United States Government Accountability Office

Washington, DC 20548 

March 6, 2009

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Tom A. Coburn 

United States Senate 

Subject: Ryan White CARE Act: Estimated Effect of Proposed Stop-Loss Provision on Urban 

Areas

You asked us to estimate the effect on Ryan White Comprehensive AIDS Resources 

Emergency Act of 1990 (CARE Act) funding to urban areas if certain stop-loss provisions are 

enacted. The CARE Act, administered by the Department of Health and Human Services’s 

(HHS) Health Resources and Services Administration (HRSA), was enacted to address the 

needs of jurisdictions, health care providers, and people with human immunodeficiency 

virus/acquired immunodeficiency syndrome (HIV/AIDS).1

 In December 2006, the Ryan White 

HIV/AIDS Treatment Modernization Act of 2006 (Modernization Act of 2006) reauthorized 

CARE Act programs for fiscal years 2007 through 2009.2

 In February 2009, the House of

Representatives passed H.R. 1105, the Omnibus Appropriations Act, 2009, which contains a 

stop-loss provision covering CARE Act funding for urban areas that receive funding under the 

CARE Act.3

 This bill has not been passed by the Senate. 

Under the CARE Act, funding for urban areas—Eligible Metropolitan Areas (EMA) and 

Transitional Grant Areas (TGA)4

—is primarily provided through three categories of grants: 

 1

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff through 300ff-121). Unless 

otherwise indicated, references to the CARE Act refer to current law. 

2

Pub. L. No. 109-415, 120 Stat. 2767. The CARE Act programs had previously been reauthorized by the 

Ryan White CARE Act Amendments of 1996 (Pub. L. No. 104-146, 110 Stat. 1346) and the Ryan White 

CARE Act Amendments of 2000 (Pub. L. No. 106-345, 114 Stat. 1319). 

3

H.R. 1105, 111th Cong. (2009). For purposes of this report, unless otherwise specified we use the term 

H.R. 1105 to refer to the bill as passed by the House of Representatives. 

4

In this report, we use the term urban areas to refer to both EMAs and TGAs. An EMA is a metropolitan 

area with a population of 50,000 or more that had more than 2,000 AIDS cases reported in the most 

recent 5-year period. The 2,000 AIDS–case criterion does not include cases of HIV that have not

progressed to AIDS. In fiscal year 2008, there were 22 EMAs. The Modernization Act of 2006 created a 

new program for TGAs. A TGA is a metropolitan area with a population of 50,000 or more, which had 

1,000 to 1,999 AIDS cases reported in the most recent 5-year period. Under this program, urban areas

that were eligible for EMA funding in fiscal year 2006 but that no longer meet the eligibility criteria for 

either EMAs or TGAs maintain their eligibility for funding and are considered TGAs until for 3 

consecutive years they (1) fail to have at least 1,000 to 1,999 AIDS cases reported in the most recent 5-

year period and (2) do not have more than 1,500 living cases of AIDS. In fiscal year 2008, there were 34

TGAs according to HRSA. 

 GAO-09-472R CARE Act Proposed Stop-Loss Provision 
(1) formula grants that are awarded based on the case counts of people with HIV/AIDS in an 

urban area; (2) supplemental grants that are awarded on a competitive basis based on an 

urban area’s demonstration of need, including criteria such as HIV/AIDS prevalence; and 

(3) Minority AIDS Initiative (MAI) grants, which are supplemental grants awarded on a 

competitive basis for urban areas to address disparities in access, treatment, care, and health 

outcomes. Changes in grantee characteristics and funding formulas can cause increases or 

decreases in grantees’ funding. 

H.R. 1105, which was passed by the House of Representatives on February 25, 2009, contains 

a provision to ensure that decreases in total 2008 Part A funding for fiscal year 2008 for each 

EMA and TGA would not exceed levels specified in the bill.5 It would limit the total funding 

decrease for an EMA for the 2008 fiscal year to no more than 6.3 percent of what the EMA 

received for the 2006 fiscal year. Decreases for a TGA for the 2008 fiscal year would be 

limited to 11.3 percent of its total funding for fiscal year 2006.6 The funding necessary to limit 

the decreases to urban areas would be given as increases to supplemental grants for fiscal 

year 2009. 

