oversight

Health Center Program: 2011 Grant Award Process Highlighted Need and Special Populations and Merits Evaluation

Published by the Government Accountability Office on 2012-05-29.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Requesters




May 2012
                             HEALTH CENTER
                             PROGRAM
                             2011 Grant Award
                             Process Highlighted
                             Need and Special
                             Populations and
                             Merits Evaluation



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GAO-12-504
                                               May 2012

                                               HEALTH CENTER PROGRAM
                                               2011 Grant Award Process Highlighted Need and
                                               Special Populations and Merits Evaluation
Highlights of GAO-12-504, a report to
congressional requesters




Why GAO Did This Study                         What GAO Found
Health centers funded in part by grants        The Department of Health and Human Services’ (HHS) Health Resources and
from HRSA’s Health Center Program,             Services Administration (HRSA) revised its New Access Point (NAP) competitive
under Section 330 of the Public Health         award process in fiscal year 2011 to increase the emphasis on the need for
Service Act, provide comprehensive             services in the applicant’s proposed service area, and on the three special
primary care services for the medically        populations—migrant and seasonal farmworkers, homeless people, and
underserved, including many poor,              residents of public housing—designated by the Public Health Service Act. The
uninsured, and Medicaid patients.              act requires that certain proportions of Health Center Program funding go to
Legislation enacted in 2009 and 2010           health centers serving the special populations. To increase the emphasis on
provided additional funding that could
                                               need, HRSA increased the weight given to need in the application review
significantly expand health center
                                               process. To target health centers serving special populations, HRSA gave extra
capacity over the next several years.
GAO was asked to review HRSA’s
                                               points in the application process to applicants proposing to serve them. When
process for awarding grants for new            this was insufficient to meet the required proportions, HRSA moved some
delivery sites and possible effects of         applicants ahead of others in the award rank order list, a method it had used in
health centers, such as competition, on        the past. The effect of HRSA’s actions on the award outcome was magnified in
other providers. This report examines          fiscal year 2011 because (1) HRSA received less program funding than it had
(1) the actions HRSA has recently              anticipated, and (2) it needed to increase the share of grants going to health
taken to target its grants for new             centers serving the special populations because HRSA had not applied the
delivery sites to health centers in            statutory proportions when it used American Recovery and Reinvestment Act
communities with demonstrated need             funding to award grants in fiscal year 2009. As a result, HRSA awarded 67 NAP
and the outcome of HRSA’s award                grants in fiscal year 2011, 57 of which went to applicants proposing to serve at
process in recent years, and (2) the           least one special population; 13 of the 57 received grants by being moved ahead
extent to which HRSA-funded health             of other applicants with equal or higher review scores. HRSA announced the
centers collaborate and compete with           extra points in application guidance, but not the potential moving of some
other health care providers in their           applicants ahead of others. As HRSA has periodically needed to take actions to
service area. GAO focused its work on          meet its statutory obligations and may need to do so again, evaluating the
NAP grants, HRSA’s primary means of            effectiveness and transparency of its most recent New Access Point grant award
establishing new health centers and            process could help it identify lessons and possible improvements for the future.
delivery sites, during fiscal years 2008
through 2011. GAO analyzed HRSA                Health centers in the communities GAO studied collaborate with other providers
documents and interviewed HRSA                 and generally do not compete with them for patients, but GAO found greater
officials, and interviewed officials from      potential for competition in rural areas. Health center officials described
11 health centers and providers and            collaborative relationships with other providers that give patients access to
officials in their service areas.              services not available through the health center. Health centers and other
                                               providers told GAO they generally do not compete for patients; health centers
What GAO Recommends
                                               typically serve patients not treated elsewhere, such as uninsured and Medicaid
The Secretary of HHS should direct the         patients. However, because the health center grant covers, on average, about 20
Administrator of HRSA to evaluate the          percent of a center’s budget, other funding must also be secured, such as by
fiscal year 2011 NAP grant award               serving insured patients, for the center to be financially sustainable. This can
process for effectiveness and                  result in competition with other providers in its service area. During the award
transparency, identify lessons learned,        process, HRSA takes steps to reduce competition by identifying nearby safety
and incorporate any improvements for           net providers and assessing whether the level of unmet need in the area
future funding cycles. HHS agreed with         warrants a grant for a new health center or delivery site. Greater potential for
GAO’s findings and recommendation              competition exists in rural areas because patients there are more likely to be
and said HRSA has begun to take                insured and rural health clinics and certain hospitals might seek to serve some of
action.
                                               the same patients as health centers, although they may not offer all of the
View GAO-12-504. For more information,         services required of health centers.
contact Debra A. Draper at (202) 512-7114 or
draperd@gao.gov.

                                                                                       United States Government Accountability Office
Contents


Letter                                                                                             1
                       Background                                                                  7
                       HRSA Revised 2011 Award Process, and Most New Access Point
                         Grants Went to Health Centers Serving Special Populations               14
                       Health Centers and Other Providers Reported Collaboration and
                         Little or No Competition, but Rural Areas Have Greater Potential
                         for Competition                                                         28
                       Conclusions                                                               33
                       Recommendation for Executive Action                                       34
                       Agency Comments                                                           35

Appendix I             New Access Point Grant Awards, Fiscal Years 2008-2011, and
                       Total Health Center Grantees, 2010                                        37



Appendix II            Ratio of Health Center Grantees to Population Living in Poverty,
                       by State, 2010                                                            40



Appendix III           Comments from the Department of Health and Human Services                 42



Appendix IV            GAO Contact and Staff Acknowledgments                                     47



Related GAO Products                                                                             48



