Housing Opportunities for Persons with AIDS (HOPWA): Distribution of Funding to the Southern States

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1 Housing Opportunities for Persons with AIDS (HOPWA): Distribution of Funding to the Southern States Lesley Hamming, JD Candidate with Carolyn McAllaster, Clinical Professor of Law Duke University School of Law Southern HIV/AIDS Strategy Initiative I. Introduction Homelessness is pervasive for people living with HIV/AIDS. Approximately half of HIVpositive persons will need housing assistance during their illness. 1 In addition, HIV rates in homeless populations are three to ten times greater than for stably-housed populations. 2 Government funding for housing through the Housing Opportunities for Persons with AIDS (HOPWA) program helps to address these high rates of homelessness. As the region with the highest rate of new HIV infections in the US, the south increasingly needs HOPWA funding. In 2010, 51% of people newly infected with HIV lived in the south, 3 even though the south accounted for only 37% of the U.S. population. 4 1 U.S. Dept. of Housing & Urban Development, Office of Community Planning & Development, Implementing the National HIV/AIDS Strategy 5 (Feb. 2011), available at 2 Daniel Kidder et al., Health Status, Health Care Use, Medication Use, and Medication Adherence Among Homeless and Housed People Living with HIV/AIDS, 97 AM. J. PUB. HEALTH 2238, 2238 (2007). 3 Centers for Disease Control and Prevention, HIV Surveillance Report (2012), available at 4 US Census Bureau, Guide to State and Local Census Geography (2010),

2 This paper compares how HOPWA funds are distributed based on an entitlement formula and competitive grants to the southern states and other regions. Several southern states are particularly affected by HIV and have high rates of poverty, insufficient access to medical care, and a cultural climate that likely contributes to the spread of HIV. These states include Alabama, Georgia, Louisiana, Mississippi, Florida, North Carolina, South Carolina, Tennessee, and Texas (the targeted states ). II. The Need for Stable Housing for Persons with HIV/AIDS Congress passed the Housing Opportunities for Persons with AIDS (HOPWA) program as one part of the Cranston-Gonzalez National Housing Act of The purpose of HOPWA was to provide States and localities with the resources and incentives to devise long-term comprehensive strategies for meeting the housing needs of persons with acquired immunodeficiency syndrome. 6 In his public statement upon signing the Cranston-Gonzalez National Housing Act, President George Bush Sr. made no mention of HOPWA, although he did applaud the Act s objective of providing decent, safe, and affordable housing for all Americans. 7 Even though President Bush did not discuss the AIDS epidemic in his public statement, the seriousness of the disease was evident. At that time, over 100,000 people in the United States had already been diagnosed with AIDS; no effective treatments had yet been developed; and Ryan White, one of the first hemophiliacs diagnosed with AIDS, had recently died. 8 5 Pub. L , Nov. 28, 1990, 104 Stat. 4079, Id. at George Bush, Nov. 28, 1990, 1990 U.S.C.C.A.N , 1990 WL (Leg.Hist.). 8 U.S. Dept. Health & Human Services, A Timeline of AIDS, AIDS.gov, 2

3 HOPWA has proved to be an important program for persons living with HIV and AIDS, providing housing for over 61,000 households across the country in FY Ninety-five percent of the individuals who received tenant-based rental assistance through HOPWA achieved housing stability and seventy-four percent of the individuals who received short-term and transitional housing through HOPWA achieved housing stability. 10 Several studies have found an association between stable housing and improved HIV/AIDS care and disease progression. 11 Studies have also demonstrated that providing stable housing to HIV-positive individuals is a cost-effective method of improving medical care. 12 In particular, the AIDS Foundation of Chicago, through the Chicago Housing for Health Partnership (CHHP), conducted a randomized control trial comparing the number of hospital, emergency room, and nursing home visits of (1) an intervention group of homeless individuals who received supportive housing and (2) a control group of homeless individuals who received the usual care provided by hospitals when discharging homeless individuals, typically consisting of transportation to an overnight shelter and 9 Phillip A. Pless, Program Support Specialist, US Department of Housing & Urban Development, Office of HIV/AIDS Housing, December 13, HIV/AIDS Housing, U.S. Department of Housing and Urban Development, sing. 11 See, e.g., Daniel Kidder et al., Health Status, Health Care Use, Medication Use, and Medication Adherence in Homeless and Housed People Living with HIV/AIDS, 97(12) AM. J. PUB. HEALTH 2238 (2007) (finding that homeless individuals living with HIV had lower CD4 counts and were less likely to have taken HIV antiretroviral medications than housed individuals); Aidala et al., Housing Need, Housing Assistance, and Connection to Medical Care, 11(6) AIDS & BEHAVIOR S101 (2007) (finding a relationship between housing need and remaining outside of HIV medical care). 12 See, e.g., David Holtgrave et al., Cost-Utility Analysis of the Housing and Health Intervention for Homeless and Unstably Housed Persons Living with HIV, AIDS & BEHAVIOR (2012) (estimating that the cost-per-quality-adjusted-life-year saved by HIV-related housing services is $62,493). 3

