Friday, August 23, 2013

Is it time to Reauthorize the Ryan White CARE Act?

On September 30th, some HIV/AIDS advocates have pontificated that the world will end with respect to supports and services afforded to people living with HIV/AIDS...but that simply isn't true. That is the date when the current Ryan White CARE Act -- which was reauthorized by Congress in 2009 as the "Ryan White HIV/AIDS Treatment Extension Act" -- is set to expire. Maybe federal lawmakers anticipated four years ago that the partisan gridlock would only worsen by today, but interestingly enough the law doesn't include language that is fairly common in reauthorizing legislation: a sunset provision.

What does that mean? In legislative terms, it means that the current law is likely (as in, very likely) to continue under the current law's framework and structure -- including appropriation levels. Putting the hysteria aside, it is nonetheless important for Ryan White stakeholders remain engaged to ensure that the "payor of last resort" safety net that the law provides remains intact, and robust funding accompanies it. Fortunately, coalitions such as the Ryan White Work Group, ADAP Coalition and the National ADAP Working Group (all of which the ADAP Advocacy Association is a member organization), are working to monitor this situation and propose meaningful advocacy strategies.

Of particular interest to most Ryan White stakeholders is the fate of the current law's "Hold Harmless" provision, which was added during a previous reauthorization. The Hold Harmless provision initially continued the previous 95% rate for the first two fiscal years, but increased to 100% of fiscal year 2010 funding for each of the fiscal years 2011 and 2012. For fiscal year 2013, the amount will be 92.5% of the previous fiscal year’s grant. This hold harmless continues to apply to both Part A and Part B grants.[1]

On July 16th, Rep. Frank Pallone (D-NJ) introduced H.R.2699. The legislation would "extend the hold harmless provisions of the Ryan White HIV/AIDS Program pending reauthorization of the overall program." The legislation has no co-sponsors and it also reportedly doesn't have the support of the majority staff on the House Committee on Energy & Commerce, Subcommittee on Health. In other words, Rep. Pallone's legislation probably isn't going anywhere in the Congress.

According to Bill McColl of AIDS United and Co-Chair of the Ryan White Work Group, "We are aware that hold harmless will be a major issue for many people in the HIV community and will be trying to develop points of agreement as the Congress works on a continuing resolution or appropriations bill in FY 2014."

Meanwhile, ADAPs have already experienced a major systemic shock between the changes in the funding formula, and the pending cuts from Sequestration. Data from the Health Resources & Services Administration (HRSA) demonstrates the changes between this year's number with last year's totals.

(Editor's Note: The totals are calculated from the actual reduction from last year per locality after subtracting accounting adjustments and carryovers from prior years). The numbers paint a picture that should keep Ryan White stakeholders on the edge of their seats.

PART A FUNDING: (Avg. Cut  7.12%)
The Part A spreadsheet encompasses all Part A areas in the country. This section of funding had experienced a few changes, including:
1) There was a new TGA in the Part A funding stream (i.e., Columbus, Ohio) , As a result, the EMA/TGA pie had to be divided up with one more additional locality.
2) Sequester had played a varying effect per locality as reflected by the percentages.
3) Shifting trends in epidemiology and formulas towards the South; therefore the cuts were somewhat cushioned and less drastic.

PART B FUNDING: (Avg. Cut  5.61%) 
The Part B Basic Earmark spreadsheet is the bulk (90-95%) of the Federal Grant to the States for ADAPs.
1) The Part B Grant for Medical Services has not been broken out yet as that will take some time to separate and compile that data as the Part B grants are multi-layered.
2) Again, Sequester had played a big factor in the reduction but the Southern States were saved the brunt of the Sequester because of a new formula change.

Eddie Hamilton, who heads up the ADAP Educational Initiative, summarized it best: "The grassroots do need to be afraid of sequester 2.0 coming up as it looks like Congress won’t be able to change that anytime soon."

In light of the current political climate on Capitol Hill, practically everyone with an interest in protecting HIV/AIDS supports and services is taking nothing to chance. Considering that the Ryan White law -- and especially the AIDS Drug Assistance Program (ADAP) -- has long enjoyed bipartisan support, education efforts to remind lawmakers of its importance are ongoing, including a new web video released by the AIDS Healthcare Foundation.


