Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

THE RYAN WHITE CARE ACT: 

LOCAL IMPLEMENTATION ISSUES 
OFFICE OF INSPE(XOR GENERAL 

The missionof the Office of Inspector General (OIG), as mandatedby Public Law 95-452, as 

amended, is to protect the integrityof the Department of Health and Human Services’ (HHS) 

programsas well as the health andwelfare of beneficiariesserved by those programs. This 

statutorymissionis carriedout througha nationwidenetwork of audits,investigations,and 

inspectionsconducted by three OIG operating components: the Office of Audit Services,the 

Office of Investigations,and the Office of Evaluationand Inspections. The OIG also informs 

the Secretaryof HHS of program and managementproblems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIGS Office of Audit Services (OAS) provides all auditingservicesfor HHS, either by 

conducting auditswith its own audit resources or by overseeing auditwork done by others. 

Audits examine the performance of HHS programsand/or its granteesand contractorsin 

carryingout their respective responsibilitiesand are intended to provide independent 

assessmentsof HHS programsand operations in order to reduce waste, abuse, and 

mismanagementand to promote economy and efficiency throughoutthe Department. 

OFFICE OF INVESTIGA~ONS 

The OIGS Office of Investigations(01) conducts criminal,civil, and administrative 

investigationsof allegationsof wrongdoing in HHS programsor to HHS beneficiariesand of 

unjustenrichmentby providers. The investigativeefforts of 01 lead to criminalconvictions, 

administrativesanctions,or civil money penalties. The 01 also oversees State Medicaid fraud 

control unitswhich investigateand prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’S Office of Evaluationand Inspections (OEI) conducts short-termmanagementand 

programevaluations(called inspections)thatfocus on issuesof concern to the Department, 

the Congress, and the public. The findingsand recommendationscontained in these inspection 

reports generate rapid, accurate,and up-to-date informationon the efficiency,vulnerability, 

and effectiveness of departmentalprograms. 

This report was prepared under the directionof WilliamC. Moran, Regional Inspector 

General, and Natalie Coen, Deputy Regional Inspector General, Office of Evaluationand 

Inspections,Region V. Participatingin thisproject were:


REGION V


Joseph L. Penkrot (Project Leader)


Ellen R. Meara


BarbaraButz


WilliamMoran


For a copy of this report, please call (312) 353-4124.


REGION II 

Lucille Cop 

HEADQUARTERS 

Alan S. Levine 
Department of Health and Human Services 

OFFICE OF


INSPECTOR GENERAL


THE RYAN WHITE CARE ACT:


LOCAL IMPLEMENTATION ISSUES 

SERVICE$


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~’ JUNE GIBBS BROWN 

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Inspector General

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EXECUTIVE SUMMARY


PURPOSE 

To describe local implementation issues facing Ryan White grantees. 

ReauthcnizationStudies 

The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (the Act) 

expires in 1995 and its first reauthorization is pending before Congress. We have 

previously examined the Act’s funding formulas, reviewed data on expenditures, and 

analyzed consortia activities and special projects of national significance. In addition, 

we studied current Centers for Disease Control and Prevention statistics and other 

reports describing the spread of the disease, 

In this current report, we utilize data both from our previous reports and from more 

current field work in developing our findings and recommendations. The more recent 

field work occurred in seven major cities that comprise 43 percent of the 1994 Title I 

Ryan White funding. As a part of our visits to those cities, we reviewed funding and 

service plans along with progress reports; listened to issues discussed and 

deliberations held at planning council and committee meetings; visited and observed 

on-going operations at a wide variety of local providers who receive funding from a 

variety of sources including Ryan White; examined minutes of meetings and other 

material collected on site; and held discussions with a range of respondents including 

public health officials, grantee administrators, local providers, and persons with 

HIV/AIDS. 

BACKGROUND 

The Act was created as a comprehensive response to the HIV epidemic and its impact 

on individuals, families, communities, cities, and States. The Act was designed to 

provide health care to those who would otherwise not have access to health care. It 

was also meant to provide emergency relief funding to communities with the highest 

number of reported AIDS cases. 