4 access to case management through a Ryan White program if HIV positive. 13 Thirty-five percent of the study participants had HIV. 14 For participants in the study who had HIV, the four-year CHHP study revealed that after one year: 55% of HIV-positive participants in the intervention group had intact immunity compared to only 34% in the usual care group (intact immunity defined as CD4>200 and viral load<100,000); 36% of HIV-positive participants in the intervention group had undetectable viral loads compared to only 19% of usual care participants; and median viral loads were 0.89 log lower in the intervention group than the usual care group. 15 In addition to these health benefits, the CHHP study revealed that the costs of providing stable housing to persons living with HIV/AIDS was more than offset by the reduced costs of hospital visits, nursing home services, prison services, and other social services. 16 Specifically, the study found that providing housing for HIV-positive individuals resulted in financial savings of: 13 David Buchanan et al., The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial, 99 AM. J. PUB. HEALTH S675 (2009); see also Laura S. Sadowski et al., Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults, 301(17) JOURNAL OF AMERICAN MEDICAL ASSOCIATION 1771, 1773 (May 6, 2009). 14 Id. 15 David Buchanan et al., The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial, 99 AM. J. PUB. HEALTH S675, S675 (2009). 16 AIDS Foundation of Chicago, Studies on Supportive Housing Yield Results for Health of Homeless and Cost Savings, available at 4

5 $1 million in public funds every year for every 100 chronically homeless individuals living with HIV/AIDS who are placed in long-term supportive housing; and $600,000 in public funds every year for every 100 chronically homeless individuals living with HIV/AIDS who are placed in short-term homeless housing. 17 Although HOPWA helps provide these health and financial benefits through supportive housing to persons living with HIV/AIDS, HOPWA s formula for distributing funds does not accord with the current geographic distribution of the disease. In 2006, the Government Accountability Office (GAO) criticized how HOPWA s funding formula relies on cumulative AIDS cases, which includes a significant number of deceased persons, for distributing funds. 18 The GAO report argued that a more equitable formula would rely on current HIV case counts. 19 The report concluded that if the formula took into account current HIV case counts, the South and the Midwest would receive a greater proportion of the HOPWA funds. 20 The U.S. Department of Housing & Urban Development (HUD) is also aware that the current HOPWA funding formula needs updating. HUD s FY 2013 Budget report proposes to update the HOPWA program to better reflect the current 17 Id. 18 Government Accountability Office, HIV AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds (February 2006), available at 19 Id. 20 Id. 5

6 understanding of HIV/AIDS and ensure that funds are directed in a more equitable and effective manner. 21 III. Overview of HOPWA Legislation HOPWA is codified in Title 42, of the United States Code. Section sets forth a list of activities for which grantees may use HOPWA grants, including providing housing information and assistance, developing and operating shelter services, providing rental assistance, rehabilitating single room occupancy dwellings, developing community residences, and any other activity for people living with HIV/AIDS that the Secretary of Housing & Urban Development (HUD) develops in cooperation with awardees. 22 The requirements for each of these activities are delineated in Section instructs HUD on how to disperse the HOPWA grants. 24 HUD must first allocate 90% of the grant money for entitlement awards and 10% for competitive grants (See Figure 1). 25 As shown in Table 1, Congress has appropriated almost $300 million for entitlement awards and approximately $30 million for competitive grants each year since fiscal year Based on President Obama s proposed budget for FY 2013, 26 HUD expects the HOPWA budget to decline slightly for the first time since the program s inception in the early 1990s U.S. Department of Housing & Urban Development, FY 2013 Budget U.S.C (2012). 23 Id. at Id. at Id. 26 Partnership for Strong Communities, Obama s FY13 Budget Increases Resources to Combat Homelessness, Cuts Other Housing Programs (Feb. 15, 2012), 27 U.S. Department of Housing & Urban Development, FY 2013 Budget. 6