Tables
                       Table 1: HRSA’s New Access Point Grants to Health Centers, Fiscal
                                Years 2008-2011                                                  10
                       Table 2: HRSA’s Scoring Criteria and Maximum Base Points
                                Awarded for New Access Point Grant Applications, Fiscal
                                Years 2008, 2009, and 2011                                       16
                       Table 3: Extra Points Awarded by HRSA to New Access Point
                                Applicants in Fiscal Year 2011                                   18




                       Page i                                        GAO-12-504 Health Center Funding
          Table 4: Selected Socioeconomic Characteristics for New Access
                   Point Grantees’ Delivery Sites, in Aggregate, Compared to
                   National Average, Fiscal Years 2008, 2009, and 2011              27
          Table 5: New Access Point Grant Awards, Fiscal Years 2008-2011,
                   and Number and Percentage of Total Health Center
                   Grantees, 2010, by State and Territory                           37
          Table 6: Ratio of Health Center Grantees to Population Living in
                   Poverty, by State, 2010                                          40


Figures
          Figure 1: Insurance Coverage of Health Center Patients,
                   Nationwide, 2010                                                   8
          Figure 2: Health Center Revenue Sources, Nationwide, 2010                   9
          Figure 3: HRSA’s New Access Point Grant Award Process in Fiscal
                   Year 2011                                                        20
          Figure 4: HRSA New Access Point Grant Awards, Fiscal Year 2011,
                   and Total Health Center Grantees, 2010                           24
          Figure 5: Number of New Access Point (NAP) Grants Awarded by
                   HRSA and Delivery Sites the Grants Funded, by Fiscal
                   Year                                                             26




          Page ii                                       GAO-12-504 Health Center Funding
Abbreviations

ACS               American Community Survey
HHS               Department of Health and Human Services
HPSA              health professional shortage area
HRSA              Health Resources and Services Administration
MUA               medically underserved area
MUP               medically underserved population
PCA               primary care association
PCO               primary care office
PPACA             Patient Protection and Affordable Care Act
UDS               Uniform Data System



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Page iii                                                GAO-12-504 Health Center Funding
United States Government Accountability Office
Washington, DC 20548




                                   May 29, 2012

                                   The Honorable Michael B. Enzi
                                   Ranking Member
                                   Committee on Health, Education, Labor, and Pensions
                                   United States Senate

                                   The Honorable Richard Burr
                                   Ranking Member
                                   Subcommittee on Children and Families
                                   Committee on Health, Education, Labor, and Pensions
                                   United States Senate

                                   The Honorable Tom Coburn
                                   Ranking Member
                                   Permanent Subcommittee on Investigations
                                   Committee on Homeland Security and Governmental Affairs
                                   United States Senate

                                   The nationwide network of health centers in the federal Health Center
                                   Program is an important component of the health care safety net for
                                   vulnerable populations, including Medicaid beneficiaries, 1 people who are
                                   uninsured, and others who may have difficulty obtaining access to health
                                   care. In 2010, more than 1,100 health centers operated more than
                                   8,100 delivery sites across all the states 2 and served more than 19 million
                                   people. These health centers provide comprehensive primary health care
                                   services—preventive, diagnostic, treatment, and emergency services, as
                                   well as referrals to specialty care—without regard to a patient’s ability to
                                   pay. Through its Health Center Program, the Department of Health and
                                   Human Services’ (HHS) Health Resources and Services Administration
                                   (HRSA) awards grants to eligible health centers under Section 330 of the
                                   Public Health Service Act. 3 HRSA funds the establishment of new health




                                   1
                                    Medicaid is a joint federal and state program that finances health insurance for certain
                                   low-income adults and children.
                                   2
                                    In this report, “state” refers to the 50 states, the District of Columbia, and Puerto Rico.
                                   There are also delivery sites in six territories.
                                   3
                                    42 U.S.C. § 254b.




                                   Page 1                                                     GAO-12-504 Health Center Funding
center delivery sites—for both new and existing grantees—through its
New Access Point grants.

To be eligible for a grant, an applicant must serve a federally designated
medically underserved area (MUA) or a federally designated medically
underserved population (MUP). 4 Among other things, HRSA is required to
ensure that an applicant has made efforts to establish and maintain
collaborative relationships with other health care providers in its service
area before awarding a grant. 5 The scope of a health center’s activities is
delineated in its grant application and consists of its services, delivery
sites, providers, target population, and service area. In addition,
applicants must describe a specific need for services in the area they plan
to serve, based on factors such as unique health care needs of the target
population or particular provider shortages. There are four types of health
centers funded through the Health Center Program: community health
centers, funded to serve all members of an underserved community, and
three types specifically funded to serve designated special populations—
migrant and seasonal farmworkers, homeless people, and residents of
public housing. 6 The four types of health centers were consolidated into a
single program in 1996; 7 prior to the consolidation, the grantees serving
the three designated special populations were funded through separate
programs.


4
  HRSA designates MUAs based on a geographic region, such as a county, and it
designates MUPs based on a specific population that demonstrates economic, cultural, or
linguistic barriers to primary care services. Criteria for designating a medically
underserved area or population include the ratio of primary care physicians per 1,000
population, infant mortality rate, percentage of the population with incomes below the
federal poverty level, and percentage of the population age 65 and older. In 1998 and
again in 2008, HRSA proposed new rules for designation of medically underserved
communities and populations with health professional shortages and/or high unmet needs
for health services. In both cases, HRSA received a large volume of critical comments
upon publication of the proposed rules, and ultimately withdrew them. Subsequently, the
2010 Patient Protection and Affordable Care Act required the formation of a negotiated
rulemaking committee to develop a comprehensive methodology and criteria for MUP and
Health Professional Shortage Area (HPSA) designations. The Negotiated Rulemaking
Committee on the Designation of MUPs and HPSAs completed its work in October 2011,
and HRSA is drafting an interim final rule.
5
42 U.S.C. § 254b(k)(3)(B).
6
 HRSA guidance states that to be funded as an organization that serves a special
population, a health center must devote at least 25 percent of its HRSA funding to serving
one or more of the three designated special populations.
7
Health Centers Consolidation Act of 1996, Pub L. No. 104-299, 110 Stat. 3626.




