State plan
under title XIX of the Social Security Act
(relating to the Medicaid program) and the
program under title XXI of such Act (relating
to the program for State children's health
insurance); and
``(v) capacity development needs resulting
from disparities in the availability of HIV-
related services in historically underserved
communities;'';
(4) in subparagraph (D) (as so redesignated), by amending the
subparagraph to read as follows:
``(D) develop a comprehensive plan for the
organization and delivery of health and support
services described in section 2604 that--
``(i) includes a strategy for identifying
individuals with HIV disease who are not
receiving such services and for informing the
individuals of and enabling the individuals to
utilize the services, giving particular
attention to eliminating disparities in access
and services among affected subpopulations and
historically underserved communities, and
including discrete goals, a timetable, and an
appropriate allocation of funds;
``(ii) includes a strategy to coordinate the
provision of such services with programs for
HIV prevention and for the prevention and
treatment of substance abuse, including
programs that provide comprehensive treatment
services for such abuse; and
``(iii) is compatible with any State or local
plan for the provision of services to
individuals with HIV disease;'';
(5) in subparagraph (F) (as so redesignated), by striking
``and'' at the end;
(6) in subparagraph (G) (as so redesignated)--
(A) by striking ``public meetings,'' and inserting
``public meetings (in accordance with paragraph
(7)),''; and
(B) by striking the period and inserting ``; and'';
and
(7) by adding at the end the following subparagraph:
``(H) coordinate with Federal grantees that provide
HIV-related services within the eligible area.''.
(b) Process for Establishing Allocation Priorities.--Section 2602 of
the Public Health Service Act (42 U.S.C. 300ff-12) is amended by adding
at the end the following subsection:
``(d) Process for Establishing Allocation Priorities.--Promptly after
the date of the submission of the report required in section 501(b) of
the Ryan White CARE Act Amendments of 2000 (relating to the
relationship between epidemiological measures and health care for
certain individuals with HIV disease), the Secretary, in consultation
with entities that receive amounts from grants under section 2601(a) or
2611, shall develop epidemiologic measures--
``(1) for establishing the number of individuals living with
HIV disease who are not receiving HIV-related health services;
and
``(2) for carrying out the duties under subsection (b)(4) and
section 2617(b).''.
(c) Training.--Section 2602 of the Public Health Service Act (42
U.S.C. 300ff-12), as amended by subsection (b) of this section, is
amended by adding at the end the following subsection:
``(e) Training Guidance and Materials.--The Secretary shall provide
to each chief elected official receiving a grant under 2601(a)
guidelines and materials for training members of the planning council
under paragraph (1) regarding the duties of the council.''.
SEC. 103. OPEN MEETINGS; OTHER ADDITIONAL PROVISIONS.
Section 2602(b) of the Public Health Service Act (42 U.S.C. 300ff-
12(b)) is amended--
(1) in paragraph (3), by striking subparagraph (C); and
(2) by adding at the end the following paragraph:
``(7) Public deliberations.--With respect to a planning
council under paragraph (1), the following applies:
``(A) The council may not be chaired solely by an
employee of the grantee under section 2601(a).
``(B) In accordance with criteria established by the
Secretary:
``(i) The meetings of the council shall be
open to the public and shall be held only after
adequate notice to the public.
``(ii) The records, reports, transcripts,
minutes, agenda, or other documents which were
made available to or prepared for or by the
council shall be available for public
inspection and copying at a single location.
``(iii) Detailed minutes of each meeting of
the council shall be kept. The accuracy of all
minutes shall be certified to by the chair of
the council.
``(iv) This subparagraph does not apply to
any disclosure of information of a personal
nature that would constitute a clearly
unwarranted invasion of personal privacy,
including any disclosure of medical information
or personnel matters.''.
Subtitle B--Type and Distribution of Grants
SEC. 111. FORMULA GRANTS.
(a) Expedited Distribution.--Section 2603(a)(2) of the Public Health
Service Act (42 U.S.C. 300ff-13(a)(2)) is amended in the first sentence
by striking ``for each of the fiscal years 1996 through 2000'' and
inserting ``for a fiscal year''.
(b) Amount of Grant; Estimate of Living Cases.--
(1) In general.--Section 2603(a)(3)) of the Public Health
Service Act (42 U.S.C. 300ff-13(a)(3)) is amended--
(A) in subparagraph (C)(i), by inserting before the
semicolon the following: ``, except that (subject to
subparagraph (D)), for grants made pursuant to this
paragraph for fiscal year 2005 and subsequent fiscal
years, the cases counted for each 12-month period
beginning on or after July 1, 2004, shall be cases of
HIV disease (as reported to and confirmed by such
Director) rather than cases of acquired immune
deficiency syndrome''; and
(B) in subparagraph (C), in the matter after and
below clause (ii)(X)--
(i) in the first sentence, by inserting
before the period the following: ``, and shall
be reported to the congressional committees of
jurisdiction''; and
(ii) by adding at the end the following
sentence: ``Updates shall as applicable take
into account the counting of cases of HIV
disease pursuant to clause (i).''
(2) Determination of secretary regarding data on hiv cases.--
Section 2603(a)(3)) of the Public Health Service Act (42 U.S.C.
300ff-13(a)(3)) is amended--
(A) by redesignating subparagraph (D) as subparagraph
(E); and
(B) by inserting after subparagraph (C) the following
subparagraph:
``(D) Determination of secretary regarding data on
hiv cases.--
``(i) In general.--Not later than July 1,
2004, the Secretary shall determine whether
there is data on cases of HIV disease from all
eligible areas (reported to and confirmed by
the Director of the Centers for Disease Control
and Prevention) sufficiently accurate and
reliable for use for purposes of subparagraph
(C)(i). In making such a determination, the
Secretary shall take into consideration the
findings of the study under section 501(b) of
the Ryan White CARE Act Amendments of 2000
(relating to the relationship between
epidemiological measures and health care for
certain individuals with HIV disease), the
fiscal impact of the use of such data, the
impact of the use of such data on the
organization and delivery of HIV-related
services in eligible areas, and the fiscal
impact of not using such data.
``(ii) Effect of adverse determination.--If
under clause (i) the Secretary determines that
data on cases of HIV disease is not
sufficiently accurate and reliable for use for
purposes of subparagraph (C)(i), then
notwithstanding such subparagraph, for any
fiscal year prior to fiscal year 2007 the
references in such subparagraph to cases of HIV
disease do not have any legal effect.
``(iii) Grants and technical assistance
regarding counting of hiv cases.--Of the
amounts appropriated under section 2675 for a
fiscal year, the Secretary shall reserve
amounts to make grants and provide technical
assistance to States and eligible areas with
respect to obtaining data on cases of HIV
disease to ensure that data on such cases is
available from all States and eligible areas as
soon as is practicable but not later than the
beginning of fiscal year 2007.''.
(c) Increases in Grant.--Section 2603(a)(4)) of the Public Health
Service Act (42 U.S.C. 300ff-13(a)(4)) is amended to read as follows:
``(4) Increases in grant.--
``(A) In general.--For each fiscal year in a
protection period for an eligible area, the Secretary
shall increase the amount of the grant made pursuant to
paragraph (2) for the area to ensure that--
``(i) for the first fiscal year in the
protection period, the grant is not less than
98 percent of the amount of the grant made for
the eligible area pursuant to such paragraph
for the base year for the protection period;
``(ii) for any second fiscal year in such
period, the grant is not less than 95.7 percent
of the amount of such base year grant;
``(iii) for any third fiscal year in such
period, the grant is not less than 91.1 percent
of the amount of the base year grant;
``(iv) for any fourth fiscal year in such
period, the grant is not less than 84.2 percent
of the amount of the base year grant; and
``(v) for any fifth or subsequent fiscal year
in such period, the grant is not less than 75
percent of the amount of the base year grant.
``(B) Base year; protection period.--With respect to
grants made pursuant to paragraph (2) for an eligible
area:
``(i) The base year for a protection period
is the fiscal year preceding the trigger grant-
reduction year.
``(ii) The first trigger grant-reduction year
is the first fiscal year (after fiscal year
2000) for which the grant for the area is less
than the grant for the area for the preceding
fiscal year.
``(iii) A protection period begins with the
trigger grant-reduction year and continues
until the beginning of the first fiscal year
for which the amount of the grant for the area
equals or exceeds the amount of the grant for
the base year for the period.
``(iv) Any subsequent trigger grant-reduction
year is the first fiscal year, after the end of
the preceding protection period, for which the
amount of the grant is less than the amount of
the grant for the preceding fiscal year.''.
SEC. 112. SUPPLEMENTAL GRANTS.
(a) In General.--Section 2603(b)(2) of the Public Health Service Act
(42 U.S.C. 300ff-13(b)(2)) is amended--
(1) in the heading for the paragraph, by striking
``Definition'' and inserting ``Amount of grant'';
(2) by redesignating subparagraphs (A) through (C) as
subparagraphs (B) through (D), respectively;
(3) by inserting before subparagraph (B) (as so redesignated)
the following subparagraph:
``(A) In general.--The amount of each grant made for
purposes of this subsection shall be determined by the
Secretary based on a weighting of factors under
paragraph (1), with severe need under subparagraph (B)
of such paragraph counting one-third.'';
(4) in subparagraph (B) (as so redesignated)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period and
inserting a semicolon; and
(C) by adding at the end the following clauses:
``(iv) the current prevalence of HIV disease;
``(v) an increasing need for HIV-related
services, including relative rates of increase
in the number of cases of HIV disease; and
``(vi) unmet need for such services, as
determined under section 2602(b)(4).'';
(5) in subparagraph (C) (as so redesignated)--
(A) by striking ``subparagraph (A)'' each place such
term appears and inserting ``subparagraph (B)''';
(B) in the second sentence, by striking ``2 years
after the date of enactment of this paragraph'' and
inserting ``18 months after the date of the enactment
of the Ryan White CARE Act Amendments of 2000''; and
(C) by inserting after the second sentence the
following sentence: ``Such a mechanism shall be
modified to reflect the findings of the study under
section 501(b) of the Ryan White CARE Act Amendments of
2000 (relating to the relationship between
epidemiological measures and health care for certain
individuals with HIV disease).''; and
(6) in subparagraph (D) (as so redesignated), by striking
``subparagraph (B)'' and inserting ``subparagraph (C)'''.
(b) Requirements for Application.--Section 2603(b)(1)(E) of the
Public Health Service Act (42 U.S.C. 300ff-13(b)(1)(E)) is amended by
inserting ``youth,'' after ``children,''.
(c) Conforming Amendment.--Section 2603(b) of the Public Health
Service Act (42 U.S.C. 300ff-13(b)) is amended--
(1) by striking paragraph (4); and
(2) by redesignating paragraph (5) as paragraph (4).
Subtitle C--Other Provisions
SEC. 121. USE OF AMOUNTS.
(a) Primary Purposes.--Section 2604(b)(1) of the Public Health
Service Act (42 U.S.C. 300ff-14(b)(1)) is amended--
(1) in the matter preceding subparagraph (A), by striking
``HIV-related--'' and inserting ``HIV-related services, as
follows:'';
(2) in subparagraph (A)--
(A) by striking ``outpatient'' and all that follows
through ``substance abuse treatment and'' and inserting
the following: ``Outpatient and ambulatory health
services, including substance abuse treatment,''; and
(B) by striking ``; and'' and inserting a period;
(3) in subparagraph (B), by striking ``(B) inpatient case
management'' and inserting ``(C) Inpatient case management'';
(4) by inserting after subparagraph (A) the following
subparagraph:
``(B) Outpatient and ambulatory support services
(including case management), to the extent that such
services facilitate, support, or sustain the delivery,
or benefits of health services for individuals and
families with HIV disease.''; and
(5) by adding at the end the following:
``(D) Outreach activities that are intended to
identify individuals with HIV disease who are not
receiving HIV-related services, and that are--
``(i) necessary to implement the strategy
under section 2602(b)(4)(D), including
activities facilitating the access of such
individuals to HIV-related primary care
services at entities described in paragraph
(3);
``(ii) conducted in a manner consistent with
the requirements under sections 2605(a)(3) and
2651(b)(2); and
``(iii) supplement, and do not supplant, such
activities that are carried out with amounts
appropriated under section 317.''.
(b) Additional Purposes.--Section 2604(b) (42 U.S.C. 300ff-14(b)) of
the Public Health Service Act is amended--
(1) by redesignating paragraph (3) as paragraph (4);
(2) by inserting after paragraph (2) the following:
``(3) Early intervention services.--
``(A) In general.--The purposes for which a grant
under section 2601 may be used include providing to
individuals with HIV disease early intervention
services described in section 2651(b)(2) (including
referrals under subparagraph (C) of such section),
subject to subparagraph (B). The entities through which
such services may be provided under the grant include
public health departments, emergency rooms, substance
abuse and mental health treatment programs,
detoxification centers, detention facilities, clinics
regarding sexually transmitted diseases, homeless
shelters, HIV disease counseling and testing sites,
health care points of entry specified by States or
eligible areas, federally qualified health centers, and
entities described in section 2652(a).
``(B) Conditions.--With respect to an entity that
proposes to provide early intervention services under
subparagraph (A), such subparagraph applies only if the
entity demonstrates to the satisfaction of the chief
elected official for the eligible area involved that--
``(i) Federal, State, or local funds are
otherwise inadequate for the early intervention
services the entity proposes to provide; and
``(ii) the entity will expend funds pursuant
to such subparagraph to supplement and not
supplant other funds available to the entity
for the provision of early intervention
services for the fiscal year involved.''; and
(3) in paragraph (4) (as so redesignated), by inserting
``youth,'' after ``children,'' each place such term appears;
(c) Quality Management.--Section 2604 of the Public Health Service
Act (42 U.S.C. 300ff-14) is amended--
(1) by redesignating subsections (c) through (f) as
subsections (d) through (g), respectively; and
(2) by inserting after subsection (b) the following:
``(c) Quality Management.--
``(1) Requirement.--The chief elected official of an eligible
area that receives a grant under this part shall provide for
the establishment of a quality management program to assess the
extent to which HIV health services provided to patients under
the grant are consistent with the most recent Public Health
Service guidelines for the treatment of HIV disease and related
opportunistic infection, and as applicable, to develop
strategies for ensuring that such services are consistent with
the guidelines.
``(2) Use of funds.--From amounts received under a grant
awarded under this part for a fiscal year, the chief elected
official of an eligible area may (in addition to amounts to
which subsection (f)(1) applies) use for activities associated
with the quality management program required in paragraph (1)
not more than the lesser of--
``(A) 5 percent of amounts received under the grant;
or
``(B) $3,000,000.''.
SEC. 122. APPLICATION.
Section 2605(a) of the Public Health Service Act (42 U.S.C. 300ff-
15(a)) is amended--
(1) by redesignating paragraphs (3) through (6) as paragraphs
(4) through (7), respectively; and
(2) by inserting after paragraph (2) the following paragraph:
``(3) that entities within the eligible area that receive
funds under a grant under section 2601(a) will maintain
relationships with appropriate entities in the area, including
entities described in section 2604(b)(3);''.
SEC. 123. REVIEW OF ADMINISTRATIVE COSTS AND COMPENSATION.
Each chief elected official of an eligible area (as defined in
section 2607 of the Public Health Service Act) shall ensure that, not
later than one year after the date of the enactment of this Act, the
planning council for the eligible area--
(1) conducts a review of the existing, available data on the
extent to which entities in the area that receive amounts from
a grant under section 2601(a) of the Public Health Service Act
have from their overall budget expended amounts for
administrative costs (including financial compensation and
benefits), expressed as a proportion and indicating the growth
in such expenditures, including a statement of the average
amount expended for such costs per client served and the
average amount expended for such costs per client served in
providing HIV-related services; and
(2) makes a determination of whether the financial
compensation of any officers or employees of such entities
exceeds that of the chief elected official of the eligible
area.
TITLE II--CARE GRANT PROGRAM
Subtitle A--General Grant Provisions
SEC. 201. PRIORITY FOR WOMEN, INFANTS, AND CHILDREN.
Section 2611(b) of the Public Health Service Act (42 U.S.C. 300ff-
21(b)) is amended by inserting ``youth,'' after ``children,'' each
place such term appears.
SEC. 202. USE OF GRANTS.
Section 2612 of the Public Health Service Act (42 U.S.C. 300ff-22) is
amended--
(1) by striking ``A State may use'' and inserting ``(a) In
General.--A State may use''; and
(2) by adding at the end the following subsections:
``(b) Support Services; Outreach.--The purposes for which a grant
under this part may be used include delivering or enhancing the
following:
``(1) Support services under section 2611(a) (including case
management) to the extent that such services facilitate,
support, or sustain the delivery, or benefits of health
services for individuals and families with HIV disease.
``(2) Outreach activities that are intended to identify
individuals with HIV disease who are not receiving HIV-related
services, and that are--
``(A) necessary to implement the strategy under
section 2617(b)(4)(B);
``(B) conducted in a manner consistent with the
requirement under section 2617(b)(6)(G); and
``(C) supplement, and do not supplant, such
activities that are carried out with amounts
appropriated under section 317.
``(c) Early Intervention Services.--
``(1) In general.--The purposes for which a grant under this
part may be used include providing to individuals with HIV
disease early intervention services described in section
2651(b)(2) (including referrals under subparagraph (C) of such
section), subject to paragraph (2). The entities through which
such services may be provided under the grant include public
health departments, emergency rooms, substance abuse and mental
health treatment programs, detoxification centers, detention
facilities, clinics regarding sexually transmitted diseases,
homeless shelters, HIV disease counseling and testing sites,
health care points of entry specified by States or eligible
areas, federally qualified health centers, and entities
described in section 2652(a).
``(2) Conditions.--With respect to an entity that proposes to
provide early intervention services under paragraph (1), such
paragraph applies only if the entity demonstrates to the
satisfaction of the State involved that--
``(A) Federal, State, or local funds are otherwise
inadequate for the early intervention services the
entity proposes to provide; and
``(B) the entity will expend funds pursuant to such
paragraph to supplement and not supplant other funds
available to the entity for the provision of early
intervention services for the fiscal year involved.
``(d) Quality Management.--
``(1) Requirement.--Each State that receives a grant under
this part shall provide for the establishment of a quality
management program to assess the extent to which HIV health
services provided to patients under the grant are consistent
with the most recent Public Health Service guidelines for the
treatment of HIV disease and related opportunistic infection,
and as applicable, to develop strategies for ensuring that such
services are consistent with the guidelines.
``(2) Use of funds.--From amounts received under a grant
awarded under this part for a fiscal year, the State may (in
addition to amounts to which section 2618(c)(5) applies) use
for activities associated with the quality management program
required in paragraph (1) not more than the lesser of--
``(A) 5 percent of amounts received under the grant;
or
``(B) $3,000,000.''.
SEC. 203. GRANTS TO ESTABLISH HIV CARE CONSORTIA.
Section 2613 of the Public Health Service Act (42 U.S.C. 300ff-23) is
amended--
(1) in subsection (b)(1)--
(A) in subparagraph (A), by inserting before the
semicolon the following: ``, particularly those
experiencing disparities in access and services and
those who reside in historically underserved
communities''; and
(B) in subparagraph (B), by inserting after ``by such
consortium'' the following: ``is consistent with the
comprehensive plan under 2617(b)(4) and'';
(2) in subsection (c)(1)--
(A) in subparagraph (D), by striking ``and'' after
the semicolon at the end;
(B) in subparagraph (E), by striking the period and
inserting ``; and'';
(C) by adding at the end the following subparagraph:
``(F) demonstrates that adequate planning occurred to
address disparities in access and services and
historically underserved communities.''; and
(3) in subsection (c)(2)--
(A) in subparagraph (B), by striking ``and'' after
the semicolon;
(B) in subparagraph (C), by striking the period and
inserting ``; and''; and
(C) by inserting after subparagraph (C) the following
subparagraph:
``(D) entities described in section 2602(b)(2).''.
SEC. 204. PROVISION OF TREATMENTS.
Section 2616 of the Public Health Service Act (42 U.S.C. 300ff-26) is
amended by adding at the end the following subsection:
``(e) Use of Health Insurance and Plans.--In carrying out subsection
(a), a State may expend a grant under this part to provide the
therapeutics described in such subsection by paying on behalf of
individuals with HIV disease the costs of purchasing or maintaining
health insurance or plans whose coverage includes a full range of such
therapeutics and appropriate primary care services.''.
SEC. 205. STATE APPLICATION.
(a) Determination of Size and Needs of Population; Comprehensive
Plan.--Section 2617(b) of the Public Health Service Act (42 U.S.C.
300ff-27(b)) is amended--
(1) by redesignating paragraphs (2) through (4) as paragraphs
(4) through (6), respectively;
(2) by inserting after paragraph (1) the following
paragraphs:
``(2) a determination of the size and demographics of the
population of individuals with HIV disease in the State;
``(3) a determination of the needs of such population, with
particular attention to--
``(A) individuals with HIV disease who are not
receiving HIV-related services; and
``(B) disparities in access and services among
affected subpopulations and historically underserved
communities;''; and
(3) in paragraph (4) (as so redesignated)--
(A) by striking ``comprehensive plan for the
organization'' and inserting ``comprehensive plan that
describes the organization'';
(B) by striking ``, including--'' and inserting ``,
and that--'';
(C) by redesignating subparagraphs (A) through (C) as
subparagraphs (D) through (F), respectively;
(D) by inserting before subparagraph (C) the
following subparagraphs:
``(A) establishes priorities for the allocation of
funds within the State based on--
``(i) size and demographics of the population
of individuals with HIV disease (as determined
under paragraph (2)) and the needs of such
population (as determined under paragraph (3));
``(ii) availability of other governmental and
nongovernmental resources to provide HIV-
related services to individuals and families
with HIV disease;
``(iii) capacity development needs resulting
from disparities in the availability of HIV-
related services in historically underserved
communities and rural communities; and
``(iv) the efficiency of the administrative
mechanism of the State for rapidly allocating
funds to the areas of greatest need within the
State;
``(B) includes a strategy for identifying individuals
with HIV disease who are not receiving such services
and for informing the individuals of and enabling the
individuals to utilize the services, giving particular
attention to eliminating disparities in access and
services among affected subpopulations and historically
underserved communities, and including discrete goals,
a timetable, and an appropriate allocation of funds;
``(C) includes a strategy to coordinate the provision
of such services with programs for HIV prevention and
for the prevention and treatment of substance abuse,
including programs that provide comprehensive treatment
services for such abuse;'';
(E) in subparagraph (D) (as redesignated by
subparagraph (C) of this paragraph), by inserting
``describes'' before ``the services and activities'';
(F) in subparagraph (E) (as so redesignated), by
inserting ``provides'' before ``a description''; and
(G) in subparagraph (F) (as so redesignated), by
inserting ``provides'' before ``a description''.
(b) Public Participation.--Section 2617(b) of the Public Health
Service Act, as amended by subsection (a) of this section, is amended--
(1) in paragraph (5), by striking ``HIV'' and inserting ``HIV
disease''; and
(2) in paragraph (6), by amending subparagraph (A) to read as
follows:
``(A) the public health agency that is administering
the grant for the State engages in a public advisory
planning process, including public hearings, that
includes the participants under paragraph (5), and
entities described in section 2602(b)(2), in developing
the comprehensive plan under paragraph (4) and
commenting on the implementation of such plan;''.
(c) Health Care Relationships.--Section 2617(b) of the Public Health
Service Act, as amended by subsection (a) of this section, is amended
in paragraph (6)--
(1) in subparagraph (E), by striking ``and'' at the end;
(2) in subparagraph (F), by striking the period and inserting
``; and''; and
(3) by adding at the end the following subparagraph:
``(G) entities within areas in which activities under
the grant are carried out will maintain relationships
with appropriate entities in the area, including
entities described in section 2612(c);''.
SEC. 206. DISTRIBUTION OF FUNDS.
(a) Minimum Allotment.-- Section 2618(b)(1)(A)(i) of the Public
Health Service Act (42 U.S.C. 300ff-28(b)(1)(A)(i)) is amended--
(1) in subclause (I), by striking ``$100,000'' and inserting
``$200,000''; and
(2) in subclause (II), by striking ``$250,000'' and inserting
``$500,000''.
(b) Amount of Grant; Estimate of Living Cases.--Section 2618(b)(2) of
the Public Health Service Act (42 U.S.C. 300ff-28(b)(2)) is amended--
(1) in subparagraph (D)(i), by inserting before the semicolon
the following: ``, except that (subject to subparagraph (E)),
for grants made pursuant to this paragraph for fiscal year 2005
and subsequent fiscal years, the cases counted for each 12-
month period beginning on or after July 1, 2004, shall be cases
of HIV disease (as reported to and confirmed by such Director)
rather than cases of acquired immune deficiency syndrome'';
(2) by redesignating subparagraphs (E) through (H) as
subparagraphs (F) through (I), respectively; and
(3) by inserting after subparagraph (D) the following
subparagraph:
``(E) Determination of secretary regarding data on
hiv cases.--If under 2603(a)(3)(D)(i) the Secretary
determines that data on cases of HIV disease is not
sufficiently accurate and reliable, then
notwithstanding subparagraph (D) of this paragraph, for
any fiscal year prior to fiscal year 2007 the
references in such subparagraph to cases of HIV disease
do not have any legal effect.''.
(c) Increases in Formula Amount.--Section 2618(b) of the Public
Health Service Act (42 U.S.C. 300ff-28(b)) is amended--
(1) in paragraph (1)(A)(ii), by inserting before the
semicolon the following: ``and then, as applicable, increased
under paragraph (2)(H)''; and
(2) in paragraph (2)--
(A) in subparagraph (A)(i), by striking
``subparagraph (H)'' and inserting ``subparagraphs (H)
and (I)''; and
(B) in subparagraph (H) (as redesignated by
subsection (b)(2) of this section), by amending the
subparagraph to read as follows:
``(H) Limitation.--
``(i) In general.--The Secretary shall ensure
that the amount of a grant awarded to a State
or territory under section 2611 for a fiscal
year is not less than--
``(I) with respect to fiscal year
2001, 99 percent;
``(II) with respect to fiscal year
2002, 98 percent;
``(III) with respect to fiscal year
2003, 97 percent;
``(IV) with respect to fiscal year
2004, 96 percent; and
``(V) with respect to fiscal year
2005, 95 percent;
of the amount such State or territory received
for fiscal year 2000 under such section. In
administering this subparagraph, the Secretary
shall, with respect to States or territories
that will under such section receive grants in
amounts that exceed the amounts that such
States received under such section for fiscal
year 2000, proportionally reduce such amounts
to ensure compliance with this subparagraph. In
making such reductions, the Secretary shall
ensure that no such State receives less than
that State received for fiscal year 2000.
``(ii) Ratable reduction.--If the amount
appropriated under section 2677 for a fiscal
year and available for grants under section
2611 is less than the amount appropriated and
available under such section for fiscal year
2000, the limitation contained in clause (i)
shall be reduced by a percentage equal to the
percentage of the reduction in such amounts
appropriated and available.''.
(d) Territories.--Section 2618(b)(1)(B) of the Public Health Service
Act (42 U.S.C. 300ff-28(b)(1)(B)) is amended by inserting ``the greater
of $50,000 or'' after ``shall be''.
(e) Separate Treatment Drug Grants.--Section 2618(b)(2) of the Public
Health Service Act, as amended by subsection (b)(3) of this section, is
amended in subparagraph (I)--
(1) by redesignating clauses (i) and (ii) as subclauses (I)
and (II), respectively;
(2) by striking ``(I) Appropriations'' and all that follows
through ``With respect to'' and inserting the following:
``(I) Appropriations for treatment drug program.--
``(i) Formula grants.--With respect to'';
(3) in subclause (I) of clause (i) (as designated by
paragraphs (1) and (2)), by striking ``100 percent'' and
inserting ``98 percent''; and
(4) by adding at the end the following clause:
``(ii) Supplemental treatment drug grants.--
``(I) In general.--With respect to
the fiscal year involved, if under
section 2677 an appropriations Act
provides an amount exclusively for
carrying out section 2616, and such
amount is not less than the amount so
provided for the preceding fiscal year,
the Secretary shall reserve 2 percent
of such amount for making grants to
States whose population of individuals
with HIV disease has, as determined by
the Secretary, a need for quantities of
therapeutics described in section
2616(a) greater than the quantities
available pursuant to clause (i). Such
a grant is available for purposes of
obtaining such therapeutics. The
Secretary shall carry out this clause
as a program of discretionary grants,
and not as a program of formula grants.
``(II) Distribution of grants.--The
Secretary shall disburse all amounts
under grants under subclause (I) for a
fiscal year not later than 240 days
after the date on which the amount
referred to in such subclause with
respect to section 2616 becomes
available.
``(III) Requirement of matching
funds.--A condition for receiving a
grant under subclause (I) is that the
State agree to make available (directly
or through donations from public or
private entities) non-Federal
contributions toward the costs of
obtaining the therapeutics involved in
an amount that is not less than 25
percent of such costs (determined in
the same manner as under
2617(d)(2)(A)).''.
(f) Technical Amendment.--Section 2618(b)(3)(B) of the Public Health
Service Act (42 U.S.C. 300ff-28(b)(3)(B)) is amended by striking ``and
the Republic of the Marshall Islands'' and inserting ``the Republic of
the Marshall Islands, the Federated States of Micronesia, and the
Republic of Palau, and only for purposes of paragraph (1) the
Commonwealth of Puerto Rico''.
SEC. 207. SUPPLEMENTAL GRANTS FOR CERTAIN STATES.
Subpart I of part B of title XXVI of the Public Health Service Act
(42 U.S.C. 300ff-11 et seq.) is amended--
(1) by striking section 2621; and
(2) by inserting after section 2620 the following section:
``SEC. 2621. SUPPLEMENTAL GRANTS.
``(a) In General.--From amounts available pursuant to subsection (d)
for a fiscal year, the Secretary shall make grants to States that meet
the conditions to receive grants under section 2611, and that have one
or more eligible communities, for the purpose of providing in such
communities comprehensive services of the type described in section
2612(a) to supplement the development and care activities, primary
care, and support services otherwise provided in such communities by
the State under a grant under section 2611.
``(b) Eligible Community.--For purposes of this section, the term
`eligible community' means a geographic area that--
``(1) is not within any eligible area as defined in section
2607; and
``(2) has a severe need for supplemental financial assistance
to combat the HIV epidemic, according to criteria developed by
the Secretary in consultation with the States, including
evidence of underserved or rural areas or both.
``(c) Application.--A grant under subsection (a) may be made to a
State if the State submits to the Secretary, as part of the State
application submitted under section 2617, such information as required
to apply for funds under this section as determined by the Secretary in
consultation with the States.
``(d) Funding.--
``(1) In general.--For the purpose of making grants under
subsection (a) for a fiscal year, the Secretary shall reserve
50 percent of the amount specified in paragraph (2).
``(2) Increases in part b funding.--
``(A) In general.--For purposes of paragraph (1), the
amount specified in this paragraph is the amount by
which the amount appropriated under section 2677 for
the fiscal year involved and available for carrying out
part B is an increase over the amount so appropriated
and available for the preceding fiscal year, subject to
subparagraphs (B) and (C).
``(B) Initial allocation year.--The allocation under
paragraph (1) shall not be made until the first fiscal
year for which the amount appropriated under section
2677 for the fiscal year involved and available for
carrying out part B is an increase of not less than
$20,000,000 over the amount so appropriated and
available for fiscal year 2000, subject to subparagraph
(C).
``(C) Exclusion regarding separate treatment drug
grants.--Each determination under subparagraph (A) or
(B) of the amount appropriated under section 2677 for a
fiscal year and available for carrying out part B shall
be made without regard to any amount to which section
2618(b)(2)(I)(i) applies.''.
Subtitle B--Provisions Concerning Pregnancy and Perinatal Transmission
of HIV
SEC. 211. REPEALS.
Subpart II of part B of title XXVI of the Public Health Service Act
(42 U.S.C. 300ff-33 et seq.) is amended--
(1) in section 2626, by striking each of subsections (d)
through (f); and
(2) by striking section 2627.
SEC. 212. GRANTS.
(a) In General.--Section 2625(c) of the Public Health Service Act (42
U.S.C. 300ff-33) is amended--
(1) in paragraph (1), by inserting at the end the following
subparagraph:
``(F) Making available to pregnant women with HIV
disease, and to the infants of women with such disease,
treatment services for such disease in accordance with
applicable recommendations of the Secretary.'';
(2) by amending paragraph (2) to read as follows:
``(2) Funding.--
``(A) Authorization of appropriations.--For the
purpose of carrying out this subsection, there are
authorized to be appropriated $30,000,000 for each of
the fiscal years 2001 through 2005. Amounts made
available under section 2677 for carrying out this part
are not available for carrying out this section unless
otherwise authorized.
``(B) Allocations for certain states.--
``(i) In general.--Of the amounts
appropriated under subparagraph (A) for a
fiscal year in excess of $10,000,000, the
Secretary shall reserve the applicable
percentage under clause (ii) for making grants
under paragraph (1) to States that under law
(including under regulations or the discretion
of State officials) have--
``(I) a requirement that all newborn
infants born in the State be tested for
HIV disease; or
``(II) a requirement that newborn
infants born in the State be tested for
HIV disease in circumstances in which
the attending obstetrician for the
birth does not know the HIV status of
the mother of the infant.
``(ii) Applicable percentage.--For purposes
of clause (i), the applicable amount for a
fiscal year is as follows:
``(I) For fiscal year 2001, 25
percent.
