| Since its inception, the HIV epidemic has changed significantly with respect to epidemiology, medical technologies, and increased reliance on public programs for treatment. Little empirical work has examined how public programs have evolved in response. I explore policy adaptation in the Ryan White HIV/AIDS Program (RW), the largest federal program for HIV care, through three chapters that address two broad questions. First, as demand for public services shifts, how do policymakers allocate federal resources within and across programs? Second, how do local programs innovate to address the changing nature of HIV care?;One chapter quantifies the extent to which RW's allocation formula has allowed the interstate distribution of federal funds to evolve in response to changes in need or other political objectives. An econometric analysis compares the effect of initial allocations on later distributions of resources to five counterfactual standards of equity that have been voiced by policymakers. I find that the initial allocations are the strongest predictor of future funds, and draw upon theoretical literature to describe causal mechanisms for this "policy inertia.";A second chapter uses a simulation model of HIV screening, disease, and treatment to forecast the cost of a recent change in federal HIV screening guidelines to government testing, discretionary, and entitlement programs. Prior analyses have demonstrated this policy's cost-effectiveness but have not examined the impact on government budgets. Expanded screening will increase government expenses by ;A third chapter assesses why some states' RW programs innovate more readily to changing circumstances, and how the pattern of policy adoption compares to that seen in other domains. Qualitative expert interviews informed a set of state-level program innovations and potential predictors of innovativeness. Statistical analyses test these hypotheses empirically. Both endogenous state characteristics and federal funding were related to policy adoption, but the direction of effect differed according to innovation's cost impact, visibility, and ease of implementation. I discuss why some innovations may not follow a classic diffusion pattern, and the roles of federal and state governments in facilitating the spread of innovation. |