7 Figure 1: HOPWA funding categories Table 1: HOPWA Funding by Fiscal Year FY 2013 (estimated) 30 Entitlement Competitive Total Awards 28 Grants ,000,000 33,000, ,000,000 FY ,800,000 32,933, ,733,188 FY ,888,030 32,727, ,615,555 FY ,485,000 30,277, ,762,869 FY ,088,500 29,428, ,516,916 FY ,417,000 29,713, ,130,000 A. Entitlement Award Distribution Ninety percent of HOPWA funding is for entitlement awards. Section sets forth the formula for determining which localities are eligible for entitlement awards in two parts. 31 In the first part of the HOPWA formula, HUD must distribute 75% of the entitlement award money to (i) cities that are the most populous unit of general local government in a metropolitan statistical area having a population greater than 500, U.S. Department of Housing & Urban Development, HOPWA Formula Allocations, /programs/formula/grants. 29 U.S. Department of Housing & Urban Development, HOPWA Programs, 30 U.S. Department of Housing & Urban Development, FY 2013 Budget U.S.C (c)(1) (2012). 7

8 and more than 1,500 cases of acquired immunodeficiency syndrome; and (ii) States with more than 1,500 cases of acquired immunodeficiency syndrome outside of metropolitan statistical areas described in clause (i). 32 The Office of Management and Budget defines a metropolitan statistical area (MSA) as a geographic area associated with at least one urbanized area that has a population of at least 50,000 and comprises the central county or counties containing the core, plus adjacent outlying counties having a high degree of social and economic integration with the central county or counties as measured through commuting. 33 As specified in the HOPWA legislation, only cities in MSAs with populations greater than 500,000 and more than 1,500 AIDS cases are eligible for the portion of the entitlement grant money specified in clause (i). 34 Areas outside of an eligible MSA may only receive funding if the area is a qualified state under clause (ii). 35 In FY 2010, 83 cities in eligible MSAs received entitlement funding under clause (i) and 40 States and Puerto Rico received entitlement funding under (ii) (see Figure 2). 36 In the second part of the HOPWA formula, HUD must distribute the remaining 25% of the entitlement award money to cities that are the most populous unit of general local government in an eligible MSA and that have a higher than average per capita incidence of acquired immunodeficiency syndrome. 37 Just like the first part of the formula, the second part of the formula is based on AIDS cases rather than HIV/AIDS cases. To determine which cities in eligible MSAs have a higher than average per capita incidence of 32 Id. 33 Office of Management & Budget, Federal Register, part IV, 2010 Standards for Delineating Metropolitan and Micropolitan Statistical Areas (June 28, 2010) U.S.C (c)(1)(A)(i) (2012). 35 Id. at 12903(c)(1)(A)(ii). 36 David Vos, Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011) (c)(1)(B). 8

9 AIDS, the cities should be ranked according to the number of AIDS cases reported to and confirmed by the Director of the Centers for Disease Control of the Public Health Service as of March 31 of the fiscal year immediately preceding the fiscal year for which the amounts are appropriated and to be allocated. 38 The legislation also notes that a single city may receive assistance under both the first and second part of the formula. 39 Therefore, with this formula, cities in eligible MSAs with higher than average incidences of AIDS receive two entitlement grants whereas cities with below average incidences of AIDS and more rural areas receive up to only one entitlement grant. In FY 2010, 29 cities in eligible MSAs received funding from the second part of the formula for having higher than average incidences of AIDS (see Table 2) Id. 39 Id. 40 David Vos, Power Point: Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011). 9

10 Figure 2: Map showing 83 MSAs, 40 States, and Puerto Rico that received entitlement grants from the first part of the HOPWA funding formula (75% fund). Table 2: 29 MSAs that received entitlement grants from the second part of the entitlement formula (25% portion) for having higher than average incidences of AIDS in FY ST FY2010 HOPWA Grantee Name Funding from 25% of entitlement funds CA Bakersfield $239,330 CA Los Angeles $757,226 CA San Francisco $3,229,925 DC District Of $7,539,343 Columbia DE Wilmington $126,422 FL Jacksonville- $1,086,760 Duval County FL Lakeland $110,444 FL Ft Lauderdale $4,781,342 FL Miami $6,140,354 FL West Palm $1,232,540 Beach FL Orlando $1,302,801 FL Tampa $1,102,912 GA Atlanta $3,999,540 10

