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What's in Their Wallets?

City Hall delays in administering federal AIDS grants are forcing New Orleans HIV service providers to use personal funds just to keep their doors open. Is this the price of "reform"?

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Five months without getting paid was all In This Together (ITT), a local HIV/AIDS agency, could afford. Michael Hickerson, ITT's executive director, and his partner, Dave Munroe, ITT's board chair, say they were keeping ITT afloat and serving 225 clients by taking out a cash advance on a personal credit card. After spending $120,000 for services since March, the two men decided in late July that ITT could no longer provide HIV/AIDS services to its clients.

"At this point, we're not fighting to get these programs back," Hickerson says. "Our clients have been transitioned; our staff is gone. What we want is the system, the process, corrected."

Local HIV/AIDS agencies say they take the same risk every year. Even though the fiscal year for funding the services they provide begins in March, it takes at least three months for City Hall to execute contracts and begin reimbursing them. Meanwhile, the agencies continue to offer a variety of critical services — medication, primary medical care, food delivery, transportation and housing assistance — without a guarantee of reimbursement from the city.

It's now August, and the city still hasn't completed the contracting process. ITT has closed its doors, and another agency says it is in "critical condition."

Fran Lawless, director of the Mayor's Office of Health Policy and AIDS Funding (MOHP), which disperses the federal funds annually, says her hands are tied. Because of the city's new contract review policy, Lawless says, all professional contracts take longer to execute. "I couldn't give [Hickerson] his money any quicker," she adds. "The mayor didn't sign those [award] letters until June 23."

The award letter to which Lawless refers does not mean ITT or similar programs will get city contracts (and funds). The city's chief administrative officer, Brenda Hatfield, followed up the June 23 award announcement with another letter stating that "the selection only prompts a negotiation and does not guarantee a city contract." The letter also warns ITT and eight other agencies, "You should begin no work until all parties execute the contract."

Following Hatfield's advice would have forced all the agencies to stop providing services as of February 29 — five months ago. They didn't. Instead, more than 4,000 people living with HIV/AIDS in the New Orleans area continued to get assistance. But how much longer can the agencies survive without funding?

The federal government allots funds annually for HIV/AIDS care and services for people in urban areas. The U.S. Department of Health and Human Services' Health Resources and Administration doles out the money through grant awards, which are given to eligible metropolitan areas that have the highest number of people living with HIV/AIDS. New Orleans, which has 4,144 people living with HIV/AIDS, is one of the areas funded by the Part A Ryan White HIV/AIDS Program, named in honor of the Indiana teenager whose struggle against AIDS and the discrimination surrounding it helped increase public education and awareness of HIV and AIDS.

On March 11, Health and Human Services Secretary Michael Leavitt announced $550 million in federal grants for Part A of the Ryan White program, with New Orleans receiving just over $7 million for primary care and support services. By that time, however, the city was just beginning to decide which agencies it would fund.

On January 31, Lawless' office solicited proposals from local providers. The deadline was February 21, a week before the Part A Ryan White 2008 fiscal year began. Under the city's new contract review policy, a selection review panel was to evaluate the proposals and choose recipient programs. In previous years, MOHP would review the proposals. Now, says Lawless, a new executive order slows down the process of awarding service contracts.

'The media wants transparency, City Council wants transparency, so you take it out of the hands of the department and you put it in the hands of an objective, neutral group of people to review the proposals," Lawless says. "Would you have time to review, say, 67 proposals that are 250-300 pages in length? It's hard to get people to do that kind of review."

According to Mayor's Executive Order CRN 08-01, which went into effect on April 4, all proposed professional service contracts are evaluated by a selection review panel that includes the city's CAO or deputy CAO, the requesting department's director, the Disadvantaged Business Enterprise Program Compliance Officer, and a community member.

While the city reviewed the proposals, local agencies such as Belle Reve, which offers assisted living for persons with AIDS, kept its operations going by borrowing money. Belle Reve's executive director, Vicki Weeks, says arranging for bank loans is something her organization has grown accustomed to, although borrowing money drives up operating costs.

"What it does — and it's not just that grant, but it's HOPWA (Housing Opportunities for People With AIDS), too, which started in January — it makes all organizations survive off a credit line," Weeks says. "They pay interest on the credit and have to fundraise to pay the interest because the interest can't be paid by a federal grant."

The city's Office of Recovery, Development and Administration oversees the HOPWA grants. HOPWA funding covers the calendar year, but, as is the case with the Ryan White funds, the city doesn't release the money until late in the year.

