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104th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES

 1st Session                                                    104-245
_______________________________________________________________________


 
                 RYAN WHITE CARE ACT AMENDMENTS OF 1995

                                _______


 September 14, 1995.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

_______________________________________________________________________


  Mr. Bliley, from the Committee on Commerce, submitted the following

                              R E P O R T

                             together with

                            ADDITIONAL VIEWS

                        [To accompany H.R. 1872]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Commerce, to whom was referred the bill 
(H.R. 1872) to amend the Public Health Service Act to revise 
and extend programs established pursuant to the Ryan White 
Comprehensive AIDS Resources Emergency Act of 1990, having 
considered the same, report favorably thereon with an amendment 
and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
The Amendment....................................................     2
Purpose and Summary..............................................    14
Background and Need for Legislation..............................    14
Hearings.........................................................    15
Committee Consideration..........................................    16
Roll Call Votes..................................................    17
Committee Oversight Findings.....................................    18
Committee on Government Reform and Oversight.....................    18
Committee Cost Estimate..........................................    18
Congressional Budget Office Estimate.............................    18
Advisory Committee Statement.....................................    22
Inflationary Impact Statement....................................    22
Section-by-section Analysis of Legislation.......................    22
Changes in Existing Law Made by the Bill, As Reported............    38
Minority and Additional Views....................................    66
  The amendment is as follows:
  Strike out all after the enacting clause and insert in lieu 
thereof the following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Ryan White CARE Act Amendments of 
1995''.

SEC. 2. REFERENCES.

  Whenever in this Act an amendment is expressed in terms of an 
amendment to a section or other provision, the reference shall be 
considered to be made to that section or other provision of the Public 
Health Service Act (42 U.S.C. 201 et seq.).

 TITLE I--EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES

SEC. 101. ESTABLISHMENT OF PROGRAM OF GRANTS.

  (a) In General.--Section 2601 (42 U.S.C. 300ff-11) is amended--
          (1) in subsection (a),
                  (A) by striking ``subject to subsection (b)'' and 
                inserting ``subject to subsections (b) through (d)''; 
                and
                  (B) by striking ``metropolitan area'' and all that 
                follows and inserting the following: ``metropolitan 
                area for which there has been reported to the Director 
                of the Centers for Disease Control and Prevention a 
                cumulative total of more than 2,000 cases of acquired 
                immune deficiency syndrome for the most recent period 
                of five calendar years for which such data are 
                available.''; and
          (2) by adding at the end thereof the following subsections:
  ``(c) Requirement Regarding Population.--In the case of a 
metropolitan area that was not an eligible area under this part for 
fiscal year 1996, the Secretary may not make a grant under this section 
for the area unless the area has a population of 500,000 or more 
individuals. For purposes of eligibility under this part, the 
boundaries of each metropolitan area are the boundaries in effect for 
fiscal year 1994.
  ``(d) Continued Status as Eligible Area.--A metropolitan area that 
was an eligible area under this part for fiscal year 1996 is an 
eligible area for fiscal year 1997 and each subsequent fiscal year.''.
  (b) Conforming Amendment Regarding Definition of Eligible Area.--
Section 2607(1) (42 U.S.C. 300ff-17(1)) is amended by striking ``The 
term'' and all that follows and inserting the following: ``The term 
`eligible area' means a metropolitan area meeting the requirements of 
section 2601 that are applicable to the area.''.

SEC. 102. HIV HEALTH SERVICES PLANNING COUNCIL.

  (a) Establishment.--Section 2602(b)(1) (42 U.S.C. 300ff-12(b)(1)) is 
amended--
          (1) in subparagraph (A), by inserting before the semicolon 
        the following: ``, including federally qualified health 
        centers'';
          (2) in subparagraph (D), by inserting before the semicolon 
        the following: ``and providers of services regarding substance 
        abuse'';
          (3) in subparagraph (G), by inserting before the semicolon 
        the following: ``and historically underserved groups and 
        subpopulations'';
          (4) in subparagraph (I), by inserting before the semicolon 
        the following: ``, including the State medicaid agency and the 
        agency administering the program under part B'';
          (5) in subparagraph (J), by striking ``and'' after the 
        semicolon;
          (6) by striking subparagraph (K); and
          (7) by adding at the end the following subparagraphs:
                  ``(K) grantees under section 2671, or, if none are 
                operating in the area, representatives of organizations 
                in the area with a history of serving children, youth, 
                women, and families living with HIV; and
                  ``(L) grantees under other HIV-related Federal 
                programs.''.
  (b) Duties.--Section 2602(b)(3) (42 U.S.C. 300ff-12(b)(3)) is 
amended--
          (1) by striking ``The planning'' in the matter preceding 
        subparagraph (A) and all that follows through the semicolon at 
        the end of subparagraph (A) and inserting the following: ``The 
        planning council under paragraph (1) shall carry out the 
        following:
                  ``(A) Establish priorities for the allocation of 
                funds within the eligible area based on the following 
                factors:
                          ``(i) Documented needs of the HIV-infected 
                        population.
                          ``(ii) Cost and outcome effectiveness of 
                        proposed strategies and interventions, to the 
                        extent that such data are reasonably available.
                          ``(iii) Priorities of the HIV-infected 
                        communities for which the services are 
                        intended.
                          ``(iv) Availability of other governmental and 
                        nongovernmental resources.'';
          (2) in subparagraph (B)--
                  (A) by striking ``develop'' and inserting 
                ``Develop''; and
                  (B) by striking ``; and'' and inserting a period;
          (3) in subparagraph (C)--
                  (A) by striking ``assess'' and inserting ``Assess'';
                  (B) by striking ``rapidly''; and
                  (C) by inserting before the period the following: ``, 
                and assess the effectiveness, either directly or 
                through contractual arrangements, of the services 
                offered in meeting the identified needs''; and
          (4) by adding at the end the following subparagraphs:
                  ``(D) Participate in the development of the statewide 
                coordinated statement of need initiated by the State 
                health department (where it has been so initiated).
                  ``(E) Obtain input on community needs through 
                conducting public meetings.''.
  (c) General Provisions.--Section 2602(b) (42 U.S.C. 300ff-12(b)) is 
amended by adding at the end the following paragraph:
          ``(4) General provisions.--
                  ``(A) Composition of council.--The planning council 
                under paragraph (1) shall (in addition to requirements 
                under such paragraph) reflect in its composition the 
                demographics of the epidemic in the eligible area 
                involved, with particular consideration given to 
                disproportionately affected and historically 
                underserved groups and subpopulations. Nominations for 
                membership on the council shall be identified through 
                an open process, and candidates shall be selected based 
                on locally delineated and publicized criteria. Such 
                criteria shall include a conflict-of-interest standard 
                for each nominee.
                  ``(B) Conflicts of interest.--
                          ``(i) The planning council under paragraph 
                        (1) may not be directly involved in the 
                        administration of a grant under section 
                        2601(a). With respect to compliance with the 
                        preceding sentence, the planning council may 
                        not designate (or otherwise be involved in the 
                        selection of) particular entities as recipients 
                        of any of the amounts provided in the grant.
                          ``(ii) An individual may serve on the 
                        planning council under paragraph (1) only if 
                        the individual agrees to comply with the 
                        following:
                                  ``(I) If the individual has a 
                                financial interest in an entity, and 
                                such entity is seeking amounts from a 
                                grant under section 2601(a), the 
                                individual will not, with respect to 
                                the purpose for which the entity seeks 
                                such amounts, participate (directly or 
                                in an advisory capacity) in the process 
                                of selecting entities to receive such 
                                amounts for such purpose.
                                  ``(II) In the case of a public or 
                                private entity of which the individual 
                                is an employee, or a public or private 
                                organization of which the individual is 
                                a member, the individual will not 
                                participate (directly or in an advisory 
                                capacity) in the process of making any 
                                decision that relates to the 
                                expenditure of a grant under section 
                                2601(a) for such entity or organization 
                                or that otherwise directly affects the 
                                entity or organization.''.

SEC. 103. TYPE AND DISTRIBUTION OF GRANTS.

  (a) Formula Grants Based on Relative Need of Areas.--Section 2603(a) 
(42 U.S.C. 300ff-13(a)) is amended--
          (1) in paragraph (1)--
                  (A) in the second sentence, by inserting ``, subject 
                to paragraph (4)'' before the period; and
                  (B) by adding at the end the following sentence: 
                ``Grants under this paragraph for a fiscal year shall 
                be disbursed not later than 60 days after the date on 
                which amounts appropriated under section 2677 become 
                available for the fiscal year, subject to any waivers 
                under section 2605(d).'';
          (2) in paragraph (2), by amending the paragraph to read as 
        follows:
          ``(2) Allocations.--Of the amount available under section 
        2677 for a fiscal year for making grants under section 
        2601(a)--
                  ``(A) the Secretary shall reserve 50 percent for 
                making grants under paragraph (1) in amounts determined 
                in accordance with paragraph (3); and
                  ``(B) the Secretary shall, after compliance with 
                subparagraph (A), reserve such funds as may be 
                necessary to carry out paragraph (4).''; and
          (3) by adding at the end the following paragraph:
          ``(4) Maximum reduction in grant.--In the case of any 
        eligible area for which a grant under paragraph (1) was made 
        for fiscal year 1995, the Secretary, in making grants under 
        such paragraph for the area for the fiscal years 1996 through 
        2000, shall (subject to the extent of the amount available 
        under section 2677 for the fiscal year involved for making 
        grants under section 2601(a)) ensure that the amounts of the 
        grants do not, relative to such grant for the area for fiscal 
        year 1995, constitute a reduction of more than the following, 
        as applicable to the fiscal year involved:
                  ``(A) 1 percent, in the case of fiscal year 1996.
                  ``(B) 2 percent, in the case of fiscal year 1997.
                  ``(C) 3 percent, in the case of fiscal year 1998.
                  ``(D) 4 percent, in the case of fiscal year 1999.
                  ``(E) 5 percent, in the case of fiscal year 2000.''.
  (b) Supplemental Grants.--Section 2603(b) (42 U.S.C. 300ff-13(b)) is 
amended--
          (1) in paragraph (1)--
                  (A) in the matter preceding subparagraph (A), by 
                striking ``Not later than'' and all that follows 
                through ``section 2605(b)--'' and inserting the 
                following: ``After allocating in accordance with 
                subsection (a) the amounts available under section 2677 
                for grants under section 2601(a) for a fiscal year, the 
                Secretary, in carrying out section 2601(a), shall from 
                the remaining amounts make grants to eligible areas 
                described in this paragraph. Such grants shall be 
                disbursed not later than 150 days after the date on 
                which amounts appropriated under section 2677 become 
                available for the fiscal year. An eligible area 
                described in this paragraph is an eligible area whose 
                application under section 2605(b)--'';
                  (B) in subparagraph (D), by striking ``and'' after 
                the semicolon;
                  (C) in subparagraph (E), by striking the period at 
                the end and inserting ``; and''; and
                  (D) by adding at the end thereof the following 
                subparagraph:
                  ``(F) demonstrates the manner in which the proposed 
                services are consistent with the local needs assessment 
                and the statewide coordinated statement of need.''; and
          (2)(A) by redesignating paragraphs (2) through (4) as 
        paragraphs (3) through (5), respectively; and
          (B) by inserting after paragraph (1) the following paragraph:
          ``(2) Priority.--
                  ``(A) Severe need.--In determining severe need in 
                accordance with paragraph (1)(B), the Secretary shall 
                give priority consideration in awarding grants under 
                this subsection to eligible areas that (in addition to 
                complying with paragraph (1)) demonstrate a more severe 
                need based on the prevalence in the eligible area of--
                          ``(i) sexually transmitted diseases, 
                        substance abuse, tuberculosis, severe mental 
                        illness, or other conditions determined 
                        relevant by the Secretary, which significantly 
                        affect the impact of HIV disease;
                          ``(ii) subpopulations with HIV disease that 
                        were previously unknown in such area; or
                          ``(iii) homelessness.
                  ``(B) Prevalence.--In determining prevalence of 
                conditions under subparagraph (A), the Secretary shall 
                use data on the prevalence of the conditions described 
                in such subparagraph among individuals with HIV disease 
                (except that, in the case of an eligible area for which 
                such data are not available, the Secretary shall use 
                data on the prevalences of the conditions in the 
                general population of such area).''.
  (c) Additional Requirements for Grants.--Section 2603 (42 U.S.C. 
300ff-13) is amended by adding at the end the following subsection:
  ``(c) Compliance With Priorities of HIV Planning Council.--
Notwithstanding any other provision of this part, the Secretary, in 
carrying out section 2601(a), may not make any grant under subsection 
(a) or (b) to an eligible area unless the application submitted by such 
area under section 2605 for the grant involved demonstrates that the 
grants made under subsections (a) and (b) to the area for the preceding 
fiscal year (if any) were expended in accordance with the priorities 
applicable to such year that were established, pursuant to section 
2602(b)(3)(A), by the planning council serving the area.''.

SEC. 104. USE OF AMOUNTS.

  Section 2604 (42 U.S.C. 300ff-14) is amended--
          (1) in subsection (b)--
                  (A) in paragraph (1)(A), by striking ``including case 
                management and comprehensive treatment services, for 
                individuals'' and inserting the following: ``including 
                HIV-related comprehensive treatment services (including 
                treatment education and measures for the prevention and 
                treatment of opportunistic infections), case 
                management, and substance abuse treatment and mental 
                health treatment, for individuals'';
                  (B) in paragraph (2)(A)--
                          (i) by inserting after ``nonprofit private 
                        entities,'' the following: ``or private for-
                        profit entities if such entities are the only 
                        available provider of quality HIV care in the 
                        area,'' ; and
                          (ii) by striking ``and homeless health 
                        centers'' and inserting ``homeless health 
                        centers, substance abuse treatment programs, 
                        and mental health programs''; and
                  (C) by adding at the end the following paragraph:
          ``(3) Priority for women, infants and children.--For the 
        purpose of providing health and support services to infants, 
        children, and women with HIV disease, the chief elected 
        official of an eligible area shall use, of the grants made for 
        the area under section 2601(a) for a fiscal year, not less than 
        the percentage constituted by the ratio of the population in 
        such area of infants, children, and women with acquired immune 
        deficiency syndrome to the general population in such area of 
        individuals with such syndrome, or 15 percent, whichever is 
        less. In expending the funds reserved under the preceding 
        sentence for a fiscal year, the chief elected official shall 
        give priority to providing, for pregnant women, measures to 
        prevent the perinatal transmission of HIV.''; and
          (2) in subsection (e), by adding at the end thereof the 
        following sentence: ``In the case of entities to which such 
        officer allocates amounts received by the officer under the 
        grant, the officer shall ensure that, of the aggregate amount 
        so allocated, the total of the expenditures by such entities 
        for administrative expenses does not exceed 10 percent (without 
        regard to whether particular entities expend more than 10 
        percent for such expenses).''.

SEC. 105. APPLICATION.

  Section 2605 (42 U.S.C. 300ff-15) is amended--
          (1) in subsection (a)--
                  (A) in paragraph (1)(B), by striking ``1-year 
                period'' and all that follows through ``eligible area'' 
                and inserting ``preceding fiscal year'';
                  (B) in paragraph (4), by striking ``and'' at the end 
                thereof;
                  (C) in paragraph (5), by striking the period at the 
                end thereof and inserting ``; and''; and
                  (D) by adding at the end thereof the following 
                paragraph:
          ``(6) that the applicant will participate in the process for 
        the statewide coordinated statement of need (where it has been 
        initiated by the State), and will ensure that the services 
        provided under the comprehensive plan are consistent with such 
        statement.'';
          (2) in subsection (b)--
                  (A) in the subsection heading, by striking 
                ``Additional''; and
                  (B) in the matter preceding paragraph (1), by 
                striking ``additional'';
          (3) by redesignating subsections (c) and (d) as subsections 
        (d) and (e), respectively; and
          (4) by inserting after subsection (b), the following 
        subsection:
  ``(c) Single Application.--Upon the request of the chief elected 
official of an eligible area, the Secretary may authorize the official 
to submit a single application through which the official 
simultaneously requests a grant pursuant to subsection (a) of section 
2603 and a grant pursuant to subsection (b) of such section. The 
Secretary may establish such criteria for carrying out this subsection 
as the Secretary determines to be appropriate.''.

SEC. 106. TECHNICAL ASSISTANCE; PLANNING GRANTS.

  Section 2606 (42 U.S.C. 300ff-16) is amended--
          (1) by inserting before ``The Administrator'' the following: 
        ``(a) In 
        General.--'';
          (2) by striking ``may, beginning'' and all that follows 
        through ``title,'' and inserting ``(referred to in this section 
        as the `Administrator') shall''; and
          (3) by adding at the end the following subsection:
  ``(b) Planning Grants Regarding Initial Eligibility for Grants.--
          ``(1) Advance payments on first-year formula grants.--With 
        respect to a fiscal year (referred to in this subsection as the 
        `planning year'), if a metropolitan area has not previously 
        received a grant under section 2601 and the Administrator 
        reasonably projects that the area will be eligible for such a 
        grant for the subsequent fiscal year, the Administrator may 
        make a grant for the planning year for the purpose of assisting 
        the area in preparing for the responsibilities of the area in 
        carrying out activities under this part.
          ``(2) Requirements.--
                  ``(A) In general.--A grant under paragraph (1) for a 
                planning year shall be made directly to the chief 
                elected official of the city or urban county that 
                administers the public health agency to which section 
                2602(a)(1) is projected to apply for purposes of such 
                paragraph. The grant may not be made in an amount 
                exceeding $75,000.
                  ``(B) Offsetting reduction in first formula grant.--
                In the case of a metropolitan area that has received a 
                grant under paragraph (1) for a planning year, the 
                first grant made pursuant to section 2603(a) for such 
                area shall be reduced by an amount equal to the amount 
                of the grant under such paragraph for the planning 
                year. With respect to amounts resulting from reductions 
                under the preceding sentence for a fiscal year, the 
                Secretary shall use such amounts to make grants under 
                section 2603(a) for the fiscal year, subject to 
                ensuring that none of such amounts are provided to any 
                metropolitan area for which such a reduction was made 
                for the fiscal year.
          ``(3) Funding.--Of the amounts available under section 2677 
        for a fiscal year for carrying out this part, the Administrator 
        may reserve not more than 1 percent for making grants under 
        paragraph (1).''.

                      TITLE II--CARE GRANT PROGRAM

SEC. 201. GENERAL USE OF GRANTS.

  Section 2612 (42 U.S.C. 300ff-22) is amended to read as follows:

``SEC. 2612. GENERAL USE OF GRANTS.

  ``(a) In General.--A State may use amounts provided under grants made 
under this part for the following:
          ``(1) To provide the services described in section 2604(b)(1) 
        for individuals with HIV disease.
          ``(2) To provide to such individuals treatments that in 
        accordance with section 2616 have been determined to prolong 
        life or prevent serious deterioration of health.
          ``(3) To provide home- and community-based care services for 
        such individuals in accordance with section 2614.
          ``(4) To provide assistance to assure the continuity of 
        health insurance coverage for such individuals in accordance 
        with section 2615.
          ``(5) To establish and operate consortia under section 2613 
        within areas most affected by HIV disease, which consortia 
        shall be designed to provide a comprehensive continuum of care 
        to individuals and families with such disease in accordance 
        with such section.
  ``(b) Priority for Women, Infants and Children.--For the purpose of 
providing health and support services to infants, children, and women 
with HIV disease, a State shall use, of the funds allocated under this 
part to the State for a fiscal year, not less than the percentage 
constituted by the ratio of the population in the State of infants, 
children, and women with acquired immune deficiency syndrome to the 
general population in the State of individuals with such syndrome, or 
15 percent, whichever is less. In expending the funds reserved under 
the preceding sentence for a fiscal year, the State shall give priority 
to providing, for pregnant women, measures to prevent the perinatal 
transmission of HIV.''.

SEC. 202. GRANTS TO ESTABLISH HIV CARE CONSORTIA.

  Section 2613 (42 U.S.C. 300ff-23) is amended--
          (1) in subsection (a)--
                  (A) in paragraph (1), by inserting ``(or private for-
                profit providers or organizations if such entities are 
                the only available providers of quality HIV care in the 
                area)'' after ``nonprofit private,''; and
                  (B) in paragraph (2)(A)--
                          (i) by inserting ``substance abuse treatment, 
                        mental health treatment,'' after ``nursing,''; 
                        and
                          (ii) by inserting after ``monitoring,'' the 
                        following: ``measures for the prevention and 
                        treatment of opportunistic infections, 
                        treatment education for patients (provided in 
                        the context of health care delivery),''; and
          (2) in subsection (c)(2)--
                  (A) in clause (ii) of subparagraph (A), by striking 
                ``and'' after the semicolon;
                  (B) in subparagraph (B), by striking the period at 
                the end and inserting ``; and''; and
                  (C) by adding after subparagraph (B) the following 
                subparagraph:
                  ``(C) grantees under section 2671, or, if none are 
                operating in the area, representatives in the area of 
                organizations with a history of serving children, 
                youth, women, and families living with HIV.''.

SEC. 203. PROVISION OF TREATMENTS.

  Section 2616(a) (42 U.S.C. 300ff-26(a)) is amended--
          (1) by striking ``may use amounts'' and inserting ``shall use 
        a portion of the amounts'';
          (2) by striking ``section 2612(a)(4)'' and inserting 
        ``section 2612(a)(2)''; and
          (3) by inserting before the period the following: ``, 
        including measures for the prevention and treatment of 
        opportunistic infections''.

SEC. 204. STATE APPLICATION.

  Section 2617(b)(2) (42 U.S.C. 300ff-27(b)(2)) is amended--
          (1) in subparagraph (A), by striking ``and'' after the 
        semicolon;
          (2) in subparagraph (B), by striking ``and'' after the 
        semicolon; and
          (3) by adding at the end thereof the following subparagraphs:
                  ``(C) a description of the activities carried out by 
                the State under section 2616; and
                  ``(D) a description of how the allocation and 
                utilization of resources are consistent with a 
                statewide coordinated statement of need, developed in 
                partnership with other grantees in the State that 
                receive funding under this title and after consultation 
                with individuals receiving services under this part.''.

SEC. 205. ALLOCATION OF ASSISTANCE BY STATES; PLANNING, EVALUATION, AND 
                    ADMINISTRATION.