``(II) For fiscal year 2002, 50
percent.
``(III) For fiscal year 2003, 50
percent.
``(IV) For fiscal year 2004, 75
percent.
``(V) For fiscal year 2005, 75
percent.
``(C) Certain provisions.--With respect to grants
under paragraph (1) that are made with amounts reserved
under subparagraph (B) of this paragraph:
``(i) Such a grant may not be made in an
amount exceeding $4,000,000.
``(ii) If pursuant to clause (i) or pursuant
to an insufficient number of qualifying
applications for such grants (or both), the
full amount reserved under subparagraph (B) for
a fiscal year is not obligated, the requirement
under such subparagraph to reserve amounts
ceases to apply.''; and
(3) by adding at the end the following paragraph:
``(4) Maintenance of effort.--A condition for the receipt of
a grant under paragraph (1) is that the State involved agree
that the grant will be used to supplement and not supplant
other funds available to the State to carry out the purposes of
the grant.''.
(b) Special Funding Rule for Fiscal Year 2001.--
(1) In general.--If for fiscal year 2001 the amount
appropriated under paragraph (2)(A) of section 2625(c) of the
Public Health Service Act is less than $14,000,000--
(A) the Secretary of Health and Human Services shall,
for the purpose of making grants under paragraph (1) of
such section, reserve from the amount specified in
paragraph (2) of this subsection an amount equal to the
difference between $14,000,000 and the amount
appropriated under paragraph (2)(A) of such section for
such fiscal year;
(B) the amount so reserved shall, for purposes of
paragraph (2)(B)(i) of such section, be considered to
have been appropriated under paragraph (2)(A) of such
section; and
(C) the percentage specified in paragraph
(2)(B)(ii)(I) of such section is deemed to be 50
percent.
(2) Allocation from increases in funding for part b.--For
purposes of paragraph (1), the amount specified in this
paragraph is the amount by which the amount appropriated under
section 2677 of the Public Health Service Act for fiscal year
2001 and available for grants under section 2611 of such Act is
an increase over the amount so appropriated and available for
fiscal year 2000.
SEC. 213. STUDY BY INSTITUTE OF MEDICINE.
Subpart II of part B of title XXVI of the Public Health Service Act
(42 U.S.C. 300ff-33 et seq.) is amended by adding at the end the
following section:
``SEC. 2630. RECOMMENDATIONS FOR REDUCING INCIDENCE OF PERINATAL
TRANSMISSION.
``(a) Study by Institute of Medicine.--
``(1) In general.--The Secretary shall request the Institute
of Medicine to enter into an agreement with the Secretary under
which such Institute conducts a study to provide the following:
``(A) For the most recent fiscal year for which the
information is available, a determination of the number
of newborn infants with HIV born in the United States
with respect to whom the attending obstetrician for the
birth did not know the HIV status of the mother.
``(B) A determination for each State of any barriers,
including legal barriers, that prevent or discourage an
obstetrician from making it a routine practice to offer
pregnant women an HIV test and a routine practice to
test newborn infants for HIV disease in circumstances
in which the obstetrician does not know the HIV status
of the mother of the infant.
``(C) Recommendations for each State for reducing the
incidence of cases of the perinatal transmission of
HIV, including recommendations on removing the barriers
identified under subparagraph (B).
If such Institute declines to conduct the study, the Secretary
shall enter into an agreement with another appropriate public
or nonprofit private entity to conduct the study.
``(2) Report.--The Secretary shall ensure that, not later
than 18 months after the effective date of this section, the
study required in paragraph (1) is completed and a report
describing the findings made in the study is submitted to the
appropriate committees of the Congress, the Secretary, and the
chief public health official of each of the States.
``(b) Progress Toward Recommendations.--Each State shall comply with
the following (as applicable to the fiscal year involved):
``(1) For fiscal year 2004, the State shall submit to the
Secretary a report describing the actions taken by the State
toward meeting the recommendations specified for the State
under subsection (a)(1)(C).
``(2) For fiscal year 2005 and each subsequent fiscal year--
``(A) the State shall make reasonable progress toward
meeting such recommendations; or
``(B) if the State has not made such progress--
``(i) the State shall cooperate with the
Director of the Centers for Disease Control and
Prevention in carrying out activities toward
meeting the recommendations; and
``(ii) the State shall submit to the
Secretary a report containing a description of
any barriers identified under subsection
(a)(1)(B) that continue to exist in the State;
as applicable, the factors underlying the
continued existence of such barriers; and a
description of how the State intends to reduce
the incidence of cases of the perinatal
transmission of HIV.
``(c) Submission of Reports to Congress.--The Secretary shall submit
to the appropriate committees of the Congress each report received by
the Secretary under subsection (b)(2)(B)(ii).''.
Subtitle C--Certain Partner Notification Programs
SEC. 221. GRANTS FOR COMPLIANT PARTNER NOTIFICATION PROGRAMS.
Part B of title XXVI of the Public Health Service Act (42 U.S.C.
300ff-21 et seq.) is amended by adding at the end the following
subpart:
``Subpart III--Certain Partner Notification Programs
``SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS.
``(a) In General.--In the case of States whose laws or regulations
are in accordance with subsection (b), the Secretary, subject to
subsection (c)(2), may make grants to the States for carrying out
programs to provide partner counseling and referral services.
``(b) Description of Compliant State Programs.--For purposes of
subsection (a), the laws or regulations of a State are in accordance
with this subsection if under such laws or regulations (including
programs carried out pursuant to the discretion of State officials) the
following policies are in effect:
``(1) The State requires that the public health officer of
the State carry out a program of partner notification to inform
partners of individuals with HIV disease that the partners may
have been exposed to the disease.
``(2)(A) In the case of a health entity that provides for the
performance on an individual of a test for HIV disease, or that
treats the individual for the disease, the State requires,
subject to subparagraph (B), that the entity confidentially
report the positive test results to the State public health
officer in a manner recommended and approved by the Director of
the Centers for Disease Control and Prevention, together with
such additional information as may be necessary for carrying
out such program.
``(B) The State may provide that the requirement of
subparagraph (A) does not apply to the testing of an individual
for HIV disease if the individual underwent the testing through
a program designed to perform the test and provide the results
to the individual without the individual disclosing his or her
identity to the program. This subparagraph may not be construed
as affecting the requirement of subparagraph (A) with respect
to a health entity that treats an individual for HIV disease.
``(3) The program under paragraph (1) is carried out in
accordance with the following:
``(A) Partners are provided with an appropriate
opportunity to learn that the partners have been
exposed to HIV disease, subject to subparagraph (B).
``(B) The State does not inform partners of the
identity of the infected individuals involved.
``(C) Counseling and testing for HIV disease are made
available to the partners and to infected individuals,
and such counseling includes information on modes of
transmission for the disease, including information on
prenatal and perinatal transmission and preventing
transmission.
``(D) Counseling of infected individuals and their
partners includes the provision of information
regarding therapeutic measures for preventing and
treating the deterioration of the immune system and
conditions arising from the disease, and the provision
of other prevention-related information.
``(E) Referrals for appropriate services are provided
to partners and infected individuals, including
referrals for support services and legal aid.
``(F) Notifications under subparagraph (A) are
provided in person, unless doing so is an unreasonable
burden on the State.
``(G) There is no criminal or civil penalty on, or
civil liability for, an infected individual if the
individual chooses not to identify the partners of the
individual, or the individual does not otherwise
cooperate with such program.
``(H) The failure of the State to notify partners is
not a basis for the civil liability of any health
entity who under the program reported to the State the
identity of the infected individual involved.
``(I) The State provides that the provisions of the
program may not be construed as prohibiting the State
from providing a notification under subparagraph (A)
without the consent of the infected individual
involved.
``(4) The State annually reports to the Director of the
Centers for Disease Control and Prevention the number of
individuals from whom the names of partners have been sought
under the program under paragraph (1), the number of such
individuals who provided the names of partners, and the number
of partners so named who were notified under the program.
``(5) The State cooperates with such Director in carrying out
a national program of partner notification, including the
sharing of information between the public health officers of
the States.
``(c) Reporting System for Cases of HIV Disease.--
``(1) Preference in making grants through fiscal year 2003.--
In making grants under subsection (a) for each of the fiscal
years 2001 through 2003, the Secretary shall give preference to
States whose reporting systems for cases of HIV disease produce
data on such cases that is sufficiently accurate and reliable
for use for purposes of section 2618(b)(2)(D)(i).
``(2) Eligibility condition after fiscal year 2003.--For
fiscal year 2004 and subsequent fiscal years, a State may not
receive a grant under subsection (a) unless the reporting
system of the State for cases of HIV disease produces data on
such cases that is sufficiently accurate and reliable for
purposes of section 2618(b)(2)(D)(i).
``(d) Authorization of Appropriations.--For the purpose of carrying
out this section, there are authorized to be appropriated $30,000,000
for fiscal year 2001, and such sums as may be necessary for each of the
fiscal years 2002 through 2005.''.
TITLE III--EARLY INTERVENTION SERVICES
Subtitle A--Formula Grants for States
SEC. 301. REPEAL OF PROGRAM.
Subpart I of part C of title XXVI of the Public Health Service Act
(42 U.S.C. 300ff-41 et seq.) is repealed.
Subtitle B--Categorical Grants
SEC. 311. PREFERENCES IN MAKING GRANTS.
Section 2653 of the Public Health Service Act (42 U.S.C. 300ff-53) is
amended by adding at the end the following subsection:
``(d) Underserved and Rural Areas.--Of the applicants who qualify for
preference under this section, the Secretary shall give preference to
applicants that will expend the grant under section 2651 to provide
early intervention under such section in rural areas or in areas that
are underserved with respect to such services.''.
SEC. 312. PLANNING AND DEVELOPMENT GRANTS.
(a) In General.--Section 2654(c)(1) of the Public Health Service Act
(42 U.S.C. 300ff-54(c)(1)) is amended by striking ``planning grants''
and all that follows and inserting the following: ``planning grants to
public and nonprofit private entities for purposes of--
``(A) enabling such entities to provide HIV early
intervention services; and
``(B) assisting the entities in expanding their
capacity to provide HIV-related health services,
including early intervention services, in low-income
communities and affected subpopulations that are
underserved with respect to such services (subject to
the condition that a grant pursuant to this
subparagraph may not be expended to purchase or improve
land, or to purchase, construct, or permanently
improve, other than minor remodeling, any building or
other facility).''.
(b) Amount; Duration.--Section 2654(c) of the Public Health Service
Act (42 U.S.C. 300ff-54(c)) is further amended--
(1) by redesignating paragraph (4) as paragraph (5); and
(2) by inserting after paragraph (3) the following:
``(4) Amount and duration of grants.--
``(A) Early intervention services.--A grant under
paragraph (1)(A) may be made in an amount not to exceed
$50,000.
``(B) Capacity development.--
``(i) Amount.--A grant under paragraph (1)(B)
may be made in an amount not to exceed
$150,000.
``(ii) Duration.--The total duration of a
grant under paragraph (1)(B), including any
renewal, may not exceed 3 years.''.
(c) Increase in Limitation.--Section 2654(c)(5) of the Public Health
Service Act (42 U.S.C. 300ff-54(c)(5)), as redesignated by subsection
(b), is amended by striking ``1 percent'' and inserting ``5 percent''.
SEC. 313. AUTHORIZATION OF APPROPRIATIONS.
Section 2655 of the Public Health Service Act (42 U.S.C. 300ff-55) is
amended by striking ``in each of'' and all that follows and inserting
``for each of the fiscal years 2001 through 2005.''.
Subtitle C--General Provisions
SEC. 321. PROVISION OF CERTAIN COUNSELING SERVICES.
Section 2662(c)(3) of the Public Health Service Act (42 U.S.C. 300ff-
62(c)(3)) is amended--
(1) in the matter preceding subparagraph (A), by striking
``counseling on--'' and inserting ``counseling--'';
(2) in each of subparagraphs (A), (B), and (D), by inserting
``on'' after the subparagraph designation; and
(3) in subparagraph (C)--
(A) by striking ``(C) the benefits'' and inserting
``(C)(i) that explains the benefits''; and
(B) by inserting after clause (i) (as designated by
subparagraph (A) of this paragraph) the following
clause:
``(ii) that emphasizes it is the duty of infected
individuals to disclose their infected status to their
sexual partners and their partners in the sharing of
hypodermic needles; that provides advice to infected
individuals on the manner in which such disclosures can
be made; and that emphasizes that it is the continuing
duty of the individuals to avoid any behaviors that
will expose others to HIV;
SEC. 322. ADDITIONAL REQUIRED AGREEMENTS.
Section 2664(g) of the Public Health Service Act (42 U.S.C. 300ff-
64(g)) is amended--
(1) in paragraph (3)--
(A) by striking ``7.5 percent'' and inserting ``10
percent''; and
(B) by striking ``and'' after the semicolon at the
end;
(2) in paragraph (4), by striking the period and inserting
``; and''; and
(3) by adding at the end the following paragraph:
``(5) the applicant will provide for the establishment of a
quality management program to assess the extent to which
medical services funded under this title that are provided to
patients are consistent with the most recent Public Health
Service guidelines for the treatment of HIV disease and related
opportunistic infections and that improvements in the access to
and quality of medical services are addressed.''.
TITLE IV--OTHER PROGRAMS AND ACTIVITIES
Subtitle A--Certain Programs for Research, Demonstrations, or Training
SEC. 401. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR
WOMEN, INFANTS, CHILDREN, AND YOUTH.
Section 2671 of the Public Health Service Act (42 U.S.C. 300ff-71) is
amended--
(1) in subsection (b)--
(A) in paragraph (1), by striking subparagraphs (C)
and (D) and inserting the following:
``(C) The applicant will demonstrate linkages to
research and how access to such research is being
offered to patients.''; and
(B) by striking paragraphs (3) and (4);
(2) in subsection (g), by adding at the end the following:
``In addition, the Secretary, in coordination with the Director
of such Institutes, shall examine the distribution and
availability of appropriate HIV-related research projects with
respect to grantees under subsection (a) for purposes of
enhancing and expanding HIV-related research, especially within
communities that are underrepresented with respect to such
projects.'';
(3) in subsection (f)--
(A) by striking the subsection heading and
designation and inserting the following:
``(f) Administration.--
``(1) Application.--''; and
(B) by adding at the end the following paragraph:
``(2) Quality management program.--A grantee under this
section shall implement a quality management program.''; and
(4) in subsection (j), by striking ``1996 through 2000'' and
inserting ``2001 through 2005''.
SEC. 402. AIDS EDUCATION AND TRAINING CENTERS.
(a) Schools; Centers.--
(1) In general.--Section 2692(a)(1) of the Public Health
Service Act (42 U.S.C. 300ff-111(a)(1)) is amended--
(A) in subparagraph (A)--
(i) by striking ``training'' and inserting
``to train'';
(ii) by striking ``and including'' and
inserting ``, including''; and
(iii) by inserting before the semicolon the
following: ``, and including (as applicable to
the type of health professional involved),
prenatal and other gynecological care for women
with HIV disease'';
(B) in subparagraph (B), by striking ``and'' after
the semicolon at the end;
(C) in subparagraph (C), by striking the period and
inserting ``; and''; and
(D) by adding at the end the following:
``(D) to develop protocols for the medical care of
women with HIV disease, including prenatal and other
gynecological care for such women.''.
(2) Dissemination of treatment guidelines; medical
consultation activities.--Not later than 90 days after the date
of the enactment of this Act, the Secretary of Health and Human
Services shall issue and begin implementation of a strategy for
the dissemination of HIV treatment information to health care
providers and patients.
(b) Dental Schools.--Section 2692(b) of the Public Health Service Act
(42 U.S.C. 300ff-111(b)) is amended--
(1) by amending paragraph (1) to read as follows:
``(1) In general.--
``(A) Grants.--The Secretary may make grants to
dental schools and programs described in subparagraph
(B) to assist such schools and programs with respect to
oral health care to patients with HIV disease.
``(B) Eligible applicants.--For purposes of this
subsection, the dental schools and programs referred to
in this subparagraph are dental schools and programs
that were described in section 777(b)(4)(B) as such
section was in effect on the day before the date of
enactment of the Health Professions Education
Partnerships Act of 1998 (Public Law 105-392) and in
addition dental hygiene programs that are accredited by
the Commission on Dental Accreditation.'';
(2) in paragraph (2), by striking ``777(b)(4)(B)'' and
inserting ``the section referred to in paragraph (1)(B)''; and
(3) by inserting after paragraph (4) the following paragraph:
``(5) Community-based care.--The Secretary may make grants to
dental schools and programs described in paragraph (1)(B) that
partner with community-based dentists to provide oral health
care to patients with HIV disease in unserved areas. Such
partnerships shall permit the training of dental students and
residents and the participation of community dentists as
adjunct faculty.''.
(c) Authorization of Appropriations.--
(1) Schools; centers.--Section 2692(c)(1) of the Public
Health Service Act (42 U.S.C. 300ff-111(c)(1)) is amended by
striking ``fiscal years 1996 through 2000'' and inserting
``fiscal years 2001 through 2005''.
(2) Dental schools.--Section 2692(c)(2) of the Public Health
Service Act (42 U.S.C. 300ff-111(c)(2)) is amended to read as
follows:
``(2) Dental schools.--
``(A) In general.--For the purpose of grants under
paragraphs (1) through (4) of subsection (b), there are
authorized to be appropriated such sums as may be
necessary for each of the fiscal years 2001 through
2005.
``(B) Community-based care.--For the purpose of
grants under subsection (b)(5), there are authorized to
be appropriated such sums as may be necessary for each
of the fiscal years 2001 through 2005.''.
Subtitle B--General Provisions in Title XXVI
SEC. 411. EVALUATIONS AND REPORTS.
Section 2674(c) of the Public Health Service Act (42 U.S.C. 300ff-
74(c)) is amended by striking ``1991 through 1995'' and inserting
``2001 through 2005''.
SEC. 412. DATA COLLECTION THROUGH CENTERS FOR DISEASE CONTROL AND
PREVENTION.
Part D of title XXVI of the Public Health Service Act (42 U.S.C.
300ff-71 et seq.) is amended--
(1) by redesignating section 2675 as section 2675A; and
(2) by inserting after section 2674 the following section:
``SEC. 2675. DATA COLLECTION.
``For the purpose of collecting and providing data for program
planning and evaluation activities under this title, there are
authorized to be appropriated to the Secretary (acting through the
Director of the Centers for Disease Control and Prevention) such sums
as may be necessary for each of the fiscal years 2001 through 2005.
Such authorization of appropriations is in addition to other
authorizations of appropriations that are available for such
purpose.''.
SEC. 413. COORDINATION.
Section 2675A of the Public Health Service Act, as redesignated by
section 412 of this Act, is amended--
(1) by amending subsection (a) to read as follows:
``(a) Requirement.--The Secretary shall ensure that the Health
Resources and Services Administration, the Centers for Disease Control
and Prevention, the Substance Abuse and Mental Health Services
Administration, and the Health Care Financing Administration coordinate
the planning, funding, and implementation of Federal HIV programs to
enhance the continuity of care and prevention services for individuals
with HIV disease or those at risk of such disease. The Secretary shall
consult with other Federal agencies, including the Department of
Veterans Affairs, as needed and utilize planning information submitted
to such agencies by the States and entities eligible for support.'';
(2) by redesignating subsections (b) and (c) as subsections
(c) and (d), respectively;
(3) by inserting after subsection (b) the following
subsection:
``(b) Report.--The Secretary shall biennially prepare and submit to
the appropriate committees of the Congress a report concerning the
coordination efforts at the Federal, State, and local levels described
in this section, including a description of Federal barriers to HIV
program integration and a strategy for eliminating such barriers and
enhancing the continuity of care and prevention services for
individuals with HIV disease or those at risk of such disease.''; and
(4) in each of subsections (c) and (d) (as redesignated by
paragraph (2) of this section), by inserting ``and prevention
services'' after ``continuity of care'' each place such term
appears.
SEC. 414. PLAN REGARDING RELEASE OF PRISONERS WITH HIV DISEASE.
Section 2675A of the Public Health Service Act, as amended by section
413(2) of this Act, is amended by adding at the end the following
subsection:
``(e) Recommendations Regarding Release of Prisoners.--After
consultation with the Attorney General and the Director of the Bureau
of Prisons, with States, with eligible areas under part A, and with
entities that receive amounts from grants under part A or B, the
Secretary, consistent with the coordination required in subsection (a),
shall develop a plan for the medical case management of and the
provision of support services to individuals who were Federal or State
prisoners and had HIV disease as of the date on which the individuals
were released from the custody of the penal system. The Secretary shall
submit the plan to the Congress not later than two years after the date
of the enactment of the Ryan White CARE Act Amendments of 2000.''.
SEC. 415. AUDITS.
Part D of title XXVI of the Public Health Service Act, as amended by
section 412 of this Act, is amended by inserting after section 2675A
the following section:
``SEC. 2675B. AUDITS.
``For fiscal year 2002 and subsequent fiscal years, the Secretary may
reduce the amounts of grants under this title to a State or political
subdivision of a State for a fiscal year if, with respect to such
grants for the second preceding fiscal year, the State or subdivision
fails to prepare audits in accordance with the procedures of section
7502 of title 31, United States Code. The Secretary shall annually
select representative samples of such audits, prepare summaries of the
selected audits, and submit the summaries to the Congress.''.
SEC. 416. ADMINISTRATIVE SIMPLIFICATION.
Part D of title XXVI of the Public Health Service Act, as amended by
section 415 of this Act, is amended by inserting after section 2675B
the following section:
``SEC. 2675C. ADMINISTRATIVE SIMPLIFICATION REGARDING PARTS A AND B.
``(a) Coordinated Disbursement.--After consultation with the States,
with eligible areas under part A, and with entities that receive
amounts from grants under part A or B, the Secretary shall develop a
plan for coordinating the disbursement of appropriations for grants
under part A with the disbursement of appropriations for grants under
part B in order to assist grantees and other recipients of amounts from
such grants in complying with the requirements of such parts. The
Secretary shall submit the plan to the Congress not later than 18
months after the date of the enactment of the Ryan White CARE Act
Amendments of 2000. Not later than two years after the date on which
the plan is so submitted, the Secretary shall complete the
implementation of the plan, notwithstanding any provision of this title
that is inconsistent with the plan.
``(b) Biennial Applications.--After consultation with the States,
with eligible areas under part A, and with entities that receive
amounts from grants under part A or B, the Secretary shall make a
determination of whether the administration of parts A and B by the
Secretary, and the efficiency of grantees under such parts in complying
with the requirements of such parts, would be improved by requiring
that applications for grants under such parts be submitted biennially
rather than annually. The Secretary shall submit such determination to
the Congress not later than two years after the date of the enactment
of the Ryan White CARE Act Amendments of 2000.
``(c) Application Simplification.--After consultation with the
States, with eligible areas under part A, and with entities that
receive amounts from grants under part A or B, the Secretary shall
develop a plan for simplifying the process for applications under parts
A and B. The Secretary shall submit the plan to the Congress not later
than 18 months after the date of the enactment of the Ryan White CARE
Act Amendments of 2000. Not later than two years after the date on
which the plan is so submitted, the Secretary shall complete the
implementation of the plan, notwithstanding any provision of this title
that is inconsistent with the plan.''.
SEC. 417. AUTHORIZATION OF APPROPRIATIONS FOR PARTS A AND B.
Section 2677 of the Public Health Service Act (42 U.S.C. 300ff-77) is
amended to read as follows:
``SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.
``(a) Part A.--For the purpose of carrying out part A, there are
authorized to be appropriated such sums as may be necessary for each of
the fiscal years 2001 through 2005.
``(b) Part B.--For the purpose of carrying out part B, there are
authorized to be appropriated such sums as may be necessary for each of
the fiscal years 2001 through 2005.''.
TITLE V--GENERAL PROVISIONS
SEC. 501. STUDIES BY INSTITUTE OF MEDICINE.
(a) State Surveillance Systems on Prevalence of HIV.--The Secretary
of Health and Human Services (referred to in this section as the
``Secretary'') shall request the Institute of Medicine to enter into an
agreement with the Secretary under which such Institute conducts a
study to provide the following:
(1) A determination of whether the surveillance system of
each of the States regarding the human immunodeficiency virus
provides for the reporting of casesof infection with the virus
in a manner that is sufficient to provide adequate and reliable
information on the number of such cases and the demographic
characteristics of such cases, both for the State in general and for
specific geographic areas in the State.
(2) A determination of whether such information is
sufficiently accurate for purposes of formula grants under
parts A and B of title XXVI of the Public Health Service Act.
(3) With respect to any State whose surveillance system does
not provide adequate and reliable information on cases of
infection with the virus, recommendations regarding the manner
in which the State can improve the system.
(b) Relationship Between Epidemiological Measures and Health Care for
Certain Individuals With HIV Disease.--
(1) In general.--The Secretary shall request the Institute of
Medicine to enter into an agreement with the Secretary under
which such Institute conducts a study concerning the
appropriate epidemiological measures and their relationship to
the financing and delivery of primary care and health-related
support services for low-income, uninsured, and under-insured
individuals with HIV disease.
(2) Issues to be considered.--The Secretary shall ensure that
the study under paragraph (1) considers the following:
(A) The availability and utility of health outcomes
measures and data for HIV primary care and support
services and the extent to which those measures and
data could be used to measure the quality of such
funded services.
(B) The effectiveness and efficiency of service
delivery (including the quality of services, health
outcomes, and resource use) within the context of a
changing health care and therapeutic environment, as
well as the changing epidemiology of the epidemic,
including determining the actual costs, potential
savings, and overall financial impact of modifying the
program under title XIX of the Social Security Act to
establish eligibility for medical assistance under such
title on the basis of infection with the human
immunodeficiency virus rather than providing such
assistance only if the infection has progressed to
acquired immune deficiency syndrome.
(C) Existing and needed epidemiological data and
other analytic tools for resource planning and
allocation decisions, specifically for estimating
severity of need of a community and the relationship to
the allocations process.
(D) Other factors determined to be relevant to
assessing an individual's or community's ability to
gain and sustain access to quality HIV services.
(c) Other Entities.--If the Institute of Medicine declines to conduct
a study under this section, the Secretary shall enter into an agreement
with another appropriate public or nonprofit private entity to conduct
the study.
(d) Report.--The Secretary shall ensure that--
(1) not later than three years after the date of the
enactment of this Act, the study required in subsection (a) is
completed and a report describing the findings made in the
study is submitted to the appropriate committees of the
Congress; and
(2) not later than two years after the date of the enactment
of this Act, the study required in subsection (b) is completed
and a report describing the findings made in the study is
submitted to such committees.
SEC. 502. DEVELOPMENT OF RAPID HIV TEST.
(a) Expansion, Intensification, and Coordination of Research and
Other Activities.--
(1) In general.--The Director of NIH shall expand, intensify,
and coordinate research and other activities of the National
Institutes of Health with respect to the development of
reliable and affordable tests for HIV disease that can rapidly
be administered and whose results can rapidly be obtained (in
this section referred to a ``rapid HIV test'').
(2) Report to congress.--The Director of NIH shall
periodically submit to the appropriate committees of Congress a
report describing the research and other activities conducted
or supported under paragraph (1).
(3) Authorization of appropriations.--For the purpose of
carrying out this subsection, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2001 through 2005.
(b) Premarket Review of Rapid HIV Tests.--
(1) In general.--Not later than 90 days after the date of the
enactment of this Act, the Secretary, in consultation with the
Director of the Centers for Disease Control and Prevention and
the Commissioner of Food and Drugs, shall submit to the
appropriate committees of the Congress a report describing the
progress made towards, and barriers to, the premarket review
and commercial distribution of rapid HIV tests. The report
shall--
(A) assess the public health need for and public
health benefits of rapid HIV tests, including the
minimization of false positive results through the
availability of multiple rapid HIV tests;
(B) make recommendations regarding the need for the
expedited review of rapid HIV test applications
submitted to the Center for Biologics Evaluation and
Research and, if such recommendations are favorable,
specify criteria and procedures for such expedited
review; and
(C) specify whether the barriers to the premarket
review of rapid HIV tests include the unnecessary
application of requirements--
(i) necessary to ensure the efficacy of
devices for donor screening to rapid HIV tests
intended for use in other screening situations;
or
(ii) for identifying antibodies to HIV
subtypes of rare incidence in the United States
to rapid HIV tests intended for use in
screening situations other than donor
screening.
(c) Guidelines of Centers for Disease Control and Prevention.--
Promptly after commercial distribution of a rapid HIV test begins, the
Secretary, acting through the Director of the Centers for Disease
Control and Prevention, shall establish or update guidelines that
include recommendations for States, hospitals, and other appropriate
entities regarding the ready availability of such tests for
administration to pregnant women who are in labor or in the late stage
of pregnancy and whose HIV status is not known to the attending
obstetrician.
TITLE VI--EFFECTIVE DATE
SEC. 601. EFFECTIVE DATE.
This Act and the amendments made by this Act take effect October 1,
2000, or upon the date of the enactment of this Act, whichever occurs
later.
Purpose and Summary
The Ryan White CARE Act Amendments of 2000 reauthorizes
programs providing for the comprehensive health care of
Americans suffering from HIV/AIDS and prevention programs to
prevent the spread of HIV.
Background and Need for Legislation
Acquired Immunodeficiency Syndrome (AIDS) cases were first
reported in the United States in 1981. In the two decades
since, more than 700,000 persons in the United States have been
diagnosed with AIDS. The General Accounting Office (GAO)
recently estimated that by the end of 1998, 300,000 persons in
the United States were living with AIDS, and that as many as
hundreds of thousands of people in this country are infected
with the human immunodeficiency virus (HIV), but have not yet
progressed to AIDS.
Because persons with AIDS faced problems obtaining
insurance coverage and access to primary care and support, the
Congress responded in 1990 by passing the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act (P.L. 101-
381). The framework of that Act, as passed, continues in force
today.
Title I of the Act provides relief to eligible metropolitan
areas (EMAs) disproportionately impacted by AIDS. By fiscal
year (FY) 1991, there were 16 EMAs receiving CARE Act Title I
funding. Currently, as of FY2000, there are 51 EMAs. Title I
relief is provided through formula and supplemental grants to
be used for case management and comprehensive treatment
services, among other things. Such grants are intended to
supplement, not supplant, State funding, and have the express
purpose of delivering or enhancing HIV-related outpatient and
ambulatory health and support services. These service include
case management, substance abuse and mental health treatment,
comprehensive treatment services, and inpatient case management
services that prevent unnecessary hospitalization or that
expedite discharges.
As originally enacted in 1990, a community was entitled to
be an EMA if the area had more than 2,000 cases of AIDS, or if
the cumulative per capita incidence of AIDS exceeded one
quarter of one percent. Under the Ryan White CARE Act
Amendments of 1996 (P.L. 104-186), this was changed so that
areas could qualify for funding under Title I if the area has a
population of 500,000 or more individuals, and the area has
reported to the Director of the Centers for Disease Control and
Prevention (CDC) a cumulative total of more than 2,000 cases of
AIDS for the most recent five calendar years.
Title I funding is, generally, equally divided amongst
formula and supplemental grants. Formula grants are distributed
to EMAs according to a complex distribution factor, taking into
account the estimated living number of AIDS cases in the EMA.
The estimated living number of AIDS cases in an EMA is
determined by the number of AIDS cases reported to, and
confirmed by, the CDC in the most recent ten year period,
multiplied (on a yearly basis) by a percentage developed by the
Secretary of the Department of Health and Human Services. Title
I supplemental grants are awarded based upon severe need,
though these grants have been awarded historically in a way
which results in a doubling of the Title I formula amount.
One important exception must be noted. The 1990 CARE Act
distributed formula funds based partially upon the historical
number of AIDS cases the EMA had experienced, irrespective of
whether the disease sufferers were still alive. The 1996 CARE
Act Amendments altered this to allocate funds based upon living
number of AIDS cases. Because the change from historic
incidences of AIDS to estimated living AIDS cases per EMA could
have caused significant disruptions in funding received by
certain EMAs, the 1996 CARE Act Amendments contained a ``hold
harmless'' clause. According to this provision, no EMA could
lose more than five percent, over five years, from the EMA's
FY1995 Title I formula grant. To fund the ``hold harmless''
provision, the amount of Title I supplemental grant funds
available to all EMAs is reduced accordingly.
Title I grants are made to the chief elected official of
the city or county in the EMA that administers the health
agency providing services to the greatest number of persons
with AIDS. This chief elected official must establish or
designate an HIV health services planning council to establish
priorities for care delivery according to Federal guidelines,
in order to receive Title I funds. Members of the councils must
reflect the demographics of the epidemic in the EMA, and it
shall include representatives of health care providers;
community-based organizations serving affected populations and
AIDS service organizations; affected communities, including
people with HIV disease or AIDS, and historically underserved
groups and subpopulations; mental health and substance abuse
providers, and others. The council may not be directly involved
in the administration of any Title I grant.
Title II funds provide formula grants to states and
territories for comprehensive care services including home and
community-based health care and support services. States use
such funds to provide services directly or through contracts
with HIV care consortia. Title II grants are also used to
provide health insurance coverage for low-income persons
through Health Insurance Continuation Programs and drug
treatments for individuals with HIV and AIDS who have limited
or no coverage from private insurance or Medicaid through AIDS
Drug Assistance Programs (ADAPs). Prior to FY1996, States
determined the amount of their Title II funds they would
dedicate to ADAPs. In FY1996, Congress began appropriating
ADAP-targeted funds under Title II.