'Last year we got it in November," says Weeks. "So from January to November, we had to survive on a credit line — and that's a lot of money."

Weeks says that getting a line of credit is much harder for smaller agencies such as ITT. Belle Reve uses its buildings as collateral for loans, but ITT leases office space and doesn't own a major asset that can be used to secure a loan. So, to keep ITT open, Munroe and Hickerson did some fundraising, solicited donations and received money from other sources. When those resources couldn't cover all of ITT's bills, the couple took out a $25,000 cash advance on their credit card.

It's because of people like Trenika Williams that Munroe and Hickerson were willing to put themselves in a financial bind. Williams learned she was HIV positive and pregnant in July 2007. At first, the 28-year-old single mother of two felt she had nowhere to turn. She tried contacting other agencies, but her phone calls weren't returned. She eventually registered with the NO/AIDS Task Force, but she felt she needed additional help.

"I needed someone to take me by the hand because I didn't know what I was doing," Williams says.

That someone was Hickerson. After hearing about ITT from a friend, Williams visited the agency's offices in February and was immediately taken with Hickerson's resourcefulness.

'If he couldn't do it himself, he sent me somewhere that could," Williams says. Williams transferred over to ITT, and until the agency closed, it gave Williams rental and utilities assistance. Williams now gets no financial help — and won't until she sees her new case manager at Leading Edge, an HIV outpatient clinic in Kenner. She says she still considers Hickerson a lifeline. "I could still call him because he gave me his personal phone number, and he told me to call him if I ever needed help."

For Hickerson, who is HIV positive, ITT is a reflection of himself. "I am this. I am these clients and that's why we provide these services," he says. Hickerson, a social worker and native New Orleanian, grew up poor and says he opened ITT in 2005 because he wanted to create an agency that would be culturally sensitive to the needs of economically disadvantaged African Americans living with HIV/AIDS. He says that 75 to 80 percent of his clients were African Americans, as was 90 percent of ITT's staff.

Hickerson adds that some of his clients were homeless and many have high medical and social needs. ITT's location on Canal Street was easily accessible to clients, and the agency could offer housing assistance through its HOPWA grant as well as medical case management services through Ryan White funds. For the fiscal year 2007-2008, ITT signed a contract with the city to provide $213,516 worth of medical case management services. Hickerson says he wasn't happy with how long it took the city to execute the contract — ITT received its first Ryan White fund reimbursement in late September, nearly seven months into its fiscal year. However, he says, ITT was bringing in clients that might have chosen to ignore their disease rather than go to other agencies, where they felt uncomfortable or misunderstood. "People have choices, and they chose [the ITT agency]," Hickerson says.

Hickerson and Munroe applied for $304,615 in Ryan White funds for 2008-2009. Because the city's application guidelines now require agencies to offer medical case management, non-medical management, transportation and outreach services, ITT had to add outreach, non-medical case management and transportation to its menu of programs.

Hickerson and Munroe heard nothing from the city until June 23, when a letter arrived stating they had been awarded a total of $149,863 in Ryan White funds. According to the letter, the funds were to be spent on non-medical case management ($125,907) and outreach ($23,956). They received nothing for medical case management.

The federal government instituted new rules and definitions this year regarding the distinction between medical case management and non-medical case management. Lawless says that agencies must interact with a patient's primary care provider to qualify for medical case management funds. She claims that ITT wasn't doing that. Munroe counters that ITT did try to contact clients' doctors, but because Lawless' office hasn't insisted that primary care providers interface with medical case manager providers like ITT, the required interaction has become a problem for many agencies.

"They're all struggling to establish lines of communication with these primary medical entities," Munroe says.

By that time, ITT's continued existence became a matter of time and money. "We didn't get enough money, and it didn't come soon enough," says Munroe.

N'R Peace is another HIV/AIDS agency that caters primarily to African Americans. Demitre Blutcher, N'R Peace's executive director, says the agency focuses on that population because, although African Americans account for only 12 percent of the nation's population, more than 53 percent of new HIV cases are in the African-American community. Blutcher says the agency tries to locate and serve people who have been "lost to care," unaware of services available and how to get them. Some of his clients have been recently released from jail and are trying to return to care.

Blutcher's agency works with 145 clients but is running out of money. Blutcher isn't sure how much longer the agency can survive.

'Being a small, minority agency, it's been tough," Blutcher says. "I have depleted my line of credit and all small fundraising projects."