To provide you with technical assistance, we developed an estimate of fiscal year 2009 Part A 

CARE Act funding for EMAs and TGAs with the stop-loss provision in H.R. 1105. We also 

developed an estimate of such funding without that provision. We used data from HHS, 

H.R. 1105, and an Explanatory Statement submitted by the Chairman of the House Committee 

on Appropriations to H.R. 1105 to estimate these amounts.7

 In order to conduct these 

analyses, we made a number of assumptions. These assumptions are described in notes to 

the accompanying tables. See enclosure I for estimates of Part A CARE Act funding for EMAs 

with and without the stop-loss provision. See enclosure II for estimates of Part A CARE Act 

funding for TGAs with and without the stop-loss provision. 

The objective of this work was to provide pertinent and timely information by showing the 

effect of the stop-loss provision on EMAs and TGAs for fiscal year 2009 that Congress can use 

in determining funding for CARE Act programs. We used data from agency reference 

documents to conduct our analyses. Because of time constraints, we did not conduct any 

additional analysis of the proposed provision. We performed our work in March 2009.

 5

Part A of the CARE Act covers funding to urban areas. Part B covers funding to states, territories, and 

the District of Columbia. 

6

The stop-loss provision in H.R. 1105 states that “within the amounts provided for Part A . . ., $10,853,000 is available . . . for increasing supplemental grants for fiscal year 2009 to metropolitan 

areas that received grant funding in fiscal year 2008 . . . to ensure that an area’s total funding under 

[Part A to an EMA] for fiscal year 2008, together with the amount of this additional funding, is not less 

than 93.7 percent of the amount of such area’s total funding under part A for fiscal year 2006, and to 

ensure . . . that an area’s total funding under [Part A to a TGA] for fiscal year 2008, together with the 

amount of this additional funding, is not less than 88.7 percent of the amount of such area’s total 

funding under part A for fiscal year 2006.” Because the provision would apply to an EMA’s or TGA’s 

“total funding” under Part A, we consider the total amount subject to the stop-loss provision to be 

formula, supplemental, and MAI grants made with Part A funds. MAI grants are authorized by 42 U.S.C. 

§ 300ff-121, which specifically directs HHS to provide funding under Part A. 

7

155 Cong. Rec. H1653, H2377 (daily ed. Feb. 23, 2009) (statement of Rep. Obey). 

 2 GAO-09-472R CARE Act Proposed Stop-Loss Provision
– – – – – 

We are sending copies of this letter to interested congressional committees. The letter will be 

available at no charge on GAO’s Web site at http://www.gao.gov. 

If you or your staff have any questions about this letter, please contact me at (202) 512-7114 

or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public 

Marcia Crosse 

Affairs may be found on the last page of this letter.

Director, Health Care 

enclosures 

 3 GAO-09-472R CARE Act Proposed Stop-Loss Provision
Enclosure I 

Total Eligible Metropolitan Area Formula, Supplemental, and Minority AIDS Initiative Grants for Fiscal Year 2006, Fiscal 

Year 2008, and Projected Funding for Fiscal Year 2009 under Part A Funding Levels Identified in the Explanatory 

Statement to H.R. 1105 

Eligible 

Metropolitan

Area (EMA) 

Fiscal year 

2006 funding 

93.7 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2008 funding

H.R. 1105:

Estimated 

fiscal year 

2009 funding 

before 

applying

stop-lossb 

H.R. 1105:

Estimated 

stop-loss 

H.R. 1105: 

Estimated 

fiscal year 

2009 funding 

after 

applying

stop loss 

Estimated 

fiscal year 

2009 funding 

without 

H.R. 1105 

stop-loss 

provision 

in place 

Atlanta, Ga. $18,869,561 $17,680,779 $17,942,992 $18,337,471 $0 $18,337,471 $18,660,212

