the subcommittee will be called to order where minus a gavel today but i don't think we really need it let me announce that the hearing this morning is on the ryan white care act amendments of two thousand and nine actually a discussion draft so we don't have a bill number and i recognize myself initially for an opening statement but this discussion draft has been circulated by chairman waxman and myself and it's based in large part on the community consensus document that was put together by a large number of age groups from all across the country though we will be using this discussion draft as a basis for our hearing today it's very much a draft and i'm interested in having conversations with the minority as well as with the senate in an effort to come up with a strong piece of legislation that can be passed by both chambers and be signed into law by the president the ryan white care act as many of you know was named after a young boy who contracted the aids virus from a blood transfusion and sadly lost his life to this horrible disease since his death in one nine hundred ninety we as a nation have made great strides in preventing and treating  large part due to the ryan white program once again aren t death sentence and hiv aids diagnosis today means a complicated and expensive mix of drugs and therapies that can allow individuals to live longer and more prolific lives and for many new knowledge of the disease has allowed for better and more targeted prevention programs that have slowed the spread of hiv aids in spite of these dances however there are nearly forty thousand new age hiv aids infections reported each year and according to the c d c approximately one point one million americans are currently living with the disease since the beginning of this epidemic an estimated five hundred eighty thousand americans with aids have died so i think it's more crucial than ever given the high number of americans suffering from the disease that we have the ryan white program accounting for roughly ten percent or i should say nineteen percent nineteen percent of all federal funds are to use on a hiv aids care program provides treatment and support services to individuals and families living with the aids virus and serves or over half a million low income americans the program is without a doubt extremely vital in our battle against this epidemic in two thousand and six congress program it included a sunset provision that will eliminate the program entirely on october first of this year and i think i'm pretty certain in saying that everyone in this room today does not want that to happen and that's why the draft legislation we're examining today the discussion dressy forces based on the community consensus document that would make a few minor improvements to the ryan white program it eliminates a sunset provision so that will never face a last minute scramble to sustain vital services to our communities in addition it would extend the current program for three years and provide more flexibility for their programs to adequately fund the ryan white program to best serve the evolving needs of patients families  communities the discussion traffic sense the exemption period for states that are still reporting cases under a code based system it will allow those states to get their names based systems fully up and running and to ensure that their data is accurate and useful in that same vein it would also ensure that no transitional grant carrier or lose their status for the duration of this extension it would continue to hold harmless provisions that were stablished during the two thousand and six reauthorization which protects grantees from large decreases in funding so that we don't disrupt the provision of care to patients we've also included a few more technical tweaks to the current ryan white program all of which guarantee that patients continue to be able to access these lifesaving and life sustaining treatments and services as i mentioned before the ryan white care act is scheduled to sunset on september thirtieth so we must act now to ensure that the patients continue receiving the excellent care that this program provides and i sincerely hope that we'll be able to work in a productive bipartisan by camel fashion to create a bill that will benefit over a million citizens fighting this disease in the united states and i want to thank the aids community for their hard work in coming together on this on the consensus document we greatly appreciate the work you've done and i now recognize here so i have my my colleague from kentucky acting as the ranking member today mr wickfield is recognized chairman thank you very much for holding this hearing on the discussion draft to reauthorize the ryan white legislation all of us are very supportive of the ryan white program and back in two thousand and six we were happy to work in a bipartisan manner to reauthorize that program for three years we do take you at your word today to work with us in a bipartisan way as we move forward to reauthorize this draft and i might say that while we love this program and we recognize the benefits of this program i have two particular areas  concern number one in the discussion draft we authorize such as necessary for two thousand and ten two thousand and twelve when you consider the financial condition of our country right now our constituents and practically every economist from every spectrum are very much concerned about the size of our debt so number one  point two billion on this program last year and another reason that i really have concern about the open ended in this this is that we have a tendency not necessarily this committee but i think all committees have a tennis relinquishing more and more authority to appropriate and that's precisely what this legislation does such as necessary so i think we would be better off putting in a number that we authorize for the two reasons that i have mentioned i would also say that another area that i'm concerned about is the grandfathering of these transitional grant areas  are requirements that must be met for the transitional grant areas to receive money and under this discussion draft if you had an area that was receiving grant money for the last three years then they would automatically be grandfathered for another three years and it certainly is possible that the need may be greater in some other areas so those are two areas that i particularly i'm concerned about but once again we're delighted that you're holding this important meeting on the discussion draft and we hope that we can work with