Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

THE RYAN WHITE CARE ACT: 

H 1992TITLE 1AND TITLE II EXPENDITURES 

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JUNE GIBBS BROWN 

Inspector General 

APRIL1994 

05-93-00331 
OFFICE OF INSPE~OR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the inte@y of the Department of Health and Human Semites’ (HHS) 

programs as well as the health and welfare of beneficiaries send by those programs. This 

statutory mission is carried out through a nationwide network of audita, investigations, and 

inspections conducted by three OIG operating components: the Offke of Audit Services, the 

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

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIGS Office of Audit Semkes (OAS) provides all auditing semices for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGA~ONS 

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


investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of


unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions,


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


control units which investigate and prosecute fraud and patient abuse in the Medicaid program.


OFFICE OF EVALUATION AND INSPECI’IONS 

The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and


program evaluations (called inspections) that focus on issues of concern to the Department,


the Congress, and the public. The findings and recommendations contained in these inspection


reports generate rapid, accurate, and up-todate information on the efilciency, vulnerability,


and effectiveness of departmental programs.


This report was prepared under the direction of William Moran, the Regional Inspector


General, and Natalie Coen, Deputy Regional lrtspector General, for the Office of Evaluation


and Inspections, Region V. Participating in this project were the following people:


Retrion V Headquarters


Barbara But~ Project Leader Alan S. Levine


Jean Dufresne


Ellen Meara


Heather Robertson


For a copy of this report, please call (312) 3534124,

Department of Health and Human Services 

OFFICE OF


INSPECTOR GENERAL 

THE RYAN WHITE CARE ACT:


~ 1992 TITLE I AND TITLE II EXPENDITURES 

$SQWC4


@ “% **4 

JUNE GIBBS BROWN 

E 

3 Inspector General 

s 

c APRIL1994 

4 

‘%%aza 05-93-00331 
TABLE OF CONTENTS


PAGE 

~ODU~ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


Combined Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


Title IExpwditures... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8


Title II Expenditures . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13


CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19


APPENDICES


ASurnmary Chart of Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1


B: Title II Expenditures by Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

INTRODUCTION


PURPOSE


To describe grantee expenditures in Fiscal Year 1992 for Title I and Title II of the


Ryan White Act.


BACKGROUND


On August 18, 1990 Congress passed Public Law 101-381 entitled The Ryan White


Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (the Act). The Act


was created as a comprehensive response to the Human Immunodeficiency Virus


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


Its purpose was to provide “emergency assistance to localities ... disproportionately


affected by the Human Irnmunodeficiency Virus epidemic and to make financial


assistance available to States and other public or private nonprofit entities to provide


for the development, organization, coordination and operation of more effective and


cost efficient systems for the delivexy of essential semices to individuals and families


with HIV disease”.


Congress funded the Ryan White Act at $221 million for Fiscal Year (FY) 1991, $276


million for FY 1992, $338 million for FY 1993, and $579.4 million for FY 1994. The


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


Service administers the Act.


Four titles direct resources to various entities, allowing maximum flexibility to


grantees, particularly at the local level, in the use of funds. The first two titles, which


are the subject of this repor$ constitute 88 percent of Ryan White funding for FY


1994.


Title ~ funded at $325.5 million for FY 1994, comprises 56 percent of Ryan White


funding. This title provides emergency relief grants to eligible metropolitan areas


(EMAs) for HIV-related outpatient and ambulatory health and support semices,


including case management and comprehensive treatment sexvices. Public or


nonprofit private “organizations are eligible for funding to provide services on a


contract basis with the EMA.


Half of the funds are distributed to EMAs through formula grants and half through


competitive supplemental grants. In FY 1992, the year addressed in this report, 18


EMAs received about $120 million (formula and supplemental fimds combined).


Title ~ funded at $183.9 million for FY 1994, comprises 32 percent of Ryan White


funding. This title provides formula grants to States and territories to improve the


quality, availability and organization of health care and support services for individuals


1 
and families with HIV disease. States receive a minimum of $100,000. 

In FY 1992, the year addressed in this report, HRSA awarded 54 formula grants to 

States and territories totaling $99 million. States have the option of using Title II 

funds in one or more of the following ways. 

�	 They may establish HIV care consortia within areas most affected by HIV 

disease, to provide a comprehensive continuum of care. Consortia must: 

consist of public and nonprofit private, health care and support semice 

providers, and community based organizations; assist in the planning, 

development, and delivery of comprehensive outpatient health and support 

services; conduct a needs assessment; and create a mechanism to periodically 

evaluate their major duties. States that report 1 percent or more of all 

AIDS cases reported to CDC nationally must use 50 percent of their funds 

to operate consortia. 

�	 They may provide home and community-based care services, including 

outreach services to individuals in rural areas. 

�	 They may provide treatments (medications) that prolong life or prevent 

serious deterioration of health. 

�	 They may provide assistance to assure the continuity of health insurance 

coverage. 

SCOPE AND METHODOLOGY 

The Ryan White CARE Act will come up for reauthorization for FY 1996. This study 

is one in a series on the implementation of the Act meant to provide information 

useful for the debate surrounding reauthorization. The other reports in the series are: 

Funding Formulas (OEI-05-93-O0330); Special Projects of National Significance (OEI05-93-00332); Consortia Activities (OEI-05-93-O0333). Our report entitled “The Ryan 

White CARE Act: Technical Report” (OEI-05-93-00334) is a companion to this report. 

This report is a descriptive analysis of Title I and Title II expenditures for FY 1992. 

Our study was not an evaluation of the Ryan White program or any individual grantee. 