11 LA Baton Rouge $1,330,258 LA New Orleans $1,383,130 MD Baltimore $5,304,468 MD Frederick $292,525 MI Detroit $60,353 MS Jackson $401,353 NC Wake County $210,326 NJ Newark $2,117,217 NJ Jersey City $1,231,259 NY New York City $21,875,106 PA Philadelphia $3,825,073 PR San Juan $1,637,336 Municipio SC Columbia $785,198 TN Memphis $523,136 TX Dallas $88,198 TX Houston $1,907,377 TOTAL $74,621,251 Although HOPWA specified which cities and states are eligible for funds in its 75% and 25% entitlement categories, the legislation did not specify how HUD was to divide the funds among the eligible cities and states. HUD promulgated rules in 24 C.F.R to take care of this task. 41 First, (b)(1) provides that the 75% entitlement grants should be distributed according to each MSA or State s proportionate share of cumulative number of AIDS cases. 42 Second, (b)(2) provides that HUD will allocate 25% of the entitlement funds in proportion to a high incidence factor. The high incidence factor is computed by multiplying the population of the metropolitan statistical area by the difference between its twelve-month-per-capita-[aids] incidence rate and the average rate for all metropolitan statistical areas with more than 500,000 population. 43 Therefore, HUD distributes the HOPWA funds based on cumulative AIDS cases for the 75% fund and the prior fiscal year s AIDS incidence rate for the 25% fund C.F.R (2012). 42 Id. 43 Id. 11

12 B. Competitive Grants Ten percent of HOPWA funding is for competitive awards. In contrast to entitlement grants, competitive grants are distributed without a formula. HUD accepts applications for these proposed projects of national significance in response to Notices of Funding Allowances (NOFAs). 44 HUD grants competitive awards to two kinds of eligible entities: (1) States or political subdivisions of States (such as towns) that do not otherwise qualify for the entitlement awards and (2) States, political subdivisions of States, or nonprofit organizations to fund special projects of national significance. 45 To determine which of the eligible States or political subdivisions of States under (1) should receive a competitive grant, HUD considers factors such as the relative numbers of AIDS cases per capita, the housing needs of those with AIDS in the community, the extent of local planning and coordination of housing programs for people living with AIDS, and the likelihood that the proposed programs will continue. 46 To determine which of the eligible States, political subdivisions, or nonprofit organizations under (2) should receive a competitive grant for special projects of national significance, HUD considers (i) the need to assess the effectiveness of a particular model for providing supportive housing for eligible persons; (ii) the innovative nature of the proposed activity; and (iii) the potential replicability of the proposed activity in other similar localities or nationally See, e.g., Department of Housing and Urban Development, Docket No. FR-5500-N-13, Notice of Funding Availability (NOFA) for HUD s Fiscal Year 2011: Housing Opportunities for Persons with AIDS (HOPWA) (c)(3). 46 Id. 47 Id. 12

13 IV. Criticisms of Existing HOPWA Formula The existing HOPWA entitlement formula for determining eligible localities in 42 U.S.C and for distributing the funds among eligible localities in 24 C.F.R does not distribute the funding in accord with the current state of the domestic epidemic. First, the formula is based on the number of AIDS cases even though the number of HIV/AIDS cases is more representative of the disease. Second, the formula is based on cumulative AIDS cases, approximately half of which are deceased individuals, rather than living HIV/AIDS cases. Third, the formula gives cities in eligible MSAs with higher than average incidences of AIDS preferential treatment and disproportionate funding compared to other cities and more rural areas. First, a formula based on the number of AIDS cases does not logically parallel the present distribution of the domestic epidemic. Today, the number of persons living with HIV/AIDS is a more accurate measure of the epidemic than the number of AIDS cases. As shown in Figure 3, at the time of HOPWA s enactment in 1990, the rate of new AIDS diagnoses and deaths was rapid. 48 Since the advent of highly active antiretroviral therapy (HAART) in 1995, however, the number of AIDS diagnoses and deaths has declined markedly while the number of persons living with HIV infection or AIDS diagnoses has been increasing at a steady rate. 49 Given that HAART may allow an HIV-positive person to stave off AIDS for decades, the formula for allocating entitlement awards should take into account both HIV and AIDS cases rather than just AIDS cases. 48 Center for Disease Control & Prevention, Morbidity & Mortality Weekly Report 691 fig. (June 3, 2011). 49 Id. 13

