# The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

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URL: https://www.frixlaw.com/law-library/documents/crs%3AR44282

## Record

- **Collection:** Congressional research report
- **Document type:** CRS Report
- **Published:** March 10, 2016
- **Citation:** R44282

## Text

The Ryan White HIV/AIDS Program:
Overview and Impact of the
Affordable Care Act
/name redacted/
Specialist in Biomedical Policy
/name redacted/
Specialist in Health Services
March 10, 2016

Congressional Research Service
7-....
www.crs.gov
R44282

The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

Summary
The Ryan White HIV/AIDS Program makes federal funds available to eligible metropolitan areas,
states, and local community-based organizations to assist with health care costs and support
services for individuals and families affected by the human immunodeficiency virus (HIV) or
acquired immune deficiency syndrome (AIDS). The Ryan White HIV/AIDS Program reports that
in 2014 it served 512,214 low-income people with HIV/AIDS in the United States, 25.4% of
whom were uninsured and 64.2% of whom were living at or below 100% of the federal poverty
level.
The Ryan White HIV/AIDS Program is administered by the Health Resources and Services
Administration (HRSA) of the Department of Health and Human Services (HHS). Its statutory
authority is Title XXVI of the Public Health Service (PHS) Act, originally enacted in 1990 and
composed of four major parts and several other components. Part A provides grants to urban areas
and mid-sized cities. Part B provides grants to states and territories; it also provides funds for the
AIDS Drug Assistance Program (ADAP). Part C provides early intervention grants to public and
private nonprofit entities. Part D provides grants to public and private nonprofit entities for
family-centered care for women, infants, children, and youth with HIV/AIDS. The other
components under Part F include the AIDS Dental Reimbursement (ADR) Program, the
Community-Based Dental Partnership Program, the AIDS Education and Training Centers
(AETCs), the Special Projects of National Significance (SPNS) Program, and the Minority AIDS
Initiative (MAI). In October 2009, the 111th Congress passed and President Obama signed the
Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87), which reauthorized the
Ryan White HIV/AIDS Program through September 30, 2013. The program’s authority is
currently expired, but Congress continues to appropriate funds for the program.
The Patient Protection and Affordable Care Act of 2010 (ACA, P.L. 111-148, as amended)
contains general provisions to increase access to health insurance; therefore, the ACA has the
potential to increase coverage for people living with HIV/AIDS. For example, ACA includes
prohibitions on the cancellation of coverage by an insurer due to a preexisting condition,
elimination of lifetime caps on insurance benefits and annual limits on coverage, and eligibility
for tax subsidies to help low- and middle-income individuals purchase coverage from a health
insurance exchange. ACA phases out the Medicare Part D “doughnut hole” (i.e., payment gap) for
HIV/AIDS individuals who are Medicare eligible, which should increase coverage of HIV/AIDS
drugs. Finally, the ACA permits states to broaden Medicaid eligibility to include non-elderly
adults. There could be a significant impact on Ryan White ADAP clients in states that expand
their Medicaid program; specifically, about half of ADAP clients would be Medicaid-eligible in
expansion states, and the remainder would likely be eligible for premium subsidies to purchase
health coverage on the exchange.
The long-range impact of ACA on the Ryan White HIV/AIDS Program—in which HIV care and
treatment services provided under Ryan White are replaced by access to such services through
health insurance coverage via ACA—remains to be determined. Prior to the ACA’s
implementation, many Ryan White patients were insured and used Ryan White funds to pay
premiums and cost sharing, and this need for funds is likely to remain as some Ryan White
patients transition to private insurance. In states that decide not to participate in the Medicaid
expansion, the need for the full range of Ryan White services would remain. However, even if all
states decide to cover the new Medicaid-eligible group, there will be gaps that the Ryan White
HIV/AIDS Program could continue to fill, such as coverage of those individuals with HIV/AIDS
who are undocumented immigrants, and training of health providers in HIV-related care. In
addition, Ryan White provides dental care and support services, such as medical transportation,

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The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

that may not be provided under Medicaid or private health insurance. The Ryan White HIV/AIDS
Program serves a public health role by keeping people in treatment and thereby decreasing the
risk of transmitting HIV to others.
Funding for the Ryan White HIV/AIDS Program in FY2016, provided in the Consolidated
Appropriations Act, 2016 (H.R. 2029, P.L. 114-113), is $2.323 billion. For FY2017, the Obama
Administration requests $2.298 billion in budget authority and $34 million via a PHS transfer for
the SPNS program, resulting in an FY2017 total of $2.332 billion for the Ryan White HIV/AIDS
Program. The $9 million increase over FY2016 is for a new SPNS initiative to expand screening
for and treatment of hepatitis C in people living with HIV. The FY2017 budget request again
proposes a consolidation of Part C and Part D, which was proposed in the FY2015 and FY2016
budget requests and rejected by Congress.

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Contents
The Ryan White HIV/AIDS Program.............................................................................................. 3
Part A—Grants to Urban Areas ................................................................................................. 3
EMAs and TGAs................................................................................................................. 3
Core Medical Services vs. Support Services ...................................................................... 4
Formula Grants, Supplemental Grants, and Number of Living HIV/AIDS Cases ............. 5
Planning Councils ............................................................................................................... 6
Unexpended Funds.............................................................................................................. 6
Part B—Grants to States ........................................................................................................... 7
Formula Grants and Number of Living HIV/AIDS Cases .................................................. 7
Supplemental Grants ........................................................................................................... 8
Emerging Community Grants ............................................................................................. 9
ADAP.................................................................................................................................. 9
Unexpended Funds............................................................................................................ 10
Part C—Early Intervention Services ........................................................................................ 11
Part D—Women, Infants, Children, and Youth ........................................................................ 11
Part E and Part G ..................................................................................................................... 12
Part F—Demonstration and Training ...................................................................................... 12
The National HIV/AIDS Strategy ................................................................................................. 14
ACA and the Ryan White HIV/AIDS Program ............................................................................. 15
Medicaid Expansion ................................................................................................................ 16
Private Insurance Expansions ................................................................................................. 17
Other ACA Provisions ............................................................................................................. 18
ACA and the Future of the Ryan White HIV/AIDS Program ................................................. 19
Reauthorization of the Ryan White HIV/AIDS Program .............................................................. 20
Appropriations ............................................................................................................................... 20
FY2016.................................................................................................................................... 20
FY2017.................................................................................................................................... 21

Figures
Figure 1. Ryan White HIV/AIDS Program Funding, FY2016 ........................................................ 2

Tables
Table 1. Federal Funding for the Ryan White HIV/AIDS Program, FY1991-FY2017 ................. 22
Table A-1. Ryan White HIV/AIDS Program Overview ................................................................ 23

Appendixes
Appendix. Summary of Ryan White HIV/AIDS Program Parts ................................................... 23

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Contacts
Author Contact Information .......................................................................................................... 25

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he Ryan White HIV/AIDS Program makes federal funds available to eligible metropolitan
areas, states and local community-based organizations to provide a number of health care
services for HIV/AIDS patients, including medical care, drug treatments, dental care,
home health care, and outpatient mental health and substance abuse treatment. The Centers for
Disease Control and Prevention (CDC) estimates that more than 1.2 million people in the United
States have HIV/AIDS.1 The Ryan White HIV/AIDS Program reports that in 2014 it served
512,214 low-income people with HIV/AIDS, 25.4% of whom were uninsured and 64.2% of
whom were living at or below 100% of the federal poverty level.2 The majority of clients in 2014
were male (70.6% male, 28.3% female, 1.1% transgender), from racial/ethnic minority
populations (47.2% Black/African American, 22.2% Hispanic/Latino, 0.5% American
Indian/Alaska Native, 1.2% Asian, 0.2% Native Hawaiian/Pacific Islander, 1.8% Multiple Races,
27% white), and aged 50 years and older (40.4%).3

T

The Ryan White HIV/AIDS Program states that in 2014, 80.4% of clients were retained in HIV
medical care (218,758 clients of 272,193 total clients).4 Clinical research has demonstrated that
treatment of HIV patients with anti-HIV (also called antiretroviral) medication reduces the
amount of virus in the blood to very low levels (also called viral suppression) and lowers the risk
of HIV transmission by 96%.5 The Ryan White HIV/AIDS Program indicates that in 2014, 81.4%
of clients achieved viral suppression (231,140 clients of 283,811 total clients).6 Among youth
aged 13-24 years, retention in care was lower (10,988 youth clients of 14,639 total youth clients,
or 75.1%) than the national Ryan White HIV/AIDS Program average and viral suppression was
much lower (10,407 youth clients of 16,117 total youth clients, or 64.6%).7
The Ryan White HIV/AIDS Program was established in law in 1990 (P.L. 101-381) and
reauthorized and amended in 1996 (P.L. 104-146), 2000 (P.L. 106-345), 2006 (P.L. 109-415), and
2009 (P.L. 111-87).8 It was enacted as Title XXVI of the Public Health Service (PHS) Act and
1

Centers for Disease Control and Prevention, HIV in the United States: At a Glance, http://www.cdc.gov/hiv/statistics/
overview/ataglance.html. CDC does not indicate the percentage of the 1.2 million population that is low-income.
2
Total comprises all clients: 96% (492,240) were living with HIV; the remainder (uninfected) family members who
received counseling and testing services. HRSA, Ryan White HIV/AIDS Program Annual Client-Level Data Report
2014, pp. 6-7 and Table 1, pp. 17-18. http://hab.hrsa.gov/data/servicesdelivered/2014RWHAPDataReport.pdf.
Published December 2015. Accessed February 17, 2016.
3
Ibid.
4
Retention in HIV medical care defined as “at least 1 outpatient ambulatory medical care visit by September 1 of the
measurement year with a second visit at least 90 days after.” Ibid., p. 8 and Table 12a, p. 35.
5
Myron S. Cohen, Ying Q. Chen, Marybeth McCauley, et al., “Prevention of HIV-1 infection with early antiretroviral
therapy,” The New England Journal of Medicine, vol. 365, no. 6 (August 11, 2011), pp. 493-505.
6
“Viral suppression was based on data for persons living with HIV who had at least 1 outpatient ambulatory medical
care visit and at least 1 viral load test during the measurement year, and whose most recent viral load test result was
<200 copies/mL.” HRSA, Ryan White HIV/AIDS Program Annual Client-Level Data Report 2014, p. 8 and Table 13a,
p. 39. http://hab.hrsa.gov/data/servicesdelivered/2014RWHAPDataReport.pdf. Published December 2015. Accessed
February 17, 2016. According to HRSA, “the reason that the total clients number—for ‘retained in medical care’ and
‘achieved viral suppression’— is different (272,193 total clients vs. 283,811 total clients) is due to the fact that these
are measured differently and are not directly comparable. While the denominator for the Ryan White Services Report
data is all Ryan White HIV/AIDS Program clients, we only collect clinical data such as viral load and medical visits on
a subset of clients. In addition, these clients are not subsets of each other so the viral suppression group may not
entirely overlap with the retention group and vice versa.” HRSA, personal communication, March 9, 2016.
7
Ibid., p. 10 and Table 17a/17b, pp. 54-55.
8
P.L. 109-415 had reauthorized the Ryan White HIV/AIDS Program through September 30, 2009. A provision in P.L.
109-415 (§703) would have repealed the Ryan White HIV/AIDS Program as of the start of FY2010. The FY2010
Continuing Appropriations Resolution (Division B of P.L. 111-68) extended authority for the Ryan White HIV/AIDS
Program through October 31, 2009. Legislation that would reauthorize the Ryan White HIV/AIDS Program, H.R. 3792
(continued...)