We did not ask for explanations from grantees of why funds were spent as they were, 

or obtain any description of the semices provided, including their quality or 

effectiveness. 

We examined how expenditures were distributed, nationally and by grantee, across 

several broad categories. Our analysis is based on data presented by grantees in yearend reports. We used the data as presented and did not attempt to veri~ its accuracy. 

For Title I, HRSA extracted, and then gave us for our analysis, expenditure data from 

year-end reports submitted by most of the grantees. We also examined a few Title I 

2 
year-end reports ourselves and contacted two grantees about incomplete or unclear 

information. For Title II, we reviewed year-end reports from grantees and 

subsequently contacted each of them about missing or unclear information. 

This inspection was conducted in accordance with the Standards for Impactions issued 

by the President’s Council on Integrity and Efficiency. 

3

FINDINGS


INTRODUCI’ION


This report describes Ryan White Fiscal Year 1992 expenditures by semice for Titles 1


and II.


Grantees are required in the law to report aggregate expenditures for each sewice.


However, in the process of gathering data for this report, we encountered a number of


problems affecting the reliability of the data as reported, problems of which readers


should be aware.


First, we found that Title II data, especially, was often incomplete or unclear, Some


grantees reported award amounts exceeding the amounts reported by HRSA, in some


cases the difference was due to FY 1991 carryover that a grantee had not reported 10


HRSA as of summer and early fall of 1993, when we gathered our data. As for


expenditures, grantees with consortia, especially, often said it was difficult to break


expenditures down by service. Some were dealing with a number of consortia and


lacked a standard reporting format. Others said that consortia reported inforrnat ion


with vmying degrees of detail or in different formats. Many grantees submitted two or


more versions of expenditures in an attempt to reconcile their figures.


Secondly, we also know, both from comments in the reports themselves and


discussions with grantees, that many grantees, for both titles, provided estimates or


obligated amounts rather than expenditures.


Notwithstanding these problems, we have based our report strictly on the figures as


presented to us by grantees. We consider this to be the best information available on


expenditures, given the time and resources available to us to obtain it. The HRSA has


been piloting and will soon implement a new data collection system for grantees.


They expect the new system to provide more detailed, timely, and accurate


information.


For purposes of analysis, we divided expenditures into four broad categories: medical


semi- pharmaceutical@ support servi~ and administration. Both the medical


sexvices and support services categories are comprised of a number of individual


semices which we ident~ in the narrative of the report. We discuss pharmaceut ica Is


immediately following medical semices, since they are directly related to the provision


of health care.


We first examine Title I and Title II expenditures combined, follow with separate 

sections describing expenditures for each title, and conclude with a brief summary 

comparison of expenditures by both titles. Throughout, we compare expenditures 

both across and within the four broad categories. We also highlight the expenditures 

of the grantees that accounted for the largest proportion of expenditures for each tit It. 
COMBINED TITI.EIAND TITLE II EXl?ENDITURES 

Me&a/ servic~ and support services each accounted for about 35 percent of combined 

*h, phm=hah for20per=n4 and a&nb&rntiofi about 10percent 

Collectively Title I and Title II grantees reported spending $210,603,992. This is 93 

percent of the FY 1992 grant awards for the two programs, combined, which HRSA 

provided to us as we collected and analyzed the data for this study in the summer and 

fall of 1993.1 

Figure 1 shows the breakdown of FY 1992 expenditures by category for both titles 

combined. Appendix A provides a comprehensive breakdown of expenditures, by 

major category and by semice, for both titles separately and combined. 

Combined Ryan White Expenditures - IT 1992 

HgU#l 

MfwPlan&Eval (11 

1 Grant awards are adjusted by HRS~ however, throughout the program year baaed on financialstatus 

reports submitted by grantee& Hence the tlnal grant award amounts for FY 1992 reported by HRSA may differ to 

some extent from the figures in this report. 

5 
Medical Services: $67.1 Million 

Medical semices constituted about a third of combined expenditures. In this category 

we placed services related to the direct provision of health care.2 Table 1 shows the 

services in this category. 

Almost half (46 percent) of medical semice expenditures went for primary medics) 

care. Following were home health semices (15 percent), mentai health (14 percent), 

and substance abuse setices (12 percent). The other six sefices collectively 

accounted for the remaining 13 percent of medical sexvice expenditures. 

Pharmaceuticals: $45.3 Million 

Twenty-two percent of expenditures went for pharmaceuticals. Expenditures under 

the We IIprovision of treatments option ($32 million) were 71 percent of all 

pharmaceutical expenditures. Title I expenditures for pharmaceuticals ($11 million) 

were 24 percent of this categoxy. The remaining $2 million was spent under the Tide 

II consortia and home- and community-based care options. 

&ID13ort Services: $75.6 Million 

Support services were 36 percent of combined expenditures, slightly more than the 

proportion spent for medical semices. In this category we included case management, 

services listed as support services in HRSA application guidances, insurance 

continuation, and a few other semices listed by grantees. See Table 1 for a list of the 

services in this category. 

Case management accounted for the largest proportion (42 percent) of support service 

expenditures. Houszkg assistance, at 13 percent, was the second largest; $8 million of 

this $10 million was spent under Title I. About $2 million was spent under the Title 11 

health insurance continuation option, amounting to 3 percent of all support semice 

expenditures. 

Administration: $22.3 Million 

Costs for administration were about 11 percent of combined expenditures. We include 

in this category expenditures for admiruktrative costs and planning and evaluation. 

Also, we include expenditures reported both at the grantee level (State or city) and at 

the Title I planning council and Title II subcontractor levels (consortia and home- and 

community-based care options). 