Page 2                                                  GAO-12-504 Health Center Funding
For each of fiscal years 2009 and 2010, HRSA allocated almost
$2.2 billion in annual appropriations to the Health Center Program; 8, 9 of
that amount, nearly $2 billion each year was used for health center
grants. 10 In addition, the American Recovery and Reinvestment Act of
2009 (Recovery Act) 11 appropriated $2 billion for health centers to be
used over those 2 years. In fiscal year 2011, HRSA allocated $1.6 billion
in annual appropriations to the Health Center Program. This amount
reflected a reduction of $604 million as a result of a reduction in
appropriations to HRSA and a rescission of appropriations made for that
year for nondefense programs; these reductions occurred after the fiscal
year had begun and resulted in HRSA receiving less funding for the
Health Center Program than it had anticipated. However, the Patient
Protection and Affordable Care Act (PPACA), as amended by the Health
Care and Education Reconciliation Act of 2010, provided an additional
$11 billion over 5 years—beginning with $1 billion for fiscal year 2011—
for the operation, expansion, and construction of health centers. 12 As a
result, health center capacity is expected to expand significantly over the
next several years.

In light of the additional funds provided to the Health Center Program
through the Recovery Act and PPACA, you asked us to review HRSA’s
awarding of new grants to communities with a need for services, and
about possible effects, such as competition, on other providers resulting
from the increased support for health centers. In this report, we examine
(1) the actions HRSA has recently taken to target its grants for new
delivery sites to health centers in communities with demonstrated need,
and the outcome of HRSA’s award process in recent years; and (2) the
extent to which federally funded health centers collaborate and compete
with other health care providers in their service area.


8
 HRSA allocates funds to the Health Center Program out of the annual appropriation
made to the agency for its programs.
9
In fiscal year 2008, the Health Center Program’s allocation was nearly $2.1 billion.
10
  The remainder was used to fund other activities that support the Health Center Program,
such as cooperative agreements with nonprofit organizations that assist health centers.
11
    Pub. L. No. 111-5, 123 Stat. 115.
12
  Pub. L. No. 111-148, § 10503, 124 Stat.119, 1004 (2010); Pub. L. No. 111-152, § 2303,
124 Stat. 1029, 1083. In this report, references to “PPACA” are to the Patient Protection
and Affordable Care Act, as amended by the Health Care and Education Reconciliation
Act of 2010.




Page 3                                                  GAO-12-504 Health Center Funding
To examine the actions HRSA has recently taken to target its grants for
new delivery sites to health centers in communities with demonstrated
need and the outcome of HRSA’s award process in recent years, we
focused our work on New Access Point grants, because these grants are
HRSA’s primary means of establishing new health centers and delivery
sites, 13 and because applicants are required to demonstrate the need for
health care services in a newly proposed service area. We reviewed
HRSA program documents and web-based resources and interviewed
HRSA officials to obtain information about the agency’s process for
awarding grants, including any changes HRSA made between fiscal
years 2008 and 2011 to the New Access Point grant application guidance
and the criteria used for reviewing and scoring applications. We also
reviewed applicant scores and rankings during that period. We
interviewed health center officials and reviewed grant applications from
nine selected health centers that received New Access Point grants
during fiscal years 2008 through 2011 to obtain the health centers’
perspective on their experience applying for a grant and to review the
information they provided to HRSA. 14 We chose the health centers based
on criteria that included geographic diversity, patient demographics
(e.g., percentage of population in poverty and insurance status), and site-
specific information (e.g., number of delivery sites operated by the
grantee and U.S. Census Bureau urban/rural continuum category). 15 We
obtained data used in our selection process from HRSA’s 2010 Uniform
Data System (UDS) and 2009-2010 Area Resource File (ARF), the most




13
  HRSA can also award funds through a competitive process to a new health center
grantee to serve an existing grantee’s service area under certain circumstances, such as
when the existing health center grantee’s grant period expires or when the existing
grantee is no longer able to serve its service area.
14
  We selected grantees that received grants for new health centers, rather than existing
grantees that received grants for new delivery sites, to focus on grantees whose
applications described all their funded delivery sites. The selected grantees were located
in the following states: California, Florida, Illinois, Kansas, New York, North Carolina,
Oklahoma, Vermont, and Virginia.
15
  Because HRSA does not collect data on the population served and types of services
provided at individual health center sites, we used the grantee’s main address as a proxy
for the site’s location. We eliminated from consideration grantees for which the main
address is a site that serves a purely administrative function.




Page 4                                                   GAO-12-504 Health Center Funding
recent data available. 16 To assess the reliability of the UDS and ARF data
elements that we used in our selection, we performed checks, such as
examining the data for missing values, and reviewed related
documentation. We determined that the UDS and ARF data were
sufficiently reliable for our purposes. We chose three grantees each from
fiscal years 2008, 2009, and 2011 to represent various funding sources. 17
(HRSA did not award any New Access Point grants in fiscal year 2010.)