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codified as Parts A, B, C, D, E, F, and G under 42 U.S.C. §300ff-11 et seq. The program is
administered by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau.
Most of the program funding is distributed to eligible entities based on formulas that take into
account the number of people living with HIV/AIDS. FY2016 funding of $2.3 billion is divided
among the individual grant programs (Parts A, B, C, D, and F) as shown in Figure 1. At the end
of this report, Table 1 provides FY1991-FY2017 request dollar amounts; the grant programs are
summarized in the Appendix.
Figure 1. Ryan White HIV/AIDS Program Funding, FY2016
Total = $2.3 billion

Source: HRSA FY2016 funding provided in the Consolidated Appropriations Act, 2016 (P.L. 114-113).
Notes: ADAP = AIDS Drugs Assistance Program; ADR = AIDS Dental Reimbursement Program; AETC = AIDS
Education and Training Centers; and SPNS = Special Projects of National Significance.

P.L. 111-87 provided specific authorization levels for Parts A, B, C, D, and F for each fiscal year
through FY2013, resulting in a four-year reauthorization for the Ryan White HIV/AIDS Program.
The program’s authority is currently expired, but Congress continues to appropriate funds for the
program. P.L. 111-87 required that the Secretary establish a national HIV/AIDS testing goal of 5
million tests annually through programs administered by HRSA and the CDC. The Secretary is
required to submit an annual report to Congress on the progress made in achieving the testing
goal, including any barriers to meeting the goal, the amount of funding necessary to meet the
goal, and the most cost-effective strategies for identifying individuals who are unaware of their
HIV status. The Secretary is also required to review each of the programs and activities
conducted by CDC as part of the Domestic HIV/AIDS Prevention Activities. Other provisions of
P.L. 111-87 are discussed below in the sections of this report on the various parts of the Ryan
White HIV/AIDS Program.
(...continued)
(Pallone), the Ryan White HIV/AIDS Treatment Extension Act of 2009, was approved by the House Energy and
Commerce on October 15, and a report was filed on October 20, 2009 (H.Rept. 111-305). The Ryan White HIV/AIDS
Treatment Extension Act of 2009, S. 1793 (Harkin), passed the Senate by voice vote on October 19, 2009. The House
passed S. 1793 on October 21, 2009, by a vote of 408-9. President Obama signed the legislation on October 30, 2009
(P.L. 111-87). P.L. 111-87 removed the sunset provision (§703 of P.L. 109-415).

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The Patient Protection and Affordable Care Act of 2010 (ACA, P.L. 111-148, as amended)
contains general provisions to increase access to health insurance and is expected to increase
coverage for people living with HIV/AIDS. These provisions include prohibitions on the
cancellation of coverage by an insurer due to a preexisting condition, elimination of lifetime caps
on insurance benefits and annual limits on coverage, and eligibility for tax subsidies to help lowand middle-income individuals purchase coverage from health insurance exchanges. In addition,
states have the option to broaden Medicaid eligibility to include single adults. ACA phases out the
Medicare Part D so-called “doughnut hole”—a gap in prescription drug coverage—for
individuals who are Medicare-eligible, including individuals with HIV/AIDS.9
The long-range impact of the health care law on HRSA’s Ryan White HIV/AIDS Program (in
which the health and treatment services provided under Ryan White are likely to be replaced to
some extent by access to such services through health coverage via ACA) remains to be
determined and may be of interest to policymakers given that authorization for the Ryan White
HIV/AIDS Program has lapsed.

The Ryan White HIV/AIDS Program
Part A—Grants to Urban Areas
Part A provides grant funds for medical and support services to eligible metropolitan and
transitional areas with high numbers of people living with HIV, as well as mid-sized areas that
have emerging needs for assistance with their HIV-infected populations.10 The boundaries of the
areas are based on the Metropolitan Statistical Areas of the U.S. Census Bureau and may range in
size from a single city or county to multiple counties that cross state boundaries.

EMAs and TGAs
Part A provides funds to eligible metropolitan areas (EMAs) with a population of at least 50,000
that have had more than 2,000 reported AIDS cases in the prior five years. An EMA would stop
being eligible if it failed for three consecutive years to have (1) a cumulative total of more than
2,000 reported cases of AIDS during the most recent five calendar years, and (2) a cumulative
total of 3,000 or more living cases of AIDS as of December 31 of the most recent year.11 Part A
currently provides grants to 24 EMAs.12

9

For description of the doughnut hole, see “Phase Out of the Coverage Gap” section in CRS Report R40611, Medicare
Part D Prescription Drug Benefit, by (name redacted) and (name redacted)
.
10
For information about FY2015 grant awards, see U.S. Department of Health and Human Services, “HHS Awards
$2.2 billion in Grants for HIV/AIDS Care and Medication,” October 21, 2015, at http://www.hhs.gov/about/news/2015/
10/21/hhs-awards-22-billion-grants-hivaids-care-and-medications.html. The list of Part A grants awards is available at
http://hab.hrsa.gov/abouthab/partafy15awards.html.
11
If an eligible metropolitan area (EMA) no longer qualified as an EMA for FY2007, it was treated as a transitional
grant area (TGA), even if it would not otherwise qualify as a TGA. Under prior law, in FY2006 a total of 51 EMAs
received funding. In FY2007 and FY2008, 22 EMAs received funding; in FY2009, 24 EMAs received funding.
Nassau-Suffolk, NY, and New Haven, CT, regained EMA status due to the results of a lawsuit filed by Nassau-Suffolk
against HHS. “County Executive Suozzi, Rep. Israel Declare Victory in Nassau-Suffolk Lawsuit to Save HIV/AIDS
Funding,” US Fed News Service, including US State News, April 28, 2008.
12
HRSA, FY2017 Justification of Estimates for Appropriations Committees, pp. 277-278,
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf.

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The 2006 reauthorization (P.L. 109-415) established a grant program for transitional grant areas
(TGAs), defined as metropolitan areas with at least 1,000 but fewer than 2,000 cumulative AIDS
cases during the most recent five calendar years.13 Unless a TGA became an EMA, it would
continue to be eligible as a TGA until it failed for three years to have (1) at least 1,000 but fewer
than 2,000 cumulative cases of AIDS during the most recent five calendar years, and (2) 1,500 or
more living cases of AIDS as of December 31 of the most recent calendar year. P.L. 111-87
permits a metropolitan area with a cumulative total of at least 1,400 but less than 1,500 living
cases of AIDS to continue to be eligible as a TGA, provided that not more than 5% of the TGA
grant award is unobligated at the end of the most recent fiscal year.
If a metropolitan area loses TGA eligibility, the entire amount of the former TGA’s formula grant
for the preceding fiscal year plus $500,000 is made available for Part B grants. During FY2015,
Part A provided grants to 29 TGAs and 24 EMAs for a total of 53 jurisdictions.14

Core Medical Services vs. Support Services
For each Part A grant, 75% of the funds must be spent on core medical services, defined as

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








outpatient/ambulatory medical care services,
AIDS Drug Assistance Program (ADAP) treatments and pharmaceutical
assistance,
oral health care,
early intervention services,
health insurance premium and cost-sharing assistance,
home health care,
medical nutrition therapy,
hospice,
home and community-based health services,
mental health and substance abuse outpatient services, and
medical case management.

The core services spending requirement may be waived if (1) there is no waiting list for receiving
treatment (under the Part B ADAP program), and (2) core medical services were available to all
individuals with HIV/AIDS who were eligible to receive such services under Part A. The
remaining 25% of funds may be used for support services, such as outreach services, medical
transportation, language services, respite care for persons caring for individuals with HIV/AIDS,
and referrals for health care and support services.
13

A total of 29 areas that had been EMAs prior to the 2006 reauthorization received funding as TGAs starting in
FY2007, and five metropolitan areas received funding as TGAs in FY2007 that were not previously eligible as an
EMA: Indianapolis, IN; Baton Rouge, LA; Charlotte, NC; Memphis, TN; and Nashville, TN. For FY2007 and FY2008,
a total of 34 TGAs received funding. For FY2009, 32 TGAs received funding; 2 former TGAs, New Haven, CT, and
Nassau-Suffolk, NY, received an EMA grant rather than a TGA grant.
14
In FY2015, Ponce, PR, was eligible for a TGA grant; however, in FY2016 Ponce is again ineligible, and it was
ineligible in FY2014 as well. HRSA, personal communication, January 20, 2016. In FY2013, Columbus, OH, began
receiving a TGA grant. In FY2011, Caguas, PR; Dutchess County, NY; Vineland, NJ; and Santa Rosa, CA, did not
receive TGA grants. Rather, Part A funds were awarded to Puerto Rico, New York, New Jersey, and California. HRSA,
FY2013 Justification of Estimates for Appropriations Committees, pp. 249 and 252, http://www.hrsa.gov/about/budget/
budgetjustification2013.pdf.

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Payer of Last Resort
Ryan White HIV/AIDS Program grantees must seek payment from other sources before using Ryan White HIV/AIDS
Program funds. The funds are intended to fill gaps in care not covered by other resources, such as Medicare,
Medicaid, State Children’s Health Insurance Program (CHIP), and private insurance. Grantees must ensure that
eligibility for other funding sources is consistently assessed and enrollment is vigorously pursued.
Sources: Part A Manual and Part B Manual, http://hab.hrsa.gov/tools2/PartA/parta/ptAsec7chap5.htm;
http://hab.hrsa.gov/manageyourgrant/files/habpartbmanual2013.pdf.

Payments under Part A (and all other parts of the Ryan White HIV/AIDS Program) must be
coordinated with other federal and nonfederal sources of funds.15 In particular, HRSA must
coordinate with Medicare and Medicaid and private health insurance because the Ryan White
HIV/AIDS Program is considered to be the “payer of last resort,” meaning the program will pay
only for services that cannot be provided using another funding source (see text box).

