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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
B
Financial Resources of States for HIV/AIDS Reporting
Several of the factors determining system accuracy, such as the ability to follow up on a backlog of cases, depend on the capacity to conduct surveillance. As one indicator of capacity, the Committee examined federal and state funding for HIV/AIDS case reporting. The Committee heard testimony from a small number of states, from the Centers for Disease Control and Prevention (CDC) staff, and from select Eligible Metropolitan Areas (EMAs) regarding surveillance capacity and funding. The Committee also reviewed information provided by state AIDS programs and from the CDC regarding state and federal contributions to HIV/AIDS surveillance for fiscal years 1999–2002.
With the exception of very large county or city health departments, state surveillance programs provide the HIV/AIDS surveillance data for Ryan White CARE Act (RWCA) planning and evaluation. While HIV reporting has been implemented in all states and cities, except Georgia and Philadelphia (as of October 2003), most states did not see a concurrent increase in financial resources to assist with the implementation of HIV reporting. Although the RWCA Amendments of 2000 authorized limited additional funds to assist states with the implementation of HIV reporting systems (Ryan White CARE Act. Sec. 300ff-13), that funding has yet to be appropriated. Even though HIV and AIDS data are perceived to be readily available for RWCA purposes at no additional cost, states must often provide specialized reports for RWCA planning that include different or more-detailed data than are provided in standard epidemiologic reports.1 Such efforts can be costly.
1
Subcommittee site visit to the CDC, April 4, 2002.
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When considering the question of surveillance capacity, there are at least two levels of system cost: one associated with the implementation of HIV reporting, and the other associated with RWCA planning efforts at state and local levels. Cost issues are relevant to the question of capacity, particularly given the pervasive fiscal austerity of states and localities.
DATA EXAMINED
Financial resources clearly affect reporting capacity. In the absence of models to estimate surveillance costs, the Committee attempted to understand more about surveillance capacity by studying the distribution of federal and state funding for surveillance programs. The Committee reviewed two sources of funding for state HIV/AIDS surveillance programs for the years 1999 through 2002: (1) self-reported state general revenue contributions for HIV and AIDS surveillance, and (2) federal core surveillance funding to states through cooperative agreements with the CDC.2
The National Alliance of State and Territorial AIDS Directors (NASTAD) administered a request for information to state AIDS directors regarding states’ general revenue contributions to their HIV/AIDS surveillance programs during fiscal years 1999–2002. Forty-one states responded to that request for information.3 States were also asked to identify expected changes in general revenue (remain constant, decrease, increase). The CDC provided data to the Committee on federal funding to states for core surveillance and for other surveillance activities for corresponding fiscal years 1999 through 2002 (CDC, 2003).
The Committee reviewed data for 1999 through 2002 for three reasons: (1) approximately one-third of states implemented HIV reporting during this time period (see Table 3-1 in chapter 3), (2) state fiscal austerity was emerging during this time period, and (3) these data were readily available from most states.
2
CDC provides “core funding” to states for their HIV/AIDS reporting systems. CDC provides additional funds to states, based on a competitive grant application process, for supplemental surveillance activities.
3
States were asked not to include state general revenue contributions to the six cities/counties in their jurisdiction that receive direct funding from CDC for HIV/AIDS reporting (Chicago, Houston, New York, Los Angeles, Philadelphia, and San Francisco). A separate request for information was made to those areas. States were also asked to exclude in-kind contributions (e.g., staff on loan from another division) and funding for general communicable disease or sexually transmitted disease surveillance.
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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
RESULTS
The Committee examined data provided by the CDC and NASTAD on federal and state contributions for HIV surveillance. The Committee converted the total spending to spending per capita, using data from the 2000 Census (U.S. Census Bureau, 2000). During 1999–2002, the majority of funds for AIDS and HIV surveillance programs came from the federal government, and in 32 states, funding was entirely from the federal government. Average federal and state funding was flat from 1999–2002. Relative state contributions were flat during the period with less than 10 percent of the total average $0.09–$0.10 spent per capita. Moreover, 33 of the 41 states that responded reported $0 of state general revenue funding for HIV/AIDS surveillance programs for fiscal years 1999, 2000, and 2002. Thirty-two states reported $0 state contributions in fiscal year 2001.
State-by-state comparisons of federal and state HIV/AIDS surveillance funding for 1999–2002 in dollar terms is found in Table B-1. State contributions to HIV/AIDS surveillance funding are only provided for the 41 states that responded to NASTAD’s request for information. Federal contributions are provided for all 50 states and the District of Columbia.
The funding picture for state HIV/AIDS surveillance programs did not change appreciably during FY1999–2002 for the 41 states that responded to the request for information.4
Table B-2 shows state general revenue contributions for HIV/AIDS surveillance as a percentage of total surveillance budgets. The aggregate reliance on federal resources for HIV/AIDS surveillance does not change greatly from year to year.