you and reach a consensus on this legislation and get it reported out of committee thank you very much epidemic half a million americans rely on the program for basic care treatment and support services it's hard to imagine how patients their families would be able to deal with the epidemic without this existing policies or clarified parts of current law that have caused confusion others make changes to mitigate the stabilising funding decreases that have resulted from the application of the two thousand and six reauthorization we'll hear more about the specific provisions from our witnesses today i think it over arching theme that will emerge is that was relatively plain fine tuning the ryan white program an continue to do its good work providing services to those most in need for another three years this is especially important because of the program's looming deadline of september thirtieth quickly it all the more important to provide that stability that's said i want to underscore the word draft that is in the title of the document the subject of today's hearing this draft was informed by technical assistance f the administration as well as a community consensus that has been endorsed by nearly three hundred organizations in forty seven states but this is just a starting point we've already begun talking through various issues raised in the draft in a bipartisan fashion will begin to go with our colleagues in the senate with a commitment to doing our best to reach an agreement before the end of this month that will take much hard work but i believe we can get there we simply have to the people who depend on the ryan white program for the services they need can't wait i look forward to working with all our colleagues on this committee in ensuring that we reach this goal and th of americans probably many of our colleagues aren't even aware of what the care act is and what it does you know in an ideal world we wouldn't have the care act because we would have already found a cure or we would already have a reliable vaccine for this disease and prevent it before it occurs and that still needs to be our foremost thought on our ultimate goal i understand how dangerous it is and how important is to have adequate resources to prevent infection and to manage the disease over a are occurring in the african american population the average eight hundred thousand population for karen county one of my counties is three times greater in the african american community than in other communities in fact infections are increasing throughout no one no one should come out on the short end of the stick because of where they live because congress simply decided to rush something through really care about this population we will focus on focus on patien group members i'm not falling to the category that we have to move quickly or rapidly i think we're learn that that's not always the best way to deal with public policy we could do a simple reauthorization with no changes but unfortunately we're falling down also the same the same trap as addressing draft bills and i hope that if and when we have to this hearing we heard changes and corrections that we and bill finally get submitted that we would have a legislative hearing on the bill in the history of this committee to do that it hasn't been the current history of this committee to do that so we're kind of back where we started from before the break here having hearings on draft legislation instead of real legislation and i hope we change course with that and i am happy to be back and happy to see all my colleagues now you're back my time are unfortunately home to sixteen percent of the nation's eight aids population and so new york we named the epicenter of the aids crisis and new york has nearly one hundred twenty thousand residents living with hiv aids in our state and cities have been proud to partner with the federal government in providing care for many of these individuals new york state receives more than three hundred million dollars in ryan white fun under all parts of this act to provide a range of health care and support services through ryan white programs twenty two thousand uninsured new yorkers receive medications and ambulatory care services and thousands more receive other services such as mental health case management nutrition and treatment here in support services these individuals must be guaranteed uninterrupted access to these vital services it's critical that congress act swiftly on the reauthorization of white the authorization act which nationwide provides life saving medications health care and support services to over half a million people as you know unlike most reauthorization congress inserted a sunset provision into the act in two thousand and six requiring congressional action by september thirtieth of this year two thousand and nine without action this important program o b terminated and care will be jeopardized while three years ago this reauthorization a subject of much disagreement and dissent and i remember because i was in the middle of it we are in a different place today fortunately members on both sides of the aisle and more than two hundred fifty organizations in the us have worked hard over the past year to develop legislative principals where there is much agreement the committee draft proposal is for a three year we authorize a sion of the ryan white hiv aids treatment modernization act while some might ask why we again working that we implement policy discussions likely to impact the program such as the development of a national aids strategy and broader health care reform are underway indeed the health reform legislation that with count continuing to develop once fully implemented will have a profound effect on our ability to provide access to health care and prevention services to individuals with hiv aids nationwide as currently drafted we will we form the private insurance market and end the practice of excluding the preexisting conditions we will leave for medicaid by allowing early treatment for individuals with hiv before they are disabled by age in the first three years of enactment and will in fact expand medicaid eligibility to cover low income childless adults i'm proud of the work i've done with you mr chairman and others to ensure that long term will create exchanges for the purpose of insurance with subsidies for low income individuals and finally we will close the medicare part donut hole over time well these are significant changes in our health care delivery system we will still need the ryan white program which remains a