  Section 2618(c) (42 U.S.C. 300ff-28(c)) is amended--
          (1) by striking paragraph (1);
          (2) by redesignating paragraphs (2) through (5) as paragraphs 
        (1) through (4), respectively; and
          (3) in paragraph (3) (as so redesignated), by adding at the 
        end the following sentences: ``In the case of entities to which 
        the State allocates amounts received by the State under the 
        grant (including consortia under section 2613), the State shall 
        ensure that, of the aggregate amount so allocated, the total of 
        the expenditures by such entities for administrative expenses 
        does not exceed 10 percent (without regard to whether 
        particular entities expend more than 10 percent for such 
        expenses). For purposes of the preceding sentence, the costs of 
        establishing and operating consortia under section 2613 shall 
        be considered administrative expenses.''.

SEC. 206. TECHNICAL ASSISTANCE.

  Section 2619 (42 U.S.C. 300ff-29) is amended by inserting before the 
period the following: ``, including technical assistance for the 
development and implementation of statewide coordinated statements of 
need''.

                 TITLE III--EARLY INTERVENTION SERVICES

SEC. 301. ESTABLISHMENT OF PROGRAM.

  Section 2651(b) (42 U.S.C. 300ff-51(b)) is amended--
          (1) in paragraph (1), by inserting before the period the 
        following: ``, and unless the applicant agrees to expend not 
        less than 50 percent of the grant for such services that are 
        specified in subparagraphs (B) through (E) of such paragraph''; 
        and
          (2) in paragraph (4), by inserting after ``nonprofit private 
        entities'' the following: ``(or private for-profit entities, if 
        such entities are the only available providers of quality HIV 
        care in the area)''.

SEC. 302. MINIMUM QUALIFICATIONS OF GRANTEES.

  Section 2652(b)(1)(B) (42 U.S.C. 300ff-52(b)(1)(B)) is amended by 
inserting after ``nonprofit private entity'' the following: ``(or a 
private for-profit entity, if such an entity is the only available 
provider of quality HIV care in the area)''.

SEC. 303. MISCELLANEOUS PROVISIONS; PLANNING AND DEVELOPMENT GRANTS.

  Section 2654 (42 U.S.C. 300ff-54) is amended by adding at the end 
thereof the following subsection:
  ``(c) Planning and Development Grants.--
          ``(1) In general.--The Secretary may provide planning grants, 
        in an amount not to exceed $50,000 for each such grant, to 
        public and nonprofit private entities for the purpose of 
        enabling such entities to provide early intervention services.
          ``(2) Requirement.--The Secretary may award a grant to an 
        entity under paragraph (1) only if the Secretary determines 
        that the entity will use such grant to assist the entity in 
        qualifying for a grant under section 2651.
          ``(3) Preference.--In awarding grants under paragraph (1), 
        the Secretary shall give preference to entities that provide 
        HIV primary care services in rural or underserved communities.
          ``(4) Limitation.--Not to exceed 1 percent of the amount 
        appropriated for a fiscal year under section 2655 may be used 
        to carry out this section.''.

SEC. 304. ADDITIONAL REQUIRED AGREEMENTS.

  Section 2664(a)(1) (42 U.S.C. 300ff-64(a)(1)) is amended--
          (1) in subparagraph (A), by striking ``and'' after the 
        semicolon; and
          (2) by adding at the end the following subparagraph:
                  ``(C) evidence that the proposed program is 
                consistent with the statewide coordinated statement of 
                need and that the applicant will participate in the 
                ongoing revision of such statement of need.''.

SEC. 305. AUTHORIZATION OF APPROPRIATIONS.

  Section 2655 (42 U.S.C. 300ff-55) is amended by striking 
``$75,000,000'' and all that follows and inserting ``such sums as may 
be necessary for each of the fiscal years 1996 through 2000.''.

                      TITLE IV--GENERAL PROVISIONS

SEC. 401. COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, 
                    INFANTS, AND CHILDREN.

  (a) In General.--Section 2671 (42 U.S.C. 300ff-71) is amended--
          (1) in subsection (a), by amending the subsection to read as 
        follows:
  ``(a) In General.--
          ``(1) Program of grants.--The Secretary, acting through the 
        Administrator of the Health Resources and Services 
        Administration and in consultation with the Director of the 
        National Institutes of Health, shall make grants to public and 
        nonprofit private entities that provide primary care (directly 
        or through contracts) for the purpose of--
                  ``(A) providing through such entities, in accordance 
                with this section, opportunities for women, infants, 
                and children to be participants in research of 
                potential clinical benefit to individuals with HIV 
                disease; and
                  ``(B) providing to women, infants, and children 
                health care on an outpatient basis.
          ``(2) Provisions regarding participation in research.--With 
        respect to the projects of research with which an applicant 
        under paragraph (1) is concerned, the Secretary may not make a 
        grant under such paragraph to the applicant unless the 
        following conditions are met:
                  ``(A) The applicant agrees to make reasonable 
                efforts--
                          ``(i) to identify which of the patients of 
                        the applicant are women, infants, and children 
                        who would be appropriate participants in the 
                        projects; and
                          ``(ii) to offer women, infants, and children 
                        the opportunity to so participate (as 
                        appropriate), including the provision of 
                        services under subsection (f).
                  ``(B) The applicant agrees that the applicant, and 
                the projects of research, will comply with accepted 
                standards of protection for human subjects (including 
                the provision of written informed consent) who 
                participate as subjects in clinical research.
                  ``(C) For the third or subsequent fiscal year for 
                which a grant under such paragraph is sought by the 
                applicant, the Secretary has determined that--
                          ``(i) a significant number of women, infants, 
                        and children who are patients of the applicant 
                        are participating in the projects (except to 
                        the extent this clause is waived under 
                        subsection (k)); and
                          ``(ii) the applicant, and the projects of 
                        research, have complied with the standards 
                        referred to in subparagraph (B).
          ``(3) Prohibition.--Receipt of services by a patient shall 
        not be conditioned upon the consent of the patient to 
        participate in research.
          ``(4) Consideration by secretary of certain circumstances.--
        In administering the requirement of paragraph (2)(C)(i), the 
        Secretary shall take into account circumstances in which a 
        grantee under paragraph (1) is temporarily unable to comply 
        with the requirement for reasons beyond the control of the 
        grantee, and shall in such circumstances provide to the grantee 
        a reasonable period of opportunity in which to reestablish 
        compliance with the requirement.'';
          (2) in subsection (c), by amending the subsection to read as 
        follows:
  ``(c) Provisions Regarding Conduct of Research.--With respect to 
eligibility for a grant under subsection (a):
          ``(1) A project of research for which subjects are sought 
        pursuant to such subsection may be conducted by the applicant 
        for the grant, or by an entity with which the applicant has 
        made arrangements for purposes of the grant. The grant may not 
        be expended for the conduct of any project of research.
          ``(2) The grant may not be made unless the Secretary makes 
        the following determinations:
                  ``(A) The applicant or other entity (as the case may 
                be under paragraph (1)) is appropriately qualified to 
                conduct the project of research. An entity shall be 
                considered to be so qualified if any research protocol 
                of the entity has been recommended for funding under 
                this Act pursuant to technical and scientific peer 
                review through the National Institutes of Health.
                  ``(B) The project of research is being conducted in 
                accordance with a research protocol to which the 
                Secretary gives priority regarding the prevention and 
                treatment of HIV disease in women, infants, and 
                children. After consultation with public and private 
                entities that conduct such research, and with providers 
                of services under this section and recipients of such 
                services, the Secretary shall establish a list of such 
                protocols that are appropriate for purposes of this 
                section. The Secretary may give priority under this 
                subparagraph to a research protocol that is not on such 
                list.'';
          (3) by striking subsection (i);
          (4) by redesignating subsections (g) and (h) as subsections 
        (h) and (i), respectively;
          (5) by inserting after subsection (f) the following 
        subsection:
  ``(g) Additional Provisions.--The Secretary may not make a grant 
under subsection (a) unless the applicant for the grant agrees as 
follows:
          ``(1) The applicant will coordinate activities under the 
        grant with other providers of health care services under this 
        Act, and under title V of the Social Security Act.
          ``(2) The applicant will participate in the statewide 
        coordinated statement of need under part B (where it has been 
        initiated by the State) and in revisions of such statement.'';
          (6) by redesignating subsection (j) as subsection (m); and
          (7) by inserting before subsection (m) (as so redesignated) 
        the following subsections:
  ``(j) Coordination With National Institutes of Health.--The Secretary 
shall develop and implement a plan that provides for the coordination 
of the activities of the National Institutes of Health with the 
activities carried out under this section. In carrying out the 
preceding sentence, the Secretary shall ensure that projects of 
research conducted or supported by such Institutes are made aware of 
applicants and grantees under this section, shall require that the 
projects, as appropriate, enter into arrangements for purposes of this 
section, and shall require that each project entering into such an 
arrangement inform the applicant or grantee under this section of the 
needs of the project for the participation of women, infants, and 
children.
  ``(k) Temporary Waiver Regarding Significant Participation.--
          ``(1) In general.--In the case of an applicant under 
        subsection (a) who received a grant under this section for 
        fiscal year 1995, the Secretary may, subject to paragraph (2), 
        provide to the applicant a waiver of the requirement of 
        subsection (a)(2)(C)(i) if the Secretary determines that the 
        applicant is making reasonable progress toward meeting the 
        requirement.
          ``(2) Termination of authority for waivers.--The Secretary 
        may not provide any waiver under paragraph (1) on or after 
        October 1, 1998. Any such waiver provided prior to such date 
        terminates on such date, or on such earlier date as the 
        Secretary may specify.
  ``(l) Training and Technical Assistance.--Of the amounts appropriated 
under subsection (m) for a fiscal year, the Secretary may use not more 
than five percent to provide training and technical assistance to 
assist applicants and grantees under subsection (a) in complying with 
the requirements of this section.''.
  (b) Conforming Amendments.--Section 2671 (42 U.S.C. 300ff-71) is 
amended--
          (1) in the heading for the section, by striking 
        ``demonstration'' and all that follows and inserting 
        ``coordinated services and access to research for women, 
        infants, and children.'';
          (2) in subsection (b), by striking ``pediatric patients and 
        pregnant women'' and inserting ``women, infants, and 
        children''; and
          (3) in each of subsections (d) through (f), by striking 
        ``pediatric'', each place such term appears.
  (c) Authorization of Appropriations.--Section 2671 (42 U.S.C. 300ff-
71) is amended in subsection (m) (as redesignated by subsection (a)(6)) 
by striking ``there are'' and all that follows and inserting the 
following: ``there are authorized to be appropriated such sums as may 
be necessary for each of the fiscal years 1996 through 2000.''.

SEC. 402. PROJECTS OF NATIONAL SIGNIFICANCE.

  (a) In General.--Part D of title XXVI (42 U.S.C. 300ff-71 et seq.) is 
amended by inserting after section 2673 the following section:

``SEC. 2673A. DEMONSTRATION PROJECTS OF NATIONAL SIGNIFICANCE.

  ``(a) In General.--The Secretary shall make grants to public and 
nonprofit private entities (including community-based organizations and 
Indian tribes and tribal organizations) for the purpose of carrying out 
demonstration projects that provide for the care and treatment of 
individuals with HIV disease, and that--
          ``(1) assess the effectiveness of particular models for the 
        care and treatment of individuals with such disease;
          ``(2) are of an innovative nature; and
          ``(3) have the potential to be replicated in similar 
        localities, or nationally.
  ``(b) Certain Projects.--Demonstration projects under subsection (a) 
shall include the development and assessment of innovative models for 
the delivery of HIV services that are designed--
          ``(1) to address the needs of special populations (including 
        individuals and families with HIV disease living in rural 
        communities, adolescents with HIV disease, Native American 
        individuals and families with HIV disease, homeless individuals 
        and families with HIV disease, hemophiliacs with HIV disease, 
        and incarcerated individuals with HIV disease); and
          ``(2) to ensure the ongoing availability of services for 
        Native American communities to enable such communities to care 
        for Native Americans with HIV disease.
  ``(c) Coordination.--The Secretary may not make a grant under this 
section unless the applicant submits evidence that the proposed program 
is consistent with the applicable statewide coordinated statement of 
need under part B, and the applicant agrees to participate in the 
ongoing revision process of such statement of need (where it has been 
initiated by the State).
  ``(d) Replication.--The Secretary shall make information concerning 
successful models developed under this section available to grantees 
under this title for the purpose of coordination, replication, and 
integration.
  ``(e) Funding; Allocation of Amounts.--
          ``(1) In general.--Of the amounts available under this title 
        for a fiscal year for each program specified in paragraph (2), 
        the Secretary shall reserve 3 percent for making grants under 
        subsection (a).
          ``(2) Relevant programs.--The programs referred to in 
        subsection (a) are the program under part A, the program under 
        part B, the program under part C, the program under section 
        2671, the program under section 2672, and the program under 
        section 2673.''.
  (b) Striking of Related Provision.--Section 2618 (42 U.S.C. 300ff-28) 
is amended by striking subsection (a).

SEC. 403. SPECIAL TRAINING PROJECTS.

  (a) Transfer of Program.--The Public Health Service Act (42 U.S.C. 
201 et seq.) is amended--
          (1) by transferring section 776 from the current placement of 
        the section;
          (2) by redesignating the section as section 2673B; and
          (3) by inserting the section after section 2673A (as added by 
        section 402(a)).
  (b) Modifications.--Section 2673B (as transferred and redesignated by 
subsection (a)) is amended--
          (1) in subsection (a)(1)--
                  (A) by striking subparagraphs (B) and (C);
                  (B) by redesignating subparagraphs (A) and (D) as 
                subparagraphs (B) and (C), respectively;
                  (C) by inserting before subparagraph (B) (as so 
                redesignated) the following subparagraph:
                  ``(A) to train health personnel, including 
                practitioners in programs under this title and other 
                community providers, in the diagnosis, treatment, and 
                prevention of HIV disease, including the prevention of 
                the perinatal transmission of the disease and including 
                measures for the prevention and treatment of 
                opportunistic infections;'';
                  (D) in subparagraph (B) (as so redesignated), by 
                adding ``and'' after the semicolon; and
                  (E) in subparagraph (C) (as so redesignated), by 
                striking ``curricula and'';
          (2) by striking subsection (c) and redesignating subsection 
        (d) as subsection (c); and
          (3) in subsection (c) (as so redesignated)--
                  (A) in paragraph (1)--
                          (i) by striking ``is authorized'' and 
                        inserting ``are authorized''; and
                          (ii) by inserting before the period the 
                        following: ``, and such sums as may be 
                        necessary for each of the fiscal years 1996 
                        through 2000''; and
                  (B) in paragraph (2)--
                          (i) by striking ``is authorized'' and 
                        inserting ``are authorized''; and
                          (ii) by inserting before the period the 
                        following: ``, and such sums as may be 
                        necessary for each of the fiscal years 1996 
                        through 2000''.

SEC. 404. EVALUATIONS AND REPORTS.

  Section 2674 (42 U.S.C. 300ff-74) is amended--
          (1) in subsection (b)--
                  (A) in the matter preceding paragraph (1), by 
                striking ``not later than 1 year'' and all that follows 
                through ``title,'' and inserting the following: ``not 
                later than October 1, 1996,'';
                  (B) by striking paragraphs (1) through (3) and 
                inserting the following paragraph:
          ``(1) evaluating the programs carried out under this title; 
        and''; and
                  (C) by redesignating paragraph (4) as paragraph (2); 
                and
          (2) by adding at the end the following subsection:
  ``(d) Allocation of Funds.--The Secretary shall carry out this 
section with amounts available under section 241. Such amounts are in 
addition to any other amounts that are available to the Secretary for 
such purpose.''.

SEC. 405. COORDINATION OF PROGRAM.

  Section 2675 of the Public Health Service Act (42 U.S.C. 300ff-75) is 
amended by adding at the end the following subsection:
  ``(d) Annual Report.--Not later than October 1, 1996, and annually 
thereafter, the Secretary shall submit to the appropriate committees of 
the Congress a report concerning coordination efforts under this title 
at the Federal, State, and local levels, including a statement of 
whether and to what extent there exist Federal barriers to integrating 
HIV-related programs.''.

                     TITLE V--ADDITIONAL PROVISIONS

SEC. 501. AMOUNT OF EMERGENCY RELIEF GRANTS.

  Paragraph (3) of section 2603(a) (42 U.S.C. 300ff-13(a)(3)) is 
amended to read as follows:
          ``(3) Amount of grant.--
                  ``(A) In general.--Subject to the extent of amounts 
                made available in appropriations Acts, a grant made for 
                purposes of this paragraph to an eligible area shall be 
                made in an amount equal to the product of--
                          ``(i) an amount equal to the amount available 
                        for distribution under paragraph (2) for the 
                        fiscal year involved; and
                          ``(ii) the percentage constituted by the 
                        ratio of the distribution factor for the 
                        eligible area to the sum of the respective 
                        distribution factors for all eligible areas.
                  ``(B) Distribution factor.--For purposes of 
                subparagraph (A)(ii), the term `distribution factor' 
                means the product of--
                          ``(i) an amount equal to the estimated number 
                        of living cases of acquired immune deficiency 
                        syndrome in the eligible area involved, as 
                        determined under subparagraph (C); and
                          ``(ii) the cost index for the eligible area 
                        involved, as determined under subparagraph (D).
                  ``(C) Estimate of living cases.--The amount 
                determined in this subparagraph is an amount equal to 
                the product of--
                          ``(i) the number of cases of acquired immune 
                        deficiency syndrome in the eligible area during 
                        each year in the most recent 120-month period 
                        for which data are available with respect to 
                        all eligible areas, as indicated by the number 
                        of such cases reported to and confirmed by the 
                        Director of the Centers for Disease Control and 
                        Prevention for each year during such period; 
                        and
                          ``(ii) with respect to--
                                  ``(I) the first year during such 
                                period, .06;
                                  ``(II) the second year during such 
                                period, .06;
                                  ``(III) the third year during such 
                                period, .08;
                                  ``(IV) the fourth year during such 
                                period, .10;
                                  ``(V) the fifth year during such 
                                period, .16;
                                  ``(VI) the sixth year during such 
                                period, .16;
                                  ``(VII) the seventh year during such 
                                period, .24;
                                  ``(VIII) the eighth year during such 
                                period, .40;
                                  ``(IX) the ninth year during such 
                                period, .57; and
                                  ``(X) the tenth year during such 
                                period, .88.
                  ``(D) Cost index.--The amount determined in this 
                subparagraph is an amount equal to the sum of--
                          ``(i) the product of--
                                  ``(I) the average hospital wage index 
                                reported by hospitals in the eligible 
                                area involved under section 
                                1886(d)(3)(E) of the Social Security 
                                Act for the 3-year period immediately 
                                preceding the year for which the grant 
                                is being awarded; and
                                  ``(II) .70; and
                          ``(ii) .30.
                  ``(E) Unexpended funds.--The Secretary may, in 
                determining the amount of a grant for a fiscal year 
                under this paragraph, adjust the grant amount to 
                reflect the amount of unexpended and uncanceled grant 
                funds remaining at the end of the fiscal year preceding 
                the year for which the grant determination is to be 
                made. The amount of any such unexpended funds shall be 
                determined using the financial status report of the 
                grantee.
                  ``(F) Puerto rico, virgin islands, guam.--For 
                purposes of subparagraph (D), the cost index for an 
                eligible area within Puerto Rico, the Virgin Islands, 
                or Guam shall be 1.0.''.

SEC. 502. AMOUNT OF CARE GRANTS.

  Section 2618 (42 U.S.C. 300ff-28), as amended by section 402(b), is 
amended by striking subsection (b) and inserting the following 
subsections:
  ``(a) Amount of Grant.--
          ``(1) In general.--Subject to subsection (b) (relating to 
        minimum grants), the amount of a grant under this part for a 
        State for a fiscal year shall be the sum of--
                  ``(A) the amount determined for the State under 
                paragraph (2); and
                  ``(B) the amount determined for the State under 
                paragraph (4) (if applicable).
          ``(2) Principal formula grants.--For purposes of paragraph 
        (1)(A), the amount determined under this paragraph for a State 
        for a fiscal year shall be the product of--
                  ``(A) the amount available under section 2677 for 
                carrying out this part, less the reservation of funds 
                made in paragraph (4)(A) and less any other applicable 
                reservation of funds authorized or required in this Act 
                (which amount is subject to subsection (b)); and
                  ``(B) the percentage constituted by the ratio of--
                          ``(i) the distribution factor for the State; 
                        to
                          ``(ii) the sum of the distribution factors 
                        for all States.
          ``(3) Distribution factor for principal formula grants.--For 
        purposes of paragraph (2)(B), the term `distribution factor' 
        means the following, as applicable:
                  ``(A) In the case of each of the 50 States, the 
                District of Columbia, and the Commonwealth of Puerto 
                Rico, the product of--
                          ``(i) the number of cases of acquired immune 
                        deficiency syndrome in the State, as indicated 
                        by the number of cases reported to and 
                        confirmed by the Secretary for the 2 most 
                        recent fiscal years for which such data are 
                        available; and
                          ``(ii) the cube root of the ratio (based on 
                        the most recent available data) of--
                                  ``(I) the average per capita income 
                                of individuals in the United States 
                                (including the territories); to
                                  ``(II) the average per capita income 
                                of individuals in the State.
                  ``(B) In the case of a territory of the United States 
                (other than the Commonwealth of Puerto Rico), the 
                number of additional cases of such syndrome in the 
                specific territory, as indicated by the number of cases 
                reported to and confirmed by the Secretary for the 2 
                most recent fiscal years for which such data is 
                available.
          ``(4) Supplemental amounts for certain states.--For purposes 
        of paragraph (1)(B), an amount shall be determined under this 
        paragraph for each State that does not contain any metropolitan 
        area whose chief elected official received a grant under part A 
        for fiscal year 1996. The amount determined under this 
        paragraph for such a State for a fiscal year shall be the 
        product of--
                  ``(A) an amount equal to 7 percent of the amount 
                available under section 2677 for carrying out this part 
                for the fiscal year (subject to subsection (b)); and
                  ``(B) the percentage constituted by the ratio of--
                          ``(i) the number of cases of acquired immune 
                        deficiency syndrome in the State (as determined 
                        under paragraph (3)(A)(i)); to
                          ``(ii) the sum of the respective numbers 
                        determined under clause (i) for each State to 
                        which this paragraph applies.
          ``(5) Definitions.--For purposes of this subsection and 
        subsection (b):
                  ``(A) The term `State' means each of the 50 States, 
                the District of Columbia, and the territories of the 
                United States.
                  ``(B) The term `territory of the United States' means 
                each of the Virgin Islands, Guam, American Samoa, the 
                Commonwealth of the Northern Mariana Islands, the 
                Commonwealth of Puerto Rico, and the Republic of the 
                Marshall Islands.
  ``(b) Minimum Amount of Grant.--
          ``(1) In general.--Subject to the extent of the amounts 
        specified in paragraphs (2)(A) and (4)(A) of subsection (a), a 
        grant under this part for a State for a fiscal year shall be 
        the greater of--
                  ``(A) the amount determined for the State under 
                subsection (a); and
                  ``(B) the amount applicable under paragraph (2) to 
                the State.
          ``(2) Applicable amount.--For purposes of paragraph (1)(B), 
        the amount applicable under this paragraph for a fiscal year is 
        the following:
                  ``(A) In the case of the 50 States, the District of 
                Columbia, and the Commonwealth of Puerto Rico--
                          ``(i) $100,000, if it has less than 90 cases 
                        of acquired immune deficiency syndrome (as 
                        determined under subsection (a)(3)(A)(i)); and
                          ``(ii) $250,000, if it has 90 or more such 
                        cases (as so determined).
                  ``(B) In the case of each of the territories of the 
                United States (other than the Commonwealth of Puerto 
                Rico), $0.0.''.