To identify the level of need in the communities served by applicants that
received New Access Point grants, we also analyzed data on selected
socioeconomic characteristics (e.g., the percentage of the population
living in poverty and the unemployment rate) for all delivery site locations
funded through these grants from fiscal years 2008 through 2011. To do
this, we determined the county in which each delivery site was located
based on its zip code, and reviewed and analyzed county-level data from
the U.S. Census Bureau’s 2006-2010 and 2008-2010 American
Community Survey (ACS), which contained the most recent available
data. 18 To assess the reliability of the ACS data elements that we used in
our analysis, we performed checks, such as examining the data for
missing values, and reviewed related documentation. We determined that
the ACS data were sufficiently reliable for our purposes.

To examine the extent to which federally funded health centers
collaborate and compete with other health care providers in their service
area, we reviewed HRSA program documentation, policies, and guidance


16
  We also obtained data from the 2008 and 2009 UDS for grantees funded in those years.
The UDS is the Health Center Program’s administrative database, through which all
grantees are required to submit data on their operations each year, including data on their
delivery sites, patients, revenues, and expenses. The ARF is a county-based health
resources database that contains data from many sources, including the U.S. Census
Bureau and the American Medical Association.
17
  New Access Point grants in fiscal year 2008 were funded by the Consolidation
Appropriations Act, 2008. Pub. L. No. 110-161, 121 Stat. 1877 (2007). All New Access
Point grants in fiscal years 2009 and 2011 were funded with Recovery Act and PPACA
funds, respectively.
18
   County-level data may not provide a fully accurate depiction of the socioeconomic
characteristics for some delivery site locations because the health center’s service area
may be smaller than the county as a whole, and other locations in the county may have
different characteristics. This could result in data linked to the delivery site being diluted by
overall county data and certain characteristics, such as the percentage of the population
living in poverty, being underestimated. However, county-level data are the best data
available.




Page 5                                                      GAO-12-504 Health Center Funding
related to collaboration and service area overlap and interviewed HRSA
officials. For this objective, we interviewed officials from the six health
center grantees selected for our first objective that received New Access
Point grants in fiscal years 2008 and 2009, but we did not include the
three 2011 grantees. We did not interview officials from the fiscal year
2011 grantees because these grantees received their awards in August
2011 and were not yet fully operational, although we did review their grant
applications for discussions of collaborative efforts. We also interviewed
officials from two additional grantees that were funded prior to 2008—
which were selected using criteria similar to those used for the other
grantees. 19 We asked the officials from both groups of health centers
about their relationships with other providers in their communities,
including any collaboration or competition with them. To obtain
information on the eight health centers’ communities and their
relationships with other providers, we also interviewed officials from
primary care associations (PCA)—nonprofit organizations that support
health centers at the state or regional level—and state primary care
offices (PCO)—state government entities that work toward addressing the
needs of the medically underserved in their states and receive funding
from HRSA and other sources. We also interviewed representatives of
hospitals and other providers, such as rural health clinics and private
physician practices, and officials from community organizations with
knowledge of the local health care environment in the health centers’
communities. The information obtained about individual health centers
and their communities through our interviews with officials from health
centers, PCAs, PCOs, hospitals, other providers, and community
organizations cannot be generalized to other health centers. In addition,
we interviewed officials from national stakeholder groups, including the
National Association of Community Health Centers, American Hospital
Association, National Association of Rural Health Clinics, and National
Rural Health Association about the extent to which there is collaboration
and competition between health centers and other providers in general.




19
  We added the two additional grantees that were initially funded prior to 2008 because
they had been in operation longer than the other selected grantees and could provide the
perspective of grantees with more years of experience. These two grantees had been
funded through the Health Center Program for 28 and 29 years, respectively. The two
additional grantees were located in Alabama and New York.




Page 6                                                 GAO-12-504 Health Center Funding
                          We conducted this performance audit from July 2011 to May 2012 in
                          accordance with generally accepted government auditing standards.
                          Those standards require that we plan and perform the audit to obtain
                          sufficient, appropriate evidence to provide a reasonable basis for our
                          findings and conclusions based on our audit objectives. We believe that
                          the evidence obtained provides a reasonable basis for our findings and
                          conclusions based on our audit objectives.


                          Health centers are private, nonprofit community-based organizations or,
Background                less commonly, public organizations such as public health department
                          clinics. Section 330 of the Public Health Service Act, which authorizes the
                          Health Center Program, requires health centers to provide a
                          comprehensive set of primary health care services, including enabling
                          services—such as language translation and transportation—that facilitate
                          access to health care. Among other things, health centers are also
                          required to have a sliding fee scale based on a patient’s ability to pay and
                          to be governed by a community board of which at least 51 percent of the
                          members are patients of the health center. 20


Health Center Patients,   In 2010, nearly 93 percent of all health center patients had incomes at or
Revenue, and Grants       below 200 percent of the federal poverty level, and nearly 72 percent had
                          incomes at or below 100 percent. 21 About 39 percent of patients were
                          insured by Medicaid, and nearly 38 percent were uninsured. See figure 1
                          for more information on insurance coverage of health center patients.




                          20
                            HRSA may waive the governing board requirement for certain centers upon a showing
                          of good cause. For information on HRSA’s oversight of the Health Center Program, see
                          GAO, Health Center Program: Improved Oversight Needed to Ensure Grantee
                          Compliance with Requirements, GAO-12-546 (Washington, D.C.: May 29, 2012).
                          21
                            The characteristics of individual health centers’ patient populations—such as insurance
                          coverage and income level—vary.




                          Page 7                                                  GAO-12-504 Health Center Funding
Figure 1: Insurance Coverage of Health Center Patients, Nationwide, 2010




Notes: The most recent available data on health center patients’ insurance coverage come from the
2010 Uniform Data System (UDS).
Children covered under the State Children’s Health Insurance Program (CHIP)—a joint federal and
state insurance program for certain low-income, uninsured children whose family income is too high
for Medicaid eligibility—are included in either the Medicaid or Other public categories.