Formula Grants, Supplemental Grants, and Number of Living
HIV/AIDS Cases
Two-thirds of the Part A appropriation is distributed through formula grants, and the remaining
one-third is distributed via competitive supplemental grants awarded on the basis of need.16 The
awarding of supplemental Part A grants is based on weighting factors. Under P.L. 111-87, success
in testing for HIV/AIDS and making individuals aware of their HIV status is counted as one-third
in making such determinations.
CDC collects the HIV case surveillance data used in the Ryan White HIV/AIDS Program
formula. In the past, some states reported their cases by name, while others used a code-based
system to protect privacy.17 CDC initially indicated its preference for name-based reporting in
1999 in order to avoid double counting. In 2005, the agency recommended that all jurisdictions
transition to name-based reporting.
In contrast to EMA and TGA eligibility definitions based on cumulative AIDS cases, grant award
amounts are based on living HIV/AIDS cases. Prior to the 2006 reauthorization, formula grants
had been distributed to EMAs in proportion to an estimate of the number of living AIDS cases in
each EMA.18 P.L. 109-415 changed the funding distribution, basing it on the number of living
15

S.Rept. 106-294, which accompanied the Ryan White CARE Act Amendments of 2000 (P.L. 106-345), states
“CARE Act funds should not be used to provide items or services for which payment has already been made or
reasonably can be expected to be made by third-party payers, including Medicaid, Medicare, SCHIP, and or other State
or local entitlement programs, prepaid health plans, or private insurance. Funds allocated by this Act shall be available
to supplement services to patients who are Medicaid beneficiaries for services not covered by Medicaid. CARE Act
grantees should ensure that eligible individuals are expeditiously enrolled in Medicaid and that CARE Act funds are
not used to pay for any Medicaid- or SCHIP-covered services for Medicaid or SCHIP enrollees.”
16
P.L. 111-87 had a Part A hold-harmless provision (which expired in FY2014) that was intended to protect some
grantees from large decreases in formula grants and was financed with Part A supplemental grant funds. GAO found
that “although 17 EMAs received hold-harmless funding in FY2009, only 7 received more funding because of the holdharmless provision than they would have received through supplemental grants in the absence of the hold-harmless
provision.” GAO, Ryan White CARE Act: Effects of Certain Funding Provisions on Grant Awards, GAO-09-894,
September 18, 2009, http://www.gao.gov/new.items/d09894.pdf.
17
Code-based reporting uses an alphanumeric code instead of a name.
18
The number of living AIDS cases was estimated from the number of reported AIDS cases over a 10-year period, with
weighting factors to reflect that not all reported cases were still alive. Under the 2000 reauthorization (P.L. 106-345),
statistics on HIV cases could have been used in the Ryan White grant formulas as early as FY2005 if the Secretary of
HHS found that HIV incidence data were sufficiently accurate and reliable. In June 2004, the Secretary determined that
(continued...)

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HIV and AIDS cases in each EMA or TGA for states that use a name-based HIV reporting
system. The requirement for name-based HIV reporting in P.L. 106-345 and P.L. 109-415
influenced states to change from code-based reporting to name-based reporting, although many
states were reluctant to do so because of privacy concerns. P.L. 109-415 provided a transition
period for states that did not have a fully mature name-based reporting system,19 and subsequently
P.L. 111-87 provided a continuation of the transition period.20 Beginning with FY2013, only
living name-based cases of HIV/AIDS are used in making Part A grant determinations.

Planning Councils
Part A grants are made to the chief elected official of the city or county in the EMA or TGA that
administers the health agency providing services to the greatest number of persons with HIV.
Priorities for care delivery are set by the HIV Health Services Planning Councils, which are
established by the chief elected official. Membership of the council must reflect the ethnic and
racial makeup of the local HIV epidemic. Although planning councils may not be mandatory for
TGAs, HRSA strongly encourages TGAs to maintain their planning councils.21 Councils may not
be directly involved in the administration of any Part A grant.
P.L. 111-87 required the Part A Planning Councils to develop a strategy for identifying individuals
with HIV/AIDS who do not know their HIV status, making them aware of their status, and
connecting them with health care and support services. Particular attention is given to “reducing
barriers to routine testing and disparities in access and services among affected subpopulations
and historically underserved communities.”22

Unexpended Funds
The 2006 reauthorization introduced restrictions on the use of unexpended funds. Starting in
FY2007, if an eligible area did not obligate all supplemental grant funds within one year of
receiving an award, the eligible area was required to return any unobligated funds. Similarly,
starting in FY2007, if an eligible area did not obligate all formula grant funds within one year of
(...continued)
HIV case reporting was incomplete and could not be used to distribute the grants.
19
The 2000 reauthorization, P.L. 106-345, did not contain a transition period for states that were moving from codebased to name-based HIV reporting as recommended by the CDC. P.L. 109-415 provided a three-year transition period
for qualifying areas. For purposes of the Part A formula, states without a sufficiently accurate and reliable name-based
reporting system had a reduction of 5% in the number of non-AIDS HIV cases reported for an eligible area to account
for duplicate cases. P.L. 109-415 identified 33 states and two territories that had a sufficiently accurate and reliable
names-based reporting system as of December 31, 2005.
20
Under P.L. 111-87, these jurisdictions incurred a 5% reduction in the number of non-AIDS HIV cases reported for
the eligible area (to account for duplicate cases caused by code-based reporting) in making Part A grant determinations
for fiscal years prior to FY2012 and a 6% reduction for FY2012. In addition, as was the case under P.L. 109-415, the
amount of the formula grant in these areas may not exceed that of the preceding fiscal year by more than 5%.
California, Washington, DC, Illinois, Maryland, Massachusetts, Oregon, and Rhode Island did not have fully mature
name-based HIV reporting systems, and GAO identified three territories that had not begun collecting name-based HIV
case counts. GAO-09-894, p. 14. For the purpose of determining Part A grant amounts, P.L. 111-87 allowed for an
increase of 3% in the number of living HIV/AIDS cases in an area for FY2010 through FY2012 if the area switched to
name-based reporting in 2007 and had experienced a decrease in funding of more than 30% in FY2007 compared with
FY2006.
21
For further information, see HRSA December 4, 2013, letter to Ryan White HIV/AIDS Program Part A Grantees at
http://hab.hrsa.gov/manageyourgrant/transitionalgrantareasplanningcouncilsmovingforward.pdf.
22
§6 of P.L. 111-87.

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receiving the award, the eligible area was required to return any unobligated funds. The eligible
area may request a waiver of the cancellation of formula grant funds, explaining how the eligible
area intends to spend the funds. If the waiver is approved, the eligible area has one additional year
in which to spend the funds, called the carryover year. If the funds are not spent by the end of the
carryover year, the eligible area is required to return the unexpended funds. Regardless of
whether the waiver for carryover was granted, under the 2006 reauthorization, the eligible area’s
formula grant funds would be reduced for the following year by an amount equal to the
unobligated balance.
The 2009 reauthorization, however, stipulated that the amount of the reduction would not include
any unobligated balance that was approved by HRSA for carryover, and the reduction in formula
grant funds does not apply if the unobligated balance is 5% or less.23 Any returned grant funds are
additional amounts available for Part A supplemental grants.

Part B—Grants to States
Part B provides grants to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin
Islands, Guam, and 5 jurisdictions in the Pacific.24 Grant funds may be used for drug treatments,
home and community-based health care, and support services or health insurance coverage for
low-income persons. Congress provides a specific appropriation for ADAP within the total Part B
funding. The remaining funds (non-ADAP) are used for Part B base grants and a supplemental
grant program. ADAP provides drug treatments for individuals with HIV who cannot afford to
pay for drugs and have limited or no coverage from private insurance, Medicaid, or Medicare Part
D. ADAP funds also may be used to purchase health insurance for eligible clients or to pay for
services that enhance access, adherence, and monitoring of drug treatments. As under Part A, 75%
of Part B funds must be spent on core medical services, and 25% may be spent on support
services (defined in “Core Medical Services vs. Support Services”).
P.L. 111-87 required that the Part B grant application provide a comprehensive plan for
identifying individuals with HIV/AIDS who are unaware of their HIV/AIDS status and enabling
those individuals access to medical treatment for HIV/AIDS. The comprehensive plan must
include efforts to remove any legal barriers, including states laws and regulations, to routine
testing.

Formula Grants and Number of Living HIV/AIDS Cases
Of the non-ADAP Part B funds, two-thirds is used for the Part B base awards, and one-third is
reserved for a supplemental grant program (see “Supplemental Grants”). The Part B base award
formula is based on three factors: (1) 75% of the award is based on the state’s proportion of the
nation’s HIV/AIDS cases; (2) 20% is based on the state’s proportion of HIV/AIDS cases outside
Part A-funded areas (EMAs and TGAs); and (3) 5% is based on the state’s proportion of
HIV/AIDS cases in states with no Part A funding.25
23

Under P.L. 109-415, the reduction in formula grant funds did not apply if the unobligated balance was 2% or less.
For information about FY2015 grant awards, see U.S. Department of Health and Human Services, “HHS Awards
$2.2 billion in Grants for HIV/AIDS Care and Medication,” October 21, 2015, at http://www.hhs.gov/about/news/2015/
10/21/hhs-awards-22-billion-grants-hivaids-care-and-medications.html. The list of Part B grants awards is available at
http://hab.hrsa.gov/abouthab/partbfy15awards.html.
25
The formula attempts to correct a problem under a previous formula: specifically, states with EMAs received a larger
amount of money, per case, than states without an EMA. GAO, Ryan White CARE Act: Factors that Impact HIV and
AIDS Funding and Client Coverage, GAO-05-841T, June 2005, http://www.gao.gov/new.items/d05841t.pdf.
24

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Prior to the 2006 reauthorization, formula grants had been distributed to states in proportion to an
estimate of the number of living AIDS cases in each state.26 Under P.L. 109-415, funding
distribution is based on the number of living HIV and AIDS cases for states that use a namebased HIV reporting system. The requirement for name-based HIV reporting influenced states to
change from code-based reporting to name-based reporting, however many states were reluctant
to do so because of privacy concerns. P.L. 109-415 provided a transition period for states that did
not have a fully mature name-based reporting system.27 If the transition period was not extended,
some grantees might not receive funding in proportion to their number of HIV/AIDS cases,
“which is the intended basis of the formula grant.”28 P.L. 111-87 provided a continuation of the
transition period.29 Beginning with FY2013, only living name-based cases of HIV/AIDS are used
in making Part B grant determinations.

Supplemental Grants
Under Section 2623(b)(2) of the PHS Act, one-third of the non-ADAP Part B appropriation is
reserved for a supplemental grant program.30 Eligible states must have a demonstrated need for
supplemental financial assistance and no cancelled grant funds or waivers permitting carryover of
funds (see “Unexpended Funds”). Priority in making supplemental grants is given to states with a
decline in funding under Part B due to the changes in the distribution formula. Supplemental
grant funds must be used for core medical services. Not later than 45 days after awarding
supplemental funds under Part B, HRSA must submit a report to Congress concerning such funds.