SEC. 503. CONSOLIDATION OF AUTHORIZATIONS OF APPROPRIATIONS.

  (a) In General.--Part D of title XXVI (42 U.S.C. 300ff-71) is amended 
by adding at the end thereof the following section:

``SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

  ``(a) In General.--For the purpose of carrying out parts A and B, 
there are authorized to be appropriated such sums as may be necessary 
for each of the fiscal years 1996 through 2000. Subject to section 
2673A and to subsection (b), of the amount appropriated under this 
section for a fiscal year, the Secretary shall make available 64 
percent of such amount to carry out part A and 36 percent of such 
amount to carry out part B.
  ``(b) Development of Methodology.--With respect to each of the fiscal 
years 1997 through 2000, the Secretary may develop and implement a 
methodology for adjusting the percentages referred to in subsection 
(a).''.
  (b) Repeals.--Sections 2608 and 2620 (42 U.S.C. 300ff-18 and 300ff-
30) are repealed.
  (c) Conforming Amendments.--Section 2605(d)(1) (as redesignated by 
section 105(3)), is amended by striking ``2608'' and inserting 
``2677''.

                        TITLE VI--EFFECTIVE DATE

SEC. 601. EFFECTIVE DATE.

  This Act takes effect October 1, 1995.

                          Purpose and Summary

    The purpose of H.R. 1872, as amended, is to reauthorize and 
revise the Ryan White CARE Act, a program of grants for the 
provision of primary health care and support services for 
people infected with the human immunodeficiency virus (HIV) and 
for those who have acquired immune deficiency syndrome (AIDS), 
the full-blown illness caused by HIV. Such services include 
outpatient health and medical services, as well as such 
ancillary services as continuation of private health insurance 
and home health care. H.R. 1872 extends the authority for this 
program for five years.
    The legislation also makes changes in the formulas by which 
funds are allocated among cities eligible for assistance and 
among States (all of which are eligible for assistance). The 
legislation also clarifies the program to assist in AIDS 
research efforts for women and children through the provision 
of health and support services. In addition, the legislation 
makes minor changes to the program of early intervention 
services provided to Federally assisted primary care centers.

                  Background and Need for Legislation

    AIDS is a collapse of the body's immune system that results 
in a wide variety of infections and cancers. While the acute 
stages of the disease are well described and generally 
recognized, these stages are the end of a spectrum of 
progressive illness caused by HIV. A person with HIV may have 
no immune decline, an immune decline accompanied by mild 
illnesses, or life-threatening conditions.
    Because of research performed over the last decade, 
treatment is now available and recommended for use 
significantly before the onset of life-threatening conditions. 
While the ability of antiviral treatment to lengthen overall 
life-expectancy is debated, the life-improving and cost-saving 
aspects of pneumonia prevention, tuberculosis prevention, and 
prevention of other opportunistic infections are clear.
    Eventually, however, it appears that most, if not all, 
people infected with HIV will become acutely ill and require 
therapeutic services. The Ryan White program, first authorized 
in 1990 and signed into law by President Bush, has provided 
significant Federal assistance to cities, States, and public 
clinics that have borne the brunt of much of AIDS service 
needs.
    By providing such assistance, the Ryan White program has 
substantially advanced the Nation's health care service 
delivery for people with AIDS and HIV. The problem of hospital 
and emergency room overcrowding has been greatly alleviated by 
the establishment of community care programs. The availability 
of prescription drugs has assisted many poor and near-poor 
Americans to stay healthy longer. The continuation of private 
health insurance has protected individuals from having to 
impoverish themselves to receive basic health care and has 
saved State Medicaid programs from needlessly financing people 
who can be maintained in private programs. Early intervention 
grants have allowed public clinics to provide AIDS counseling, 
testing, and therapeutic drugs to their patients without 
compromising basic primary care services. And the assistance 
for community programs that care for women and children has 
provided quality services and allowed research dollars for 
pediatric and maternal AIDS projects to go further.
    By almost any measure, the program has been a success. 
After five years of experience and of change in the 
demographics of the epidemic, however, the program does require 
some realignment and redirection. Service dollars should be 
targeted to those areas with the highest need for caring for 
living people, not just those areas where AIDS was first 
evidenced in the U.S. Service dollars should be balanced more 
adequately between cities and States. The program should be 
more directed toward first serving basic needs of all people 
with HIV and then providing other important, but not vital, 
services. The clinical care financed should include research 
advances and new knowledge, such as the recent progress in 
using antiviral drugs to reduce perinatal infection.
    Such legislative course corrections are essential to 
maintain a continually improving and successful program. Even 
as the epidemic continues, and expands primarily among the poor 
and the uninsured, and even as people with the disease live 
longer, available funds nonetheless will remain limited. In 
such circumstances, targeting of assistance will be more and 
more essential to assure that all people with HIV have basic 
needs met, whether they live in rural or urban areas, in high- 
or low-incidence areas, or are adults or children. Without a 
realistic approach to program changes, some areas will be 
unable to meet minimum requirements, leaving their residents 
vulnerable to preventable illness or without access to life-
sustaining care. This legislation is intended to face these 
difficult problems and to address them prospectively and with 
pragmatism.

                                Hearings

    The Subcommittee on Health and the Environment held two 
days of hearings on AIDS health care issues, including the Ryan 
White program (April 5, 1995 and May 11, 1995). Testimony at 
these hearings was received from 27 witnesses, including 
Members of Congress, representatives of the Administration, and 
representatives of health care professionals and persons served 
by the Ryan White program.
    Testifying before the Subcommittee on April 5, 1995 were: 
The Honorable Steve Gunderson, Member of Congress, accompanied 
by: Mr. Matt Fletcher, former Minority Staff Director, 
Committee on Government Operations; The Honorable Thomas 
Barrett, Member of Congress; Mr. William Freeman, Executive 
Director, National Association of People with AIDS; Mr. Richard 
L. Tafel, Executive Director, Log Cabin Republicans; Ms. Wanda 
Lockhart, Gainesville, Florida; The Honorable Philip R. Lee, 
MD, Assistant Secretary for Health, Department of Health and 
Human Services, accompanied by: Dr. Ciro Sumaya, Dr. Steve 
Bowen, and Dr. Eric Goosby; Mr. William Scanlon, Associate 
Director for Medicaid and, Intergovernmental Relations Health, 
Education and Human Services Division, General Accounting 
Office, NGB-HEHS, accompanied by: Mr. Jerry Fastrup; Mr. 
Shepherd Smith, Americans for a Sound AIDS/HIV Policy; Mr. 
Michael Weinstein, Executive Director, AIDS Health Care 
Foundation, representing The Campaign for Fairness; Mr. Harold 
Cox, Director, Client Services, AIDS Action Committee; Ms. 
Diana Jones-Ritter, Deputy Director, Office of Public Health, 
New York State, Department of Health, accompanied by: Dr. Nilsa 
Gutierrez, Director of the AIDS Institute; Mr. Mark Barnes, 
Executive Director, AIDS Action Council; Ms. Miguelina 
Maldonado, Director of Government Relations & Policy, National 
Minority AIDS Council; Dr. John Sleasman, Assistant Professor, 
Department of Pediatrics, University of Florida College of 
Medicine; Ms. Mildred Williamson, MSW, Administrator, Women and 
Children HIV Program, Cook County Hospital, representing the 
National AIDS Policy Center; Dr. Renslow Sherer, Director, Cook 
County HIV Primary Care Center; and Dr. Henry Cherrick, Dean, 
School of Dentistry, University of California at Los Angeles 
Center for Health Sciences, representing the American 
Association of Dental Schools.
    Testifying before the Subcommittee on May 11, 1995 were: 
The Honorable Gary L. Ackerman, Member of Congress; The 
Honorable Connie Morella, Member of Congress; The Honorable 
Nancy Pelosi, Member of Congress; Dr. Helene D. Gayle, MPH, 
Associate Director, Centers for Disease Control, Washington, 
and Acting Director, National Center for Prevention Services; 
Dr. James Balsey, Chief of Pediatric Medicine Branch, Division 
of AIDS, (NIAID, NIH); Mr. W. Shepherd Smith, President, 
Americans for a Sound AIDS/HIV Policy; Dr. Charles M. van der 
Horst, Division of Infectious Diseases, University of North 
Carolina at Chapel Hill; Dr. Lewis Cooper, Pediatric Service, 
St. Lukes Roosevelt Hospital Center; Dr. Michael Mennuti, 
Chair, Committee on Obstetric Practice, American College of 
Obstetricians and Gynecologists; Ms. Miguelina Maldonado, 
Director of Government Relations and Policy, National Minority 
AIDS Council, representing the National Organizations 
Responding to AIDS; and Commissioner David Mulligan, 
Massachusetts Department of Public Health, representing the 
Association of State and Territorial Health Officials.

                        Committee Consideration

    On June 14, 1995, the Subcommittee on Health and 
Environment met in open session and considered a Subcommittee 
Print. The Subcommittee approved the introduction of a clean 
bill for Full Committee consideration by a unanimous voice 
vote, a quorum being present. H.R. 1872 was introduced in the 
House as a clean bill on June 16, 1995. On July 13, 1995, the 
Committee met in open session and ordered reported the bill 
H.R. 1872, as amended, by a roll call vote of 41 to 0, a quorum 
being present.

                             Rollcall Votes

    Pursuant to clause 2(l)(2)(B) of rule XI of the Rules of 
the House of Representatives, following are listed the recorded 
votes on the motion to report H.R. 1872 and on amendments 
offered to the measure, including the names of those Members 
voting for and against.

                          rollcall vote no. 56

    Bill: H.R. 1872, Ryan White CARE Act Amendments of 1995.
    Quorum call: 24 Members answered present.

----------------------------------------------------------------------------------------------------------------
       Representative          Aye      Nay     Present         Representative          Aye      Nay     Present
----------------------------------------------------------------------------------------------------------------
Mr. Bliley.................  .......  .......         X  Mr. Dingell................  .......  .......         X
Mr. Moorhead...............  .......  .......  ........  Mr. Waxman.................  .......  .......  ........
Mr. Fields.................  .......  .......  ........  Mr. Markey.................  .......  .......  ........
Mr. Oxley..................  .......  .......  ........  Mr. Tauzin.................  .......  .......  ........
Mr. Bilirakis..............  .......  .......         X  Mr. Wyden..................  .......  .......         X
Mr. Schaefer...............  .......  .......         X  Mr. Hall...................  .......  .......  ........
Mr. Barton.................  .......  .......  ........  Mr. Bryant.................  .......  .......  ........
Mr. Hastert................  .......  .......         X  Mr. Boucher................  .......  .......  ........
Mr. Upton..................  .......  .......  ........  Mr. Manton.................  .......  .......  ........
Mr. Stearns................  .......  .......         X  Mr. Towns..................  .......  .......  ........
Mr. Paxon..................  .......  .......  ........  Mr. Studds.................  .......  .......         X
Mr. Gillmor................  .......  .......  ........  Mr. Pallone................  .......  .......         X
Mr. Klug...................  .......  .......  ........  Mr. Brown..................  .......  .......         X
Mr. Franks.................  .......  .......         X  Mrs. Lincoln...............  .......  .......         X
Mr. Greenwood..............  .......  .......         X  Mr. Gordon.................  .......  .......  ........
Mr. Crapo..................  .......  .......         X  Ms. Furse..................  .......  .......         X
Mr. Cox....................  .......  .......  ........  Mr. Deutsch................  .......  .......  ........
Mr. Deal...................  .......  .......  ........  Mr. Rush...................  .......  .......  ........
Mr. Burr...................  .......  .......         X  Ms. Eshoo..................  .......  .......         X
Mr. Bilbray................  .......  .......         X  Mr. Klink..................  .......  .......         X
Mr. Whitfield..............  .......  .......         X  Mr. Stupak.................  .......  .......         X
Mr. Ganske.................  .......  .......         X  ...........................  .......  .......  ........
Mr. Frisa..................  .......  .......  ........  ...........................  .......  .......  ........
Mr. Norwood................  .......  .......  ........  ...........................  .......  .......  ........
Mr. White..................  .......  .......         X  ...........................  .......  .......  ........
Mr. Coburn.................  .......  .......         X  ...........................  .......  .......  ........
----------------------------------------------------------------------------------------------------------------

                          ROLLCALL VOTE NO. 57

    Bill: H.R. 1872, Ryan White CARE Act Amendments of 1995.
    Motion: Motion by Mr. Bilirakis to order H.R. 1872 reported 
to the House, as amended.
    Disposition: AGREED TO, by a roll call vote of 41 ayes to 0 
nays.

----------------------------------------------------------------------------------------------------------------
     Representative          Aye       Nay      Pesent        Representative          Aye       Nay     Present 
----------------------------------------------------------------------------------------------------------------
Mr. Bliley..............        X   ........  .........  Mr. Dingell.............        X   ........  .........
Mr. Moorhead............        X   ........  .........  Mr. Waxman..............        X   ........  .........
Mr. Fields..............  ........  ........  .........  Mr. Markey..............        X   ........  .........
Mr. Oxley...............  ........  ........  .........  Mr. Tauzin..............  ........  ........  .........
Mr. Bilirakis...........        X   ........  .........  Mr. Wyden...............        X   ........  .........
Mr. Schaefer............        X   ........  .........  Mr. Hall................        X   ........  .........
Mr. Barton..............        X   ........  .........  Mr. Bryant..............  ........  ........  .........
Mr. Hastert.............        X   ........  .........  Mr. Boucher.............        X   ........  .........
Mr. Upton...............        X   ........  .........  Mr. Manton..............        X   ........  .........
Mr. Stearns.............        X   ........  .........  Mr. Towns...............        X   ........  .........
Mr. Paxon...............        X   ........  .........  Mr. Studds..............        X   ........  .........
Mr. Gillmor.............        X   ........  .........  Mr. Pallone.............        X   ........  .........
Mr. Klug................        X   ........  .........  Mr. Brown...............        X   ........  .........
Mr. Franks..............        X   ........  .........  Mrs. Lincoln............        X   ........  .........
Mr. Greenwood...........        X   ........  .........  Mr. Gordon..............        X   ........  .........
Mr. Crapo...............  ........  ........  .........  Ms. Furse...............        X   ........  .........
Mr. Cox.................        X   ........  .........  Mr. Deutsch.............        X   ........  .........
Mr. Deal................        X   ........  .........  Mr. Rush................        X   ........  .........
Mr. Burr................        X   ........  .........  Ms. Eshoo...............        X   ........  .........
Mr. Bilbray.............        X   ........  .........  Mr. Klink...............        X   ........  .........
Mr. Whitfield...........        X   ........  .........  Mr. Stupak..............        X   ........  .........
Mr. Ganske..............        X   ........  .........  ........................  ........  ........  .........
Mr. Frisa...............        X   ........  .........  ........................  ........  ........  .........
Mr. Norwood.............  ........  ........  .........  ........................  ........  ........  .........
Mr. White...............        X   ........  .........  ........................  ........  ........  .........
Mr. Coburn..............        X                                                                               
----------------------------------------------------------------------------------------------------------------

                              VOICE VOTES

    Bill: H.R. 1872, Ryan White CARE Act Amendments of 1995.
    Amendment: Amendment by Mr. Bilirakis re: technical 
corrections.
    Disposition: Agreed to, by a voice vote.
    Amendment: Amendment by Mr. Deutsch re: strike Medicare 
wage index from Title I and direct the Secretary of HHS to 
conduct a study of allocation formulas.
    Disposition: Withdrawn, by unanimous consent.
    Amendment: Amendment by Mr. Burr re: amend funding 
inequities with respect to rural areas.
    Disposition: Withdrawn, by unanimous consent.
    Amendment: Amendment by Mr. Coburn re: HIV testing of women 
and infants.
    Disposition: Withdrawn, by unanimous consent.

                      Committee Oversight Findings

    Pursuant to clause 2(l)(3)(A) of rule XI of the Rules of 
the House of Representatives, the Subcommittee on Health and 
Environment held oversight and legislative hearings and made 
findings that are reflected in this report.

              Committee on Government Reform and Oversight

    Pursuant to clause 2(l)(3)(D) of rule XI of the Rules of 
the House of Representatives, no oversight findings have been 
submitted to the Committee by the Committee on Government 
Reform and Oversight.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
Section 403 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 2(l)(3)(C) of rule XI of the Rules of 
the House of Representatives, following is the cost estimate 
provided by the Congressional Budget Office pursuant to Section 
403 of the Congressional Budget Act of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                   Washington, DC, August 15, 1995.
Hon. Thomas J. Bliley, Jr.,
Chairman, Committee on Commerce,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1872, the Ryan 
White CARE Act Amendments of 1995. This revised estimate 
incorporates newly obtained information regarding past funding 
levels for certain provisions of the Ryan White CARE Act of 
1990. It updates CBO's previous estimate of August 4, 1995.
    Enacting H.R. 1872 would not affect direct spending or 
receipts. Therefore, pay-as-you-go procedures would not apply 
to the bill.
    If you wish further details on this estimate, we will be 
pleased to provide them.
            Sincerely,
                                              James L. Blum
                                   (For June E. O'Neill, Director.)
    Enclosure.

               congressional budget office cost estimate

    1. Bill number: H.R. 1872.
    2. Bill title: The Ryan White CARE Act Amendments of 1995.
    3. Bill status: As ordered reported by the House Committee 
on Commerce on June 16, 1995.
    4. Bill purpose: H.R. 1872 would reauthorize various 
programs established pursuant to the Ryan White CARE Act of 
1990. The bill would also change requirements for some of these 
programs.
    5. Estimated cost to the Federal Government: Because the 
bill does not authorize specific amounts, the following table 
summarizes the estimated authorizations and outlays that would 
result from this bill under two different sets of assumptions. 
The first set of assumptions accounts for the program changes 
proposed in the bill and adjusts the estimated amounts for 
projected inflation after 1995. The second set of assumptions 
makes no allowance for projected inflation.

------------------------------------------------------------------------
                                      Projected Under H.R. 1872         
                            --------------------------------------------
                             1995 \1\   1996   1997   1998   1999   2000
------------------------------------------------------------------------
Estimated Authorizations of                                             
 Appropriations--assuming                                               
 program changes and                                                    
 adjustments for projected                                              
 inflation:                                                             
    Emergency Relief.......      357     368    381    395    409    423
    CARE Grants............      198     185    192    198    205    212
    Early Intervention                                                  
     Grants................       52      54     56     58     60     62
    Grants for Coordinated                                              
     Services..............       26      27     28     29     30     31
    AIDS Education and                                                  
     Training..............       23      24     25     26     27     28
    Demonstration Projects                                              
     of National                                                        
     Significance..........    (\2\)      19     20     20     21     22
                            --------------------------------------------
      Total Estimated                                                   
       Authorizations......      656     677    701    726    751    778
      Total Estimated                                                   
       Outlays.............      605     661    686    710    735    761
Estimated Authorizations of                                             
 Appropriations--assuming                                               
 continued funding at the                                               
 1995 level, adjusted for                                               
 program changes:                                                       
      Total Estimated                                                   
       Authorizations......      656     657    657    657    657    657
      Total Estimated                                                   
       Outlays.............      605     651    657    657    657    657
------------------------------------------------------------------------
\1\ Authorization amounts in this column are actual appropriations for  
  fiscal year 1995.                                                     
\2\ Demonstration Projects authorization amount for 1995 is included in 
  the CARE grants total.                                                
                                                                        
Notes: Details may not add to totals because of rounding.               