2 For th~ reaaon, we placed case management in the “support setices” category. 

6 
The Act defines adminktrative costs as expenditures for administration, accounting, 

reporting, and program oversight and, for both Titles, requires that grantees spend no 

more than 5 percent of their grants for administrative costs. However, in September, 

1993, HRSA’S Office of the General Counsel issued a legal opinion stating that this 

cap applies only to a city or State as Ryan White Act grantee and “not to the 

individual service providers who will be the ultimate recipients of the grant funds.” 

Hence additional administrative expenditures are allowed pertaining to the Title I 

planning councils and Title II subcontractors. 

Administrative costs were about 8 percent of all FY 1992 expenditures. Grantee costs 

accounted for 5 percent; the remainder went for costs associated with planning 

councils or consortia administration. 

An additional 3 percent went for planning and evaluation expenditures. 

�	 Some Title I grantees reported such expenditures despite the fact that the 

Act makes no mention of allowances for planning and evaluation for Title I. 

We do not know whether these expenditures were made by at the grantee or 

the planning council level. 

�	 For Title 11, almost all planning and evaluation expenditures were reported at 

the State level; a small amount reported under the Title 11consortia or 

home- and community-based care options. 

7

TITI.E I EXPENDH’UR= 

M-services andsuppt services each conduted about 40pem& of lltle I 

qenddum. Mannaceuticalr were IOpemen& and adminkmtiq 9~m 

Information about Title I expenditures is based on reports from 17 of the 18 cities 

funded in FY 1992? Collectively these 17 cities reported spending $112,692,350, 

which is 93 percent of the amount they were awarded, or 88 percent of Title I funds 

awarded (formula and supplemental) to all 18 grantees in FY 1992. 

The three largest grantees - New York City, San Francisco, and Los Angeles - spent 

about $67 million, or 60 percent of all Title I expenditures reported. 

We sometimes refer to Title I grantees in this report as “cities,” and our analysis 

relates strictly to their expenditures of FY 1992 Title I dollars. Figure 2 shows the 

breakdown of Title I expenditures by categoV. Table 1 on the next page shows these 

expenditures broken out by grantee. 

Title I Expenditures - FY 1992 

Medical Saulw6 (43%) 

Mmln/PM &Evd (9%) 

~ (lo% pput se3 Newarkj New Jersey, had not submitted its rqxxt 10 I{RSA at the time we conducted this study. 

8 
Table 1 

GRANTEE4 

WV York city Ny. ” ,.: 

$anF@@sco CA 

Los Angels CA 

Metro Dade Cty 

FL (Miami) 

Harris Cty TX 

(Houston) 

Washington DC 

Chicago XL 

Philadelphia PA 

San Juan PR 

Boston MA 

San Diego CA 

Dallas Cty TX 

Fulton Cty GA 

(Atlanta) 

Broward Cty FL 

(Ft.Lauderdale) 

Hudson Cty NJ 

Oakland CA 

Baltimore MD 

TOTAL “ 

Title I 

Expenditures by Category 

as Percentof all l?qenditures” 

% % % 70 

AWA@ SPENT MED PHARM SUPP ADMIN 

36J90,210 ~45L),mo 33 21 35 11 

21,6Q418 21$62J75 61 I o 31 8 

9,925,225 10,?59,820 50 0 40 11 

6,740,073 6,587,864 34 14 39 14 

6>77,597 5S62300 51 1 46 L? 

5,286,485 3,943343 48 2 45 5 

4,431,632 4>27,152 54 0 37 9 

4,238,608 2>69,502 40 0 49 11 

3,579,982 3,579,983 20 46 19 15 

3369,149 2,940S2 20 0 80 0 

397,916 3054,788 33 0 63 5 

3,203~0 3,1%320 45 1 48 6 

3,148,612 2,899,666 74 1 20 5 

3,097,663 3,058,920 45 20 28 6 

2W,466 2306S81 27 0 68 5 

2J23,466 1,975382 32 0 52 0 

1,898,561 918,072 36 0 64 0 

$121,189,283 $112,69Z350 na na na na 

�May not add to 100 due to rounding, 

4 N~rk not included.


5 As of fall, 1993; formula and supplemental funds combined.


9 
Medical semice expenditures, reported by all grantees, were 43 percent of all Title I 

expenditures. For nine cities, including New York, medical services constituted a third 

to just under half of all expenditures; for five cities, including San Francisco and Los 

tigeles, medical services were half or more of all expenditures. 

& shown in Table 2, 4 of the 10 semices in this category made up the vast majority of 

expenditures, both for all grantees combined and for the three largest grantees. The 

table also shows, however, that between the three largest grantees, the proportion of 

dollars spent for each service varied considerably. 

Table 2 

Title I 

Top Four Medical Services 

as Proportionof All Me&al ServiceExpenditures ($48.7 M) 

Substance :, 16% 23% 22% 1270 

TOTAL 89% 

l?imary medical care expenditures ($23.2 million) were reported by 16 grantees.’ 

Seven grantees spent between 25 and 49 percent of their medical semice dollars on 

this service; seven spent between 50 percent and 97 percent. This semice also 

represented the largest proportion of Title I expenditures, at 21 percent. 

Pharm aceuticals: $10.7 Million 

Nine percent of Title I expenditures was for pharmaceuticals, reported by eight 

grantees. The four top spenders proportionally were San Juan (46 percent), New 

6 W/MeNew York spent proportionately lessthan the other hvo largest granteea on primary medical care, it 

spent one fiRh of all its Title I dollars for pharmaceuticakxin comparison, the two California grantees had no 

pharmaceutical expenditures. (See Table 1.) 

