United States Government Accountability Office

Washington, DC 20548 

August 3, 2009 

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

This correspondence was revised August 7, 2009 

to correct the numbers that appear in three 

columns of the table in enclosure II. The 

columns in the table that have been corrected 

are, “Fiscal year 2009 funding,” “H.R. 3293: 

Estimated stop-loss,” and “H.R. 3293: Estimated 

fiscal year 2010 funding after applying stop-loss.”

Subject: Ryan White CARE Act: Estimated Effect of Proposed Stop-Loss Provision in H.R. 

3293 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 a certain stop-loss provision is 

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 (RWTMA) reauthorized CARE Act programs 

for fiscal years 2007 through 2009.2

 In July 2009, the House of Representatives passed H.R. 

3293, the Departments of Labor, Health and Human Services, and Education, and Related 

Agencies Appropriation Act, 2010, 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) formula grants that are awarded based on the case counts of people with HIV/AIDS in an 

 

1

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

1990 CARE Act added title XXVI to the Public Health Service Act. Unless otherwise indicated, 

references to the CARE Act refer to current title XXVI. 

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. 3293, 111th Cong. (2009). For purposes of this report, unless otherwise specified, we use the term 

H.R. 3293 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 2009, there were 24 EMAs according to HRSA. The RWTMA 

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 2009, there 

were 32 TGAs according to HRSA. 

 GAO-09-947R CARE Act Proposed Stop-Loss Provision 
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 grantees’ characteristics and funding formulas can cause increases or 

decreases in grantees’ funding. 

H.R. 3293, which was passed by the House of Representatives on July 24, 2009, contains a 

provision to ensure that decreases in total Part A funding for fiscal year 2009 for each EMA 

and TGA would not exceed levels specified in the bill.5

 It would limit the total funding 

decrease for the 2009 fiscal year to no more than 7.6 percent of what the EMA or TGA 

received for the 2006 fiscal year.6

 The funding necessary to limit the decreases to urban areas 

would be given as increases to supplemental grants for fiscal year 2010. 

To provide you with technical assistance, we developed an estimate of fiscal year 2010 Part A 

CARE Act funding for EMAs and TGAs with the stop-loss provision in H.R. 3293.7

 We also 

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

H.R. 3293, and the report of the House Committee on Appropriations accompanying H.R. 

3293 to estimate these amounts.8

 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 stoploss 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 2010 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 July and August 

2009. 

 

5

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

associated jurisdictions, and the District of Columbia. 

6

The stop-loss provision in H.R. 3293 states that “within the amounts provided for Part A . . ., $6,021,000 

shall be available . . . for increasing supplemental grants for fiscal year 2010 to metropolitan and 

transitional areas that received grant funding in fiscal year 2009 . . . to ensure that an area’s total 

funding under [Part A to an EMA or TGA] for fiscal year 2009, together with the amount of this 

additional funding, is not less than 92.4 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

We previously provided similar estimates for H.R. 1105. See GAO, Ryan White CARE Act: Estimated 

Effect of Proposed Stop-Loss Provision on Urban Areas, GAO-09-472R (Washington, D.C.: Mar. 6, 

2009). 

8

H.R. Rep. No. 111-220 (2009). 

 2 GAO-09-947R 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 

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

Marcia Crosse 

Director, Health Care 

Enclosures 

 3 GAO-09-947R CARE Act Proposed Stop-Loss Provision
Enclosure I 

4 GAO-09-947R CARE Act Proposed Stop-Loss Provision 

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

Year 2009, and Projected Funding for Fiscal Year 2010 under Part A Funding Levels Identified in the Report of the House 

Committee on Appropriations Accompanying H.R. 3293 

Eligible 

Metropolitan 

Area (EMA) 

Fiscal year 

2006 funding 

92.4 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2009 funding

H.R. 3293:

Estimated 

fiscal year 

2010 funding 

before 

applying 

stop-lossb 

H.R. 3293:

Estimated 

stop-loss 

H.R. 3293: 

Estimated 

fiscal year 

2010 funding 

after 

applying 

stop-loss 

Estimated 

fiscal year 

2010 funding 

without 

H.R. 3293 

stop-loss 

provision 

in place 

Atlanta, Ga. $18,869,561 $17,435,474 $18,443,431 $19,707,774 $0 $19,707,774 $20,111,240

Baltimore, Md. 20,628,895 19,061,099 22,804,651 25,146,942 0 25,146,942 25,668,616