26

The number of living AIDS cases was estimated from the number of reported AIDS cases over a 10-year period, with
weighting factors to reflect that not all reported cases were still alive. Under the 2000 reauthorization (P.L. 106-345),
statistics on HIV cases would have been used in the Ryan White HIV/AIDS Program grant formulas as early as
FY2005 if the Secretary of HHS found that HIV incidence data were sufficiently accurate and reliable. In June 2004,
the Secretary determined that HIV case reporting was incomplete and could not be used to distribute the grants. Under
P.L. 106-345, HIV case data would have been used for determining FY2007 grant amounts. However, P.L. 106-345 did
not contain a transition period for states that were moving to name-based HIV reporting, as recommended by the CDC.
P.L. 109-415 had a three-year transition period for qualifying areas.
27
According to a 2009 GAO report, 47 of the 59 Part B grantees had HRSA use their name-based HIV case counts to
determine FY2009 formula funding and the remaining 12 grantees had HRSA use code-based HIV case counts. Of the
12 grantees, 7 were collecting name-based HIV case counts as of December 31, 2007, and 5 were not. The seven
grantees were California, Washington, DC, Illinois, Maryland, Massachusetts, Oregon, and Rhode Island. All but
Maryland could have had HRSA use their name-based HIV case counts to determine formula funding but instead had
HRSA use their code-based counts. Maryland’s name-based HIV reporting system had not been determined to be
operational and, therefore, did not have that option. The five grantees were Hawaii, Vermont, the Federated States of
Micronesia, Palau, and the Republic of the Marshall Islands. Hawaii and Vermont transitioned to name-based reporting
in 2008; the remaining three had not begun collecting name-based HIV case counts. GAO, Ryan White CARE Act:
Effects of Certain Funding Provisions on Grant Awards, GAO-09-894, September 18, 2009, http://www.gao.gov/
new.items/d09894.pdf.
28
Ibid., p. 16.
29
Under P.L. 111-87, these jurisdictions incurred a 5% reduction in the number of non-AIDS HIV cases reported for
the eligible area (to account for duplicate cases caused by code-based reporting) in making Part B grant determinations
for fiscal years prior to FY2012 and a 6% reduction for FY2012. For the purpose of determining Part B grant amounts,
P.L. 111-87 would allow an increase of 3% in the number of living HIV/AIDS cases in an area for FY2010 through
FY2012 if the area switched to name-based reporting in 2007 and had experienced a decrease in funding of more than
30% in FY2007 compared with FY2006.
30
P.L. 111-87 contained a hold-harmless provision for Part B that protected grantees from large decreases in funding.
The hold-harmless provision was funded by reducing the amount reserved for the Part B supplemental grant program
and by any unobligated funds repaid by the states. The hold harmless provision expired in FY2014.

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Emerging Community Grants
An “emerging community” is defined as a metropolitan area with cumulative total of at least 500
and fewer than 1,000 reported cases of AIDS during the most recent five calendar years.31 The
metropolitan area continues as an emerging community until it fails for three consecutive fiscal
years (1) to have the required number of AIDS cases and (2) to have a cumulative total of 750 or
more living cases of AIDS as of December 31 of the most recent calendar year. The grant amount
is determined by the amount set aside by the Secretary (authorized at $5 million) and by the
proportion of the total number of living cases of HIV/AIDS in emerging communities in the state
to the total number of living cases of HIV/AIDS in emerging communities nationwide.

ADAP
In 2013, a total of 264,955 clients—or about 55.2% of HIV-positive people in regular care
(defined as two or more medical visits per year) in the United States—received their medications
through state ADAPs.32 ADAP funds are distributed via a formula based on each state’s
proportion of living HIV and AIDS cases.33 P.L. 111-87 provided a continuation of the transition
period for states that did not have a fully mature name-based HIV reporting system.34 Beginning
with FY2013, only living name-based cases of HIV/AIDS are used in making ADAP grant
determinations.
Five percent of the ADAP appropriation is set aside for ADAP supplemental grants.35 States are
eligible for these grants if they demonstrate a severe need to increase the availability of
HIV/AIDS drugs. There is a state-match requirement ($1 state for every $4 federal) for ADAP
supplemental grants that may be waived under certain circumstances. The state’s ADAP
formulary—a list of therapeutics—must have at least one drug from every class of HIV/AIDS
drugs. The list is based on the clinical practice guidelines issued by HHS for the use of
HIV/AIDS drugs.36
According to a May 2015 report produced by the National Alliance of State and Territorial AIDS
Directors (NASTAD), in FY2014 federal funds provided 43% of the national ADAP budget, state
contributions provided 11%, and drug rebates provided another 43%.37 In the past, many states
had to implement cost containment measures—such as waiting lists, lowered income eligibility
criteria, reduced formulary, capped enrollment, monthly or annual expenditure cap, client cost
31

PHS Act, §2621(d).
HRSA, FY2017 Justification of Estimates for Appropriations Committees, p. 267,
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf.
33
ADAP operates in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American
Samoa, the Commonwealth of the Northern Mariana Islands, and the Republic of Palau.
34
Under P.L. 111-87, these jurisdictions incurred a 5% reduction in the number of non-AIDS HIV cases reported for
the eligible area (to account for duplicate cases caused by code-based reporting) in making ADAP grant determinations
for fiscal years prior to FY2012 and a 6% reduction for FY2012.
35
Like Part A and Part B formula grants, ADAP formula grants also had a hold-harmless provision, which expired in
FY2014. Its purpose was to protect some grantees from large decreases in formula grants, and it was financed with
ADAP supplemental grant funds.
36
Guidelines are available at http://aidsinfo.nih.gov/Guidelines/Default.aspx?MenuItem=Guidelines.
37
The remaining 3% consisted of other state or federal funds. NASTAD, National ADAP Monitoring Project, 2015
Annual Report, May 2015, p. 22, at http://www.nastad.org. As covered entities under the Public Health Service Act
(PHSA) §340B Drug Pricing Program, ADAPs qualify for rebates on drug purchases made on behalf of their patients.
For more information on the PHSA §340B program, see http://www.hrsa.gov/opa/eligibilityandregistration/ryanwhite/
index.html.
32

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sharing—because of insufficient ADAP funds. The George W. Bush Administration and Barack
Obama Administration provided supplemental ADAP grants to help alleviate this problem.38
ADAP is the payer of last resort for HIV/AIDS drugs. As such, it coordinates with other programs
available to pay for HIV/AIDs drugs and helps people enroll in other programs (including private
insurance) that could be used to pay for HIV/AIDS drugs. In particular, ADAPs coordinate with
state Medicaid programs and seek to enroll people in Medicaid when eligible. It also retroactively
bills Medicaid for services provided to people who obtain Medicaid eligibility retroactively.39

Unexpended Funds
Starting in FY2007, states were required to obligate grant funds by the end of the grant year for
Part B formula grants, supplemental grants, emerging communities grants, ADAP grants, and
supplemental ADAP grants. For supplemental ADAP grants, supplemental grants, and emerging
communities grants, if there is an unobligated balance at the end of the grant year, states must
return the amount and the funds will be used for additional supplemental grants.
For Part B formula grants and ADAP grants, if there is an unobligated balance, states must either
return the unexpended funds or apply for a waiver to use the funds in the next year. If the waiver
is approved, the funds would be available for one more year, called the carryover year. If a state
fails to use the funds in the carryover year, the state must return the funds, which will be used for
supplemental grants.
For states with an unobligated balance for their Part B formula grant or an ADAP grant, the
amount of the grant for the next year would be reduced by the amount of the unobligated balance.
The 2009 reauthorization allowed that the amount of the reduction would not include any
unobligated balance that was approved by HRSA for carryover; if the amount of the unobligated
balance was 5% or less, the grant reduction would not apply.40 The funds from grant reduction are
used for supplemental grants.
Drug rebates are received by Part B grantees from pharmaceutical manufacturers following the
purchase of drugs for ADAPs. There is a federal requirement that drug rebate funds be spent
before federal funds are obligated. Because states may receive the rebates late in the year, some
states may incur an unobligated balance penalty. In September 2009 GAO reported that both
grantees and HRSA found that the requirement to spend drug rebate funds before obligating
federal funds makes it more difficult to avoid unobligated balances.41 According to GAO, HRSA
38

On September 18, 2007, the George W. Bush Administration announced supplemental ADAP grants totaling $39.5
million to 14 states (Alabama, Alaska, Georgia, Indiana, Iowa, Montana, North Carolina, Oklahoma, Oregon, South
Carolina, Texas, Utah, Virginia, and Wisconsin), the Virgin Islands, and Puerto Rico. On June 23, 2004, the George W.
Bush Administration announced what it described as a one-time $20 million initiative for 10 states with ADAP waiting
lists (Alabama, Alaska, Colorado, Idaho, Iowa, Kentucky, Montana, North Carolina, South Dakota, and West Virginia).
In July 2010, HHS Secretary Kathleen Sebelius announced the reallocation of $25 million in funds from dozens of
programs throughout HHS for ADAP. The additional funds were targeted for states with ADAP waiting lists or other
cost containment strategies. On July 19, 2012, HHS Secretary Kathleen Sebelius announced that $69 million would be
sent to 23 states (Alabama, Alaska, Arizona, California, Colorado, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky,
Louisiana, Montana, Nebraska, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Utah, Virginia,
Washington, and Wisconsin) Puerto Rico and the Virgin Islands through Ryan White ADAP to eliminate waiting lists.
39
Letter from Cindy Mann, Director, Center for Medicaid and CHIP Services, and Mary Wakefield, Administration,
Health Resources and Services Administration, “Coordination Between Medicaid and Ryan White HIV/AIDS
Programs,” May 1, 2013, http://www.medicaid.gov/federal-policy-guidance/downloads/cib-05-01-2013.pdf.
40
Under P.L. 109-415, the reduction in formula grant funds did not apply if the unobligated balance was 2% or less.
41
GAO, Ryan White CARE Act: Effects of Certain Funding Provisions on Grant Awards, GAO-09-894, September 18,
2009, p. 24, http://www.gao.gov/new.items/d09894.pdf. GAO found that nine states and seven territories received
(continued...)

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tried to address this problem by asking HHS for an exemption from the relevant regulations for
grantees using drug rebates, but the request was denied.42 Under P.L. 111-87, if an expenditure of
ADAP rebate funds triggered a penalty, the Secretary may deem a state’s unobligated balance to
be reduced by the amount of the rebate. Any unobligated amount returned to the Secretary would
be used for ADAP supplemental grants or Part B supplemental grants.