7 Just prior to issuingthis report, we learned that San Diego spent $751,850 and Baltimore spent $766,522 on 

primary medical care. Ilwse figures are not included in the report. 

10 
York City (21 percent), Fort Lauderdale (20 percent), and Miami (14 percent). The 

other four cities each spent 2 percent or less on pharmaceuticals. Two of the largest 

grantees, San Francisco and Los Angeles, reported no expenditures for 

pharmaceuticals. 

SurYDortServices: $43.2 Million. 

Support semices expenditures, reported by all grantees, constituted 38 percent of all 

Title I expenditures, ranging from 19 percent (San Juan) to 80 percent (Boston) across 

grantees. Nine grantees, including the three largest, spent between 33 and 49 percent 

on support services. The five grantees with the highest proportion of Title I 

expenditures for support semices (between 52 and 80 percent) all received relatively 

small Title I grants (less than $4 million). (See Table 1.) 

Table 3 shows the five services that constituted the majority of support service


expenditures, for all grantees combined and for the three largest grantees. Unlike the


medical semice category, where four sexvices comprised the bulk of expenditures,


expenditures in this category were much more spread out across services. However, as


with medical setices, the three largest grantees spent considerably different


proportions of dollars on each sexvice.


Grantees spent the highest proportions of support service dollars on case management


($15 million) and housing assistance ($8 million). These two setices comprised one


i5fth of all Title I expenditures. Furthermore, as Table 3 shows, they comprised over


half of all support semice expenditures.


Table 3


Title I 

Top Support Services 

as Proportionof all Support SeMces (S43.2 M) 

Support Service 

Case Management 

r-rousing 

Food .Assistance 

Outreach/Info. & Ref. 

Other counseUnot 

mntl hlth 

TOTAL 

‘ Ml gralttees, N* San Los 

York Francisco Angeles 

:’ 34% 33% 21% 2s% 

19% 18% 35% 31% 

11% 12% 13% 170 

,’ 8%. 13% 3% 1070 

7% 8% o% 14% 

79% 84% 72%8 81%


8 San Francisco spent 10 percent each on advocacyand buddyJcompanionseMces. 

11 
Sixteen grantees reported case management expenditures.g 

�	 Case management accounted for 13 percent of all Title I expenditures, 

ranging across grantees from 7 percent (San Francisco) to 41 percent (Jersey 

City). 

�	 Case management comprised a third of all Title I support sewice 

expenditures, ranging from 17 percent (Boston) to 81 percent (San Juan), 

spread somewhat evenly across grantees. 

Housing assrktance expenditures ($8 million), reported by 13 grantees, comprised 7 

percent of all Title 1 expenditures, ranging from less than 1 percent (San Diego) to 20 

percent (Boston). 

As a proportion of support service dollars, only, housi”ngassistance expenditures ranged 

from under 1 percent (San Diego) to 47 percent (Ft. Lauderdale), with 10 of the 13 

grantees spending under 25 percent of their support service dollars on this service. 

Administration: $9.9 Million 

Expenditures in this category amounted to 9 percent of all Title I expenditures. 

The Act allows Title I grantees to spend up to 5 percent of their grant awards for 

athzinistrative costs, with additional expenditures allowed related to planning councils 

per HRSA’S Office of the General Counsel. The Act does not address expenditures 

for planning and evaluation relative to Title I; however as noted below, some grantees 

reported expenditures of this type in addition to administrative costs. 

�	 Seven percent of expenditures were for administrative costs. Three grantees 

reported no expenditures for administrative costs. Grantee expenditures 

reported by the remaining 14 cities amounted to 6 percent of all Title I 

expenditures. As best we can determine from this self-reported, unaudited 

data, it appears that five grantees exceeded the 5 percent cap. 

�	 Six Title I grantees reported spending a total of $1 million in administrative 

expenditures related to planning councils. 

�	 An additional 2 percent went for planning and evaluation (including needs 

assessment), reported by nine grantees. We do not know whether these 

expenditures were made at the grantee or planning council level. 

9 Just prior to issuing this report, we teamed that San Diego spent $651,393 on case management. This figure 

is not included in the report. 

12 
Mwrmaauticds and supyw?t sdet?s each accounted for about 33pemer@ @all llde 11 . u@m&UWX Medical St7ViC62$W~ 19~~ and a&nin&mtiow 13 percent 

Information on Title II expenditures is based on reports from all 54 State and


territorial grantees. Collectively these grantees reported spending $97,911,642. This is


98 percent of the total Title 11 award amount reported by HRSA. $99,754,335.10


The four largest grantees - California, New York, Texas, and Florida - spent $51


million, or 52 percent of all Title II expenditures.


We sometimes refer to Title II grantees as “States” and our conclusions relate strictly


to their expenditures of N 1992 Title II dollars. Figure 3 shows the breakdown of


Title II expenditures by category. Table 4 on the next page shows these expenditures


broken out by grantee. Appendix B contains tables showing expenditures broken out


by the four major options (as opposed to the four categories, which constitute the


discussion here).


Ttile II Expenditures - FY1992 

R@#u 3 

ptl~ (s5%) 

10 ‘l%egranteea themselvesreported total grant awards cxceedmgHRSA’Sfigure slightly,at $100,205,97S. We 

do not know whether the difference between the figures ISdue 10errors by grantees, carryover not reported to 

HRSA as of the time we collected this data, or somethmg else. 