Boston, Mass. 13,339,141 12,325,366 13,325,857 14,826,513 0 14,826,513 15,112,210

Chicago, Ill. 25,044,633 23,141,241 27,410,446 30,399,044 0 30,399,044 31,030,149

Dallas, Tex. 13,196,377 12,193,452 14,491,860 16,135,491 0 16,135,491 16,461,969

Detroit, Mich. 8,428,477 7,787,913 8,811,003 9,649,668 0 9,649,668 9,847,320

Ft. Lauderdale, 

Fla. 14,963,638 13,826,402 15,225,814 16,723,935 0 16,723,935 17,082,041

Houston, Tex. 19,953,520 18,437,052 20,280,028 21,759,462 0 21,759,462 22,212,613

Los Angeles, Calif. 34,895,377 32,243,328 38,596,755 42,753,540 0 42,753,540 43,664,418

Miami, Fla. 23,999,914 22,175,921 26,268,588 28,295,403 0 28,295,403 28,886,672

Nassau-Suffolk, 

N.Y. 6,148,307 5,681,036 6,063,346 6,133,107 0 6,133,107 6,261,448

New Haven, 

Conn. 6,684,594 6,176,565 6,486,178 6,427,638 0 6,427,638 6,554,241

New Orleans, La. 7,434,812 6,869,766 7,715,228 8,372,305 0 8,372,305 8,546,858

New York, N.Y. 120,423,326 111,271,153 111,058,281 111,399,388 212,873 111,612,261 112,851,459

Newark, N.J. 14,752,254 13,631,083 14,294,358 14,957,651 0 14,957,651 15,263,596

Orlando, Fla. 8,561,273 7,910,616 8,184,316 9,102,265 0 9,102,265 9,276,330

Philadelphia, Pa. 22,384,551 20,683,325 23,627,921 25,849,435 0 25,849,435 26,384,731

Phoenix, Ariz. 6,519,338 6,023,868 7,891,520 8,817,069 0 8,817,069 9,003,693

San Diego, Calif. 9,269,256 8,564,793 11,406,079 12,701,493 0 12,701,493 12,969,540

San Francisco, 

Calif. 27,964,864 25,839,534 20,682,998 20,800,605 5,156,537 25,957,142 21,094,812

San Juan, P.R. 13,470,347 12,446,601 13,303,840 13,353,898 0 13,353,898 13,521,736

Tampa-St. 

Petersburg, Fla. 9,571,830 8,844,371 9,618,021 10,283,094 0 10,283,094 10,499,803

Washington, D.C. 26,923,066 24,876,913 29,292,798 32,484,738 0 32,484,738 33,151,677

West Palm 

Beach, Fla. 8,276,018 7,647,041 8,594,359 8,632,210 0 8,632,210 8,755,423

Total $481,703,369 $445,093,913 $483,877,677 $514,712,668 $5,369,409c$520,082,078 $524,212,595

Source: GAO analysis of HHS data, H.R. 3293, and the Report of the House Committee on Appropriations Accompanying H.R. 3293. 

Notes: The projected fiscal year 2010 funding in this table is based on the funding amount for urban areas identified in the Report of the House 

Committee on Appropriations Accompanying H.R. 3293. We assumed that the percentage of Part A funding allotted to EMAs and the percentage 

allotted to Transitional Grant Areas (TGA) in fiscal year 2010 would be the same as the percentage allotted to each in fiscal year 2009. 

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

HIV/AIDS case counts that the Health Resources and Services Administration (HRSA) used to determine fiscal year 2009 funding. 
Enclosure I 

We cannot determine the exact effect of the stop-loss provision on total funding for each EMA for fiscal year 2010. It is not possible to determine 

exactly how each EMA would be affected by the 7.6 percent stop-loss for EMAs because it is not known how HRSA will award fiscal year 2010 

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 2010 supplemental funding for EMAs, we calculated the percentage of fiscal year 2009 total funding that each area’s fiscal 

year 2009 supplemental funding represented. We then multiplied that percentage by the estimated total supplemental funding to be available for 

distribution in fiscal year 2010. For example, if an EMA received 2 percent of the total supplemental funding available for distribution to EMAs in 

fiscal year 2009, then we estimated that area’s supplemental funding in fiscal year 2010 to be 2 percent of the amount of supplemental funding 

available for distribution to EMAs. 

We developed our estimate of fiscal year 2009 MAI funding for EMAs by applying the percentage increase in MAI funding from 2008 to 2009 at the 

EMA level. 