last resort to address unmet needs and services particularly over the next three years in conclusion mr chairman i want to commend you i want to commend you for the draft bill which addresses many of the points raised in the community consensus document as well as the specific concerns of my home state while there are some issues related to rebates and gran funding but i will continue to work with the chairman on prior things to mark up i support the draft bill i look forward to the discussion today and again mr chairman i want to emphasize our thanks to you because you have been such an important and  thank you mr chairman i appreciate the hearing that we're having today and want to welcome our witnesses in zero six my colleagues in the past what i think was a thoughtful bipartisan  dental service drug abuse mental health and related health care needs to run program provides an important safety net in assisting the under insured in keeping health insurance and provides care to the uninsured the program reinforces the fact that keeping people on private insurance provides a great benefit to the individual and to the community we have seen success with this program as we move forward reauthorization it is imperative that this committee work in a bipartisan manner to best serve the recipients of this program and to meet their needs congress needs to be good stewards  federal fund and that we appropriate funding and spending limits in place and not open and those authorization access to care is one of the biggest concerns among my constituents there are real problems in health care but what we know is replacing private care with a government bureaucrat won't increase access and it will not fix our health care system in colleagues on this side of the aisle have joined me in offering plans for doing that my constituents are telling us repeatedly not one another eight hundred billion dollars in higher taxes for a government run plan that is be an optimist and i think the fact that this committee is basically together on the importance of the ryan white act may be a good omen for the health in the next few weeks it is crucial that we stay together on this urge prompt action on the discussion draft this program provides critical medical care and support services to people with hiv across the country and it is especially important to metropolitan areas like los angeles county which is it is a payer of last resort picks up the costs after other sources of funding are exhausted it helps patients as has been pointed out a third of them have no insurance and more than half are under insured in the current economic climate absolutely a matter of life and death faced with a budget shortfall california was forced to cut some of its funding and moreover rising unemployment and the growing ranks of the uninsured means more and more share with you short stories from back home in florida stories that display the life changing impact that ryan white has had on many lives christopher from florida says i was diagnosed with hiv back in the summer of two thousand and i was fresh out of college with no health insurance it was only through government assistance programs that were funded largely by the ryan white initiative that i was able to help check up and blood work done i was a patient care clinic in st petersburg florida i have since begun working and have had insurance for four years but could not have gotten through the five years without the assistance of the  a productive discussion about how we can focus on the ways we can strengthen the care act so that it continues to meet the health needs of persons living with hiv disease and their families especially as they're living longer which is a good thing this is  issue is it specially important to my home state of california my colleagues who are from the same state are here as well which has a second largest disease burden in the united states and a significant number of new cases each year particularly among the latino population as you know california is experiencing a severe budget crisis state aid funding has been drastically reduced my constituents and all those affected across the state need this is distance from ryan white more than ever too often their livelihood and that of their families depend on this care i want to associate myself with the remarks of my colleague from texas dr burgess as one who also represents portions of of a rural area three mid sized counties on the central coast of california i'm concerned that funds are disproportionately assigned to more urban areas i represent the main source of hiv services between los angeles and san francisco and i want to ensure that central coast providers have what they need to provide resources september thirtieth will be here before we know it we must act now to reauthorize the legislation mandi said to hear my panelists today about how we can work together and we can work together in a bipartisan way i believe on this committee to ensure that the thousands of members of our hiv community in california across the country continue to receive health care and support services thank you for your testimony and i look forward to hearing it  people across the country in every single community that have been diagnosed with hiv aids and what the ryan white care act represents to them is a very very important effort that has worked with bipartisan support in the congress it's provided billions of dollars and most importantly it has helped to not only improve lives save lives but extend the i thought that the legislation failed to uphold the tradition of the original legislation because it created a system of what i termed winners and losers in the allocation of federal resources at that time i offered  amendment in committee with several of my colleagues from the california new york and new jersey delegation to increase the overall authorization in the bill and to extend the hold harmless provisions of the bill by two years  to ensure that the historic epicenters of the disease do not experience precipitous decline in funding levels from year to year unfortunately our amendment was defeated by a single vote by just a single vote nearly three hundred organizations across the country who work together to form a consensus about what recommendations should be included in this reauthorization and i want to salute every single one of those organizations for their work that's sending an incredible level of advocacy and collaboration that's why we're able to move this kind of legislation forward into represent the best in terms of partnership