Monday, May 08, 2006

Slicing the RWCA pie

Nasty Texas weather has us offline, so I am catching up with last week’s rather full inbox while I wait for the green light on the modem. One tidbit, which I probably would have skipped for lack of time, was a news item distributed by the CDC:

"Burr and Other Senators Take Issue with Formula for AIDS Care Money" Winston-Salem Journal (05.04.06):: Mary M. Shaffrey

The news report shows the senator from North Carolina taking up the fight to get a more “equitable” distribution of funds. Here's his press release.
Why do states like Alabama have waiting lists for people to get basic drugs while places like New York, Houston and San Francisco have so much money that they provide acupuncture, massage therapy, dog-walking and ‘companion services’? Ryan White himself would not get the proper funding under the current funding formula,” Sessions said, referring to the Indiana teenager who died in 1990 after contracting AIDS from hemophilia treatments.

The issue is, of course, how the funds are distributed among the states by the formula in the Ryan White CARE Act (RWCA). Since the beginning, the RWCA has distributed funds based on the number of AIDS cases reported by area. These numbers were cumulative, meaning that both living and deceased persons were included in the formula. Places like San Francisco and New York City, where the earliest cases were diagnoses had, of course, the highest numbers and would receive a larger portion of the funds.

This also included places like Houston and Dallas and, eventually, Fort Worth, San Antonio, and Austin. These Texas cities are Title I cities and receive separate grants directly to their metropolitan areas. Places like El Paso, the Valley, and parts of East Texas never seemed to reach those high numbers despite having significant case loads.

HRSA and the CDC have been pressing states to improve their reporting of HIV cases so that RWCA funding can eventually be directed toward areas where the highest number of living cases (people living with HIV and AIDS) are found, so that, unlike Medicare (and Medicaid in most places) can do a better job of taking care of people who are newly diagnosed and whose illness has not yet progressed to an AIDS diagnosis. From a public health standpoint, this is reasonable.

Some states have, however, dragged their feet on the issue. Texas did its own foot dragging (with help from Texas AIDS Network, we should acknowledge) for several years as we debated named reporting for HIV. The concern was confidentiality. Texas went from a confidential/anonymous testing scheme (with poor tracking) to confidential testing with a unique identifier (with slightly better tracking) to the current process of confidential testing with names reported (with much better tracking). This puts Texas in a comparatively good position to have good information on which to base RWCA funding formulas based on either reported AIDS cases or reported cases of persons living with HIV/AIDS.

Over the years, the RWCA has been modified to move toward funding living cases. To prevent abandonment of infrastructure in areas where higher funding had previously been available, “hold harmless” provisions were added, so that funds in those areas were cut by only a small percentage each year. The “hold harmless” funds were generally taken out of funds that had been set aside for supplemental grants.

Those “hold harmless” provisions and their associated bites out of supplemental funds have put the bite on extra funding that Texas has relied on in the past. For example, the Texas HIV Medication Program is eligible to receive supplemental funds because of the tight eligibility requirements under which the program operates. This year’s supplemental grant is expected to be lower because of the increasing need to take funds out of supplemental grants for the “hold harmless” formulas. The flip side of that problem, lest we think that the simple solution is to get rid of “hold harmless” provisions, is that Houston, for one, benefits from “hold harmless” provisions in another title of the grant. Without those provisions, essential funds to Houston would be cut and services to a substantial portion of the people living with HIV/AIDS in Texas would suffer.

It looks like there’s no good answer for Texas, doesn’t it? Except for this: the funds needed to support HIV/AIDS treatment and services have increased very little under this administration, and in some cases they have decreased. At the same, the number of people living with HIV/AIDS has increased significantly. Perhaps the good senators from North Carolina would do themselves and the rest of us a better service by supporting increased funding for the RWCA rather than looking for ways to slice the pie to their better advantage. It’s not how the pie is sliced that is the problem. It’s that the pie is shrinking.

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