The Health Resources and Services Administration (HRSA) within the Public Health 

Service administers the Act. In fiscal year 1994, grantees received $579.4 million in 

Ryan White funds from the funded provisions of the Act. 

i 
FINDINGS 

ErnagingHWL41DSpopulationspresentservicedeliveqproblem for Ryan U%ite 

grantetn 

HIV/AIDS is increasing among minorities, women, immigrants, young people, and 

those who do not speak English. In all likelihood, the number of those infected in the 

emerging HIV/AIDS populations is greatly underestimated. In minority, immigrant, 

and non-English speaking communities, cultural mores often discourage those who 

might be infected with HIV/AIDS from being tested or seeking treatment. The 

emerging populations affected by HIV/AIDS are difficult to serve because of their 

many needs and often their overwhelming poverty further complicates their treatment. 

In addition to living with HIV/AIDS, they may also suffer from substance abuse or 

addiction, hopelessness, mental illness, or other conditions requiring considerable care. 

In spiteof Mom by grantees,many respondentsbelievethatRyan Whiteprogramsdo not 

serveminoritiesand otheremeq$ngpopulationsas wellas theyshould 

In each city visited, respondents spoke of the gaps in services or lack of facilities for 

these populations. Many also pointed to the lack of cultural, language, or gender 

appropriate programs. In some cities, services for emerging populations exist, but 

geography and/or lack of transportation make them difficult to access. 

Littleprogramoutcome evaluationhas been undertakenat the nutionalor locallevelk 

While individual success stories in problem areas can be identified in each community 

we visited, little program outcome evaluation has been undertaken that measures 

whether the Act is accomplishing its overall goals. Client satisfaction surveys are 

relatively widespread among providers at the local level, but these surveys are limited 

to an assessment of an individual provider’s services rather than a comprehensive 

evaluation of the Ryan White program in their communities. 

RECOMMENDATIONS 

llaeHW shouldworkwithRyan Whitegranteesto identifiand disseminatewaysto 

serve the emergingpopulationsaffectedby HW/!S 

Thel%blic HealthServiceshoulddeveihppracticalwaysto determinewhetherRyan 

Whiteprogramgoak arebeingaccomplkhedoveralland by individualgrantees 

ii 
AGENCY COMMENTS 

We received comments from the Assistant Secretary for Planning and Evaluation, and 

the Assistant Secretary for Health. Both support the recommendations and suggested 

pertinent clarifications. Their comments are included in Appendices A and B 

respectively. We made appropriate revisions to the report based on their comments. 

... 

111 
�

TABLE OF CONTENTS


PAGE


EXECUTIVE SUMMARY


INTRODUCITON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1


FINDINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


.Facing servked elivery problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


.Difficulties servingnewHIv/~Ds populations . . . . . . . . . . . . . . . . . . . . . . . . . . 7


Evaluating the Ryan White program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,8


RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11


AGENCY COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...12


APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. A-l


APPENDIX B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B-l

INTRODUCTION


PURPOSE 

To describe local implementation issues facing Ryan White grantees. 

Reauthokation Stu&s 

The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (the Act) 

expires in 1995 and its first reauthorization is pending before Congress. We have 

previously examined the Act’s funding formulas, reviewed data on expenditures, and 

analyzed consortia activities and special projects of national significance. In addition, 

we studied current Centers for Disease Control and Prevention statistics and other 

reports describing the spread of the disease. 

In this current report, we supplement previously acquired data with observations and 

discussions at the local level. These included our attending planning council and 

committee meetings; visiting local project sites and providers; holding discussions with 

grantee administrators, project staff, providers, and persons with HIV/AIDSl; and 

reviewing funding and service plans, and progress reports. 

This study is complemented by another report, Eramplesof Local Coordination (OEI05-93-00335) that describes experiences of Ryan White grantees. The previous Ryan 

White CARE Act reports are: Funding Fomwlas (OEI-05-93-00330); FY 1992 ~“tle I 

and Title 11 Expendinues (OEI-05-93-00331); Consom”a Activities (OEI-05-93-O0333); 

FY 1992 Special Projects of National Significance - Expenditures by Service (OEI-05-93-

00332); and, Technical Repoti of 1992 Expenditures (OEI-05-93-O0334). The General 

Accounting Office (GAO) recently released a report describing the extent to which 

Ryan White services are provided to minorities, women, and substance abusers. While 

GAO did not examine the barriers to providing Ryan White semices to these emerging 

HIV/AIDS populations, their findings dovetail with this report regarding grantees’ 

limitations in treating these populations. 

BACKGROUND 

In response to over 128,000 cases of AIDS reported to the Centers for Disease 

Contr~l and Prevention (CDC), the 78,000 AI’DS deaths, and the nearly one million 

infected with HIV, Congress passed The Ryan White Comprehensive AIDS Resources 

Emergency Act of 1990. The Act was created as a comprehensive response to the 

1 Since the l@an White Act enables grantees to deliver a wide range of services to people alagnosed with either HIV or AIDS, 

thi.$report uses the term “HIV/AIDY to refer to either or both groups of @an White clienti. 