Table B-3 presents data from the 11 states that implemented HIV reporting during the analysis period. These data show that for the majority of these states, there was little change in the amount of state or federal funding for surveillance during the period when they were implementing HIV reporting. Only California substantially increased funding in the years just prior to implementation of HIV reporting. Pennsylvania began general revenue contributions prior to implementing HIV reporting, but Kansas discontinued general revenue contributions the year following implementation of HIV reporting. Federal funding increased for Vermont, Hawaii, Alaska, and Kansas during this period, but was essentially flat for other states.
4
Financial data were adjusted for inflation using the All Items Consumer Price Index. U.S. City average, nonseasonally adjusted, All Urban Consumers. (U.S. Department of Labor, Bureau of Labor Statistics). [Online] http://data.bls.gov.SeriesID:CUUS0000SA0.
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TABLE B-1 State and Federal Contributions for HIV/AIDS Surveillance for FY1999–2002, in Dollars (N=51)
FY1999
FY2000
State
State General Revenue (in $)
Federal Revenue (in $)
State General Revenue (in $)
Federal Revenue (in $)
Alabama
Not Available*
572,603
Not Available
786,712
Alaska
0
115,000
0
115,000
Arizona
125,000
340,573
125,000
398,133
Arkansas
0
238,727
0
207,653
Californiaa
5,116,200
3,914,875
7,746,000
4,058,017
Colorado
0
537,822
0
467,772
Connecticut
Not Available
346,444
Not Available
298,319
Delaware
0
112,664
0
113,005
District of Columbia
Not Available
388,336
Not Available
485,865
Florida
634,227
1,806,242
634,227
1,760,761
Georgia
0
196,816
0
297,909
Hawaii
0
31,505
0
135,989
Idaho
0
75,000
0
75,000
Illinois
Not Available
1,010,508b
Not Available
1,409,531b
Indiana
0
274,633
0
280,708
Iowa
0
29,476
0
129,151
Kansas
42,900
90,200
42,900
127,301
Kentucky
0
109,852
0
117,000
Louisiana
7,500
772,966
7,500
774,042
Maine
0
112,947
0
72,319
Maryland
Not Available
956,359
Not Available
956,359
Massachusetts
0
226,901
0
483,925
Michigan
0
851,426
0
881,745
Minnesota
0
189,568
0
232,345
Mississippi
0
243,071
0
220,000
Missouri
0
550,203
0
577,455
Montana
0
68,105
0
67,124
Nebraska
0
83,635
0
120,000
Nevada
Not Available
310,600
Not Available
327,494
New Hampshire
Not Available
83,200
Not Available
77,985
New Jersey
616,000
2,202,177
553,000
2,089,025
New Mexico
Not Available
163,320
Not Available
213,479
New York
1,607,028
4,525,303c
1,809,183
4,394,123c
North Carolina
0
406,125
0
1,292d
North Dakota
0
59,675
0
59,251
Ohio
0
176,228
0
399,052
Oklahoma
0
286,509
0
286,509
Oregon
Not Available
330,108
Not Available
320,108
Pennsylvania
0
1,079,110e
0
1,092,184e
Rhode Island
Not Available
213,218
Not Available
214,304
South Carolina
0
446,217
0
486,314
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FY2001
FY2002
State General Revenue (in $)
Federal Revenue (in $)
State General Revenue (in $)
Federal Revenue (in $)
Not Available
551,606
Not Available
557,276
0
120,750
0
120,750
125,000
423,863
125,000
380,226
0
218,036
0
218,036
7,746,000
3,927,473
7,746,000
4,042,160
0
522,250
0
318,972
Not Available
433,988
Not Available
454,338
0
126,864
0
126,904
Not Available
487,435
Not Available
510,158
634,227
1,896,204
634,227
183,146
0
69,973
0
384,666
0
173,417
0
173,418
0
78,750
0
64,184
Not Available
750,838b
Not Available
988,642b
0
362,653
0
325,508
0
169,198
0
143,412
42,900
135,344
0
130,144
0
122,850
0
122,850
7,500
812,010
7,500
322,866
0
103,530
0
106,688
Not Available
988,653
Not Available
874,028
0
488,190
0
409,864
0
925,832
0
924,110
0
144,096
0
247,094
0
132,424
0
132,720
0
601,078
0
601,078
0
63,100
0
67,772
0
126,000
0
126,000
Not Available
343,869
Not Available
343,870
Not Available
87,681
Not Available
76,838
692,000
2,260,092
400,000
2,224,150
Not Available
179,071
Not Available
153,312
1,726,081
4,097,758c
1,590,230
4,484,826c
0
228,949
0
374,534
0
61,067
0
62,214
0
481,189
0
516,746
0
300,834
0
300,834
Not Available
326,113
Not Available
336,114
100,000
1,128,759e
100,000
966,010e
Not Available
226,169
Not Available
226,170
0
501,745
0
371,358
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FY1999
FY2000
State
State General Revenue (in $)
Federal Revenue (in $)
State General Revenue (in $)
Federal Revenue (in $)
South Dakota
0
52,048
0
54,404
Tennessee
0
526,858
0
505,200
Texas
263,006
1,627,176f
263,006
1,401,897f
Utah
0
115,481
0
141,092
Vermont
0
64,294
0
75,056
Virginia
0
339,806
0
423,268
Washington
0
748,702
0
760,952
West Virginia
0
182,351
0
204,419
Wisconsin
0
342,445
0
342,445
Wyoming
0
52,690
0
52,689
aIncludes funding for Los Angeles and San Francisco.