13 
Title II 

Expenditures by Catego~ 

as Percentof allEqxmditurea* 

% % % % 

GRANTEE AWARD SPENT MED PHARM SUPP ADMIN 

NewYork 17#i93#58 16#59$H3 .14 41 31 1 14 

California I 16&7,%0 wfw69 14 30 41 16 

Florida “’”“ 17 49 24 I 10 

~~’” \ 8s%737 8,W7,832 ’24 36 52 7 

Puerto Rico 5,681,717 4,975,1% 21 46 25 8 

NewJersey 4,711,438 4,688,987 2s 35 23 17 

Georgia 3,201,172 3,155,728 28 37 30 6 

Illinois 2,829J36 3275,301 12 39 30 20 

Pennsylvania 2,536,697 2,702,830 9 42 35 13 

Maryland 2368,486 2~,486 49 4 30 17 

Massachusetts 1,793,707 - 1,837,845 2s 5 52 18 

North Carolina 1,684,757 1,169,266 24 20 53 3 

Louisiana 1,672S04 1,727,415 36 0 54 10 

Ohio 1,423,256 1~76,800 5 42 44 9 

Virginia 1,405,219 1,405,219 23 30 28 19 

Wash.D.C 1J85,438 1334,463 11 27 34 28 

Missouri 1330,774 1,289,726 38 43 12 8 

Washington 1322$95 1,418,902 50 23 12 14 

Michigan 1,213,083 1,213,083 9 11 73 7 

Cf.)nnecticut 999,652 1,068,399 9 34 41 16 

OYorado 838,453 857,391 15 20 49 15 

South Carolina 795,067 782,319 32 56 5 7 

Alabama 790,676 788,423 9 83 3 5 

Tennessee 737,498 737,498 0 99 0 1 

Indiana 728,781 898,781 19 61 0 19 

Arizona 687,616 687,616 26 36 32 5 

14 
% % 70 % 

GIUNTEE 

Oregon


Misaiaaippi


Minnesota


Wisconsin


Kentucky


Arkattaaa


Oklahoma


Nevada


Hawaii


Utah


Kansas


NewMexico


Rhode Island


Delaware


WestVirginia


Iowa


Maine


NewHampahire


Nebraaka


Alaska


Idaho


Montana


North Dakota


AWARD 

658351 

616,440 

602,682 

539,014 

528,039 

497308 

490,547 

443,483 

366,974 

329,083 

274,616 

254,732 

194,400 

173,168 

168383 

164,436 

163,401 

149,133 

117,188 

100,OOO 

100,OOO 

100,OOO 

100,OOO 

South Dakota “ 100,OOO 

Vermont 100,OOO 

Wyoming 100,OOO 

Virgin Islands 28,087 

Guam 4323 

�May not add to 100 due to rounding. 

SPENT 

679,447 

616,440 

320,898 

526,602 

299,009 

497308 

488,209 

443,483 

442,934 

327,846 

270,693 

254,714 

203,048 

173,168 

168383 

164,436 

163,401 

186J56 

90,109 

123,955 

100,OOO 

100,016 

100,OOO 

103,386 

92,405 

100,001 

26,890 

4,618 

MED PHARM SUPP ADMIN 

9 51 32 8 

46 44 0 10 

16 0 61 22 

26 0 48 26 

3 73 23 1 

20 49 15 17 

17 55 14 13 

17 52 20 10 

10 45 36 9 

27 62 11 0 

9 75 10 5 

15 32 44 10 

0 59 32 10 

8 23 63 6 

6 36 50 8 

13 36 38 14 

0 0 100 0 

15 81 1 3 

3 77 14 6 

18 13 54 16 

0 90 0 10 

24 36 21 19 

32 59 0 10 

9 86 0 5 

0 57 0 43 

37 37 16 10 

7 86 0 7 

0 100 0 0 

15

Medical Semites: $18.4 million 

Nineteen percent of Title II expenditures were for medical services. Forty-eight States 

reported medical sexvices expenditures, either under the consortia option (it was 34 

percent of all consortia expenditures) or the home-and cornrnunity-bwed care option 

(87 percent). 

Expenditures for medical services ranged across grantees from 1 percent (Kansas) to 

63 percent (Mississippi) of total expenditures. However most grantees (35 out of 48, 

including the four largest grantees) spent a quarter or less; 21 of the 48, including New 

York and California, spent 15 percent or less. 

As shown in Table 5, four services accounted for 90 percent or more of Title II 

medical semice expenditures, for all grantees combined and for three of the four 

largest grantees. 

Table S 

TitleII 

Top Four MedicalSeMcea 

as Proportion of AUMedical Scmice Eqenditures (S18.3 M) 

?lorida I Texas II 

MedicalCare 

Home Health ‘ 32%? 

Mental Health :“’..“.’79$ 

TOTAL .; ;g~% ,. 

Primary medical care expenditures totalled $8 million. Almost all were reported by 36 

of the 43 States with consortia and this service comprised 15 percent of all consortia 

expenditures. 

Twenty States reported home health care expenditures ($6 million). This service 

comprised 71 percent of all dollars spent under the home- and community-based care 

option, compared with 6 percent of all consortia expenditures. 

11 Texas spent more than the other three grantees on haspice (13 percent) and residential care (15 percent). 

16 
Pharmaceuticals: $34.6 Million 

Thirty-five percent of Title II expenditures went for pharmaceuticals. Expenditures 

ranged across grantees from 4 to 100 percent of total expenditures; for the four largest 

grantees they ranged from 17 percent to 49 percent. 

Forty-seven of the 54 grantees adopted the pharmaceutical option; 3 adopted only this 

option. These 47 grantees collectively spent $32 million on the option - one third of 

all Title II expenditures. For 16 States, all with awards under $1 million, this option 

accounted for half or more of their total expenditures; for 8 of the 16, it accounted for 

70 percent. 