Grants are awarded to States based upon a weighted formula
that accounts for two factors: (1) the estimated number of
living AIDS cases in the State; and (2) the estimated number of
living AIDS cases in the State who are not in a Title I EMA.
States with more than 1% of the total AIDS cases reported
nationally must contribute State matching funds based on a
formula, and grants may not be made to any State that does not
make a good faith effort to notify a spouse of an HIV-infected
patient that the spouse should seek testing.
Further, Title II provides up to $10 million for States
which certify that they have in effect regulations or measures
to adopt CDC guidelines concerning HIV virus counseling and
voluntary testing for pregnant women. Priority is given to
States that have the greatest proportion of HIV seroprevalance
among child bearing women, as determined by the CDC.
Early intervention services are provided for under Title
III of the CARE Act. Under this, public and private nonprofit
entities already providing primary care services to low-income
and medically underserved populations compete for grants to
provide HIV testing, risk reduction counseling, case
management, outreach, medical evaluation, transmission
prevention, oral health, nutritional and mental health
services, and clinical care. Community health centers, homeless
programs, local health departments, family planning programs,
hemophilia diagnostic and treatment centers, as well as other
nonprofit community-based programs all compete for Title III
grants.
When enacted in 1990, Title IV authorized a number of
different HIV-related programs, but the only one for which
funds were appropriated was pediatric demonstration grants. In
the 1996 CARE Act Amendments, this funded program was replaced
with a program of grants for coordinated services and access to
research for women, infants, children and youth. Such grants
provide opportunities for women, infants, children and youth to
be voluntary participants in research of potential clinical
benefit to individuals with HIV and AIDS. Such individuals are
provided access to health care on an outpatient basis, case
management, referrals, transportation, child care, and other
services which enable participation.
Other programs under the CARE Act which have been funded
include special projects of national significance for the care
and treatment of individuals with HIV/AIDS, AIDS Education and
Training Centers program (AETC), and the AIDS Dental
Reimbursement program.
Funding Fairness. The Committee has amended and enhanced
the CARE Act to respond to significant changes in the HIV/AIDS
epidemic. It is important to the Committee that no eligible
metropolitan area lose its ability to provide services
authorized under the CARE Act. At the same time, it is equally
important to the Committee that no EMA receive significantly
more Title I formula funding on a per case basis than other
similarly-situated EMAs.
It is the Committee's intention that, over time, each EMA
should receive Title I formula funds in proportion to its
estimated number of living HIV cases. The GAO has reported,
however, that presently one EMA, the San Francisco EMA,
receives dramatically more Title I funding on a per case basis
than any other EMA. For example, GAO reports that in FY 1999
San Francisco spent $5,598 per AIDS case, while the other 50
EMAs spent between $2,509 and $3,132 per AIDS case. More
specifically, GAO reported that the San Francisco EMA receives
roughly 80% more per in Title I grant funds per AIDS case than
other EMAs.
A few have defended this disparity by stating that per
patient cost is higher than other places because the costs of
care in services in the Bay Area is so inflated. But even if
CARE Act money were adjusted for funding the cost of providing
medical care (it presently is not), San Francisco still
receives far more than any other EMA per capita. The
accompanying graph uses the Medicare hospital cost wage index
cost adjuster on the per capita Title I formula and
discretionary grant money used in chart 1. Even with these
adjustments, it is clear that the San Francisco EMA still gets
the most of all EMAs. With similar cost structures as San
Francisco, Oakland and San Jose in the Bay Area join New York
at the bottom of Title I funding.
The present disparity in funding results from the way EMAs
were funded under Title I when the CARE Act was enacted in
1990. Originally, EMAs were funded based upon the cumulative
number of AIDS cases the EMA experienced. In 1996, Title I
formula funding was altered to compensate EMAs based upon the
estimated number of living AIDS cases in the EMA, rather than
the cumulative caseload of living and dead AIDS cases. So that
certain EMAs would not find their Title I formula funding
dramatically decreased, a hold harmless provision was included
in the reauthorization limiting funding cuts to no more than
five percent, over five years, from the 1995 Title I formula
amount.
The GAO reports that presently only the San Francisco EMA
benefits from this hold harmless provision, thus explaining the
disparity in funding. During the July 11, 2000 hearing before
the Subcommittee on Health and Environment, the GAO
acknowledged that a reason for this is that San Francisco's
basis of funding, due to the hold harmless, still compensates
the EMA for individuals who have long ago died.
To ensure that per case funding is more equitable, H.R.
4807 reforms the hold harmless provision which limits funding
reductions to EMAs. According to the provision in this bill, no
EMA would experience a reduction greater than 25% of its base
year formula allocation over the next five fiscal years. Such a
regime would still leave the San Francisco EMA with more Title
I formula funds on a per case basis than any other EMA, while
still alleviating some of the unfair funding disparities.
As a way to protect State funding provided by Title II, the
legislation contains a hold harmless provision which ensures
that no State will see more than a one percent cut in Title II
formula funds per fiscal year. This reflects a continuation of
present law. It is important to note that no State has
benefitted from this provision since its enactment.
The Committee intends that Title I supplemental awards are
not intended to be allocated on the basis of formula grant
allocations. Instead, such supplemental awards are to be
directed to those eligible areas with ``severe need,'' or the
greatest or expanding public health challenges in confronting
the epidemic. The Committee has included additional factors to
be considered in the assessment of severe need, including the
current prevalence of HIV/AIDS, and the degree of increasing
and unmet needs for services. Additionally, the Committee
believes that syphilis, hepatitis B and hepatitis C should be
regarded as important co-morbidities to HIV/AIDS.
It is the Committee's strong view that HRSA's Bureau of
HIV/AIDS should employ standard, quantitative measures to the
maximum extent possible in lieu of narrative self-reporting
when awarding supplemental awards. The Committee renews the
Bureau's obligation to develop in a timely manner a mechanism
for determining severe need upon the basis of national,
quantitative incidence data. In this regard, the Committee
recognizes that adequate and reliable data on HIV prevalence
may not be uniformly available in all eligible areas on the
date of enactment. The Committee also notes that ``HIV
disease'' under the CARE Act encompasses both persons living
with AIDS as well as persons diagnosed as HIV positive who have
not developed AIDS.
Just as importantly, for the first time the CARE Act will
recognize the need for Title II supplemental grants with the
passage of H.R. 4807. These grants are intended for areas,
other than EMAs, experiencing a severe need for supplemental
financial assistance. Like with Title I supplemental awards, it
is the Committee's intention that Title II supplemental awards
should not be allocated in proportion to formula awards, but
rather on the basis of demonstrated severe need.
The Committee intends that preference should be given to
shift Title III grants to addressing the needs of rural areas
and underserved areas. This preference is intended to further
shift CARE Act programs towards eliminating disparities in
access and services among affected subpopulations and
historically underserved communities.
The Committee strongly supports the use of Title I funds to
conduct outreach activities to identify individuals with HIV/
AIDS who are not receiving services, and get them under medical
care and treatment. President Reagan's HIV Commission concluded
that ``early diagnosis of HIV infection is essential'' because
HIV infection ``can be treated more effectively when detected
early.'' The Committee concurs with these findings and
acknowledges that the medical breakthroughs which have been
developed in the twelve years since the issuance of this report
make early intervention even more important. This authorization
reflects the Committee's intent to increase the coordination
between HIV prevention and HIV care and treatment services in
all CARE Act programs. The Committee expects such activities
will be of particular importance when focusing on underserved
populations, and of particular value in bringing into and
retain in care those individuals who are knowledgeable of their
status but are not receiving services.
HIV Reporting. According to CDC, in June 1999 there were an
estimated 287,946 Americans living with AIDS. Currently, CDC is
not able to determine how many Americans were living with HIV,
because only 29 states report HIV cases. CDC expects all states
to be reporting newly diagnosed HIV cases by 2003 and than an
additional 1 to 3 years may be needed to get all HIV cases
entered into such new reporting systems. It is difficult for
regions without reliable HIV surveillance to adequately address
the needs or understand the scope of the epidemic.
The identification of HIV reporting as a serious public
health concern was identified by the first Presidential
Commission on HIV, appointed by President Reagan, which issued
the ``Report of the Presidential Commission on the Human
Immunodeficiency Virus Epidemic'' on June 24, 1988. According
to that report:
The term ``AIDS'' is obsolete. ``HIV infection'' more
correctly defines the problem. The medical, public
health, political, and community leadership must focus
on the full course of HIV infection rather than
concentrating on later stages of the disease (ARC and
AIDS). Continual focus on AIDS rather than the entire
spectrum of HIV disease has left our nation unable to
deal adequately with the epidemic. Federal and state
data collection efforts must now be focused on early
HIV reports, while still collecting data on symptomatic
disease.
Eleven and a half years later, the CDC has implemented
proposals consistent with proposals made by President Reagan's
Commission on the Human Immunodeficiency Virus Epidemic.
To address the challenge of insufficient value being
derived from AIDS data alone, CDC joined the Council of State
and Territorial Epidemiologists (CSTE) to recommend in December
1999 that all states and territories include name surveillance
for HIV infection as an extension of their AIDS surveillance
activities. On May 11, 2000,
Surgeon General Satcher testified before the Subcommittee
on Health and Environment that he agreed with the CDC and CSTE
recommendation. In light of the consensus that has finally
emerged, the Committee believes all jurisdictions should shift
the focus fromAIDS to the full spectrum of HIV infection for
improved prevention and care. Federal funding as well should be based
upon the full extent of the disease rather than only on the late stages
defined as AIDS. This will ensure more equitable funding and more
timely and appropriate responses.
The consequences and human toll of dithering over HIV
reporting over the last decade has been high, and not just in
this country. The Committee believes that other public health
institutions throughout the world have not yet adopted HIV
reporting, and for this reason the Committee strongly
recommends that the CDC should work in consultation with HRSA
on all international HIV/AIDS initiatives to avoid repeating
mistakes made in the past. The Committee is also concerned
that, because public health institutions had no data to show
the rate of growth of HIV cases among various American cultural
and ethnic communities, communities of color are
disproportionately affected and infected by the HIV epidemic.
HIV Case Classification. The Committee is aware of concerns
that the heterosexual and NIR categories as currently defined
may result in systematic underreporting of heterosexual cases
of HIV, which could be detrimental to addressing the prevention
needs of certain groups, particularly communities of color.
This classification system may have been satisfactory early
in the epidemic, but the changing dynamics of the HIV/AIDS
epidemic require a timely reassessment and refinement of
current classification methods. The Committee applauds the
CDC's recognition of State efforts to accomplish these goals,
including Virginia's efforts to identify NIR cases with
multiple sex partners. The CDC has indicated that it is also
currently reassessing HIV/AIDS case classification methods to
ensure the most adequate understanding of the disease and its
modes of transmission and to properly allocate and target
resources to those groups that are increasingly at risk of
infection, such as African American females.
Based on this understanding, the Committee urges the
Secretary to commit to an agenda of coordinated actions with
the States and patient advocates, including the development and
validation of rigorous sampling techniques, the promulgation of
formal guidance to the States, the provision of technical
assistance to State and local health authorities, and the
expansion of the CDC's current pilot projects with interested
States. Finally, the Committee applauds the CDC's commitment to
hold a public meeting to obtain expert opinion on this issue,
and its current efforts to consult with the Committee prior to
the meeting regarding its attendance.
Demographics and Needs of Populations with HIV Disease. The
comprehensive service delivery plan is an effective way to
demonstrate the organization and delivery of CARE Act services
based upon the planning, priority setting, and funding
allocation processes conducted by the planning council. The
intent of the legislation is also to have the additional
factors reflected in the plan. Those factors include
disparities in access to medical and health-related support
services by specific subpopulations; the needs of persons with
HIV not in care; capacity development needs; and quality of HIV
primary care and health-related supportive services. Both the
planning process and the resulting plan should include the
participation of, and address the needs of, populations and
subpopulations living with HIV and AIDS.
The Committee requires that Planning Councils determine the
size, demographics and needs of the population with HIV
disease. The Committee recognizes that adequate and reliable
data on HIV prevalence may not be uniformly available in all
eligible areas on the date of enactment. Therefore, priorities
for the allocation of funds and the comprehensive plan should
reflect HIV prevalence to the extent that data are reasonably
available. The Committee also notes that ``HIV disease'' under
the CARE Act encompasses both persons living with AIDS as well
as persons diagnosed as HIV positive who have not developed
AIDS.
The reauthorization bill reflects the Committee position
that priority setting and funding allocation decisions should
be based on the size and demographic characteristics of the
populations with HIV disease in the eligible area. Planning,
priority setting, and funding allocation processes must take
into account shifts in the local HIV/AIDS epidemic, existing
health HIV-related disparities, and resulting negative health
outcomes.
The Committee intends Planning Councils to develop a
strategy to identify individuals with HIV disease who are not
receiving services and to inform and enable such individuals to
receive services under Title I. The Committee wants CARE Act
providers to work actively to bring into and retain in care
those individuals who are unaware of their HIV status and those
who are knowledgeable of their status but are not receiving
services. As part of this process, the Committee believes
strongly in the importance of Planning Councils focusing on
eliminating disparities in access and services among affected
subpopulations and historically underserved communities. The
Committee recognizes that the availability or lack of HIV
prevalence data in particular EMAs will be reflected in the
scope, goals, timetable and allocation of funds for
implementation of the strategy.
The Committee also intends Planning Councils to develop a
strategy to coordinate the provision of Title I services with
HIV prevention services and substance abuse prevention and
treatment services. The Committee has amended numerous aspects
of CARE Act programs to enhance the coordination between HIV
prevention and HIV care and treatment services. The Committee
further requests that the Secretary work with title I grant
recipients and providers to establish epidemiologic measures
and tools for use by EMAs in identifying the number of
individuals with HIV infection, especially those who are not in
care.
The Committee expects that the development of such measures
will refine and expand the ability of EMAs and Planning
Councils to identify and provide services to individuals with
HIV disease who are not receiving services. The efforts on the
part of EMAs and Planning Councils to accomplish these
important tasks, however, should not be delayed until this
process is complete. Instead, the Committee expects EMAs and
Planning Councils to establish and implement strategies
responsive to these urgent needs before the development of
nationally uniform measures, to the extent that is practicable
and to which necessary prevalence data is reasonably available.
Early Intervention Services. The Committee authorizes early
intervention services as eligible services under certain
circumstances in Titles I and II. The Committee intends to
allow grantees to provide certain early intervention services,
such as HIV counseling, testing, and referral services, to
individuals at high risk for HIV infection in accordance with
statewide planning and regional consortia planning activities.
Additionally, the Committee intends that the types of
organizations that may provide early intervention services are
the same as those that provide other HIV-related services
through Parts B or C of the Act, or are points of access into
the health care system for individuals at high risk for HIV, as
specified by States under guidance from HRSA's Bureau of HIV/
AIDS.
The Committee recognizes that these organizations may
include traditional community based organizations (CBOs) that
act as points of entry and/or referral agencies into the health
care system, especially for traditionally underserved and
minority populations. This provision is solely for the purpose
of expanding the scope of primary care services to include HIV
testing, counseling, and referral. The Committee recognizes the
importance of early intervention services in increasing access
to medical services through established relations with a broad
network of health care entry points and HIV medical providers
that serve as critical entry points for medical services for
uninsured, and underinsured, low-income and rural communities.
The Committee specifically intends that funds not be used to
supplant other funds available to States for the provision of
early intervention services and that these funds are utilized
only when existing Federal, State or local funds are inadequate
to provide these services. Further, the Committee intends that
such services need to be provided according to guidelines
established by the CDC and according to the laws and
administrative regulations of State and local governments. The
Committee expects that the Secretary, working with grantees and
the public health community, will provide guidance to establish
the appropriate parameters for the use of CARE Act funds for
these purposes and to coordinate these activities with existing
early intervention services. The Committee recognizes that
other funding sources may exist for these services and expects
all grantees to seek out and use these funds to enhance medical
care to the extent they are reasonably available.
The Committee finds that all counseling for HIV-infected
individuals should emphasize that it is the duty of infected
individuals to disclose their infected status to their sexual
partners and others who are they potentially may place at risk
of infection. The Committee recognizes that proper counseling
better enables individuals living with HIV to make such
disclosures. The Committee intends for entities providing care
under this legislation will provide such counseling and
emphasize that it is the continuing duty of the infected
individuals to avoid any behaviors that will expose others to
HIV.
The Committee heard testimony in 1998 from an HIV infected
man who became infected because his partner hid his HIV status
and did so after counseling from Federally supported
organizations which did not advise him to disclose. The
Committee believes that this policy all those who are infected
should be provided proper advice to disclose and provided the
counseling to do so. Recent studies have found that the
continuing epidemic in the United States is being driven by
infected individuals who do not disclose their status and
continue to engage in risky behaviors. The Committee believes
that existing prevention policies have failed to adequately
address such behavior and have enabled them to continue. This
provision will provide better secondary prevention and protect
the infected from other health complications including dual HIV
infection.
Rapid HIV Test. The Committee also seeks to expand and
coordinate efforts at the NIH and FDA to develop rapid HIV
tests. Accurate and affordable rapid HIV tests have many
potentially important applications, one of which would be to
help diagnose pregnant women whose HIV status is not known late
in pregnancy or at the time of labor. The purpose of this
initiative is to help increase opportunities for individuals,
including pregnant women, to learn their HIV status. The
Committee recognizes that labor is not an ideal time to obtain
consent for testing or to discuss the implications of a
positive test result. It is not the intent of this Committee to
diminish the right of patients to make an informed decision to
be tested. In establishing or updating relevant guidelines, CDC
should address how to ensure that the meaningful decision
making ability of patients is preserved. These guidelines
should recognize that states have varying laws and policies
related to the communication of test results. The Committee
encourages the FDA to facilitate CDC's ability to use rapid HIV
tests as soon as possible, consistent with the FDA's approval
process.
Partner Notification. The results of various regional
studies confirm that partner notification is a useful and
effective intervention and prevention tool. Infected
individuals are less likely to notify partners themselves, but
will cooperate with programs conducted by public health
professionals. Studies and surveys have also concluded that
partners notified about potential exposure to HIV support
notification programs.
The Presidential Commission on HIV stated, ``public health
authorities across the United States must begin immediately to
institute confidential partner notification, the system by
which intimate contacts of the person carrying sexually
transmitted diseases, including HIV, are warned of their
exposure.''
Partner notification has proven to be highly effective. Up
to 90 percent of those who test positive cooperate voluntarily
with notification. Further, even higher proportions of those
partners contacted--usually 90% or more--voluntarily obtain an
HIV test. But only 10 percent or less of people who have
recently tested HIV-positive manage, by themselves, to notify
their partners.
Partner notification is especially important for women
because many HIV-infected women do not engage in high risk
behaviors but were infected by a partner who does. Recent
studies indicate that AIDS develops more quickly in women who
would therefore benefit from being alerted to their condition
as early as possible. Partner notification has been credited,
in part, by the public health community for the fact that
syphilis cases in the U.S. have fallen to the lowest levels in
history.
The Committee heard testimony from the State of Florida,
which recently enacted a partner notification program, that
such ``activities are effective interventions for reaching
individuals at high risk of HIV infection and are unaware of
their risk.'' States have been successful in reducing the
number of new HIV infections--contrary to national trends--in
large part to effective partner notification programs.
The legislation authorizes $30 million for states to enact
such policies, but does not require that they do so as a
condition of eligibility for Title II funding. States with
systems that are approved by the CDC will receive preference
for these grants. No State that does not meet the CDC
surveillance recommendations will be eligible for these funds
after 2004.
Vulnerable Populations. The Committee is concerned that not
all Americans receive the same quality of treatment under the
CARE Act. As the GAO found in its report entitled ``HIV/AIDS:
Use of Ryan White CARE Act and Other Assistance Grant Funds'':
Women also did not fare as well as men on most of the
measures. Finally, exposure category was a significant
factor; those who had acquired their infection by
injecting drugs or through heterosexual sex had less
favorable patterns of care than did men who had sex
with men [MSM].
Therefore, the Committee strongly encourages the Office of HIV/
AIDS Policy and the Office on Women's Health (OWH) to provide a
report to Congress on all activities conducted by the US
Department of Health and Human Services that impact women who
are infected and affected by HIV/AIDS. The report shall include
an evaluation by the OWH of the scope and effectiveness of
these activities. It will also identify gapsin prevention and
care services and in research involving or targeted towards women
living with HIV/AIDS. The HHS Secretary shall direct the appropriate
agencies within the Department to collaborate with the OWH on such a
report.
Priority for Women, Infants, Children and Youth. The
Committee has expanded the existing priority on services for
women, infants and children to also include youth. The
Committee intends the term ``youth'' to include persons between
the ages of 13 and 24, and the term ``children'' to include
those under the age of 13, including infants.
The Committee emphasizes that the minimum amount
established by H.R. 4807 is in no way to be construed as a
maximum on how much a planning council may spend on these
populations. The Committee also recognizes that these priority
populations often comprise a greater proportion of HIV cases
rather than AIDS cases in a local area. If data on HIV, rather
than the endstage of AIDS, are available, planning councils
should take this into account when allocating resources.
The Committee recognizes that, according to the CDC, young
people ages 24 and under account for at least half of new HIV
infections. The Committee urges planning councils to assure
that more is done to provide appropriate services to youth,
including prevention, in coordination with Title IV grantees
operating in the area.
Perinatal Transmission. Perinatal transmission of HIV is
the leading cause of pediatric cases AIDS, and the Committee
recognizes the importance of life-saving newborn screening
programs. According to the 1998 Institute of Medicine report
``Reducing the Odds: Public Health Screening Programs'', these
programs have a long pedigree in the public health profession:
The first parental screening program mandated by law
was for syphilis in the 1930s and 1940s. In early
1960s, many states mandated newborn screening for PKU,
a condition that can lead to mental retardation without
dietary interventions, and other inborn errors of
metabolism. Screening for other inborn errors of
metabolism (congenital hypothyroidism, galactosemia,
homocystinuria, histidenemia, maple syrup urine
disease, and tyrosinemia) followed in the 1970s. In the
early 1970s, many states initiated mandatory screening
for sickle cell disease, a disease that had limited
treatment options, in a variety of populations. Later
in the same decade, maternal serum alpha-fetoprotein
tests were introduced, on a voluntary basis, to help
detect neural tube defects. Today, specific tests
mandated or recommended as standards of practice vary
substantially across state lines. Mandatory prenatal
and newborn testing for substance abuse is increasingly
common.
Despite improved progress in developing effective
strategies to reduce perinatal HIV transmission, the CDC
estimates that nearly 7,000 HIV-infected women give birth in
the United States each year and as many as 400 babies continue
to be born with HIV infection each year. Breastfeeding by HIV-
infected mothers poses additional significant risk of infection
to babies.
Even if there were no effective therapies for perinatal HIV
transmission, routine testing still would benefit the public
health. As the 1998 IOM report pointed out,
In 1936, Thomas Parran, the U.S. Surgeon General,
established a program for controlling syphilis that
included mandatory prenatal blood tests * * *. Although
these laws were passed before the introduction of
antibiotic treatment, they resulted in rapid decline in
congenital transmission through case finding * * *
contact tracing, and the difficult and less effective
therapies available at the time. Perhaps the most
important aspect of these screening programs was that
by making testing routine, they overcame the resistance
of physicians to risk offending patients by suggesting
a test for syphilis.
Fortunately, medical advances have made it possible to
nearly eliminate perinatal HIV transmission. In 1994, research
studies demonstrated that the administration of antiretroviral
medication during pregnancy, during labor, and to the infant
immediately following birth can significantly reduce the
transmission of HIV from an infected mother to her baby. From
1994 to 1999, as a result of these interventions, pediatric
AIDS cases resulting from perinatal HIV transmission declined
by nearly 80 percent. Subsequent studies have indicated that
cesarean sections further reduce the risk of transmission.
Studies also indicate that, even if treatment begins shortly
after birth, antiretroviral therapy can substantially reduce
the chance that an HIV-exposed child will become infected.
Due to the availability of interventions to reduce
perinatal HIV transmission and to improve the health of HIV-
infected women and their children, it is important to increase
the number of pregnant women who receive prenatal care and are
tested for HIV. In 1995, the House approved a measure requiring
universal HIV testing of all newborns. The American Medical
Association recommends HIV testing for all pregnant women and
newborns with counseling and recommendations for appropriate
treatment. The IOM has recommended the adoption of a national
policy of universal HIV testing, with patient notification, as
a routine component of prenatal care. Regrettably, according to
the IOM, 15 percent of HIV-infected pregnant women receive no
prenatal care at all.
The routine offering of HIV testing to pregnant women
should be a standard of care. Sufficient information must be
provided to a pregnant woman so she can make an informed
decision to be tested. Studies show that the vast majority of
pregnant women will accept an HIV test if it is offered to
them. In addition, testing newborns whose mothers' HIV status
is unknown helps to ensure that children at risk for HIV are
identified and provided treatment.
The offering of HIV testing to pregnant women and to
newborns whose mothers' HIV status is unknown, combined with
appropriate counseling and treatment, can significantly reduce
perinatal HIV transmission, improve access to medical care for
HIV-infected women and children, and provide opportunities to
further reduce HIV transmission among adults.
For the reasons cited above, the Committee finds the
following: (1) universal, routine offering of HIV testing to
pregnant women should be a standard of care; (2) HIV testing of
newborns whose mothers' HIV status is unknown a standard of
care; and (3) relevant medical organizations, public and
private payers of health insurance, and public health officials
should issue or update relevant HIV counseling, testing and
treatment guidelines accordingly.
The Committee also recognizes the need for additional
resources to further reduce perinatal HIV transmission. The
legislation authorizes an additional $20 million for activities
to reduce perinatal transmission, including outreach,
education, testing and treatment for pregnant women and their
newborns.
The current statute requires, as a condition of funding,
that States have regulations or measures to adopt CDC
guidelines concerning HIVcounseling and testing for pregnant
women and newborns. Women who initially refuse testing should be
encouraged to reconsider at later points in their pregnancy. When
appropriate, pregnant women who accept testing when it is initially
offered and test negative should be encouraged to get tested again
later in pregnancy.
Additionally, consistent with State laws and regulations,
sufficient information should be provided to all pregnant women
so they can make an informed decision to be tested for HIV.
Adequate training and education should be provided to prenatal
care providers on the risks of perinatal transmission, and the
importance of offering HIV tests to all pregnant women, the
benefits of interventions, and the availability of referral
sites for women who test positive should be emphasized.
The Committee also believes that it is also important that
appropriate post-test counseling, referrals, and linkages to
care for HIV-positive women and their children be provided, and
that women are not counseled to terminate their pregnancies on
the basis of HIV status. States should also have to show that
they are taking steps to increase the proportion of women who
receive prenatal care, including targeted outreach and
education efforts in areas with highest numbers of women who
get no or inadequate prenatal care. Reforms to State insurance
laws should require that, if health insurance is in effect for
an individual, the insurer involved may not (without the
consent of the individual) discontinue the insurance, or alter
the terms of the insurance, solely on the basis that an
individual has been tested for HIV or is infected with HIV.
The Committee has reserved a portion of the additional
funding for States that conduct HIV testing of all newborns, or
newborns whose mothers' HIV status is unknown. If newborn
testing is conducted, in order to maximize the opportunity for
reduction of perinatal transmission after birth, the Committee
urges states to assure that test results are provided within 48
hours. The Committee recognizes that HIV test results for the
newborn will generally also reveal the HIV status of the
mother. Therefore, if a newborn tests positive for HIV, it is
essential for the mother to be informed of the test results and
provided care in a sensitive manner that is consistent not only
with CDC guidelines, but also with appropriate measures to
protect the confidentiality of both mother and child.
The Committee encourages all states, including those that
do not apply for this additional funding, to take these steps
and other activities as necessary to reduce perinatal HIV
transmission. States are encouraged to coordinate their
activities with those of Title IV grantees and other entities
that provide services related to the reduction of perinatal HIV
transmission. Where appropriate, states are encouraged to
provide a portion of grants under this section to Title IV
grantees operating in the State.
To assure that there are no financial barriers to the
offering of HIV testing to all pregnant women or to providing
treatment to reduce perinatal HIV transmission and improve the
health of HIV-positive women and children, the Committee
encourages all payers of health insurance, both public and
private, to assure that HIV testing and treatment during
pregnancy and for the mother and child are covered benefits.
The Committee requires that States report to Congress on
the progress toward meeting the recommendations of the IOM.
Those who have not made progress toward meeting such
recommendations must, as a condition of receiving funding,
cooperate with the CDC and submit a report to the Secretary on
progress identifying and overcoming barriers to eliminating
perinatal HIV transmission.
The Committee does not intend that this bill detrimentally
affect religious practices or religious freedom. However,
nothing in this bill is designed to preempt existing or
prohibit new State religious accommodation laws that allow
those with religious objections to decline to have their
newborn infants tested for HIV disease if such exemptions exist
under state law for other reportable diseases. Further,
religious accommodation laws enacted by recipient States shall
have no impact whatsoever on the level of federal funding
received by the recipient State.
The Committee heard testimony from Mr. Tom Liberti, Chief,
Bureau of HIV/AIDS, Florida Department of Health, who detailed
how the enactment of a successful HIV reporting system enabled
the state to better address the epidemic, particularly within
the African-American and Hispanic communities. The availability
of such a system will better ensure that all communities
affected are recognized and are receiving appropriate care and
medical access, thereby reducing disparities and allowing for
the equitable allocation of funds.
Minority AIDS Initiative. While the Ryan White CARE Act, in
general, has had significant success in addressing the needs of
individuals and communities affected by the disease, ethnic and
racial minority communities continue to experience disparities
in health outcomes in terms of HIV and AIDS. The legislation
includes several provisions that intend to refocus and enhance
representation, planning, prioritization, and allocation of
CARE Act resources to address disparities in health outcomes
and the needs of historically underserved and vulnerable
communities.
According to the written testimony of Loretta Davis-
Satterla, Director, Division of HIV/AIDS-STD with the Michigan
Department of Community Health submitted for the Subcommittee
on Health and Environment hearing on May 11, 2000:
In Michigan, confidential HIV reporting has been
required by statute since 1989. Confidential HIV
reporting has greatly enhanced Michigan's ability to
rapidly and effectively respond to the dynamics of this
epidemic * * * In contrast to AIDS case surveillance,
HIV case surveillance provides data to better
characterize populations in which HIV infection has
been newly diagnosed, including persons with evidence
of recent HIV infection. Compared with persons living
with AIDS, those reported living with HIV infection in
Michigan are more likely to be women (18% for AIDS vs
26% for HIV) and African Americans (55% for AIDS and
62% for HIV). Approximately 1% of AIDS cases occurred
in both persons aged 13-19 years and 20-24 years. In
comparison, 4% of HIV cases occurred in persons aged
13-19 years and 13% of HIV cases occurred in persons
20-24 years. Thus, AIDS case surveillance alone does
not accurately reflect the extent of the HIV epidemic
among African Americans, women, adolescents and young
adults.
In addition, the Committee affirms the intent of the
Minority AIDS Initiative (MAI) in addressing the unique needs
of ethnic and racial minority communities. The initiative is
intended to complement and supplement, not supplant, the
efforts of the Ryan White CARE Act and other national AIDS
programs. The MAI was instituted in response to the
overwhelming and disproportionate impact of the HIV epidemic on
ethnic and racial minority communities.
The MAI is intended to address the needs of Americans in
highly impacted communities by enhancing outreach and
education, strengthening technical assistance, and supporting
capacity building of ethnic and racial minority community based
organizations and institutions and providers to deliver
culturally competent and appropriate HIV-related prevention,
health care, and support services. The initiative also seeks to
expand or fund new research initiatives to develop and evaluate
culturally competent intervention strategies directed towards
reducing and ultimately eliminating the HIV-related health
disparities experienced by ethnic and racial minority
populations. In this regard, the MAI may prove to be a
significant component of an overall strategy for addressing the
disease. The Committee encourages the Department of Health and
Human Services to include the MAI in its efforts to achieve an
integrated and coordinated system of HIV/AIDS care and
treatment. With respect to entities that currently receive or
have received planning grants through special initiatives such
as the MAI, the Committee intends that these entities will be
still be eligible for such grants under Part C if they meet the
appropriate funding criteria.
MAI funding is intended to be targeted to ethnic and racial
minority-governed and staffed organizations and where no such
organization exist, to institutions that have a history of
providing culturally competent services to the communities and
populations they are targeting. The funding is intended to
build capacity and infrastructure within these communities, and
fill gaps in critically needed HIV and AIDS services. This
includes providing primary HIV prevention, increasing access to
HIV and related health and support services, and ensuring
continuity of care for ethnic and racial minority populations
and sub-populations including minority women, youth, MSMs,
substance abusers, homeless, incarcerated and recently-released
individuals.