    The costs of this bill fall within budget function 550.
    6. Basis of estimate: H.R. 1872 reauthorizes funding for 
Ryan White CARE Act programs at such sums as may be necessary 
for fiscal years 1996 through 2000. Because H.R. 1872 changes 
the requirements for some of these programs, CBO estimated the 
funding changes that would be necessary to meet the bill's 
requirements.
    Emergency Relief Grants.--H.R. 1872 would limit eligibility 
for emergency relief grants to metropolitan areas with 
populations over 500,000 residents. It would also restrict 
grant eligibility to cities with a cumulative five-year total 
of more than 2,000 AIDS cases. The Department of Health and 
Human Services states that these limitations would prevent 
growth in the number of eligible grantees. However, cities 
designated as eligible areas in fiscal year 1996 will retain 
their eligibility in future years, even if their population or 
cumulative number of AIDS cases falls below these minimum 
levels.
    The estimated authorization levels in the above table are 
based on the 1995 appropriation of $357 million. If 
appropriations are increased to reflect projected inflation, 
estimated authorization amounts would increase to $368 million 
in fiscal year 1996 and $423 million in fiscal year 2000.
    CARE Grants.--The bill would reauthorize and implement 
several changes to the program that provides grants for the 
operation of HIV service delivery consortia under Title II of 
the Ryan White CARE Act. CBO calculated the authorization 
levels by adjusting the amount appropriated for fiscal year 
1995, $198 million, for the effects of changes the bill would 
make to the current program. These changes are detailed below. 
Accounting for all of these changes, and assuming that 
appropriations are increased to reflect projected inflation, 
CBO estimates authorization amounts for Title II programs at 
$185 million in fiscal year 1996, rising to $212 million in 
fiscal year 2000.
    H.R. 1872 would remove the authorization for Special 
Projects of National Significance under Title II. Currently, 
this program is authorized at a maximum of 10 percent of Title 
II funding; over the past two years, it has been funded at an 
average of 10 percent of Title II funding. CBO estimated the 
decrease in authorization amounts that would result from 
removal of this program by applying the average percentage to 
estimated Title II authorization levels for fiscal year 1995. 
The estimated reduction resulting from this program change 
would be $20 million. Assuming adjustments to reflect projected 
inflation, CBO projects $184 million in authorizations for 
fiscal year 1996 and $211 million for fiscal year 2000.
    The bill would also increase the minimum grant amount that 
states are awarded under Title II. States with fewer than 90 
cases of AIDS in a given fiscal year would receive a minimum of 
$100,000 in Title II grant money; states with 90 or more cases 
of AIDS in a given fiscal year would be awarded a minimum grant 
of $250,000. While these grant floors also apply to the 
District of Columbia, they are not applicable to U.S. 
territories, with the exception of Puerto Rico. CBO estimates 
that an additional $1 million would be required to fulfill this 
minimum grant requirement for fiscal years 1996-2000.
    Early Intervention Grants.--H.R. 1872 would also 
reauthorize early intervention grants at such sums as may be 
necessary for fiscal years 1996 through 2000. The estimated 
authorization amounts in the table above are based on the 1995 
appropriation of $52 million. Assuming that appropriations are 
increased to reflect projected inflation, CBO calculated that 
authorization amounts would range from $54 million in fiscal 
year 1996 to $62 million in fiscal year 2000.
    Coordinated Services and Access to Research.--Grants to 
coordinate systems of care for women and children would be 
reauthorized at such sums as may be necessary for fiscal years 
1996 through 2000. The estimated authorization levels in the 
above table are based on the 1995 appropriation of $26 million. 
Assuming that appropriations increase with projected inflation, 
estimated authorization amounts would grow to $27 million in 
fiscal year 1996, and to $31 million in fiscal year 2000.
    Special Training Projects.--H.R. 1872 would incorporate 
into the Ryan White Act section 776 of the Public Health 
Service Act, which authorizes funds for training programs for 
health practitioners who treat HIV-positive individuals. The 
estimated authorization amounts in the table above are based on 
the 1995 appropriation of $23 million. Assuming that 
appropriations increase to compensate for projected inflation, 
estimated authorization amounts would rise to $24 million in 
fiscal year 1996, and $28 million in fiscal year 2000.
    Demonstration Projects of National Significance.--The bill 
would authorize funding for demonstration projects to assess 
the effectiveness of models for the treatment and care of HIV-
infected individuals. Particular emphasis is placed on programs 
serving specific populations of HIV-infected individuals, such 
as the homeless, Native Americans, and prison inmates. These 
projects would be funded by a three percent set-aside of the 
total amounts available for Emergency Relief Grants (Title I), 
CARE Grants (Title II), Early Intervention Grants (Title III), 
and Grants for Coordinated Services and Access to Research 
(section 2671 of the Public Health Service Act), as amended by 
H.R. 1872. Under the assumption that appropriations are 
increased to reflect projected inflation, CBO calculates 
authorization levels of $19 million for fiscal year 1996, and 
$22 million for fiscal year 2000.
    This estimate assumes that all authorizations are fully 
appropriated at the beginning of each fiscal year. Outlays are 
estimated using spending rates computed by CBO on the basis of 
recent program data.
    7. Pay-as-you-go considerations: None.
    8. Estimated cost to State and local governments: The Ryan 
White Act requires states that receive funding under Titles II 
and III of the act to provide nonfederal matching contributions 
and specifies the amount of such contributions. Nonfederal 
funds could come from state and local governments.
    9. Estimate comparison: None.
    10. Previous CBO estimate: On August 4, 1995, CBO prepared 
a cost estimate of H.R. 1872. This estimate has been revised to 
reflect newly obtained information regarding funding levels for 
Special Projects of National Significance. On April 3, 1995, 
CBO prepared a cost estimate for S. 641, a similar bill ordered 
reported by the Senate Committee on Labor and Human Resources 
on March 29, 1995.
    11. Estimate prepared by: Anne Hunt.
    12. Estimate approved by: Paul N. Van de Water, Assistant 
Director for Budget Analysis.

                      Advisory Committee Statement

    No advisory committees within the meaning of Section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                     Inflationary Impact Statement

    Pursuant to clause 2(l)(4) of rule XI of the Rules of the 
House of Representatives, the Committee finds that the bill 
would have no inflationary impact.

             Section-by-Section Analysis of the Legislation

Section 1. Short title

    Section 1 establishes the short title of the Act to be the 
Ryan White CARE Act Amendments of 1995.

Section 2. References

    Section 2 establishes that all references are to the Public 
Health Service Act.

 Title I--Emergency Relief for Areas With Substantial Need for Services

Section 101. Establishment of program of grants

    Section 101 makes modifications in the criteria for 
determination of areas eligible for assistance under Part A of 
the Ryan White Program, Formula Grants to Eligible Metropolitan 
Areas (EMAs). Under current law, any metropolitan area is 
eligible if it has reported (and the Centers for Disease 
Control and Prevention (CDC) has confirmed) 2,000 cases of 
AIDS, no matter when the cases were reported. In addition, 
areas are eligible if the per capita incidence of cumulative 
cases of AIDS is not less than 0.0025.
    Section 101 revises these criteria to provide that 
eligibility is established only if a metropolitan area has 
reported (and CDC has confirmed) 2,000 cases of AIDS in the 
most recent five years. In addition, eligibility is limited to 
those areas with a population of 500,000 or more. These new 
limitations of eligibility are prospective only, and the 
legislation makes clear that a metropolitan area eligible for 
1996 will retain that eligibility.
    These changes have been made to target the limited funds 
available for Title I grants more accurately. Over the past 
five years of the program, it has become clear that the AIDS 
epidemic is emerging as a serious problem in many cities and 
counties that were only mildly affected by the disease in 1990. 
In addition, the artifact of the per capita incidence 
eligibility has produced some unexpected eligibility for areas 
that have a small number of people with AIDS. The new 
limitations imposed on eligibility will allow funds to be 
directed toward areas that are experiencing an immediate need 
for primary health care services for people living with AIDS.

Section 102. HIV Health Services Planning Council

    Section 102 modifies the provisions of current law 
regarding the HIV health services planning council. Under 
current law, the planning council is made up of a wide variety 
of community representatives and establishes priorities for the 
allocation of funds, develops a plan for the organization and 
delivery of health services, and assesses the efficiency of the 
allocation of funds.
    Section 102 would ensure representation of several 
additional professionals and agencies not currently required. 
These new members (who already are serving on planning councils 
in many areas) would include representatives of Federally 
qualified health centers (such as Community and Migrant Health 
Centers and other Federally assisted primary care clinics), 
providers of substance abuse services, historically underserved 
groups, the State Medicaid agency, the State agency 
administering the State Ryan White programs (described below), 
grantees under Section 2671 (the program for coordinated 
services and access to research for women, infants, and 
children, described below), and grantees under other HIV-
related Federal programs (such as AIDS research programs (both 
in the community and in research sites), prevention programs, 
AIDS professional training programs, and tuberculosis control 
programs). The council's composition is also intended to 
reflect the demographics of the epidemic in the area involved.
    This section also makes changes in the duties of the 
planning council. In establishing priorities for the allocation 
of funds, the planning council is to base its actions on the 
documented needs of people with HIV, the cost and outcome 
effectiveness of proposed strategies and interventions, the 
priorities of the communities involved, and the availability of 
other resources (both governmental and private). The council is 
also to assess the effectiveness of the services offered in 
meeting identified needs, participate in the development of the 
Statewide coordinated statement of need (described below), and 
conduct public meetings to obtain input on community needs.
    The Committee intends these clarifications to ensure that 
planning councils work to ensure that basic services (such as 
infection preventing drugs and physician care) are provided to 
all persons in the area before funds are expended to provide 
supplemental and support services (such as ancillary health 
services or support services not directly related to health 
care or basic needs). While it has been suggested that the 
Committee act to narrow the range of services eligible for 
funding to those that are purely primary care in nature 
(including prescription drugs), the Committee has refrained 
from doing so, recognizing that service needs do vary from 
location to location. (Transportation services, for instance, 
may be of a secondary priority in areas with strong mass 
transit systems but may be a necessary basic service in areas 
in which mass transit is limited.) The Committee has, 
therefore, continued to rely on community planning councils to 
set local priorities. However, the Committee expects the 
Department of Health and Human Services (HHS) to ensure that 
planning councils receive guidance on what should be considered 
basic services and receive clear direction that basic, cost-
effective services for low-income and uninsured people in need 
of HIV care are to be addressed before less vital services or 
services for more affluent or insured people are given priority 
or funded.
    Section 102 also places conflict of interest restrictions 
on members of planning councils. Under the terms of the bill, 
the planning council may not be directly involved in the 
administration of a grant, nor may it designate or be involved 
in the selection of particular entities as recipients of 
amounts provided under the grant. Individual members of the 
planning councils are also required to recuse themselves from 
any matter regarding an entity in which the individual has a 
financial interest or by which the individual is employed.
    Conflicts of interest and appearances of conflicts of 
interest have been anecdotally reported to the Committee. The 
Committee has added these provisions to assure that planning 
councils will be acting clearly in the public interest. The 
Committee does not intend that members of planning councils be 
excluded from providing their individual unique expertise to 
project review activities, when such review would be less 
effective or appropriate without this experience, so long as no 
individual is involved in a review that deals with a program, 
organization, or agency in which he or she has an interest. 
Where a planning council member participates in a review, 
however, that individual may not participate in the actual 
decision regarding the selection of a grantee or sub-grantee or 
contractors. Further, the Committee emphasizes that it expects 
such restrictions to be applied, through an area's own conflict 
of interest requirements, to representatives or employees of 
public agencies, where decisions about allocation of grant 
funds would affect their own agencies or programs.

Section 103. Type and distribution of grants

    Section 103 makes changes in the method of allocating 
formula grants, provides for a maximum amount by which grants 
may be reduced, and sets priorities for the review and approval 
of supplemental grants. Section 103 also prohibits the 
Secretary of HHS from making any formula or supplemental grant 
unless the application demonstrates that funds awarded for the 
previous year were expended in accordance with the priorities 
established by the planning council.
    Formula grants under the legislation will change 
incrementally from current distribution. The combination of 
factors specified in eligibility (such as the elimination of 
prevalence eligibility, the limitation of cases eligible for 
inclusion to those occurring within the last five years, and 
the limitation of awards to those areas with populations over 
500,000), work to make awards to cities more commensurate with 
the current severe needs, but they also result in reductions 
for some cities. Therefore, the Committee has included a 
special protection providing for a limitation on the reduction 
in a grant. The Committee has done so in recognition of the 
transition period that may be needed for these incremental 
reductions. The Committee does not intend that these 
limitations freeze current programs in an area, but rather 
address overall spending; areas that are protected by the 
provisions limiting loss nonetheless are expected to review 
their programs and services to assure that they address basic 
needs first and meet the criteria of the planning process.
    In the program of supplemental grants to eligible areas, 
the legislation makes a series of technical amendments and also 
requires that the area's application demonstrate the manner in 
which proposed services are consistent with State and local 
needs assessments. The legislation also provides a series of 
factors to be given priority consideration in awarding 
supplemental grants. These factors include the relative 
prevalence of sexually transmitted diseases, drug abuse, 
tuberculosis, and mental illness among HIV-infected individuals 
in the area; subpopulations with HIV disease that were 
previously unknown in the area; and homelessness. The Committee 
intends these factors to be used to direct funds at areas that 
are hardest hit by the AIDS epidemic. These factors are 
intended to be used as indicators of severe need, not as a 
mandate for coverage of services for these conditions. Funds 
provided under the Ryan White CARE Act are to be used to 
provide HIV/AIDS-related services. Treatment for the conditions 
listed should be provided only in conjunction with providing 
other health care services to individuals with HIV/AIDS. In 
some years, the award of supplemental grants has appeared to 
follow in lockstep the award of formula grants. The Committee 
emphasizes that this was not the original intention of this 
program nor its intention in this reauthorization. Supplemental 
grants are intended to be awarded to areas with especially 
severe need for basic services and to areas that demonstrate 
that funding will be particularly well used for basic care. 
Competitive project grant review is necessary to address these 
needs and take advantage of these opportunities.
    Finally, Section 103 makes subsequent funding of formula 
and supplemental grants contingent on an area demonstrating 
that previous funds have been used in accordance with 
priorities established by the planning council. This provision 
supplements current law in Section 2604(a), in which the area's 
chief elected official (to whom funds are paid) must agree 
prospectively that funds will be used according to the 
priorities established by the planning council; the addition 
made by the legislation provides an enforcement mechanism to be 
used retrospectively as well. The Committee is disturbed by 
reports that in some cases plans have been developed but never 
implemented and funds have been spent in ways not contemplated 
by the plan. Again, since funds are so limited and the need for 
basic services is so great, the Committee feels it necessary to 
require that all activities be planned and coordinated.

Section 104. Use of amounts

    Section 104 makes changes in the general provisions 
regarding use of funds. These changes include clarification of 
services to be funded; expansion of the type of entities that 
may be funded; an establishment of a priority for services for 
women, infants, and children; and a limitation on 
administrative costs.
    The first part of Section 104 clarifies that services to be 
funded include delivery and enhancement of HIV-related 
treatment education and measures for the prevention and 
treatment of opportunistic infections, as well as substance 
abuse treatment and mental health treatment. Although many 
areas are already providing these basic services under the 
rubric of outpatient health services, the Committee has added 
this clarification to emphasize that basic primary care 
services are to be addressed in their entirety. The Committee 
has received reports of disproportionate and duplicative use of 
case management services in lieu of more generally needed 
primary care services, and, although the Committee has retained 
case management as an eligible use of funds, it expects HHS and 
local planning councils to assure that spending goes toward 
delivery and enhancement of true health services and not simply 
to case management and social services.
    The second part of Section 104 allows local areas to use 
funds to provide services through private, for-profit entities 
if such entities are the only available providers of quality 
care. The Committee recognizes that private practitioners often 
provide the best care in an area and has made this change to 
allow local planning councils flexibility in choosing 
providers. The Committee notes, however, that all conflict of 
interest provisions apply fully to for-profit providers and 
also expects HHS and the planning councils to assure that 
charges and fees are appropriate.
    In addition, this part specifically adds substance abuse 
treatment programs and mental health programs to the catalogue 
of entities eligible for funding.
    The third part of Section 104 establishes a priority on 
services for women, infants, and children. A similar priority 
has been in place in current law for States (discussed below). 
The chief elected official of the area is required to allocate 
a minimum amount of the area's funding for services for these 
populations. The minimum amount is designated as the proportion 
of an area's AIDS cases made up of women, infants, and 
children, or 15 percent of overall funding, whichever is less. 
The elected official is also to give priority in the 
expenditure of these funds to measures to prevent perinatal 
transmission of HIV. For purposes of this calculation, the 
Committee intends the term ``children'' to include persons 
under the age of 21 and for the calculation to include only 
those cases of the previous five years, as described in Section 
2601 (discussed above). Although the bill directs the chief 
elected official to use the funds for this purpose, the 
requirement should be incorporated by the planning council of 
each city in determining priorities for services and how funds 
should be allocated.
    The Committee emphasizes that the minimum amount 
established by this section is in no way to be construed as a 
maximum on how much a planning council may spend on these 
populations. If a local area's caseload of women and children 
is, for example, 10 percent, it must at a minimum devote 10 
percent of its funding to this group, but it may devote much 
larger amounts if it chooses; similarly, if an area's caseload 
of women and children is 30 percent, it must at a minimum 
devote 15 percent of its funding to this group, but it may 
devote a proportionate amount or much larger amounts if it 
chooses. The Committee has selected a minimum and not a 
strictly proportionate amount to allow local areas some 
flexibility while assuring that these newest groups of HIV-
infected people are not neglected. The Committee expects 
planning councils to devote appropriate amounts of funding as 
part of the planning council process that recognizes the 
relative needs of the community served.
    The Committee has designated a local priority for services 
to prevent perinatal transmission because of the great promise 
of recent research developments in this area. The findings of 
the National Institutes of Health's (NIH) 076 trial have 
demonstrated the first pharmaceutical intervention to prevent 
infection in the baby of an HIV-infected woman if AZT is taken 
during pregnancy; these findings provide hope for significantly 
reducing the number of cases of pediatric AIDS. While the 
Committee has allowed local planning councils to designate 
other services for women, infants, and children to fulfill its 
percentage priority for such populations, the Committee 
emphasizes that, in terms of compassion, human costs, and 
health care spending, such primary prevention of perinatal 
transmission is a very important opportunity.
    The fourth part of Section 104 establishes a flexible cap 
on administrative costs. The local area may allow funded 
entities varying amounts of administrative cost spending so 
long as the aggregate amount that is spent for non-service 
purposes (by the local area and all of its contractors and 
subcontractors) is limited to no more than 10 percent of the 
funding to the area. The Committee has been very disturbed by 
reports of high administrative costs in some programs and 
instructs HHS to assure that such diversion of funds from 
health services does not recur; when funds are necessarily 
limited, large overhead costs serve to ration care 
unnecessarily. The Committee recognizes, however, that some 
entities (especially new ones or entities serving populations 
that have been historically underserved or are difficult to 
treat) have disproportionately high administrative costs. 
Rather than attempting a one-size-fits-all solution to such 
specific problems, the Committee has allowed local areas to 
allocate administrative costs flexibly but within a limited 
range. The Committee emphasizes that any area that can restrain 
administrative costs to less than 10 percent should do so and 
that the set amount should be regarded as a ceiling, not a 
floor.

Section 105. Application

    Section 105 makes changes in the assurances necessary for 
funding and provides flexibility to local areas to submit a 
single application for both formula and supplementary grants.
    The first substantive change in Section 105 is a 
modification in the requirements of current law regarding 
maintenance of effort on the part of the eligible area. Current 
law provides that an eligible area must maintain levels of 
expenditures equal to those of the year preceding the first 
fiscal year for which it received a grant (e.g., if a city 
first received a grant in FY 93, the maintenance of effort 
required would be the amount expended during FY 92). The bill 
provides that the maintenance of effort be based on the updated 
level of spending in the most recent fiscal year.
    The second provision requires that the applicant assure 
that it will participate in the Statewide coordinated statement 
of need (where it has been initiated by the State) and will 
ensure that its services are consistent with that statement. 
This provision was included to emphasize the need to reduce 
duplication in services, improve coordination of services, and 
assure that basic services for all persons with HIV are 
provided at an equitable level. While allowing States 
flexibility and thus not mandating development of an annual 
statewide coordinated statement of need, the Committee 
encourages States to initiate such a process.
    The final provision of Section 105 authorizes the Secretary 
of HHS to allow an area to submit a single application, 
simultaneously requesting formula and supplementary grants. 
This provision is added to allow for lower administrative 
costs, thus making more funds available for services.

Section 106. Technical assistance; planning grants

    Section 106 creates a new authority for planning grants to 
areas that have not received funding under this program before 
and that, on the basis of the eligibility criteria discussed 
above, are expected to receive funding in the next fiscal year. 
These planning grants are limited to a maximum of $75,000 and 
are to be offset from funds awarded to the area for services in 
the subsequent year. The total funding level for planning 
grants is limited to an overall level of one percent of funds 
under this part.
    The Committee has created this planning grant authority in 
recognition of the difficulty a local area may have in 
preparing to provide services on first receiving funding. 
Rather than delaying the beginning of basic health care 
services and perhaps needlessly raising administrative costs, 
the area can use the year preceding its first grant year to 
plan, organize, and prepare for service delivery. This 
authority will result in no increased spending, inasmuch as the 
Committee has required that there be an offset against funding 
to the area in the subsequent year.

                      Title II--Care Grant Program

Section 201. General use of grants

    Section 201 makes changes in the general use of grants 
under Title II of the Ryan White program, formula grants to 
States. The first change is to make clear that States may use 
these funds to provide the broad range of services that local 
areas may provide under Title I. This provision is added to 
increase State flexibility, not to displace the locally planned 
allocation of services between cities and States or to 
duplicate such services. As described above, the Committee has 
required that local areas participate in Statewide coordinated 
planning and expects that efforts will be made to assure that 
basic health care services are made available across the State 
through thoughtful combinations of Title I and Title II funds.
    In addition, Section 201 continues a priority for services 
for women, infants, and children. As for the identical 
provision as applied to funds for local areas, the priority 
requires that the State use a minimum amount of the State's 
funding for these populations. The minimum amount is designated 
as the proportion of a State's AIDS cases that are made up of 
women, infants, and children, or 15 percent of overall funding, 
whichever is less. The State is also to give priority in the 
expenditure of these funds to measures to prevent perinatal 
transmission of HIV. For purposes of this calculation, the 
Committee intends the term ``children'' to include persons 
under the age of 21 and for the calculation to include only 
those cases of the previous two years, as described in Section 
2618 of current law.
    As explained with respect to Title I funding, the Committee 
emphasizes that the minimum amount established by this section 
is not to be construed as a maximum on how much a State may 
spend on these populations. The Committee intends to allow 
States some flexibility while assuring that these populations 
are not neglected. The Committee anticipates that, in general, 
States will devote appropriate amounts of funding as part of 
the planning process that recognizes the relative need of the 
State's residents.
    As for funding to local areas, the Committee has designated 
a State priority for services to prevent perinatal 
transmission, although States may designate other services for 
women, infants, and children to fulfill its percentage priority 
for such populations. Again, the Committee emphasizes that 
primary prevention of perinatal transmission is a very 
important opportunity.

Section 202. Grants to establish HIV care consortia

    Section 202 makes minor changes in the provisions of 
current law regarding the establishment of HIV care consortia. 
This section makes private, for-profit providers eligible for 
funding (as discussed above at Section 104), adds substance 
abuse treatment and mental health treatment to the list of 
services that may be included (as discussed above at Section 
104), emphasizes the provision of measures for the prevention 
and treatment of opportunistic infections (as discussed above 
at Section 104), and adds grantees under Section 2671 to the 
list of entities with which a consortium is to consult in 
establishing its plan.

