Audit of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, Title II, Administered by the Health Resources and Services Administration

EXECUTIVE SUMMARY:

This report provides the results of our audit of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, Title II (CARE Act), Administered by the Health Resources and Services Administration (HRSA). The CARE Act is intended to supplement amounts States were spending on the Human Immunodeficiency Virus (HIV 1)epidemic and to improve services for HIV positive individuals and their families who would otherwise have no access to health care (i.e., the CARE Act was intended to be the payor of last resort). The objective of our audit was to determine whether HRSA procedures are effective to ensure that States (1) maintain their required level-of-effort for HIV related activities, and (2) utilize Ryan White funds as a payor of last resort for services to individuals with HIV.

As a prelude to a nationwide audit, we reviewed the State of Connecticut process for supporting assurances relative to (1) the State maintaining its required level-of-effort for HIV related activities, and (2) CARE Act finds being used as the payor of last resort. Annually, the State of Connecticut provided the assurances that the State was meeting these two requirements. We found, however, that the State of Connecticut:

Could not support the assurance that the State was maintaining its required level-of-effort for HIV related activities. We found the Connecticut's reports of State funded HIV related expenditures were not based on reliable information. In this respect, the Connecticut reports were not accurate or complete.

Did not always use CARE Act funds as the payor of last resort. For the five years ended June 30, 1995, Connecticut used CARE Act funds to pay $995,000 for drug assistance for low income individuals when State funds were available. Further, data provided by State officials indicate a significant portion of another $635,000 (Fiscal Years (FYs) 1995 and 1996) was used for services provided to inmates who were the responsibility of the State.

In March and August 1996, HRSA provided grantees with draft policy guidance on several programmatic issues. However, the draft policies did not provide specific guidance to grantees relating to States (1) maintaining their required level-of-effort for HIV related activities, and (2) utilizing State funded programs such as State drug assistance or programs for inmates under the custody of the State prior to CARE Act funding.

Initially, we intended to perform audits in several States, Connecticut being the first. We issued a final report to Connecticut officials on September 27, 1996 (CIN: A-01 -96-O 1501). We discussed and shared the Connecticut audit results with HRSA officials in August 1996. In consideration of the issues noted in the State of Connecticut, HRSA officials informed us that they are willing to initiate actions which would preclude the necessity of audits in other States. This should ensure that more CARE Act funds are available for services to HIV individuals.

Relative to level-of-effort for HIV related activities, we recommend that HRSA (1) provide guidance to States regarding what data to consistently report, year to year, as HIV related expenditures, (2) require States to describe their methodology for compiling HIV expenditure data, and (3) require States to report HIV related expenditures funded by the State for the previous two years in each grant application. Further, we recommend that HRSA inform States what could happen with future funding should States not maintain the required level of effort.

Relative to utilizing Ryan White finds as payor of last resort for services to individuals with HIV, we recommend that HRSA issue specific guidance that CARE Act funds should only be used to supplement and enhance existing State programs, particularly State funded drug assistance programs and programs for inmates under the custody of the States.

In response to our draft report, HRSA officials concur with our recommendations.

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