Baltimore, Md. 20,628,895 19,329,275 20,594,272 23,889,479 0 23,889,479 24,292,574

Boston, Mass. 13,339,141 12,498,775 14,027,340 16,274,966 0 16,274,966 16,564,752

Chicago, Ill. 25,044,633 23,466,821 26,632,351 30,882,913 0 30,882,913 31,427,282

Dallas, Tex. 13,196,377 12,365,005 13,547,516 15,792,149 0 15,792,149 16,070,891

Detroit, Mich. 8,428,477 7,897,483 8,055,626 9,201,600 0 9,201,600 9,360,130

Ft. Lauderdale,

Fla. 14,963,638 14,020,929 15,171,291 17,501,950 0 17,501,950 17,810,954

Houston, Tex. 19,953,520 18,696,448 20,094,436 22,938,330 0 22,938,330 23,338,238

Los Angeles, Calif. 34,895,377 32,696,968 36,013,941 41,310,363 0 41,310,363 42,038,454

Miami, Fla. 23,999,914 22,487,919 24,974,906 28,478,276 0 28,478,276 28,964,002

New Orleans, La. 7,434,812 6,966,419 7,669,652 8,838,306 0 8,838,306 8,994,183

New York, N.Y. 120,423,326 112,836,656 111,883,651 114,607,968 953,005 115,560,973 116,582,701

Newark, N.J. 14,752,254 13,822,862 14,038,197 15,447,478 0 15,447,478 15,713,291

Orlando, Fla. 8,561,273 8,021,913 7,968,264 9,047,025 53,649 9,100,674 9,204,349

Philadelphia, Pa. 22,384,551 20,974,324 22,773,161 25,550,597 0 25,550,597 25,994,618

Phoenix, Ariz. 6,519,338 6,108,620 7,522,978 8,762,472 0 8,762,472 8,923,024

San Diego, Calif. 9,269,256 8,685,293 10,955,986 12,877,535 0 12,877,535 13,109,380

San Francisco, 

Calif. 27,964,864 26,203,078 19,419,733 19,722,536 6,783,345 26,505,881 19,815,968

San Juan, P.R. 13,470,347 12,621,715 12,877,445 13,087,902 0 13,087,902 13,148,287

Tampa–St. 

Petersburg, Fla. 9,571,830 8,968,805 9,524,707 10,465,933 0 10,465,933 10,652,830

Washington, D.C. 26,923,066 25,226,913 27,911,311 31,591,530 0 31,591,530 32,142,719

West Palm 

Beach, Fla. 8,276,018 7,754,629 8,352,071 8,602,738 0 8,602,738 8,753,459

Total $468,870,468 $439,331,629 $457,951,827 $503,209,515 $7,789,999c$510,999,514 $511,562,296

Source: GAO analysis of HHS data, H.R. 1105, and the Explanatory Statement to H.R. 1105. 

Notes: The projected fiscal year 2009 funding in this table is based on the funding amount for urban areas identified in the Explanatory Statement 

to H.R. 1105. We assumed that the percent of Part A funding allotted to EMAs and the percent allotted to Transitional Grant Areas (TGA) in fiscal 

year 2009 would be the same as the percent allotted to each in fiscal year 2008. 

Because updated human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) case counts were not available, we used the 

HIV/AIDS case counts that Health Resources and Services Administration (HRSA) used to determine fiscal year 2008 funding. 

We cannot determine the exact effect of the stop-loss provision on total funding for each EMA for fiscal year 2009. It is not possible to determine 

exactly how each EMA would be affected by the 6.3 percent stop-loss for EMAs because it is not known how HRSA will award fiscal year 2009 

supplemental and Minority AIDS Initiative (MAI) grants and because the case counts on which formula grants will be based are not yet available. 