Incarcerated Populations. The Committee recognizes that HIV
public health interventions implemented in correctional
settings have great potential to have a significant impact on
the epidemic. The success of in-prison interventions requires
continuation of medical treatment and behavior modification
following release. Post-release failure of inmates to adhere to
HIV medical regimens may pose public health dangers by
fostering development and transmission of drug-resistant HIV
variants. Also, because the vast majority of inmates will be
released to their communities, prison, jail, and similar
restricted institutions intervention is vital to reduce HIV
transmission to the general public. Therefore, the Committee
believes that improved discharge planning and continuity of
care between correctional facilities and communities are needed
to increase the likelihood that HIV-positive releasees will
obtain the care they need and take precautions to avoid
spreading the disease. Effective pre-release programs can also
help inmates make positive changes in their lives to avoid
returning to crime, with the resulting reduced recidivism rates
yielding significant benefits to society. The Committee
therefore urges the Secretary to give favorable consideration
to grants under the Ryan White CARE Act for programs that
provide linkages with correctional discharge planning and other
transitional services needed to help HIV-positive inmates move
successfully from correctional institutions to their
communities. These transitional services, which may be needed
up to six months prior to release, may include, but are not
limited to, clinical referrals, psychosocial services,
enrollment in medical care funding programs, a short-term
supply of medications upon release, HIV pre-release
identification efforts, HIV prevention education, HIV related
counseling, coordination and referral, and linkages for
substance abuse treatment, and HIV related case management
services and linkages to CARE Act programs in their
communities.
In addition to prisons and jails, other residential
institutions, such as substance abuse treatment facilities and
mental health institutions, also have a high concentration of
persons at high risk of HIV infection and pose similar
intervention opportunities and challenges. The Committee thus
urges the Secretary to give favorable consideration to grants
under the Ryan White CARE Act for programs that provide
discharge planning and other transitional services, including
the types of services enumerated above, which are needed to
help HIV-positive institutional residents move successfully
from institutions to their communities.
Quality Assurance. The Committee recognizes the importance
of having CARE Act grantees ensure that quality services are
provided to people living with HIV and that the quality
management activities are conducted on an ongoing basis.
Quality management activities should: assess the extent to
which HIV health services provided under this grant are
consistent with Public Health Service guidelines for the
treatment of HIV and the treatment and prevention of related
opportunistic infections and, as applicable, lead to the
development of strategies to ensure that such services are
consistent with the guidelines and that social support services
are provided in a manner as to gain or enhance the benefits of
health care services.
The Committee expects the Secretary to provide States with
guidance and technical assistance for establishing quality
management programs, including disseminating such models that
have been developed by States and are already being utilized by
Title II programs and in clinical practice environments. The
Committee hopes that States will communicate and coordinate
CARE Act requirements with other payers to the extent possible
to ensure consistency in quality management activities. The
Committee expects that most States have quality management
systems in place already and that they utilize mechanisms such
as peer chart reviews or patient prescription pattern
monitoring. The Committee places responsibility on the
Secretary to ensure that PHS guidelines, as well as population
characteristics and trends in the use of HIV services, are
communicated to all CARE Act grantees and sub-grantees. This
information, the Committee believes, will assist grantees in
ensuring the highest quality of HIV care among CARE Act
providers.
The Committee intends that the Secretary provide
clarification and guidance regarding the distinction between
use of CARE Act funds for such program expenditures that are
covered as either planning and evaluation and funds for program
support costs. Program support costs are described as any
expenditure related to the provision of delivering or receiving
health services supported by CARE Act funds. As applied to the
clinical quality programs, these costs include, but are not
limited to, activities such as chart review, peer-to-peer
review activities, data collection to measure health indicators
or outcomes, or other types of activities related to the
development or implementation of a clinical quality improvement
program. Planning and evaluation costs are related to the
collection and analysis of system and process indicators for
purposes of determining the impact and effectiveness of funded
health-related support services in providing access to and
support of individuals and communities within the health
delivery system.
HIV Consortia. The Committee intends that States continue
to work with local Consortia to ensure that they identify
potential disparities in access to HIV care services at the
local level, with aspecial emphasis on those experiencing
disparities in access to care, historically underserved populations,
and HIV infected persons not in care. However, the Committee does not
intend that States and/or Consortia be mandated to consult with all
entities referenced as part of the planning process under Part A. The
Committee intends that States and Consortia will continue to work with
the appropriate entities in their jurisdictions to assess and plan
services at the local level. Reference to entities included in the
Title I planning process is intended to provide guidance to the States
that such entities are important constituencies which the States should
endeavor to include in their planning processes. The Committee intends
that the States require local Consortia to document their efforts to
identify and address access disparities at the local level, as
appropriate.
Title II Comprehensive Plan. The comprehensive service
delivery plan is an effective way to demonstrate the
organization and delivery of CARE Act services, based upon the
planning, priority setting, and funding allocations processes
conducted by the State. The Committee intends that States may
demonstrate compliance with the new requirement of an enhanced
process of public participation by indicating in their
applications existing mechanisms for consumer and community
input, and describing how such mechanisms influence the use and
distribution of funds and the number of persons not in care and
unmet needs of persons not receiving health services. The
Committee intends States to develop a strategy to identify
individuals with HIV disease who are not receiving services and
to inform and enable such individuals to receive services under
Title II. The Committee wants CARE Act providers to work
actively to bring into and retain in care those individuals who
are unaware of their HIV status and those who are knowledgeable
of their status but are not receiving services. As part of this
process, the Committee believes strongly in the importance of
the States focusing on eliminating disparities in access and
services among affected subpopulations and historically
underserved communities. The Committee recognizes that the
availability or lack of HIV prevalence data in particular
States will be reflected in the scope, goals, timetable and
allocation of funds for implementation of the strategy.
The Committee also intends States to develop a strategy to
coordinate the provision of Title II services with HIV
prevention services and substance abuse prevention and
treatment services. The Committee has amended numerous aspects
of CARE Act programs to enhance the coordination between HIV
prevention and HIV care and treatment services.
The Committee intends that additional factors be reflected
in the plan such as disparities in access to medical and
health-related support services by subpopulations. Upon the
development of measures by the Secretary and Title II grantees,
as described above, the needs of persons with HIV not in care
should be considered in the comprehensive plan. Both the
planning process and the resulting plan should continue to
include the participation of, and address the needs of,
populations and subpopulations living with HIV and AIDS. The
specific needs of populations or subgroups, such as women,
people of color, persons who are underinsured or uninsured,
youth, homeless persons, persons living in rural areas, or
persons with substance abuse or other co-occurring conditions
within the State need to be specifically addressed. States
should continue to consider the availability of services
through other public and private health care payers and
providers including Medicaid, the State Children's Health
Insurance Program (SCHIP) and other public and private sources
of health care reimbursement. States should ensure that there
are strong coordinating mechanisms between Ryan White and the
State Medicaid programs to assure optimal health care for
persons living with HIV disease. States should continue to
collaborate with other health care and social service providers
and payers through the Statewide Coordinated Statement of Need
(SCSN) process. The Committee does not intend to mandate that
States devote specific portions of their Title II grant funds
to specific activities. The Committee recognizes the need for
flexibility for States in the administration of Title II
programs in order to ensure that local needs are addressed.
ADAP. The legislation strengthens the ADAP program to
assist States that are struggling to provide medications to all
of their needy clients. The Committee has also sought to
strengthen the ability of local communities, States, and
service organizations to reach those communities and
populations that have been historically most underserved, as
well as those that are experiencing rapid increases in HIV
infection and AIDS case counts but that have not been brought
into the care system developed under Ryan White. The purpose of
these changes is to ensure a strong system of health care
delivery and access to therapies commensurate with evolving
needs.
This section has been amended to permit States to utilize
funds under this section to purchase and maintain health
insurance on behalf of individuals with HIV disease whose
coverage provides a full range of HIV therapeutics and primary
care services. The Committee recognizes the cost-effectiveness
and potential cost-savings of such a mechanism in the provision
of treatments and the fact that several States have already
fully integrated such mechanisms into their treatment provision
systems.
Grants for Coordinated Services and Access to Research for
Women, Infants, Children and Youth. The Committee does not
intend to require Title IV applicants to file separate reports
to the Secretary to demonstrate linkages to research and how
access to such research is offered to patients. Instead, such
reporting may be completed as part of the existing grantee
reporting process. The report on the distribution and
availability of ongoing and appropriate HIV/AIDS-related
research projects shall not be interpreted as requiring the
Secretary to recommend the redistribution of funds for such
research projects or to act on redistributing these funds based
on the report's findings.
Early Intervention Services. The Committee expects that
EMAs will provide services to American Indian and Native
American peoples. Native Americans and American Indians are
eligible for Ryan White services through State and Federal
citizenship. The Committee supports better co-ordination of
Ryan White services for Native Americans and American Indians
in order that they may realize the full potential of HIV/AIDS-
related primary care and support services provided through CARE
Act funding.
The Committee also recognizes that the US Department of
Veterans Affairs is the largest single direct provider of HIV
care and services in the US. Over 18,000 veterans received HIV
care at VA facilities in 1999. Veterans with HIV infection are
eligible to participate in Ryan White Title I programs when
they meet eligibility requirements set by Title I Planning
Councils, and EMA plans for the delivery of services must
account for the availability of VA services. VA facilities are
eligible providers of HIV health and support services where
appropriate. The Committee expects that HRSA's Bureau of HIV/
AIDS shall encourage Ryan White grantees to develop
collaborations between providers and VA facilities to optimize
coordination and access to care to all persons in Title I EMAs.
The Committee understands that the Secretary has convened a
Public Health Service Working Group on HIV Treatment
Information Dissemination, which has produced recommendations
and a strategy for the dissemination of HIV treatment
information to health care providers and patients. Recognizing
the importance of such a strategy, the Committee intends that
the Secretary issue and begin implementation of the strategy to
improve the quality of care received by people living with HIV/
AIDS.
Administrative Simplification. The Committee is aware of
the enormous administrative burden that the current grant
application process places on States and recipients of grants
under Part A. The Committee is concerned that the current
application process may divert critical resources from the
provision of care. Therefore, the Committee directs the
Secretary to consult with States and recipients of grants under
Part A regarding the coordinated disbursement of funds under
Part A with the disbursement of funds under Part B, the
implementation of a biennial application process under Parts A
and B, and the overall simplification and streamlining of the
grant application for funds under Parts A and B. The Committee
expects that the Secretary will undertake this consultation
with States and entities receiving funds under Part A in an
expeditious manner and will work with these States and entities
to implement agreed upon strategies as soon as possible.
Audits and Consumer Participation. The Committee intends
that to the maximum extent possible the funds made available
through this legislation are intended for the actual medical
and support services needs of the infected population, and not
simply ``quality of life'' issues. According to a November 13,
1997 New York Times story, some services that have been offered
using Federal funds included ``free dog walking.'' Any funds
misallocated through frivolity, waste or outright fraud deny
someone else living with HIV much needed care.
At the July 11, 2000 hearing the Subcommittee heard
testimony from Jose Fernando Colon, Coordinator for Pacientes
de SIDA Pro Politica Sana (AIDS Patients for Sane Policies) in
San Juan, Puerto Rico. Mr. Colon detailed for the Committee how
millions of dollars of money intended for AIDS services was
diverted for personal and political purposes, resulting in
numerous Federal Court convictions in Puerto Rico. He testified
that in 1993 the Department of Health and Human Services was
made aware of possible misconduct, but that no investigation
was ever conducted.
The GAO reported to the Congress on October 18, 1999 that
they had identified two other cases in which fraud and abuse
have occurred in regard to CARE Act funds. However, the GAO did
not find such fraud and abuse to be either systemic or
widespread among grantees or in CARE Act programs. As HRSA
Administrator Claude Fox, MD testified to the Subcommittee:
The GAO has looked at it and said there is not a
widespread problem. We agree with the provisions in
this bill. We want to do everything that we can do
within reason to make sure that these funds are well
spent. But we do not believe that it is a widespread
problem.
H.R. 4807 includes important provisions to prevent and detect
fraud with CARE Act funds.
The legislation also contains important provisions which
ensure that not less than 33% of Title I HIV Health Services
Planning Councils are composed of individuals who are receiving
HIV-related services.
The Committee emphasizes that its intent is to ensure that
patients and consumers of Title I services constitute a
substantial proportion of Planning Council memberships. The
prohibition of officers, employees and consultants is not
intended to impede the participation of qualified, motivated
volunteers with Title I grantees from serving on Planning
Councils where they do not maintain significant financial
relationships with such grantees. In contrast to such
significant financial relationships, volunteers may be
reimbursed reasonable incidental costs, including for training
and transportation, which help to facilitate their important
contribution to the Planning Councils.
The Committee intends that Planning Councils ensure its
members are knowledgeable about their duties, the functions of
the Councils, and the Councils' role in the organization and
delivery of HIV/AIDS health and support services. The provision
of training guidance and materials to the Councils by HRSA's
Bureau of HIV/AIDS will go far to ensure that Council members,
particularly patients and consumers of HIV/AIDS services, can
serve effectively and improve the allocation of resources and
the planning and implementation of Title I services.
The Committee also expects Planning Councils to provide
assistance, such as transportation and childcare, to facilitate
the participation of consumers, particularly those from
affected subpopulations and historically underserved
communities.
Further, the bill ensures that grants will be available for
training members of these planning councils, and that planning
council meetings will be open to the public. Mr. Colon stated
that these types of reforms will lead to increased
accountability, and the Committee agrees with this assessment.
Further, for the first time, the Committee intends that the
Secretary may reduce grants to States or political subdivisions
of States which fail to prepare and submit audits to the
Secretary. From these audits, the Secretary must annually
randomly review samples of the audits, ensuring that CARE Act
funds are being appropriately expended.
Hearings
The Subcommittee on Health and Environment held a hearing
on July 11, 2000. The Subcommittee received testimony from:
Claude Earl Fox, M.D., M.P.H., Administrator, Health Resources
and Services Administration, accompanied by Joseph O'Neil,
M.D., M.P.H., Associate Administrator, Bureau of HIV/AIDS,
Health Resources and Services Administration; Ms. Janet
Heinrich, Associate Director, US General Accounting Office,
accompanied by Mr. Jerry Fastrup, Assistant Director, US
General Accounting Office; Ms. Jeanne White, National
Spokesperson, AIDS Action; Mr. Tom Liberti, Chief, Bureau of
HIV/AIDS, Florida Department of Health; Guthrie S. Birkhead,
M.D., M.P.H., Director, AIDS Institute, New York State
Department of Health; Mr. Joe Davy, Policy Advocate, Columbus
AIDS Task Force; Ms. Dorothy Mann, Board Member, AIDS Alliance
for Children, Youth & Families; Mr. Jose F. Colon, Coordinator,
Pacientes de SIDA Pro Politica Sana and; Mr. Eugene Jackson,
Deputy Executive Director for Policy, National Association of
People with AIDS.
Committee Consideration
On July 13, 2000, the Full Committee met in open markup
session and ordered reported H.R. 4807, the Ryan White CARE Act
Amendments of 2000, as amended, by a voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto.
There were no record votes taken in connection with ordering
H.R. 4807 reported. A motion by Mr. Bliley to order H.R. 4807
reported to the House, with an amendment, was agreed to by a
voice vote.
The following amendments were agreed to by a voice vote:
An amendment by Mr. Coburn, No. 1, making various
technical changes to the bill; and
An amendment by Mr. Strickland, No. 4, ordering
States, consortia, and supplemental grant applicants to
seek comment from an expanded body of stakeholders used
by Title I EMA cities when preparing their required
plans.
The following amendments were withdrawn by unanimous
consent:
An amendment by Ms. Eshoo, No. 2, replacing the
``hold harmless'' provision in the bill with the Senate
provision reducing the cut in Title I funds to 2% per
year over 5 years; and
An amendment by Ms. DeGette, No. 3, giving States the
option to cover pregnant women under the State
Children's Health Insurance Program.
Committee Oversight Findings
Pursuant to clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the Committee held legislative and
oversight hearings and made findings that are reflected in this
report.
Committee on Government Reform Oversight Findings
Pursuant to clause 3(c)(4) of rule XIII of the Rules of the
House of Representatives, no oversight findings have been
submitted to the Committee by the Committee on Government
Reform.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee finds that H.R.
4807, the Ryan White CARE Act Amendments of 2000, would result
in no new or increased budget authority, entitlement authority,
or tax expenditures or revenues.
Committee Cost Estimate
The Committee adopts as its own the cost estimate prepared
by the Director of the Congressional Budget Office pursuant to
section 402 of the Congressional Budget Act of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
provided by the Congressional Budget Office pursuant to section
402 of the Congressional Budget Act of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, July 24, 2000.
Hon. Tom Bliley,
Chairman, Committee on Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 4807, the Ryan
White CARE Act Amendments of 2000.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Julia
Christensen.
Sincerely,
Steven Lieberman
(For Dan L. Crippen, Director).
Enclosure.
H.R. 4807--Ryan White Care Act Amendments of 2000
Summary: H.R. 4807 would reauthorize programs in title XXVI
of the Public Health Services Act, which was created by the
Ryan White CARE Act (Public Law 101-381). Programs funded under
the Ryan White CARE Act address the needs of individuals living
with HIV disease. The bill would amend certain provisions under
that title to increase access to care and require that care to
be consistent with the guidelines of the Public Health Service
(PHS). The bill also would create new grant programs to:
Pay for health care services for individuals
with HIV disease in states ineligible for emergency
relief grants;
Establish partner notification programs in
the states, and
Provide to states technical assistance with
setting up data surveillance and reporting systems
related to HIV disease and other funding for data
collection efforts.
The Health Resources and Services Administration (HRSA)
under the Department of Health and Human Services (HHS)
administers most of the Ryan White CARE Act programs; small
portions are implemented through the Centers for Disease
Control and Prevention (CDC) and the National Institutes of
Health (NIH). Assuming the appropriation of the necessary
amounts, CBO estimates that implementing H.R. 4807 would cost
$351 million in 2001 and $6.7 billion over the 2001-2005
period, without adjusting for inflation. The five-year total
would be $7 billion if adjustments for inflation are included.
The legislation would not affect direct spending or receipts;
therefore, pay-as-you-go procedures would not apply.
H.R. 4807 contains no private-sector mandates as defined in
the Unfunded Mandates Reform Act (UMRA). It does contain an
intergovernmental mandate as defined in UMRA, but it also
contains new budget authority for grants that may be used by
states to cover the costs associated with the mandate.
Consequently, the threshold established in UMRA ($55 million in
2000, adjusted annually for inflation) would not be exceeded.
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 4807 is shown in Table 1. The costs of
this legislation fall within budget function 550 (health).
TABLE 1.--BUDGETARY IMPACT OF H.R. 4807
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------
2000 2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
SPENDING SUBJECT TO APPROPRIATION
Spending Under Current Law:
Budget Authority \1\........................................ 1,605 0 0 0 0 0
Estimated Outlays........................................... 1,376 1,209 248 64 (\2\) 0
Without Adjustment for Inflation
Proposed Changes:
Estimated Authorization Level............................... 0 1,711 1,711 1,711 1,711 1,711
Estimated Outlays........................................... 0 351 1,402 1,608 1,676 1,678
Spending Under H.R. 4807
Estimated Authorization Level \1\........................... 1,605 1,711 1,711 1,711 1,711 1,711
Estimated Outlays........................................... 1,376 1,559 1,650 1,672 1,676 1,678
With Adjustments for Inflation
Proposed Changes:
Estimated Authorization Level............................... 0 1,793 1,766 1,800 1,834 1,866
Estimated Outlays........................................... 0 356 1,431 1,663 1,764 1,798
Spending Under H.R. 4807:
Estimated Authorization Level \1\........................... 1,605 1,739 1,766 1,800 1,834 1,866
Estimated Outlays........................................... 1,376 1,565 1,679 1,728 1,764 1,798
----------------------------------------------------------------------------------------------------------------
\1\ The 2000 level is the amount appropriated for that year for title XXVI programs.
\2\ Less than $500,000.
Basis of estimate: For this estimate, CBO assumes that the
bill will be enacted by the end of fiscal year 2000 and that
outlays will follow historical spending rates for the
authorized activities. Where specified in H.R. 4807, CBO
assumes the authorized amounts would be appropriated. Where
appropriations of such sums as necessary are authorized, CBO
based its estimates on amounts spent in the past for similar
types of activities. Table 1 shows two alternative spending
paths: one assuming no increase to account for inflation, and
one with annual inflation adjustments.
Reauthorization of existing programs
The authorizations for appropriations for most of the
programs under the Ryan White CARE Act expire at the end of
fiscal year 2000. H.R. 4807 would reauthorize those programs
for fiscal years 2001 through 2005. Table 2 shows the amount
appropriated in fiscal year 2000, and the estimated
authorization levels under H.R. 4807 for fiscal years 2001
through 2005, with adjustments for inflation.
TABLE 2.--TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS AUTHORIZED IN H.R. 4807, WITH
ADJUSTMENTS FOR INFLATION
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------
2000 2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
Programs Administered by HRSA
Reauthorizations: \1\
Part A (Title I of the Ryan White CARE Act) emergency relief 547 556 566 576 586 597
grants.....................................................
Part B (Title II) HIV care grants........................... 824 839 853 868 884 900
Part C (Title III) early intervention services.............. 138 141 143 146 149 151
Part D (Title IV) pediatric AIDS: women, children, and youth 51 52 53 54 55 56
Part D (Title IV) evaluations and reports................... 0 4 4 4 4 4
Part F demonstration and training AIDS education and 27 27 28 28 29 29
training centers...........................................
Dental reimbursements....................................... 8 8 8 8 9 9
Modifications to Current Programs:
Planning and capacity development grants.................... 0 6 6 6 6 6
AIDS education and training centers......................... 0 15 17 20 20 21
Other activities............................................ 0 6 1 1 1 1
New programs:
Supplemental grants for certain states ineligible for Part A 0 0 0 0 3 3
grants.....................................................
Complaint partner notification program...................... 0 30 31 31 32 32
-----------------------------------------------
Subtotal.................................................. 1,595 1,683 1,709 1,743 1,777 1,808
Programs Administered by CDC
HIV-related services for pregnant women and newborns \1\........ 10 30 30 30 30 30
Data collection, reports, and other activities.................. 0 25 26 26 26 27
Provisions Administered by NIH
Expansion of HIV research funds for affordable HIV testing and 0 1 1 1 1 1
issuance of reports............................................
-----------------------------------------------
Total Proposed Changes.................................... 1,605 1,739 1,766 1,800 1,834 1,866
----------------------------------------------------------------------------------------------------------------
\1\ The 2000 level is the amount appropriated for that year.
HRSA Programs. The bill would reauthorize several programs
organized under different parts of the Ryan White Care Act:
Part A of title XXVI, (also known as title I of
the Ryan White CARE Act), is the Emergency Relief Grant
program. It provides grants to eligible metropolitan areas
(EMAs) severely affected by the HIV epidemic. The funds are
used for outpatient and ambulatory health care and other
support services provided by community-based systems to low-
income or under-insured people living with HIV/AIDS.
Part B, (title II of the act), is the HIV Care
Grant program. It provides grants to states and territories for
health care and social support services. Services are delivered
primarily through consortia of providers of HIV services. Some
Part B funds also are earmarked to pay for drug treatment for
certain individuals with HIV disease. In addition, states may
use grant money to help low-income individuals purchase health
insurance through Health Insurance Continuation programs.
Part C, (title III of the act), is the Early
Intervention Services program. It awards grants to public and
private nonprofit community-based programs that provide
comprehensive primary health care services targeting at-risk
populations and aim to reduce or prevent HIV-related morbidity.
Part D, (title IV of the act), contains general
provisions. The pediatric AIDS: women, children, and youth
program provides funding to improve and expand the primary care
and support services for special populations living with HIV
disease. The program aims to increase access to comprehensive,
coordinated, community-based family-centered systems of care
for infected individuals and their families.
Part F \1\ contains the demonstration and
training programs. It authorizes a network of regional centers
that conduct HIV/AIDS education and training programs for
healthcare providers, special projects of national significance
relating to the development of innovative models of HIV/AIDS
care, and financial assistance to dental schools for
uncompensated oral health care costs for patients with HIV
disease.
---------------------------------------------------------------------------
\1\ There has never been an appropriation for Part E, which
requires the Secretary to make grants to state and local governments to
assist them in disseminating guidelines to emergency responses
employees regarding reducing the risk in the workplace of becoming
infected with AIDS.
---------------------------------------------------------------------------
CBO estimates that reauthorizing those provisions would
cost $325 million in 2001 and $6.6 billion over the 2001-2005
period.
CDC Programs. H.R. 4807 would authorize a CDC-administered
program that provides HIV-related services to pregnant women
and newborns. The bill would authorize the appropriation of $30
million a year and would expand the services covered under the
program. If at least $10 million is appropriated, part of the
amount above $10 million would be set aside for states that
comply with certain requirements such as mandatory testing. CBO
estimates that this provision would cost $11 million in 2001
and $122 million over the 2001-2005 period.
Modifications to current programs
The bill would make several modifications to existing
programs. Those changes and their estimated budgetary effects
are described below. In total, CBO estimates that implementing
these modifications would cost $5 million in 2001 and $102
million over the 2001-2005 period.
Planning and Capacity Development Grants. Section 312 of
H.R. 4807 would authorize a program of capacity development
grants to assist public and nonprofit private entities in
expanding their ability to provide primary care and early
intervention services to individuals with HIV disease in
underserved communities. Under current law, a maximum of 1
percent of the amount appropriated for Part C can be used for
planning grants. H.R. 4807 would increase to 5 percent the
proportion that could be earmarked for the new capacity
development grants and the planning grants. The maximum new
capacity development grantwould be set at $150,000 under the
bill. CBO estimates this provision would cost $1 million in 2001 and
$23 million through 2005.
AIDS Education and Training Centers and Dental
Reimbursements. H.R. 4807 would allow the Secretary of HHS to
fund projects to develop and disseminate treatment guidelines
and protocols for prenatal and gynecological care of women with
HIV disease. It also would authorize training of health
professionals in that area. H.R. 4807 would require the
Secretary to develop and implement a strategy for disseminating
HIV-related information to health care providers and patients.
The bill also would modify the dental school grant program to
allow partnership agreements between dental programs and
community-based dentists to provide services in unserved areas.
Finally, the bill would permit certified dental hygiene
programs to receive reimbursement for uncompensated oral health
care services provided to individuals with HIV disease under
the dental reimbursement program. CBO estimates that those
provisions would cost $3 million in 2001 and $71 million over
the 2000-2005 period.
Other HRSA Activities. H.R. 4807 would require that formula
grants reauthorized under Parts A and B use the number of HIV
disease cases and AIDS cases in the distribution formulas in
fiscal year 2005 and subsequent years. This provision would
have no direct impact on federal spending. The bill would
require the federal government to assist states with the new
data requirements that would directly raise their program
costs.
Part A grants. The bill would extend indefinitely the
requirement that 50 percent of appropriated funds for Part A be
disbursed within 60 days after the appropriation becomes
available. (Those funds are disbursed in the form of formula
grants.) A ``hold harmless'' provision in the bill would also
change the limit on the amount by which grants to states could
decline from year to year. Those provisions would affect the
distribution of annual appropriations and the expedited
disbursement might affect the pattern at which such
appropriations would be spent during the year (by increasing
the amounts disbursed within 60 days of appropriation), but CBO
anticipates that they would not affect total program spending.
Part B grants. Section 206 of the bill would double the
minimum Part B base award to $200,000 for states with fewer
than 90 living cases of AIDS and to $500,000 for states with 90
or more living cases of AIDS. It would also add the Federated
States of Micronesia and the Republic of Palau as entities
eligible to receive Part B funds. The bill also would modify
the hold harmless formula for Part B grants. CBO estimates
those changes would cost less than $500,000 in 2001 and $4
million over the 2001-2005 period.
Additional HRSA activities and reports. H.R. 4807 would
require several new activities by the Secretary of HHS and many
new studies and reports. The Secretary, through the
Administrator of HRSA and in consultation with grant
recipients, would be required to conduct a review of several
administrative procedures for grants provided under Parts A and
B, and develop new coordinated and more efficient procedures.
Submission of the various plans for implementing such changes
to the Congress would be due within 18 to 24 months of
enactment.
The bill also would require that the Secretary provide
training manuals and guidance materials to the Planning Council
members who make allocation decisions about Part A grants. It
also would require that the Secretary develop national
quantitative incidence data and design a mechanism for its use
in making awards for the supplemental grant money that goes to
states demonstrating ``severe need.''
The bill also would require that the Secretary of HHS, in
consultation with others, develop a plan regarding appropriate
care following the release of prisoners with HIV disease within
two years following enactment.
H.R. 4807 would require federal coordination among federal
HIV programs concerning planning, funding, and implementation
issues. This provision would affect programs administered by
HRSA, CDC, the Substance Abuse and Mental Health Services
Administration, and the Health Care Financing Administration.
The bill would require biannual reports to the Congress with an
analysis of the federal barriers to HIV program integration,
including proposals to eliminate those barriers, as well as a
status report on the coordination efforts at the federal,
state, and local levels.
The Secretary would be required to request that the
Institute of Medicine (IOM) complete a study, within two years
after the enactment of H.R. 4807, regarding the appropriate
epidemiological measures and their relationship to health-
related support services for certain individuals with HIV. The
Secretary would have to report to the Congress within 90 days
of the request's completion. The bill also would require that
the Secretary request IOM to conduct a study on the reliability
of surveillance systems used by the states and to issue
recommendations to improve those systems within three years of
enactment. H.R. 4807 also would require that the Secretary
request IOM to conduct a study within 18 months of enactment on
perinatal transmission of HIV across the states, including an
analysis of barriers to the testing of newborns and pregnant
women, and to provide state-by-state recommendations to reduce
perinatal transmission of HIV.
CBO estimates those activities and reports would cost about
$1 million in 2001 and $5 million over 2001 through 2005.
New HRSA programs
In addition to reauthorizing current programs and making
certain programmatic changes, the bill would provide
authorizations for two new provisions in the Ryan White CARE
Act that would increase program costs. The estimated
appropriations authorized in the bill for these provisions is
also shown in Table 2.
New Supplemental Grants for Certain States. Section 207 of
H.R. 4807 would create a new supplemental grant program to meet
HIV care and support needs in areas that are not eligible for
Part A grants. The Secretary of HHS would be required to
reserve 50 percent of the increase in funding for Part B grants
(other than that earmarked for state AIDS drug assistance
programs, or ADAPs) for these supplemental grants--which would
be awarded competitively to states in ``severe need'' for
additional resources. However, the program would not begin
until the amount appropriated under Part B (excluding ADAP
funds) is $20 million higher than the amount appropriated in
2000. Under the inflation-adjusted assumptions used for this
estimate such a trigger would not be reached until 2004. CBO
estimates that the new program would have no effect on federal
spending in 2001 but would cost $3 million over the 2001-2005
period.
Compliant Partner Notification Program. H.R. 4807 would
establish a new grant program for partner notification,
counseling, and referral services. States would have to
cooperate with CDC and comply with certain requirements,
including information sharing between states, to be eligible to
receive funds. The bill would authorize $30 million for this
program in 2001 and such sums as necessary through 2005.
Assuming appropriation of the necessary amounts, CBO estimates
that implementing this provision would cost $6 million in 2001
and a total of $121 million through 2005.
NIH activities and reports
H.R. 4807 would direct the Secretary, through the Director
of the NIH, to examine the distribution and availability of
HIV-related clinical research programs for women, infants,
children, and youth. Although H.R. 4807 does not require
submission of a report to the Congress, CBO believes the bill's
intent is to have the results of the evaluation transmitted to
the Congress. The bill also would require that NIH expand its
research efforts in the development of rapid HIV tests and to
provide progress reports to the Congress. CBO estimates that
those provisions would cost less than $500,000 in 2001 and $5
million over the 2001-2005 period.
CDC activities and reports
H.R. 4807 would authorize a new program for CDC to collect
data and provide information support to the Ryan White program
and its grantees for planning and evaluation activities. Based
on the resources CDC currently devotes to supporting the
improvement of states' HIV surveillance systems, CBO estimates
that up to an additional 40 percent of that amount would be
needed, or about $25 million starting in fiscal year 2001. It
also would require that the Secretary, in consultation with CDC
and the Food and Drug Administration, submit an analysis of
issues surrounding pre-market reviews and commercial
distribution of rapid HIV tests of the Congress within 90 days
of enactment. In addition, the bill would require the CDC to
establish guidelines for the use of rapid HIV tests, with
specific recommendations for states, hospitals, and other
entities on the availability of HIV tests for administration to
pregnant women in labor or in late-stage pregnancy with unknown
HIV status. CBO estimates that those activities and reports
would increase costs by $9 million in 2001 and $105 million
over the 2001-2005 period.
Pay-as-you-go considerations: None.
Estimated impact on state, local, and tribal governments:
The bill contains an intergovernmental mandate as defined in
UMRA because it would require states to implement
recommendations by the Institute on Medicine for increasing the
routine testing of pregnant women and newborn children for HIV.
States would be required to submit reports that describe their
progress toward implementing the recommendations and barriers
in the state that inhibit an obstetrician's ability to
routinely test pregnant women and newborn infants for HIV.
The bill also would authorize $30 million annually in
grants for testing and treating case of perinatal HIV. CBO
assumes that states would be allowed to use these grants to
comply with the intergovernmental mandate and that the costs of
the mandate would be well below that amount. The bill also
would expand the purposes for which a number of grants could be
used, including outpatient ambulatory and support services,
inpatient case management, and early intervention. Additional
requirements for grants include increased outreach, data
collection, and implementation of quality management
procedures. Such requirements would not be intergovernmental
mandates as defined in UMRA because they are conditions of
federal assistance.
Estimated impact on the private sector: The bill contains
no private-sector mandates as defined in UMRA.