For three of the four largest grantees, pharmaceutical expenditures made up 30 to 50 

percent of all expenditures; for the fourth grantee (Texas), they were 16 percent. 

An additional $2 million on pharmaceuticals under the consortia option was spent by 

slightly over half of the States with consortia. 

SUDDOI-t Services: $32.4 Million 

Support service expenditures were 33 percent of Title II expenditures, considerably 

exceeding the 19 percent for medical semices. Forty-four grantees reported support 

semice expenditures. For 9 States, support services made up 50 to 75 percent of their 

expenditures; for one (Maine) it accounted for 100 percent. For the four largest 

grantees, support services were 25 to 50 percent of total expenditures. 

Most support sedce expenditures were reported under the consortia option, and 

support semices were 58 percent of all consortia expenditures. 

Case management, reported by 36 grantees, was the service that accounted for the 

greatest proportion of support service expenditures. Grantees spent $17 million on 

this service. 

� Case management constituted 54 percent of all Title II support service 

expenditures the 15 other support sexvices were 6 percent or less, each. 

� Proportionately, case management expenditures were not evenly distributed 

across grantees. The four largest grantees collectively spent 57 percent of all 

Title II case management dollars; and each of these grantees spent between 

45 and 66 percent of their support sexvice dollars on this one service. 

� Almost all case management spending was reported under the consortia 

option. Thirty-four of the 43 States with consortia provided case 

management, and this service accounted for a third of all consortia 

expenditures. 

17

Administration: $12.7 Million 

The Act allows Title II grantees to spend up to 5 percent of their grant awards for 

adnzinkrazive costs (administration, accounting, reporting and program oversight 

functions), and up to an additional 5 percent for planning and evak.ztion. According 

to HRSA’S Office of the General Counsel, additional expenditures are allowed for 

subgrantees (that is, under the consortia or the home- and community-based care 

options). 

Administrative expenditures were 13 percent of all Title II expenditures: 8 percent for 

adrninktrative costs and 5 percent for planning and evaluation. 

� State expenditures for administrative costs were 4 percent of Title II 

expenditures. As best we can determine from this self-reported, unaudited 

data, it appears that two grantees exceeded the 5 percent cap. 

Administrative costs reported under the consortia and (to a much lesser 

extent) home- and community-based care options totalled another 4 percent. 

� State expenditures for planning and evaluation also totalled 4 percent. With 

the caveat noted above regarding the quality of the data, we believe that two 

grantees exceeded the 5 percent cap. An additional 1 percent was reported 

for planning and evaluation under the consortia and home- and communitybased care options. 

18

CONCLUSIONS 

Medical Semites 

This category accounted for one third of all expenditures for both titles combined. 

However cities outspent States more than two to one on medical semices. This was 

true for the category as a whole ( 43 percent versus 19 percent, respectively, of all 

expenditures) as well as for most of the individual services in the category (see 

Appendix A), beginning with prima?y medical care. The exception is home healfh care 

(4 percent for cities versus 6 percent for States). 

Pharmaceuticals 

States outspent cities three and a half to one on pharmaceutical expenditures (35 

percent versus 10 percent, respectively, of all expenditures). 

Surmort Semites 

For both cities and States, case management accounted for about 15 percent of all 

expenditures, and this service accounted for the largest proportion of support se mice 

expenditures. However, States spent more of their support semice dollars on this 

sefice than cities (54 percent versus 34 percent); also, cities spent higher proportions 

on all other semices in the category, beginning with housing assistance. 

Administration 

& best as we can determine horn the self-reported, unaudited data on administrate i~’e 

expenditures submitted by grantees, we believe that Title I expenditures overall for 

admz”nkrafive costs slightly exceeded the Congressionally established cap of 5 perce nr. 

although most of the grantees appear not to have exceeded the cap. Title II 

expenditures overall were below the cap, with only two grantees appearing to exceed 

it. 

An additional 3 percent of adminkazive cost expenditures were made by planning 

councils and consortia or home- and community-based care providers. 

Some Title I grantees spent funds for planning and evaluation which amounted to 1 

percent of all FY 1992 expenditures. Title II expenditures remained under the cap. at 

4 percent. 

19

SUMMARY OF RYAN WHITE FY 1992 EXPENDITURES 

BY CATEGORY AND BY SERVICE WITHIN CATEGORY 

TITLE 1,TITLE 11,AND COMBINED 

I TITLE I % OF I TITLE II % OF I COMBINED % OF 

EXPEND. TOTAL I EXPEND. TOTAL I TOTAL TOTAL 

TOTAL EXPENDITURES ~ 112,6S2,350 53.5% I 97,911,642 46.5% I 210,603,992 100.0% 

CATEGORY/Service 

MEDICAL SERVICES 

Medical Care 

Dental Care 

Substance Abuse 

Mental Health 

Home Health 

In-Home Hospice 

Rehab Care 

Residential Care 

Inpatient Personnel 

Dur. Med. Equip. 

PHARMACEUTICALS 

SUPPORT SERVICES 

Case Management 

Housing Asst. 

Food Bank/Home Meals 

Outrch/info & Ref. 

Other Counsel. 

“Othef/Not SPOO. 

Client Advocacy 

Day-Respite Care 

Buddy/Companion 

Transpofi 

Volunteer Support 

Emerg. Financial 

Legal Services 

Adopwoster Care 

Educ/Risk Reduc. 