Health center revenue comes from multiple sources, including public and
private insurance and grants from federal, state, and local governments
and private organizations. The single largest source of health center
revenue is Medicaid, which provided nearly 38 percent of health center
revenue in 2010. (See fig. 2.) Together, HRSA Health Center Program
grants funded through annual appropriations and grants funded through
the Recovery Act constituted about 21 percent of total health center
revenue in that year. 22




22
  The revenue from grants funded through annual appropriations accounted for
15.7 percent of the total, and the revenue from grants funded through the Recovery Act
accounted for 5.7 percent of the total.




Page 8                                                        GAO-12-504 Health Center Funding
Figure 2: Health Center Revenue Sources, Nationwide, 2010




Note: The most recent available data on health centers’ revenue sources come from the 2010
Uniform Data System (UDS).
a
 The Recovery Act is the American Recovery and Reinvestment Act of 2009. Pub. L. No. 111-5,
123 Stat. 115 (Feb. 17, 2009).


The Health Center Program provides several types of grants, and New
Access Point grants are used to establish new health center delivery
sites—whether for a new health center grantee or an existing grantee. 23
Grantees may request funding to operate one or more types of health
centers, such as a community health center and one serving migrant and
seasonal farmworkers. Once a health center is an established grantee, it
must compete periodically to maintain its grant funding for its specific
service area. The vast majority of health center grant funds distributed



23
  Other types of competitive grants that the Health Center Program provides include
grants to expand the types of services available at a given delivery site and planning
grants to assist organizations in planning a potential HRSA-supported health center. In
addition, HRSA has provided competitive grants to health centers to support construction
and renovation, which were funded through the Recovery Act and PPACA.




Page 9                                                      GAO-12-504 Health Center Funding
each year by HRSA—for example, 96 percent in fiscal year 2008—are
used to support continuing operations for established grantees and their
existing delivery sites; New Access Point grants made up about 1 percent
of the funds distributed in fiscal year 2008, the last year these grants were
funded through annual appropriations. In fiscal years 2009 and 2011,
HRSA used additional resources provided through the Recovery Act and
PPACA, respectively, to fund New Access Point grants. See table 1 for
more information on the New Access Point grants HRSA awarded in
fiscal years 2008 through 2011.

Table 1: HRSA’s New Access Point Grants to Health Centers, Fiscal Years 2008-
2011

                                     Number of New Access           Total dollar amount provided
    Fiscal year                         Point grant awards      through New Access Point grants
    2008                                               41                                 $22.0 million
                                                         a
    2009                                              126                                $154.9 million
                                                         b
    2010                                            None                                           N/A
                                                            c
    2011                                               67                                 $28.8 million
Source: GAO analysis of HRSA data.
a
    In fiscal year 2009, HRSA used Recovery Act funds for all New Access Point grants.
b
    In fiscal year 2010, HRSA did not award any New Access Point grants.
c
In fiscal year 2011, HRSA used PPACA funds for all New Access Point grants.


HRSA has cooperative agreements with PCAs to provide training and
technical assistance to health centers and other safety net providers,
support the development of health centers in their state, and enhance the
operations and performance of health centers. PCAs also assist in
planning for the growth of health centers in their states and help
communities apply for and obtain funds for new health centers and
delivery sites. HRSA also relies on PCAs to identify underserved areas
and populations in their state/region.




Page 10                                                           GAO-12-504 Health Center Funding
HRSA’s Award Process for   HRSA uses a competitive process to award New Access Point grants. 24
New Access Point Grants
                           Announcement and Assistance. After announcing a funding opportunity
                           via its website and Grants.gov, HRSA issues grant application guidance,
                           which includes the forms applicants need to submit and a detailed
                           description of the application review criteria and process. HRSA also
                           provides applicants with access to technical assistance during the
                           development of grant applications. For example, through cooperative
                           agreements with HRSA, PCAs and the National Association of
                           Community Health Centers offer training sessions on topics such as
                           proposal writing and conducting a community assessment, which may
                           include an analysis of the other providers in an area and any unmet
                           health care needs.

                           Application Preparation and Submission. Applicants must prepare and
                           submit the application materials to HRSA through Grants.gov and the
                           agency’s website. The application materials include several narrative
                           sections as outlined in the guidance from HRSA, as well as attachments
                           such as a proposed budget, organizational chart, and summary of any
                           current or proposed contracts to provide services outlined in the
                           application.

                           Eligibility. Grant applications undergo an initial review for eligibility in
                           which HRSA screens applications based on specific criteria, as described
                           in the funding announcement. For example, the applicant must be
                           applying for a grant for which it is eligible (e.g., certain HRSA grants are
                           available only to existing grantees), and the application must include all
                           required documents.

                           Review. Independent reviewers who are not affiliated with the Health
                           Center Program, but have experience in a field relevant to the program,
                           are selected by HRSA to review and score all eligible applications against
                           established criteria, each of which has a specified point range. (We
                           discuss the review criteria and point ranges in greater detail below.) For
                           example, reviewers assess the description of the specific need for
                           services in the area the applicant plans to serve—including the
                           characteristics of its target population, the availability of services from



                           24
                             The process HRSA uses to award New Access Point grants is generally the same
                           process it uses for its other competitive grant awards.




                           Page 11                                             GAO-12-504 Health Center Funding
other providers, and any gaps in the availability of services—as well as
the applicant’s capacity and readiness to initiate the proposed services.
After reviewers score the applications, all applicants are ranked in an
initial rank order list, which is provided to HRSA officials for grant award
consideration.