Previous CBO estimate: On May 10, 2000, CBO transmitted a
cost estimate for S. 2311, the Ryan White CARE Act Amendments
of 2000, as ordered reported by the Senate Committee on Health,
Education, Labor, and Pensions on April 12, 2000. The two bills
would make different changes to the Ryan White CARE Act, and
the two estimates reflect those differences.
Estimated prepared by: Federal Costs: For HRSA: Julia M.
Christensen. For CDC: Jeanne M. De Sa. For NIH: Christopher J.
Topoleski. Impact on State, Local, and Tribal Governments: Leo
Lex. Impacts on the Private Sector: Jennifer Bullard.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates prepared by the Director of the Congressional Budget
Office pursuant to section 423 of the Unfunded Mandates Reform
Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for this legislation is provided in
Article I, section 8, clause 3, which grants Congress the power
to regulate commerce with foreign nations, among the several
States, and with the Indian tribes.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1. Short title; table of contents
This section provides the short title of the legislation,
the ``Ryan White CARE Act Amendments of 2000,'' and includes a
table of contents.
TITLE I--EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES
Subtitle A--HIV Health Services Planning Councils
Section 101. Membership of councils
Subsection (a) changes the requirements for representation
on an HIV Health Services Planning Council. Under current law,
the Council must reflect in its composition the demographics of
the epidemic in the eligible area. New language requires that
the Council reflect in its composition the demographics of the
population of individuals with HIV disease in the eligible
area. This subsection clarifies the requirement that
representatives to the Council from affected communities must
include people with HIV disease. Representatives to the Council
who are grantees under other Federal HIV programs may include
providers of HIV prevention services. This subsection also adds
the new requirement that the Council include representatives of
individuals who formerly were Federal, State, or local
prisoners, were released from the custody of the penal system
during the preceding three years, and had HIV disease when so
released.
Subsection (b) establishes a new requirement that at least
33% of the Council must be individuals who are receiving HIV-
related services under Part A, the Emergency Relief Grant
Program, must not be officers, employees, or consultants to any
entity receiving such a grant, and do not represent such
entity. An individual will be considered as receiving such
services if the individual is the parent or caregiver of a
minor child who is receiving HIV services. This restriction
does not apply to entities receiving grants under other parts
of the Ryan White CARE Act.
Section 102. Duties of councils
Section 102(a) adds to the duties of the HIV Health Service
Planning Council the requirements to determine the size and
demographics of the population of individuals with HIV disease
and the needs of the population, with particular attention to
individuals with HIV disease who are not receiving HIV-related
services, and disparities in access and services among affected
subpopulations and historically underserved communities.
This provision also rewrites current law on priorities that
the Council must take into account in allocating of funds. The
Council must take into account the size and demographics of the
population with HIV disease; the demonstrated (or probable)
cost effectiveness and outcome effectiveness of proposed
strategies; the priorities of the communities for whom the
services are intended; the availability of government and
nongovernmental sources of funding, including Medicaid and the
SCHIP program; and the capacity development needs in
historically underserved areas. In developing a comprehensive
plan for the organization and delivery of health and support
services, the Council must include a strategy for identifying
individuals with HIV disease who are not receiving services and
for enabling such individuals to utilize the services, giving
particular attention to eliminating disparities, and including
discrete goals, a timetable, and an appropriate allocation of
funds and a strategy to coordinate the provision of such
services with programs for HIV prevention and for the
prevention and treatment of substance abuse. The plan must be
compatible with any State or local plan providing HIV services.
The Council must coordinate with Federal grantees that provide
HIV-related services within their area.
After receipt of a report by the Institute of Medicine, the
Secretary of Health and Human Services, in consultation with
entities that receive grants under Part A and Part B, must
develop epidemiologic measures for establishing the number of
individuals living with HIV disease who are not receiving HIV-
related services and carrying out the duties of the Council.
The Secretary must provide guidelines and materials for
training members of the planning Council regarding their duties
to each chief elected official receiving a grant under Part A.
Section 103. Open meetings; other additional provisions
This section sets forth additional provisions with respect
to public deliberations of the Planning Council. The Council
may not be chaired solely by an employee of the grantee under
Part A. Further, Council meetings must be open to the public
and held after adequate notice and documents prepared by or
made available to the Council must be made available for public
inspection and copying. The Council must keep detailed minutes
and their accuracy must be certified by the Council chair. This
section does not apply to the disclosure of personal
information that would constitute an invasion of privacy,
including medical or personnel matters.
Subtitle B--Type and Distribution of Grants
Section 111. Formula grants
Subsection (a) changes current law, which states that Part
A grant funds for eligible areas must be distributed not later
than 60 days after such funds are made available ``for each of
the fiscal years 1996 through 2000.'' The amendment applies to
a generic fiscal year.
Subsection (b) provides that, for grants made for FY2005
and subsequent fiscal years, the cases counted for each 12-
month period beginning on or after July 1, 2004, must be cases
of HIV disease (as confirmed by the Centers for Disease Control
and Prevention(CDC)) rather than cases of acquired immune
deficiency syndrome as under current law. The update of the
yearly percentages used to determine grant amounts must be
reported to the congressional committees of jurisdiction and,
as applicable, the updates must take into account HIV cases.
This subsection also requires the Secretary to determine
whether sufficiently accurate and reliable data exists on cases
of HIV disease. If the Secretary determines, by July 1, 2004,
that there is not sufficiently accurate and reliable data on
cases of HIV disease from all eligible areas, then references
in this section to cases of HIV disease do not have any legal
effect. From amounts appropriated for CDC grants on data
collection, the Secretary is required to reserve funds to make
grants and provide technical assistance to States and eligible
areas for obtaining data on cases of HIV disease to ensure that
data on such cases is available from all States and eligible
areas as soon as practicable but not later than the beginning
of FY2007.
Subsection (c) revises the limitation on the reduction in
funding for a grant from one fiscal year to the next which may
occur in certain eligible areas. Under current law, grants made
under Part A for fiscal year 2000 cannot be less than 95% of
the amount received by the eligible area in fiscal year 1995.
This provision stipulates that for each fiscal year in a
protection period for an eligible area, the amount of the grant
is increased to ensure that: (1) for the first fiscal year in
the protection period, the grant is not less than 98% of the
amount of the grant made for the base year for the protection
period; (2) for any second fiscal year in such period, the
grant is not less than 95.7% of the base year grant; (3) for
any third fiscal year in such period, the grant is not less
than 91.1% of the base year grant; (4) for any fourth fiscal
year, the grant is not less than 84.2% of the base year grant;
and (5) for any fifth or subsequent fiscal year in such period,
the grant is not less than 75% of the base year grant. This
provision also defines the base year for a protection period as
the fiscal year preceding the trigger grant-reduction year.
Further, it defines the first trigger grant-reduction year as
the first fiscal year (after FY2000) for which the grant for
the area is less than the grant for the preceding fiscal year.
A protection period begins with the trigger grant-reduction
year and continues until the beginning of the first fiscal year
for which the grant equals or exceeds the amount of the grant
for the base year. Any subsequent trigger grant-reduction year
is the first fiscal year after the end of the preceding
protection period, for which the grant is less than the grant
for preceding fiscal year.
Section 112. Supplemental grants
Current law provides a series of factors to be given
priority consideration in awarding supplemental grants.
Subsection (a) directs that the Secretary must count ``severe
need'' as one-third when weighing factors to determine
supplemental grant amounts. It also adds as new factors in
determining severe need the current prevalence of HIV disease,
the increasing need for HIV-related services, and unmet need
for such services. Further, it directs the Secretary to develop
a mechanism to use national, quantitative incidence data not
later than 18 months after the enactment. The mechanism should
be modified to reflect the findings of the IOM report on
epidemiological measures and health care for individuals with
HIV disease.
Subsection (b) makes conforming amendments to the statute.
Subtitle C--Other Provisions
Section 121. Use of amounts
The legislation makes some technical changes to the general
primary purposes for the use of grant funds under Part A
regarding outpatient and ambulatory health or support services,
and inpatient case management. Subsection (a) specifically
defines outpatient and ambulatory support services as including
case management, to the extent that such services facilitate,
support, or sustain the delivery, or benefits of health
services. It also includes outreach activities as a new general
primary purpose for the use of grant amounts. The outreach
activities are intended to identify individuals with HIV
disease who are not receiving HIV-related services.
Subsection (b) authorizes the use of Title I grants for
early intervention services. (Under current law, such services
are only provided under Title III.) The entities which may
receive grants for such services include: public health
departments, emergency rooms, substance abuse and mental health
treatment programs, detoxification centers, detention
facilities, clinics regarding sexually transmitted diseases,
homeless shelters, HIV disease counseling and testing sites,
State health care points of entry or eligible areas, federally
qualified health centers, and entities providing early
intervention services. The entity must demonstrate to the chief
elected official that Federal, State, or local funds are
inadequate for the services to be provided and that the entity
will supplement and not supplant other available funds for such
services.
Subsection (c) specifies that the chief elected official
must establish a quality management program to assess the
extent to which services are consistent with Public Health
Service guidelines for the treatment of HIV disease, and as
applicable, to develop strategies to ensure that such services
are consistent with the guidelines. Restricts spending on such
program to the lesser of 5% of the Title I grant received or $3
million.
Section 122. Application
In addition to other assurances specified under current law
that are to be included on an application, entities within an
eligible area that receive grant funds must maintain
relationships with appropriate entities in the area, including
those conducting early intervention services.
Section 123. Review of administrative costs and compensation
Each chief elected official must ensure, not later than one
year after the date of enactment of this legislation, that the
planning Council reviews available data on the administrative
costs (including financial compensation and benefits) of
entities receiving grants; and determineswhether compensation
of any officers or employees of such entities exceeds that of the chief
elected official.
TITLE II--CARE GRANT PROGRAM
Subtitle A--General Grant Provisions
Section 201. Priority for women, infants, and children
Under current law, a priority for services is provided for
women, infants, and children; this section adds youth to this
group.
Section 202. Use of grants
Under current law, Part B grants funds may be used to
provide a variety of health services for individuals and
families with HIV disease including: outpatient and ambulatory
health and support services; inpatient case management;
outreach activities; establishment and operation of HIV care
consortia; home-based and community-based care services;
continuity of health insurance coverage; and, therapeutics to
treat HIV disease. This section specifies that States may use
Part B grant funds for: (1) support services, including case
management, to the extent that such services facilitate,
support, or sustain the delivery, or benefits of health
services for individuals and families with HIV disease; (2)
outreach activities that are intended to identify individuals
with HIV disease who are not receiving HIV-related services;
(3) early intervention services (under current law, such
services are only provided under Title III); and (4) quality
management program to assess the extent to which services are
consistent with Public Health Service guidelines for the
treatment of HIV disease, and as applicable, to develop
strategies to ensure that such services are consistent with the
guidelines. It also restricts spending on quality management to
the lesser of 5% of the Part B grant received or $3 million.
(The guidelines and restrictions governing Part B grants for
quality management are the same as those required for Part A.)
Section 203. Grants to establish HIV CARE consortia
This section adds new language regarding the assurances and
the application submitted by a consortium to a State for Part B
grant assistance. Current law requests that a consortium
provide a number of assurances along with the application to a
State for Part B grant funds. It stipulates that a consortium
must provide the State with assurances that it has identified
populations with HIV disease, particularly those experiencing
disparities in access and services and those who reside in
historically underserved communities. In addition, the
consortium must provide assurances that its service plan is
consistent with the State comprehensive plan for the
organization and delivery of HIV health care and support
services. The consortium must also demonstrate in the
application for Part B grant funds that adequate planning
occurred to address disparities in access and services in
historically underserved communities.
Section 204. Provision of treatments
This section makes changes in how States may use funds
under Part B to provide treatments for individuals with HIV
disease. Current law authorizes States to provide prescription
drugs to low-income individuals with HIV disease. New language
allows a State to expend grants to pay, on behalf of
individuals with HIV disease, the costs of purchasing or
maintaining health insurance or plans whose coverage includes a
full range of such therapeutics and appropriate primary care
services.
Section 205. State application
Subsection (a) makes additions to the information that must
be included in the State application for Part B funds (these
changes are similar to those made to the duties of the Planning
Council under Title). This subsection specifies that a State
application must contain determinations of: (1) the size and
demographics of the population of individuals with HIV disease;
and (2) the needs of the population, with particular attention
to individuals with HIV disease who are not receiving HIV-
related services, and disparities in access and services among
affected subpopulations and historically underserved
communities.
The State application must provide a comprehensive plan
that, in addition to current law requirements, establishes
priorities for the allocation of funds based on: size and
demographics of the population with HIV disease; the
availability of other governmental and nongovernmental
resources; the capacity development needs resulting from
disparities in the availability of HIV-related services in
historically underserved communities and rural communities; and
the efficiency of the administrative mechanism of the State for
rapidly allocating funds to the areas of greatest need. The
comprehensive plan must also include: (1) a strategy for
identifying individuals with HIV disease who are not receiving
services and for enabling such individuals to utilize the
services, giving particular attention to eliminating
disparities, and including discrete goals, a timetable, and an
appropriate allocation of funds; and (2) a strategy to
coordinate the provision of such services with programs for HIV
prevention and for the prevention and treatment of substance
abuse.
Subsection (b) revises the public hearing process. Current
law provides that the public health agency administering the
grant for the State will conduct public hearings concerning the
proposed use and distribution of funds received under Part B.
This subsection specifies that the public health agency
administering the grant for the State must engage in a public
advisory planning process, including public hearings, when
developing the comprehensive plan for the State application.
This public advisory planning process must include the same
participants represented when developing the statewide
coordinated statement of need and shall to the extent possible
include entities described in section 2602(b)(2).
Subsection (c) requires that, along with the State
application for Part B funds, the State must provide an
assurance that entities located within areas in which grant
activities are carried out must maintain relationships with
appropriate entities in the area, including those providing
early intervention services.
Section 206. Distribution of funds
Subsection (a) doubles the minimum allotments for grants
under Part B. For States with less than 90 living cases of
AIDS, the minimum grant is $200,000 instead of $100,000 in
current law. The minimum grant for States with 90 or more
living cases of AIDS is$500,000 instead of $250,000 in current
law. In addition, each territory is eligible for a minimum funding
level of $50,000; current law does not provide a minimum funding level
for territories.
Current law uses an estimate of the number of living cases
of AIDS within the State or territory in the formula which
determines the amount of a State grant under Part B. Subsection
(b) provides that when estimating living cases for grants made
for FY2005 and subsequent fiscal years, the cases counted for
each 12-month period beginning on or after July 1, 2004, shall
be cases of HIV disease (as confirmed by CDC) rather than cases
of AIDS, as in current law. However, if the Secretary
determines by July 1, 2004, that there is not sufficiently
accurate and reliable data on cases of HIV disease from all
eligible areas, then references in this section to cases of HIV
disease do not have any legal effect.
Subsection (c) revises the limitation on the reduction in
funding for a grant from one fiscal year to the next which may
occur in certain States.
Subsection (d) provides that each territory is eligible for
a minimum funding level of $50,000, duplicating a change made
in this bill by section 206, subsection (a).
Subsection (e) authorizes the Secretary to reserve 2% of
AIDS drug assistance program funds to make grants to States
whose HIV patients have a need for therapeutics that is not
being met by the current ADAP program within the State. These
grants are discretionary grants and not formula grants. It also
requires such grants to be distributed not later than 240 days
after ADAP funds become available. States must match such
grants with non-federal contributions of not less than 25% of
the costs.
In current law, the term ``territory of the United States''
is defined as American Samoa, the Commonwealth of the Northern
Mariana Islands and the Republic of the Marshall Islands.
``State'' is defined as the 50 States, the District of
Columbia, the Commonwealth of Puerto Rico, the Virgin Islands,
and Guam. Subsection (f) amends the definition of the
territories to include the Federated States of Micronesia, the
Republic of Palau, and for purposes of determining minimum
grant level, the Commonwealth of Puerto Rico.
Section 207. Supplemental grants for certain states
This section removes a section of current law, which is
replaced by section 413. A new supplemental grant program is
created for States that have eligible communities with a severe
need for comprehensive HIV-related services and which are not
eligible for grants under Part A. States must submit an
application that details the need for services in such
communities. The program becomes effective when the amount
appropriated to Title II (excluding ADAP) is at least $20
million greater than the appropriation for Title II in FY2000.
Subtitle B--Provisions Concerning Pregnancy and Perinatal Transmission
of HIV
Section 211. Repeals
This section repeals provisions regarding the testing of
pregnant women and newborn infants.
Section 212. Grants
Subsection (a) includes treatment services, in accordance
with applicable recommendations of the Secretary, for pregnant
women (with HIV disease) and their infants as an additional
purpose for making grants. Under current law, this section
allows the Secretary to make grants to States that have adopted
the CDC guidelines on HIV counseling and voluntary testing of
pregnant women. Such grants are used for: counseling pregnant
women on HIV disease; outreach efforts to women at risk of HIV
who are not receiving prenatal care; voluntary testing; and,
offsetting various State costs in implementing this section.
Authorizes $30 million for each of fiscal years 2001 through
2005. When such appropriations are in excess of $10 million,
the Secretary must reserve a percentage for making grants to
States that under law have a requirement that all newborn
infants be tested for HIV disease; or a requirement that
newborn infants born in the State be tested for HIV disease
where the attending obstetrician does not know the HIV status
of the mother. The percentages to be reserved are: 25% for
FY2001, 50% for FY2002, 50% for FY2003, 75% for FY2004, and 75%
for FY2005. No grant may exceed $4 million and if the reserved
amounts are not obligated, then the requirement to reserve such
amounts will not apply. A State in receipt of such funds under
this section must agree that the grant will supplement and not
supplant other available funds to carry out the purposes of the
grant.
Subsection (b) establishes a special funding rule if FY2001
appropriations are less than $14 million for this section. The
Secretary is required to reserve certain amounts from increased
FY2001 funding for Title II that is above such appropriations
for FY2000.
Section 213. Study by Institute of Medicine
This section adds a new section requiring the Secretary to
request that the Institute of Medicine conduct a study to: (1)
determine the number of newborn infants with HIV born in the
United States where the attending obstetrician did not know the
HIV status of the mother; (2) determine State barriers that
prevent or discourage an obstetrician from making it a routine
practice to offer pregnant women an HIV test and a routine
practice to test newborn infants for HIV disease in
circumstances in which the obstetrician does not know the HIV
status of the mother; and (3) provide recommendations for each
State for reducing perinatal transmission of HIV. It requires
the report to be submitted to the appropriate congressional
committees, the Secretary, and the chief public health official
of each State. Beginning in FY2004, each State is required to
report to the Secretary on progress being made toward meeting
such recommendations. For FY2005 and each subsequent fiscal
year, the State must demonstrate that it has made reasonable
progress toward meeting the recommendations. If the State has
not made reasonable progress, the State must cooperate with the
CDC Director in carrying out activities toward meeting the
recommendations, and the State must submit a report to the
Secretary containing a description of any barriers that
continue to exist in the State and a description of how the
State intends to reduce the incidence of perinatal HIV cases.
The Secretary must make funds under section 212 grants
available to the States for the purposes of this section and is
required to submit the State reports to the appropriate
congressional committees.
The Committee recognizes that the IOM completed a report on
this topic in 1998. It is not the intent of the Committee to
duplicate any material compiled for that report. The study is
to make broad recommendations for each State to and assist
States in reducing the incidence of perinatal HIV transmission.
The Committee recognizesthat some States have had few, if any,
such cases in recent years. An analysis of the efforts of these states
may provide useful information to states that continue to have higher
rates of perinatal HIV transmission.
Subtitle C--Certain Partner Notification Programs
Section 221. Grants for compliant partner notification programs
This section adds a new subpart to the Ryan White CARE Act
that provides grants for partner notification programs. It
authorizes appropriations of $30 million for FY2001 and such
sums as necessary for each of the fiscal years 2002 through
2005 for grants to States to carry out programs to provide
partner counseling and referral services. In order to receive a
grant under this new subpart, a State must have the following
policies in effect: (1) a program for partner notification to
inform partners of individuals with HIV disease that the
partners may have been exposed to HIV; (2) a system for
confidentially reporting positive test results for HIV; (3)
specific counseling and referral measures; (4) reports to CDC
on the number of individuals solicited for names of partners,
the number who provided the names, and the number of notified
partners; (5) cooperation with CDC in a national program of
partner notification in which information is shared between
public health officers of the States. In making grants, the
Secretary must give preference for each of the fiscal years
FY2001 through FY2003 to States whose reporting systems for
cases of HIV disease produce sufficiently accurate and reliable
data. A State may not receive a grant for FY2004 or subsequent
fiscal years unless its reporting system produces reliable
data.
TITLE III--EARLY INTERVENTION SERVICES
Subtitle A--Formula Grants for States
Section 301. Repeal of program
This section repeals subpart I of part C of title XXVI of
the PHSA. (Subpart I was not reauthorized in 1995.) Subpart I
provided formula grants to States for early intervention
services such as HIV testing and counseling, other clinical or
diagnostic services, and referrals to providers of health
support services or biomedical research facilities.
Subtitle B--Categorical Grants
Section 311. Preferences in making grants
Under current law, the Secretary must give preference to
any qualified applicants that are experiencing an increase in
the burden of providing services regarding HIV disease. This
new provision adds that the Secretary must give preference to
those that will expend the grant to provide services in
underserved or rural areas.
Section 312. Planning and development grants
Current law allows the use of planning and development
grants to assist entities in expanding their capacity to
provide early intervention services. Subsection (a) provides
that the grants are to be used to assist entities in expanding
their capacity to provide services, including early
intervention, in low-income communities and affected
subpopulations that are underserved. Such grants may not be
used to purchase or improve land, or to purchase, construct, or
permanently improve any building or other facility.
Current law provides that planning grants under this
section to provide early intervention services may not exceed
$50,000. Subsection (b) specifies that grants for early
intervention services under paragraph (1)(A) may not exceed
$50,000, and grants for capacity development for low-income and
underserved populations under paragraph (1)(B) may not exceed
$150,000 and their duration may not exceed three years.
Subsection (c) increases to five percent (currently one
percent) the amount of appropriations for this subpart that may
be used to carry out this section.
Section 313. Authorization of appropriations
This section extends authorized appropriations of such sums
as necessary for this subpart for each of the fiscal years 2001
through 2005.
Subtitle C--General Provisions
Section 321. Provision of certain counseling services
Presently, current law specifies what additional
information (such as early interventions services, health care
referrals) is to be conveyed to an individual receiving a
positive result on an HIV test. This section adds new language
specifying that when grant applicants counsel individuals
regarding a positive HIV test result, they must provide
counseling that: (1) emphasizes the duty of infected
individuals to disclose their infected status to their sexual
partners and their partners in the sharing of hypodermic
needles; (2) provides advice on the manner in which such
disclosures can be made; and (3) emphasizes the continuing duty
to avoid any behaviors that will expose others to HIV.
Section 322. Additional required agreements
This section adds new language provides that the applicant
will not expend more than 10%, instead of the current 7.5%, for
administrative expenses, including planning and evaluation of
the grant. In addition, new language specifies that applicants
are required to establish a quality management program to
assess the extent to which medical services under this title
are consistent with the most recent Public Health Service
guidelines for the treatment of HIV disease and related
opportunistic infections and that improvements in access to and
quality of medical services are addressed.
TITLE IV--OTHER PROGRAMS AND ACTIVITIES
Subtitle A--Certain Programs for Research, Demonstrations, or Training
Section 401. Grants for coordinated services and access to research for
women, infants, children, and youth
This section removes language in current law specifying
that a significant number of women, infants, children and youth
who are patients of the applicant will be participating in
research projects. This section provides new language
specifying that grant applicants mustdemonstrate linkages to
research and how access to such research is being offered to patients.
The Secretary, in coordination with the Director of the National
Institutes of Health (NIH), is required to examine the distribution and
availability of appropriate HIV-related research projects to enhance
and expand HIV-related research, especially in communities that are
under represented with respect to such projects. Grantees must also
implement a quality management program. Authorized appropriations are
extended through FY2005.
Section 402. AIDS education and training centers
The Committee believes that the Dental Reimbursement
Program is a cost-effective program that provides quality oral
health care to people living with HIV/AIDS, and trains
providers to effectively and safely deliver care to these
patients. The Committee has reauthorized the program and
maintained its current format of providing retrospective
reimbursement to dental schools and residency programs. In
addition, the Committee has established new grants for
community-based care to support collaborative efforts between
dental education programs and community-based providers
directed at providing oral health care to patients with HIV
disease in currently unserved areas and communities without
dental education programs.
Although the Dental Program has been successful, there is
still a large HIV/AIDS population that has not benefitted
because there is not a dental education institution
participating in their area. These patients are also in need of
dental services that could be provided at community sites if
more community-based providers would partner with a dental
school or residency program. In these partnerships, dental
students or residents could provide treatment for HIV/AIDS
patients in underserved communities under the direction of a
community-based dentist who would serve as adjunct faculty. By
encouraging dental educational institutions to partner with
community-based providers, the Committee intends to address the
unmet need in these areas by ensuring that dental treatment for
the HIV/AIDS population is available in all areas of the
country, not just where dental schools are located.
Current law allows eligible entities to use grant funds for
the training of health personnel in the diagnosis, treatment
and prevention of HIV disease, including the prevention of the
perinatal transmission of the disease and the prevention and
treatment of opportunistic infections. Subsection (a) provides
that grants may be used to train health professionals in
prenatal and other gynecological care for women with HIV
disease. The Secretary may also make grants to such entities to
develop protocols for the medical care of women with HIV
disease, including prenatal and other gynecological care. In
addition, the bill directs the Secretary to, not later than 90
days after enactment, issue and begin implementation of a
strategy for the dissemination of HIV treatment information to
health care providers and patients.
Under current law, the Secretary may make grants to assist
schools and programs with respect to oral health care to
patients with HIV disease. Such schools and programs include:
(1) dental schools and post doctoral dental education programs;
and (2) dental hygiene programs that are accredited by the
Commission on Dental Accreditation. Subsection (b) provides
that the Secretary may also make grants to schools and
programs, as described in the previous sentence, that partner
with community-based dentists to provide oral health care to
patients with HIV disease in unserved areas. The partnerships
must permit the training of dental students and residents and
the participation of community dentists as adjunct faculty.
Subsection (c) authorizes appropriations of such sums as
necessary for programs under this section for fiscal years 2001
through 2005.
Subtitle B--General Provisions in Title XXVI
Section 411. Evaluations and reports
This section authorizes appropriations for the Secretary to
evaluate programs under the Ryan White CARE Act for each of the
fiscal years 2001 through 2005.
Section 412. Data collection through centers for disease control and
prevention
This section redesignates section 2675 as section 2675A,
and adds a new section 2675 which authorizes appropriations to
the Secretary (acting through the Director of CDC) of such sums
as may be necessary for each of the fiscal years 2001 through
2005 to collect and provide data for program planning and
evaluation activities. That authorization is in addition to
other authorizations for such purpose.
Section 413. Coordination
Current law provides that the Secretary will assure that
the Health Resources and Services Administration (HRSA) and CDC
will coordinate the planning and funding of programs authorized
under this title to assure that health support services for
individuals with HIV disease are integrated with each other and
that the continuity of care of individuals with HIV is
enhanced. This section provides that the Secretary must ensure
that there is coordination of the planning, funding, and
implementation of Federal HIV programs regarding continuity of
care and prevention services among the following agencies:
HRSA, CDC, SAMHSA, and the Health Care Financing Administration
(HCFA). In addition, the Secretary must consult with other
Federal agencies, including the Department of Veterans Affairs,
as needed and utilize planning information submitted to such
agencies by the States. This section also requires that the
Secretary report biennially to the appropriate congressional
committees on the coordination efforts at the Federal, State,
and local levels. The report should include a description of
Federal barriers to HIV program integration and a strategy for
eliminating such barriers. It also inserts ``prevention
services'' after the term ``continuity of care'' each place the
term appears.
Section 414. Plan regarding release of prisoners with HIV disease
This section adds a new subsection to section 2675A which
directs the Secretary to develop a plan for the medical case
management of and the provision of support services to
individuals who were Federal or State prisoners and had HIV
disease on the date they were released from custody. The
Secretary must consult with the Attorney General, the Director
of the Bureau of Prisons, the States, eligible areas and
certain grant recipients in developing such plan. The Secretary
must report to the Congress on such a plan not later than two
years after the date of enactment of this legislation.
Section 415. Audits
Section 2675B stipulates that for FY2002 and subsequent
fiscal years, the Secretary may reduce grant amounts to a State
or politicalsubdivision of a State for a fiscal year, if the
State or subdivision fails to prepare audits for the second preceding
fiscal year. The Secretary must annually submit representative samples
of such audits to the Congress.
Section 416. Administrative simplification
Section 2675C requires the Secretary, after consultations
with specified entities receiving grants under this title, to:
(1) Develop a plan for coordinating the disbursement of grants
to eligible areas under Part A with the disbursement of grants
to States under Part B; (2) make a determination on whether the
efficiency of grantees would be improved by their submitting
applications biennially rather than annually; and (3) develop a
plan for simplifying the process for applications by eligible
areas under Part A and States under Part B. The Secretary must
submit both plans to the Congress not later than 18 months
after the date of enactment of this bill. The Secretary must
submit the determination to Congress not later than 2 years
after the date of enactment. The Secretary must complete
implementation of both plans not later than 2 years after the
date of their submission.
Section 417. Authorization of appropriations for Parts A and B
This section authorizes appropriations for fiscal years
2001 through 2005 to carry out Part A (Title I) grants to
eligible areas, and Part B (Title II) CARE grants to States.
TITLE V--GENERAL PROVISIONS
Section 501. Studies by Institute of Medicine
Subsection (a) requires that the Secretary ask the
Institute of Medicine to conduct a study that provides the
following: (1) a determination of whether the surveillance
system of each State regarding HIV provides for the reporting
of cases of infection in a manner that is sufficient to provide
adequate and reliable information on the number of such cases
and the demographic characteristics of such cases, both for the
State in general and for specific geographic areas; (2) a
determination of whether such information is sufficiently
accurate for purposes of grant formulas to eligible areas under
Part A and States under Part B; and (3) recommendations on the
manner in which a State can improve its surveillance system.
Subsection (b) requires that the Secretary ask the
Institute of Medicine to conduct a study on appropriate
epidemiologic measures and their relation to the financing and
delivery of health services to low-income, uninsured and
underinsured people living with HIV disease. The study should
consider existing and needed health care and epidemiological
data and its relation to efficiency and effectiveness of care
delivery, quality of care, resource allocation, and access to
HIV services. The study should also determine the actual costs,
potential savings, and financial impact of modifying the
Medicaid program to establish eligibility for medical
assistance on the basis of HIV infection rather than providing
assistance only if the infection has progressed to AIDS.
Subsection (c) authorizes the Secretary to contract with
other entities if the Institute of Medicine declines to conduct
the study. Subsection (d) directs the Secretary to report to
the appropriate congressional committees not later than three
years after the date of enactment of this Act for the
surveillance study, and not later than two years after
enactment for the epidemiological study.
Section 502. Development of rapid HIV test
Subsection (a) requires the Director of NIH to expand,
intensify, and coordinate research and other activities of NIH
for the development of reliable and affordable tests for HIV
disease that can rapidly be administered and whose results can
be rapidly obtained. Requires periodic progress reports to the
appropriate congressional committees. It also authorizes
appropriations as necessary for FY2001 through 2005.
Subsection (b) requires that the Secretary, in consultation
with the Director of CDC and the Commissioner of Food and
Drugs, submit to the appropriate committees a report describing
the progress made towards, and barriers to, the premarket
review and commercial distribution of rapid HIV tests. The
report must (1) to assess the public health need for, and
benefits of, rapid HIV tests; (2) make recommendations
regarding the need for expedited review of rapid HIV test
applications submitted to the Center for Biologics Evaluation
and Research (including criteria for expedited review for
favorable recommendations); and (3) specify whether the
barriers to premarket review include the unnecessary
application of requirements concerning donor screening.
Subsection (c) requires that the Director of CDC, promptly
after commercial distribution of a rapid HIV test begins,
establish or update guidelines that include recommendations for
States, hospitals, and other appropriate entities regarding the
ready availability of such tests for administration to pregnant
women who are in labor or in the late stage of pregnancy and
whose HIV status is not known to the attending obstetrician.
TITLE VI--EFFECTIVE DATE
Section 601. Effective date
This section establishes the effective date of the
legislation as October 1, 2000, or upon the date of its
enactment, whichever occurs later.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE XXVI--HIV HEALTH CARE SERVICES PROGRAM
Part A--Emergency Relief for Areas With Substantial Need for Services
* * * * * * *
SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL.
(a) * * *
(b) HIV Health Services Planning Council.--
(1) Establishment.--To be eligible for assistance
under this part, the chief elected official described
in subsection (a)(1) shall establish or designate an
HIV health services planning council that shall reflect
in its composition the [demographics of the epidemic in
the eligible area involved,] demographics of the
population of individuals with HIV disease in the
eligible area involved, with particular consideration
given to disproportionately affected and historically
underserved groups and subpopulations. Nominations for
membership on the council shall be identified through
an open process and candidates shall be selected based
on locally delineated and publicized criteria. Such
criteria shall include a conflict-of-interest standard
that is in accordance with paragraph (5).