4 GAO-09-472R CARE Act Proposed Stop-Loss Provision 
Enclosure I 

To estimate fiscal year 2009 supplemental funding for EMAs, we calculated the percent of fiscal year 2008 total funding that each area’s fiscal year 

2008 supplemental funding represented. We then multiplied that percentage by the estimated total supplemental funding to be available for 

distribution in fiscal year 2009. For example, if an EMA received 2 percent of the total supplemental funding available for distribution to EMAs in 

fiscal year 2008, then we estimated that area’s supplemental funding in fiscal year 2009 to be 2 percent of the amount of supplemental funding 

available for distribution to EMAs.

We based our estimate of fiscal year 2009 MAI funding for EMAs on the amount to be reserved for fiscal year 2009 Part A MAI funding in the Ryan 

White HIV/AIDS Treatment Modernization Act of 2006 (Modernization Act of 2006). (The exact amount used was 95.985 percent of the amount 

specified in the Modernization Act of 2006. This amount was used because this was the percent of the amount specified in the Modernization Act of 

2006 for fiscal years 2007 and 2008 that had been distributed in those years.) We calculated the percent of fiscal year 2008 total funding that each 

area’s fiscal year 2008 MAI funding represented. We then multiplied that percentage by the estimated total MAI funding to be available for

distribution in fiscal year 2009. For example, if an EMA received 2 percent of the total MAI funding available for distribution to EMAs in fiscal year 

2008, then we estimated that area’s MAI funding in fiscal year 2009 to be 2 percent of the amount of supplemental funding available for distribution 

to EMAs. 

a

Under the stop-loss provision in H.R. 1105, an EMA is ensured that its total formula, supplemental, and MAI grants for fiscal year 2008 would not 

be less than 93.7 percent of what it received for fiscal year 2006. 

b

The total funding that an EMA would receive in fiscal year 2009 with the stop-loss provision in place can be found by adding the amount in this 

column to the amount in the column titled “H.R. 1105: Estimated stop-loss.” 

c

We estimate the funding needed to satisfy the H.R. 1105 stop-loss provision for both EMAs and TGAs to be $11,130,937. However, the amount 

specified in H.R. 1105 to cover the stop-loss provision is $10,853,000, a difference of $277,937. See enclosure II for the funding needed to satisfy 

the stop-loss provision for TGAs. 

 5 GAO-09-472R CARE Act Proposed Stop-Loss Provision
Enclosure II 

Total Transitional Grant Area Formula, Supplemental, and Minority AIDS Initiative Grants for Fiscal Year 2006, Fiscal Year 

2008, and Projected Funding for Fiscal Year 2009 under Part A Funding Levels Identified in the Explanatory Statement to 

H.R. 1105 

Transitional Grant 

Area (TGA) 

Fiscal year 

2006 funding 

88.7 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2008 funding

H.R. 1105:

Estimated 

fiscal year 

2009 funding 

before 

applying

stop-lossb

H.R. 1105: 

Estimated 

stop-loss 

H.R. 1105: 

Estimated 

fiscal year 

2009 funding 

after 

applying

stop loss 

Estimated 

fiscal year 

2009 funding 

without 

H.R. 1105 

stop-loss 

provision 

in place

Austin, Tex. $3,719,076 $3,298,820 $3,780,228 $4,162,255 $0 $4,162,255 $4,232,183

Baton Rouge, La. 0 0 3,235,045 3,558,823 0 3,558,823 3,617,603

Bergen-Passaic, 

N.J. 4,485,650 3,978,772 3,772,874 4,151,023 205,898 4,356,920 4,219,835

Caguas, P.R. 1,648,356 1,462,092 1,063,691 1,167,262 398,401 1,565,663 1,185,745

Charlotte-Gastonia, 

N.C.-S.C. 0 0 4,676,968 5,143,544 0 5,143,544 5,228,264

Cleveland, Ohio 3,349,096 2,970,648 3,911,591 4,302,543 0 4,302,543 4,373,547

Denver, Colo. 4,283,042 3,799,058 7,298,643 8,048,873 0 8,048,873 8,187,495

Dutchess County, 

N.Y. 1,367,584 1,213,047 1,155,700 1,269,994 57,347 1,327,341 1,290,615

Fort Worth, Tex. 3,409,819 3,024,509 3,588,582 3,952,428 0 3,952,428 4,019,120

Hartford, Conn. 4,666,281 4,138,991 3,185,949 3,503,924 953,042 4,456,966 3,561,619