Assessment of Service Area Overlap. Once applications have been
scored and ranked, HRSA conducts a review of the potential for service
area overlap between proposed delivery sites and certain existing safety
net providers, including hospitals. 25 HRSA has a policy describing this
process. HRSA first identifies the existing safety net providers and the
patient population in the area to determine whether there is any unmet
need. This step includes determining the size of the population with
incomes below 200 percent of the federal poverty level and the size of the
population without health insurance. HRSA then assesses the applicant’s
ability to fill any service gaps identified in the area. On rare occasions,
HRSA may also conduct a site visit to an area to collect additional
information to inform its decision. After its assessment, the agency may
determine that there is not sufficient unmet need in the area to warrant a
grant award or it may choose to award a grant despite service area
overlap if it determines that the level of unmet need exceeds the capacity
of existing providers.

Award Decisions. The Associate Administrator for Primary Health Care
in HRSA makes final award decisions.

•    Basis of Award Decisions. The Associate Administrator bases
     award decisions on the ranked application scores, while also taking
     into account a variety of factors such as whether the applicant is
     located in a sparsely populated rural area, the urban/rural mix of grant



25
  According to HRSA, the safety net providers included in its review are federally qualified
health centers, public hospitals/health department primary care clinics, critical access
hospitals with primary care capacity, and rural health clinics. Generally, critical access
hospitals are small hospitals—with no more than 25 inpatient beds—in rural communities.
Rural health clinics provide primary care services similar to those provided by health
centers in underserved rural communities; however, they are not required to provide the
range of services offered by health centers or to serve all individuals. Both critical access
hospitals and rural health clinics are certified as such by the Centers for Medicare &
Medicaid Services and receive enhanced payments for the services they provide to
Medicare and Medicaid patients. Rural health clinics receive enhanced payments that are
lower than the rate health centers receive.




Page 12                                                   GAO-12-504 Health Center Funding
      awards, 26 and the distribution of funds across the different types of
      health centers.

•     Required Funding Proportions for Designated Special
      Populations. The Public Health Service Act requires that HRSA
      ensure that a certain proportion of the total annual appropriation
      allocated to the Health Center Program is made available for grants
      serving each of the three designated special populations—migrant
      and seasonal farmworkers, homeless people, and residents of public
      housing. 27 These populations are particularly vulnerable and often
      have specific health and access problems. The proportions of funding
      that must be maintained are 8.6 percent for health centers serving
      migrant and seasonal farmworkers, 8.7 percent for health centers
      serving homeless people, and 1.2 percent for health centers serving
      residents of public housing. 28 These proportions were established
      when the Health Center Program was consolidated in 1996 and were
      generally maintained in subsequent legislation authorizing
      appropriations for the Health Center program. Most recently,
      legislation authorizing appropriations in 2008 and 2010 did not alter
      these proportions. 29




26
  HRSA is required to make awards so that 40 to 60 percent of patients expected to be
served reside in rural areas. 42 U.S.C. § 254b(k)(4).
27
    42 U.S.C. § 254b(r)(2)(B).
28
  In previous years, HRSA has taken actions when making New Access Point grant
awards to ensure that these proportions were met. For example, in fiscal year 2004, it
chose to award grants only to applicants requesting funding to serve migrant and
homeless populations. See GAO, Health Centers: Competition for Grants and Efforts to
Measure Performance Have Increased, GAO-05-645 (Washington, D.C.: July 13, 2005),
40.
29
  The proportional funding requirement was established when the Health Center Program
was consolidated in 1996 to maintain for fiscal year 1997 the proportions of funding that
previously were provided for these same designated populations when they were funded
through separate programs. HRSA was permitted to increase or decrease these
proportions by 10 percent for fiscal years 1998 and 1999, but during those years HRSA
maintained the 1997 proportions without adjusting them, and HRSA continued to award
grants in the same proportions in fiscal years 2000 and 2001. In 2002, legislation
authorizing appropriations for the Health Center Program required that the proportions be
maintained going forward.




Page 13                                                GAO-12-504 Health Center Funding
                       •     Required Consideration of Sparsely Populated Areas. The Public
                             Health Service Act also requires that HRSA give special consideration
                             to applicants in sparsely populated areas. 30 HRSA defines these as
                             areas with seven or fewer residents per square mile.

                       Funding for Grant Awards. For New Access Point grants, HRSA
                       approves funding for a 2-year project period; prior to fiscal year 2009, the
                       project period for New Access Point grants was up to 3 years. HRSA
                       provides an initial grant for the first year of the project; a health center
                       grantee obtains grants for each subsequent year in the project period
                       through a noncompetitive process in which the grantee must demonstrate
                       that it has made satisfactory progress in providing services. 31 A grantee
                       demonstrates its progress by submitting a progress report for HRSA’s
                       review. At the end of the New Access Point project period, new health
                       center grantees compete to continue receiving Health Center Program
                       funding to serve their service area; the project period for these
                       competitive continuing operations grants is typically 3 or 5 years. 32


                       HRSA revised its New Access Point award process for fiscal year 2011 to
HRSA Revised 2011      increase the emphasis on need and on the designated special
Award Process, and     populations. As a result of these changes and HRSA’s receiving less
                       fiscal year 2011 funding than it had anticipated, a high proportion of
Most New Access        grants went to health centers serving the designated special populations.
Point Grants Went to
Health Centers
Serving Special
Populations




                       30
                           42 U.S.C. § 254b(p).
                       31
                           Noncompetitive continuation funding is also contingent on the availability of funds.
                       32
                         These competitive continuing operations grants are known as Service Area Competition
                       grants.