(2) Representation.--The HIV health services planning
council shall include representatives of--
(A) * * *
* * * * * * *
(G) affected communities, including people
with HIV disease [or AIDS] and historically
underserved groups and subpopulations;
* * * * * * *
(K) grantees under section 2671, or, if none
are operating in the area, representatives of
organizations with a history of serving
children, youth, women, and families living
with HIV and operating in the area; [and]
(L) grantees under other Federal HIV
programs[.], including but not limited to
providers of HIV prevention services; and
(M) representatives of individuals who
formerly were Federal, State, or local
prisoners, were released from the custody of
the penal system during the preceding three
years, and had HIV disease as of the date on
which the individuals were so released.
(3) Method of providing for council.--
(A) * * *
* * * * * * *
[(C) Chairperson.--A planning council may not
be chaired solely by an employee of the
grantee.]
* * * * * * *
(4) Duties.--The planning council established or
designated under paragraph (1) shall--
(A) determine the size and demographics of
the population of individuals with HIV disease;
(B) determine the needs of such population,
with particular attention to--
(i) individuals with HIV disease who
are not receiving HIV-related services;
and
(ii) disparities in access and
services among affected subpopulations
and historically underserved
communities;
[(A)] (C) establish priorities for the
allocation of funds within the eligible area,
including how best to meet each such priority
and additional factors that a grantee should
consider in allocating funds under a grant
based on the--
[(i) documented needs of the HIV-
infected population;
[(ii) cost and outcome effectiveness
of proposed strategies and
interventions, to the extent that such
data are reasonably available (either
demonstrated or probable);
[(iii) priorities of the HIV-infected
communities for whom the services are
intended; and
[(iv) availability of other
governmental and nongovernmental
resources;]
(i) size and demographics of the
population of individuals with HIV
disease (as determined under
subparagraph (A)) and the needs of such
population (as determined under
subparagraph (B));
(ii) demonstrated (or probable) cost
effectiveness and outcome effectiveness
of proposed strategies and
interventions, to the extent that data
are reasonably available;
(iii) priorities of the communities
with HIV disease for whom the services
are intended;
(iv) availability of other
governmental and nongovernmental
resources to provide HIV-related
services to individuals and families
with HIV disease, including the State
plan under title XIX of the Social
Security Act (relating to the Medicaid
program) and the program under title
XXI of such Act (relating to the
program for State children's health
insurance); and
(v) capacity development needs
resulting from disparities in the
availability of HIV-related services in
historically underserved communities;
[(B) develop a comprehensive plan for the
organization and delivery of health services
described in section 2604 that is compatible
with any existing State or local plan regarding
the provision of health services to individuals
with HIV disease;]
(D) develop a comprehensive plan for the
organization and delivery of health and support
services described in section 2604 that--
(i) includes a strategy for
identifying individuals with HIV
disease who are not receiving such
services and for informing the
individuals of and enabling the
individuals to utilize the services,
giving particular attention to
eliminating disparities in access and
services among affected subpopulations
and historically underserved
communities, and including discrete
goals, a timetable, and an appropriate
allocation of funds;
(ii) includes a strategy to
coordinate the provision of such
services with programs for HIV
prevention and for the prevention and
treatment of substance abuse, including
programs that provide comprehensive
treatment services for such abuse; and
(iii) is compatible with any State or
local plan for the provision of
services to individuals with HIV
disease;
[(C)] (E) assess the efficiency of the
administrative mechanism in rapidly allocating
funds to the areas of greatest need within the
eligible area, and at the discretion of the
planning council, assess the effectiveness,
either directly or through contractual
arrangements, of the services offered in
meeting the identified needs;
[(D)] (F) participate in the development of
the statewide coordinated statement of need
initiated by the State public health agency
responsible for administering grants under part
B; [and]
[(E)] (G) establish methods for obtaining
input on community needs and priorities which
may include [public meetings,] public meetings
(in accordance with paragraph (7)), conducting
focus groups, and convening ad-hoc panels[.];
and
(H) coordinate with Federal grantees that
provide HIV-related services within the
eligible area.
* * * * * * *
(5) Conflicts of interest.--
(A) * * *
* * * * * * *
(C) Composition of council.--The following
applies regarding the membership of a planning
council under paragraph (1):
(i) Not less than 33 percent of the
council shall be individuals who are
receiving HIV-related services pursuant
to a grant under section 2601(a), are
not officers, employees, or consultants
to any entity that receives amounts
from such a grant, and do not represent
any such entity, and reflect the
demographics of the population of
individuals with HIV disease as
determined under paragraph (4)(A). For
purposes of the preceding sentence, an
individual shall be considered to be
receiving such services if the
individual is a parent of, or a
caregiver for, a minor child who is
receiving such services.
(ii) With respect to membership on
the planning council, clause (i) may
not be construed as having any effect
on entities that receive funds from
grants under any of parts B through F
but do not receive funds from grants
under section 2601(a), on officers or
employees of such entities, or on
individuals who represent such
entities.
* * * * * * *
(7) Public deliberations.--With respect to a planning
council under paragraph (1), the following applies:
(A) The council may not be chaired solely by
an employee of the grantee under section
2601(a).
(B) In accordance with criteria established
by the Secretary:
(i) The meetings of the council shall
be open to the public and shall be held
only after adequate notice to the
public.
(ii) The records, reports,
transcripts, minutes, agenda, or other
documents which were made available to
or prepared for or by the council shall
be available for public inspection and
copying at a single location.
(iii) Detailed minutes of each
meeting of the council shall be kept.
The accuracy of all minutes shall be
certified to by the chair of the
council.
(iv) This subparagraph does not apply
to any disclosure of information of a
personal nature that would constitute a
clearly unwarranted invasion of
personal privacy, including any
disclosure of medical information or
personnel matters.
* * * * * * *
(d) Process for Establishing Allocation Priorities.--Promptly
after the date of the submission of the report required in
section 501(b) of the Ryan White CARE Act Amendments of 2000
(relating to the relationship between epidemiological measures
and health care for certain individuals with HIV disease), the
Secretary, in consultation with entities that receive amounts
from grants under section 2601(a) or 2611, shall develop
epidemiologic measures--
(1) for establishing the number of individuals living
with HIV disease who are not receiving HIV-related
health services; and
(2) for carrying out the duties under subsection
(b)(4) and section 2617(b).
(e) Training Guidance and Materials.--The Secretary shall
provide to each chief elected official receiving a grant under
2601(a) guidelines and materials for training members of the
planning council under paragraph (1) regarding the duties of
the council.
SEC. 2603. TYPE AND DISTRIBUTION OF GRANTS.
(a) Grants Based on Relative Need of Area.--
(1) * * *
(2) Expedited distribution.--Not later than 60 days
after an appropriation becomes available to carry out
this part [for each of the fiscal years 1996 through
2000] for a fiscal year, the Secretary shall, except in
the case of waivers granted under section 2605(c),
disburse 50 percent of the amount appropriated under
section 2677 for such fiscal year through grants to
eligible areas under section 2601(a), in accordance
with paragraph (3). The Secretary shall reserve an
additional percentage of the amount appropriated under
section 2677 for a fiscal year for grants under part A
to make grants to eligible areas under section 2601(a)
in accordance with paragraph (4).
(3) Amount of grant.--
(A) * * *
* * * * * * *
(C) Estimate of living cases.--The amount
determined in this subparagraph is an amount
equal to the product of--
(i) the number of cases of acquired
immune deficiency syndrome in the
eligible area during each year in the
most recent 120-month period for which
data are available with respect to all
eligible areas, as indicated by the
number of such cases reported to and
confirmed by the Director of the
Centers for Disease Control and
Prevention for each year during such
period, except that (subject to
subparagraph (D)), for grants made
pursuant to this paragraph for fiscal
year 2005 and subsequent fiscal years,
the cases counted for each 12-month
period beginning on or after July 1,
2004, shall be cases of HIV disease (as
reported to and confirmed by such
Director) rather than cases of acquired
immune deficiency syndrome; and
(ii) with respect to--
(I) * * *
* * * * * * *
(X) the tenth year during
such period, .88.
The yearly percentage described in subparagraph
(ii) shall be updated biennially by the
Secretary, after consultation with the Centers
for Disease Control and Prevention, and shall
be reported to the congressional committees of
jurisdiction. The first such update shall occur
prior to the determination of grant awards
under this part for fiscal year 1998. Updates
shall as applicable take into account the
counting of cases of HIV disease pursuant to
clause (i).
(D) Determination of secretary regarding data
on hiv cases.--
(i) In general.--Not later than July
1, 2004, the Secretary shall determine
whether there is data on cases of HIV
disease from all eligible areas
(reported to and confirmed by the
Director of the Centers for Disease
Control and Prevention) sufficiently
accurate and reliable for use for
purposes of subparagraph (C)(i). In
making such a determination, the
Secretary shall take into consideration
the findings of the study under section
501(b) of the Ryan White CARE Act
Amendments of 2000 (relating to the
relationship between epidemiological
measures and health care for certain
individuals with HIV disease), the
fiscal impact of the use of such data,
the impact of the use of such data on
the organization and delivery of HIV-
related services in eligible areas, and
the fiscal impact of not using such
data.
(ii) Effect of adverse
determination.--If under clause (i) the
Secretary determines that data on cases
of HIV disease is not sufficiently
accurate and reliable for use for
purposes of subparagraph (C)(i), then
notwithstanding such subparagraph, for
any fiscal year prior to fiscal year
2007 the references in such
subparagraph to cases of HIV disease do
not have any legal effect.
(iii) Grants and technical assistance
regarding counting of hiv cases.--Of
the amounts appropriated under section
2675 for a fiscal year, the Secretary
shall reserve amounts to make grants
and provide technical assistance to
States and eligible areas with respect
to obtaining data on cases of HIV
disease to ensure that data on such
cases is available from all States and
eligible areas as soon as is
practicable but not later than the
beginning of fiscal year 2007.
[(D)] (E) Unexpended funds.--The Secretary
may, in determining the amount of a grant for a
fiscal year under this paragraph, adjust the
grant amount to reflect the amount of
unexpended and uncanceled grant funds remaining
at the end of the fiscal year preceding the
year for which the grant determination is to be
made. The amount of any such unexpended funds
shall be determined using the financial status
report of the grantee.
[(4) Increase in grant.--With respect to an eligible
area under section 2601(a), the Secretary shall
increase the amount of a grant under paragraph (2) for
a fiscal year to ensure that such eligible area
receives not less than--
[(A) with respect to fiscal year 1996, 100
percent;
[(B) with respect to fiscal year 1997, 99
percent;
[(C) with respect to fiscal year 1998, 98
percent;
[(D) with respect to fiscal year 1999, 96.5
percent; and
[(E) with respect to fiscal year 2000, 95
percent;
of the amount allocated for fiscal year 1995 to such
entity under this subsection.]
(4) Increases in grant.--
(A) In general.--For each fiscal year in a
protection period for an eligible area, the
Secretary shall increase the amount of the
grant made pursuant to paragraph (2) for the
area to ensure that--
(i) for the first fiscal year in the
protection period, the grant is not
less than 98 percent of the amount of
the grant made for the eligible area
pursuant to such paragraph for the base
year for the protection period;
(ii) for any second fiscal year in
such period, the grant is not less than
95.7 percent of the amount of such base
year grant;
(iii) for any third fiscal year in
such period, the grant is not less than
91.1 percent of the amount of the base
year grant;
(iv) for any fourth fiscal year in
such period, the grant is not less than
84.2 percent of the amount of the base
year grant; and
(v) for any fifth or subsequent
fiscal year in such period, the grant
is not less than 75 percent of the
amount of the base year grant.
(B) Base year; protection period.--With
respect to grants made pursuant to paragraph
(2) for an eligible area:
(i) The base year for a protection
period is the fiscal year preceding the
trigger grant-reduction year.
(ii) The first trigger grant-
reduction year is the first fiscal year
(after fiscal year 2000) for which the
grant for the area is less than the
grant for the area for the preceding
fiscal year.
(iii) A protection period begins with
the trigger grant-reduction year and
continues until the beginning of the
first fiscal year for which the amount
of the grant for the area equals or
exceeds the amount of the grant for the
base year for the period.
(iv) Any subsequent trigger grant-
reduction year is the first fiscal
year, after the end of the preceding
protection period, for which the amount
of the grant is less than the amount of
the grant for the preceding fiscal
year.
(b) Supplemental Grants.--
(1) In general.--Not later than 150 days after the
date on which appropriations are made under section
2677 for a fiscal year, the Secretary shall disburse
the remainder of amounts not disbursed under section
2603(a)(2) for such fiscal year for the purpose of
making grants under section 2601(a) to eligible areas
whose application under section 2605(b)--
(A) * * *
* * * * * * *
(E) demonstrates that resources will be
allocated in accordance with the local
demographic incidence of AIDS including
appropriate allocations for services for
infants, children, youth, women, and families
with HIV disease;
* * * * * * *
(2) [Definition] Amount of grant.--
(A) In general.--The amount of each grant
made for purposes of this subsection shall be
determined by the Secretary based on a
weighting of factors under paragraph (1), with
severe need under subparagraph (B) of such
paragraph counting one-third.
[(A)] (B) Severe need.--In determining severe
need in accordance with paragraph (1)(B), the
Secretary shall consider the ability of the
qualified applicant to expend funds efficiently
and the impact of relevant factors on the cost
and complexity of delivering health care and
support services to individuals with HIV
disease in the eligible area, including factors
such as--
(i) sexually transmitted diseases,
substance abuse, tuberculosis, severe
mental illness, or other comorbid
factors determined relevant by the
Secretary;
(ii) new or growing subpopulations of
individuals with HIV disease; [and]
(iii) homelessness[.];
(iv) the current prevalence of HIV
disease;
(v) an increasing need for HIV-
related services, including relative
rates of increase in the number of
cases of HIV disease; and
(vi) unmet need for such services, as
determined under section 2602(b)(4).
[(B)] (C) Prevalence.--In determining the
impact of the factors described in subparagraph
[(A)] (B), the Secretary shall, to the extent
practicable, use national, quantitative
incidence data that are available for each
eligible area. Not later than [2 years after
the date of enactment of this paragraph] 18
months after the date of the enactment of the
Ryan White CARE Act Amendments of 2000, the
Secretary shall develop a mechanism to utilize
such data. Such a mechanism shall be modified
to reflect the findings of the study under
section 501(b) of the Ryan White CARE Act
Amendments of 2000 (relating to the
relationship between epidemiological measures
and health care for certain individuals with
HIV disease). In the absence of such data, the
Secretary may consider a detailed description
and qualitative analysis of severe need, as
determined under subparagraph [(A)] (B),
including any local prevalence data gathered
and analyzed by the eligible area.
[(C)] (D) Priority.--Subsequent to the
development of the quantitative mechanism
described in subparagraph [(B)] (C), the
Secretary shall phase in, over a 3-year period
beginning in fiscal year 1998, the use of such
a mechanism to determine the severe need of an
eligible area compared to other eligible areas
and to determine, in part, the amount of
supplemental funds awarded to the eligible area
under this part.
[(4) Amount of grant.--The amount of each grant made
for purposes of this subsection shall be determined by
the Secretary based on the application submitted by the
eligible area under section 2605(b).]
[(5)] (4) Failure to submit.--
(A) * * *
* * * * * * *
SEC. 2604. USE OF AMOUNTS.
(a) * * *
(b) Primary Purposes.--
(1) In general.--The chief elected official shall use
amounts received under a grant under section 2601 to
provide direct financial assistance to entities
described in paragraph (2) for the purpose of
delivering or enhancing [HIV-
related--] HIV-related services, as follows:
(A) [outpatient and ambulatory health and
support services, including case management,
substance abuse treatment and] Outpatient and
ambulatory health services, including substance
abuse treatment, mental health treatment, and
comprehensive treatment services, which shall
include treatment education and prophylactic
treatment for opportunistic infections, for
individuals and families with HIV disease[;
and].
(B) Outpatient and ambulatory support
services (including case management), to the
extent that such services facilitate, support,
or sustain the delivery, or benefits of health
services for individuals and families with HIV
disease.
[(B) inpatient case management] (C) Inpatient
case management services that prevent
unnecessary hospitalization or that expedite
discharge, as medically appropriate, from
inpatient facilities.
(D) Outreach activities that are intended to
identify individuals with HIV disease who are
not receiving HIV-related services, and that
are--
(i) necessary to implement the
strategy under section 2602(b)(4)(D),
including activities facilitating the
access of such individuals to HIV-
related primary care services at
entities described in paragraph (3);
(ii) conducted in a manner consistent
with the requirements under sections
2605(a)(3) and 2651(b)(2); and
(iii) supplement, and do not
supplant, such activities that are
carried out with amounts appropriated
under section 317.
* * * * * * *
(3) Early intervention services.--
(A) In general.--The purposes for which a
grant under section 2601 may be used include
providing to individuals with HIV disease early
intervention services described in section
2651(b)(2) (including referrals under
subparagraph (C) of such section), subject to
subparagraph (B). The entities through which
such services may be provided under the grant
include public health departments, emergency
rooms, substance abuse and mental health
treatment programs, detoxification centers,
detention facilities, clinics regarding
sexually transmitted diseases, homeless
shelters, HIV disease counseling and testing
sites, health care points of entry specified by
States or eligible areas, federally qualified
health centers, and entities described in
section 2652(a).
(B) Conditions.--With respect to an entity
that proposes to provide early intervention
services under subparagraph (A), such
subparagraph applies only if the entity
demonstrates to the satisfaction of the chief
elected official for the eligible area involved
that--
(i) Federal, State, or local funds
are otherwise inadequate for the early
intervention services the entity
proposes to provide; and
(ii) the entity will expend funds
pursuant to such subparagraph to
supplement and not supplant other funds
available to the entity for the
provision of early intervention
services for the fiscal year involved.
[(3)] (4) Priority for women, infants and children.--
For the purpose of providing health and support
services to infants, children, youth, and women with
HIV disease, including treatment measures to prevent
the perinatal transmission of HIV, the chief elected
official of an eligible area, in accordance with the
established priorities of the planning council, shall
use, from the grants made for the area under section
2601(a) for a fiscal year, not less than the percentage
constituted by the ratio of the population in such area
of infants, children, youth, and women with acquired
immune deficiency syndrome to the general population in
such area of individuals with such syndrome.
(c) Quality Management.--
(1) Requirement.--The chief elected official of an
eligible area that receives a grant under this part
shall provide for the establishment of a quality
management program to assess the extent to which HIV
health services provided to patients under the grant
are consistent with the most recent Public Health
Service guidelines for the treatment of HIV disease and
related opportunistic infection, and as applicable, to
develop strategies for ensuring that such services are
consistent with the guidelines.
(2) Use of funds.--From amounts received under a
grant awarded under this part for a fiscal year, the
chief elected official of an eligible area may (in
addition to amounts to which subsection (f)(1) applies)
use for activities associated with the quality
management program required in paragraph (1) not more
than the lesser of--
(A) 5 percent of amounts received under the
grant; or
(B) $3,000,000.
[(c)] (d) Limited Expenditures for Personnel Needs.--
(1) * * *
* * * * * * *
[(d)] (e) Requirement of Status as Medicaid Provider.--
(1) * * *
[(e)] (f) Administration.--
(1) In general.--The chief executive officer of an
eligible area shall not use in excess of 5 percent of
amounts receivedunder a grant awarded under this part
for administration. In the case of entities and subcontractors to which
such officer allocates amounts received by the officer under the grant,
the officer shall ensure that, of the aggregate amount so allocated,
the total of the expenditures by such entities for administrative
expenses does not exceed 10 percent (without regard to whether
particular entities expend more than 10 percent for such expenses).
* * * * * * *
[(f)] (g) Construction.--A State may not use amounts received
under a grant awarded under this part to purchase or improve
land, or to purchase, construct, or permanently improve (other
than minor remodeling) any building or other facility, or to
make cash payments to intended recipients of services.
SEC. 2605. APPLICATION.
(a) In General.--To be eligible to receive a grant under
section 2601, an eligible area shall prepare and submit to the
Secretary an application, in accordance with subsection (c)
regarding a single application and grant award, at such time,
in such form, and containing such information as the Secretary
shall require, including assurances adequate to ensure--
(1) * * *
* * * * * * *
(3) that entities within the eligible area that
receive funds under a grant under section 2601(a) will
maintain relationships with appropriate entities in the
area, including entities described in section
2604(b)(3);
[(3)] (4) that entities within the eligible area that
will receive funds under a grant provided under section
2601(a) shall participate in an established HIV
community-based continuum of care if such continuum
exists within the eligible area;
[(4)] (5) that funds received under a grant awarded
under this part will not be utilized to make payments
for any item or service to the extent that payment has
been made, or can reasonably be expected to be made,
with respect to that item or service--
(A) under any State compensation program,
under an insurance policy, or under any Federal
or State health benefits program; or
(B) by an entity that provides health
services on a prepaid basis;
[(5)] (6) to the maximum extent practicable, that--
(A) HIV health care and support services
provided with assistance made available under
this part will be provided without regard--
(i) * * *
* * * * * * *
[(6)] (7) that the applicant has participated, or
will agree to participate, in the statewide coordinated
statement of need process where it has been initiated
by the State public health agency responsible for
administering grants under part B, and ensure that the
services provided under the comprehensive plan are
consistent with the statewide coordinated statement of
need.
* * * * * * *
Part B--Care Grant Program
Subpart I--General Grant Provisions
SEC. 2611. GRANTS.
(a) * * *
(b) Priority for Women, Infants and Children.--For the
purpose of providing health and support services to infants,
children, youth, and women with HIV disease, including
treatment measures to prevent the perinatal transmission of
HIV, a State shall use, of the funds allocated under this part
to the State for a fiscal year, not less than the percentage
constituted by the ratio of the population in the State of
infants, children, youth, and women with acquired immune
deficiency syndrome to the general population in the State of
individuals with such syndrome.
* * * * * * *
SEC. 2612. GENERAL USE OF GRANTS.
(a) In General.--A State may use amounts provided under
grants made under this part--
(1) * * *
(b) Support Services; Outreach.--The purposes for which a
grant under this part may be used include delivering or
enhancing the following:
(1) Support services under section 2611(a) (including
case management) to the extent that such services
facilitate, support, or sustain the delivery, or
benefits of health services for individuals and
families with HIV disease.
(2) Outreach activities that are intended to identify
individuals with HIV disease who are not receiving HIV-
related services, and that are--
(A) necessary to implement the strategy under
section 2617(b)(4)(B);
(B) conducted in a manner consistent with the
requirement under section 2617(b)(6)(G); and
(C) supplement, and do not supplant, such
activities that are carried out with amounts
appropriated under section 317.
(c) Early Intervention Services.--
(1) In general.--The purposes for which a grant under
this part may be used include providing to individuals
with HIV disease early intervention services described
in section 2651(b)(2) (including referrals under
subparagraph (C) of such section), subject to paragraph
(2). The entities through which such services may be
provided under the grant include public health
departments, emergency rooms, substance abuse and
mental health treatment programs, detoxification
centers, detention facilities, clinics regarding
sexually transmitted diseases, homeless shelters, HIV
disease counseling and testing sites, health care
points of entry specified by States or eligible areas,
federally qualified health centers, and entities
described in section 2652(a).
(2) Conditions.--With respect to an entity that
proposes to provide early intervention services under
paragraph (1), such paragraph applies only if the
entity demonstrates to the satisfaction of the State
involved that--
(A) Federal, State, or local funds are
otherwise inadequate for the early intervention
services the entity proposes to provide; and
(B) the entity will expend funds pursuant to
such paragraph to supplement and not supplant
other funds available to the entity for the
provision of early intervention services for
the fiscal year involved.
(d) Quality Management.--
(1) Requirement.--Each State that receives a grant
under this part shall provide for the establishment of
a quality management program to assess the extent to
which HIV health services provided to patients under
the grant are consistent with the most recent Public
Health Service guidelines for the treatment of HIV
disease and related opportunistic infection, and as
applicable, to develop strategies for ensuring that
such services are consistent with the guidelines.
(2) Use of funds.--From amounts received under a
grant awarded under this part for a fiscal year, the
State may (in addition to amounts to which section
2618(c)(5) applies) use for activities associated with
the quality management program required in paragraph
(1) not more than the lesser of--
(A) 5 percent of amounts received under the
grant; or
(B) $3,000,000.
SEC. 2613. GRANTS TO ESTABLISH HIV CARE CONSORTIA.
(a) * * *
(b) Assurances.--
(1) Requirement.--To receive assistance from a State
under subsection (a), an applicant consortium shall
provide the State with assurances that--
(A) within any locality in which such
consortium is to operate, the populations and
subpopulations of individuals and families with
HIV disease have been identified by the
consortium, particularly those experiencing
disparities in access and services and those
who reside in historically underserved
communities;
(B) the service plan established under
subsection (c)(2) by such consortium is
consistent with the comprehensive plan under
2617(b)(4) and addresses the special care and
service needs of the populations and
subpopulations identified under subparagraph
(A); and
* * * * * * *
(c) Application.--
(1) In general.--To receive assistance from the State
under subsection (a), a consortium shall prepare and
submit to the State, an application that--
(A) * * *
* * * * * * *
(D) demonstrates that the consortium has
created a mechanism to evaluate periodically--
(i) * * *
(ii) the cost-effectiveness of the
mechanisms employed by the consortium
to deliver comprehensive care; [and]
(E) demonstrates that the consortium will
report to the State the results of the
evaluations described in subparagraph (D) and
shall make available to the State or the
Secretary, on request, such data and
information on the program methodology that may
be required to perform an independent
evaluation[.]; and
(F) demonstrates that adequate planning
occurred to address disparities in access and
services and historically underserved
communities.
(2) Consultation.--In establishing the plan required
under paragraph (1)(B), the consortium shall consult
with--
(A) * * *
(B) not less than one community-based
organization that is organized solely for the
purpose of providing HIV-related support
services to individuals with HIV disease; [and]
(C) grantees under section 2671, or, if none
are operating in the area, representatives in
the area of organizations with a history of
serving children, youth, women, and families
living with HIV[.]; and
(D) entities described in section 2602(b)(2).
The organization to be consulted under subparagraph (B)
shall be at the discretion of the applicant consortium.
* * * * * * *
SEC. 2616. PROVISION OF TREATMENTS.
(a) * * *
* * * * * * *
(e) Use of Health Insurance and Plans.--In carrying out
subsection (a), a State may expend a grant under this part to
provide the therapeutics described in such subsection by paying
on behalf of individuals with HIV disease the costs of
purchasing or maintaining health insurance or plans whose
coverage includes a full range of such therapeutics and
appropriate primary care services.
SEC. 2617. STATE APPLICATION.
(a) * * *
(b) Description of Intended Uses and Agreements.--The
application submitted under subsection (a) shall contain--
(1) * * *
(2) a determination of the size and demographics of
the population of individuals with HIV disease in the
State;
(3) a determination of the needs of such population,
with particular attention to--
(A) individuals with HIV disease who are not
receiving HIV-related services; and
(B) disparities in access and services among
affected subpopulations and historically
underserved communities;
[(2)] (4) a [comprehensive plan for the organization]
comprehensive plan that describes the organization and
delivery of HIV health care and support services to be
funded with assistance received under this part that
shall include a description of the purposes for which
the State intends to use such assistance[, including--
], and that--
(A) establishes priorities for the allocation
of funds within the State based on--
(i) size and demographics of the
population of individuals with HIV
disease (as determined under paragraph
(2)) and the needs of such population
(as determined under paragraph (3));
(ii) availability of other
governmental and nongovernmental
resources to provide HIV-related
services to individuals and families
with HIV disease;
(iii) capacity development needs
resulting from disparities in the
availability of HIV-related services in
historically underserved communities
and rural communities; and
(iv) the efficiency of the
administrative mechanism of the State
for rapidly allocating funds to the
areas of greatest need within the
State;
(B) includes a strategy for identifying
individuals with HIV disease who are not
receiving such services and for informing the
individuals of and enabling the individuals to
utilize the services, giving particular
attention to eliminating disparities in access
and services among affected subpopulations and
historically underserved communities, and
including discrete goals, a timetable, and an
appropriate allocation of funds;
(C) includes a strategy to coordinate the
provision of such services with programs for
HIV prevention and for the prevention and
treatment of substance abuse, including
programs that provide comprehensive treatment
services for such abuse;
[(A)] (D) describes the services and
activities to be provided and an explanation of
the manner in which the elements of the program
to be implemented by the State with such
assistance will maximize the quality of health
and support services available to individuals
with HIV disease throughout the State;
[(B)] (E) provides a description of the
manner in which services funded with assistance
provided under this part will be coordinated
with other available related services for
individuals with HIV disease; and
[(C)] (F) provides a description of how the
allocation and utilization of resources are
consistent with the statewide coordinated
statement of need (including traditionally
underserved populations and subpopulations)
developed in partnership with other grantees in
the State that receive funding under this
title; and
[(3)] (5) an assurance that the public health agency
administering the grant for the State will periodically
convene a meeting of individuals with HIV disease,
representatives of grantees under each part under this
title, providers, and public agency representatives for
the purpose of developing a statewide coordinated
statement of need; and
[(4)] (6) an assurance by the State that--
[(A) the public health agency that is
administering the grant for the State will
conduct public hearings concerning the proposed
use and distribution of the assistance to be
received under this part;]
(A) the public health agency that is
administering the grant for the State engages
in a public advisory planning process,
including public hearings, that includes the
participants under paragraph (5), and entities
described in section 2602(b)(2), in developing
the comprehensive plan under paragraph (4) and
commenting on the implementation of such plan;
* * * * * * *
(E) the State will maintain HIV-related
activities at a level that is equal to not less
than the level of such expenditures by the
State for the 1-year period preceding the
fiscal year for which the State is applying to
receive a grant under this part; [and]
(F) the State will ensure that grant funds
are not utilized to make payments for any item
or service to the extent that payment has been
made, or can reasonably be expected to be made,
with respect to that item or service--
(i) * * *
(ii) by an entity that provides
health services on a prepaid basis[.];
and
(G) entities within areas in which activities
under the grant are carried out will maintain
relationships with appropriate entities in the
area, including entities described in section
2612(c);
* * * * * * *
SEC. 2618. DISTRIBUTION OF FUNDS.
(b) Amount of Grant to State.--
(1) Minimum allotment.--Subject to the extent of
amounts made available under section 2677, the amount
of a grant to be made under this part for--
(A) each of the several States and the
District of Columbia for a fiscal year shall be
the greater of--
(i)(I) with respect to a State or
District that has less than 90 living
cases of acquired immune deficiency
syndrome, as determined under paragraph
(2)(D), [$100,000] $200,000; or
(II) with respect to a State or
District that has 90 or more living
cases of acquired immune deficiency
syndrome, as determined under paragraph
(2)(D), [$250,000] $500,000;
(ii) an amount determined under
paragraph (2) and then, as applicable,
increased under paragraph (2)(H); and
(B) each territory of the United States, as
defined in paragraph (3), shall be the greater
of $50,000 or an amount determined under
paragraph (2).
(2) Determination.--
(A) Formula.--The amount referred to in
paragraph (1)(A)(ii) for a State and paragraph
(1)(B) for a territory of the United States
shall be the product of--
(i) an amount equal to the amount
appropriated under section 2677 for the
fiscal year involved for grants under
part B, subject to [subparagraph (H)]
subparagraphs (H) and (I); and
* * * * * * *
(D) Estimate of living cases.--The amount
determined in this subparagraph is an amount
equal to the product of--
(i) the number of cases of acquired
immune deficiency syndrome in the State
or territory during each year in the
most recent 120-month period for which
data are available with respect to all
States and territories, as indicated by
the number of such cases reported to
and confirmed by the Director of the
Centers for Disease Control and
Prevention for each year during such
period, except that (subject to
subparagraph (E)), for grants made
pursuant to this paragraph for fiscal
year 2005 and subsequent fiscal years,
the cases counted for each 12-month
period beginning on or after July 1,
2004, shall be cases of HIV disease (as
reported to and confirmed by such
Director) rather than cases of acquired
immune deficiency syndrome; and
(E) Determination of secretary regarding data
on hiv cases.--If under 2603(a)(3)(D)(i) the
Secretary determines that data on cases of HIV
disease is not sufficiently accurate and
reliable, then notwithstanding subparagraph (D)
of this paragraph, for any fiscal year prior to
fiscal year 2007 the references in such
subparagraph to cases of HIV disease do not
have any legal effect.
[(E)] (F) Puerto rico, virgin islands,
guam.--For purposes of subparagraph (D), the
cost index for Puerto Rico, the Virgin Islands,
and Guam shall be 1.0.
[(F)] (G) Unexpended funds.--The Secretary
may, in determining the amount of a grant for a
fiscal year under this subsection, adjust the
grant amount to reflect the amount of
unexpended and uncanceled grant funds remaining
at the end of the fiscal year preceding the
year for which the grant determination is to be
made. The amount of any such unexpended funds
shall be determined using the financial status
report of the grantee.
[(G) Limitation.--
[(i) In general.--The Secretary shall
ensure that the amount of a grant
awarded to a State or territory for a
fiscal year under this part is equal to
not less than--
[(I) with respect to fiscal
year 1996, 100 percent;
[(II) with respect to fiscal
year 1997, 99 percent;
[(III) with respect to fiscal
year 1998, 98 percent;
[(IV) with respect to fiscal
year 1999, 96.5 percent; and
[(V) with respect to fiscal
year 2000, 95 percent;
of the amount such State or territory
received for fiscal year 1995 under
this part. In administering this
subparagraph, the Secretary shall, with
respect to States that will receive
grants in amounts that exceed the
amounts that such States received under
this part in fiscal year 1995,
proportionally reduce such amounts to
ensure compliance with this
subparagraph. In making such
reductions, the Secretary shall ensure
that no such State receives less than
that State received for fiscal year
1995.