In the city's specifications for Ryan White funding, it encourages minority agencies like Blutcher's and Hickerson's to apply. Lawless cautions, however, that agencies should still have at least a year's worth of reserve funds for operating costs. "They really should, to operate," Lawless says. "Anybody would have a hard time, but realistically, within six months, we usually have the contracts executed, which is fairly quick considering other city contracts."

That's not how the federal government views it. David Bowman, a spokesperson for HRSA, writes in an email response that "the local award process must be done within a reasonable amount of time. The expectation is 120 days; however we have no control over delays at the local level." Later in the same email, he adds that the HRSA project officer has been in contact with the city about the delays.

Ralph Brisueno is the director of the Ryan White program for the City of Baltimore. Brisueno reports that his department is already planning for the next fiscal year of Ryan White funds. He says funding is a competitive process and the request for proposals goes out in November, so that as soon as the federal government announces funding totals, the award letters, which establish funding, are delivered to agencies. Brisueno says that Baltimore, like New Orleans, operates on a reimbursement system — work is completed before payment — so agencies received the first Ryan White-funded payment in April, one month into the fiscal year. When Brisueno was informed that New Orleans agencies still aren't under contract and haven't yet been paid for services, he was blunt in his assessment.

"That's a tragic situation, because it puts everyone in a bind."

Gambit Weekly contacted Part A Ryan White programs in Fort Lauderdale, Fla.; Norfolk, Va., and Miami. All reported that contracts were signed and are being funded.

Noel Twilbeck, executive director of NO/AIDS Task Force, says the funding delays also affect larger agencies like his because it creates a cash-flow burden: agencies have to continue paying bills for services while waiting for the city to reimburse them. Twilbeck knows the process could be better and he mentions other Ryan White cities, New York and Boston. As for the award letter not actually guaranteeing a contract, Twilbeck says that it's something that agencies are willing to risk because it means people continue to get the services they need.

"If we didn't, we couldn't offer primary care, case management, delivered meals, mental health, etc.," Twilbeck explains. "We would have to stop on February 28 (normally, the last day in the fiscal year). We do take a chance every year even with the award letter."

Lawless says she finds it "interesting" that Blutcher and Hickerson would tell a reporter about their financial difficulties, but they didn't inform her office. She suggests that the two agencies' financial problems might be of their own making and not because the city hasn't yet funded them.

"I can't tell an agency how to handle their finances," Lawless says. "But we have 12 other agencies that are in operation and if [Hickerson] can't sustain the needs of his clients, they can go elsewhere."

So why haven't other HIV/AIDS agencies publicly complained about the city's failure to pay out monies in a timely fashion? The answer could be a simple one: fear. Hickerson and Munroe say that the other agencies are afraid that if they speak out, they may be denied a contract, or given less. They point out that last year they alerted the National Minority AIDS Council about the city's inefficient funding process. The Washington D.C.-based council sent a letter to Mayor Nagin and then flew down to discuss the situation with city officials. Ravinia Cozier, NMAC's director of public policy and government relations, says that city officials didn't seem to understand the urgency of the crisis. After the meeting, NMAC sent a second letter outlying its concerns and recommendations.

The city never responded to the second letter, says Cozier.

Cozier adds that culturally sensitive minority agencies such as ITT play a vital role in serving those living with HIV/AIDS.

"People need to feel confident that the people who serve them will understand not just HIV/AIDS but the many complicated obstacles in their life, from poverty, education, housing, jobs, etc., and how this disease impacts all of those issues and others."

Although Lawless categorically denies Hickerson and Munroe's claims, there could be some truth to the accusation. An anonymous source from another local HIV/AIDS agency contacted Gambit Weekly regarding why ITT didn't receive adequate funding. The source didn't want to be identified for fear that MOHP would cut off the source's own city funding. The source was quite clear, however, on the question of whom ITT was serving before it ceased HIV/AIDS services and who was responsible for the closure.

"These are the poorest people of the poor. [The city] literally drove Michael out of business. He was working with people NO/AIDS didn't know how to work with."

Michael Hickerson says that he started In This Together (ITT) in order to reach out to poor, African-American HIV/AIDS clients who are often overlooked by other agencies. - DAVID WINKLER-SCHMIT
  • David Winkler-Schmit
  • Michael Hickerson says that he started In This Together (ITT) in order to reach out to poor, African-American HIV/AIDS clients who are often overlooked by other agencies.
Trenika Williams turned to Michael Hickerson and ITT for help when she found out she was pregnant and HIV positive. - TRACIE MORRIS-SCHAEFER
  • Tracie Morris-Schaefer
  • Trenika Williams turned to Michael Hickerson and ITT for help when she found out she was pregnant and HIV positive.

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