bIncludes funding for Chicago.
cIncludes funding for New York City.
d$1,292 was allocated to North Carolina in 2000 due to unexpended and carryover funding from the previous year.
eIncludes funding for Philadelphia.
fIncludes funding for Houston.
*Not available means there was no response to NASTAD’s request for information.
NOTE: Data from states is self-reported and has not been independently verified.
SOURCE: NASTAD, 2003.
TABLE B-2 State Funding for HIV/AIDS Surveillance as a Percent of Total State HIV/AIDS Surveillance Budget, FY1999–2002 (N = 41)
Fiscal Year
Mean (%)
1999
4.48
2000
4.36
2001
4.65
2002
3.51
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FY2001
FY2002
State General Revenue (in $)
Federal Revenue (in $)
State General Revenue (in $)
Federal Revenue (in $)
0
47,024
0
44,454
0
581,102
0
616,100
268,872
1,308,762f
268,872
1,086,330f
0
168,719
0
179,268
0
128,832
0
82,526
0
444,332
0
393,084
0
802,181
0
770,510
0
199,627
0
225,750
0
383,851
0
341,914
0
51,555
0
57,954
TABLE B-3 State and Core Federal Funding for Surveillance by States Implementing HIV Surveillance per 1,000 Adult Population, FY1999–2002, by State (N = 11)
State Funding (in $)
Federal Funding (in $)
State
1999
2000
2001
2002
1999
2000
2001
2002
Alaska
0*
0
0
0
20*
20
190
190
California
150
230
230
230*
120
120
120
120*
Delaware
0
0
0*
0
160
140
160*
160
Hawaii
0
0
0*
0
30
110
140*
140
Kansas
20
20
20
0
30*
50
50
50
Kentucky
0
0*
0
0
30
30*
30
10
Maine
0*
0
0
0
90*
60
80
80
Montana
0
0*
0
0
80
70*
70
80
New York
80
100*
90
80
80
80*
90
80
Pennsylvania
0
0
10
10*
40
40
40
40*
Vermont
0
0*
0
0
110
120*
210
140
*Year of HIV surveillance implementation
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As one of several potential indicators of capacity, these data imply that more financial resources might be required to accommodate the current and additional information needs or demands of the HIV/AIDS surveillance programs vis-à-vis use of information for RWCA planning, allocation, or evaluation. States are facing significant financial crises, and while several states are newly implementing HIV reporting, most programs do not anticipate additional state general revenue contributions. According to the 41 states that responded to the NASTAD request for information, 65 percent (27) reported that they expect their state’s contributions for HIV/AIDS surveillance to remain constant; 7.3 percent (3) reported that they expect a decrease; while 2.4 percent (1) reported they expect an increase. State dependence upon federal funding for HIV surveillance activity, and for the provision of HIV/AIDS data for RWCA planning, evaluation, and allocation is apparent.
The use of financial data to understand capacity has limitations. For example, some resources used for other surveillance may partially support HIV/AIDS surveillance. Furthermore, the Committee did not have the ability to calculate the incremental costs of implementing specific HIV surveillance and reporting activities. Nevertheless, it appears that states are being required to engage in additional surveillance and reporting activities without a commensurate increase in state or federal resources. Additional assessments of the incremental costs of such activities would be helpful in determining overall funding needed to support HIV/AIDS surveillance activities.
REFERENCES
CDC (Centers for Disease Control and Prevention). 2003. FY02 Surveillance by State Final. (Email communication, Patricia Sweeney, CDC, May 2, 2003).
NASTAD. 2003. Request for Information: State/Local Funding for HIV/AIDS Surveillance.
U.S. Census Bureau. 2000. Population, Housing Units, Area and Density (geographies ranked by total population). [Online]. Available: http://factfinder.census.gov/ [accessed June 25, 2003].
U.S. Department of Labor. Bureau of Labor Statistics. [Online]. Available: http://data.bls.gov. Series ID: CUUS0000SA0.
Representative terms from entire chapter:
surveillance programs