[(ii) Ratable reduction.--If the
amount appropriated under section 2677
and available for allocation under this
part is less than the amount
appropriated and available under this
part for fiscal year 1995, the
limitation contained in clause (i)
shall be reduced by a percentage equal
to the percentage of the reduction in
such amounts appropriated and
available.]
(H) Limitation.--
(i) In general.--The Secretary shall
ensure that the amount of a grant
awarded to a State or territory under
section 2611 for a fiscal year is not
less than--
(I) with respect to fiscal
year 2001, 99 percent;
(II) with respect to fiscal
year 2002, 98 percent;
(III) with respect to fiscal
year 2003, 97 percent;
(IV) with respect to fiscal
year 2004, 96 percent; and
(V) with respect to fiscal
year 2005, 95 percent;
of the amount such State or territory
received for fiscal year 2000 under
such section. In administering this
subparagraph, the Secretary shall, with
respect to States or territories that
will under such section receive grants
in amounts that exceed the amounts that
such States received under such section
for fiscal year 2000, proportionally
reduce such amounts to ensure
compliance with this subparagraph. In
making such reductions, the Secretary
shall ensure that no such State
receives less than that State received
for fiscal year 2000.
(ii) Ratable reduction.--If the
amount appropriated under section 2677
for a fiscal year and available for
grants under section 2611 is less than
the amount appropriated and available
under such section for fiscal year
2000, the limitation contained in
clause (i) shall be reduced by a
percentage equal to the percentage of
the reduction in such amounts
appropriated and available.
[(H) Appropriations for treatment drug
program.--With respect to]
(I) Appropriations for treatment drug
program.--
(i) Formula grants.--With respect to
the fiscal year involved, if under
section 2677 an appropriations Act
provides an amount exclusively for
carrying out section 2616, the portion
of such amount allocated to a State
shall be the product of--
[(i)] (I) [100] 98 percent of such
amount; and
[(ii)] (II) the percentage
constituted by the ratio of the State
distribution factor for the State (as
determined under subparagraph (B)) to
the sum of the State distribution
factors for all States.
(ii) Supplemental treatment drug
grants.--
(I) In general.--With respect
to the fiscal year involved, if
under section 2677 an
appropriations Act provides an
amount exclusively for carrying
out section 2616, and such
amount is not less than the
amount so provided for the
preceding fiscal year, the
Secretary shall reserve 2
percent of such amount for
making grants to States whose
population of individuals with
HIV disease has, as determined
by the Secretary, a need for
quantities of therapeutics
described in section 2616(a)
greater than the quantities
available pursuant to clause
(i). Such a grant is available
for purposes of obtaining such
therapeutics. The Secretary
shall carry out this clause as
a program of discretionary
grants, and not as a program of
formula grants.
(II) Distribution of
grants.--The Secretary shall
disburse all amounts under
grants under subclause (I) for
a fiscal year not later than
240 days after the date on
which the amount referred to in
such subclause with respect to
section 2616 becomes available.
(III) Requirement of matching
funds.--A condition for
receiving a grant under
subclause (I) is that the State
agree to make available
(directly or through donations
from public or private
entities) non-Federal
contributions toward the costs
of obtaining the therapeutics
involved in an amount that is
not less than 25 percent of
such costs (determined in the
same manner as under
2617(d)(2)(A)).
* * * * * * *
(3) Definitions.--As used in this subsection--
(A) * * *
(B) the term ``territory of the United
States'' means, American Samoa, the
Commonwealth of the NorthernMariana Islands,
[and the Republic of the Marshall Islands] the Republic of the
Marshall Islands, the Federated States of Micronesia, and the Republic
of Palau, and only for purposes of paragraph (1) the Commonwealth of
Puerto Rico.
* * * * * * *
[SEC. 2621. COORDINATION.
[The Secretary shall ensure that the Health Resources and
Services Administration, the Centers for Disease Control and
Prevention, and the Substance Abuse and Mental Health Services
Administration coordinate the planning and implementation of
Federal HIV programs in order to facilitate the local
development of a complete continuum of HIV-related services for
individuals with HIV disease and those at risk of such disease.
Not later than October 1, 1996, and biennially thereafter, the
Secretary shall submit to the appropriate committees of the
Congress a report concerning coordination efforts under this
title at the Federal, State, and local levels, including a
statement of whether and to what extent there exist Federal
barriers to integrating HIV-related programs.]
SEC. 2621. SUPPLEMENTAL GRANTS.
(a) In General.--From amounts available pursuant to
subsection (d) for a fiscal year, the Secretary shall make
grants to States that meet the conditions to receive grants
under section 2611, and that have one or more eligible
communities, for the purpose of providing in such communities
comprehensive services of the type described in section 2612(a)
to supplement the development and care activities, primary
care, and support services otherwise provided in such
communities by the State under a grant under section 2611.
(b) Eligible Community.--For purposes of this section, the
term ``eligible community'' means a geographic area that--
(1) is not within any eligible area as defined in
section 2607; and
(2) has a severe need for supplemental financial
assistance to combat the HIV epidemic, according to
criteria developed by the Secretary in consultation
with the States, including evidence of underserved or
rural areas or both.
(c) Application.--A grant under subsection (a) may be made to
a State if the State submits to the Secretary, as part of the
State application submitted under section 2617, such
information as required to apply for funds under this section
as determined by the Secretary in consultation with the States.
(d) Funding.--
(1) In general.--For the purpose of making grants
under subsection (a) for a fiscal year, the Secretary
shall reserve 50 percent of the amount specified in
paragraph (2).
(2) Increases in part b funding.--
(A) In general.--For purposes of paragraph
(1), the amount specified in this paragraph is
the amount by which the amount appropriated
under section 2677 for the fiscal year involved
and available for carrying out part B is an
increase over the amount so appropriated and
available for the preceding fiscal year,
subject to subparagraphs (B) and (C).
(B) Initial allocation year.--The allocation
under paragraph (1) shall not be made until the
first fiscal year for which the amount
appropriated under section 2677 for the fiscal
year involved and available for carrying out
part B is an increase of not less than
$20,000,000 over the amount so appropriated and
available for fiscal year 2000, subject to
subparagraph (C).
(C) Exclusion regarding separate treatment
drug grants.--Each determination under
subparagraph (A) or (B) of the amount
appropriated under section 2677 for a fiscal
year and available for carrying out part B
shall be made without regard to any amount to
which section 2618(b)(2)(I)(i) applies.
* * * * * * *
Subpart II--Provisions Concerning Pregnancy and Perinatal Transmission
of HIV
SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN.
(a) * * *
* * * * * * *
(c) Additional Funds Regarding Women and Infants.--
(1) In general.--If a State provides the
certification required in subsection (a) and is
receiving funds under part B for a fiscal year, the
Secretary may (from the amounts available pursuant to
paragraph (2)) make a grant to the State for the fiscal
year for the following purposes:
(A) * * *
* * * * * * *
(F) Making available to pregnant women with
HIV disease, and to the infants of women with
such disease, treatment services for such
disease in accordance with applicable
recommendations of the Secretary.
[(2) Funding.--For purposes of carrying out this
subsection, there are authorized to be appropriated
$10,000,000 for each of the fiscal years 1996 through
2000. Amounts made available under section 2677 for
carrying out this part are not available for carrying
out this section unless otherwise authorized.]
(2) Funding.--
(A) Authorization of appropriations.--For the
purpose of carrying out this subsection, there
are authorized to be appropriated $30,000,000
for each of the fiscal years 2001 through 2005.
Amounts made available under section 2677 for
carrying out this part are not available for
carrying out this section unless otherwise
authorized.
(B) Allocations for certain states.--
(i) In general.--Of the amounts
appropriated under subparagraph (A) for
a fiscal year in excess of $10,000,000,
the Secretary shall reserve the
applicable percentage under clause (ii)
for making grants under paragraph (1)
to States that under law (including
under regulations or the discretion of
State officials) have--
(I) a requirement that all
newborn infants born in the
State be tested for HIV
disease; or
(II) a requirement that
newborn infants born in the
State be tested for HIV disease
in circumstances in which the
attending obstetrician for the
birth does not know the HIV
status of the mother of the
infant.
(ii) Applicable percentage.--For
purposes of clause (i), the applicable
amount for a fiscal year is as follows:
(I) For fiscal year 2001, 25
percent.
(II) For fiscal year 2002, 50
percent.
(III) For fiscal year 2003,
50 percent.
(IV) For fiscal year 2004, 75
percent.
(V) For fiscal year 2005, 75
percent.
(C) Certain provisions.--With respect to
grants under paragraph (1) that are made with
amounts reserved under subparagraph (B) of this
paragraph:
(i) Such a grant may not be made in
an amount exceeding $4,000,000.
(ii) If pursuant to clause (i) or
pursuant to an insufficient number of
qualifying applications for such grants
(or both), the full amount reserved
under subparagraph (B) for a fiscal
year is not obligated, the requirement
under such subparagraph to reserve
amounts ceases to apply.
* * * * * * *
(4) Maintenance of effort.--A condition for the
receipt of a grant under paragraph (1) is that the
State involved agree that the grant will be used to
supplement and not supplant other funds available to
the State to carry out the purposes of the grant.
* * * * * * *
SEC. 2626. PERINATAL TRANSMISSION OF HIV DISEASE; CONTINGENT
REQUIREMENT REGARDING STATE GRANTS UNDER THIS PART.
(a) * * *
* * * * * * *
[(d) Determination by Secretary.--Not later than 180 days
after the expiration of the 18-month period beginning on the
date on which the system is implemented under subsection (c),
the Secretary shall publish in the Federal Register a
determination of whether it has become a routine practice in
the provision of health care in the United States to carry out
each of the activities described in paragraphs (1) through (4)
of section 2627. In making the determination, the Secretary
shall consult with the States and with other public or private
entities that have knowledge or expertise relevant to the
determination.
[(e) Contingent Applicability.--
[(1) In general.--If the determination published in
the Federal Register under subsection (d) is that (for
purposes of such subsection) the activities involved
have become routine practices, paragraph (2) shall
apply on and after the expiration of the 18-month
period beginning on the date on which the determination
is so published.
[(2) Requirement.--Subject to subsection (f), the
Secretary shall not make a grant under part B to a
State unless the State meets not less than one of the
following requirements:
[(A) A 50 percent reduction (or a comparable
measure for States with less than 10 cases) in
the rate of new cases of AIDS (recognizing that
AIDS is a suboptimal proxy for tracking HIV in
infants and was selected because such data is
universally available) as a result of perinatal
transmission as compared to the rate of such
cases reported in 1993 (a State may use HIV
data if such data is available).
[(B) At least 95 percent of women in the
State who have received at least two prenatal
visits (consultations) prior to 34 weeks
gestation with a health care provider or
provider group have been tested for the human
immunodeficiency virus.
[(C) The State has in effect, in statute or
through regulations, the requirements specified
in paragraphs (1) through (5) of section 2627.
[(f) Limitation Regarding Availability of Funds.--With
respect to an activity described in any of paragraphs (1)
through (4) of section 2627, the requirements established by a
State under this section apply for purposes of this section
only to the extent that the following sources of funds are
available for carrying out the activity:
[(1) Federal funds provided to the State in grants
under part B or under section 2625, or through other
Federal sources under which payments for routine HIV
testing, counseling or treatment are an eligible use.
[(2) Funds that the State or private entities have
elected to provide, including through entering into
contracts under which health benefits are provided.
This section does not require any entity to expend non-
Federal funds.
[SEC. 2627. TESTING OF PREGNANT WOMEN AND NEWBORN INFANTS.
[An activity or requirement described in this section is any
of the following:
[(1) In the case of newborn infants who are born in
the State and whose biological mothers have not
undergone prenatal testing for HIV disease, that each
such infant undergo testing for such disease.
[(2) That the results of such testing of a newborn
infant be promptly disclosed in accordance with the
following, as applicable to the infant involved:
[(A) To the biological mother of the infant
(without regard to whether she is the legal
guardian of the infant).
[(B) If the State is the legal guardian of
the infant:
[(i) To the appropriate official of
the State agency with responsibility
for the care of the infant.
[(ii) To the appropriate official of
each authorized agency providing
assistance in the placement of the
infant.
[(iii) If the authorized agency is
giving significant consideration to
approving an individual as a foster
parent of the infant, to the
prospective foster parent.
[(iv) If the authorized agency is
giving significant consideration to
approving an individual as an adoptive
parent of the infant, to the
prospective adoptive parent.
[(C) If neither the biological mother nor the
State is the legal guardian of the infant, to
another legal guardian of the infant.
[(D) To the child's health care provider.
[(3) That, in the case of prenatal testing for HIV
disease that is conducted in the State, the results of
such testing be promptly disclosed to the pregnant
woman involved.
[(4) That, in disclosing the test results to an
individual under paragraph (2) or (3), appropriate
counseling on the human immunodeficiency virus be made
available to the individual (except in the case of a
disclosure to an official of a State or an authorized
agency).
[(5) With respect to State insurance laws, that such
laws require--
[(A) that, if health insurance is in effect
for an individual, the insurer involved may not
(without the consent of the individual)
discontinue the insurance, or alter the terms
of the insurance (except as provided in
subparagraph (C)), solely on the basis that the
individual is infected with HIV disease or
solely on the basis that the individual has
been tested for the disease or its
manifestation;
[(B) that subparagraph (A) does not apply to
an individual who, in applying for the health
insurance involved, knowingly misrepresented
the HIV status of the individual; and
[(C) that subparagraph (A) does not apply to
any reasonable alteration in the terms of
health insurance for an individual with HIV
disease that would have been made if the
individual had a serious disease other than HIV
disease.
For purposes of this subparagraph, a statute or
regulation shall be deemed to regulate insurance for
purposes of this paragraph only to the extent that such
statute or regulation is treated as regulating
insurance for purposes of section 514(b)(2) of the
Employee Retirement Income Security Act of 1974.]
* * * * * * *
SEC. 2630. RECOMMENDATIONS FOR REDUCING INCIDENCE OF PERINATAL
TRANSMISSION.
(a) Study by Institute of Medicine.--
(1) In general.--The Secretary shall request the
Institute of Medicine to enter into an agreement with
the Secretary under which such Institute conducts a
study to provide the following:
(A) For the most recent fiscal year for which
the information is available, a determination
of the number of newborn infants with HIV born
in the United States with respect to whom the
attending obstetrician for the birth did not
know the HIV status of the mother.
(B) A determination for each State of any
barriers, including legal barriers, that
prevent or discourage an obstetrician from
making it a routine practice to offer pregnant
women an HIV test and a routine practice to
test newborn infants for HIV disease in
circumstances in which the obstetrician does
not know the HIV status of the mother of the
infant.
(C) Recommendations for each State for
reducing the incidence of cases of the
perinatal transmission of HIV, including
recommendations on removing the barriers
identified under subparagraph (B).
If such Institute declines to conduct the study, the
Secretary shall enter into an agreement with another
appropriate public or nonprofit private entity to
conduct the study.
(2) Report.--The Secretary shall ensure that, not
later than 18 months after the effective date of this
section, the study required in paragraph (1) is
completed and a report describing the findings made in
the study is submitted to the appropriate committees of
the Congress, the Secretary, and the chief public
health official of each of the States.
(b) Progress Toward Recommendations.--Each State shall comply
with the following (as applicable to the fiscal year involved):
(1) For fiscal year 2004, the State shall submit to
the Secretary a report describing the actions taken by
the State toward meeting the recommendations specified
for the State under subsection (a)(1)(C).
(2) For fiscal year 2005 and each subsequent fiscal
year--
(A) the State shall make reasonable progress
toward meeting such recommendations; or
(B) if the State has not made such progress--
(i) the State shall cooperate with
the Director of the Centers for Disease
Control and Prevention in carrying out
activities toward meeting the
recommendations; and
(ii) the State shall submit to the
Secretary a report containing a
description of any barriers identified
under subsection (a)(1)(B) that
continue to exist in the State; as
applicable, the factors underlying the
continued existence of such barriers;
and a description of how the State
intends to reduce the incidence of
cases of the perinatal transmission of
HIV.
(c) Submission of Reports to Congress.--The Secretary shall
submit to the appropriate committees of the Congress each
report received by the Secretary under subsection
(b)(2)(B)(ii).
Subpart III--Certain Partner Notification Programs
SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS.
(a) In General.--In the case of States whose laws or
regulations are in accordance with subsection (b), the
Secretary, subject to subsection (c)(2), may make grants to the
States for carrying out programs to provide partner counseling
and referral services.
(b) Description of Compliant State Programs.--For purposes of
subsection (a), the laws or regulations of a State are in
accordance with this subsection if under such laws or
regulations (including programs carried out pursuant to the
discretion of State officials) the following policies are in
effect:
(1) The State requires that the public health officer
of the State carry out a program of partner
notification to inform partners of individuals with HIV
disease that the partners may have been exposed to the
disease.
(2)(A) In the case of a health entity that provides
for the performance on an individual of a test for HIV
disease, or that treats the individual for the disease,
the State requires, subject to subparagraph (B), that
the entity confidentially report the positive test
results to the State public health officer in a manner
recommended and approved by the Director of the Centers
for Disease Control and Prevention, together with such
additional information as may be necessary for carrying
out such program.
(B) The State may provide that the requirement of
subparagraph (A) does not apply to the testing of an
individual for HIV disease if the individual underwent
the testing through a program designed to perform the
test and provide the results to the individual without
the individual disclosing his or her identity to the
program. This subparagraph may not be construed as
affecting the requirement of subparagraph (A) with
respect to a health entity that treats an individual
for HIV disease.
(3) The program under paragraph (1) is carried out in
accordance with the following:
(A) Partners are provided with an appropriate
opportunity to learn that the partners have
been exposed to HIV disease, subject to
subparagraph (B).
(B) The State does not inform partners of the
identity of the infected individuals involved.
(C) Counseling and testing for HIV disease
are made available to the partners and to
infected individuals, and such counseling
includes information on modes of transmission
for the disease, including information on
prenatal and perinatal transmission and
preventing transmission.
(D) Counseling of infected individuals and
their partners includes the provision of
information regarding therapeutic measures for
preventing and treating the deterioration of
the immune system and conditions arising from
the disease, and the provision of other
prevention-related information.
(E) Referrals for appropriate services are
provided to partners and infected individuals,
including referrals for support services and
legal aid.
(F) Notifications under subparagraph (A) are
provided in person, unless doing so is an
unreasonable burden on the State.
(G) There is no criminal or civil penalty on,
or civil liability for, an infected individual
if the individual chooses not to identify the
partners of the individual, or the individual
does not otherwise cooperate with such program.
(H) The failure of the State to notify
partners is not a basis for the civil liability
of any health entity who under the program
reported to the State the identity of the
infected individual involved.
(I) The State provides that the provisions of
the program may not be construed as prohibiting
the State from providing a notification under
subparagraph (A) without the consent of the
infected individual involved.
(4) The State annually reports to the Director of the
Centers for Disease Control and Prevention the number
of individuals from whom the names of partners have
been sought under the program under paragraph (1), the
number of such individuals who provided the names of
partners, and the number of partners so named who were
notified under the program.
(5) The State cooperates with such Director in
carrying out a national program of partner
notification, including the sharing of information
between the public health officers of the States.
(c) Reporting System for Cases of HIV Disease.--
(1) Preference in making grants through fiscal year
2003.--In making grants under subsection (a) for each
of the fiscal years 2001 through 2003, the Secretary
shall give preference to States whose reporting systems
for cases of HIV disease produce data on such cases
that is sufficiently accurate and reliable for use for
purposes of section 2618(b)(2)(D)(i).
(2) Eligibility condition after fiscal year 2003.--
For fiscal year 2004 and subsequent fiscal years, a
State may not receive a grant under subsection (a)
unless the reporting system of the State for cases of
HIV disease produces data on such cases that is
sufficiently accurate and reliable for purposes of
section 2618(b)(2)(D)(i).
(d) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated $30,000,000 for fiscal year 2001, and such sums as
may be necessary for each of the fiscal years 2002 through
2005.
* * * * * * *
Part C--Early Intervention Services
[Subpart I--Formula Grants for States
[SEC. 2641. ESTABLISHMENT OF PROGRAM.
[(a) Allotments for States.--For the purposes described in
subsection (b), the Secretary, acting through the Director of
the Centers for Disease Control and Prevention and in
consultation with the Administrator of the Health Resources and
Services Administration, shall for each of the fiscal years
1991 through 1995 make an allotment for each State in an amount
determined in accordance with section 2649. The Secretary shall
make payments, as grants, to each State from the allotment for
the State for the fiscal year involved if the Secretary
approves for the fiscal year an application submitted by the
State pursuant to section 2665.
[(b) Purposes of Grants.--
[(1) In general.--The Secretary may not make a grant
under subsection (a) unless the State involved agrees
to expend the grant for the purposes of providing, on
an outpatient basis, each of the early intervention
services specified in paragraph (2) with respect to HIV
disease.
[(2) Specification of early intervention services.--
The early intervention services referred to in
paragraph (1) are--
[(A) counseling individuals with respect to
HIV disease in accordance with section 2662;
[(B) testing individuals with respect to such
disease, including tests to confirm the
presence of the disease, tests to diagnose the
extent of the deficiency in the immune system,
and tests to provide information on appropriate
therapeutic measures for preventing and
treating the deterioration of the immune system
and for preventing and treating conditions
arising from the disease;
[(C) referrals described in paragraph (3);
[(D) other clinical and diagnostic services
with respect to HIV disease, and periodic
medical evaluations of individuals with the
disease; and
[(E) providing the therapeutic measures
described in subparagraph (B).
[(3) Referrals.--The services referred to in
paragraph (2)(C) are referrals of individuals with HIV
disease to appropriate providers of health and support
services, including, as appropriate--
(A) to entities receiving amounts under part
A or B for the provision of such services;
[(B) to biomedical research facilities of
institutions of higher education that offer
experimental treatment for such disease, or to
community-based organizations or other entities
that provide such treatment; or
[(C) to grantees under section 2671, in the
case of pregnant women.
[(4) Requirement of availability of all early
intervention services through each grantee.--The
Secretary may not make a grant under subsection (a)
unless the State involved agrees that each of the early
intervention services specified in paragraph (2) will
be available through the State. With respect to
compliance with such agreement, a State may expend the
grant to provide the early intervention services
directly, and may expend the grant to enter into
agreements with public or nonprofit private entities
under which the entities provide the services.
[(5) Optional services.--A State receiving a grant
under subsection (a)--
[(A) may expend not more than 5 percent of
the grant to provide early intervention
services through making grants to hospitals
that--
[(i) for the most recent fiscal year
for which the data is available, have
admitted--
[(I) not fewer than 250
individuals with acquired
immune deficiency syndrome; or
[(II) a number of such
individuals constituting 20
percent of the number of
inpatients of the hospital
admitted during such period;
[(ii) agree to offer and encourage
such services with respect to
inpatients of the hospitals; and
[(iii) agree that subsections (c) and
(d) of section 2644 will apply to the
hospitals to the same extent and in the
same manner as such subsections apply
to entities described in such section;
[(B) may expend the grant to provide outreach
services to individuals who may have HIV
disease, or may be at risk of the disease, and
who may be unaware of the availability and
potential benefits of early treatment of the
disease, and to provide outreach services to
health care professionals who may be unaware of
such availability and potential benefits; and
[(C) may, in the case of individuals who seek
early intervention services from the grantee,
expend the grant--
[(i) for case management to provide
coordination in the provision of health
care services to the individuals and to
review the extent of utilization of the
services by the individuals; and
[(ii) to provide assistance to the
individuals regarding establishing the
eligibility of the individuals for
financial assistance and services under
Federal, State, or local programs
providing for health services, mental
health services, social services, or
other appropriate services.
[(6) Allocations.--
[(A) Subject to subparagraphs (B) and (C),
the Secretary may not make a grant under
subsection (a) unless the State involved
agrees--
[(i) to expend not less than 35
percent of the grant to provide the
early intervention services specified
in subparagraphs (A) through (C) of
paragraph (2); and
[(ii) to expend not less than 35
percent of the grant to provide the
early intervention services specified
in subparagraphs (D) and (E) of such
paragraph.
[(B) With respect to compliance with the
agreement under subparagraph (A), amounts
reserved by a State for fiscal year 1991 for
purposes of clauses (i) and (ii) of such
subparagraph may be expended to provide the
services specified in paragraph (5).
[(C) The Secretary shall ensure that, of the
amounts appropriated under section 2650 for
fiscal year 1991, an amount equal to
$130,000,000 is expended to provide the early
intervention services specified in
subparagraphs (A) through (C) of paragraph (2).
[SEC. 2642. PROVISION OF SERVICES THROUGH MEDICAID PROVIDERS.
[(a) In General.--Subject to subsection (b), the Secretary
may not make a grant under section 2641 to a State unless, in
the case of any service described in subsection (b) of such
section that is available pursuant to the State plan approved
under title XIX of the Social Security Act for the State--
[(1) the State will provide the service through a
State entity, and the State entity has entered into a
participation agreement under the State plan and is
qualified to receive payments under such plan; or
[(2) the State will enter into an agreement with a
public or nonprofit private entity under which the
entity will provide the service, and the entity has
entered into such a participation agreement and is
qualified to receive such payments.
[(b) Waiver Regarding Certain Secondary Agreements.--
[(1) In general.--In the case of an entity making an
agreement pursuant to subsection (a)(2) regarding the
provision of services, the requirement established in
such subsection regarding a participation agreement
shall be waived by the Secretary if the entity does
not, in providing health care services, impose a charge
or accept reimbursement available from any third-party
payor, including reimbursement under any insurance
policy or under any Federal or State health benefits
program.
[(2) Acceptance of voluntary donations.--A
determination by the Secretary of whether an entity
referred to in paragraph (1) meets the criteria for a
waiver under such subparagraph shall be made without
regard to whether the entity accepts voluntary
donations for the purpose of providing services to the
public.
[SEC. 2643. REQUIREMENT OF MATCHING FUNDS.
[(a) In General.--In the case of any State to which the
criterion described in subsection (c) applies, the Secretary
may not make a grant under section 2641 unless the State agrees
that, with respect to the costs to be incurred by the State in
carrying out the purpose referred to in such subsection, the
State will, subject to subsection (b)(2), make available
(directly or through donations from public or private entities)
non-Federal contributions toward such costs in an amount equal
to--
[(1) for the first fiscal year for which such
criterion applies to the State, not less than 16\2/3\
percent of such costs ($1 for each $5 of Federal funds
provided in the grant);
[(2) for any second such fiscal year, not less than
20 percent of such costs ($1 for each $4 of Federal
funds provided in the grant);
[(3) for any third such fiscal year, not less than 25
percent of such costs ($1 for each $3 of Federal funds
provided in the grant); and
[(4) for any subsequent fiscal year, not less than
33\1/3\ percent of such costs ($1 for each $2 of
Federal funds provided in the grant).
[(b) Determination of Amount of Non-Federal Contribution.--
[(1) In general.--Non-Federal contributions required
in subsection (a) may be in cash or in kind, fairly
evaluated, including plant, equipment, or services.
Amounts provided by the Federal Government, and any
portion of any service subsidized by the Federal
Government, may not be included in determining the
amount of such non-Federal contributions.
[(2) Inclusion of certain amounts.--
[(A) In making a determination of the amount
of non-Federal contributions made by a State
for purposes of subsection (a), the Secretary
shall, subject to subparagraph (B), include any
non-Federal contributions provided by the State
for HIV-related services, without regard to
whether the contributions are made for programs
established pursuant to this title.
[(B) In making a determination for purposes
of subparagraph (A), the Secretary may not
include any non-Federal contributions provided
by the State as a condition of receiving
Federal funds under any program under this
title (except for the program established in
section 2641) or under other provisions of law.
[(c) Applicability of Matching Requirement.--
[(1) Percentage of national number of cases.--
[(A) The criterion referred to in subsection
(a) is, with respect to a State, that the
number of cases of acquired immune deficiency
syndrome reported to and confirmed by the
Director of the Centers for Disease Control and
Prevention for the State for the period
described in subparagraph (B) constitutes more
than 1 percent of the number of such cases
reported to and confirmed by the Director for
the United States for such period.
[(B) The period referred to in subparagraph
(A) is the 2-year period preceding the fiscal
year for which the State involved is applying
to receive a grant under section 2641.
[(2) Exemption.--For purposes of paragraph (1), the
number of cases of acquired immune deficiency syndrome
reported and confirmed for the Commonwealth of Puerto
Rico for any fiscal year shall be deemed to be less
than 1 percent.
[(d) Diminished State Contribution.--With respect to a State
that does not make available the entire amount of the non-
Federal contribution referred to in subsection (a), the State
shall continue to be eligible to receive Federal funds under a
grant under section 2641, except that the Secretary in
providing Federal funds under the grant shall provide such
funds (in accordance with the ratios prescribed in paragraph
(1)) only with respect to the amount of funds contributed by
such State.
[SEC. 2644. OFFERING AND ENCOURAGING EARLY INTERVENTION SERVICES.
[(a) In General.--The Secretary may not make a grant under
section 2641 unless, in the case of entities to which the State
provides amounts from the grant for the provision of early
intervention services, the State involved agrees that--
[(1) if the entity is a health care provider that
regularly provides treatment for sexually transmitted
diseases, the entity will offer and encourage such
services with respect to individuals to whom the entity
provides such treatment;
[(2) if the entity is a health care provider that
regularly provides treatment for intravenous substance
abuse, the entity will offer and encourage such
services with respect to individuals to whom the entity
provides such treatment;
[(3) if the entity is a family planning clinic, the
entity will offer and encourage such services with
respect to individuals to whom the entity provides
family planning services and whom the entity has reason
to believe has HIV disease; and
[(4) if the entity is a health care provider that
provides treatment for tuberculosis, the entity will
offer and encourage such services with respect to
individuals to whom the entity provides such treatment.
[(b) Sufficiency of Amount of Grant.--With respect to
compliance with the agreement made under subsection (a), an
entity to which subsection (a) applies may be required to
offer, encourage, and provide early intervention services only
to the extent that the amount of the grant is sufficient to pay
the costs of offering, encouraging, and providing the services.
[(c) Criteria for Offering and Encouraging.--Subject to
section 2641(b)(4), an entity to which subsection (a) applies
is, for purposes of such subsection, offering and encouraging
early intervention services with respect to the individuals
involved if the entity--
[(1) offers such services to the individuals, and
encourages the individuals to receive the services, as
a regular practice in the course of providing the
health care involved; and
[(2) provides the early intervention services only
with the consent of the individuals.
[SEC. 2645. NOTIFICATION OF CERTAIN INDIVIDUALS RECEIVING BLOOD
TRANSFUSIONS.
[(a) In General.--The Secretary may not make a grant under
section 2641 unless the State involved provides assurances
satisfactory to the Secretary that, with respect to individuals
in the State receiving, between January 1, 1978, and April 1,
1985 (inclusive), a transfusion of whole blood or a blood-
clotting factor, the State will provide public education and
information for the purpose of--
[(1) encouraging the population of such individuals
to receive early intervention services; and
[(2) informing such population of any health
facilities in the geographic area involved that provide
such services.
[(b) Rule of Construction.--An agreement made under
subsection (a) may not be construed to require that, in
carrying out the activities described in such subsection, a
State receiving a grantunder section 2641 provide individual
notifications to the individuals described in such subsection.
[SEC. 2646. REPORTING AND PARTNER NOTIFICATION.
[(a) Reporting.--The Secretary may not make a grant under
section 2641 unless, with respect to testing for HIV disease,
the State involved provides assurances satisfactory to the
Secretary that the State will require that any entity carrying
out such testing confidentially report to the State public
health officer information sufficient--
[(1) to perform statistical and epidemiological
analyses of the incidence in the State of cases of such
disease;
[(2) to perform statistical and epidemiological
analyses of the demographic characteristics of the
population of individuals in the State who have the
disease; and
[(3) to assess the adequacy of early intervention
services in the State.
[(b) Partner Notification.--The Secretary may not make a
grant under section 2641 unless the State involved provides
assurances satisfactory to the Secretary that the State will
require that the public health officer of the State, to the
extent appropriate in the determination of the officer, carry
out a program of partner notification regarding cases of HIV
disease.
[(c) Rules of Construction.--An agreement made under this
section may not be construed--
[(1) to require or prohibit any State from providing
that identifying information concerning individuals
with HIV disease is required to be submitted to the
State; or
[(2) to require any State to establish a requirement
that entities other than the public health officer of
the State are required to make the notifications
referred to in subsection (b).
[SEC. 2647. REQUIREMENT OF STATE LAW PROTECTION AGAINST INTENTIONAL
TRANSMISSION.
[(a) In General.--The Secretary may not make a grant under
section 2641 to a State unless the chief executive officer
determines that the criminal laws of the State are adequate to
prosecute any HIV infected individual, subject to the condition
described in subsection (b), who--
[(1) makes a donation of blood, semen, or breast
milk, if the individual knows that he or she is
infected with HIV and intends, through such donation,
to expose another HIV in the event that the donation is
utilized;
[(2) engages in sexual activity if the individual
knows that he or she is infected with HIV and intends,
through such sexual activity, to expose another to HIV;
and
[(3) injects himself or herself with a hypodermic
needle and subsequently provides the needle to another
person for purposes of hypodermic injection, if the
individual knows that he or she is infected and
intends, through the provision of the needle, to expose
another to such etiologic agent in the event that the
needle is utilized.
