The Ryan White HIV/AIDS Program makes federal funds available to metropolitan areas and states to provide a number of health care services for HIV/AIDS patients including medical care, drug treatments, dental care, home health care, and outpatient mental health and substance abuse treatment. The program currently serves more than half a million low-income people with HIV/AIDS in the United States; 29% of those served are uninsured, and an additional 56% are underinsured. The Ryan White program was established in law in 1990 ( P.L. 101-381 ) and reauthorized and amended in 1996 ( P.L. 104-146 ), 2000 ( P.L. 106-345 ), 2006 ( P.L. 109-415 ), and 2009 ( P.L. 111-87 ). It was enacted as Title XXVI of the Public Health Service (PHS) Act and codified as Parts A, B, C, D, E, F, and G under 42 U.S.C. § 300ff-11 et seq. The program is administered by the HRSA HIV/AIDS Bureau. Most Ryan White funding is distributed to eligible entities based on formulas that take into account living cases of HIV/AIDS. Funding for the individual grant programs (Parts A, B, C, D, and F) is shown in Figure 1 and in Table 1 at the end of this report. Figure 1. Ryan White Funding, FY2012Total = $2.4 billionSource: HRSA, FY2013 Justification of Estimates for Appropriations Committees, p. 238-271. P.L. 111-87 provided specific authorization levels for Parts A, B, C, D, and F for each fiscal year through FY2013, resulting in a four-year reauthorization for the Ryan White program. P.L. 111-87 required that the Secretary establish a national HIV/AIDS testing goal of 5 million tests annually through programs administered by HRSA and CDC. The Secretary is required to submit an annual report to Congress on the progress made in achieving the testing goal, including any barriers to meeting the goal, the amount of funding necessary to meet the goal, and the most cost-effective strategies for identifying individuals who are unaware of their HIV status. The Secretary is also required to review each of the programs and activities conducted by CDC as part of the Domestic HIV/AIDS Prevention Activities. The other provisions of P.L. 111-87 are discussed below in the sections of this report on the various parts of the Ryan White program. The Patient Protection and Affordable Care Act of 2010 (ACA, P.L. 111-148 , as amended) contains general provisions to increase access to health insurance and which, therefore, should increase coverage for people living with HIV/AIDS. They include prohibitions on the cancellation of coverage by an insurer due to a preexisting condition, elimination of lifetime caps on insurance benefits and annual limits on coverage, and eligibility for tax subsidies to assist low- and middle-income individuals in the purchase of coverage from health insurance exchanges. In addition, at state option, Medicaid eligibility will be broadened to include single adults, and ACA phases out the Medicare Part D so-called doughnut hole for HIV/AIDS individuals who are Medicare eligible. The long-range impact of the health care law on HRSA's Ryan White program (meaning the replacement of health and treatment services provided under Ryan White with access to such services through health coverage via ACA) remains to be determined. Part A provides funds to urban areas with high numbers of people living with HIV, as well as mid-sized cities that have emerging needs for assistance with their HIV-infected populations. The boundaries of the areas are based on the Metropolitan Statistical Areas of the U.S. Census Bureau and may range in size from a single city or county to multiple counties that cross state boundaries. According to HRSA, "more than 80% of Part A clients are people of color, and 30% are women." Part A provides funds to eligible metropolitan areas (EMAs) with a population of at least 50,000 that have had more than 2,000 reported AIDS cases in the prior five years. An EMA would stop being eligible if it failed for three consecutive years, to have: (a) a cumulative total of more than 2,000 reported cases of AIDS during the most recent five calendar years, and (b) a cumulative total of 3,000 or more living cases of AIDS as of December 31 of the most recent year. Part A currently provides grants to 24 EMAs. The 2006 reauthorization ( P.L. 109-415 ) established a grant program for transitional grant areas (TGAs), defined as metropolitan areas with at least 1,000 but fewer than 2,000 cumulative AIDS cases during the most recent five calendar years. Unless a TGA became an EMA, it would continue to be eligible as a TGA until it failed for three years