Part C—Early Intervention Services
Part C grants provide HIV primary care in the outpatient setting to low-income, medically
underserved people living with HIV/AIDS.43 Part C “provides grants directly to community and
faith based primary health clinics and public health providers in 49 states, Puerto Rico, the
District of Columbia and the U.S. Virgin Islands.”44 Under current law, 75% of a Part C grant
must be used for core medical services, and not less than 50% of a grant must be used for early
intervention services. Part C grants are awarded to facilities that focus on underserved
populations, including federally qualified health centers, family planning clinics, hemophilia
centers, rural health clinics, Indian Health Service facilities, and certain health facilities and
community-based organizations that provide early intervention services to people infected with
HIV/AIDS through intravenous drug use. Part C services include counseling, HIV testing,
referrals, clinical and diagnostic services regarding HIV/AIDS, drug treatments under ADAP,
treatment adherence, oral health, mental health, substance abuse services, and support services. A
small portion of Part C funds are used for capacity development grants. The Consolidated
Appropriations Act, 2016 (H.R. 2029, P.L. 114-113), provides a $4 million increase for Part C in
FY2016.

Part D—Women, Infants, Children, and Youth
Part D provides grants to public and nonprofit entities for family-centered care for women,
infants, children, and youth with HIV/AIDS.45 Such individuals are provided
outpatient/ambulatory health care, case management, referrals, and other services to enable
participation in the program, including services designed to recruit and retain youth with HIV.
Grantees must coordinate with programs promoting the reduction and elimination of risk of
HIV/AIDS for youth. P.L. 111-87 clarified that Part D should be the payer of last resort when Part
D clients have access to other forms of health care coverage, such as Medicaid and the Children’s
(...continued)
reduced Part B grant amounts in the 2009 grant year because they had unobligated balances over 2% in the 2007 grant
year. “Part B base funding penalties ranged from $6,433 in Palau to $1,493,935 in Ohio. ADAP base funding penalties
ranged from $26,233 in Maine to $12,670,248 in Pennsylvania.” Almost half of the grantees interviewed by GAO said
the 2% threshold was too low, and some suggested that 5% would be more reasonable. However, GAO noted that “only
2 of the 16 Part B grantees that received penalties for unobligated balances had unobligated balances of less than 5%.”
42
Ibid., pp. 30-31.
43
The FY2015 grant awards for Part C were announced on October 21, 2015; the grant award announcement is
available at http://www.hhs.gov/about/news/2015/10/21/hhs-awards-22-billion-grants-hivaids-care-andmedications.html. The list of Part C Early Intervention Services (EIS) grants awards is available at http://hab.hrsa.gov/
abouthab/partceisfy15awards.html. The list of Part C Capacity Development grant awards is available at
http://hab.hrsa.gov/abouthab/partccapacityfy15awards.html.
44
HRSA, FY2017 Justification of Estimates for Appropriations Committees, p. 288,
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf.
45
The FY2015 grant awards for Part D were announced on October 21, 2015; the grant award announcement is
available at http://www.hhs.gov/about/news/2015/10/21/hhs-awards-22-billion-grants-hivaids-care-andmedications.html. The list of Part D grants awards is available at http://hab.hrsa.gov/abouthab/partdfy15awards.html.

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Health Insurance Program. The FY2015 and FY2016 Obama Administration budget requests
proposed consolidating Part D with Part C in order to “expand the focus on women, infants,
children and youth across all the funded recipients, increase points of access for these populations
and reduce duplication of effort and reporting/administrative burden among co-funded recipients.
In 2014, approximately 67% of Part D Programs funded by the Ryan White HIV/AIDS Program
were dually funded under Part C.”46 The House and the Senate rejected the consolidation proposal
in FY2015 and in FY2016.

Part E and Part G
In the past, Part E authorized grants for emergency response employees and established
procedures for notifications of infectious diseases exposure; Part E was never funded. The 2006
reauthorization (P.L. 109-415) deleted the sections of Part E on emergency response and inserted
into Part E several sections, with some text changes, from Part D (on coordination, audits,
definitions, and a prohibition on promotion of intravenous drug use or sexual activity) and two
new sections on public health emergencies and certain privacy protections.
P.L. 109-415 inadvertently deleted language on “procedures for the notification of occupational
infectious diseases exposure” from Part E of Ryan White. This was a matter of some concern for
the emergency response community, and reinstatement of the relevant language was requested.47
P.L. 111-87 reinserted the deleted language on “procedures for the notification of occupational
infectious diseases exposure” into a new Part G of Title XXVI of the PHS Act, including a change
from the original language that would permit the Secretary to suspend the requirements in a
public health emergency.

Part F—Demonstration and Training
Part F provides support for the AIDS Dental Reimbursement (ADR) Program, the CommunityBased Dental Partnership Program, the AIDS Education and Training Centers (AETCs), the
Special Projects of National Significance (SPNS) Program, and the Minority AIDS Initiative
(MAI).48 The ADR reimburses dental schools for oral health care to HIV/AIDS patients and the
Community-Based Dental Partnership Program provides oral health care to HIV/AIDS patients in
underserved areas and supports the training of dental students and residents.49 The AETC

46

HRSA, FY2017 Justification of Estimates for Appropriations Committees, p. 292.
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf.
47
Katherine West, “Ryan White Notification Law for Emergency Response Employees Deleted: 10 Reasons Why We
Need it Back,” EMS Magazine, October 2008, at http://www.emsresponder.com/print/EMS-Magazine/Ryan-WhiteNotification-Law-for-Emergency-Response-Employees-Deleted—10-Reasons-Why-We-Need-It-Back/1$8394; James
R. Cross, JD, “Ryan White Notification Law Repealed: The Deletion of Emergency Response Provisions Demands
Attention,” Journal of Emergency Medical Services, March 2008, pp. 136-137; and National Association of State EMS
Officials, “NASEMSO Issue Brief on the Repeal of Emergency-Response Provisions Contained in the Ryan White
CARE Act,” March 2008, at http://www.nasemsd.org/Advocacy/PositionsResolutions/documents/
RyanWhiteIssueBrief032508.pdf.
48
Both the dental and the AETC programs were transferred legislatively from Title VII of the PHS Act.
49
The FY2015 grant awards for Part F were announced on October 21, 2015; the grant award announcement is
available at http://www.hhs.gov/about/news/2015/10/21/hhs-awards-22-billion-grants-hivaids-care-andmedications.html. The list of Part F Dental Reimbursement Program and Community-Based Dental Partnership
Program grants awards is available at http://hab.hrsa.gov/abouthab/partffy15awards.html.

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program provides specialized clinical education and consultation for health providers on HIV
transmission, treatment, and prevention.50
The SPNS program awards grants to support the development of innovative models of HIV
treatment.51 Under statute, the SPNS program is to be funded, up to $25 million, from amounts
appropriated for Parts A, B, C, and D; this was not changed by reauthorization. However, from
FY2003 through FY2014, each Labor-HHS appropriations bill provided $25 million for the
SPNS program via a funding mechanism known as the “PHS evaluation tap.”52 The FY2015
appropriation, FY2016 request, and FY2016 House appropriation bill include funding for SPNS
directly via budget authority rather than through the PHS evaluation tap. The Senate did not
propose funding for SPNS in FY2016.53 The Consolidated Appropriations Act, 2016 (H.R. 2029,
P.L. 114-113), provides $25 million in budget authority for SPNS in FY2016. The FY2017
request would provide $34 million for SPNS via the PHS evaluation tap. The $9 million increase
over FY2016 is requested for a new SPNS initiative to expand screening for and treatment of
hepatitis C in people living with HIV.
P.L. 109-415 codified MAI as part of the Ryan White HIV/AIDS Program under Part F of Title
XXVI of the PHS Act.54 Under P.L. 109-415, MAI provided funding for competitive grants (via
Parts A, B, C, D, and F-AETC) that evaluate and address the disproportionate impact of
HIV/AIDS on racial and ethnic minorities. P.L. 111-87 directed HRSA to develop a formula for
awarding MAI grants under Part A and Part B “that ensures that funding is provided based on the
distribution of populations disproportionately impacted by HIV/AIDS.”55 The law directed HRSA
to synchronize the schedule of application submissions and funding of MAI grants with the
schedule of the corresponding Ryan White HIV/AIDS Program part.
P.L. 111-87 required GAO to provide a report for Congress within one year of enactment that
describes MAI activities across HHS. The GAO report found that MAI grantees were providing
mostly support services similar to the support services (community outreach and education,
staff/provider training) the grantees provided with core HIV/AIDS funding from HRSA.56 GAO
found that the multiple funding streams “carried separate administrative requirements that caused

50

The FY2015 grant awards for Part F were announced on October 21, 2015; the grant award announcement is
available at http://www.hhs.gov/about/news/2015/10/21/hhs-awards-22-billion-grants-hivaids-care-andmedications.html. The list of Part F AETC grant awards is available at http://hab.hrsa.gov/abouthab/
aetcfy15awards.html.
51
For a list of current SPNS initiatives, see http://hab.hrsa.gov/abouthab/partfspns.html.
52
The tap, authorized under §241 of the PHS Act, transfers money among PHS agencies for particular activities as
specified by the appropriators. For further information, see CRS Report R43304, Public Health Service Agencies:
Overview and Funding (FY2010-FY2016).
53
S.Rept. 114-74, pp. 50-51, and 228-229.
54
The MAI began in 1998 with the White House announcement of a series of initiatives targeting appropriated funds
for HIV/AIDS prevention and treatment programs in minority communities. The Congressional Black Caucus worked
with the Clinton Administration to formulate the approach. MAI activities are supported by the following agencies and
offices in HHS: HRSA; CDC; National Institutes of Health; Substance Abuse and Mental Health Services
Administration; Minority Communities Fund; Office of Minority Health; and Office of Women’s Health. GAO was
required by P.L. 109-415 to provide a report on a variety of issues related to MAI: U.S. Government Accountability
Office, Ryan White CARE Act: Implementation of the New Minority AIDS Initiative Provisions, GAO-09-315, March
27, 2009, http://www.gao.gov/new.items/d09315.pdf.
55
Previously under P.L. 109-415, a competitive grant system was used to award Part A and Part B MAI grants.
56
U.S. Government Accountability Office, Minority AIDS Initiative: Consolidation of Fragmented HIV/AIDS Funding
Could Reduce Administrative Challenges, GAO-14-84, November 22, 2013, p. 12, http://www.gao.gov/assets/660/
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administrative challenges” for the grantees.57 The use of multiple funding streams “raises the
possibility of inefficiencies and requires unnecessarily duplicative application and reporting
requirements of grantees that could otherwise be using their resources to provide needed
services.”58 GAO recommended that MAI funding should be consolidated into core HIV/AIDS
funding, and HHS stated that this would “align with the National HIV/AIDS Strategy and federal
program accountability goals.”59 P.L. 111-87 also required, within six months of publication of
the GAO report, that HHS submit to Congress a departmental plan for using MAI funds, taking
into consideration the best practices described in the GAO report.60

The National HIV/AIDS Strategy
The National HIV/AIDS Strategy (NHAS) is a five-year plan detailing the “principles, priorities,
and actions” to guide the “collective national response to the HIV epidemic.”61 The NHAS was
first released in July 2010 and updated in July 2015.62 The current NHAS goals are as follows:
1.
2.
3.
4.

