From: MPetrelis@aol.com Date: Thu, 15 Jun 2000 13:15:48 EDT Subject: LA v. SF for federal Ryan White AIDS funding June 14, 2000 Roland Foster Office of Representative Tom Coburn, M.D. 429 Cannon House Office Building Washington, DC 20515 SAN FRANCISCO BAY AREA DELEGATION LETTER Dear Mr. Foster: Thank you for sharing the letter from members of the San Francisco Bay area Congressional delegation. As requested, I am responding to some of the issues raised in the letter. The San Francisco Title I jurisdiction includes San Mateo and Marin counties, while the Oakland Title I jurisdiction comprises Alameda and Contra Costa counties. Attached is a worksheet that describes the Title I formula award for Year 09 for each jurisdiction represented by one or more of the signatories. The columns following the formula award indicate the number of living AIDS cases for each jurisdiction as estimated by the Health Resources and Services Administration (the "ten year weighted band") and by the Centers for Disease Control and Prevention. As you can see, the allocation of formula funds per case is roughly twice as much in the San Francisco EMA as for the other jurisdictions represented by signatories of the delegation letter. The delegation argues for appropriations increases and changes in the formula for the use of living cases and a density factor. It is a paradox, then, that the delegation seems to endorse Senate Bill S.2311, which contains none of these provisions. Nonetheless, the letter underscores broad areas of agreement among Los Angeles County, the San Francisco Congressional delegation and other advocates throughout the country: there are too few funds to support all needed services for people with HIV/AIDS in Title I jurisdictions; living AIDS cases are a better measure of need than the ten-year weighted band; there is a shared commitment to ensuring that funds are directed to areas of greatest need. Unlike other advocacy efforts, Los Angeles County has articulated a number of means to achieve more equitable distribution of funds. Unfortunately, these efforts have not always attracted the attention that discussion of the "hold harmless" provision has enjoyed. Particularly absent from the delegation's letter is any sense of commitment to the institutionalization or other continuation of the Minority AIDS Initiative. There is one key area of disagreement. The delegation clearly places the highest priority on maintaining existing systems without regard to changes in need for services. Given the extreme disparities in funding, it is clear that the burden of unmet need is unfairly distributed and, ironically, the burden is greatest in those jurisdictions with newest and most rapidly emerging need. Absent sufficient appropriations increases to fund all necessary services, difficult choices must be made. Los Angeles County believes that a more appropriate balance between maintaining needed service delivery systems and creating equally necessary service delivery systems can be achieved by a more progressive approach to the "hold harmless" provision. Although adding a density factor to the Title I formula could be acceptable to Los Angeles County, I am concerned that the timing is such that it may disrupt authorization efforts. Los Angeles County released its position on CARE Act reauthorization in April of 1999, invited a national discussion of this important national issue. The single greatest disappointment in that effort has been the limited policy discussions that could have resulted in agreement on including the density factor, and perhaps other factors, the could have improved services to people with HIV/AIDS. Los Angeles County concurs that any policy that could destabilize any health care system should be approached with great caution. However, given the great shifts in the epidemic, the even greater shifts projected over the course of the next authorization, and the ongoing insufficiency of funding, difficult choices must be made. I believe it is our ethical responsibility to ensure that those jurisdictions faced with increasing need are provided with increased resources. A "hold harmless" of two percent does not accomplish this objective. The delegation letter avers they are joining "the national AIDS community." Los Angeles County respectfully disagrees. Despite broad and deep support for CARE Act reauthorization, there remains a lack of unanimity among advocates and advocacy groups on how best to design the formula for distribution of Title I funds. The most vocal proponent of the two percent "hold harmless" provision is the CAEAR Coalition, which abandoned its efforts to achieve consensus and adopted its position by a majority vote among fewer than half of Title I eligible areas. You are aware of delegation letters from the southern California and Texas members of the House supporting a more progressive approach to the distribution of Title I formula funds. The delegation letter suggests that additional correction can be had through the allocation of supplemental funds. The supplemental program is competitive, although the criteria for judgment have not always been clear. In competitive applications, jurisdictions that are receiving greater per capita formula award are at an inherent advantage over those that receive much lower sums, simply because the generous funding has allowed for the development of capacity to implement, evaluate and promote services. The competition is simply not a level playing field. As you know, the supplemental funds have historically been distributed in proportions roughly equal to the formula awards, thereby doubling the impact of any policy made for the distribution of formula funds. Although this practice may be corrected by the reauthorized CARE Act, careful consideration will have to be exercised to ensure that supplemental funds make a meaningful contribution towards achieving system-wide equity. Thank you again for your interest in this vital matter. If you have any questions or need additional information, please call me at (213) 351-8001 or Gunther Freehill at (213) 351-8340. Very truly yours, Charles L. Henry, Director Office of AIDS Programs and Policy cc: Mark Finucane Jonathan E. Fielding John F. Schunhoff Barbara Masters Susan J. White Gunther Freehill Enclosure: Formula Year 09 HRSA CDC Dec 1998 Cases Per Case Cases Per Case Oakland EMA 3,146,873 2,035 $ 1,546 2,805 $ 1,122 San Jose EMA 1,268,028 820 $ 1,546 1,197 $ 1,059 San Francisco EMA 18,475,245 6,079 $ 3,039 8,660 $ 2,133 Santa Rosa EMA 603,087 390 $ 1,546 575 $ 1,049 ------------------------------------- Michael Petrelis Welcome to AIDS-STATISTICS www.AIDS-statistics.com 2215-R Market Street, #413 San Francisco, CA 94114