between advocacy groups and people who are on the ground dealing with issues out there and those of us in congress who are trying to respond we're on a tight timeline of course that's been alluded to my hope is that we can work in a  bipartisan fashion to get this legislation done so that we don't hit hard that we're concerned about i think that can happen and obviously starting right today as we as we begin our september business starting with particular which is part of my district and there are some tremendous organizations throughout the state and in the city of baltimore who've been working for many many years to address these concerns there's a group here to day life link and actually i'd like you to raise your hands so people can see how many of you out there that's that's the kind of advocacy that has brought forward this kind of legislation allow it to become a political football and election year so as to protect the program from being eliminated as included in the last authorization we will probably just have to kick the ball down the road a little longer just to keep the program on in this country and society that you now are at the forefront of advocating for a strong reauthorization of this law in connecticut this program has been critical to providing low income individuals with the medical and support services that they need and without this funding millions of americans and thousands of my constituents would struggle to find that cutting edge medical service that has been increasingly successful in treating the disease but to say that the transition through the last reauthorization of the program in connecticut has been rocky would be an understatement since the two thousand and six reauthorization the connecticut delegation and those responsible for administering a program in the state have gone round and round with her and the court system to ensure that the state's largest communities  in particular new haven and hartford with actually exist outside of my district receive adequate funds through the program and are treated fairly through the interpretational the resulting congressional and legal battles have resulted in favorable treatment for connecticut but i'm sure it's the preference of everyone involved to ensure that this current reauthorization does not result in the battles of the last three years being played out again in connecticut or in california or in other parts cross country that's why along with representative eshoo and others on this committee i'm encouraged  the draft legislation provides for the continuation and expansion of the laws hold harmless provisions well addressing once and for all the need for continued stop loss funding for jurisdictions that without it could face significant yearly funding decreases  open ended in terms of the appropriation some of the grandfathering provisions but having a bill before us having a legislative hearing being willing to do this are all good signs even though this is an opening statement my question to you mr chairman do you plan and chairman waxman plan on moving a bill fairly quickly or is this more of a get input here we do plan to  move a bill but not before we get more input from you from the republicans and also from the senate but we we realize that we have this you know october first deadline so we'd like to move quickly ok thank you mr chairman and  i think i speak for all the members of the minority we do very willing to work in an expedited timeframe we do hope it is an open process and we are allowed to input into the system before the decisions are made ok and the second person is just there to help not to testify understand we as you know have five minute opening statements they become part of the record and so i would now recognize you for five minutes thank you is program administered by the health resources and services administration within the department of health and human services in addition i would like to thank the chairman members of the committee and their staff for all of the hard work on this very important legislation let me start by expressing the administration's strong support for continuation of the ryan white program and its reauthorization it is a component of our nation's fight against h before i begin my testimony i would like to announce but today the center for medicare and medicaid services has released a new proposal to cover voluntary action screening for medicare beneficiaries who are at risk for infection and for women who are pregnant today's proposed decision would allow high risk medicare beneficiaries to learn of hiv status any time by requesting an hiv screening test and if necessary seek appropriate counseling and therapy i know you'll look forward to hearing more about this new plan in the weeks to come as accept public comment and issues its final coverage decision the department of health and human services is committed to helping promote the president's strategy to bring an end to the domestic damage in the country and this new proposal will allow those who may be at risk of action to find out quickly and early so that they can start getting treatment ron white provides critical medical care and support services to uninsured under insured and low income people living with hiv aids who have no other source of care hiv aids bureau grants are awarded to cities states and local community based organizations for the purpose of providing primary medical care and support services to individuals living with hiv i saw this firsthand on my very first site as administrator to ryan wade grant in chicago and philadelphia there i observe the difference these programs make and patients live with this in mind i would like to talk broadly about the administration's vision for reauthorizing this program since its inception in of parts a b c and s which are differentiated by the types of services rendered and or by the entities receiving funding purser recommends a four year reauthorization to minimize disruption of funding and services for grants and clients and to permit time for the implementation of health care reform policies and programs to expand to examine the impact on ron wyden the administration would also support a three year reauthorization consistent with the draft bill in addition hearses supports the language proposed in the energy and commerce draft legislation to eliminate the repeal language that was part of the last reauthorization presently part a and b grant are subject to three different penalties if they have unused funds remaining by the end of the grant a year first barring a