Reduce new infections.
Increase access to care and improve health outcomes for people living with HIV.
Reduce HIV-related health disparities and health inequities.
Achieve a more coordinated national response to the HIV epidemic.

The NHAS cites the Ryan White HIV/AIDS Program as a critical source of lifesaving care and
treatment for individuals living with HIV. Moreover, providing such treatment “not only improves
the health outcomes for individuals with HIV, it serves the public health benefit of helping to
prevent HIV transmission.”63 Clinical research has demonstrated that early treatment of HIV
patients with antiretroviral medication results in viral suppression and reduces the risk of HIV
transmission by 96%.64 However, CDC data indicate that in 2012, only 30% of people living with
HIV were virally suppressed.65 According to HRSA, the Ryan White HIV/AIDS Program grant
awards, by supporting cities, states, and communities in the treatment of HIV patients, will allow
the goals of the updated NHAS to be achieved.66

57

Ibid.
Ibid., p. 23.
59
Ibid., pp. 23-24.
60
HHS states that this report is in the HHS clearance process.
61
https://www.aids.gov/federal-resources/national-hiv-aids-strategy/overview/.
62
https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf.
63
The White House, “Fact Sheet: The National HIV/AIDS Strategy Updated to 2020,” press release, July 30, 2015,
https://www.whitehouse.gov/the-press-office/2015/07/30/fact-sheet-national-hivaids-strategy-updated-2020.
64
Myron S. Cohen, Ying Q. Chen, Marybeth McCauley, et al., “Prevention of HIV-1 infection with early antiretroviral
therapy,” The New England Journal of Medicine, vol. 365, no. 6 (August 11, 2011), pp. 493-505.
65
CDC, “Monitoring selected national HIV prevention and care objectives by using HIV surveillance data – United
States and 6 dependent areas – 2013,” HIV Surveillance Supplemental Report, vol. 20, no. 2 (July 2015),
http://www.cdc.gov/hiv/library/reports/surveillance/.
66
HRSA, “HHS awards $2.2 billion in grants for HIV/AIDS care and medications,” press release, October 21, 2015,
http://www.hhs.gov/about/news/2015/10/21/hhs-awards-22-billion-grants-hivaids-care-and-medications.html.
58

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ACA and the Ryan White HIV/AIDS Program
Prior to the implementation of the ACA (P.L. 111-148, as amended), obtaining private health
insurance was difficult for individuals with HIV/AIDS and others living with serious preexisting
medical conditions.67 A 2011 Institute of Medicine (IOM) report estimated that in urban areas,
only about 13% of HIV patients in 2010 had private health insurance; most HIV patients were
covered by Medicaid (36%), Medicare (12%), or a combination of these two programs (6%).68
The remaining individuals were either uninsured and obtained services through the Ryan White
HIV/AIDS Program (24%), or their insurance coverage information was missing or unknown
(8%).69 In 2012, the Ryan White HIV/AIDS Program served more than a half million low-income
individuals with HIV/AIDS in the United States, of whom 28% were uninsured and 59% were
underinsured.70 The CDC estimates that more than 1.2 million people have HIV/AIDS, but does
not indicate the percentage of this population that is low income.71 Among those who were
underinsured, Ryan White HIV/AIDS Program funds were used to supplement insurance gaps.72
The ACA expanded insurance coverage through a number of different provisions. Specifically, it
expanded public coverage for low-income individuals through the Medicaid program.73 It also
made a number of changes to the private insurance market, created a standardized marketplace
for individuals to purchase insurance coverage and premium subsidies for individuals whose
incomes were too high for Medicaid, but were otherwise unable to afford private insurance
coverage.74
The ACA may affect the need for, and use of, certain services provided by the Ryan White
HIV/AIDS Program. For example, about half of ADAP clients would be Medicaid-eligible in
expansion states, and the remainder would likely be eligible for premium subsidies to purchase
health coverage on the exchange.75 This section describes the ACA changes that are relevant to
67

Jeffrey S. Crowley and Connie Garner, Reimagining the Ryan White HIV.AIDs Program: Aligning The Ryan White
HIV/AIDS Program with Insurance Coverage, O'Neill Institute for National & Global Health Law, Issue Brief no. 1,
Washington, DC, June 2015, https://www.law.georgetown.edu/oneillinstitute/research/documents/
AligningwithInsurance1.pdf.
68
According to the IOM report, “there are no recent national estimates of health coverage of individuals with HIV. The
HIV Cost and Service Utilization Study (HCSUS), for example, the only nationally representative study of people with
HIV/AIDS in care, was conducted from 1994 to 2000. A more recent analysis of data from a convenience sample
involving 12 medical sites located in urban cities throughout the United States showed that the majority of patients
were covered under Medicaid (42%, including those dually eligible for Medicare) and the Ryan White HIV/AIDS
Program (24%). These data likely do not represent the national picture of health coverage of individuals with HIV,
however, such as those in non-urban areas.” IOM (Institute of Medicine), 2011, HIV Screening and Access to Care:
Exploring the Impact of Policies on Access to and Provision of HIV Care, Washington, DC: The National Academies
Press, pp. 7-8.
69
Ibid.
70
HRSA, FY2016 Justification of Estimates for Appropriations Committees, p. 278.
71
Centers for Disease Control and Prevention, HIV in the United States: At a Glance, http://www.cdc.gov/hiv/
statistics/overview/ataglance.html.
72
Jennifer Kates et al., Health Insurance Coverage for People with HIV Under the Affordable Care Act Experiences in
Five States, The Kaiser Family Foundation, Issue Brief, Washington, DC, December 2014.
73
Medicaid is a federal-state matching entitlement program; the federal portion currently varies from 50% in relatively
affluent states to almost 80% in less affluent states.
74
CRS Report R42069, Private Health Insurance Market Reforms in the Patient Protection and Affordable Care Act
(ACA).
75
National ADAP Monitoring Project Annual Report: 2015 Annual Report, National Alliance of State and Territorial
AIDS Directors, Washington, DC, May 2015, Chart 17, p. 27, https://www.nastad.org/resource/national-adap(continued...)

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the Ryan White HIV/AIDS Program and its service population. The section also highlights some
of the services provided under the Ryan White HIV/AIDS Program that are not covered by the
ACA.

Medicaid Expansion
Beginning January 2014, states have the option to expand Medicaid coverage for adults under the
age of 65 with incomes up to 133% of the federal poverty level (FPL).76 This expansion, where
implemented, is a significant change for the Medicaid program, which generally requires
individuals to belong to a categorically eligible group: children, pregnant women, parents of
dependent children, the elderly, or the disabled.77 Some states elected to implement the Medicaid
expansion prior to January 2014; these states include California, Colorado, Connecticut, the
District of Columbia, Minnesota, New Jersey, and Washington State.78 As of November 2015,
more than half of all states (including the District of Columbia) have adopted the Medicaid
expansion.79
The Medicaid expansion may have a significant impact on the Ryan White ADAP program.
NASTAD indicates that about half of ADAP clients would be Medicaid-eligible in expansion
states.80 HRSA is examining the effects of Medicaid expansion on the ADAP program. So far,
HRSA has found that Medicaid expansion states reduced their number of ADAP clients; in
contrast, non-expansion states saw an increase in ADAP clients.81 In expansion states ADAP
funds may still be used to supplement Medicaid coverage. For example, ADAP funds can be used
to assist people with Medicaid cost sharing and to pay for monthly prescriptions because some
states limit the number of monthly prescriptions its Medicaid program will pay for.
HRSA predicts that the Medicaid expansion will have minimal effects on the non-ADAP parts of
the Ryan White HIV/AIDS Program, primarily because data show that, prior to the ACA,
Medicaid beneficiaries accessed Ryan White primary medical care services.82 HRSA predicts that
the use of these services by Medicaid beneficiaries will continue. HRSA also found that most
non-ADAP clients are insured (either publicly or privately).83 In addition, the Ryan White
HIV/AIDS Program provides certain services, such as dental care, that not all state Medicaid
programs provide to adults. As such, even in states that have expanded their Medicaid program,
there may be services that the Ryan White HIV/AIDS Program can provide.

(...continued)
monitoring-project-2015-annual-report.
76
For the new eligibility group, the federal government will pay 100% of the costs for 2014-2016; the federal share
will gradually be reduced to 90% by 2020. See CRS Report R43564, The ACA Medicaid Expansion.
77
In 2011, less than 1% of Medicaid enrollees had HIV. Prior to ACA, most individual with HIV who were on
Medicaid qualified for the program because they were disabled. Jen Kates, Medicaid and HIV: A National Analysis,
The Henry J. Kaiser Family Foundation, Washington, DC, October 2011, pp. 5 and 8.
78
CRS Report R43357, Medicaid: An Overview.
79
The Henry J. Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, http://kff.org/
health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.
80
National ADAP Monitoring Project Annual Report: 2015 Annual Report, National Alliance of State and Territorial
AIDS Directors, Washington, DC, May 2015, Chart 17, p. 27, https://www.nastad.org/resource/national-adapmonitoring-project-2015-annual-report.
81
Personal communication, Health Resources and Services Administration, Office of Legislation, June 12, 2015.
82
Ibid.
83
Ibid.

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Private Insurance Expansions
Private health insurance is generally of two types: group (e.g., employer sponsored) and nongroup. The ACA generally made changes to non-group coverage in ways that may increase access
to health insurance for the U.S. population as well as coverage for people living with
HIV/AIDS.84 Specifically, the ACA prohibits the cancellation of coverage by an insurer due to a
preexisting condition, and eliminates the lifetime caps on insurance benefits.85 Individuals with
HIV/AIDs may have been at risk for either policy cancellation or of reaching lifetime caps. It is
expected that these ACA changes will benefit the HIV/AIDS population.86
The ACA required that U.S. citizens and legal residents have qualifying health insurance or pay a
penalty. Private insurance plans are considered to be qualifying health insurance if they cover
certain “essential health benefits,” which are 10 broad benefit categories, such as outpatient and
ambulatory care and prescription drugs.87 Although a number of essential health benefit
categories overlap with the services that the Ryan White HIV/AIDS Program can provide, the
overlap is not complete. For example, the Ryan White HIV/AIDS Program provides case
management, oral health care, hospice services, and home and community-based services, among
others, that are not required to be covered in exchange plans. Conversely, exchange plans are
required to cover some services—such as inpatient hospital care—that the Ryan White HIV/AIDS
Program cannot.88
As noted, the ACA required that U.S. citizens and legal residents have qualifying health insurance
or pay a penalty. To help people meet this requirement, the ACA created health insurance
exchanges—marketplaces—and provided subsidies to individuals with incomes between 100%
and 400% of the federal poverty level.89 NASTAD indicates that about half of ADAP clients
would be eligible for premium subsidies to purchase health coverage on the exchange.90