Sign Lang/lnterp, 

Insurance 

ADMINISTRATION 

Admin. costs 

Plan/Eval 

I %OF % I % OF % I % OF


I TITLE I TITLE I OF TITLE II TITLE II OF I COMBINED COMBINE :F


EXPEND. EXPEND. CATEGORY I EXPEND. EXPEND. CATEGORY I TOTAL EXPEND. CATEGORY 

I 48,746,018 43.3% 100.0% I t 8,406,760 18.8% 100.0% I 67,152,778 31 .9% 100.0% 

I 23,229,170 20.6% 47.7% I 7,624,836 8.0% 42.5% I 31,054,006 14.7% 46.2% 

I 2,770,711 2.5% 5.7% I 1,6S7,736 1.7% @.2% I 4,468,447 2.1% 6.7% 

I 8,005,212 7.1% 16.4% I 251,452 0.3% 1.4% I 8,2 S6,664 3.9% 12.3% 

I 7,759,640 6.9% 15.9% 1,329,530 1.4% 7.2% I 9,069,170 4.3% 13.5% 

I 4,253,888 3.8% 8.7% 5,948,S40 6.1% 32.3% I 10,202,528 4.6% 15.2% 

1,013,316 0.9% 2.1% 373,223 0.4% 2.0% 1,386,539 0.7% 2.1% 

/ 968,704 0.s% 2.0% 44,760 0.0% 0.2% 1,034,484 0.5% 1.5% 

I 632,752 0.6% 1.3% 666,324 0.7% 3.6% 1,299,076 0.6% 1.9% 

91,625 0.1% 0.2% 0 0.0% 0.0% 91,625 0.0% 0.1% 

I 0 0.0% 0.0% 270,239 0.3% 1.5% 270,239 0.1% 0.4% 

I 10,745,819 9.5% 100.0% 34,632,562 35.4% 100.0% 45,378,381 21 .5% 100.0% 

I 

I 43,213,238 38.3% 100.0% 32,470,285 33.2% 100.0% 75,663,523 35.9% 100.0% 

14,743,352 13.1% 34.1% 17,355,868 17.7% 53.5% 32,099,220 15.2% 42,4% 

I 8,026,538 7.1% 18.6% 2,077,637 2.1% 6.4% 10,104,175 4.8% 13,4% 

4,786,296 4.2% 11.1% 1,321,785 1.3% 4.1% 6,108,081 2.9% 8.1% 

/ 3,456,689 3.1% 8.0% 768,S56 0.8% 2.4% 4,225,855 2.0% 5.6% 

I 2,827,464 2.5% 6.5% 1,169,980 1.2% 3.7% 4,017,444 1.9% 5.3% 

2,204,441 2.0% 5.1% 2,663,737 2.7% 8.2% 4,874,178 2.3% 6.4% 

I 1,474,046 1.3% 3.4% 676,794 0.7% 2.1% 2,150,640 1.0% 2.8% 

I 1,308,944 1.2% 3.0% 402,365 0.4% 1.2% 1,711,329 0.8% 2.3% 

I 1,185,134 1,1% 2.7% 485,293 0.5% 1.5% 1,670,427 0.8% 2.2% 

I 1,029,559 0.9% 2.4% 1,959,289 2.0% 6.0% 2,988,848 1.4% 3.9% 

808,264 0.7% 1.9% 0.0% 0.0% 808,264 0.4% 1.1% 

/ 526,780 0.5% 1.2% 1,219,946 1.2% 3.8% 1,746,726 0.8% 2.3% 

313,359 0.3% 0.7% 0.0% 0.0% 313,359 0.1% 0.4% 

I 256,205 0.2% 0.6% 3Q,050 0.0% 0.1% 295,255 0.1% 0,4% 

I 174,330 0.2% 0.4% 160,248 0.2% 0.5% 334,578 0.2% 0.4% 

I 9f,627 0.1% 0.2% 12,000 0.0% o.o% 103,627 0.0% 0.1% 

I o 0.0% 0.0% 2,131,317 2.2% 6.6% 2,131,317 1.0% 2.8% 

I 

I 9,987,275 8.9% 100.0% 12,402,035 12.7% 100.0% I 22,369,310 10,6% 100.0% 

I 7,738,368 6.9% 77.5% 8,037,122 8.2% 64.8% I 15,775,490 7.5% 70.5% 

2,248,907 2.0% 22.5% 4,364,913 4.5% 35.2% I 6,613,820 3.1% 29.5% 

I I 

A-1

APPENDIX B


TITLE II EXPENDH’URES, BY OPTION 

This appendix presents a number of tables that portray Title II expenditures by option. 

The four options are: consortia, treatment (pharmaceuticals), home- and communitybased care, and insurance continuation. 

B-1

Table 8 Grantee Expenditures by Option 

as Proportion of Toted Expenditures 

State I Pharma- I Home& Comm. 