We developed our estimate of fiscal year 2010 MAI funding for EMAs by applying the percentage increase in MAI funding from 2008 to 2010 at the 

EMA level. 

a

Under the stop-loss provision in H.R. 3293, an EMA is ensured that its total formula, supplemental, and MAI grants for fiscal year 2009 would not 

be less than 92.4 percent of what it received for fiscal year 2006. 

b

The total funding that an EMA would receive in fiscal year 2010 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. 3293: Estimated stop-loss.” 

C

We estimate the funding needed to satisfy the H.R. 3293 stop-loss provision for both EMAs and TGAs to be $6,083,536. However, the amount 

specified in H.R. 3293 to cover the stop-loss provision is $6,021,000, a difference of $62,536. 

 5 GAO-09-947R CARE Act Proposed Stop-Loss Provision
Enclosure II 

6 GAO-09-947R CARE Act Proposed Stop-Loss Provision 

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

Year 2009, and Projected Funding for Fiscal Year 2010 under Part A Funding Levels Identified in the Report of the 

House Committee on Appropriations Accompanying H.R. 3293 

Transitional Grant 

Area (TGA) 

Fiscal year 

2006 funding 

92.4 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2009 funding

H.R. 3293:

Estimated 

fiscal year 

2010 funding 

before 

applying 

stop-lossb

H.R. 3293: 

Estimated 

stop-loss 

H.R. 3293: 

Estimated 

fiscal year 

2010 funding 

after 

applying 

stop-loss 

Estimated 

fiscal year 

2010 funding 

without 

H.R. 3293 

stop-loss 

provision 

in place

Austin, Tex. $3,719,076 $3,436,426 $4,329,840 $4,519,204 $0 $4,519,204 $4,560,116

Baton Rouge, La. . . 3,911,761 4,076,689 0 4,076,689 4,113,182

Bergen-Passaic, 

N.J. 4,485,650 4,144,741 4,301,488 4,484,236 0 4,484,236 4,524,341

Caguas, P.R. 1,648,356 1,523,081 1,363,379 1,418,137 159,702 1,577,839 1,430,471

Charlotte-Gastonia, 

N.C.-S.C. . . 5,362,616 5,587,907 0 5,587,907 5,637,621

Cleveland, Ohio 3,349,096 3,094,565 4,466,289 4,654,743 0 4,654,743 4,696,212

Denver, Colo. 4,283,042 3,957,531 8,049,378 8,411,822 0 8,411,822 8,489,556

Dutchess County, 

N.Y. 1,367,584 1,263,648 1,365,972 1,422,476 0 1,422,476 1,435,007

Fort Worth, Tex. 3,409,819 3,150,673 4,128,320 4,310,233 0 4,310,233 4,349,412

Hartford, Conn. 4,666,281 4,311,644 3,925,802 4,093,472 385,842 4,479,315 4,130,073

Indianapolis, Ind. . . 3,917,484 4,088,912 0 4,088,912 4,126,162

Jacksonville, Fla. 4,913,816 4,540,366 5,536,454 5,771,055 0 5,771,055 5,822,477

Jersey City, N.J. 5,145,142 4,754,111 5,156,330 5,370,359 0 5,370,359 5,417,646

Kansas City, Mo. 2,916,485 2,694,832 4,576,239 4,782,134 0 4,782,134 4,825,967

Las Vegas, Nev. 4,323,627 3,995,031 5,752,723 6,005,835 0 6,005,835 6,060,917

Memphis, Tenn. . . 6,552,332 6,817,556 0 6,817,556 6,877,281

MiddlesexSomersetHunterdon, N.J. 2,595,663 2,398,393 2,560,831 2,664,756 0 2,664,756 2,688,640

MinneapolisSt. Paul, Minn. 3,046,512 2,814,977 5,383,400 5,619,313 0 5,619,313 5,670,330

Nashville, Tenn. . . 4,425,521 4,621,449 0 4,621,449 4,663,632

Norfolk, Va. 4,414,760 4,079,238 5,955,970 6,208,726 0 6,208,726 6,264,379

Oakland, Calif. 5,735,837 5,299,913 6,247,360 7,133,337 0 7,133,337 7,197,747

Orange County, 

Calif. 4,858,579 4,489,327 5,510,768 6,399,695 0 6,399,695 6,457,970

Ponce, P.R. 2,391,444 2,209,694 2,060,941 2,143,591 148,753 2,292,345 2,162,452

Portland, Ore. 3,401,956 3,143,407 3,594,591 4,104,575 0 4,104,575 4,143,000

Riverside-San 

Bernardino, Calif. 7,074,521 6,536,857 7,428,352 8,551,314 0 8,551,314 8,630,571
Enclosure II 