Indianapolis, Ind. 0 0 3,587,145 3,952,045 0 3,952,045 4,019,096

Jacksonville, Fla. 4,913,816 4,358,555 4,826,190 5,308,171 0 5,308,171 5,395,750

Jersey City, N.J. 5,145,142 4,563,741 4,593,150 5,048,353 0 5,048,353 5,130,699

Kansas City, Mo. 2,916,485 2,586,922 4,011,340 4,420,666 0 4,420,666 4,496,001

Las Vegas, Nev. 4,323,627 3,835,057 4,552,895 5,017,196 0 5,017,196 5,102,314

Memphis, Tenn. 0 0 5,859,876 6,438,653 0 6,438,653 6,543,133

MiddlesexSomersetHunterdon, N.J. 2,595,663 2,302,353 2,462,767 2,711,055 0 2,711,055 2,756,415

Minneapolis–

St. Paul, Minn. 3,046,512 2,702,256 4,675,211 5,148,836 0 5,148,836 5,235,593

Nashville, Tenn. 0 0 3,743,376 4,123,916 0 4,123,916 4,193,729

Nassau-Suffolk, 

N.Y. 6,148,307 5,453,548 4,811,511 5,295,773 642,037 5,937,810 5,384,059

New Haven, Conn. 6,684,594 5,929,235 5,209,416 5,735,036 719,819 6,454,855 5,831,010

Norfolk, Va. 4,414,760 3,915,892 5,360,103 5,898,719 0 5,898,719 5,996,942

Oakland, Calif. 5,735,837 5,087,687 5,867,538 6,462,486 0 6,462,486 6,570,622

Orange County,

Calif. 4,858,579 4,309,560 5,332,920 5,877,173 0 5,877,173 5,976,553

Ponce, P.R. 2,391,444 2,121,211 1,926,154 2,117,579 195,057 2,312,636 2,152,253

Portland, Ore. 3,401,956 3,017,535 3,310,036 3,714,698 0 3,714,698 3,779,492

Riverside–San 

Bernardino, Calif. 7,074,521 6,275,100 6,949,457 7,667,837 0 7,667,837 7,800,012

Sacramento, Calif. 2,778,729 2,464,733 2,325,684 2,565,172 139,049 2,704,221 2,609,095

6 GAO-09-472R CARE Act Proposed Stop-Loss Provision 
Enclosure II 

Transitional Grant 

Area (TGA) 

Fiscal year 

2006 funding 

88.7 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2008 funding

H.R. 1105:

Estimated 

fiscal year 

2009 funding 

before 

applying

stop-lossb

H.R. 1105: 

Estimated 

stop-loss 

H.R. 1105: 

Estimated 

fiscal year 

2009 funding 

after 

applying

stop loss 

Estimated 

fiscal year 

2009 funding 

without 

H.R. 1105 

stop-loss 

provision 

in place

San Antonio, Tex. 3,325,881 2,950,056 3,969,302 4,368,560 0 4,368,560 4,441,414

San Jose, Calif. 2,304,762 2,044,324 2,578,512 2,841,808 0 2,841,808 2,889,886

Santa Rosa, Calif. 1,028,634 912,398 1,072,099 1,182,455 0 1,182,455 1,202,669

Seattle, Wash. 5,445,484 4,830,144 6,316,558 6,969,212 0 6,969,212 7,089,141

St. Louis, Mo. 4,502,572 3,993,781 5,796,624 6,098,186 0 6,098,186 6,199,596

Vineland-MillvilleBridgeton, N.J. 849,715 753,697 723,408 795,232 30,289 825,521 808,204

Total $110,815,924 $98,293,725 $135,530,543 $149,019,485 $3,340,938c$152,360,424 $151,519,703

Source: GAO analysis of HHS data, H.R. 1105, and the Explanatory Statement to H.R. 1105. 