84

See description in CRS Report R42069, Private Health Insurance Market Reforms in the Patient Protection and
Affordable Care Act (ACA).
85
Ibid.
86
Sean R. Cahill, Kenneth H. Mayer, and Stephen L. Boswell, “The Ryan White HIV/AIDS Program in the Age of
Health Care Reform,” American Journal of Public Health, vol. 105, no. 6 (June 2015), pp. 1078-1085. Prior to ACA’s
2014 implementation, some individuals with HIV may have obtained health insurance coverage under the Pre-Existing
Condition Insurance Plan, or PCIP created in §1101 of the ACA. This was a temporary (July 1, 2010, through
December 31, 2013) state or federally administered program that served as a “bridge for people with pre-existing
conditions who cannot obtain health insurance coverage in today’s private insurance market.” PCIPs were phased out
as of January 2014. Although some ADAPs reported barriers in coordination with PCIPs, as of December 2011, 24
ADAPs had enrolled 2,393 clients in PCIPs. See National Alliance of State and Territorial AIDS Directors, ADAP
Coordination with Pre-Existing Condition Insurance Plans (PCIPs), December 2011, http://www.nastad.org/Docs/
103359_ADAP%20and%20PCIPs%20-%20December%202011.pdf.
87
CRS Report R44163, The Patient Protection and Affordable Care Act’s Essential Health Benefits (EHB).
88
Jeffrey S. Crowley and Connie Garner, Reimagining the Ryan White HIV.AIDs Program: Aligning The Ryan White
HIV/AIDS Program with Insurance Coverage, O'Neill Institute for National & Global Health Law, Issue Brief no. 1,
Washington, DC, June 2015, https://www.law.georgetown.edu/oneillinstitute/research/documents/
AligningwithInsurance1.pdf.
89
CRS Report R44065, Overview of Health Insurance Exchanges. In states that did not expand Medicaid, some
individuals may have too little income to qualify for insurance subsidies, but may not be eligible for Medicaid because
they do not belong to a categorical eligibility group (e.g., they are a childless adult).
90
National ADAP Monitoring Project Annual Report: 2015 Annual Report, National Alliance of State and Territorial
AIDS Directors, Washington, DC, May 2015, Chart 17, p. 27, https://www.nastad.org/resource/national-adapmonitoring-project-2015-annual-report.

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Ryan White HIV/AIDS Program funds may also be used to pay premiums or cost sharing for
individuals who enroll in private insurance plans, including plans offered on an exchange. The
Ryan White HIV/AIDS Program continues to be the payer of last resort; as such, the use of funds
for insurance coverage is and has been a goal of the program. HRSA and others note that Ryan
White funds are increasingly being used for insurance premiums and cost sharing.91
A 2014 study by the Kaiser Family Foundation looked at ACA implementation in five states,
examining the use of Ryan White HIV/AIDS Program funds and challenges that individuals
faced.92 This study suggests that Ryan White HIV/AIDS Program funds were being increasingly
used to help people enroll in exchange plans and then to educate people about how to use
insurance coverage. This was particularly a challenge, as some Ryan White clients had little
experience with the use of health insurance. In some cases, this lack of experience resulted in
individuals enrolling in a high-deductible plan, which would pay only after the deductible had
been met. As such, some could not afford to meet this deductible and continued to rely on the
ADAP program for their medication.93 The Kaiser study found that the ACA changes to insurance
coverage has enabled some Ryan White clients to better manage their non-HIV related medical
conditions.
HRSA notes that there have been challenges with coverage of HIV medication under exchange
plans.94 Other studies have also found that some individuals who transitioned from the Ryan
White HIV/AIDS Program to an exchange plan have experienced difficulty obtaining their HIV
medication. Specifically, there was large variation in cost of HIV drugs depending on the plan
design; certain insurance plans placed all HIV drugs in the most expensive tier, resulting in
greater out of pocket spending (an estimated $3,000 annually),95 or causing individuals to rely on
Ryan White funds to pay their drug costs. Some contend that, as a result, Ryan White funds are
being used for expenses that could be covered by insurance plans.96

Other ACA Provisions
Because ACA expands insurance coverage to those previously uninsured, the law also includes
provisions that support changes to physician training, compensation, and practice.97 These
changes are intended to increase the size of the medical workforce, alter its composition (more
primary care providers or other specialties in shortage), and incentivize practice in rural or other
underserved areas.

91

Personal communication, Health Resources and Services Administration, Office of Legislation, June 12, 2015; and
Jennifer Kates et al., Health Insurance Coverage for People with HIV Under the Affordable Care Act Experiences in
Five States, The Kaiser Family Foundation, Issue Brief, Washington, DC, December 2014.
92
Jennifer Kates et al., Health Insurance Coverage for People with HIV Under the Affordable Care Act Experiences in
Five States, The Kaiser Family Foundation, Issue Brief, Washington, DC, December 2014.
93
Ibid.
94
Personal communication, Health Resources and Services Administration, Office of Legislation, June 12, 2015.
95
Douglas B. Jacobs and Benjamin D. Sommers, “Using Drugs to Discriminate—Adverse Selection in the Insurance
Marketplace,” The New England Journal of Medicine, vol. 372, no. 5 (January 29, 2015), pp. 399-402.
96
Jeffrey S. Crowley and Connie Garner, Reimagining the Ryan White HIV.AIDs Program: Aligning The Ryan White
HIV/AIDS Program with Insurance Coverage, O'Neill Institute for National & Global Health Law, Issue Brief no. 1,
Washington, DC, June 2015, https://www.law.georgetown.edu/oneillinstitute/research/documents/
AligningwithInsurance1.pdf.
97
CRS Report R42029, Physician Supply and the Affordable Care Act.

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The ACA includes a number of sections that aim to incentivize changes to the delivery of health
care services. Specifically, the ACA supports models of care that are patient-centered with an
emphasis on improved care coordination, the integrated delivery of health care services, and an
increased emphasis on primary and preventive care. For example, the law creates the option for
states to establish “health homes” for individuals with chronic conditions, including behavioral
health disorders, in the Medicaid program.98
ACA also permanently authorized the federal health center program administered by HRSA and
created the Community Health Center Fund, including $9.5 billion to be appropriated for health
center operations in FY2011 through FY2015.99 Although these funds were initially intended to
expand the health center program, they have been partially used to supplement its annual
appropriation. Despite this, the overall funding, the number of health centers available, and the
services they provide have increased during this period.100 Many health centers receive Ryan
White HIV/AIDS Program funds to provide health services, including HIV testing.

ACA and the Future of the Ryan White HIV/AIDS Program
The long-range impact of ACA on the Ryan White HIV/AIDS Program—in which HIV care and
treatment services provided under the Ryan White HIV/AIDS Program are replaced by access to
such services through health coverage via ACA—remains to be determined. In those states that
do not participate in the Medicaid expansion, the need for the full range of services under Ryan
White would remain. However, even if all states decide to cover the new Medicaid-eligible group
provided under ACA, there will be gaps that the Ryan White HIV/AIDS Program could continue
to fill, such as coverage of those individuals with HIV/AIDS who are undocumented immigrants
or legal immigrants within the five-year Medicaid ban.101 Ryan White also provides dental care
and support services, such as medical transportation, that may not be provided under Medicaid or
private health insurance. Some analysts expect that the need for Ryan White funds to pay
premiums and out of pocket expenses for individuals who are able to obtain private health
insurance coverage on an exchange should continue and may grow. Such expenses may be
significant if individuals enroll in high-deductible plans or for those who are on long-term
medication.102
Ryan White HIV/AIDS Program funds are also used to train health care providers. The ACA, by
expanding coverage, could increase the need for such training. Although this issue is debated,
some analysts have voiced concerns about whether enough physicians will be available to care for
individuals who were previously uninsured.103 There may also be shortages in particular

98

Section 2703(a) of ACA defines “health home” as “a designated provider (including a provider that operates in
coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic
conditions to provide health home services.”
99
CRS Report R43911, The Community Health Center Fund: In Brief. This funding was extended until FY2017 in the
Medicare Access and CHIP Reauthorization Act of 2015; see CRS Report R43962, The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA; P.L. 114-10).
100
CRS Report R43911, The Community Health Center Fund: In Brief; see Figure 1.
101
For further information about the five year ban, see Office of the Assistant Secretary for Planning and Evaluation,
ASPE Issue Brief: Overview of Immigrants’ Eligibility for SNAP, TANF, Medicaid, and CHIP, March 2012,
http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml.
102
CRS Legal Sidebar WSLG886, Can Third Parties Pay Health Insurance Premiums in the Exchanges?, by (name red
acted)
.
103
CRS Report R42029, Physician Supply and the Affordable Care Act.

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The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

geographical areas or certain specialists, such as primary care or those who are knowledgeable
about HIV/AIDS.104
Advocates for the Ryan White HIV/AIDS Program also note that the program plays a public
health role by providing health education and seeking to increase treatment compliance as a way
of reducing HIV transmission thereby seeking to prevent the infection of other individuals.105
This public health role differs from the role of payers, who generally do not focus on public
health initiatives. In addition, much of the work to retain people in treatment is accomplished by
the Ryan White HIV/AIDS Program’s case management services, which are less likely to be
duplicated by the coverage that insurance programs provide under the ACA.106

Reauthorization of the Ryan White HIV/AIDS
Program
P.L. 111-87 provided authority for the Ryan White HIV/AIDS Program through FY2013. Section
2(a) of P.L. 111-87 removed the sunset provision that had been included in the 2006
reauthorization (§703 of P.L. 109-415). The program’s authority is currently expired, but
Congress continues to appropriate funds for the program to carry out Title XXVI and Title III of
the PHS Act. As noted above (“ACA and the Ryan White HIV/AIDS Program”), the role of the
Ryan White HIV/AIDS Program has been and may continue to be altered by the ACA,
particularly state decisions on Medicaid expansion. Such changes may be taken into consideration
should Congress undertake another reauthorization of the Ryan White HIV/AIDS Program or
consider making changes to the ACA.

Appropriations
FY2016
For FY2016, the Obama Administration requested a total of $2.323 billion for the Ryan White
HIV/AIDS Program, an increase of $4 million compared with FY2015; the increase would go to
Part C. As in FY2015, the FY2016 budget request again proposed consolidating Part D funds into
Part C.
The House Appropriations Committee reported H.R. 3020, the FY2016 Labor/HHS/Education
bill on June 24, 2015 (H.Rept. 114-195). The House bill would have provided $2.319 billion for
the Ryan White HIV/AIDS Program, the same as the FY2015-enacted level, without the
consolidation of Parts C and D. The Senate Appropriations Committee reported S. 1695 on June
25, 2015 (S.Rept. 114-74). The Senate bill would have provided $2.294 billion for the Ryan
White HIV/AIDS Program, $25 million less than the FY2015-enacted level. The Senate bill did
104

During July 2012, HRSA conducted a series of four listening sessions to allow stakeholders, including Ryan White
grantees, advocacy organizations, state and local administrators, and others to provide comments on all aspects of the
Ryan White HIV/AIDS Program in preparation for possible reauthorization. HRSA, Ryan White HIV/AIDS Program
Reauthorization, Recorded Listening Sessions, available at http://hab.hrsa.gov/reauthorization/index.html.
105
Jeffrey S. Crowley and Connie Garner, Reimagining the Ryan White HIV.AIDs Program: Aligning The Ryan White
HIV/AIDS Program with Insurance Coverage, O'Neill Institute for National & Global Health Law, Issue Brief no. 1,
Washington, DC, June 2015, https://www.law.georgetown.edu/oneillinstitute/research/documents/
AligningwithInsurance1.pdf.
106
Ibid.

