Subject: LA v. SF for federal Ryan White AIDS funding
From: [email-masked]
Date: Thu, 15 Jun 2000 13:15:48 EDT

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 

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