waiver for formula fun grantees must return any unspent formula and supplemental funds to her at the end of the grant year second grantees with more than two percent of on obligated formula fund at the end of the grand year will receive a reduction in the subsequent gr third grantees with more than two percent of i'm obligated formula funds cannot apply for supplemental funds for the subsequent grants year encourages amending these penalties for parts a and b grantees because of the financial and administrative burden it places on them her sister just eliminating the penalty that requires a decrease in a grant to subsequent grant award by an amount equal to the obligated balance remaining from the current year's award the elimination of the provision helps to ensure the grantees will have sufficient funds so they will not have to interrupt service to individuals living with hiv in addition person recommends raising the threshold from two percent to five percent for the penalty that prevents grantees from receiving supplemental funds when they have an obligated formula fund both of these provisions are contained in the committee's current draft and we are appreciative of their inclusion person also suggests offsetting future year awards for grants with on obligated balances as opposed to cancellation of the amount the change from a deep into an offset would retain the intent of the law well simplifying penalty administration and expediting the redistribution of funds to other grantees to provide hiv aids care person supports eliminating the distinction between e m data are available by eliminating the distinction the appropriation for part could be distributed proportionally across all highly impacted jurisdictions based on the number of living hiv aids cases this award levels so that important hiv aids services in those jurisdictions are not interrupted this recommendation is reflected in the energy and commerce draft legislation six transitional branch areas are at risk of losing their status under part in fiscal year two thousand and eleven due to their inability to meet the definition of it based on aids cases count hearses eager to work with you to resolve this issue we are over a quarter century into the epidemic with my background of a nurse and as a nurse educator i know homeport and it is for us to train a new kind of health professionals to replace the first wave of experts that are nearing retirement we also need a new generation of health care workers to meet the difficult clinical challenges that are emerging in a world where section with treatment is managed as a chronic condition person suggests implementing a program for the participants that provides training of sufficient duration to ensure that new health professionals are properly trained to provide hiv care and are strategically placed in areas with high need of hiv medical finally person proposes to permit additional time for code based reporting states to transition to name based reporting systems for a living count upon which funding is under current jurisdictions are still in the process of converting to name based reporting system without an extension code based reporting states will be unable to receive funding after two thousand and nine which will disrupt services to patients with hiv aids in those areas we are appreciative of this being included in the draft legislation in summary i want to acknowledge the dedication of the advocacy community its work on the consensus document and it's incredible commitment to those individuals with the obama administration is committed to working with you with congress to reauthorize the ryan white program and to ensure that critical services continue beyond september members of the committee basically allowed five minutes for each member of recognize myself initially in the ryan white program is one that o m b has rated as highly effective and i'm sure her so will continue its good work in the ministry and i want to thank you for that you said that the administration supports at least three year extension i think you actually mentioned four but you could live with three would you tell us why that's the case in other words what would be the impact time more mature namespace surveillance systems in place and time to evaluate the impact of health care reform policies and programs and their implications for run ok well my second question is about this code base versus name basis and i know you and i mean i understand that the penalties help motivate states is a transition to the name based reporting and so that's why you have them now the discussion draft would maintain current law for code based reporting so that states can tune in their progress to name based reporting you know would still be able to progress but is it your understanding that the a jurisdiction still using the code based reporting are making enough progress toward a name basis to more or should we be forward and then say you want to continue this policy of having certain penalties but still allowing them to do to use the old system at least temporarily correct ok now i don't i don't think you mentioned the severity of need indexed i want to mention that one of the recommendations from the community consensus and it's also in the discussion draft is to clarify that hearses should not yet begin implementation of the severity of need index the two thousand  currently jurisdictions submit applications that are scored through an object of review process to determine level of need and subsequent funding congress's direction person contracted with an organization to establish and h for verity of need collaboration to develop this index but you're referencing the collaboration was comprised of a multi tiered expert body broadly representative of a hearse of staff national experts ryan white program and consumers based on the institute of medicine recommendations there were four panels for expert panels that were convinced to identify relevant data sources and measures that demonstrate needs in terms of area characteristics patient coverage and  the associated costs and so on the panel prepared written reports reviewing more than fifty six variables and forwarded nineteen for inclusion in a draft varity of need indexed some of the nineteen remaining variables were eliminated for reasons such as lack of uniformly highly qualified quality data at the state level person and our team that we contracted with analyze the recommendations of the panels completed supplemental studies and develop draft model of severity of need to be applied the index uses