1 
HIV epidemic and its impact on individuals, families, communities, cities, and States. 

The Act was designed to provide health care to persons with HIV/AIDS who would 

otherwise not have access to health care. It was also meant to provide emergency 

relief funding to communities with the highest number of reported AIDS cases. 

Congress attempted to meet a number of needs with the Act. They attempted to 

address the needs of urban areas hit hardest by the epidemic, and to assist smaller 

cities and rural areas experiencing rapid rates of growth. They also intended to 

confront emerging problems facing local public and private organizations. 

As a result, the Act is multifaceted, with four titles directing resources to various 

entities and allowing grantees maximum flexibility in the use of funds, particularly at 

the local level. The Federal role is minimized in favor of State and local control. The 

Health Resources and Services Administration (HRSA) within the Public Health 

Service administers the Act. In fiscal year (FY) 1994, grantees received $579.4 million 

in Ryan White funds. 

Title I - Grants to Cities 

Title I provides emergency relief grants to eligible metropolitan areas (EMAs) 

disproportionately affected by the HIV epidemic. Congress intended these funds to 

relieve the overwhelming burden that HIV imposed on urban health care systems. 

Grants are for HIV-related outpatient and ambulatory health and support services, 

including case management and comprehensive treatment services. Title I funds 

comprise 56 percent of the FY 1994 Ryan White appropriation. 

Grants are awarded to cities, specifically to the chief elected official (CEO) that 

administers the public agency providing outpatient and ambulatory services to the 

greatest number of individuals with AIDS, in most cases the public health agency. 

Under Title I, the CEO is required to establish a planning council representing health 

and social service agencies, individuals with AIDS, State government, community 

leaders, AIDS organizations, and others. This planning council is responsible for: (1) 

establishing priorities for the allocation of funds, (2) developing a comprehensive plan 

for the organization and delivery of services, and (3) assessing the efficiency of the 

administrative mechanism in rapidly allocating the funds to areas of greatest need 

within the EMA. 

Public or non-profit private organizations are eligible for funding to provide services 

on a contract basis with the EMA. These organizations include hospitals, communitybased organizations, hospices, ambulatory care facilities, community, homeless and 

migrant health centers. 

L 
Title II- Grants to States 

Title II provides grants to States and territories to improve the quality, availability and 

organization of health care and support services for individuals and families with HIV 

disease. A major intent of Title II was to develop service delivery systems to provide 

essential services throughout the complex course of HIV disease. Title II funds 

comprise 32 percent of the FY 1994 Ryan White appropriation. 

States have the option of using Title II funds in one or more of the following ways. 

They may establish HIV care consortia in areas most directly affected by the disease. 

Consortia are community-based, coordinated, continuums of care to which all persons 

with HIV/AIDS would have access. These continuums of care are intended to close 

existing gaps in services, coordinate health and support services, build community 

infrastructure and service networks with an emphasis on integration of expanded 

community resources, and provide continuity of care through case management. 

Other State options for Title 11funds include providing home and community-based 

care services, including outreach services to individuals in rural areas. States may also 

furnish medications that prolong life or prevent serious deterioration of health. In 

addition, they may also provide assistance to assure the continuity of health insurance 

coverage. 

Title III(b) - Grants to Communitv Health Providers 

Title III(b) supports early intemention services on an out-patient basis, including 

counseling, testing, referrals, clinical and diagnostic services, and other therapeutic 

services. It provides competitive grants to private non-profit organizations and public 

migrant, community, and homeless health centers, hemophilia centers, and federallyqualified health centers. Title III(b) funds comprise 8 percent of the FY 1994 Ryan 

White appropriation. 

Title IV - Grants for Pediatric AIDS 

Title IV aims to improve and expand the system of comprehensive care services and 

increase access to research for children, youth, women and families who are infected 

with or affected by HIV/AIDS. Title IV grantees provide, arrange, or coordinate a 

wide range of services. These services include prevention and education activities, 

primary medical care, psychosocial services, substance abuse treatment, housing, child 

welfare, legal advocacy, and other support activities. Comprehensive systems of care 

are linked with clinical research trials and other research activities, intended to 

increase access for a target population of children, youth, women and families. Title 

IV funds comprise 4 percent of the FY 1994 Ryan White appropriation. 

3