Section 203. Provision of treatments

    Section 203 makes changes in how States may use funds under 
Title II to provide treatments that have been determined to 
prolong life or prevent the serious deterioration of health 
from HIV disease. Current law has authorized States to provide 
prescription drugs to people afflicted with HIV who are low-
income, as defined by the State. The bill, first, requires that 
all States devote a portion of their grants to these purposes; 
secondly, it emphasizes that the use of measures for the 
prevention and treatment of opportunistic infections is an 
allowable use of funds.
    In light of the significant improvements in drugs to 
prevent opportunistic infections (discussed above in Background 
for Legislation), the life-improving and cost-saving nature of 
early intervention is clear. Moreover, it is now clear that a 
range of antiviral drugs can be used for this purpose, and that 
such drugs can prevent perinatal transmission of HIV. The 
Committee has required all States to devote some portion of 
their Federal funds to these purposes in recognition of the 
basic primary care value that these drugs now have. Recognizing 
that funds for HIV health care services will become 
increasingly limited, the Committee renews its emphasis on 
making essential services, such as prescription drugs, 
available to all who need them before important but non-
essential services are provided. As discussed below at Section 
205, the Committee has freed States from some measures to which 
they were previously required to adhere; the Committee has done 
so to free funds for States to improve the range of preventive 
and therapeutic drugs that are provided under this section and 
to make improvements in access to these drugs. The Committee 
understands that the Secretary, through the Health Resources 
and Services Administration (HRSA), has initiated a process to 
identify a formulary for drugs provided under this program, and 
encourages the States to participate in this process.

Section 204. State application

    Section 204 makes changes in the standard for State 
applications. This section requires that States include a 
description of the activities carried out under the program of 
provision of treatments (described above at Section 203) and a 
description of how the allocation and utilization of resources 
are consistent with the State's assessment of needs and are 
developed in coordination with other grantees in the State.

Section 205. Allocation of assistance by States; planning, evaluation, 
        and administration

    Section 205 eliminates an existing requirement (Section 
2618(c)) that States with more than one percent of the cases of 
AIDS in the Nation spend half of their grants under this part 
for the establishment and operation of consortia. States are 
still allowed to perform such activities with grant funds but 
they are not required to do so. As discussed above, the 
Committee has taken this action to free States to provide basic 
care, early intervention, and prescription drugs to as many 
persons with HIV in the State as possible.
    Second, under Section 205, as described in Section 104, the 
administrative costs of a State and all of its contractors and 
subcontractors are limited to an aggregate of 10 percent of the 
grant. The Committee has been disturbed by reports of high 
administrative costs in some programs and instructs HHS to 
assure that such diversion of funds from health services does 
not recur; when funds are necessarily limited, large overhead 
costs serve to ration care unnecessarily. The Committee 
recognizes, however, that some entities (especially new ones or 
entities serving populations that have been historically 
underserved or are difficult to treat) have disproportionately 
high administrative costs. Rather than attempting a one-size-
fits-all solution to such specific problems, the Committee has 
allowed States to allocate administrative costs flexibly but 
within a limited range. The Committee emphasizes that any State 
that can restrain administrative costs to less than 10 percent 
should do so and that the set amount should be regarded as a 
ceiling, not a floor.

Section 206. Technical assistance

    Section 206 clarifies that the Secretary's provision of 
technical assistance may include assistance in the development 
and implementation of Statewide coordinated statements of need.

                 Title III--Early Intervention Services

Section 301. Establishment of program

    Section 301 makes several changes in the program of grants 
for early intervention services to clinics that provide more 
generalized primary health care. This section requires minimum 
amounts to be spent on services and allows private, for-profit 
entities to be subcontractors for services under this part.
    Under current law, the services eligible for funding 
include counseling, testing, and follow-up treatment necessary 
to prevent and treat both the deterioration of the immune 
system and the conditions arising from that deterioration. The 
legislation requires that at least 50 percent of funds received 
by each entity be spent on services other than counseling, case 
management, and outreach. The Committee has adopted this change 
because it has received reports of grantees that have sought to 
spend most of their funds on non-medical services, while 
referring their clients elsewhere for health care. The 
Committee emphasizes that the bulk of these funds are to be 
spent providing basic, primary care services, especially since 
such services may not be available elsewhere to the clients of 
these clinics.
    The funds provided by Title III are intended to encourage 
early intervention for people who might otherwise receive care 
only when they become acutely ill. Given the breakthroughs in 
preventive services, early diagnosis (through counseling and 
testing) is a more important element of clinical care than ever 
before, and a significant expansion of early intervention 
services to people engaging in high-risk behavior is merited. 
Since the epidemic in many areas of the Nation has turned 
toward poor people who have no primary care physician or 
insurance, supplementation of primary care sites where these 
people already go for services is the most practical way of 
serving them. The supplementation of these clinics is also a 
means to make HIV counseling, testing, and care a part of the 
mainstream of basic health services, reaching many people who 
do not recognize themselves to be at high risk and making HIV 
care (including testing) more routine.

Section 302. Minimum qualifications of grantees

    Section 302 makes a conforming amendment to allow entities 
to qualify for funding if they use private, for-profit agencies 
as subcontractors for services.

Section 303. Miscellaneous provisions; planning and development grants

    Section 303 authorizes the Secretary of HHS to make 
planning grants of no more than $50,000 each to assist entities 
in planning, developing, and providing services under this 
part. Preferences for planning grants are to be given to 
entities that provide primary care services in rural and 
underserved areas.
    The Committee has established these planning grants as a 
means to expand the number of clinics that are providing early 
intervention services. Given the spread of the epidemic to many 
areas (including rural areas, especially in the Southeast) that 
it did not affect significantly at the time that the Ryan White 
CARE Act was adopted initially, the Committee believes that 
many new poverty primary care sites should be providing basic 
HIV services. Inasmuch as few of these areas will have the 
wherewithal or the overall need to establish AIDS-specific 
programs, supplementation of existing sites is the most 
practical and immediate means of reaching rural and underserved 
people with HIV.

Section 304. Additional required agreements

    Section 304 requires that, as a condition of receiving 
funding, an entity must provide evidence that the services to 
be provided are consistent with the Statewide coordinated 
system of need and that the entity will participate in the 
ongoing revision of that statement (where it has been initiated 
by the State).

Section 305. Authorization of appropriations

    Section 305 extends authorizations for the program of early 
intervention services through the year 2000 at a level of such 
sums as may be necessary.

                      Title IV--General Provisions

Section 401. Coordinated services and access to research for women, 
        infants, and children

    Section 401 revises the program of coordinated services and 
access to research for women, infants, and children. This 
program was originally enacted in response to a serious lack of 
biomedical research on AIDS among these populations, leaving 
many of their specific HIV-related problems unstudied and 
unaddressed and thus delaying the application of general HIV-
related advances (such as antiviral research). In 1989 and 
1990, researchers said that much of the problem with conducting 
such research was a lack of access to the populations, meaning 
that recruitment and retention of women, infants, and children 
were particularly difficult. This program was enacted to 
provide sites at which comprehensive health care services could 
be offered to this population in coordination with simple 
enrollment in research studies and protocols.
    The Committee has revised and extended the program, 
emphasizing that all funds are to be used for health and 
support services (with research funding coming from NIH and 
other public and private sources) and that the principal goal 
of the program is to increase research among women, infants, 
and children. The Committee intends that this program foster a 
symbiotic relationship between services and research.
    The new Subsection (a) of the revised Section 2671 revises 
the statement of purpose of the program, clarifying that 
grantees are to provide opportunities for women, infants, and 
children to participate in research but are not expected to 
conduct the research themselves (although they are permitted to 
if they so choose). In addition, it clarifies that health care 
services are to be provided to women, infants, and children 
regardless of whether they participate in research projects. 
For purposes of this section, the Committee intends that the 
term ``children'' includes persons up to the age of 21. The 
Committee recognizes that HIV-infected adolescents and their 
families have significant and unique needs, and expects this 
program to continue to include such individuals and their 
families.
    Subsection (a) also makes clear that grantees are to 
identify their clients that might be appropriate participants 
in research, to offer each woman, infant, and child the 
opportunity to participate in research, and facilitate such 
participation. Grantees (and their cooperating researchers) are 
required to comply with accepted standards of protection for 
human subjects, including requirements for written informed 
consent.
    Subsection (a) requires that grantees demonstrate, by a 
time certain as a condition of future funding, that a 
significant number of its clients are participating in research 
projects and that the grantee and the research projects are in 
compliance with the standards of protection for human subjects 
and the priority of the research protocol. The date certain for 
a grantee that has received no waivers under the waiver 
provision described below is the end of the second year of 
funding; for a grantee which has received a waiver described 
below, the date certain is the end of the last year of its 
waiver. If grantees are able to comply with these provisions 
sooner, they are encouraged to do so.
    The Committee has adopted this provision because of 
concerns that have evolved since original enactment. Many 
current grantees are former pediatric AIDS health services 
demonstration projects. For those demonstration projects, the 
principal mission was health service delivery to women, 
infants, and children. Several years ago, the demonstration 
projects were authorized under this section and were given a 
period of transition to add the research coordination 
activities contemplated by the statute. Some of these programs 
have indeed done this and have provided exceptional research 
opportunities to their clients, but the Committee remains 
concerned that for other grantees additional effort is needed.
    The Committee has allowed for a gradual phase-in of the 
requirement that a grantee have a significant number of 
research participants because it does not want to disrupt 
generally successful service delivery programs unnecessarily. 
Rather, the Committee anticipates that by the dates certain 
specified in the statute, all programs will have adjusted their 
emphasis to include among their service efforts opportunities 
for research participation.
    The Committee also intends that the term ``significant 
number'' be interpreted in a relative way by HHS. For grantees 
located in areas where research activities are widespread, a 
``significant number'' of clients should be quite high; for 
grantees located in more remote areas or areas in which 
research on AIDS in women, infants, and children is difficult 
to gain access to, a significant number of clients might be 
relatively lower. The Committee intends that the Secretary, in 
determining a ``significant number,'' take account of a variety 
of factors, including incidence of HIV infection and AIDS in 
the population of women, infants, and children in the area and 
the number and type of clients serviced by the grantee, as well 
as the nature and availability of research protocols accessible 
to the clients of the grantee.
    Subsection (a) further prohibits a grantee from 
conditioning services to a patient upon the consent of the 
patient to participate in research. The legislation also allows 
the Secretary of HHS to take into account circumstances in 
which a grantee is temporarily unable to comply with the 
requirement for reasons beyond the grantee's control and to 
allow the grantee reasonable time to come into compliance.
    The Committee has added this provision in recognition of 
the fact that interruptions in coordination with research 
projects inevitably will occur. Researchers finish their work, 
lose their funding, and change their protocols. In these and 
similar instances, the Committee anticipates that the Secretary 
of HHS will allow and assist grantees to find new research 
opportunities to offer to their clients.
     The bill also establishes a new Subsection (c) of Section 
2671, regarding conduct of research. While no funds under this 
section may be used to pay for research, grantees may conduct 
research with other funds if they wish. Entities that conduct 
research must be qualified to do so, and entities that have 
been recommended for funding by the NIH are deemed to be so 
qualified.
    In addition, Subsection (c) requires that, after 
consultation with public and private entities that conduct 
research, with providers of services under this section, and 
with recipients of services, the Secretary of HHS is to 
establish a list of research protocols that are of high 
priority for purposes of this section. In addition, grantees 
may seek a designation of priority for a research project that 
is not on the Secretary's list. As distinct from current law, 
research projects may be conducted by public or private 
entities.
    The Committee has included this requirement so that the 
research projects that are assisted by the cooperation of 
grantees under this section will be of the highest priority in 
the improvement of outcomes for women, infants, and children. 
Since funding for this program is necessarily limited, an 
establishment of relative priority of the research with which 
grantees are cooperating is needed. Recognizing that grantees 
may wish to associate themselves with other projects as well, 
the Committee has provided the opportunity for them to 
demonstrate to the Secretary of HHS that another project is of 
equal or higher priority to those on the Secretary's list.
    The Committee has allowed cooperation with private research 
opportunities in recognition that some projects undertaken by 
non-profit foundations and pharmaceutical companies may indeed 
be the best projects with which a grantee may associate itself.
    The new Subsection (g) of Section 2671 requires that 
grantees coordinate their activities with other providers under 
the Ryan White CARE Act and under the Maternal and Child Health 
(MCH) block grant, and that they participate in the Statewide 
coordinated statement of need. Since other parts of this title 
and of the MCH program provide services for women, infants and 
children, such coordination is needed to assure that services 
are not duplicated and to assure that the maximum number of 
such people receive basic care.
    The new Subsection (j) of Section 2671 requires that the 
Secretary develop and implement a plan for the coordination of 
activities under this section with those of the NIH. In 
carrying out this requirement, the Secretary is to ensure that 
appropriate projects of NIH-funded research are made aware of 
the applicants and grantees under this section and are required 
to enter into arrangements contemplated by this section.
    This provision is included because the Committee believes 
that only with the full coordination and cooperation with NIH 
can the relationship between research and services occur. 
Grantees have reported to the Committee that many NIH-funded 
research projects have been unresponsive to their attempts to 
coordinate their health services activities with the research 
efforts of the projects. Indeed, it has been reported to the 
Committee that the NIH itself has done little if anything to 
assure that NIH-supported projects take advantage of the ready 
availability of an appropriate research population. Again, 
noting that both research and service dollars are limited, the 
Committee expects the Secretary to remedy this problem and to 
coordinate NIH and Ryan White program activities.
    The bill creates a new Subsection (k), regarding temporary 
waivers of the requirement of significant participation in 
research. Subsection (k) allows the Secretary to waive the 
requirement of the new Subsection (a)(2)(C)(i), described above 
(regarding the participation of a significant number of clients 
in research projects) if the applicant received funding under 
this section for Fiscal Year 1995 and if the Secretary 
determines that the applicant is making reasonable progress 
toward meeting the requirement. The waiver authority of the 
Secretary is terminated on October 1, 1998.
    This subsection was added to allow for an orderly 
transition in those instances in which a grantee is 
experiencing difficulty providing research opportunities to its 
clients. The Committee does not intend that these waivers be 
granted across-the-board or without a review of individual 
circumstances. Rather, such waivers should take into account 
each grantee's effort and progress. Grantees with waivers 
should be given additional help by the Secretary (both through 
Ryan White and the NIH) in meeting the goals of this program.
    A new Subsection (l) is added to allow the Secretary to use 
up to five percent of grant funds to provide training and 
technical assistance in complying with the requirements of the 
program. The Committee intends that this authority be used 
during the initial years of the new authorization in order to 
complete the transition of the program from a demonstration of 
services to one of combining research and services.
    Subsection (b) of Section 401 makes conforming amendments 
to current law.
    Subsection (c) extends the authorization of appropriations 
through the year 2000 at the level of such sums as may be 
necessary.

Section 402. Projects of national significance

    Section 402 reauthorizes and amends the program of grants 
for Special Projects of National Significance (SPNS) (Section 
2618 in current law). These projects are selected on the basis 
of three criteria: the project's ability to assess the 
effectiveness of particular models of care and treatment; the 
project's innovative nature; and the project's potential for 
replication. The bill clarifies that projects are to be 
designed to address the needs of special populations of people 
afflicted with HIV (including people in rural areas, 
adolescents, Native Americans, people who are homeless, people 
with hemophilia, and people who are incarcerated) as well as to 
ensure the availability of services for Native American 
communities. Grantees under this section are to demonstrate 
that their activities are consistent with a Statewide statement 
of need and that the grantees will participate in the revision 
of that statement (where it has been initiated by the State). 
The Secretary is to make information concerning successful 
models of care available to other grantees under the Ryan White 
program. Funding for the Special Projects authority is provided 
by reserving three percent of the funds available under other 
parts of the Ryan White CARE Act.

Section 403. Special training projects

    Section 403 transfers the AIDS Education and Training 
Program (AETC) and the Dental Reimbursement Program from 
Section 776 of the Public Health Service Act to a new Section 
2673B. The Committee believes that these programs which provide 
training to health professionals in the care of AIDS patients 
and, in the case of the dental program, actual services to 
individuals with HIV/AIDS is more appropriately placed in the 
Ryan White CARE Act. The AETC authority is also amended to 
clarify its purposes to be (1) to train practitioners and 
community providers in the diagnosis and treatment of HIV, 
including measures for the prevention and treatment of 
opportunistic infections; (2) to train faculty of health 
professions schools to be able to teach health professions 
students to provide for the health needs of people with HIV; 
and (3) to develop and disseminate curricula and resource 
materials.
    The HIV/AIDS Dental Program teaches dental students and 
residents to diagnose and treat the serious and painful dental 
diseases and multiple oral manifestations arising from AIDS. 
Dentists are often the first to recognize the symptoms of HIV/
AIDS and make appropriate referrals for further medical care. 
Under this program, dental schools and hospitals are partially 
reimbursed for the cost of providing oral health care for 
patients with HIV and AIDS. This program is critical since 
dental benefits are seldom included in a basic health insurance 
plan in the public or private sector. It encourages the 
provision of oral health care to people throughout the nation 
and provides extensive training for dental students and 
residents in the management of the oral care of those suffering 
from AIDS. Educationally, there is no substitute for the 
clinical training dental students and residents gain through 
this program.
    Authorizations of appropriations for both the general 
health professions training projects and for the special 
program for dental schools are extended through the year 2000 
at such sums as may be necessary.

Section 404. Evaluations and reports

    Section 404 extends and simplifies the requirements of 
evaluations and reports. The section also requires that the 
Secretary make available to HRSA, for purposes of evaluating 
Ryan White CARE Act programs, funds available under Section 241 
of the Public Health Service Act, and eliminates the separate 
authorization of appropriations for this purpose.

Section 405. Coordination of program

    Section 405 requires the Secretary to submit a report on 
the coordination of the programs authorized under this title at 
the Federal, State, and local levels.

                     Title V--Additional Provisions

Section 501. Amount of emergency relief grants

    Section 501 revises the formula by which grants are made to 
local areas. In general, funds are allocated among eligible 
areas (as described above at Section 101) on the basis of the 
estimated number of living cases of AIDS in the area times the 
cost index for the area. The number of living cases is 
determined through a weighted average of cases over the most 
recent 10 year period. The cost index is based on the Medicare 
hospital wage index, adjusted to reflect the difference between 
in-patient hospital and outpatient care costs.
    These factors were arrived at after significant 
consultation with HHS, the General Accounting Office, affected 
areas (both those currently funded and those not), and experts 
in the field. As discussed above, a special provision 
restricting the maximum amount that an area will lose has been 
included to provide for transition. The Committee emphasizes 
that this formula and its factors are intended for use only in 
the Ryan White program and are not to be considered appropriate 
for other uses for other programs.

Section 502. Amount of care grants.

    Section 502 revises the formula by which grants are made to 
States and territories. In general, funds are allocated among 
States on the basis of distribution factors that include the 
relative number of AIDS cases reported by the State in the two 
most recent fiscal years and the relative per capita income of 
the State (as in current law). However, to resolve concerns 
about distribution inequities between States which have Title I 
grantees (EMAs) and those which do not, 7 percent of the 
appropriation allocated to Title II is set aside, before 
calculating the formula distribution, for providing additional 
funds to non-EMA States. (Under current law, 10 percent of the 
Title II funds is used for the SPNS program; under this bill, 
the SPNS is funded from 3 percent of all other programs, 
including State grants. Thus, there is a 7 percent 
``remainder'' [which was never part of the formula allocation 
under current law] in Title II which can be set aside for 
another purpose.) This 7 percent is distributed to non-EMA 
States (largely rural States) according to their 2-year case 
average. Then, funds from all States are used to ensure that no 
State receives less than $100,000 or, if there are 90 or more 
cases of AIDS in the State, less than $250,000. The result is 
that no State drops below its current level of funding, and 
non-EMA States realize a substantial increase over current 
funding levels.
    This method of awarding grants among the States and 
territories was arrived at after significant consultation with 
HHS, the General Accounting Office, the States, and experts in 
the field. The Committee emphasizes that this formula and its 
factors are intended for use only in the Ryan White program and 
are not to be considered appropriate for other uses for other 
programs.

Section 503. Consolidation of authorizations of appropriations

    Section 503 extends the authorization of appropriations for 
Part A (Title I, Emergency Relief for Areas with Substantial 
Need for Services) and Part B (Title II, Care Grants) through 
the year 2000 at such sums as may be necessary. In addition, 
Section 503 establishes the relative allocation of funds 
between Part A and Part B to be 64 percent for Part A and 36 
percent for Part B for at least the first fiscal year. For 
Fiscal Years 1997 through 2000, the Secretary may develop and 
implement a methodology for adjusting the ratio of Part A to 
Part B.
    The Committee has established this ongoing relative 
allocation in response to concerns that competition for funding 
between local areas and States has been counter to the 
fundamental intent of the Ryan White CARE Act--to serve all 
people with AIDS, whether they reside in cities, rural areas, 
or other parts of the State. This provision is an attempt to 
focus all concerned parties on the need to work toward 
providing basic primary health care services to all people with 
HIV in the Nation. Since the defined purposes of Parts A and B 
are now to be roughly parallel, the Committee believes that no 
good is served by an ongoing rivalry for funds between cities 
and States. Significant unjustifiable differences in funding 
from area to area can only serve to distort an already complex 
health care delivery system. In some cases, this competition 
for funding, generated by the current separate appropriations 
process, has been to provide public subsidies in one area for 
discretionary services while denying poor persons living in 
another area sufficient funding for even the most minimal 
health care and prescription drugs. At a time when funds will 
be restricted but the epidemic will continue, such unjustified 
disparities must come to an end. The Committee strongly 
encourages the Secretary to devise a method by which funds may 
continue to be appropriately allocated to assure basic services 
to all who cannot provide them themselves, taking account of 
the variety of factors that affect the need for funding changes 
including the addition of new EMAs to the Title I program, 
increasing cost and availability of drugs provided under Title 
II, the changing demographics of AIDS, and any other relevant 
factors.

                        Title VI--Effective Date

Section 601. Effective date

    Section 601 establishes the effective date of this Act to 
be October 1, 1995.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3 of rule XIII of the Rules of the 
House of Representatives, changes in existing law made by the 
bill, as reported, are shown as follows (existing law proposed 
to be omitted is enclosed in black brackets, new matter is 
printed in italic, existing law in which no change is proposed 
is shown in roman):

                       PUBLIC HEALTH SERVICE ACT

          * * * * * * *

              TITLE XXVI--HIV HEALTH CARE SERVICES PROGRAM

 Part A--Emergency Relief for Areas With Substantial Need for Services

SEC. 2601. ESTABLISHMENT OF PROGRAM OF GRANTS.