data measures comparable across jurisdictions and based on quantitative measure is established from existing national data sources we've also in two thousand and eight conduct contracted to conduct an independent analysis of that methodology and the independent evaluators concluded that the process that was used to develop that severity of need index was comprehensive but some elements of the formulation fail to meet being with us today and we appreciate your input in your opening statement you mentioned that there is an epidemic in the country today what is the definition of an epidemic and is there a certain number of cases that you must have to be called an epidemic or would you just clarify that for me what that means  certain criteria like so many thousands whatever whatever which is the way it should be done because with limited dollars you want to go where it's most needed so it would seem to me that if you just ourselves thank you very much i have a couple questions for you during my time one to share with you my concern to learn that the centers for disease control and prevention c estimates that the number of births to women living with hiv increased approximately thirty percent from two thousand to two thousand and six i mean this is there are all kinds of new phenomena arising within this area of hiv aids chronic length of living with the disease a whole new raft of issues that need to be addressed i believe i'm sure you are considering this is something that needs to be dealt with as well do you have any ideas or plans in place to address the needs of women and children and families in light of the growing numbers of hiv positive women of childbearing age perhaps you can discuss if you will help part of the legislation will help to ensure that their needs are met well part of your right party is a part of the ryan white program that is probably most targeted toward exactly the population of which you are concerned of course allocate funds through public and private organizations community based organizations and universities and can provide outpatient or ambulatory care directly to you or through contracts that are awarded  it is really designed to serve women infants children living with hiv aids support and provide support services to those individuals that's really a target population we also have resources that are available through part spins program referred to shorthand that can be allocated to direct research and other activities to particular target  is really targeted to mention women and children young adults thank you and part of the our goal then in our communities especially is to identify and encourage people to get tested so that they can understand that they are and that they can get into some of these programs and be able to deal with it early on that topic i'm concerned you heard in several opening statements about the impact of several of our state budgets on the ability to care for a hiv and aids patient i've heard just horrendous stories in my district in california about matters of life and death really if this  budget is going to employ to cut drastically the services on which people really depend for their care they're going to have to choose between their medicine and their food i mean i'm sure it's not just confined to my district i can see people in your hearing from a number of states about the challenges that they're facing locally and certainly california is one of those states that we're trying to monitor and work with the causeway as possible on the front end the administration of course strongly supports continuation of this program first and foremost to provide vital funding to states and cities to provide services to people living with hiv aids in part perhaps to address your can say your  question might be useful for you to know too that the president's fiscal year two thousand and ten budget request provides asked for an increase of about fifty three point nine million over the fiscal year two thousand nine omnibus level that funding would continue to support over twenty three hundred providers that would help half a million individuals living with hiv obtain access to life sustaining care and services so in fact there is an additional request and a request for additional funding i should say that should help to mitigate a bit of those concerns but bottom line we are aware of that and working as closely as we can with jurisdictions and states that are feeling particular pressure to maintain their services to this very vulnerable population where you can be assured that there are many members of our congress and including in this committee who will seek to look for further funds if that is necessary as we see some of these state budgets unfold i don't think it's really hit yet as hard as we're going to see in the coming months where we are really facing in our communities and it's not just the population unfortunately but this is one that is clearly made itself known to me and i know my colleagues will share in wanting to help you with it if there's any emergency funding that can be made available and surely the increase in the budget for next year is going to be something it was intended i'm i'm i'm sure to ex services but at least it will provide that stopgap hopefully for some of the states where it'll get to the bottom falling out and i appreciate your awareness of and concern for this situation again and we are we are aware we are concerned and we have been trying to collect data or information at least anecdotally from our contacts in each of the states so we've got a little bit of a litmus test about how things are going at the state level we'll continue to try and do that and then share that information will encourage their them locally to reach out to you let you know what the status is thank you thank you thank you ranking member mr barr thank you mr chairman i don't think i'll ask them if they're on the record for the administration they him and say that it's their personal position and so i'm just i'm not being devious i'm glad the chairman told in the hearing and i'm glad you're here but as a senior republican i want to ask committee we try to set the policy and and set the provisions and then we pass it over to the appropriations committee and then they're supposed to implement by passing the funding bills this draft one of the problems that my so you're willing to work we will work with you but also with mr blount and mr waxman so it's you know i might point out if we had a vote right now on my side when we've got five and they've got two but they probably