to have (a) at least 1,000 but fewer than 2,000 cases of AIDS during the most recent five calendar years, and (b) 1,500 or more living cases of AIDS as of December 31 of the most recent calendar year. P.L. 111-87 permits a metropolitan area with a cumulative total of at least 1,400 but less than 1,500 living cases of AIDS to continue to be eligible as a TGA provided that not more than 5% of the TGA grant award is unobligated as of the end of the most recent fiscal year. Under P.L. 109-415 , total amounts reserved for Part A EMAs and TGAs are adjusted based, in part, on the changing eligibility status of metropolitan areas. P.L. 111-87 contained provisions that modified the transfer of Part A grant funds to Part B for metropolitan areas that lose TGA eligibility. Specifically, if a metropolitan area were to lose TGA eligibility, the state containing the TGA would receive 75% of the TGA formula grant in the first year after the loss of TGA eligibility, 50% in the second year, and 25% in the third year. The remainder in each year is made available for Part B grants, as is the entire amount of the former TGA's formula grant in the fourth year after the loss of eligibility. Part A currently provides grants to 28 TGAs and "funds 4 states (California, New Jersey, New York and Puerto Rico) that have a city that was previously a TGA." For each Part A grant, 75% of the funds must be spent on core medical services, defined as outpatient and ambulatory health services, AIDS Drug Assistance Program (ADAP) treatments and pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost-sharing assistance, home health, medical nutrition therapy, hospice, home and community-based health services, mental health and substance abuse outpatient services, and medical case management. The requirement may be waived if (1) there is no waiting list for receiving treatment (under the Part B ADAP program), and (2) core medical services were available to all individuals with HIV/AIDS who were eligible to receive such services under Part A. The remaining 25% of funds may be used for support services, such as outreach services, medical transportation, language services, respite care for persons caring for individuals with HIV/AIDS, and referrals for health care and support services. Two-thirds of the Part A appropriation is distributed through formula grants, and the remaining one-third is distributed via competitive supplemental grants awarded on the basis of need. The awarding of supplemental Part A grants is based on weighting factors. Under P.L. 111-87 , success in testing for HIV/AIDS and making individuals aware of their HIV status is counted as one-third in making such determinations. CDC collects the statistics used in the Ryan White formula. In the past, some states reported their cases by name, while others used a code-based system to protect privacy. CDC initially indicated its preference for name-based reporting in 1999 in order to avoid double counting. In 2005, the agency recommended that all jurisdictions transition to name-based reporting. In contrast to EMA and TGA eligibility definitions that are based on cumulative AIDS cases, grant award amounts are based on living HIV/AIDS cases. Prior to the 2006 reauthorization, formula grants had been distributed to EMAs in proportion to an estimate of the number of living AIDS cases in each EMA. P.L. 109-415 changed the funding distribution, basing it on the number of living HIV and AIDS cases in each EMA or TGA for states that use a name-based HIV reporting system. The requirement for name-based HIV reporting in P.L. 106-345 and P.L. 109-415 influenced states to change from code-based reporting to name-based reporting. P.L. 109-415 provided a transition period for states that did not have a fully mature name-based reporting system. P.L. 111-87 provided a continuation of the transition period for states that did not have a fully mature name-based HIV reporting system. Under P.L. 111-87 , these jurisdictions incur a 5% reduction in the number of non-AIDS HIV cases reported for the eligible area (to account for duplicate cases caused by code-based reporting) in making Part A grant determinations for fiscal years prior to FY2012 and a 6% reduction for FY2012. Beginning with FY2013, only living name-based cases of HIV/AIDS would be used in making Part A grant determinations. In addition, as was the case under P.L. 109-415 , the amount of the formula grant in these areas may not exceed that of the preceding fiscal year by more than 5%. For the purpose of determining Part A grant amounts, P.L.