14 Figure 3: Estimated number of AIDS diagnoses and deaths, estimated number of persons living with AIDS diagnosis, and estimated number of persons living with diagnosed or undiagnosed HIV infection among persons aged > 13 years in the United States from Second, a formula based on the cumulative number of AIDS cases does not logically parallel the state of the epidemic because it includes a significant number of deceased people. As shown in Figure 3, the number of AIDS diagnoses and deaths peaked approximately twenty years ago in 1995, right before the introduction of HAART. 51 Because of the high AIDS diagnosis rate in the early years of the epidemic, basing the formula on cumulative cases skews the allocation of funding toward areas where the disease originated in the United States and where high numbers of AIDS cases were reported in the early years of the epidemic. David Vos, the Director of the Office of HIV/AIDS Housing in HUD, stated that of the 1,071,940 cumulative AIDS cases included in 50 Center for Disease Control & Prevention, Morbidity & Mortality Weekly Report 691 fig. (June 3, 2011). 51 Id. at 691 Fig. 14

15 the formula in fiscal year 2010, 591,615 were deceased individuals. 52 Therefore, over half of the people HUD considers when distributing the HOPWA funds to eligible localities are deceased. States and cities where the HIV/AIDS epidemic began later, after the introduction of HAART, are expected to have a greater proportion of HIV cases compared to cumulative AIDS cases than in locations where the epidemic originated. As shown in Figure 4, for FY 2011, states and cities in the Great Plains and southeast United States had higher ratios of people living with HIV/AIDS to cumulative AIDS cases than in states where the disease originated. 53 HUD s use of cumulative AIDS cases is interesting considering the enabling statute, 42 U.S.C , never uses the term cumulative. The requirement of cumulative AIDS cases only appears in 24 C.F.R David Vos, Power point: Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011). 53 David Vos, U.S. Department of Housing & Urban Development, Housing as a Platform for Health (Dec. 7, 2011). 15

16 Figure 4: Ratio of Count of Persons Living with HIV to Cumulative Count of Persons with AIDS among all States and MSAs receiving FY 2011 HOPWA funding. Third, the formula gives cities in eligible MSAs with higher than average incidences of AIDS a disproportionately large share of HOPWA funding compared to cities with lower than average incidences and more rural areas. Specifically, 42 U.S.C provides that a single city may receive two kinds of entitlement grants. In the first part of the formula, 12903(c)(1)(A), a city may receive an entitlement grant when it is the most populous unit of general local government in a metropolitan statistical area having a population greater than 500,000 and more than 1,500 cases of acquired immunodeficiency 16

17 syndrome. 54 In the second part of the formula, 12903(c)(1)(B), a city may receive another entitlement grant when it is the most populous unit of general local government in a MSA having a population greater than 500,000 and more than 1,500 cases of AIDS and it has a higher than average per capita incidence of acquired immunodeficiency syndrome. 55 The legislation makes clear that a single city may receive assistance under both 12903(c)(1)(A) and 12903(c)(1)(B). 56 Giving a single city two bites of the apple has resulted in some cities receiving a disproportionately large share of the HOPWA funding. David Vos, Director of the Office of HIV/AIDS Housing in HUD, has calculated that this formula resulted in giving $10,030 per person living with HIV/AIDS in these doubly eligible cities and only $202 per person living with HIV/AIDS for other eligible localities in FY Furthermore, the seven largest MSAs received 72% of this double entitlement grant money, 58 evidencing that urban areas received a disproportionately large piece of the entitlement grant funding. V. Existing HOPWA Legislation s Impact on the Southern States A. Entitlement Grants If the formula 24 C.F.R (b)(1) for distributing the 75% portion of the entitlement fund used the number of people living with HIV/AIDS rather than cumulative AIDS cases, the South would receive a larger share of the entitlement fund. As shown in Table 3, the south received 37.8% of the HOPWA funds allocated under 42 U.S.C (c)(1)(A) in fiscal year 2010, but had 41.9% of PLWHA live in this region. The 4.1% U.S.C (c)(1)(A) (2012). 55 Id. at 12903(c)(1)(B). 56 Id. 57 David Vos, Power Point: U.S. Department of Housing & Urban Development, Housing as a Platform for Health (Dec. 7, 2011). 58 Id. 17