Transitional Grant 

Area (TGA) 

Fiscal year 

2006 funding 

92.4 percent 

of fiscal 

year 2006 

fundinga

Fiscal year 

2009 funding

H.R. 3293:

Estimated 

fiscal year 

2010 funding 

before 

applying 

stop-lossb

H.R. 3293: 

Estimated 

stop-loss 

H.R. 3293: 

Estimated 

fiscal year 

2010 funding 

after 

applying 

stop-loss 

Estimated 

fiscal year 

2010 funding 

without 

H.R. 3293 

stop-loss 

provision 

in place

Sacramento, Calif. 2,778,729 2,567,546 2,547,716 2,910,176 19,830 2,930,006 2,937,012

San Antonio, Tex. 3,325,881 3,073,114 4,498,708 4,691,215 0 4,691,215 4,733,379

San Jose, Calif. 2,304,762 2,129,600 2,624,926 3,031,684 0 3,031,684 3,059,273

Santa Rosa, Calif. 1,028,634 950,458 1,169,829 1,330,617 0 1,330,617 1,342,865

Seattle, Wash. 5,445,484 5,031,627 7,222,731 7,551,142 0 7,551,142 7,620,959

St. Louis, Mo. 4,502,572 4,160,377 6,017,700 6,265,481 0 6,265,481 6,321,480

Vineland-MillvilleBridgeton, N.J. 849,715 785,137 822,767 855,056 0 855,056 862,594

Total $97,983,023 $90,536,313 $140,768,518 $149,896,898 $714,127 c $150,611,025 $151,252,725

Source: GAO analysis of HHS data, H.R. 3293, and the Report of the House Committee on Appropriations Accompanying H.R. 3293. 

Notes: The projected fiscal year 2010 funding in this table is based on the funding amount for urban areas identified in the Report of the House 

Committee on Appropriations Accompanying H.R. 3293. We assumed that the percentage of Part A funding allotted to Eligible Metropolitan Areas 

and the percentage allotted to TGAs in fiscal year 2010 would be the same as the percentage allotted to each in fiscal year 2009. 

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

HIV/AIDS case counts that the Health Resources and Services Administration (HRSA) used to determine fiscal year 2009 funding. 

We cannot determine the exact effect of the stop-loss provision on total funding for each TGA for fiscal year 2010. It is not possible to determine 

exactly how each TGA would be affected by the 7.6 percent stop-loss provision for TGAs because it is not known how HRSA will award fiscal 

year 2010 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 2010 supplemental funding for TGAs, we calculated the percentage of fiscal year 2009 total funding that each area’s fiscal 

year 2009 supplemental funding represented. We then multiplied that percentage by the estimated total supplemental funding to be available for 

distribution in fiscal year 2010. For example, if a TGA received 2 percent of the total supplemental funding available for distribution to TGAs in fiscal 

year 2009, then we estimated that area’s supplemental funding in fiscal year 2010 to be 2 percent of the amount of supplemental funding available 

for distribution to TGAs. 

We developed our estimate of fiscal year 2009 MAI funding for TGAs by applying the percentage increase in MAI funding from 2008 to 2009 at the 

TGA level. 

We developed our estimate of fiscal year 2010 MAI funding for TGAs by applying the percentage increase in MAI funding from 2008 to 2010 at the 

TGA level. 

a

Under the stop-loss provision in H.R. 3293, a TGA is ensured that its total formula, supplemental, and MAI grants for fiscal year 2009 would not be 

less than 92.4 percent of what it received for fiscal year 2006. 

b

The total funding that a TGA would receive in fiscal year 2010 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. 3293: Estimated stop-loss.” 

C

We estimate the funding needed to satisfy the H.R. 3293 stop-loss provision for both EMAs and TGAs to be $6,083,536. However, the amount 

specified in H.R. 3293 to cover the stop-loss provision is $6,021,000, a difference of $62,536. 

 7 GAO-09-947R CARE Act Proposed Stop-Loss Provision
Enclosure III 

8 GAO-09-947R CARE Act Proposed Stop-Loss Provision 

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; Robert Copeland, 

Assistant Director; Martha Kelly, Assistant Director; Helen Desaulniers; Rachel Svoboda; 

Jennifer Whitworth; and Suzanne Worth. 

(290808) 
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