                       Page 14                                                    GAO-12-504 Health Center Funding
HRSA Increased Weight       HRSA revised the New Access Point grant application and award process
Given to Need and           for fiscal year 2011. According to HRSA officials, it did so to better target
Emphasized Special          resources to communities with high need because it found that the
                            previous process did not adequately factor need into the application
Populations in 2011 Award   score, and because past applicants and grantees expressed concerns
Process                     about this issue. One step HRSA took was to increase the need score
                            from 10 to 30 points, out of a maximum of 100 base points. (See table 2.)
                            Twenty of the 30 points are available for applicant responses provided on
                            an attached form that documents barriers to access to care and various
                            health indicators in the proposed service area, and the remaining
                            10 points are available based on the applicant’s narrative describing
                            health care need. 33




                            33
                              Independent reviewers assess only the 10 points from the application’s narrative on
                            need. The 20 points from the attached form are based on data submitted by the applicant
                            and converted to predetermined point values as detailed in HRSA’s application guidance.




                            Page 15                                               GAO-12-504 Health Center Funding
Table 2: HRSA’s Scoring Criteria and Maximum Base Points Awarded for New Access Point Grant Applications, Fiscal Years
2008, 2009, and 2011

                                                                                       Maximum base points for     Maximum base points for
Scoring criterion        Description                                                  fiscal years 2008 and 2009          fiscal year 2011
Need                     The applicant’s description of health care need                                     10                            30
                         in the proposed service area.
Response                 The applicant’s proposal to respond to the                                          30                            20
                         health care need.
                                                                                                               a
Collaboration            The applicant’s plans for coordinating services                                   N/A                             10
                         with other providers in its proposed service area.
Evaluative measures      The applicant’s ability to measure its own                                          10                             5
                         performance.
Impact                   The applicant’s justification for requested                                         10                             5
                         funding and explanation of how it will increase
                         access to care.
Resources/Capabilities   The applicant’s organizational and financial plan                                   15                            10
                         and past accomplishments.
Support requested        The applicant’s budget.                                                             10                            10
Governance               The applicant’s plans for establishing a                                            10                            10
                         governing board.
                                                                                                                                            b
Readiness                The applicant’s ability to begin providing                                           5                           N/A
                         services.
                         Total                                                                              100                           100
                                            Source: GAO analysis of HRSA documents.

                                            Note: HRSA did not award any New Access Point grants in fiscal year 2010.
                                            a
                                             For fiscal year 2011 New Access Point applications, HRSA included a separate criterion for
                                            Collaboration that formerly was part of the Response criterion in fiscal year 2008 and 2009
                                            applications.
                                            b
                                             For fiscal year 2011 New Access Point applications, HRSA eliminated the Readiness criterion; some
                                            of the Readiness provisions became a part of the Resources/Capabilities criterion.


                                            HRSA also revised its award process in fiscal year 2011 to award extra
                                            points, which HRSA calls priority points, over the maximum 100 base
                                            points to applicants seeking to serve the three designated special
                                            populations and sparsely populated areas. HRSA did this to help it
                                            continue to meet the Public Health Service Act requirements regarding
                                            these populations. 34 In addition, HRSA decided to award extra points to
                                            applicants seeking to serve high-poverty areas to further increase the
                                            emphasis on need in the award process. This was the first time HRSA



                                            34
                                                42 U.S.C. §§ 254b(r)(2)(B), (p).




                                            Page 16                                                         GAO-12-504 Health Center Funding
awarded such extra points, and the application guidance described how
the points would be awarded, providing transparency for this aspect of the
process. (See table 3.) HRSA officials applied the extra points to
applicants’ base scores out of 100; 35 these adjusted scores were used to
update and finalize the rank order list of all applicants. HRSA awarded
from 5 to 10 extra points for serving one or more of the designated
special populations, 5 extra points for serving a sparsely populated area,
and up to 5 extra points for serving a high-poverty area.




35
  For each application, HRSA averages the scores assigned by each reviewer in the
panel. Depending on the number of applications it receives, HRSA may use multiple
review panels during a funding cycle. When this occurs, HRSA uses a statistical method
to adjust the scores for variation among different review panels. This process could result
in adjusted scores of over 100 before extra points have been awarded.




Page 17                                                  GAO-12-504 Health Center Funding
Table 3: Extra Points Awarded by HRSA to New Access Point Applicants in Fiscal Year 2011

                                                                                             Percentage of funding
                                                                                                to be used to serve
Population served                Description                                                   special populations       Extra points awarded
Designated special populations   The applicant intends to serve one or                                 ≥25% - 35%                                5
                                 more of the three designated special                                  >35% - 45%                                6
                                 populations—migrant and seasonal
                                 farmworkers, homeless, or public                                      >45% - 55%                                7
                                 housing—with at least 25 percent of                                   >55% - 65%                                8
                                 its HRSA funding.
                                                                                                       >65% - 75%                                9
                                                                                                             >75%                           10
                                                                                                                  a
Sparsely populated area          The applicant is located in a sparsely                                       N/A                                5
                                 populated area of seven or fewer
                                 people per square mile.
                                                                                        Percentage of population
                                                                                       at or below 100 percent of
                                                                                         the federal poverty level
High-poverty area                The applicant serves a high-poverty                                   >30% - 42%                                1
                                 area—over 30 percent of the population                              >42% - 46.6%                                2
                                 is at or below 100 percent of the federal
                                 poverty level.                                                     >46.6% - 50.9%                               3
                                                                                                     >50.9% - 56%                                4
                                                                                                             >56%                                5
                                            Source: GAO analysis of HRSA application guidance.

                                            Note: The Public Health Service Act requires that HRSA award a certain proportion of funds to serve
                                            each of the designated special populations, and that it give special consideration to applicants in
                                            sparsely populated areas when making awards.
                                            a
                                             Applicants that met the sparsely populated area description received 5 extra points. HRSA did not
                                            offer a range for this population.