have if we're really trying to solve the problem of helping those families and individuals that have that population does change over time and it's location changes over time we would like to have some ability to move the money where the people are still need assistance as opposed to where they may be in the so we're not opposing transitional grants we're not even really totally opposing the grandfathering but we would like to work with mr waxman and others on the majority with the obama administration to see if we couldn't move that some of those want to really emphasize i was chairman when we passed the last reauthorization bill in two thousand and six and i was very proud that was one of the things that we did during my chairmanship i'm very glad that you and mr  continue to have this bill in some appropriation rider this year to year and we also agree that as the changes in location changes we need and there's been some allusion to courses there would be to the fact that we're wrestling here with a larger health insurance reform effort where we would hope that we would get to a place where there's much broader coverage available to people who don't have the same numbers of either uninsured or underinsured people but i also anticipate that we shouldn't fall into the trap of thinking that they'll be some kind of one for one corollary in terms of reducing the support that exists through this program and i wonder if you could speak to the fact that so much of what makes dimension to what is offered through the resources that will continue to be absolutely critical and individual now has insurance coverage through more conventional means as a result of some of the reforms programs authorizations hopefully based upon cases and money and historical aspect and we do know population this is going to be an issue to follow the money if you haven't figured that out now because people are going to say ok we've got areas that have historically been high we don't want to disenfranchise that pool of money from illinois chicago is a big area they're always talking me about left on her chicago but i'm a rural representative what if there is a national debt threefold so far this year it's hard for us to go back to the public and say blank check we don't know much better if we did some analysis saying here's a population here here's the amount we need and we have historically been able to come back for supplemental request and added money if we guessed wrong and i mean terribly wrong but i would respect across the board and with that thank you mr chairman gentleman from georgia mr gingrich chairman thank you and it is amazing how often this happens you sit there for an hour hour and a possibly even help these patients five hundred thousand nationwide to be productive citizens god help them and we need to help them no question about it but if you've got areas where the caseload is going down  professionals we need i don't have numbers with me or an estimation with me i'd be happy to go back and provide that information that would be very very helpful for us especially with respect to the concern expressed on the other side of the aisle on the most significant challenges are about managing and helping to support patients for example that have co morbidities multiple diseases at one time so an individual diabetes for example that is also diagnosed with frankly some residual stigma associated with this disease and so that's another area that clinicians are helped by being trained by having education about this particular disease that isn't common to diabetes congestive heart failure and other chronic illnesses are there changes that we need to make to the ryan white program to accommodate this training that we're going to have to be providing to the next generation of providers and so through the testimony that i provided earlier and mentioning the increased funding amount that we support for the education training centers is a strategy to ensure that providers have that that necessary so it's really more funding not not necessarily types of training but we also have resources that are made available through projects of national significance to look at new health care with health care needs without special population ok just one last area i want to talk about and that's food nutrition because as you know those are critical components for the survival of people living with hiv aids and we have a wonderful wonderful program in denver project angel heart focuses on nutrition for folks with hiv it can reduce the side effects of retroviral medications make them easier to tolerate  and also a lot of these medications don't work if you don't take them with so i'm wondering if you can discuss hearses recent guidance on food and  nutrition and while you're looking for the guidance i'm wondering if you have recommendations for food nutrition services under parts of the ryan white program so in terms of nutrition services we have a definition of that fall under that definition fall within that category we also have a set of services that fall into a category referred to as support services and i'm talking about medical nutrition therapy and the core medical services category in that medical nutrition therapy and that circumstance is provided by a licensed registered dietitian outside of a primary care visit the provision of nutritional services nutritional supplements may be provided pursuant to a physician's recommendation and then with a nutritional plan developed by a licensed registered dietitian nutritional services that are not provided by our license registered dietitian are considered of support service nutritional services that are supplements that are not provided pursuant to a physician's recommendation again linked to a nutritional plan developed by th support services category thank you thank you very much mr chairman thank you and thank you for your for your testimony and we may have some additional questions that  members will send for the i know mr burgess mentioned in particular but we'll get those to you fairly quickly so you can respond but thank you very much appreciate it and then i'd ask the second panel to come forward thank you for being with us today let me introduce each of you the second panel on my left to right the first is marcia cross dr marcia cross who's a health care director for the u s government accounting office  second is miss julie schofield who is executive director of the national alliance of state and territorial aids directors and third is donna lane suite dr sweet i should say who is a professor at the