  (a) Eligible Areas.--The Secretary, acting through the 
Administrator of the Health Resources and Services 
Administration, shall, [subject to subsection (b)] subject to 
subsections (b) through (d), make grants in accordance with 
section 2603 for the purpose of assisting in the provision of 
the services specified in 2604 in any [metropolitan area for 
which, as of June 30, 1990, in the case of grants for fiscal 
year 1991, and as of March 31 of the most recent fiscal year 
for which such data is available in the case of a grant for any 
subsequent fiscal year--
          [(1) there has been reported to and confirmed by the 
        Director of the Centers for Disease Control and 
        Prevention a cumulative total of more than 2,000 cases 
        of acquired immune deficiency syndrome; or
          [(2) the per capita incidence of cumulative cases of 
        such syndrome (computed on the basis of the most 
        recently available data on the population of the area) 
        is not less than 0.0025.] metropolitan area for which 
        there has been reported to the Director of the Centers 
        for Disease Control and Prevention a cumulative total 
        of more than 2,000 cases of acquired immune deficiency 
        syndrome for the most recent period of five calendar 
        years for which such data are available.
          * * * * * * *
  (c) Requirement Regarding Population.--In the case of a 
metropolitan area that was not an eligible area under this part 
for fiscal year 1996, the Secretary may not make a grant under 
this section for the area unless the area has a population of 
500,000 or more individuals. For purposes of eligibility under 
this part, the boundaries of each metropolitan area are the 
boundaries in effect for fiscal year 1994.
  (d) Continued Status as Eligible Area.--A metropolitan area 
that was an eligible area under this part for fiscal year 1996 
is an eligible area for fiscal year 1997 and each subsequent 
fiscal year.

SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL.

  (a) * * *
  (b) HIV Health Services Planning Council.--
          (1) Establishment.--To be eligible for assistance 
        under this part, the chief elected official described 
        in subsection (a)(1) shall establish or designate an 
        HIV health services planning council that shall include 
        representatives of--
                  (A) health care providers, including 
                federally qualified health centers;
                  (B) community-based and AIDS service 
                organizations;
                  (C) social service providers;
                  (D) mental health care providers and 
                providers of services regarding substance 
                abuse;
                  (E) local public health agencies;
                  (F) hospital planning agencies or health care 
                planning agencies;
                  (G) affected communities, including 
                individuals with HIV disease and historically 
                underserved groups and subpopulations;
                  (H) non-elected community leaders;
                  (I) State government, including the State 
                medicaid agency and the agency administering 
                the program under part B;
                  (J) grantees under subpart II of part C; 
                [and]
                  [(K) the lead agency of any Health Resources 
                and Services Administration adult and pediatric 
                HIV-related care demonstration project 
                operating in the area to be served.]
                  (K) grantees under section 2671, or, if none 
                are operating in the area, representatives of 
                organizations in the area with a history of 
                serving children, youth, women, and families 
                living with HIV; and
                  (L) grantees under other HIV-related Federal 
                programs.
          * * * * * * *
          (3) Duties.--[The planning council established or 
        designated under paragraph (1) shall--
                  [(A) establish priorities for the allocation 
                of funds within the eligible area;] The 
                planning council under paragraph (1) shall 
                carry out the following:
                  (A) Establish priorities for the allocation 
                of funds within the eligible area based on the 
                following factors:
                          (i) Documented needs of the HIV-
                        infected population.
                          (ii) Cost and outcome effectiveness 
                        of proposed strategies and 
                        interventions, to the extent that such 
                        data are reasonably available.
                          (iii) Priorities of the HIV-infected 
                        communities for which the services are 
                        intended.
                          (iv) Availability of other 
                        governmental and nongovernmental 
                        resources.
                  (B) [develop] Develop a comprehensive plan 
                for the organization and delivery of health 
                services described in section 2604 that is 
                compatible with any existing State or local 
                plan regarding the provision of health services 
                to individuals with HIV disease[; and].
                  (C) [assess] Assess the efficiency of the 
                administrative mechanism in [rapidly] 
                allocating funds to the areas of greatest need 
                within the eligible area, and assess the 
                effectiveness, either directly or through 
                contractual arrangements, of the services 
                offered in meeting the identified needs.
                  (D) Participate in the development of the 
                statewide coordinated statement of need 
                initiated by the State health department (where 
                it has been so initiated).
                  (E) Obtain input on community needs through 
                conducting public meetings.
          (4) General provisions.--
                  (A) Composition of council.--The planning 
                council under paragraph (1) shall (in addition 
                to requirements under such paragraph) reflect 
                in its composition the demographics of the 
                epidemic in the eligible area involved, with 
                particular consideration given to 
                disproportionately affected and historically 
                underserved groups and subpopulations. 
                Nominations for membership on the council shall 
                be identified through an open process, and 
                candidates shall be selected based on locally 
                delineated and publicized criteria. Such 
                criteria shall include a conflict-of-interest 
                standard for each nominee.
                  (B) Conflicts of interest.--
                          (i) The planning council under 
                        paragraph (1) may not be directly 
                        involved in the administration of a 
                        grant under section 2601(a). With 
                        respect to compliance with the 
                        preceding sentence, the planning 
                        council may not designate (or otherwise 
                        be involved in the selection of) 
                        particular entities as recipients of 
                        any of the amounts provided in the 
                        grant.
                          (ii) An individual may serve on the 
                        planning council under paragraph (1) 
                        only if the individual agrees to comply 
                        with the following:
                                  (I) If the individual has a 
                                financial interest in an 
                                entity, and such entity is 
                                seeking amounts from a grant 
                                under section 2601(a), the 
                                individual will not, with 
                                respect to the purpose for 
                                which the entity seeks such 
                                amounts, participate (directly 
                                or in an advisory capacity) in 
                                the process of selecting 
                                entities to receive such 
                                amounts for such purpose.
                                  (II) In the case of a public 
                                or private entity of which the 
                                individual is an employee, or a 
                                public or private organization 
                                of which the individual is a 
                                member, the individual will not 
                                participate (directly or in an 
                                advisory capacity) in the 
                                process of making any decision 
                                that relates to the expenditure 
                                of a grant under section 
                                2601(a) for such entity or 
                                organization or that otherwise 
                                directly affects the entity or 
                                organization.

SEC. 2603. TYPE AND DISTRIBUTION OF GRANTS.

  (a) Grants Based on Relative Need of Area.--
          (1) In general.--In carrying out section 2601(a), the 
        Secretary shall make a grant for each eligible area for 
        which an application under section 2605(a) has been 
        approved. Each such grant shall be made in an amount 
        determined in accordance with paragraph (3), subject to 
        paragraph (4). Grants under this paragraph for a fiscal 
        year shall be disbursed not later than 60 days after 
        the date on which amounts appropriated under section 
        2677 become available for the fiscal year, subject to 
        any waivers under section 2605(d).
          [(2) Expedited distribution.--Not later than--
                  [(A) 90 days after an appropriation becomes 
                available to carry out this part for fiscal 
                year 1991; and
                  [(B) 60 days after an appropriation becomes 
                available to carry out this part for each of 
                fiscal years 1992 through 1995;
        the Secretary shall, except in the case of waivers 
        granted under section 2605(c), disburse 50 percent of 
        the amount appropriated under section 2608 for such 
        fiscal year through grants to eligible areas under 
        section 2601(a).
          [(3) Amount of grant.--
                  [(A) In general.--
                          [(i) Subject to the extent of amounts 
                        made available in appropriations Acts, 
                        a grant made for purposes of this 
                        paragraph to an eligible area shall be 
                        made in an amount equal to the product 
                        of--
                                  [(I) an amount equal to the 
                                amount available for 
                                distribution under paragraph 
                                (2) for the fiscal year 
                                involved; and
                                  [(II) the percentage 
                                constituted by the ratio of the 
                                distribution factor for the 
                                eligible area to the sum of the 
                                respective distribution factors 
                                for all eligible areas.
                          [(ii) For purposes of clause (i)(II), 
                        the term ``distribution factor'' means 
                        the sum of--
                                  [(I) an amount equal to the 
                                product of 3 and the amount 
                                determined under subparagraph 
                                (B) for the eligible area 
                                involved; and
                                  [(II) an amount equal to the 
                                product of the amount 
                                determined under subparagraph 
                                (B) for the eligible area and 
                                the amount determined under 
                                subparagraph (C) for the area.
                  [(B) Amount relating to cumulative number of 
                cases.--The amount determined in this 
                subparagraph is an amount equal to the ratio 
                of--
                          [(i) an amount equal to the 
                        cumulative number of cases of acquired 
                        immune deficiency syndrome in the 
                        eligible area involved, as indicated by 
                        the number of such cases reported to 
                        and confirmed by the Director of the 
                        Centers for Disease Control and 
                        Prevention by the applicable date 
                        specified in section 2601(a); to
                          [(ii) an amount equal to the sum of 
                        the respective amounts determined under 
                        clause (i) for each eligible area for 
                        which an application for a grant for 
                        purposes of this paragraph has been 
                        approved.
                  [(C) Amount relating to per capita incidence 
                of cases.--The amount determined in this 
                subparagraph is an amount equal to the ratio 
                of--
                          [(i) the per capita incidence of 
                        cumulative cases of acquired immune 
                        deficiency syndrome in the eligible 
                        area involved (computed on the basis of 
                        the most recently available data on the 
                        population of the area); to
                          [(ii) the per capita incidence of 
                        cumulative such cases in all eligible 
                        areas for which applications for grants 
                        for purposes of this paragraph have 
                        been approved (computed on the basis of 
                        the most recently available data on the 
                        population of the areas).]
          (2) Allocations.--Of the amount available under 
        section 2677 for a fiscal year for making grants under 
        section 2601(a)--
                  (A) the Secretary shall reserve 50 percent 
                for making grants under paragraph (1) in 
                amounts determined in accordance with paragraph 
                (3); and
                  (B) the Secretary shall, after compliance 
                with subparagraph (A), reserve such funds as 
                may be necessary to carry out paragraph (4).
          (3) Amount of grant.--
                  (A) In general.--Subject to the extent of 
                amounts made available in appropriations Acts, 
                a grant made for purposes of this paragraph to 
                an eligible area shall be made in an amount 
                equal to the product of--
                          (i) an amount equal to the amount 
                        available for distribution under 
                        paragraph (2) for the fiscal year 
                        involved; and
                          (ii) the percentage constituted by 
                        the ratio of the distribution factor 
                        for the eligible area to the sum of the 
                        respective distribution factors for all 
                        eligible areas.
                  (B) Distribution factor.--For purposes of 
                subparagraph (A)(ii), the term ``distribution 
                factor'' means the product of--
                          (i) an amount equal to the estimated 
                        number of living cases of acquired 
                        immune deficiency syndrome in the 
                        eligible area involved, as determined 
                        under subparagraph (C); and
                          (ii) the cost index for the eligible 
                        area involved, as determined under 
                        subparagraph (D).
                  (C) Estimate of living cases.--The amount 
                determined in this subparagraph is an amount 
                equal to the product of--
                          (i) the number of cases of acquired 
                        immune deficiency syndrome in the 
                        eligible area during each year in the 
                        most recent 120-month period for which 
                        data are available with respect to all 
                        eligible areas, as indicated by the 
                        number of such cases reported to and 
                        confirmed by the Director of the 
                        Centers for Disease Control and 
                        Prevention for each year during such 
                        period; and
                          (ii) with respect to--
                                  (I) the first year during 
                                such period, .06;
                                  (II) the second year during 
                                such period, .06;
                                  (III) the third year during 
                                such period, .08;
                                  (IV) the fourth year during 
                                such period, .10;
                                  (V) the fifth year during 
                                such period, .16;
                                  (VI) the sixth year during 
                                such period, .16;
                                  (VII) the seventh year during 
                                such period, .24;
                                  (VIII) the eighth year during 
                                such period, .40;
                                  (IX) the ninth year during 
                                such period, .57; and
                                  (X) the tenth year during 
                                such period, .88.
                  (D) Cost index.--The amount determined in 
                this subparagraph is an amount equal to the sum 
                of--
                          (i) the product of--
                                  (I) the average hospital wage 
                                index reported by hospitals in 
                                the eligible area involved 
                                under section 1886(d)(3)(E) of 
                                the Social Security Act for the 
                                3-year period immediately 
                                preceding the year for which 
                                the grant is being awarded; and
                                  (II) .70; and
                          (ii) .30.
                  (E) Unexpended funds.--The Secretary may, in 
                determining the amount of a grant for a fiscal 
                year under this paragraph, adjust the grant 
                amount to reflect the amount of unexpended and 
                uncanceled grant funds remaining at the end of 
                the fiscal year preceding the year for which 
                the grant determination is to be made. The 
                amount of any such unexpended funds shall be 
                determined using the financial status report of 
                the grantee.
                  (F) Puerto rico, virgin islands, guam.--For 
                purposes of subparagraph (D), the cost index 
                for an eligible area within Puerto Rico, the 
                Virgin Islands, or Guam shall be 1.0.
          (4) Maximum reduction in grant.--In the case of any 
        eligible area for which a grant under paragraph (1) was 
        made for fiscal year 1995, the Secretary, in making 
        grants under such paragraph for the area for the fiscal 
        years 1996 through 2000, shall (subject to the extent 
        of the amount available under section 2677 for the 
        fiscal year involved for making grants under section 
        2601(a)) ensure that the amounts of the grants do not, 
        relative to such grant for the area for fiscal year 
        1995, constitute a reduction of more than the 
        following, as applicable to the fiscal year involved:
                  (A) 1 percent, in the case of fiscal year 
                1996.
                  (B) 2 percent, in the case of fiscal year 
                1997.
                  (C) 3 percent, in the case of fiscal year 
                1998.
                  (D) 4 percent, in the case of fiscal year 
                1999.
                  (E) 5 percent, in the case of fiscal year 
                2000.
  (b) Supplemental Grants.--
          (1) In general.--[Not later than 150 days after the 
        date on which appropriations are made under section 
        2608 for a fiscal year, the Secretary shall disburse 
        the remainder of amounts not disbursed under section 
        2603(a)(2) for such fiscal year for the purpose of 
        making grants under section 2601(a) to eligible areas 
        whose application under section 2605(b)--] After 
        allocating in accordance with subsection (a) the 
        amounts available under section 2677 for grants under 
        section 2601(a) for a fiscal year, the Secretary, in 
        carrying out section 2601(a), shall from the remaining 
        amounts make grants to eligible areas described in this 
        paragraph. Such grants shall be disbursed not later 
        than 150 days after the date on which amounts 
        appropriated under section 2677 become available for 
        the fiscal year. An eligible area described in this 
        paragraph is an eligible area whose application under 
        section 2605(b)--
                  (A) contains a report concerning the 
                dissemination of emergency relief funds under 
                subsection (a) and the plan for utilization of 
                such funds;
                  (B) demonstrates the severe need in such area 
                for supplemental financial assistance to combat 
                the HIV epidemic;
                  (C) demonstrates the existing commitment of 
                local resources of the area, both financial and 
                in-kind, to combating the HIV epidemic;
                  (D) demonstrates the ability of the area to 
                utilize such supplemental financial resources 
                in a manner that is immediately responsive and 
                cost effective; [and]
                  (E) demonstrates that resources will be 
                allocated in accordance with the local 
                demographic incidence of AIDS including 
                appropriate allocations for services for 
                infants, children, women, and families with HIV 
                disease[.]; and
                  (F) demonstrates the manner in which the 
                proposed services are consistent with the local 
                needs assessment and the statewide coordinated 
                statement of need.
          (2) Priority.--
                  (A) Severe need.--In determining severe need 
                in accordance with paragraph (1)(B), the 
                Secretary shall give priority consideration in 
                awarding grants under this subsection to 
                eligible areas that (in addition to complying 
                with paragraph (1)) demonstrate a more severe 
                need based on the prevalence in the eligible 
                area of--
                          (i) sexually transmitted diseases, 
                        substance abuse, tuberculosis, severe 
                        mental illness, or other conditions 
                        determined relevant by the Secretary, 
                        which significantly affect the impact 
                        of HIV disease;
                          (ii) subpopulations with HIV disease 
                        that were previously unknown in such 
                        area; or
                          (iii) homelessness.
                  (B) Prevalence.--In determining prevalence of 
                conditions under subparagraph (A), the 
                Secretary shall use data on the prevalence of 
                the conditions described in such subparagraph 
                among individuals with HIV disease (except 
                that, in the case of an eligible area for which 
                such data are not available, the Secretary 
                shall use data on the prevalences of the 
                conditions in the general population of such 
                area).
          [(2)] (3) Remainder of amounts.--In determining the 
        amount of funds to be obligated under paragraph (1), 
        the Secretary shall include amounts that are not paid 
        to the eligible areas under expedited procedures under 
        section 2603(a)(2) as a result of--
                  (A) the failure of any eligible area to 
                submit an application under section 2605(c); or
                  (B) any eligible area informing the Secretary 
                that such eligible area does not intend to 
                expend the full amount of its grant under such 
                section.
          [(3)] (4) Amount of grant.--The amount of each grant 
        made for purposes of this subsection shall be 
        determined by the Secretary based on the application 
        submitted by the eligible area under section 2605(b).
          [(4)] (5) Failure to submit.--
                  (A) In general.--The failure of an eligible 
                area to submit an application for an expedited 
                grant under section 2603(a)(2) shall not result 
                in such area being ineligible for a grant under 
                this subsection.
                  (B) Application.--The application of an 
                eligible area submitted under section 2605(b) 
                shall contain the assurances required under 
                subsection (a) of such section if such eligible 
                area fails to submit an application for an 
                expedited grants under section 2603(a)(2).
  (c) Compliance With Priorities of HIV Planning Council.--
Notwithstanding any other provision of this part, the 
Secretary, in carrying out section 2601(a), may not make any 
grant under subsection (a) or (b) to an eligible area unless 
the application submitted by such area under section 2605 for 
the grant involved demonstrates that the grants made under 
subsections (a) and (b) to the area for the preceding fiscal 
year (if any) were expended in accordance with the priorities 
applicable to such year that were established, pursuant to 
section 2602(b)(3)(A), by the planning council serving the 
area.

SEC. 2604. USE OF AMOUNTS.

  (a) * * *
  (b) Primary Purposes.--
          (1) In general.--The chief elected official shall use 
        amounts received under a grant under section 2601 to 
        provide direct financial assistance to entities 
        described in paragraph (2) for the purpose of 
        delivering or enhancing HIV-related--
                  (A) outpatient and ambulatory health and 
                support services, [including case management 
                and comprehensive treatment services, for 
                individuals] including HIV-related 
                comprehensive treatment services (including 
                treatment education and measures for the 
                prevention and treatment of opportunistic 
                infections), case management, and substance 
                abuse treatment and mental health treatment, 
                for individuals and families with HIV disease; 
                and
                  (B) inpatient case management services that 
                prevent unnecessary hospitalization or that 
                expedite discharge, as medically appropriate, 
                from inpatient facilities.
          (2) Appropriate entities.--
                  (A) In general.--Subject to subparagraph (B), 
                direct financial assistance may be provided 
                under paragraph (1) to public or nonprofit 
                private entities, or private for-profit 
                entities if such entities are the only 
                available provider of quality HIV care in the 
                area, including hospitals (which may include 
                Department of Veterans Affairs facilities), 
                community-based organizations, hospices, 
                ambulatory care facilities, community health 
                centers, migrant health centers, [and homeless 
                health centers] homeless health centers, 
                substance abuse treatment programs, and mental 
                health programs.
                  (B) Priority.--In providing direct financial 
                assistance under paragraph (1) the chief 
                elected official shall give priority to 
                entities that are currently participating in 
                Health Resources and Services Administration 
                HIV health care demonstration projects.
          (3) Priority for women, infants and children.--For 
        the purpose of providing health and support services to 
        infants, children, and women with HIV disease, the 
        chief elected official of an eligible area shall use, 
        of the grants made for the area under section 2601(a) 
        for a fiscal year, not less than the percentage 
        constituted by the ratio of the population in such area 
        of infants, children, and women with acquired immune 
        deficiency syndrome to the general population in such 
        area of individuals with such syndrome, or 15 percent, 
        whichever is less. In expending the funds reserved 
        under the preceding sentence for a fiscal year, the 
        chief elected official shall give priority to 
        providing, for pregnant women, measures to prevent the 
        perinatal transmission of HIV.
          * * * * * * *
  (e) Administration and Planning.--The chief executive officer 
of an eligible area shall not use in excess of 5 percent of 
amounts received under a grant awarded under this part for 
administration, accounting, reporting, and program oversight 
functions. In the case of entities to which such officer 
allocates amounts received by the officer under the grant, the 
officer shall ensure that, of the aggregate amount so 
allocated, the total of the expenditures by such entities for 
administrative expenses does not exceed 10 percent (without 
regard to whether particular entities expend more than 10 
percent for such expenses).
          * * * * * * *

SEC. 2605. APPLICATION.

  (a) In General.--To be eligible to receive a grant under 
section 2601, an eligible area shall prepare and submit to the 
Secretary an application at such time, in such form, and 
containing such information as the Secretary shall require, 
including assurances adequate to ensure--
          (1)(A) * * *
          (B) that the political subdivisions within the 
        eligible area will maintain the level of expenditures 
        by such political subdivisions for HIV-related services 
        for individuals with HIV disease at a level that is 
        equal to the level of such expenditures by such 
        political subdivisions for the [1-year period preceding 
        the first fiscal year for which a grant is received by 
        the eligible area] preceding fiscal year; and
          * * * * * * *
          (4) that funds received under a grant awarded under 
        this part will not be utilized to make payments for any 
        item or service to the extent that payment has been 
        made, or can reasonably be expected to be made, with 
        respect to that item or service--
                  (A) under any State compensation program, 
                under an insurance policy, or under any Federal 
                or State health benefits program; or
                  (B) by an entity that provides health 
                services on a prepaid basis; [and]
          (5) to the maximum extent practicable, that--
                  (A) HIV health care and support services 
                provided with assistance made available under 
                this part will be provided without regard--
                          (i) to the ability of the individual 
                        to pay for such services; and
                          (ii) to the current or past health 
                        condition of the individual to be 
                        served;
                  (B) such services will be provided in a 
                setting that is accessible to low-income 
                individuals with HIV-disease; and
                  (C) a program of outreach will be provided to 
                low-income individuals with HIV-disease to 
                inform such individuals of such services[.]; 
                and
          (6) that the applicant will participate in the 
        process for the statewide coordinated statement of need 
        (where it has been initiated by the State), and will 
        ensure that the services provided under the 
        comprehensive plan are consistent with such statement.
  (b) [Additional] Application.--An eligible area that desires 
to receive a grant under section 2603(b) shall prepare and 
submit to the Secretary an [additional] application at such 
time, in such form, and containing such information as the 
Secretary shall require, including the information required 
under such subsection and information concerning--
          (1) the number of individuals to be served within the 
        eligible area with assistance provided under the grant;
          (2) demographic data on the population of such 
        individuals;
          (3) the average cost of providing each category of 
        HIV-related health services and the extent to which 
        such cost is paid by third-party payors; and
          (4) the aggregate amounts expended for each such 
        category of services.
  (c) Single Application.--Upon the request of the chief 
elected official of an eligible area, the Secretary may 
authorize the official to submit a single application through 
which the official simultaneously requests a grant pursuant to 
subsection (a) of section 2603 and a grant pursuant to 
subsection (b) of such section. The Secretary may establish 
such criteria for carrying out this subsection as the Secretary 
determines to be appropriate.
  [(c)] (d) Date Certain for Submission.--
          (1) Requirement.--Except as provided in paragraph 
        (2), to be eligible to receive a grant under section 
        2601(a) for a fiscal year, an application under 
        subsection (a) shall be submitted not later than 45 
        days after the date on which appropriations are made 
        under section [2608] 2677 for the fiscal year.
          * * * * * * *
  [(d)] (e) Requirements Regarding Imposition of Charges for 
Services.--
          (1) In general.--The Secretary may not make a grant 
        under section 2601 to an eligible area unless the 
        eligible area provides assurances that in the provision 
        of services with assistance provided under the grant--
                  (A) * * *
          * * * * * * *

SEC. 2606. TECHNICAL ASSISTANCE.