18 discrepancy between share of HOPWA entitlement funds and disease burden translates into approximately a loss of $9.2 million for the region. Table 3: Comparison of regions percent of cumulative AIDS cases to percent of living HIV/AIDS cases. All targeted states have a higher proportion of people living with HIV/AIDS than proportion of cumulative AIDS cases. Figure 5 shows how much each of the targeted states percent of 12903(c)(1)(A) funding if the formula in 24 C.F.R (b)(1) changed from cumulative AIDS cases to living HIV/AIDS cases. Florida and Texas would see little change in their funding, but Alabama, Mississippi, and North Carolina could see increases of over 30 percent. Amending the funding formula to use the number of people living with HIV/AIDS rather than cumulative AIDS cases should result in all of the targeted states receiving an increase in 12903(c)(1)(A) HOPWA funding. 18

19 Figure 5: Comparison of southern targeted states potential percent increase in HOPWA entitlement awards from 12903(c)(1)(A) by changing the basis of the 24 C.F.R (b)(1) formula from cumulative AIDS cases to persons living with HIV/AIDS. In addition to changing the formula in 24 C.F.R (b)(1) to PLWHA rather than cumulative AIDS, 12903(c)(1)(B) could be completely eliminated to remove the bonus funds for cities that have a higher than average per capita incidence of acquired immunodeficiency syndrome. The data in Table 3 and Figure 5 does not take into account the bonus funds. Figure 6 compares the total entitlement funds received by each of the targeted states in FY 2010, including funds from 12903(c)(1)(A) & (B), to how the entitlement funds could have been distributed based solely on the number of PLWHA in each state. As shown in Figure 6, Alabama, Mississippi, North Carolina, South Carolina, Tennessee, and Texas would receive increased funding whereas Florida, Georgia, and Louisiana would receive less funding. The change in funding that would occur for all states is displayed in Appendix A. 19

20 Figure 6: Comparison of southern targeted states potential percent increase in HOPWA entitlement awards if eliminate 12903(c)(1)(B) and distribute the HOPWA entitlement budget according to number of PLWHA. 45,000, ,000, ,000, ,000, Total HOPWA Entitlement Funding in FY 2010 Total HOPWA Funding if formula changed to be based on PLWHA in FY ,000, ,000, ,000, ,000, ,000, AL FL GA LA MS NC SC TN TX Some of the proposals for updating the HOPWA formula from 12903(c)(1)(A) and (B) include incorporating into the formula: data on persons living with HIV/AIDS rather than cumulative AIDS cases; housing costs (such as fair market rents) and housing affordability, availability, and quality; poverty rates and area household incomes; and other factors such as neighborhood market conditions, community amenities, and service infrastructure. 20

21 B. Competitive Awards Even though the competitive awards (10% to total HOPWA funding) are distributed based on evaluating applications and not on a formula, one can examine the competitive award grants over the last several years to look at the amount of competitive awards the southern region has won compared to other regions. The distribution of competitive grants can also be compared to each region s proportion of PLWHA. Based on data from the Kaiser Family Foundation, the percent of PLWHA by Census Bureau region as of December is as follows: Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX) = 31.73% Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) = 41.9%; Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY) = 25.58%; Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI) = 11.4%; Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI) = 18.9% Puerto Rico + Guam = 2.14% For an equitable distribution of the competitive funds, one would expect that the distribution of competitive HOPWA funding would largely mirror the distribution of PLWHA across the U.S. As shown in Table 4, however, the Census Bureau southern region received only approximately 21% of the competitive grant funding over the last four years even though the Census Bureau southern region has 42% of PLWHA. Similarly, the southern targeted states received only approximately 12.7% of the competitive grant 59 Kaiser Family Foundation, People Living with HIV/AIDS as of December 2008, 21

22 funding over the last four years even though the Census Bureau southern region has 31.7% of PLWHA. In contrast, the Census Bureau Northeast, Midwest, and West all received higher proportions of the competitive HOPWA grants than their proportions of PLWHA (see Figure 7). Table 5 provides a breakdown of the number of competitive awards given per Census Bureau region and Table 6 provides a breakdown of the total amount of competitive grants given to each Census Bureau region by fiscal year. Figure 8 shows the dollar amount of competitive award received by each Census Bureau region averaged over fiscal years divided by each Census Bureau region s number of PLWHA. The south, especially the targeted states, has received less competitive grant money per PLWHA over the last several years than other regions. Table 4: Percent competitive award $ by Census Bureau region, FY Southern States (AL, Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX) AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY) Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI) Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI) Total for census bureau regions FY FY FY FY Average