State Expenditures Consotia % ceuticals %1 Based Care % Insuranoe % 

I I 

AK 123,955 121,737 98% o o% ] o o% I o o% 

AL 766,423 54,888 7% 554,682 70% I 141,111 18% I 0 o% 

AR 497,308 460,713 93% o 0%1 o o% I 0 o% 

AZ 687,616 464,227 70% 164,544 27% I o o% I 0 o% 

CA 15,862,488 7,607,254 48% 4,594,012 29% 917,295 6% I 600,000 4% 

co 857,391 552,630 64% 174,662 20% 84,502 6% 0 o% 

CT 1,068,399 597,171 56% I 364,388 34% o o% 0 o% 

DC 1,334,463 664,970 51% I 366,054 27% 170,116 13% 0 o% 

DE 173,188 53,800 31% I 40,000 23% 25,000 14% 49,200 26% 

FL 10,754,102 5,633,059 54% I 4,455,121 41% o o% 0 o% 

GA 3,155,728 1,482,554 47% I 1,164,025 37% 45,000 1% 337,056 11% 

GU 4,878 0 o% I 4,618 100 o o% 0 o% 

HI 442,934 f75,864 40% I 192,060 43% o o% I 75,000 17% 

1A 164,438 00,000 55% I 58,071 35% o o% I 0 o% 

ID 100%000 0 o% I 90,000 90% o o% I 0 o% 

IL 3,275,301 1,860,633 57% I 1,273,875 39% o o% I 0 o% 

IN 8Q8,781 308,194 34% I 551,945 61% o o% I 0 o% 

KS 270,883 0 o% ! 203,S14 75% 25,532 9% 27,713 1o% 

KY 299,008 0 o% I 212,715 71% 14,016 5% 6e,646 23% 

u 1,727,415 1,124,648 65% I o o% 423,258 25% 12,857 1% 

MA 1,537,645 1,195,000 65% I 73,080 4% 386,000 21% 0 o% 

MD 2,388,488 1,828,532 77% I 100,000 4% 237,252 10% 0 o% 

ME 163,401 163,401 100 I o o% o o% 0 o% 

Ml 1,213,06S 012,929 75% 129,500 11% 90,000 7% 0 o% 

MN 320,888 199,3e9 62% o o% o o% 79,763 25% 

MO 1,288,726 636,442 49% 648,181 43% o o% 1 0 o% 

MS 616,440 0 o% 272,637 44% 264,645 46% I 0 o% 

MT 100,016 57,970 S8% 30,63s 31% o 0%1 4,286 4% 

NC 1,189,266 947,422 81% 221,644 19% o o% I 0 o% 

ND 100,000 90,000 00% o o% o o% 1 0 o% 

NE 90,108 15,592 17% 89,297 77% 900 1% 1 0 o% 

NH 186,356 0 o% 150,393 81% 29,564 18% I 0 o% 

NJ 4,686,987 2,407,708 51% 1,613,087 34% 205,602 4% 1 0 o% 

NM 254,714 63,000 25% 81,214 32% 38,000 15% I 50,000 20% 

NV 443,463 0 o% 232,000 52% 165,230 37% I 0 o% 

NY 18,269,813 8,179,780 50% 6,608,157 41% o o% I 0 o% 

OH 1,376,800 70S,92S 51% 571,478 42% I o o% 1 0 o% 

OK 488,208 160,000 33% 241,299 49% I 62,500 13% [ 0 o% 

OR 679,447 280,323 41% 341,680 50% I o o% 1 0 o% 

PA 2,702,630 1,495,888 55% 1,136,075 42% I 20,516 1% 1 0 o% 

PR 4,975,198 2,640,859 57% 1,e25,497 39% I 0 o% I 0 o% 

RI 203,048 0 o% 119,700 59% I o o% I 64,000 32% 

Sc 782,319 297,252 38% 368,404 47% I 60,000 8% 0 o% 

SD 103,386 u o% 88,87e 64% I 32,507 31% 0 o% 

TN 737,498 o o% 729,007 99% I o o% 0 o% 

TX 8,197,532 5,650,886 8s% 1,200,000 15% I o o% 757,422 9% 

UT 327,546 99,067 30% 202,719 62% I 26,060 8% 0 o% 

VA 1,405,219 871,219 62% 400,000 28% I o o% 0 o% 

VI 26,680 0 o% 22,680 66% I 2,000 7% 0 o% 

v-r 92,405 30,000 32% 52,405 57% I o o% 0 o% 

WA 1,418,902 712,451 50% 329,173 23% I 272,566 19% I 0 o% 

WI 526,602 460,878 91% o o% I o o% 1 0 o% 

w 188,363 10S,016 65% 50,000 30% I 0 o% 1 0 o% 

WY 100,001 48.577 49% 37,249 37% I 0 o% 1 4,175 4% 

I 

TOTAL 97,911,642 51,970,653 53% , 32,410,740 32% I 3,729,376 4% I 2,131,317 2% 

“ This table doea not show adminislMmn, u evaluatirm md planning expendwree 8tTCludedm told State expmditurea. 

B-2

Table 9 

Expenditures by Option 

All Grantees (N=54) 

Option # Grantees 

Providing 

Consortia I 43 

Pharmauxticala I 47 

Home-& Cmun.- 1 2s 

BasedCare


Inauranee I 13


Total All Options I na


Expend.on 

Owion 

$51.9M 

$32.4M 

$3.7M 

$2.1 M 

$90.2M 

Aa % of Total 

Exvend.[$97.9M)” 

53% 

33% 

470 

2% 

92% 

* Including expenditures for administration and ptanningkvaluation. 

Table 10 

Expenditures by Option 

Four Largest Grantees 

as Percent of Each Grantee’s Total Expenditures 

Grantee . Total % GxIsortia % Pharm. % H- 70 Inaur. 

Expend.* CBC 

NewYork I S16.2M 

California ! S15.8 M 

Florida . I $10.7M 

Texaa I $8.1 M 69% 115%10%19’% 

* Including expenditures for admuustratmrt and planningkvaluation. 

B-3

‘I?mbk11 

Percent of Title 11Expenditures


Spent byFour LargestGranteesvs All Other Grantees


@Option


Option Expend. % Largest Grantee3 % Other 

(N=4) Grantees (N=50) 

All Options combmed 47% 

Consortia ~ $51.9 M ~ 53% 47% ~ 

Pharmaceuticals I $324 M I 52% i 48% 

Home- & Community- $3.7 M 25% 75% 

Based Care 

InmramxContinuation[ $21 M I 64% [ 36% 

B-4