“I think this bill is a fitting tribute to Ryan White, although it is not nearly what he deserves. But it is one of the finest pieces of legislation to come out of this body,” said Orrin Hatch (R-UT) during the final speeches of the Senate floor debate on the original Ryan White Comprehensive AIDS Resources Emergency (CARE) Act legislation.1 Hatch, a vocal and steadfast supporter of the legislation, made the inclusion of a funding stream to provide services in all States and Territories a top priority in crafting and passing the bill.2
Although much of the attention at the time was on the crisis in the hardest-hit urban centers, Hatch wanted to ensure that funds were available to address HIV/AIDS nationwide. As the ranking Republican member of the Senate Committee on Labor and Human Resources, his support was key to moving the bill forward.
Grants to the States were included in the original version of the Senate bill, and the language made specific reference to “individuals and families with HIV disease in urban and rural areas,” highlighting the desire to serve those outside urban epicenters—a theme that would grow in subsequent years. State grants were not included in the initial House version, but they were ultimately included as Title II (now Part B) in the final version of the bill that passed into law. Over the course of the Ryan White Program, Part B grew into the single largest component of the act, primarily as a result of significant increases in funds to support access to drug therapies.
Collaboration Affects the Scope and Reach of Services
As established, Title II provided States with a variety of mechanisms to provide HIV care and support to their residents, including grants for home- and community-based services, health insurance continuation, and care consortia to provide a wide range of medical and support services. The Title II consortia—associations of public and nonprofit providers working together to assess needs and deliver services—were very much like the service demonstration grants that HRSA had funded in metropolitan areas in the late 1980s and that also provided much of the basis for the structure of Title I.3
“The main thing is that people were empowered by their government to advocate for their health,” says Christopher Bates, who led the DC Care Consortium in Washington, DC. “People who had HIV, advocates, providers, and government sat around the table and planned. They became a part of the process to conduct needs assessments, determine priorities, and allocate dollars into categories based on collective input.”4
Discussing the impact of the new funding stream in the state of New York, Humberto Cruz of the New York State AIDS Institute says, “Ryan White became an element in the overall strategy to address the epidemic. By 1991, New York had built a system of HIV care and support services financed by Medicaid and State and Federal grant dollars. A critical aspect of Ryan White funding was that it provided enhanced resources to maximize our response.”5
AIDS Drug Reimbursement Program
At its inception, the Title II program also integrated the existing AIDS Drug Reimbursement Program and provided treatments through what became known as the AIDS Drug Assistance Program (ADAP). The Drug Reimbursement Program was launched in 1987 shortly after the Food and Drug Administration’s approval of AZT (zidovudine), when Congress appropriated funds to provide access to this breakthrough medication for people without private insurance or eligibility for Medicaid, Medicare, or State programs. Initially, only AZT was covered, but the list of covered drugs grew to nearly 30 in some States when the program was integrated into the Ryan White Program.6