[(b) Consent to Risk of Transmission.--The State laws
described in subsection (a) need not apply to circumstances
under which the conduct described in paragraphs (1) through (3)
of subsection (a) if the individual who is subjected to the
behavior involved knows that the other individual is infected
and provides prior informed consent to the activity.
[(c) State Certification With Respect to Required Laws.--With
respect to complying with subsection (a) as a condition of
receiving a grant under section 2641, the Secretary may not
require a State to enact any statute, or to issue any
regulation, if the chief executive officer of the State
certifies to the Secretary that the laws of the State are
adequate. The existence of a criminal law of general
application, which can be applied to the conduct described in
paragraphs (1) through (3) of subsection (a), is sufficient for
compliance with this section.
[(d) Time Limitations With Respect to Required Laws.--With
respect to receiving a grant under section 2641, if a State is
unable to certify compliance with subsection (a), the Secretary
may make a grant to a State under such section if--
[(1) for each of the fiscal years 1991 and 1992, the
State provides assurances satisfactory to the Secretary
that by not later than October 1, 1992, the State will
have in place or will establish the prohibitions
described in subsection (a); and
[(2) for fiscal year 1993 and subsequent fiscal
years, the State has established such prohibitions.
[SEC. 2648. TESTING AND OTHER EARLY INTERVENTION SERVICES FOR STATE
PRISONERS.
[(a) In General.--In addition to grants under section 2641,
the Secretary may make grants to States for the purpose of
assisting the States in providing early intervention services
to individuals sentenced by the State to a term of
imprisonment. The Secretary may make such a grant only if the
State involved requires, subject to subsection (d), that--
[(1) the services be provided to such individuals;
and
[(2) each such individual be informed of the
requirements of subsection (c) regarding testing and be
informed of the results of such testing of the
individual.
[(b) Requirement of Matching Funds.--
[(1) In general.--The Secretary may not make a grant
under subsection (a) unless the State involved agrees
that, with respect to the costs to be incurred by the
State in carrying out the purpose described in such
subsection, the State will make available (directly or
through donations from public or private entities) non-
Federal contributions toward such costs in an amount
equal to--
[(A) for the first fiscal year of payments
under the grant, not less than $1 for each $2
of Federal funds provided in the grant; and
[(B) for any subsequent fiscal year of such
payments, not less than $1 for each $1 of
Federal funds provided in the grant.
[(2) Determination of amount of non-federal
contribution.--Non-Federal contributions required in
paragraph (1) may be in cash or in kind, fairly
evaluated, including plant, equipment, or services.
Amounts provided by the Federal Government, and
services (or portions of services) subsidized by the
Federal Government, may not be included in determining
the amount of such non-Federal contributions.
[(c) Testing.--The Secretary may not make a grant under
subsection (a) unless--
[(1) the State involved requires that, subject to
subsection (d), any individual sentenced by the State
to a term of imprisonment be tested for HIV disease--
[(A) upon entering the State penal system;
and
[(B) during the 30-day period preceding the
date on which the individual is released from
such system;
[(2) with respect to informing employees of the penal
system of the results of such testing of the
individual, the State--
[(A) upon the request of any such employee,
provides the results to the employee in any
case in which the medical officer of the prison
determines that there is a reasonable basis for
believing that the employee has been exposed by
the individual to such disease; and
[(B) informs the employees of the
availability to the employees of such results
under the conditions described in subparagraph
(A);
[(3) with respect to informing the spouse of the
individual of the results of such testing of the
individual, the State--
[(A) upon the request of the spouse, provides
such results to the spouse prior to any
conjugal visit and provides such results to the
spouse during the period described in paragraph
(1)(B); and
[(B) informs the spouse of the availability
to the spouse of such results under the
conditions described in subparagraph (A);
[(4) with respect to such testing upon entering the
State penal system of such an individual who has been
convicted of rape or aggravated sexual assault, the
State--
[(A) upon the request of the victim of the
rape or assault, provides such results to the
victim; and
[(B) informs the victim of the availability
to the victim of such results; and
[(5) the State, except as provided in any of
paragraphs (2) through (4), maintains the
confidentiality of the results of testing for HIV
disease in each prison operated by the State or with
amounts provided by the State, and makes disclosures of
such results only as medically necessary.
[(d) Determination of Prisons Subject to Requirement.--
[(1) In general.--The Secretary may not make a grant
under subsection (a) unless the State involved agrees
that the requirement established in such subsection
regarding the provision of early intervention services
to inmates will apply only to inmates who are
incarcerated in prisons with respect to which the State
public health officer, after consultation with the
chief State correctional officer, has, on the basis of
the criteria described in paragraph (2), determined
that the provision of such services is appropriate with
respect to the public health and safety.
[(2) Description of criteria.--The criteria to be
considered for purposes of paragraph (1) are--
[(A) with respect to the geographic areas in
which inmates of the prison involved resided
before incarceration in the prison--
[(i) the severity of the epidemic of
HIV disease in the areas during the
period in which the inmates resided in
the areas; and
[(ii) the incidence, in the areas
during such period, of behavior that
places individuals at significant risk
of developing HIV disease; and
[(B) the extent to which medical examinations
conducted by the State for inmates of the
prison involved indicate that the inmates have
engaged in such behavior.
[(e) Applicability of Provisions Regarding Informed Consent,
Counseling, and Other Matters.--The Secretary may not make a
grant under subsection (a) unless the State involved agrees
that sections 2641(b)(4), 2662, and 2664(c) will apply to the
provision of early intervention services pursuant to the grant
in the same manner and to the same extent as such sections
apply to the provision of such services by grantees under
section 2641.
[(f) Requirement of Application.--The Secretary may not make
a grant under subsection (a) unless an application for the
grant is submitted to the Secretary and the application is in
such form, is made in such manner, and contains such
agreements, assurances, and information as the Secretary
determines to be necessary to carry out this section.
[(g) Rule of Construction.--With respect to testing inmates
of State prisons for HIV disease without the consent of the
inmates, the agreements made under this section may not be
construed to authorize, prohibit, or require any State to
conduct such testing, except as provided in subparagraphs (A)
and (B) of subsection (c)(1).
[(h) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of the fiscal years 1988 through
1995.
[SEC. 2649. DETERMINATION OF AMOUNT OF ALLOTMENTS.
[(a) Minimum Allotment.--Subject to the extent of amounts
made available in appropriations Acts, the amount of an
allotment under section 2641(a) for a State for a fiscal year
shall be the greater of--
[(1) $100,000 for each of the several States, the
District of Columbia, and the Commonwealth of Puerto
Rico, and $50,000 for each of the territories of the
United States other than the Commonwealth of Puerto
Rico; and
[(2) an amount determined under subsection (b).
[(b) Determination Under Formula.--The amount referred to in
subsection (a)(2) is the product of--
[(1) an amount equal to the amount appropriated under
section 2650 for the fiscal year involved; and
[(2) a percentage equal to the quotient of--
[(A) an amount equal to the number of cases
of acquired immune deficiency syndrome reported
to and confirmed by the Director of the Centers
for Disease Control and Prevention for the
State involved for the most recent fiscal year
for which such data is available; divided by
[(B) an amount equal to the number of cases
of acquired immune deficiency syndrome reported
to and confirmed by the Director of the Centers
for Disease Control and Prevention for the
United States for the most recent fiscal year
for which such data is available.
[(c) Certain Allocations by Secretary.--
[(1) Discretionary grants to certain states.--After
determining the amount of an allotment under subsection
(a) for a fiscal year, the Secretary shall reduce the
amount of the allotment of each State by 10 percent.
From the amounts available as a result of such
reductions, the Secretary shall, on a discretionary
basis, make grants to States receiving allotments for
the fiscal year involved. Such grants shall be made
subject to each of the agreements and assurances
required as a condition of receiving grants under
section 2641.
[(2) Grants to certain political subdivisions.--
[(A)(i) In the case of a State containing any
political subdivision described in clause (ii),
the Secretary shall, subject to subparagraph
(B), make a reduction in the amount of the
allotment under subsection (a) for the State
for each fiscal year in an amount necessary for
carrying out subparagraphs (B) and (C) with
respect to the political subdivision. Any such
reduction shall be in addition to the reduction
required in paragraph (1) for the fiscal year
involved.
[(ii) The political subdivision referred to
in clause (i) is any political subdivision that
received a cooperative agreement from the
Secretary, acting through the Director of the
Centers for Disease Control and Prevention, for
fiscal year 1990 for programs to provide
counseling and testing with respect to acquired
immune deficiency syndrome.
[(B) In the case of a State described in
subparagraph (A), the Secretary shall, from the
amounts made available as a result of
reductions under such subparagraph, make a
grant each fiscal year to each political
subdivision described in such subparagraph that
exists in the State if the political
subdivision involved agrees that the provisions
of subparts II and III will apply to the
political subdivision to the same extent and in
the same manner as such subparts apply to
entities receiving grants under section
2651(a).
[(C) Grants under subparagraph (B) for a
fiscal year for a political subdivision shall
be provided in an amount equal to the amount
received by the political subdivision in fiscal
year 1990 under the cooperative agreement
described in subparagraph (A).
[(d) Disposition of Certain Funds Appropriated for
Allotments.--
[(1) In general.--Any amounts available pursuant to
paragraph (2) shall, in accordance with paragraph (3),
be allotted by the Secretary each fiscal year to States
receiving payments under section 2641(a) for the fiscal
year (other than any State referred to in paragraph
(2)(C)). The Secretary shall make payments, as grants,
to each such State from any such allotment for the
State for the fiscal year involved.
[(2) Specification of amounts.--The amounts referred
to in paragraph (1) are any amounts that are not paid
to States under section 2641(a) as a result of--
[(A) the failure of any State to submit an
application under section 2651;
[(B) the failure, in the determination of the
Secretary, of any State to prepare the
application in compliance with such section or
to submit the application within a reasonable
period of time; or
[(C) any State informing the Secretary that
the State does not intend to expend the full
amount of the allotment made to the State.
[(3) Amount of allotment.--The amount of an allotment
under paragraph (1) for a State for a fiscal year shall
be an amount equal to the product of--
[(A) an amount equal to the amount available
pursuant to paragraph (2) for the fiscal year
involved; and
[(B) the percentage determined under
subsection (b)(2) for the State.
[(e) Transition Rules.--
[(1) For the fiscal years 1991 through 1993, the
amount of an allotment under section 2641 shall be the
greater of the amount determined under subsection (a)
and an amount equal to the amount applicable under
paragraph (2) for the fiscal year involved.
[(2) For purposes of paragraph (1)--
[(A) the amount applicable for fiscal year
1991 is an amount equal to the amount received
by the State involved from the Secretary,
acting through the Director of the Centers for
Disease Control and Prevention, for fiscal year
1990 for the provision of counseling and
testing services with respect to HIV;
[(B) the amount applicable for fiscal year
1992 is 85 percent of the amount specified in
subparagraph (A); and
[(C) the amount applicable for fiscal year
1993 is 70 percent of the amount specified in
subparagraph (A).
[SEC. 2649A. MISCELLANEOUS PROVISIONS.
[The Secretary may not make a grant under section 2641
unless--
[(1) the State involved submits to the Secretary a
comprehensive plan for the organization and delivery of
the early intervention services to be funded with the
grant that includes a description of the purposes for
which the State intends to use such assistance,
including--
[(A) the services and activities to be
provided and an explanation of the manner in
which the elements of the program to be
implemented by the State with the grant will
maximize the quality of early intervention
services available to individuals with HIV
disease throughout the State; and
[(B) a description of the manner in which
services funded with the grant will be
coordinated with other available related
services for individuals with HIV disease; and
[(2) the State agrees that--
[(A) the public health agency administering
the grant will conduct public hearings
regarding the proposed use and distribution of
the grant;
[(B) to the maximum extent practicable, early
intervention services delivered pursuant to the
grant will be provided without regard to the
ability of the individual to pay for such
services and without regard to the current or
past health condition of the individual with
HIV disease;
[(C) early intervention services under the
grant will be provided in settings accessible
to low-income individuals with HIV disease; and
[(D) outreach to low-income individuals with
HIV disease will be provided to inform such
individuals of the services available pursuant
to the grant.
[SEC. 2650. AUTHORIZATION OF APPROPRIATIONS.
For the purpose of making grants under section 2641, there
are authorized to be appropriated $230,000,000 for fiscal year
1991, and such sums as may be necessary for each of the fiscal
years 1992 through 1995.
* * * * * * *
Subpart II--Categorical Grants
* * * * * * *
SEC. 2653. PREFERENCES IN MAKING GRANTS.
(a) * * *
* * * * * * *
(d) Underserved and Rural Areas.--Of the applicants who
qualify for preference under this section, the Secretary shall
give preference to applicants that will expend the grant under
section 2651 to provide early intervention under such section
in rural areas or in areas that are underserved with respect to
such services.
SEC. 2654. MISCELLANEOUS PROVISIONS.
(a) * * *
* * * * * * *
(c) Planning and Development Grants.--
(1) In general.--The Secretary may provide [planning
grants, in an amount not to exceed $50,000 for each
such grant, to public and nonprofit private entities
for the purpose of enabling such entities to provide
HIV early intervention services.] planning grants to
public and nonprofit private entities for purposes of--
(A) enabling such entities to provide HIV
early intervention services; and
(B) assisting the entities in expanding their
capacity to provide HIV-related health
services, including early intervention
services, in low-income communities and
affected subpopulations that are underserved
with respect to such services (subject to the
condition that a grant pursuant to this
subparagraph may not be expended to purchase or
improve land, or to purchase, construct, or
permanently improve, other than minor
remodeling, any building or other facility).
* * * * * * *
(4) Amount and duration of grants.--
(A) Early intervention services.--A grant
under paragraph (1)(A) may be made in an amount
not to exceed $50,000.
(B) Capacity development.--
(i) Amount.--A grant under paragraph
(1)(B) may be made in an amount not to
exceed $150,000.
(ii) Duration.--The total duration of
a grant under paragraph (1)(B),
including any renewal, may not exceed 3
years.
[(4)] (5) Limitation.--Not to exceed [1] 5 percent of
the amount appropriated for a fiscal year under section
2655 may be used to carry out this section.
SEC. 2655. AUTHORIZATION OF APPROPRIATIONS.
For the purpose of making grants under section 2651, there
are authorized to be appropriated such sums as may be necessary
[in each of the fiscal years 1996, 1997, 1998, 1999, and 2000.]
for each of the fiscal years 2001 through 2005.
Subpart III--General Provisions
* * * * * * *
SEC. 2662. PROVISION OF CERTAIN COUNSELING SERVICES.
(a) * * *
* * * * * * *
(c) Counseling of Individuals With Positive Test Results.--
The Secretary may not make a grant under this part unless the
applicant for the grant agrees that, if the results of testing
for HIV disease indicate that the individual has the disease,
the applicant will provide to the individual appropriate
counseling regarding such disease, including--
(1) * * *
* * * * * * *
(3) providing counseling [on]--
(A) on the availability, through the
applicant, of early intervention services;
(B) on the availability in the geographic
area of appropriate health care, mental health
care, and social and support services,
including providing referrals for such
services, as appropriate;
[(C) the benefits] (C)(i) that explains the
benefits of locating and counseling any
individual by whom the infected individual may
have been exposed to HIV and any individual
whom the infected individual may have exposed
to HIV; and
(ii) that emphasizes it is the duty of
infected individuals to disclose their infected
status to their sexual partners and their
partners in the sharing of hypodermic needles;
that provides advice to infected individuals on
the manner in which such disclosures can be
made; and that emphasizes that it is the
continuing duty of the individuals to avoid any
behaviors that will expose others to HIV;
(D) on the availability of the services of
public health authorities with respect to
locating and counseling any individual
described in subparagraph (C).
* * * * * * *
SEC. 2664. ADDITIONAL REQUIRED AGREEMENTS.
(a) * * *
* * * * * * *
(g) Administration of Grant.--The Secretary may not make a
grant under this part unless the applicant for the grant agrees
that--
(1) * * *
* * * * * * *
(3) the applicant will not expend more than [7.5] 10
percent including planning and evaluation of the grant
for administrative expenses with respect to the grant;
[and]
(4) the applicant will submit evidence that the
proposed program is consistent with the statewide
coordinated statement of need and agree to participate
in the ongoing revision of such statement of need[.];
and
(5) the applicant will provide for the establishment
of a quality management program to assess the extent to
which medical services funded under this title that are
provided to patients are consistent with the most
recent Public Health Service guidelines for the
treatment of HIV disease and related opportunistic
infections and that improvements in the access to and
quality of medical services are addressed.
* * * * * * *
Part D--General Provisions
SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR
WOMEN, INFANTS, CHILDREN, AND YOUTH.
(a) * * *
(b) Provisions Regarding Participation in Research.--
(1) In general.--With respect to the projects of
research with which an applicant under subsection (a)
is concerned, the Secretary may make a grant under such
subsection to the applicant only if the following
conditions are met:
(A) * * *
* * * * * * *
[(C) For the first and second fiscal years
for which grants under subsection (a) are to be
made to the applicant, the applicant agrees
that, not later than the end of the second
fiscal year of receiving such a grant, a
significant number of women, infants, children,
and youth who are patients of the applicant
will be participating in the projects of
research.
[(D) Except as provided in paragraph (3) (and
paragraph (4), as applicable), for the third
and subsequent fiscal years for which such
grants are to be made to the applicant, the
Secretary has determined that a significant
number of such individuals are participating in
the projects.]
(C) The applicant will demonstrate linkages
to research and how access to such research is
being offered to patients.
* * * * * * *
[(3) Significant participation; consideration by
secretary of certain circumstances.--In administering
the requirement of paragraph (1)(D), the Secretary
shall take into account circumstances in which a
grantee under subsection (a) is temporarily unable to
comply with the requirement for reasons beyond the
control of the grantee, and shall in such circumstances
provide to the grantee a reasonable period of
opportunity in which to reestablish compliance with the
requirement.
[(4) Significant participation; temporary waiver for
original grantees.--
[(A) In general.--In the case of an applicant
under subsection (a) who received a grant under
such subsection for fiscal year 1995, the
Secretary may, subject to subparagraph (B),
provide to the applicant a waiver of the
requirement of paragraph (1)(D) if the
Secretary determines that the applicant is
making reasonable progress toward meeting the
requirement.
[(B) Termination of authority for waivers.--
The Secretary may not provide any waiver under
subparagraph (A) on or after October 1, 1998.
Any such waiver provided prior to such date
terminates on such date, or on such earlier
date as the Secretary may specify.]
[(f) Application.--]
(f) Administration.--
(1) Application.--A grant under subsection (a) may be
made only if an application for the grant is submitted
to the Secretary and the application is in such form,
is made in such manner, and contains such agreements,
assurances, and information as the Secretary determines
to be necessary to carry out this section.
(2) Quality management program.--A grantee under this
section shall implement a quality management program.
(g) Coordination With National Institutes of Health.--The
Secretary shall develop and implement a plan that provides for
the coordination of the activities of the National Institutes
of Health with the activities carried out under this section.
In carrying out the preceding sentence, the Secretary shall
ensure that projects of research conducted or supported by such
Institutes are made aware of applicants and grantees under
subsection (a), shall require that the projects, as
appropriate, enter into arrangements for purposes of such
subsection, and shall require that each project entering into
such an arrangement inform the applicant or granteeunder such
subsection of the needs of the project for the participation of women,
infants, children, and youth. In addition, the Secretary, in
coordination with the Director of such Institutes, shall examine the
distribution and availability of appropriate HIV-related research
projects with respect to grantees under subsection (a) for purposes of
enhancing and expanding HIV-related research, especially within
communities that are underrepresented with respect to such projects.
* * * * * * *
(j) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years [1996 through 2000] 2001 through 2005.
* * * * * * *
SEC. 2674. EVALUATIONS AND REPORTS.
(a) * * *
* * * * * * *
(c) Authorization of Appropriations.--There are authorized to
be appropriated to carry out this section, such sums as may be
necessary for each of the fiscal years [1991 through 1995] 2001
through 2005.
* * * * * * *
SEC. 2675. DATA COLLECTION.
For the purpose of collecting and providing data for program
planning and evaluation activities under this title, there are
authorized to be appropriated to the Secretary (acting through
the Director of the Centers for Disease Control and Prevention)
such sums as may be necessary for each of the fiscal years 2001
through 2005. Such authorization of appropriations is in
addition to other authorizations of appropriations that are
available for such purpose.
SEC. [2675] 2675A. COORDINATION.
[(a) Requirement.--The Secretary shall assure that the Health
Resources and Services Administration and the Centers for
Disease Control and Prevention will coordinate the planning of
the funding of programs authorized under this title to assure
that health support services for individuals with HIV disease
are integrated with each other and that the continuity of care
of individuals with HIV disease is enhanced. In coordinating
the allocation of funds made available under this title the
Health Resources and Services Administration and the Centers
for Disease Control and Prevention shall utilize planning
information submitted to such agencies by the States and
entities eligible for support.]
(a) Requirement.--The Secretary shall ensure that the Health
Resources and Services Administration, the Centers for Disease
Control and Prevention, the Substance Abuse and Mental Health
Services Administration, and the Health Care Financing
Administration coordinate the planning, funding, and
implementation of Federal HIV programs to enhance the
continuity of care and prevention services for individuals with
HIV disease or those at risk of such disease. The Secretary
shall consult with other Federal agencies, including the
Department of Veterans Affairs, as needed and utilize planning
information submitted to such agencies by the States and
entities eligible for support.
(b) Report.--The Secretary shall biennially prepare and
submit to the appropriate committees of the Congress a report
concerning the coordination efforts at the Federal, State, and
local levels described in this section, including a description
of Federal barriers to HIV program integration and a strategy
for eliminating such barriers and enhancing the continuity of
care and prevention services for individuals with HIV disease
or those at risk of such disease.
[(b)] (c) Integration by State.--As a condition of receipt of
funds under this title, a State shall assure the Secretary that
health support services funded under this title will be
integrated with each other, that programs will be coordinated
with other available programs (including Medicaid) and that the
continuity of care and prevention services of individuals with
HIV disease is enhanced.
[(c)] (d) Integration by Local or Private Entities.--As a
condition of receipt of funds under this title, a local
government or private nonprofit entity shall assure the
Secretary that services funded under this title will be
integrated with each other, that programs will be coordinated
with other available programs (including Medicaid) and that the
continuity of care and prevention services of individuals with
HIV is enhanced.
(e) Recommendations Regarding Release of Prisoners.--After
consultation with the Attorney General and the Director of the
Bureau of Prisons, with States, with eligible areas under part
A, and with entities that receive amounts from grants under
part A or B, the Secretary, consistent with the coordination
required in subsection (a), shall develop a plan for the
medical case management of and the provision of support
services to individuals who were Federal or State prisoners and
had HIV disease as of the date on which the individuals were
released from the custody of the penal system. The Secretary
shall submit the plan to the Congress not later than two years
after the date of the enactment of the Ryan White CARE Act
Amendments of 2000.
SEC. 2675B. AUDITS.
For fiscal year 2002 and subsequent fiscal years, the
Secretary may reduce the amounts of grants under this title to
a State or political subdivision of a State for a fiscal year
if, with respect to such grants for the second preceding fiscal
year, the State or subdivision fails to prepare audits in
accordance with the procedures of section 7502 of title 31,
United States Code. The Secretary shall annually select
representative samples of such audits, prepare summaries of the
selected audits, and submit the summaries to the Congress.
SEC. 2675C. ADMINISTRATIVE SIMPLIFICATION REGARDING PARTS A AND B.
(a) Coordinated Disbursement.--After consultation with the
States, with eligible areas under part A, and with entities
that receive amounts from grants under part A or B, the
Secretary shall develop a plan for coordinating the
disbursement of appropriations for grants under part A with the
disbursement of appropriations for grants under part B in order
to assist grantees and other recipients of amounts from such
grants in complying with the requirements of such parts. The
Secretary shall submit the plan to the Congress not later than
18 months after the date of the enactment of the Ryan White
CARE Act Amendments of 2000. Not later than two years after the
date on which the plan is so submitted, the Secretary shall
complete the implementation of the plan, notwithstanding any
provision of this title that is inconsistent with the plan.
(b) Biennial Applications.--After consultation with the
States, with eligible areas under part A, and with entities
that receive amounts from grants under part A or B, the
Secretary shall make a determination of whether the
administration of parts A and B by the Secretary, and the
efficiency of grantees under such parts in complying with the
requirements of such parts, would be improved by requiring that
applications for grants under such parts be submitted
biennially rather than annually. The Secretary shall submit
such determination to the Congress not later than two years
after the date of the enactment of the Ryan White CARE Act
Amendments of 2000.
(c) Application Simplification.--After consultation with the
States, with eligible areas under part A, and with entities
that receive amounts from grants under part A or B, the
Secretary shall develop a plan for simplifying the process for
applications under parts A and B. The Secretary shall submit
the plan to the Congress not later than 18 months after the
date of the enactment of the Ryan White CARE Act Amendments of
2000. Not later than two years after the date on which the plan
is so submitted, the Secretary shall complete the
implementation of the plan, notwithstanding any provision of
this title that is inconsistent with the plan.
[SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.
[(a) In General.--Subject to subsection (b), there are
authorized to be appropriated to make grants under parts A and
B, such sums as may be necessary for each of the fiscal years
1996 through 2000.
[(b) Development of Methodology.--
[(1) In general.--With respect to each of the fiscal
years 1997 through 2000, the Secretary shall develop
and implement a methodology for adjusting the
percentages allocated to part A and part B to account
for grants to new eligible areas under part A and other
relevant factors. Not later than July 1, 1996, the
Secretary shall prepare and submit to the appropriate
committees of Congress a report regarding the findings
with respect to the methodology developed under this
paragraph.
[(2) Failure to implement.--If the Secretary
determines that such a methodology under paragraph (1)
cannot be developed, there are authorized to be
appropriated--
[(A) such sums as may be necessary to carry
out part A for each of the fiscal years 1997
through 2000; and
[(B) such sums as may be necessary to carry
out part B for each of the fiscal years 1997
through 2000.]
SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.
(a) Part A.--For the purpose of carrying out part A, there
are authorized to be appropriated such sums as may be necessary
for each of the fiscal years 2001 through 2005.
(b) Part B.--For the purpose of carrying out part B, there
are authorized to be appropriated such sums as may be necessary
for each of the fiscal years 2001 through 2005.
* * * * * * *
PART F--DEMONSTRATION AND TRAINING
* * * * * * *
Subpart II--AIDS Education and Training Centers
SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS.
(a) Schools; Centers.--
(1) In general.--The Secretary may make grants and
enter into contracts to assist public and nonprofit
private entities and schools and academic health
science centers in meeting the costs of projects--
(A) [training] to train health personnel,
including practitioners in programs under this
title and other community providers, in the
diagnosis, treatment, and prevention of HIV
disease, including the prevention of the
perinatal transmission of the disease [and
including], including measures for the
prevention and treatment of opportunistic
infections, and including (as applicable to the
type of health professional involved), prenatal
and other gynecological care for women with HIV
disease;
(B) to train the faculty of schools of, and
graduate departments or programs of, medicine,
nursing, osteopathic medicine, dentistry,
public health, allied health, and mental health
practice to teach health professions students
to provide for the health care needs of
individuals with HIV disease; [and]
(C) to develop and disseminate curricula and
resource materials relating to the care and
treatment of individuals with such disease and
the prevention of the disease among individuals
who are at risk of contracting the disease[.];
and
(D) to develop protocols for the medical care
of women with HIV disease, including prenatal
and other gynecological care for such women.
* * * * * * *
(b) Dental Schools.--
[(1) In general.--The Secretary may make grants to
assist dental schools and programs described in section
777(b)(4)(B) with respect to oral health care to
patients with HIV disease.]
(1) In general.--
(A) Grants.--The Secretary may make grants to
dental schools and programs described in
subparagraph (B) to assist such schools and
programs with respect to oral health care to
patients with HIV disease.
(B) Eligible applicants.--For purposes of
this subsection, the dental schools and
programs referred to in this subparagraph are
dental schools and programs that were described
in section 777(b)(4)(B) as such section was in
effect on the day before the date of enactment
of the Health Professions Education
Partnerships Act of 1998 (Public Law 105-392)
and in addition dental hygiene programs that
are accredited by the Commission on Dental
Accreditation.
(2) Application.--Each dental school or program
described in section [777(b)(4)(B)] the section
referred to in paragraph (1)(B) may annually submit an
application documenting the unreimbursed costs of oral
health care provided to patients with HIV disease by
that school or hospital during the prior year.
* * * * * * *
(5) Community-based care.--The Secretary may make
grants to dental schools and programs described in
paragraph (1)(B) that partner with community-based
dentists to provide oral health care to patients with
HIV disease in unserved areas. Such partnerships shall
permit the training of dental students and residents
and the participation of community dentists as adjunct
faculty.
(c) Authorization of Appropriations.--
(1) Schools; centers.--For the purpose of grants
under subsection (a), there are authorized to be
appropriated such sums as may be necessary for each of
the [fiscal years 1996 through 2000] fiscal years 2001
through 2005.
[(2) Dental schools.--For the purpose of grants under
subsection (b), there are authorized to be appropriated
such sums as may be necessary for each of the fiscal
years 1996 through 2000.]
(2) Dental schools.--
(A) In general.--For the purpose of grants
under paragraphs (1) through (4) of subsection
(b), there are authorized to be appropriated
such sums as may be necessary for each of the
fiscal years 2001 through 2005.
(B) Community-based care.--For the purpose of
grants under subsection (b)(5), there are
authorized to be appropriated such sums as may
be necessary for each of the fiscal years 2001
through 2005.
* * * * * * *
ADDITIONAL VIEWS
While I support the overall goal of the Coburn-Waxman Ryan
White CARE Act Amendments of 2000, H.R. 4807, I must take issue
with one key provision of the bill, the ``hold harmless''
provision for Title I Eligible Metropolitan Areas (EMAs). I
herewith express my strong objections to this provision and
urge that it be modified.
The original CARE Act legislation of 1990 included two
factors in Title I formula grants: cumulative AIDS cases and
``density.'' The ``density factor'' took into account the
number of AIDS cases per 100,000 people in a given EMA. When
the CARE Act was reauthorized in 1996, the criteria for Title I
formula grants were changed. A ``ten year weighted case band,''
which gives greater ``weight'' to recently diagnosed AIDS cases
on the theory that this information is more likely to measure
``living AIDS cases,'' was substituted for the count of
cumulative AIDS cases and the density factor was eliminated
entirely. These changes, particularly the removal of the
density factor, necessitated the inclusion of a ``hold
harmless'' provision to prevent EMAs from experiencing dramatic
funding losses.
Under current law, a Title I EMA can lose no more than one
percent of its funding each year, allowing for a five percent
loss over five years. H.R. 4807 would alter this dramatically
by allowing an EMA to lose 25 percent of its funding over five
years. The result will be a rapid decline among systems of care
and reduced access to vital HIV/AIDS services.
The Senate bill reauthorizing the CARE Act, S. 2301, alters
the ``hold harmless'' provision to allow for a 10 percent
reduction in funding for an EMA over five years, a doubling of
the rate in the current law. The Senate provision allows for a
reasonable redirecting of resources without undermining systems
of care through huge funding losses. I urge the Conferees to
adopt the Senate provision when this bill goes to Conference.
The 25 percent formula reduction included in H.R. 4807 is
troubling for many reasons. The only EMA likely to experience
the full 25% reduction in funding is San Francisco, meaning
that this change will directly impact my constituents.
It has been stated that San Francisco receives ``too much''
money relative to the number of people living with HIV/AIDS.
This is false. The AIDS epidemic is still a national crisis and
no EMA, including San Francisco, receives enough CARE Act
funding to meet all the needs of those living with HIV/AIDS. As
more people with HIV live longer due to life-saving but
expensive combination therapies, the strain on public health
systems is increasing, not decreasing. Reducing an EMA's Title
I funding by 25 percent would seriously destabilize systems of
care in that community.
The ten year weighted case band that is used to allocate
Title I formula funding seriously undercounts the number of
people accessing CARE Act services. As noted previously, a
recently diagnosed AIDS case is given greater ``weight'' under
this formula. However, the use of highly active antiretroviral
therapy has made this method of measurement far less accurate.
Combination therapies have allowed many people with AIDS to
live longer than 10 years and prevented many with HIV from
advancing to an AIDS diagnosis as quickly as in the past. As a
result, more people than ever are utilizing CARE Act services
but many of them aren't being counted in the current Title I
formula methodology. The hold harmless provision in H.R. 4807
would have the effect of punishing EMAs like San Francisco for
effective intervention to care for and prolong the lives of
those with HIV.
Proponents of the 25 percent hold harmless provision have
offered a per capita analysis of each EMA to show that San
Francisco receives too much in CARE Act funds. This argument is
misleading and obscures the fact that CARE Act funding is
designed to support public health systems in cities where large
numbers of AIDS cases threaten the system with collapse and is
not tied to individuals with AIDS. A per capita analysis
ignores other relevant factors as well, such as the wide
variance in cost of care among geographic areas, making direct
comparison very difficult. Similarly, CARE Act services are
accessed at varying rates in different areas.
I support the reauthorization of the Ryan White CARE Act;
however, it's vital that the more moderate Senate position on
the hold harmless issue be adopted in Conference and I urge my
colleagues to do so.
Anna G. Eshoo.