Renewing the Commitment: The 2005 Reauthorization of the Ryan White CARE Act

Four Titles and Other Programs: The Structure of the CARE Act

The Ryan White CARE Act is structured as four major titles and other, smaller programs. Each title is set up as a different funding stream, with different recipients:

• Title I: Provides grants to cities and surrounding areas (eligible metropolitan areas -- EMAs) with high AIDS prevalence

• Title II: Provides grants to all 50 states and the territories
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• Title II -- AIDS Drug Assistance Program (ADAP): Goes to all 50 states and the territories as a set-aside within Title II to purchase medications for people living with HIV/AIDS

• Title III: Provides funding for primary medical care, frequently through community health centers

• Title IV: Provides grants for comprehensive care for women, children, youth, and families

• Part F -- Dental reimbursement: Provides for dental services for people living with HIV/AIDS

• Part F -- AIDS Education and Training Centers (AETCs): Provides funds for training health care providers

• Special Projects of National Significance -- SPNS: Supports demonstration projects on new models of HIV/AIDS care delivery

Titles I, II (base), III, IV, and Part F Dental are considered "care-providing," meaning their funding is used primarily to provide medical and support services. The Title II set-aside for ADAP is used to purchase medications, and the remainder of the CARE Act is dedicated to training, promotion of best practices, and innovative program models. The CARE Act is administered by the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA).

In fiscal year 2005, the appropriation for the Ryan White CARE Act was approximately $2.048 billion, an overall increase of about $28 million (1.3 percent) over fiscal year 2004. However, the funding increase was entirely within the AIDS Drug Assistance Program, and this masks the fact that the care-providing titles all took funding cuts due to an overall rescission of federal funding in the omnibus appropriations bill. In both fiscal years 2004 and 2005, the other programs lost money, with losses in the CARE Act totaling approximately $28 million. Further, though ADAP has received modest funding increases, these increases are not adequate to meet the existing and growing need for anti-AIDS medications. Overall, the CARE Act every year is being asked to do more and more with less and less.

Women, Infants, Children and Youth (WICY) Set-Asides

To respond to the needs of women, infants, children, and youth (WICY) affected by HIV/AIDS, Titles I and II are structured to include a WICY "set-aside" to provide care specifically for these populations. The WICY requirements ensure that a percentage of CARE Act resources is allocated equal to the percentage that each of the populations -- women, infants, children, and youth -- constitute within the overall HIV/AIDS epidemic in a given area. Thus, if an area has an HIV/AIDS epidemic in which 35 percent of the cases occur among women, then at least 35 percent of the resources must be devoted to women's care, and so forth for each of the groups. These funding requirements are coordinated through Title I planning councils, Title II planning bodies, and public health officials.

States and EMAs may request WICY "waivers," which allow them to count their Medicaid and SCHIP expenditures as meeting the requirements of the WICY set-aside. However, few states and EMAs have exercised this option, and preliminary data suggest that grantees under Titles I and II have been able to meet their WICY requirements, resulting in essential resources being targeted to the WICY populations.