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not agree to the proposed consolidation of Parts C and D and did not provide $25 million in
funding for SPNS.
On September 30, 2015, the President signed into law the Continuing Appropriations Act, 2016
(P.L. 114-53, H.R. 719), which provided funding for the Ryan White HIV/AIDS Program through
December 11, 2015, at the same level as in the FY2015 Consolidated and Further Continuing
Appropriations Act (P.L. 113-235), minus an across-the-board reduction of 0.2108%. The Further
Continuing Appropriations Act, 2016, (H.R. 2250, P.L. 114-96) provided funding through
December 16, 2015, under the same conditions and funding rate as P.L. 114-53.
On December 17 and 18, 2015, the House and Senate passed the Consolidated Appropriations
Act, 2016 (H.R. 2029, P.L. 114-113), which the President signed on December 18, 2015. The
measure provides a total of $2.323 billion for the Ryan White HIV/AIDS Program in FY2016,
including the $25 million for SPNS, but did not agree to the consolidation of Parts C and D.

FY2017
The Obama Administration requests $2.298 billion in budget authority and $34 million via the
PHS evaluation tap—for SPNS—resulting in a total of $2.332 billion for the Ryan White
HIV/AIDS Program in FY2017. The $9 million increase over FY2016 would be for a new SPNS
initiative to expand screening for and treatment of hepatitis C in people living with HIV. The
FY2017 budget request again proposes a consolidation of Part C and Part D, which was proposed
in the FY2015 and FY2016 budget requests and rejected by Congress.

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Table 1. Federal Funding for the Ryan White HIV/AIDS Program, FY1991-FY2017
($ in millions)

Part B

(ADAP)
(nonadd)

Part
C

Part
D

Part F
AETC

Part F
Dental

87.8

87.8

—

44.9

19.5

17.0

—

257.0

FY1992

120.5

106.6

—

48.7

19.3

16.9

—

312.0

FY1993

184.8

115.3

—

48.0

20.9

16.4

—

385.4

FY1994

325.5

183.9

—

48.0

22.0

16.4

7.0

602.8

FY1995

356.5

198.1

—

52.3

26.0

16.3

6.9

656.2

FY1996

391.7

260.8

(52)

56.9

29.0

12.0

6.9

757.4

FY1997

449.8

417.0

(167)

69.6

36.0

16.3

7.5

996.3

FY1998

464.7

542.8

(285.5)

76.2

40.8

17.2

7.8

1,150.2

FY1999

505.0

737.8

(461.0)

94.3

46.0

20.0

7.8

1,410.9

FY2000

546.3

823.8

(528.0)

138.4

51.0

26.6

8.0

1,594.2

FY2001

604.2

910.9

(589.0)

185.9

65.0

31.6

10.0

1,807.6

FY2002

619.4

977.2

(639.0)

193.8

71.0

35.3

13.5

1,910.2

FY2003

618.7

1,053.4

(714.3)

198.4

73.6

35.6

13.4

1,993.0

FY2004

615.0

1,085.9

(748.9)

197.2

73.1

35.3

13.3

2,019.9

FY2005

610.1

1,121.8

(787.5)

195.6

72.5

35.1

13.2

2,048.3

FY2006

603.6

1,119.7

(789.0)

193.5

71.7

34.6

13.1

2,036.3

FY2007

604.0

1,195.5

(789.5)

193.7

71.8

34.7

13.1

2,112.8

FY2008

627.1

1,195.2

(794.4)

198.8

73.7

34.1

12.9

2,141.8

FY2009

663.1

1,223.8

(815.0)

201.9

76.8

34.4

13.4

2,213.4

FY2010

678.1

1,276.8

(860.0)

206.4

77.6

34.7

13.6

2,290.2

FY2011

672.5

1,308.1

(885.0)

205.6

77.3

34.6

13.5

2,311.7

FY2012

666.1

1,360.8

(933.3)

215.1

77.2

34.5

13.5

2,367.2

FY2013

624.3

1,287.5

(886.3)

194.4

72.3

32.4

12.6

2,223.6

FY2014

649.4

1,314.4

(900.3)

205.5

72.4

33.2

13.0

2,288.0

FY2015

655.9

1,315.0

(900.3)

201.1

75.1

33.6

13.1

25

2,318.8

FY2016

655.9

1,315.0

(900.3)

205.1

75.1

33.6

13.1

25

2,322.8

FY2017 Request

655.9

1,315.0

(900.3)

280.2

---

33.6

13.1

Part
A

FY1991

Fiscal Year

SPNS

Total

2,297.8

Sources: HRSA, FY2017 Justification of Estimates for Appropriations Committees, pp. 263-302,
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf. Amounts for earlier years are from prior HRSA
Justification documents.
Notes: Totals for FY2002 through FY2014 do not include $25 million for the Special Projects of National
Significance (SPNS) provided via the PHS program evaluation tap (§241 of the PHS Act). FY2015 and FY2016
appropriations include funding for SPNS via budget authority. Total for FY2017 request does not include $34
million for SPNS via the PHS program evaluation tap. Totals may not add due to rounding.

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Appendix. Summary of Ryan White HIV/AIDS Program Parts
Table A-1. Ryan White HIV/AIDS Program Overview
Program Part

Eligibility

Allocation Method

Uses of Funds

Part A—Grants to
Urban Areas: Eligible
Metropolitan Area
(EMA) grants and
Transitional Grant Areas
(TGA)

EMAs have a population of at least 50,000 and
more than 2,000 reported AIDS cases in the
prior five years.
TGAs have a population of at least 50,000 and
at least 1,000, but fewer than 2,000 cumulative
reported AIDS cases in the prior five years.

2/3 of funds are distributed as formula
grants based on reported living cases of
HIV/AIDS. The remaining 1/3 are
competitive supplemental grants
distributed on the basis of need and
other factors, such as an area’s success
in HIV/AIDS testing.

75% of funds must be used for core medical
services (outpatient and home health services,
ADAP treatments and case management).
25% of funds may be used for support services
(outreach, medical transportation, language
services, and respite care).

Part B—Base Grants to
States

All 50 states, DC, Puerto Rico, and territories.

2/3 of funds are distributed as formula
grants based on reported living cases of
HIV/AIDS and other factors. Remaining
1/3 are supplemental grants distributed
competitively on the basis of need.

75% of funds must be used for core medical
services (outpatient and home health services,
ADAP treatments and case management).
25% of funds may be used for support services
(outreach, medical transportation, language
services, and respite care)

Part B—AIDS Drug
Assistance Program
(ADAP)

All 50 states, DC, Puerto Rico, and territories.

Formula grants based on reported living
cases of HIV/AIDS; 5% is set aside for
ADAP supplemental grants distributed
based on need.

Administration of state ADAP programs,
primarily to provide HIV drugs, insurance
continuation, drug co-pays and deductibles.

Part B—Emerging
Communities Grants

Grants to states that have a metropolitan area
with a population of at least 50,000 and a
cumulative total of at least 500 but fewer than
1,000 reported cases of AIDS during the most
recent five calendar years.

Formula grants based on reported living
cases of HIV/AIDS.

Grants for core medical services and support
services.

Part B—Emergency
Relief Funds

States and territories.

Grants distributed based on need.

Grants to help states prevent, reduce,
eliminate ADAP waitlists or cost-containment
measures.

Part C—Early
Intervention Services
(EIS)

Health care entities that serve underserved
populations (federally qualified health centers,
family planning clinics, and hemophilia centers).

Competitive grants, cooperative
agreements, and contracts.

75% of a grant must be used for core medical
services, and not less than 50% must be used
for EIS (counseling and HIV testing).

CRS-23

Program Part

Eligibility

Allocation Method

Uses of Funds

Part C—Capacity
Development Grants

Public and non-profit entities that are or intend
to become HIV providers. Entities that
currently provide Ryan White HIV/AIDS
Program services are also eligible.

Competitive grants, cooperative
agreements, and contracts.

Grants to improve the infrastructure and
capacity of eligible entities to enable facilities to
provide comprehensive HIV/AIDS services.
Examples include management systems to track
financial and health care information of HIV
patients, and service delivery system
improvement.

Part D—Women,
Infants, Children, and
Youth

Public and nonprofit entities that provide
primary medical care to HIV positive women,
infants, and children. State and local
governments, Indian Tribes, Tribal
Organizations, and faith and community based
organizations are also eligible.

Competitive grants, cooperative
agreements, and contracts.

Grants for family-centered care for women,
infants, children, and youth with HIV/AIDS.
Outpatient health care, case management,
referrals, and other services to enable
participation in the program, including services
designed to recruit and retain youth with HIV.

Part F—AIDS Dental
Reimbursement (ADR)
Program

Accredited dental schools, post-doctoral dental
education programs, and dental hygiene
education programs.

Competitive grants.

Reimbursement for dental services provided to
individuals with HIV/AIDS.

Part F—Community-Based Partnerships of dental education programs and
Dental Partnership
community based organizations.
Program

Competitive grants, cooperative
agreements, and contracts.

Grants to support collaborations between
dental education programs and communitybased partners to deliver oral health services in
community settings while training students and
residents enrolled in accredited dental
education programs.

Part F—AIDS Education
and Training Centers
(AETCs),

Grants support 11 regional centers and more
than 130 locally associated sites.

Competitive grants, cooperative
agreements, and contracts.

Specialized clinical education and consultation
for health providers on HIV transmission,
treatment, and prevention.

Part F—Special Projects
of National Significance
(SPNS) Program

Entities that have received Ryan White
HIV/AIDS Program funds.

Competitive grants.

Grants to quickly respond to emerging needs.

Minority AIDS Initiative
(MAI)

Entities that have received Ryan White
HIV/AIDS Program funds.

Formula and competitive grants.

Activities such as education and outreach to
improve minority access to the services
available through the Ryan White HIV/AIDS
Program.

Source: CRS analysis of HRSA Budget Justification, agency program documents, and program statute.
Note: Part E/G is not included in the table because this program has never been funded.

CRS-24

The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

Author Contact Information
(name redacted)
Specialist in Biomedical Policy
[redacted]@crs.loc.gov , 7-....

Congressional Research Service

(name redacted)
Specialist in Health Services
[redacted]@crs.loc.gov, 7-....

25

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR44282. Public record. Not legal advice.