Notes: The projected fiscal year 2009 funding in this table is based on the funding amount for urban areas identified in the Explanatory Statement 

to H.R. 1105. We assumed that the percent of Part A funding allotted to Eligible Metropolitan Areas (EMA)and the percent allotted to TGAs in fiscal 

year 2009 would be the same as the percent allotted to each in fiscal year 2008. 

Because updated human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) case counts were not available, we used the 

HIV/AIDS case counts that Health Resources and Services Administration (HRSA) used to determine fiscal year 2008 funding. 

We cannot determine the exact effect of the stop-loss provision on total funding for each TGA for fiscal year 2009. It is not possible to determine 

exactly how each TGA would be affected by the 11.3 percent stop-loss provision for TGAs because it is not known how HRSA will award fiscal year 

2009 supplemental and Minority AIDS Initiative (MAI) grants and because the case counts on which formula grants will be based are not yet 

available. 

To estimate fiscal year 2009 supplemental funding for TGAs, we calculated the percent of fiscal year 2008 total funding that each area’s fiscal year 

2008 supplemental funding represented. We then multiplied that percentage by the estimated total supplemental funding to be available for 

distribution in fiscal year 2009. For example, if a TGA received 2 percent of the total supplemental funding available for distribution to TGAs in fiscal 

year 2008, then we estimated that area’s supplemental funding in fiscal year 2009 to be 2 percent of the amount of supplemental funding available 

for distribution to TGAs. 

We based our estimate of fiscal year 2009 MAI funding for TGAs on the amount to be reserved for fiscal year 2009 Part A MAI funding in the Ryan 

White HIV/AIDS Treatment Modernization Act of 2006 (Modernization Act of 2006). (The exact amount used was 95.985 percent of the amount 

specified in the Modernization Act of 2006. This amount was used because this was the percent of the amount specified in the Modernization Act of 

2006 for fiscal years 2007 and 2008 that had been distributed in those years.) We calculated the percent of fiscal year 2008 total funding that each 

area’s fiscal year 2008 MAI funding represented. We then multiplied that percentage by the estimated total MAI funding to be available for

distribution in fiscal year 2009. For example, if a TGA received 2 percent of the total MAI funding available for distribution to TGAs in fiscal year

2008, then we estimated that area’s MAI funding in fiscal year 2009 to be 2 percent of the amount of supplemental funding available for distribution 

to TGAs. 

a

Under the stop-loss provision in H.R. 1105, a TGA is ensured that its total formula, supplemental, and MAI grants for fiscal year 2008 would not be 

less than 88.7 percent of what it received for fiscal year 2006. 

b

The total funding that a TGA would receive in fiscal year 2009 with the stop-loss provision in place can be found by adding the amount in this 

column to the amount in the column titled “H.R. 1105: Estimated stop-loss.” 

c

We estimate the funding needed to satisfy the H.R. 1105 stop-loss provision for both EMAs and TGAs to be $11,130,937. However, the amount 

specified in H.R. 1105 to cover the stop-loss provision is $10,853,000, a difference of $277,937. See enclosure I for the funding needed to satisfy 

the stop-loss provision for EMAs.

 7 GAO-09-472R CARE Act Proposed Stop-Loss Provision
Enclosure III 

GAO Contacts and Staff Acknowledgments 

For information about this letter, please contact Marcia Crosse, Director, Health Care, who 

can be reached at (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page of this letter. Major 

contributors to this letter were Thomas Conahan, Assistant Director; Martha Kelly, Assistant 

Director; Robert Copeland; Helen Desaulniers; Rachel Moskowitz; Jennifer Whitworth; and 

Suzanne Worth. 

(290775) 

8 GAO-09-472R CARE Act Proposed Stop-Loss Provision 
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