23 Figure 7: Comparison of each Census Bureau region s percent competitive award from Table 4 to each Census Bureau region s percent PLWHA Average % competitive award, FY % PLWHA in Targeted States Southern States Northeast States Midwest States Western States Table 5: Number of competitive awards allocated to each Census Bureau region of the United States by fiscal year. 60 Southern States (AL, Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX) AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY) Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI) Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI) Total for Census Bureau regions FY FY FY FY U.S. Department of Housing & Urban Development, Homelessness Resource Exchange, HOPWA Programs, Grantees, and Reports, arternum=&rptlevel=byallstates&stateorgrantee=all&grantee=competitive. 23

24 Table 6: Total Competitive Grants Awarded by Census Bureau Region and FY Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX) Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY) Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI) Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI) FY 2012 $746,853 $2,152,803 $11,378,119 $8,984,462 $10,417,804 FY 2011 $6,636,782 $10,830,282 $9,087,402 $1,852,291 $9,584,150 FY 2010 $6,577,577 $11,131,460 $8,462,398 $1,840,791 $8,843,220 FY 2009 $1,658,228 $1,658,228 $10,443,514 $8,731,829 $8,594,845 Figure 8: Average dollar amount of competitive award received by each Census Bureau region during FY divided by the each Census Bureau region s number of PLWHA. $60 $50 $40 $30 $20 $10 Average Competitive Award/PLWHA $0 Targeted States Southern States Northeast States Midwest States Western States 24

25 This research reveals that the southern states, especially the targeted southern states, are receiving a disproportionately smaller share of the HOPWA competitive awards compared to their share of PLWHA. The reasons for this disproportionately small share of the HOPWA competitive awards are not clear. First, it is possible that the evaluation process for competitive grant applications is disfavoring southern states. Second, it is possible that fewer organizations in the southern states are applying for competitive awards. Third, it is possible that the organizations in the southern states that are applying are not submitting quality applications. More investigation into the number of applications received from each region, as well as more details about the evaluation process for the applications, would help elucidate the reasons for the southern region s lower distribution of HOPWA competitive grants. VI. Conclusion Preliminary research shows that the southern states would receive a greater proportion of the HOPWA entitlement funding under 12903(c)(1)(A) if the formula were amended to take into account persons living with HIV/AIDS rather than cumulative AIDS cases. For some southern states, the change is significant. North Carolina, for example, would see an increase of close to 50% in its HOPWA funding with this change. Preliminary research also shows that southern states have historically received fewer competitive awards than their share of PLWHA would indicate. It is not clear whether this discrepancy is due to fewer southern entities applying for these grants, southern entities submitting applications of poorer quality, or a HUD evaluation process that favors other regions. 25

26 Appendix A: Effect on HOPWA Entitlement Distribution from eliminating 12903(c)(1)(B) and distributing funds based on Number of PLWHA. Total HOPWA Entitlement Funds distributed in FY 2010 based on cumulative AIDS cases and including 12903(c)(1)(B) Potential distribution of funds if formula changed to PLWHA and 12903(c)(1)(B) were eliminated ST AL $3,581,932 AK 0 $221,859 AR $1,638,267 AZ $4,017,092 CA $38,245,396 CO $3,663,418 CT $3,721,964 DC $5,507,794 DE $1,070,951 FL $32,068,257 GA $11,022,436 0 $31,156 HI $771,372 ID 0 $254,727 IA $559,784 IL $11,126,518 IN $2,835,554 KS $918,251 KY $1,560,890 LA $5,775,532 MA $5,651,592 ME 0 $338,267 MT 0 $122,228 MD $11,689,041 MI $4,680,615 MN $2,088,490 MO $3,815,775 MS $2,829,049 ND $59,573 NC $7,914,009 NE $526,231 NH 0 $377,298 NJ $11,685,618 NM $809,718 NV $2,296,655 NY $42,318,979 OH $5,671,450 26

27 OK $1,606,768 OR $1,665,314 PA $11,303,869 PR $6,349,011 RI $832,657 SD 0 $131,130 SC $4,889,122 TN $5,050,381 TX $21,575,818 UT $760,416 VT 0 $119,831 VI 0 $195,154 VA $6,768,763 WA $3,510,033 WI $1,666,341 WY 0 $76,692 WV $515,960 27

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