Recommendations to Guide the 2005 Reauthorization of the Ryan White CARE Act

NASTAD's recommendations to address CARE Act accountability focus on: accountability of HRSA and CARE Act grantees and the HRSA administrative tap.

Accountability of HRSA and CARE Act Grantees

States and territories, as Title II grantees, are monitored in a rigorous manner by HRSA. States and territories are required to provide program budget and fiscal reports and detailed contractor/provider budget packages each year. Grantees must also provide HRSA with a budget package for each Title II subgrantee with whom they contract. This package provides HRSA with a detailed explanation of the intent of the contract, the services to be offered and the dollars provided. States must also offer a detailed explanation of their subgrantee monitoring process. In addition, all CARE Act grantees are required to submit a CARE Act Data Report (CADR) annually. The CADR collects information on all clients that have received at least one CARE Act service. Data collected include: information on co-morbid conditions; prescribed medications; type of service provided; characteristics of clients; and information related to pregnant clients and the services they receive. In addition, ADAPs currently provide monthly reports on client utilization and also quarterly pricing reports.

States have processes to monitor the organization with which they subcontract to provide services to individuals living with HIV/AIDS. The majority of states have a process that includes both fiscal monitoring and program monitoring. States must also ensure that subgrantees have quality management programs in place, which help the subgrantee and the state identify problems that may impact health status outcomes. While HRSA does not mandate the process by which states must monitor their subgrantees, states are required to provide extensive detail about their various monitoring programs.

Since the enactment of CARE Act in 1990, the Office of the Inspector General (OIG) within the Department of Health and Human Services has audited HRSA's HIV/AIDS Bureau and CARE Act grantees at least 25 times to ensure accountability in the usage of CARE Act resources. The OIG routinely audits Title II grantees and their subgrantees for compliance with operating procedures, as well as conducting inspections and evaluations of the programs. Findings from these audits often result in more restrictive subgrantee monitoring programs, many of which place additional burdens on state health departments.

HRSA has recently consolidated its grants management offices, relocating most Title II monitoring responsibilities from regional offices to the national headquarters, and created the Office of Performance Review (OPR). In response to OIG reports, HRSA has indicated that HAB and the OPR will comprehensively review each of HRSA's grantees. NASTAD supports accountability of all CARE Act programs and grantees and believes that the current system of audits and evaluations upholds this.

• RECOMMENDATION #31 -- (Legislative) Support existing accountability processes through which states monitor their subgrantees.
  • RECOMMENDATION #31a -- (Legislative) Oppose any legislative mandates prescribing a one-size-fits-all set of standards for states in monitoring their subgrantees. Any new standards for grantees' monitoring of subgrantees should reflect that a common protocol does not fit all grantees. Any new standards should be constructed administratively in consultation with states and territories.

  • RECOMMENDATION #31b -- (Administrative) -- Require HRSA's Office of Performance Review to simplify additional requests to states for performance reviews of subgrantees. NASTAD recognizes the importance of grantee monitoring. However, much of the information needed to assess accountability and other programmatic goals can be found in the data already required by HRSA.

HRSA Administrative and SPNS Tap Accountability

HRSA takes an administrative tap on the funds appropriated by Congress. All titles of the CARE Act are subject to the administrative tap. The ADAP earmark in Title II is exempt from an administrative tap and thus the tap is taken entirely from the Title II base. In the three most recent fiscal years, HRSA has taken between 3% and 3.6% off the Title II base appropriation for the administrative tap.

NASTAD appreciates that much of these funds pay for salaries and overhead for HAB. State AIDS directors believe these funds should be used to ensure that HAB has a knowledgeable staff that can provide in-depth technical assistance to states to enhance and improve their programs. NASTAD is increasingly concerned that much of this technical assistance has been outsourced and that comprehensive knowledge of state programs does not reside within HAB.

Special Projects of National Significance (SPNS)²⁵ is funded through a percentage tap on Title I, Title II base, Title II and Title IV of the CARE Act -- up to $25 million. SPNS support the development of innovative HIV/AIDS service delivery models that have potential for replication in other jurisdictions. In recent years, the SPNS tap has been funded through an evaluation tap taken by HHS through authority in Section 241 of the PHS Act. For FY2005, that tap is 2.4% of the entire CARE Act or $49 million, out of which SPNS receives $25 million, with the other $24 million going to fill gaps in other PHS programs.

• RECOMMENDATION #32 -- (Legislative) Require HRSA to give a comprehensive accounting of the administrative tap to Congress on an annual basis.

• RECOMMENDATION #33 -- (Legislative) Require HRSA to provide CARE Act grantees and Congress with a comprehensive accounting of how CARE Act funded SPNS research is being translated into practice.

• RECOMMENDATION #34 -- (Legislative) Exempt the CARE Act from the HHS evaluation tap.