Mr. Speaker, 19 years ago, I came to Congress to fight AIDS, a disease that has taken nearly 18,000 lives in my city of San Francisco alone. We have lost friends, family, and loved ones, but we have not lost our will to fight this terrible…
Mr. Speaker, 19 years ago, I came to Congress to fight AIDS, a disease that has taken nearly 18,000 lives in my city of San Francisco alone.
We have lost friends, family, and loved ones, but we have not lost our will to fight this terrible disease. This year, we mark the 25th anniversary of the first diagnosis of AIDS--a stark reminder that this epidemic is still among us, and that our work is not done.
Yet as we grieve for those we have lost, we are filled with hope as we see the strength of those who are fighting and living full lives with HIV and AIDS. This would not be possible without the help of the Federal Government through initiatives such as the Ryan White CARE Act. The act has been instrumental in our fight to defeat AIDS. It has greatly improved the quality and availability of health care services for people living with and affected by HIV and AIDS. I was proud to be a part of the creation of the Ryan White CARE Act.
Unfortunately, I must rise in opposition to this reauthorization.
There are a number of good provisions in this bill, including the recognition of emerging communities and the use of actual living AIDS counts rather than estimated living AIDS cases. That change will benefit many communities, including my constituents in San Francisco.
However, when it comes to meeting the needs of people living with AIDS, our mantra should be the same as the physicians who care for all patients: first, do no harm. The primary problem with this legislation is that it fails to provide adequate funding for the treatment of HIV/ AIDS patients.
Had this Administration and the Republican-controlled Congress made a priority of funding the Ryan White program over the last several years, I would be standing here in strong support of this bill. But they have not, and I cannot support this bill.
Yet funding in this bill simply won't be able to meet the current demand for HIV/AIDS care in the United States. Under this reauthorization, San Francisco, with the highest per capita caseload of people living with AIDS in the country, stands to lose almost $30 million over the next 5 years.
That is a far cry from the bipartisan consensus we were able to achieve on this issue between 1993 and 2001. During that time, funding--adjusted for both inflation and caseload growth--under the Ryan CARE Act increased by 70 percent.
Since 2001, funding has declined by 35 percent.
The problem is not that one part of the country gets too much money and some other parts of the country are left behind. Instead, people suffering from this disease--and those caring for them--are being forced to compete for pieces of an ever-shrinking pie.
If funding for this Act had simply kept pace with the number of people with AIDS and inflation, my city and all other cities and States would be getting increases in funding instead of grappling with how they can stretch--and where they will have to sacrifice--in meeting the growing demand for services.
In fact, the impact of the cuts will be compounded, because in San Francisco, these funds form the basis for matching funds from the city.
Due in no small part to this Federal, State and local investment, more people are living with HIV and AIDS now than dying from it. That is remarkable.
As the epicenter of the epidemic, San Francisco has experienced terrible loss of life--but from that loss, my city has created a standard of care that has been a model for the Nation.
But our problem has not gone away. There are more people living with AIDS in the San Francisco's area than at any point in the epidemic's history.
This legislation has far-reaching implications for the stability of HIV/AIDS funding in our State and cities. The programs funded by the Ryan White CARE Act have literally been life-savers for people who live with HIV/AIDS.
It has provided critical support to the cities that have been the center of the epidemic, and to States that have been funding critical drug and support programs to treat the disease. This cut in funding to San Francisco means a loss in services for patients receiving primary medical care, a lack of access to counseling, support, outreach services, transitional and emergency housing and emergency payments for health care costs.
Where do these people go? What do we tell them when their ability to receive support to fight HIV/AIDS is cut off?
In prior reauthorizations of the Ryan White CARE Act, the changes that have been made were made at the margins in order to deal with emerging problems and developments; these changes did not, however, disrupt an initiative that was working.
Unlike those past reauthorizations, this bill would have a drastic destabilizing effect on many of the hardest-hit areas of the country, including California.
A basic goal of this reauthorization must be to ensure that the actions we take do not destabilize systems already in place. Unfortunately, the bill fails to meet this goal and jeopardizes the critical funding of areas throughout the country, in general, and the State and cities of California in particular.
In addition, the bill prematurely incorporates HIV reporting into the allocation formula, eliminates the hold harmless provision just when San Francisco and California need it the most, and allows the Administration to devise and implement a whole new funding formula without Congressional approval.
It is for these reasons, I must oppose this bill. And I will submit the entirety of my statement for the record.
The second major problem with this legislation is that there is simply no way to incorporate data on HIV cases into the funding formula on a consistent and comparable basis
across jurisdictions. The 2000 reauthorization of the Act included a requirement that HIV cases be incorporated into the funding distribution by no later than 2007. At that time, HIV reporting systems were in various stages of development across the country; although some states and cities had been reporting HIV cases by name since 1985, others had yet to implement an HIV-reporting system at all. Given this landscape, the drafters understood the need to provide sufficient time to allow states and cities to begin collecting HIV cases. At the time, they believed seven years to be adequate for such a transition. As it turns out, it was not.