[Photo: AHF Ryan White Video]

One thing is for certain, prematurely opening up a popular law that doesn't require reauthorization could prove disastrous in the hyper-partisan, hyper-political environment that has consumed the current Congress.  Any suggestion to the contrary simply ignores the political realities that exist today. A more cautious approach might be pursuing a legislative technical fix.

The reality of the situation is best summarized by Bill Arnold, President & CEO of the Community Access National Network (CANN): "The issue boils down to congressional staff has no appetite to enter the debate over a full reauthorization until they have data after Affordable Care Act implementation, and can assess the impacts nationally, as well as locally."

Arnold suggests that the data won’t be available until well after “opening day” on January 1, 2014, and it will likely take all of that same year to clean and sort through the data. "That argues for a serious attempt to reauthorize in 2015, especially since it will also be past congressional election," Arnold said.

The bottom line is Ryan White stakeholders must remain vigilant in their efforts to maintain the nation's oldest and only law solely dedicated to providing life-sustaining supports and services to people living with HIV/AIDS in the United States. No one could disagree that the need exists. How the "community" achieves that objective is open to interpretation.

Stay tuned.

[1] Department of Public Health, Los Angeles County, California, "SECTION-BY-SECTION DESCRIPTION OF RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT OF 2009,” December 2009.



1 comment:

ADAP Advocacy Association said...

September 6, 2013

TO: HIV/AIDS Community Partners

FR: Ann Lefert, National Alliance of State and Territorial AIDS Directors and Bill McColl, AIDS United
Co-Chairs of the Ryan White Work Group, Federal AIDS Policy Partnership

RE: Update: Ryan White Program Current Status

As Co-Chairs of the Ryan White Work Group, we wanted to provide you with an update on the Ryan White Program. As you know, the current authorization ends on September 30, 2013. However, there is no “sunset” provision in the legislation. Therefore even if Congress does not take action, the Ryan White Program will remain a part of the law allowing funding to continue to be appropriated through the annual congressional appropriations process.

This summer, the Ryan White Work Group conducted many Congressional visits to discuss the future of the Ryan White Program. Overwhelmingly, the bipartisan response from Congressional offices has been that reauthorization should wait until the Affordable Care Act (ACA) is implemented and additional details are known about its impacts on individuals living with HIV/AIDS. Both Republican and Democratic offices have stated that the austerity of the current budget environment could mean massive cuts to Ryan White Program funding authorization levels if the Ryan White Program was reauthorized this year. Many programs currently being reauthorized by Congress have received funding levels far below their previously authorized levels. The vast majority of offices state that the Ryan White Program has bipartisan support for continuation even after implementation of the ACA. Many offices also understood that the results of implementation of the ACA would vary around the country depending on Medicaid expansion and other variables.

Although the general consensus of the Ryan White Working Group has been that delaying reauthorization is the optimal choice, other members of the HIV community have been advocating for a reauthorization this year. This has created some confusion on Capitol Hill and within the HIV community. To be clear, we all believe that the Ryan White Program must be continued and in the importance of ensuring access to care for people living with HIV. The Ryan White Work Group believes that the HIV community must first work to ensure continued, adequate funding for the Ryan White Program. We must also fight against sequestration and further budget cuts.

The HIV community also needs to strongly focus on successfully accomplishing implementation of the ACA and the integration of the Ryan White Program into the new health system. The Ryan White Program must be used to dramatically improve both treatment and potential prevention outcomes in communities where people living with HIV/AIDS are not receiving the health benefits of being in care, on treatment and virally suppressed. A valued quality of the Ryan White Program is its responsiveness to the unique needs of individual jurisdictions. This flexibility is essential as communities use the Ryan White Program in conjunction with other resources to increase access to the expanding number of people diagnosed with HIV in need of treatment, care and supportive services.

The Ryan White Work Group continues to work closely with the Administration, Congress and community advocates. We will certainly seek to reauthorize when there is stronger political agreement that it can be accomplished in a constructive manner without the threat of lower authorization levels and when the impact of the ACA is better understood. In the meantime, the Ryan White Work Groups seeks to ensure that the Ryan White Program continues and that the comprehensive services provided to clients today continue to be available as the Ryan White Program is integrated into the coverage offered through the Affordable Care Act.

If you have questions or are interested in joining the Ryan White Work Group or any of the subcommittees please contact Ann Lefert (alefert@nastad.org) or Bill McColl (wmccoll@aidsunited.org).