  (a) In General.--The Administrator of the Health Resources 
and Services Administration [may, beginning on the date of 
enactment of this title,] (referred to in this section as the 
``Administrator'') shall provide technical assistance to assist 
entities in complying with the requirements of this part in 
order to make such entities eligible to receive a grant under 
this part.
  (b) Planning Grants Regarding Initial Eligibility for 
Grants.--
          (1) Advance payments on first-year formula grants.--
        With respect to a fiscal year (referred to in this 
        subsection as the ``planning year''), if a metropolitan 
        area has not previously received a grant under section 
        2601 and the Administrator reasonably projects that the 
        area will be eligible for such a grant for the 
        subsequent fiscal year, the Administrator may make a 
        grant for the planning year for the purpose of 
        assisting the area in preparing for the 
        responsibilities of the area in carrying out activities 
        under this part.
          (2) Requirements.--
                  (A) In general.--A grant under paragraph (1) 
                for a planning year shall be made directly to 
                the chief elected official of the city or urban 
                county that administers the public health 
                agency to which section 2602(a)(1) is projected 
                to apply for purposes of such paragraph. The 
                grant may not be made in an amount exceeding 
                $75,000.
                  (B) Offsetting reduction in first formula 
                grant.--In the case of a metropolitan area that 
                has received a grant under paragraph (1) for a 
                planning year, the first grant made pursuant to 
                section 2603(a) for such area shall be reduced 
                by an amount equal to the amount of the grant 
                under such paragraph for the planning year. 
                With respect to amounts resulting from 
                reductions under the preceding sentence for a 
                fiscal year, the Secretary shall use such 
                amounts to make grants under section 2603(a) 
                for the fiscal year, subject to ensuring that 
                none of such amounts are provided to any 
                metropolitan area for which such a reduction 
                was made for the fiscal year.
          (3) Funding.--Of the amounts available under section 
        2677 for a fiscal year for carrying out this part, the 
        Administrator may reserve not more than 1 percent for 
        making grants under paragraph (1).

SEC. 2607. DEFINITIONS.

  For purposes of this part:
          (1) Eligible area.--[The term ``eligible area'' means 
        a metropolitan area described in section 2601(a).] The 
        term ``eligible area'' means a metropolitan area 
        meeting the requirements of section 2601 that are 
        applicable to the area.
          (2) Metropolitan area.--The term ``metropolitan 
        area'' means an area referred to in the HIV/AIDS 
        Surveillance Report of the Centers for Disease Control 
        and Prevention as a metropolitan area.

[SEC. 2608. AUTHORIZATION OF APPROPRIATIONS.

  [There are authorized to be appropriated to make grants under 
this part, $275,000,000 in each of the fiscal years 1991 and 
1992, and such sums as may be necessary in each of the fiscal 
years 1993 through 1995.]

                       Part B--Care Grant Program

          * * * * * * *

[SEC. 2612. GENERAL USE OF GRANTS.

  [(a) In General.--A State may use amounts provided under 
grants made under this part--
          [(1) to establish and operate HIV care consortia 
        within areas most affected by HIV disease that shall be 
        designed to provide a comprehensive continuum of care 
        to individuals and families with HIV disease in 
        accordance with section 2613;
          [(2) to provide home- and community-based care 
        services for individuals with HIV disease in accordance 
        with section 2614;
          [(3) to provide assistance to assure the continuity 
        of health insurance coverage for individuals with HIV 
        disease in accordance with section 2615; and
          [(4) to provide treatments, that have been determined 
        to prolong life or prevent serious deterioration of 
        health, to individuals with HIV disease in accordance 
        with section 2616.
  [(b) Infants and Women, Etc.--A State shall use not less than 
15 percent of funds allocated under this part to provide health 
and support services to infants, children, women, and families 
with HIV disease.]

SEC. 2612. GENERAL USE OF GRANTS.

  (a) In General.--A State may use amounts provided under 
grants made under this part for the following:
          (1) To provide the services described in section 
        2604(b)(1) for individuals with HIV disease.
          (2) To provide to such individuals treatments that in 
        accordance with section 2616 have been determined to 
        prolong life or prevent serious deterioration of 
        health.
          (3) To provide home- and community-based care 
        services for such individuals in accordance with 
        section 2614.
          (4) To provide assistance to assure the continuity of 
        health insurance coverage for such individuals in 
        accordance with section 2615.
          (5) To establish and operate consortia under section 
        2613 within areas most affected by HIV disease, which 
        consortia shall be designed to provide a comprehensive 
        continuum of care to individuals and families with such 
        disease in accordance with such section.
  (b) Priority for Women, Infants and Children.--For the 
purpose of providing health and support services to infants, 
children, and women with HIV disease, a State shall use, of the 
funds allocated under this part to the State for a fiscal year, 
not less than the percentage constituted by the ratio of the 
population in the State of infants, children, and women with 
acquired immune deficiency syndrome to the general population 
in the State of individuals with such syndrome, or 15 percent, 
whichever is less. In expending the funds reserved under the 
preceding sentence for a fiscal year, the State shall give 
priority to providing, for pregnant women, measures to prevent 
the perinatal transmission of HIV.

SEC. 2613. GRANTS TO ESTABLISH HIV CARE CONSORTIA.

  (a) Consortia.--A State may use amounts provided under a 
grant awarded under this part to provide assistance under 
section 2612(a)(1) to an entity that--
          (1) is an association of one or more public, and one 
        or more nonprofit private, (or private for-profit 
        providers or organizations if such entities are the 
        only available providers of quality HIV care in the 
        area) health care and support service providers and 
        community based organizations operating within areas 
        determined by the State to be most affected by HIV 
        disease; and
          (2) agrees to use such assistance for the planning, 
        development and delivery, through the direct provision 
        of services or through entering into agreements with 
        other entities for the provision of such services, of 
        comprehensive outpatient health and support services 
        for individuals with HIV disease,  that may include--
                  (A) essential health services such as case 
                management services, medical, nursing, 
                substance abuse treatment, mental health 
                treatment, and dental care, diagnostics, 
                monitoring, measures for the prevention and 
                treatment of opportunistic infections, 
                treatment education for patients (provided in 
                the context of health care delivery), and 
                medical follow-up services, mental health, 
                developmental, and rehabilitation services, 
                home health and hospice care; and
                  (B) essential support services such as 
                transportation services, attendant care, 
                homemaker services, day or respite care, 
                benefits advocacy, advocacy services provided 
                through public and nonprofit private entities, 
                and services that are incidental to the 
                provision of health care services for 
                individuals with HIV disease including 
                nutrition services, housing referral services, 
                and child welfare and family services 
                (including foster care and adoption services).
An entity or entities of the type described in this subsection 
shall hereinafter be referred to in this title as a 
``consortium'' or ``consortia''.
          * * * * * * *
  (c) Application.--
          (1) * * *
          (2) Consultation.--In establishing the plan required 
        under paragraph (1)(B), the consortium shall consult 
        with--
                  (A)(i) the public health agency that provides 
                or supports ambulatory and outpatient HIV-
                related health care services within the 
                geographic area to be served; or
                  (ii) in the case of a public health agency 
                that does not directly provide such HIV-related 
                health care services such agency shall consult 
                with an entity or entities that directly 
                provide ambulatory and outpatient HIV-related 
                health care services within the geographic area 
                to be served; [and]
                  (B) not less than one community-based 
                organization that is organized solely for the 
                purpose of providing HIV-related support 
                services to individuals with HIV disease[.]; 
                and
                  (C) grantees under section 2671, or, if none 
                are operating in the area, representatives in 
                the area of organizations with a history of 
                serving children, youth, women, and families 
                living with HIV.
        The organization to be consulted under subparagraph (B) 
        shall be at the discretion of the applicant consortium.
          * * * * * * *

SEC. 2616. PROVISION OF TREATMENTS.

  (a) In General.--A State [may use amounts] shall use a 
portion of the amounts provided under a grant awarded under 
this part to establish a program under section [2612(a)(4)] 
2612(a)(2) to provide treatments that have been determined to 
prolong life or prevent the serious deterioration of health 
arising from HIV disease in eligible individuals, including 
measures for the prevention and treatment of opportunistic 
infections.
          * * * * * * *

SEC. 2617. STATE APPLICATION.

  (a) * * *
  (b) Description of Intended Uses and Agreements.--The 
application submitted under subsection (a) shall contain--
          (1) * * *
          (2) a comprehensive plan for the organization and 
        delivery of HIV health care and support services to be 
        funded with assistance received under this part that 
        shall include a description of the purposes for which 
        the State intends to use such assistance, including--
                  (A) the services and activities to be 
                provided and an explanation of the manner in 
                which the elements of the program to be 
                implemented by the State with such assistance 
                will maximize the quality of health and support 
                services available to individuals with HIV 
                disease throughout the State; [and]
                  (B) a description of the manner in which 
                services funded with assistance provided under 
                this part will be coordinated with other 
                available related services for individuals with 
                HIV disease; [and]
                  (C) a description of the activities carried 
                out by the State under section 2616; and
                  (D) a description of how the allocation and 
                utilization of resources are consistent with a 
                statewide coordinated statement of need, 
                developed in partnership with other grantees in 
                the State that receive funding under this title 
                and after consultation with individuals 
                receiving services under this part.
          * * * * * * *

SEC. 2618. DISTRIBUTION OF FUNDS.

  [(a) Special Projects of a National Significance.--
          [(1) In general.--Of the amount appropriated under 
        section 2620 for each fiscal year, the Secretary shall 
        use not to exceed 10 percent of such amount to 
        establish and administer a special projects of national 
        significance program to award direct grants to public 
        and nonprofit private entities including community-
        based organizations to fund special programs for the 
        care and treatment of individuals with HIV disease.
          [(2) Grants.--The Secretary shall award grants under 
        subsection (a) based on--
                  [(A) the need to assess the effectiveness of 
                a particular model for the care and treatment 
                of individuals with HIV disease;
                  [(B) the innovative nature of the proposed 
                activity; and
                  [(C) the potential replicability of the 
                proposed activity in other similar localities 
                or nationally.
          [(3) Special projects.--Special projects of a 
        national significance may include those that are 
        designed to--
                  [(A) establish a system designed to increase 
                the number of health care facilities willing 
                and able to serve low-income individuals and 
                families with HIV disease;
                  [(B) deliver drug abuse treatment and HIV 
                health care services at a single location, 
                through either an outpatient or residential 
                facility;
                  [(C) provide support and respite care for 
                participants in family-based care networks 
                critical to the delivery of comprehensive HIV 
                care in the minority community;
                  [(D) deliver an enhanced spectrum of 
                comprehensive health care and support services 
                to underserved hemophilia populations, 
                including minorities and those in rural and 
                underserved areas, utilizing established 
                networks of hemophilia diagnostic and treatment 
                centers and community-based outreach systems;
                  [(E) deliver HIV health care and support 
                services to Indians with HIV disease and their 
                families;
                  [(F) improve the provision of HIV health care 
                and support services to individuals and 
                families with HIV disease located in rural 
                areas;
                  [(G) deliver HIV health care and support 
                services to homeless individuals and families 
                with HIV disease; and
                  [(H) deliver HIV health care and support 
                services to individuals with HIV disease who 
                are incarcerated.
  [(b) Amount of Grant to State.--
          [(1) Minimum allotment.--Subject to the extent of 
        amounts made available under section 2620, the amount 
        of a grant to be made under this part for--
                  [(A) each of the several States and the 
                District of Columbia for a fiscal year shall be 
                the greater of--
                          [(i) $100,000, and
                          [(ii) an amount determined under 
                        paragraph (2); and
                  [(B) each territory of the United States, as 
                defined in paragraph 3, shall be an amount 
                determined under paragraph (2).
          [(2) Determination.--
                  [(A) Formula.--The amount referred to in 
                paragraph (1)(A)(ii) for a State and paragraph 
                (1)(B) for a territory of the United States 
                shall be the product of--
                          [(i) an amount equal to the amount 
                        appropriated under section 2620 for the 
                        fiscal year involved; and
                          [(ii) the ratio of the distribution 
                        factor for the State or territory to 
                        the sum of the distribution factors for 
                        all the States or territories.
                  [(B) Distribution factor.--As used in 
                subparagraph (A)(ii), the term ``distribution 
                factor'' means--
                          [(i) in the case of a State, the 
                        product of--
                                  [(I) the number of cases of 
                                acquired immune deficiency 
                                syndrome in the State, as 
                                indicated by the number of 
                                cases reported to and confirmed 
                                by the Secretary for the 2 most 
                                recent fiscal years for which 
                                such data are available; and
                                  [(II) the cube root of the 
                                ratio (based on the most recent 
                                available data) of--
                                          [(aa) the average per 
                                        capita income of 
                                        individuals in the 
                                        United States 
                                        (including the 
                                        territories); to
                                          [(bb) the average per 
                                        capita income of 
                                        individuals in the 
                                        State; and
                          [(ii) in the case of a territory of 
                        the United States the number of 
                        additional cases of such syndrome in 
                        the specific territory, as indicated by 
                        the number of cases reported to and 
                        confirmed by the Secretary for the 2 
                        most recent fiscal years for which such 
                        data is available.
          [(3) Definitions.--As used in this subsection--
                  [(A) the term ``State'' means each of the 50 
                States, the District of Columbia and the 
                Commonwealth of Puerto Rico; and
                  [(B) the term ``territory of the United 
                States'' means the Virgin Islands, Guam, 
                American Samoa, the Commonwealth of the 
                Northern Mariana Islands, and the Republic of 
                the Marshall Islands.]
  (a) Amount of Grant.--
          (1) In general.--Subject to subsection (b) (relating 
        to minimum grants), the amount of a grant under this 
        part for a State for a fiscal year shall be the sum 
        of--
                  (A) the amount determined for the State under 
                paragraph (2); and
                  (B) the amount determined for the State under 
                paragraph (4) (if applicable).
          (2) Principal formula grants.--For purposes of 
        paragraph (1)(A), the amount determined under this 
        paragraph for a State for a fiscal year shall be the 
        product of--
                  (A) the amount available under section 2677 
                for carrying out this part, less the 
                reservation of funds made in paragraph (4)(A) 
                and less any other applicable reservation of 
                funds authorized or required in this Act (which 
                amount is subject to subsection (b)); and
                  (B) the percentage constituted by the ratio 
                of--
                          (i) the distribution factor for the 
                        State; to
                          (ii) the sum of the distribution 
                        factors for all States.
          (3) Distribution factor for principal formula 
        grants.--For purposes of paragraph (2)(B), the term 
        ``distribution factor'' means the following, as 
        applicable:
                  (A) In the case of each of the 50 States, the 
                District of Columbia, and the Commonwealth of 
                Puerto Rico, the product of--
                          (i) the number of cases of acquired 
                        immune deficiency syndrome in the 
                        State, as indicated by the number of 
                        cases reported to and confirmed by the 
                        Secretary for the 2 most recent fiscal 
                        years for which such data are 
                        available; and
                          (ii) the cube root of the ratio 
                        (based on the most recent available 
                        data) of--
                                  (I) the average per capita 
                                income of individuals in the 
                                United States (including the 
                                territories); to
                                  (II) the average per capita 
                                income of individuals in the 
                                State.
                  (B) In the case of a territory of the United 
                States (other than the Commonwealth of Puerto 
                Rico), the number of additional cases of such 
                syndrome in the specific territory, as 
                indicated by the number of cases reported to 
                and confirmed by the Secretary for the 2 most 
                recent fiscal years for which such data is 
                available.
          (4) Supplemental amounts for certain states.--For 
        purposes of paragraph (1)(B), an amount shall be 
        determined under this paragraph for each State that 
        does not contain any metropolitan area whose chief 
        elected official received a grant under part A for 
        fiscal year 1996. The amount determined under this 
        paragraph for such a State for a fiscal year shall be 
        the product of--
                  (A) an amount equal to 7 percent of the 
                amount available under section 2677 for 
                carrying out this part for the fiscal year 
                (subject to subsection (b)); and
                  (B) the percentage constituted by the ratio 
                of--
                          (i) the number of cases of acquired 
                        immune deficiency syndrome in the State 
                        (as determined under paragraph 
                        (3)(A)(i)); to
                          (ii) the sum of the respective 
                        numbers determined under clause (i) for 
                        each State to which this paragraph 
                        applies.
          (5) Definitions.--For purposes of this subsection and 
        subsection (b):
                  (A) The term ``State'' means each of the 50 
                States, the District of Columbia, and the 
                territories of the United States.
                  (B) The term ``territory of the United 
                States'' means each of the Virgin Islands, 
                Guam, American Samoa, the Commonwealth of the 
                Northern Mariana Islands, the Commonwealth of 
                Puerto Rico, and the Republic of the Marshall 
                Islands.
  (b) Minimum Amount of Grant.--
          (1) In general.--Subject to the extent of the amounts 
        specified in paragraphs (2)(A) and (4)(A) of subsection 
        (a), a grant under this part for a State for a fiscal 
        year shall be the greater of--
                  (A) the amount determined for the State under 
                subsection (a); and
                  (B) the amount applicable under paragraph (2) 
                to the State.
          (2) Applicable amount.--For purposes of paragraph 
        (1)(B), the amount applicable under this paragraph for 
        a fiscal year is the following:
                  (A) In the case of the 50 States, the 
                District of Columbia, and the Commonwealth of 
                Puerto Rico--
                          (i) $100,000, if it has less than 90 
                        cases of acquired immune deficiency 
                        syndrome (as determined under 
                        subsection (a)(3)(A)(i)); and
                          (ii) $250,000, if it has 90 or more 
                        such cases (as so determined).
                  (B) In the case of each of the territories of 
                the United States (other than the Commonwealth 
                of Puerto Rico), $0.0.
  (c) Allocation of Assistance by States.--
          [(1) Consortia.--In a State that has reported 1 
        percent or more of all AIDS cases reported to and 
        confirmed by the Centers for Disease Control and 
        Prevention in all States, not less than 50 percent of 
        the amount received by the State under a grant awarded 
        under this part shall be utilized for the creation and 
        operation of community-based comprehensive care 
        consortia under section 2613, in those areas within the 
        State in which the largest number of individuals with 
        HIV disease reside.]
          [(2)] (1) Allowances.--Prior to allocating assistance 
        under this subsection, a State shall consider the unmet 
        needs of those areas that have not received financial 
        assistance under part A.
          [(3)] (2) Planning and evaluations.--A State may not 
        use in excess of 5 percent of amounts received under a 
        grant awarded under this part for planning and 
        evaluation activities.
          [(4)] (3) Administration.--A State may not use in 
        excess of 5 percent of amounts received under a grant 
        awarded under this part for administration, accounting, 
        reporting, and program oversight functions. In the case 
        of entities to which the State allocates amounts 
        received by the State under the grant (including 
        consortia under section 2613), the State shall ensure 
        that, of the aggregate amount so allocated, the total 
        of the expenditures by such entities for administrative 
        expenses does not exceed 10 percent (without regard to 
        whether particular entities expend more than 10 percent 
        for such expenses). For purposes of the preceding 
        sentence, the costs of establishing and operating 
        consortia under section 2613 shall be considered 
        administrative expenses.
          [(5)] (4) Construction.--A State may not use amounts 
        received under a grant awarded under this part to 
        purchase or improve land, or to purchase, construct, or 
        permanently improve (other than minor remodeling) any 
        building or other facility, or to make cash payments to 
        intended recipients of services.
          * * * * * * *

SEC. 2619. TECHNICAL ASSISTANCE.

  The Secretary may provide technical assistance in 
administering and coordinating the activities authorized under 
section 2612, including technical assistance for the 
development and implementation of statewide coordinated 
statements of need.

[SEC. 2620. AUTHORIZATION OF APPROPRIATIONS.

  [There are authorized to be appropriated to make grants under 
this part, $275,000,000 in each of the fiscal years 1991 and 
1992, and such sums as may be necessary in each of the fiscal 
years 1993 through 1995.]

                  Part C--Early Intervention Services

                  Subpart I--Formula Grants for States

          * * * * * * *

                     Subpart II--Categorical Grants

SEC. 2651. ESTABLISHMENT OF PROGRAM.

  (a) * * *
  (b) Purposes of Grants.--
          (1) In general.--The Secretary may not make a grant 
        under subsection (a) unless the applicant for the grant 
        agrees to expend the grant for the purposes of 
        providing, on an outpatient basis, each of the early 
        intervention services specified in paragraph (2) with 
        respect to HIV disease, and unless the applicant agrees 
        to expend not less than 50 percent of the grant for 
        such services that are specified in subparagraphs (B) 
        through (E) of such paragraph.
          * * * * * * *
          (4) Requirement of availability of all early 
        intervention services through each grantee.--The 
        Secretary may not make a grant under subsection (a) 
        unless the applicant for the grant agrees that each of 
        the early intervention services specified in paragraph 
        (2) will be available through the grantee. With respect 
        to compliance with such agreement, such a grantee may 
        expend the grant to provide the early intervention 
        services directly, and may expend the grant to enter 
        into agreements with public or nonprofit private 
        entities (or private for-profit entities, if such 
        entities are the only available providers of quality 
        HIV care in the area) under which the entities provide 
        the services.
          * * * * * * *

SEC. 2652. MINIMUM QUALIFICATIONS OF GRANTEES.