As HIV reporting systems were developed, variations among these systems across jurisdictions emerged. Some areas reported HIV by the individual's name along with other identifying information. Others, like California, as a means of protecting the individual's confidentiality, opted not to report the person's name at all, and instead included only a unique code identifying the individual. The 2000 reauthorization of the Ryan White Act did not specify which type of reporting system jurisdictions were required to use and nothing in the law prohibited this kind of variation. So long as the Secretary found that the data on HIV cases was ``sufficiently accurate and reliable,'' jurisdictions were free to report cases by name or by code. Thus, whether an area began collecting HIV by name or by code, they were on equally solid ground under the law.
It was not until December 2005, that CDC first gave a clear indication that it would deem only cases reported by name to be ``sufficiently accurate and reliable.'' In a letter to all code-based States, CDC set forth its strong recommendation that those States convert their systems to names-based--it did not, however, establish any sort of legal requirement. At that point, 13 States used some form of a code-based reporting system. In response to CDC's announcement, almost all code-based States began the process of converting. their HIV reporting systems to names-based systems.
The reported bill would rely exclusively on names-based HIV and AIDS cases in making funding allocations starting in fiscal year 2011. In order to meet this deadline, and have all of their names-based HIV cases counted for funding purposes, code-based jurisdictions will be required to have completely converted to names-based systems in less than 3 years.
For large and diverse code-based States with several very large cities, like California, this is simply not enough time to make this change. California essentially has to start from scratch. In its code- based system, California currently has approximately 40,000 cases of HIV (non-AIDS). Under California law, these cases cannot simply be re- tallied under the new names-based system. In order to incorporate these cases into the new system, the State must contact each of these 40,000 individuals, and ask them to come in to a testing site to be re-tested. Some of these individuals are homeless. Some are drug-abusers. Many don't speak English. When personnel and resources are already strained, California will simply not be able to get all of these individuals entered into the names-based system in 3 years.
The experience of other large code-based systems provides a sense of the difficulty of this task. New York, for example, converted to a names-based system in 2000 and is now considered by CDC to be mature. However, it is widely acknowledged that New York's current names-based HIV count severely undercounts the true burden of HIV in the State simply because it has not had enough time to find and report all of its HIV cases.
I cannot support legislation that would disadvantage my State and city and take large amounts of dollars away simply because the data system is incomplete. The number of persons with HIV and with need for services remains. They should not lose needed services because of an unrealistic data requirement.
Under the language of the proposal, it is also unclear on what basis the funds will be allocated. GAO and the State of California, both of which have modeled the bill, have quite different case counts for the same State and city. The proposed language says code-based numbers are used to determine funding allocations. HRSA numbers used by GAO in their estimates are not code-based numbers. Those numbers purport to show need--not any scientific way of counting cases and a method which surely varies from jurisdiction to jurisdiction depending on how much the grantee estimated. What assurance is there that the GAO numbers will be used to allocate funds in fiscal year 2007 and the out years? This does not pass the test of good government.
Under the proposed language, the case count used in 2010 and 2011 in making the allocation to San Francisco will be substantially less than the actual number of HIV positive individuals who currently live in San Francisco. That simply is unfair and is not good policy.
Because HIV reporting systems across the country remain in a state of flux, it is critical that this reauthorization protect against severe losses in funding when the bill requires that the funding be based on HIV cases. The most effective way to accomplish this protection is to incorporate a hold-harmless provision for the entire life of the bill. Unfortunately, the current bill protects a jurisdiction's funding for only the first 3 years. This is not enough.
California faces the most drastic cuts at the very time the hold harmless under the bill comes to an end. By California's estimates, the State stands to lose nearly 25 percent of its total Ryan White Care Act funding during the 5th year of the bill alone. Our State simply cannot sustain these kinds of losses.
In year 5, when transition to names-based reporting becomes mandatory, California (and all other jurisdictions moving to names- based reporting) will lose substantially. The amount of loss is difficult to ascertain, because it will depend entirely upon how quickly California and other jurisdictions can transition to names- based reporting.
The elimination of the hold harmless will have a devastating impact on the provision of HIV/AIDS services in San Francisco. The hold harmless was adopted to protect the epicenters of this disease from experiencing drastic reductions in CARE funding from year to year that would disrupt the systems of care in place, and eliminating it now would cause this very consequence. As you may know, the city of San Francisco consistently has invested local funds into the fight against this disease and the care of those living with HIV/AIDS. San Francisco has been conscientiously preparing to absorb cuts as a result of the eventual loss of the hold harmless, but the more than one-third cut in funding proposed is punitive and will eliminate critical care for thousands of people living with HIV/AIDS.
Finally, I cannot support the bill's inclusion of the so-called ``severity of need index'' (SONI). The bill requires the Secretary to develop a SONI to measure the relative needs of individuals living with HIV/AIDS, but fails to specify the factors that should be incorporated into this index, leaving it entirely up to the Secretary. Further, the bill then permits the Secretary to completely discard the current funding formula and distribute funding on the basis of this SONI beginning as early as FY 2011 without Congressional action. This is unacceptable. Congress--not the Administration--should be solely responsible for making such a drastic shift in the way funds are distributed under the Act.