department of internal medicine at the university of kentucky need kentucky school of medicine and board chair of the american academy of h i b medicine we try to ask you to limit your remarks to five minutes of course you can always submit your statement for the record and after you're done we'll take some questions from the members and i'll start on my left with dr cross i hope i'm pronouncing it correctly minority aids initiative or grants as we've heard separate supplemental grant to address disparities for minorities in access to treatment and health outcomes three other parts of the program provide last reauthorized in two thousand congress made a number of changes in the structure and funding requirements of the program with the goals of better targeting funding to areas of need and increasing the proportion of funding going to direct service delivery for example congress changed the process by which award grants under part from a formula based soley on demographics to a competitive process to better target funding grant reported that not all of their party administrative expenses were covered by the ten percent allowance and they were for money from their organizations general operating budget or other sources to cover their actual costs in addition services however it remains to be seen whether the move to a competitive process or the part d administrative it will meet the goals of better targeting funding to areas increasing the proportion of funding going to direct service delivery moving forward mr chairman complete my prepared remarks i'd be happy to respond to any questions you or other members of the subcommittee  assistance program funds each year to provide comprehensive care and treatment for individuals living in their jurisdiction along with aids action co chairs the ryan white work group an affiliated work group of the federal aids policy partnership the ryan white work group is a coalition of national local and community based service providers and hiv aids organizations the work group developed the community center consensus document which currently has over three hundred signatures from forty seven states and puerto rico there is an exceptional level of cohesiveness in the community around the path for extending ryan white program and a growing call for action by the september thirtieth deadline i'm submitting the community consensus document for the hearing record the community is extremely pleased to see that the draft legislation closely follows the community consensus document and even more pleased with the leadership being demonstrated by the committee to act quickly in the community support of three year extension of ryan white that essentially restart the clock and continues many important provisions for grant these include the continuation of protections and penalties for states with maturing namespace hiv reporting system hold harmless protection along with the extension of protection for transitional dollars ninety nine as a result in the last ten years my clinic patient load has doubled and yet my funding has remained the same to supplement our dollars we often do things like annual bake sales and other things that the community does become a highly manageable disease with proper care and treatment in the mid ninety's mortality rates plummeted with many medicines and treatments that allowed better ways of fighting the virus patients are living longer which brings about medical challenges  school on nine twenty five states and three territories were held harmless for base funding or a d a p funds or both and hold harmless is specifically intended to make sure that states don't face precipitous decline in funding that would destabilize systems and services can you tell us more about why the community consensus including groups from states with both older and newer epidemics the extensions of the whole protection well i think planning grants and capacity development grants this year part c was appropriated two hundred and one point nine million dollars which is only a one point five six percent increase over fiscal year two a way i do agree that this one point five six increase simply inadequate and what has been the impact of limited funding in on your clinic and other parts providers well thank you it's certainly been inadequate grant applications but we're able to fund a very very few and this doctor who are back here supporting dr wakefield i've known for many years and i know that they are also concerned about the fact that they have many many people demonstrating need like my clinics but the money that was available for expansion grants was simply not enough to give almost anybody what they needed so yes we need more and i think it's interesting the such necessary was a part of the last  authorization but as i have read the bills prior to that starting in one nine hundred ninety there were never any money put in a specified amount but always such as until the last time so whatever has been in it is inadequate and i think what we need is across the board for all of our programs what it's done for my clinic is simply made me truly the seventy five twenty five doesn't mean much to me because i spend ninety five per cent on medical care between the laboratory studies for cancer viral types that i need to do to do quality medical care i have simply had to cut out all of the other niceties other than case management transportation food services things like that individual fund raising philanthropic things in the community because there's just not enough money in the grant to do the medical care ok i appreciate that those are good examples for the next three years basically the length of the extension of the draft can you elaborate on this recommendation why does the community feel it's important to ensure continued funding for these re meetings and phone calls have been i mean when you put three hundred voices on a phone call it a call that i think the fact that there has been a consensus is something we should all be proud of because we have work to make it a consensus the last question is more services that i would like to have in order to do the medical care so that's all about the money if i have enough money then seventy five twenty five would be an issue and i would love to be able to go back to the days when i was able to offer we submit those to the committee clerk within ten days or so and you'd be notified you know when those come through but again i want to thank you all i know there were a lot of members here for the last hour but the questions are good and the answers were