  (a) * * *
  (b) Status as Medicaid Provider.--
          (1) In general.--Subject to paragraph (2), the 
        Secretary may not make a grant under section 2651 for 
        the provision of services described in subsection (b) 
        of such section in a State unless, in the case of any 
        such service that is available pursuant to the State 
        plan approved under title XIX of the Social Security 
        Act for the State--
                  (A) the applicant for the grant will provide 
                the service directly, and the applicant has 
                entered into a participation agreement under 
                the State plan and is qualified to receive 
                payments under such plan; or
                  (B) the applicant for the grant will enter 
                into an agreement with a public or nonprofit 
                private entity (or a private for-profit entity, 
                if such an entity is the only available 
                provider of quality HIV care in the area) under 
                which the entity will provide the service, and 
                the entity has entered into such a 
                participation agreement and is qualified to 
                receive such payments.
          * * * * * * *

SEC. 2654. MISCELLANEOUS PROVISIONS.

  (a) * * *
          * * * * * * *
  (c) Planning and Development Grants.--
          (1) In general.--The Secretary may provide planning 
        grants, in an amount not to exceed $50,000 for each 
        such grant, to public and nonprofit private entities 
        for the purpose of enabling such entities to provide 
        early intervention services.
          (2) Requirement.--The Secretary may award a grant to 
        an entity under paragraph (1) only if the Secretary 
        determines that the entity will use such grant to 
        assist the entity in qualifying for a grant under 
        section 2651.
          (3) Preference.--In awarding grants under paragraph 
        (1), the Secretary shall give preference to entities 
        that provide HIV primary care services in rural or 
        underserved communities.
          (4) Limitation.--Not to exceed 1 percent of the 
        amount appropriated for a fiscal year under section 
        2655 may be used to carry out this section.

SEC. 2655. AUTHORIZATION OF APPROPRIATIONS.

  For the purpose of making grants under section 2651, there 
are authorized to be appropriated [$75,000,000 for fiscal years 
1991, and such sums as may be necessary for each of the fiscal 
years 1992 through 1995.] such sums as may be necessary for 
each of the fiscal years 1996 through 2000.

                    Subpart III--General Provisions

          * * * * * * *

SEC. 2664. ADDITIONAL REQUIRED AGREEMENTS.

  (a) Reports to Secretary.--The Secretary may not make a grant 
under this part unless--
          (1) the applicant submits to the Secretary--
                  (A) a specification of the expenditures made 
                by the applicant for early intervention 
                services for the fiscal year preceding the 
                fiscal year for which the applicant is applying 
                to receive the grant; [and]
                  (B) an estimate of the number of individuals 
                to whom the applicant has provided such 
                services for such fiscal year; and
                  (C) evidence that the proposed program is 
                consistent with the statewide coordinated 
                statement of need and that the applicant will 
                participate in the ongoing revision of such 
                statement of need.
          * * * * * * *

                       Part D--General Provisions

SEC. 2671. [DEMONSTRATION GRANTS FOR RESEARCH AND SERVICES FOR 
                    PEDIATRIC PATIENTS REGARDING ACQUIRED IMMUNE 
                    DEFICIENCY SYNDROME.] COORDINATED SERVICES AND 
                    ACCESS TO RESEARCH FOR WOMEN, INFANTS, AND 
                    CHILDREN.

  [(a) In General.--The Secretary, acting through the 
Administrator of the Health Resources and Services 
Administration and the Director of the National Institutes of 
Health, shall make demonstration grants to community health 
centers, and other appropriate public or nonprofit private 
entities that provide primary health care to the public, for 
the purpose of--
          [(1) conducting, at the health facilities of such 
        entities, clinical research on therapies for pediatric 
        patients with HIV disease as well as pregnant women 
        with HIV disease; and
          [(2) with respect to the pediatric patients who 
        participate in such research, providing health care on 
        an outpatient basis to such patients and the families 
        of such patients.]
  (a) In General.--
          (1) Program of grants.--The Secretary, acting through 
        the Administrator of the Health Resources and Services 
        Administration and in consultation with the Director of 
        the National Institutes of Health, shall make grants to 
        public and nonprofit private entities that provide 
        primary care (directly or through contracts) for the 
        purpose of--
                  (A) providing through such entities, in 
                accordance with this section, opportunities for 
                women, infants, and children to be participants 
                in research of potential clinical benefit to 
                individuals with HIV disease; and
                  (B) providing to women, infants, and children 
                health care on an outpatient basis.
          (2) Provisions regarding participation in research.--
        With respect to the projects of research with which an 
        applicant under paragraph (1) is concerned, the 
        Secretary may not make a grant under such paragraph to 
        the applicant unless the following conditions are met:
                  (A) The applicant agrees to make reasonable 
                efforts--
                          (i) to identify which of the patients 
                        of the applicant are women, infants, 
                        and children who would be appropriate 
                        participants in the projects; and
                          (ii) to offer women, infants, and 
                        children the opportunity to so 
                        participate (as appropriate), including 
                        the provision of services under 
                        subsection (f).
                  (B) The applicant agrees that the applicant, 
                and the projects of research, will comply with 
                accepted standards of protection for human 
                subjects (including the provision of written 
                informed consent) who participate as subjects 
                in clinical research.
                  (C) For the third or subsequent fiscal year 
                for which a grant under such paragraph is 
                sought by the applicant, the Secretary has 
                determined that--
                          (i) a significant number of women, 
                        infants, and children who are patients 
                        of the applicant are participating in 
                        the projects (except to the extent this 
                        clause is waived under subsection (k)); 
                        and
                          (ii) the applicant, and the projects 
                        of research, have complied with the 
                        standards referred to in subparagraph 
                        (B).
          (3) Prohibition.--Receipt of services by a patient 
        shall not be conditioned upon the consent of the 
        patient to participate in research.
          (4) Consideration by secretary of certain 
        circumstances.--In administering the requirement of 
        paragraph (2)(C)(i), the Secretary shall take into 
        account circumstances in which a grantee under 
        paragraph (1) is temporarily unable to comply with the 
        requirement for reasons beyond the control of the 
        grantee, and shall in such circumstances provide to the 
        grantee a reasonable period of opportunity in which to 
        reestablish compliance with the requirement.
  (b) Minimum Qualifications of Grantees.--The Secretary may 
not make a grant under subsection (a) unless the health 
facility operated by the applicant for the grant serves a 
significant number of [pediatric patients and pregnant women] 
women, infants, and children with HIV disease.
  [(c) Cooperation With Biomedical Institutions.--
          [(1) Design of research protocol.--The Secretary may 
        not make a grant under subsection (a) unless the 
        applicant for the grant--
                  [(A) has entered into a cooperative agreement 
                or contract with an appropriately qualified 
                entity with expertise in biomedical research 
                under which the entity will assist the 
                applicant in designing and conducting a 
                protocol for the research to be conducted 
                pursuant to the grant; and
                  [(B) agrees to provide the clinical data 
                developed in the research to the Director of 
                the National Institutes of Health.
          [(2) Analysis and evaluation.--The Secretary, acting 
        through the Director of the National Institutes of 
        Health--
                  [(A) may assist grantees under subsection (a) 
                in designing and conducting protocols described 
                in subparagraph (A) of paragraph (1); and
                  [(B) shall analyze and evaluate the data 
                submitted to the Director pursuant to 
                subparagraph (B) of such paragraph.]
  (c) Provisions Regarding Conduct of Research.--With respect 
to eligibility for a grant under subsection (a):
          (1) A project of research for which subjects are 
        sought pursuant to such subsection may be conducted by 
        the applicant for the grant, or by an entity with which 
        the applicant has made arrangements for purposes of the 
        grant. The grant may not be expended for the conduct of 
        any project of research.
          (2) The grant may not be made unless the Secretary 
        makes the following determinations:
                  (A) The applicant or other entity (as the 
                case may be under paragraph (1)) is 
                appropriately qualified to conduct the project 
                of research. An entity shall be considered to 
                be so qualified if any research protocol of the 
                entity has been recommended for funding under 
                this Act pursuant to technical and scientific 
                peer review through the National Institutes of 
                Health.
                  (B) The project of research is being 
                conducted in accordance with a research 
                protocol to which the Secretary gives priority 
                regarding the prevention and treatment of HIV 
                disease in women, infants, and children. After 
                consultation with public and private entities 
                that conduct such research, and with providers 
                of services under this section and recipients 
                of such services, the Secretary shall establish 
                a list of such protocols that are appropriate 
                for purposes of this section. The Secretary may 
                give priority under this subparagraph to a 
                research protocol that is not on such list.
  (d) Case Management.--The Secretary may not make a grant 
under subsection (a) unless the applicant for the grant agrees 
to provide for the case management of the [pediatric] patient 
involved and the family of the patient.
  (e) Referrals for Additional Services.--The Secretary may not 
make a grant under subsection (a) unless the applicant for the 
grant agrees to provide for the [pediatric] patient involved 
and the family of the patient--
          (1) referrals for inpatient hospital services, 
        treatment for substance abuse, and mental health 
        services; and
          (2) referrals for other social and support services, 
        as appropriate.
  (f) Incidental Services.--The Secretary may not make a grant 
under subsection (a) unless the applicant for the grant agrees 
to provide the family of the [pediatric] patient involved with 
such transportation, child care, and other incidental services 
as may be necessary to enable the [pediatric] patient and the 
family of the patient to participate in the program established 
by the applicant pursuant to such subsection.
  (g) Additional Provisions.--The Secretary may not make a 
grant under subsection (a) unless the applicant for the grant 
agrees as follows:
          (1) The applicant will coordinate activities under 
        the grant with other providers of health care services 
        under this Act, and under title V of the Social 
        Security Act.
          (2) The applicant will participate in the statewide 
        coordinated statement of need under part B (where it 
        has been initiated by the State) and in revisions of 
        such statement.
  [(g)] (h) Application.--The Secretary may not make a grant 
under subsection (a) unless an application for the grant is 
submitted to the Secretary and the application is in such form, 
is made in such manner, and contains such agreements, 
assurances, and information as the Secretary determines to be 
necessary to carry out this section.
  [(h)] (i) Evaluations.--The Secretary shall, directly or 
through contracts with public and private entities, provide for 
evaluations of programs carried out pursuant to subsection (a).
  [(i) Definition.--For purposes of this section, the term 
``community health center'' has the meaning given such term in 
section 330(a).]
  (j) Coordination With National Institutes of Health.--The 
Secretary shall develop and implement a plan that provides for 
the coordination of the activities of the National Institutes 
of Health with the activities carried out under this section. 
In carrying out the preceding sentence, the Secretary shall 
ensure that projects of research conducted or supported by such 
Institutes are made aware of applicants and grantees under this 
section, shall require that the projects, as appropriate, enter 
into arrangements for purposes of this section, and shall 
require that each project entering into such an arrangement 
inform the applicant or grantee under this section of the needs 
of the project for the participation of women, infants, and 
children.
  (k) Temporary Waiver Regarding Significant Participation.--
          (1) In general.--In the case of an applicant under 
        subsection (a) who received a grant under this section 
        for fiscal year 1995, the Secretary may, subject to 
        paragraph (2), provide to the applicant a waiver of the 
        requirement of subsection (a)(2)(C)(i) if the Secretary 
        determines that the applicant is making reasonable 
        progress toward meeting the requirement.
          (2) Termination of authority for waivers.--The 
        Secretary may not provide any waiver under paragraph 
        (1) on or after October 1, 1998. Any such waiver 
        provided prior to such date terminates on such date, or 
        on such earlier date as the Secretary may specify.
  (l) Training and Technical Assistance.--Of the amounts 
appropriated under subsection (m) for a fiscal year, the 
Secretary may use not more than five percent to provide 
training and technical assistance to assist applicants and 
grantees under subsection (a) in complying with the 
requirements of this section.
  [(j)] (m) Authorization of Appropriations.--For the purpose 
of carrying out this section, [there are authorized to be 
appropriated $20,000,000 for fiscal year 1991, and such sums as 
may be necessary for each of the fiscal years 1992 through 
1995.] there are authorized to be appropriated such sums as may 
be necessary for each of the fiscal years 1996 through 2000.
          * * * * * * *

SEC. 2673A. DEMONSTRATION PROJECTS OF NATIONAL SIGNIFICANCE.

  (a) In General.--The Secretary shall make grants to public 
and nonprofit private entities (including community-based 
organizations and Indian tribes and tribal organizations) for 
the purpose of carrying out demonstration projects that provide 
for the care and treatment of individuals with HIV disease, and 
that--
          (1) assess the effectiveness of particular models for 
        the care and treatment of individuals with such 
        disease;
          (2) are of an innovative nature; and
          (3) have the potential to be replicated in similar 
        localities, or nationally.
  (b) Certain Projects.--Demonstration projects under 
subsection (a) shall include the development and assessment of 
innovative models for the delivery of HIV services that are 
designed--
          (1) to address the needs of special populations 
        (including individuals and families with HIV disease 
        living in rural communities, adolescents with HIV 
        disease, Native American individuals and families with 
        HIV disease, homeless individuals and families with HIV 
        disease, hemophiliacs with HIV disease, and 
        incarcerated individuals with HIV disease); and
          (2) to ensure the ongoing availability of services 
        for Native American communities to enable such 
        communities to care for Native Americans with HIV 
        disease.
  (c) Coordination.--The Secretary may not make a grant under 
this section unless the applicant submits evidence that the 
proposed program is consistent with the applicable statewide 
coordinated statement of need under part B, and the applicant 
agrees to participate in the ongoing revision process of such 
statement of need (where it has been initiated by the State).
  (d) Replication.--The Secretary shall make information 
concerning successful models developed under this section 
available to grantees under this title for the purpose of 
coordination, replication, and integration.
  (e) Funding; Allocation of Amounts.--
          (1) In general.--Of the amounts available under this 
        title for a fiscal year for each program specified in 
        paragraph (2), the Secretary shall reserve 3 percent 
        for making grants under subsection (a).
          (2) Relevant programs.--The programs referred to in 
        subsection (a) are the program under part A, the 
        program under part B, the program under part C, the 
        program under section 2671, the program under section 
        2672, and the program under section 2673.

SEC. [776.] 2673B. ACQUIRED IMMUNE DEFICIENCY SYNDROME.

  (a) Schools; Centers.--
          (1) In general.--The Secretary may make grants and 
        enter into contracts to assist public and nonprofit 
        private entities and schools and academic health 
        science centers in meeting the costs of projects--
                  (A) to train health personnel, including 
                practitioners in programs under this title and 
                other community providers, in the diagnosis, 
                treatment, and prevention of HIV disease, 
                including the prevention of the perinatal 
                transmission of the disease and including 
                measures for the prevention and treatment of 
                opportunistic infections;
                  [(A)] (B) to train the faculty of schools of, 
                and graduate departments or programs of, 
                medicine, nursing, osteopathic medicine, 
                dentistry, public health, allied health, and 
                mental health practice to teach health 
                professions students to provide for the health 
                care needs of individuals with HIV disease; and
                  [(B) to train practitioners to provide for 
                the health care needs of such individuals;
                  [(C) with respect to improving clinical 
                skills in the diagnosis, treatment, and 
                prevention of such disease, to educate and 
                train the health professionals and clinical 
                staff of schools of medicine, osteopathic 
                medicine, and dentistry; and]
                  [(D)] (C) to develop and disseminate 
                [curricula and] resource materials relating to 
                the care and treatment of individuals with such 
                disease and the prevention of the disease among 
                individuals who are at risk of contracting the 
                disease.
          (2) Preference in making grants.--In making grants 
        under paragraph (1), the Secretary shall give 
        preference to qualified projects which will--
                  (A) train, or result in the training of, 
                health professionals who will provide treatment 
                for minority individuals with HIV disease and 
                other individuals who are at high risk of 
                contracting such disease; and
                  (B) train, or result in the training of, 
                minority health professionals and minority 
                allied health professionals to provide 
                treatment for individuals with such disease.
          (3) Application.--No grant or contract may be made 
        under paragraph (1) unless an application is submitted 
        to the Secretary in such form, at such time, and 
        containing such information, as the Secretary may 
        prescribe.
          * * * * * * *
  [(c) Definition.--For purposes of this section:
          [(1) The term ``HIV disease'' means infection with 
        the human immunodeficiency virus, and includes any 
        condition arising from such infection.
          [(2) The term ``human immunodeficiency virus'' means 
        the etiologic agent for acquired immune deficiency 
        syndrome.]
  [(d)] (c) Authorization of Appropriations.--
          (1) Schools; centers.--For the purpose of grants 
        under subsection (a), there [is] are authorized to be 
        appropriated $23,000,000 for each of the fiscal years 
        1993 through 1995, and such sums as may be necessary 
        for each of the fiscal years 1996 through 2000.
          (2) Dental schools.--For the purpose of grants under 
        subsection (b), there [is] are authorized to be 
        appropriated $7,000,000 for each of the fiscal years 
        1993 through 1995, and such sums as may be necessary 
        for each of the fiscal years 1996 through 2000.

SEC. 2674. EVALUATIONS AND REPORTS.

  (a) Evaluations.--The Secretary shall, directly or through 
grants and contracts, evaluate programs carried out under this 
title.
  (b) Report to Congress.--The Secretary shall, [not later than 
1 year after the date on which amounts are first appropriated 
under this title,] not later than October 1, 1996, and annually 
thereafter, prepare and submit to the appropriate Committees of 
Congress a report--
          [(1) summarizing all of the reports that are required 
        to be submitted to the Secretary under this title;
          [(2) recommending criteria to be used in determining 
        the geographic areas with the most substantial need for 
        HIV-related health services;
          [(3) summarizing all of the evaluations carried out 
        pursuant to subsection (a) during the period for which 
        the report under this subsection is prepared; and]
          (1) evaluating the programs carried out under this 
        title; and
          [(4)] (2) making such recommendations for 
        administrative and legislative initiatives with respect 
        to this title as the Secretary determines to be 
        appropriate.
  (c) Authorization of Appropriations.--There are authorized to 
be appropriated to carry out this section, such sums as may be 
necessary for each of the fiscal years 1991 through 1995.
  (d) Allocation of Funds.--The Secretary shall carry out this 
section with amounts available under section 241. Such amounts 
are in addition to any other amounts that are available to the 
Secretary for such purpose.

SEC. 2675. COORDINATION.

  (a) * * *
          * * * * * * *
  (d) Annual Report.--Not later than October 1, 1996, and 
annually thereafter, the Secretary shall submit to the 
appropriate committees of the Congress a report concerning 
coordination efforts under this title at the Federal, State, 
and local levels, including a statement of whether and to what 
extent there exist Federal barriers to integrating HIV-related 
programs.
          * * * * * * *

SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

  (a) In General.--For the purpose of carrying out parts A and 
B, there are authorized to be appropriated such sums as may be 
necessary for each of the fiscal years 1996 through 2000. 
Subject to section 2673A and to subsection (b), of the amount 
appropriated under this section for a fiscal year, the 
Secretary shall make available 64 percent of such amount to 
carry out part A and 36 percent of such amount to carry out 
part B.
  (b) Development of Methodology.--With respect to each of the 
fiscal years 1997 through 2000, the Secretary may develop and 
implement a methodology for adjusting the percentages referred 
to in subsection (a).
          * * * * * * *

  ADDITIONAL VIEWS OF THE HONORABLE RICHARD BURR, THE HONORABLE SCOTT 
 KLUG, AND THE HONORABLE ED WHITFIELD TO H.R. 1872, REAUTHORIZATION OF 
                        THE RYAN WHITE CARE ACT

    Several members of the Commerce Committee raised great 
concern regarding the funding formulas of H.R. 1872 during 
subcommittee and full committee mark up of the bill.
    The central theme of reauthorization of the CARE Act is the 
necessity to achieve more equitable distribution of funding. 
H.R. 1872 fails to appropriately address this theme. Many 
cities designated as ``emergency metropolitan areas'' receive 
as much as four or even five times the amount of funding on a 
per case basis as Title II areas. This disparity in funding 
does not address the vast changes in the AIDS epidemic since 
the bill first became law.
    The funding formulas of H.R. 1872 fail to remedy the 
funding inequities in current law. These formulas:
          Maintain the practice of ``double counting'' AIDS 
        cases which allows for states with Title I EMAs to 
        count AIDS cases reported in these cities once for 
        Title I grants and again for the state's Title II 
        grant;
          Severely restricts the ability of the Title I equity 
        formula to be implemented because of the high ``hold 
        harmless'' floor; and
          Utilize an imprecise measure of AIDS caseloads, the 
        number of reported AIDS cases in the previous two 
        years, instead of the weighted cumulative AIDS cases 
        method developed by GAO.
    Under Title II of H.R. 1872, 28 states and a majority of 
smaller cities and rural areas are disadvantaged by the funding 
formula. This formula refuses to recognize the expansion of the 
tragic AIDS epidemic into smaller urban centers, cities, towns 
and rural areas throughout this country.

                                   Richard Burr.
                                   Scott Klug.
                                   Ed Whitfield.

 ADDITIONAL VIEWS OF THE HONORABLE BLANCHE LAMBERT LINCOLN, REGARDING 
                THE RYAN WHITE CARE ACT TITLE II FUNDING

                 The Changing Face of the AIDS Epidemic

    Tragically, the AIDS epidemic has continued to expand since 
the CARE Act first became law in 1990. The epidemic has grown 
to now encompass urban, suburban and rural areas in every state 
across the nation. The reauthorization provides us an historic 
opportunity to ensure that the CARE Act is modified to meet the 
needs of the changing face of AIDS.

          52% of AIDS cases reported nationally are now outside 
        of the original 16 epicenters designated as ``emergency 
        metropolitan area''.
          The AIDS epidemic is expanding most rapidly in rural 
        areas of the country. Fully 17% of AIDS cases are now 
        reported in small cities, towns and rural areas 
        throughout the country.

    To accurately reflect the changes in the AIDS epidemic and 
to effectively meet the needs of people living with AIDS, the 
formulas of the CARE Act must achieve more equitable 
distribution of funds. No longer is it acceptable for a Title I 
city to receive as much as four or five times the amount of 
funding as Title II areas of the country on a per case basis.
    During sub-committee and full committee mark-up, I gave an 
example of how we in rural areas have been affected by these 
funding inequities. Recently, one of the sub-grantees of Ryan 
White funding in my congressional district received a phone 
call from a St. Louis man who has AIDS. This man, who is 
originally from my district and wanted to move back to take 
care of a friend who was dying from the disease, realized that 
this would be impossible when he learned of the substantially 
less amount of money he would receive for services in Arkansas 
than he would receive in St. Louis, a Title 1 area. The man 
stated that per client funding in St. Louis is around $3500; in 
the First District of Arkansas, per client funding is merely 
$617.
    The funding formulas of the CARE Act contribute greatly to 
this disparity in service delivery.

                                   Blanche Lambert Lincoln.