                                            In fiscal year 2011, HRSA also used a method it had used before to
                                            produce its final list of applicants awarded funding—moving certain
                                            applicants proposing to use at least 25 percent of their grant funding to
                                            serve one or more of the designated special populations ahead of other
                                            applicants in the rank order list. HRSA used this method to ensure that it
                                            met the statutory requirement that the specified proportion of funds be
                                            provided to applicants serving the three designated special populations.
                                            HRSA’s application guidance in fiscal years 2008 and 2011 stated that
                                            HRSA would consider the need to meet proportional requirements for the
                                            designated special populations and would give special consideration to




                                            Page 18                                                             GAO-12-504 Health Center Funding
applicants serving them in making awards. 36 However, the guidance did
not specifically describe the method that HRSA would use to do so,
limiting the transparency of this aspect of the award process. HRSA had
used this method for the designated special populations in fiscal year
2008, as well as in the past. In addition, in fiscal year 2008 HRSA gave a
preference to applicants in sparsely populated areas, which moved these
applicants ahead of others in the rank order list; HRSA eliminated the
preference for the fiscal year 2011 funding cycle. 37 (See fig. 3 for a
depiction of the award process in fiscal year 2011.)




36
  HRSA took action in fiscal year 2011 to encourage applications from organizations
proposing to serve these special populations by highlighting the topic in its application
guidance, describing the new extra points in its national conference calls with potential
applicants to discuss grant opportunities, and working with partners such as national
organizations focused on migrant farmworkers and the homeless.
37
  HRSA did not use the method of moving applicants ahead of others in the rank order list
for any of these populations in fiscal year 2009.




Page 19                                                   GAO-12-504 Health Center Funding
Figure 3: HRSA’s New Access Point Grant Award Process in Fiscal Year 2011




                                       a
                                        During the application scoring process, HRSA averages the scores assigned by each independent
                                       reviewer in the panel. Depending on the number of applications it receives, HRSA may use multiple
                                       review panels during a funding cycle. When this occurs, HRSA uses a statistical method to adjust the
                                       scores for variation among different review panels. This process could result in adjusted scores of
                                       over 100 before extra points have been awarded. This illustration does not reflect this process.
                                       b
                                        For fiscal year 2011 New Access Point applications, grantees were able to score over the maximum
                                       100 base points by indicating that they intended to serve: any of the three designated special
                                       populations—migrant and seasonal farmworkers, homeless people, and residents of public housing—
                                       and sparsely populated or high-poverty areas.




                                       Page 20                                                       GAO-12-504 Health Center Funding
In part, HRSA needed to target the designated special populations when
awarding fiscal year 2011 New Access Point grants because of its fiscal
year 2009 award funding process and results. HRSA did not apply the
Public Health Service Act’s funding proportions to the New Access Point
grants awarded in fiscal year 2009. 38 Few of these grants went to
applicants proposing to serve the designated special populations. When
the fiscal year 2009 New Access Point project periods ended in fiscal
year 2011, continuing operations grants for the fiscal year 2009 grantees
were funded through PPACA. HRSA applied the required funding
proportions for designated special populations to the fiscal year 2011
grants made with PPACA funding, including grants for continued
operations and New Access Point grants. As a result, HRSA determined
that in fiscal year 2011 it needed to increase the share of New Access
Point grant funding dedicated to special populations to help the agency
meet the required funding proportions. This need influenced HRSA’s
decision to award extra points to applicants proposing to serve these
special populations. HRSA officials told us that they made the grants
funded through PPACA in the same manner they would have if they used
annual appropriations, and, as a result, had to take the required funding
proportions into account.

In addition to making application and award process changes in fiscal
year 2011, HRSA used a new tool in assessing service area overlap. In
2010, HRSA began using a web-based tool—UDS Mapper—in its
assessment of potential service area overlap between proposed delivery
sites and certain existing safety net providers, to better facilitate its ability
to target New Access Point awards to areas with need and to minimize
service area overlap. The agency uses UDS Mapper to identify existing
safety net providers, including hospitals, in the service area of an
applicant’s proposed delivery site. 39 UDS Mapper includes data from
federal sources such as HRSA’s UDS, the U.S. Census Bureau, and the
Centers for Medicare & Medicaid Services. However, UDS Mapper does
not include information about private physician practices, except for those




38
  HRSA determined at that time that the proportions were not required for grants made
with Recovery Act funding.
39
  In addition to safety net hospitals, UDS Mapper also includes the locations of non-safety
net hospitals.




Page 21                                                 GAO-12-504 Health Center Funding
                            participating in the National Health Service Corps program. 40 HRSA
                            officials told us this information is challenging to obtain because there is
                            no good data source on such providers and their patient populations.
                            HRSA officials said that in its service area overlap assessment, the
                            agency relies in part on information submitted by applicants about the
                            locations of private physician practices.


HRSA’s Increased Focus on   As a result of the increased focus on designated special populations and
Special Populations and     HRSA’s receiving less fiscal year 2011 funding than it had anticipated,
Receipt of Less Funding     HRSA awarded over 80 percent of fiscal year 2011 New Access Point
                            grants to applicants seeking to serve the designated special populations.
than It Had Anticipated     HRSA had announced that it expected to award about 350 New Access
Resulted in Large           Point grants in fiscal year 2011, based on increased funding from
Proportion of 2011 Awards   PPACA, but after the total amount of funding the agency anticipated
Going to Health Centers     being available was reduced, it instead awarded 67 grants, which
Serving These Populations   represented 8 percent of the 810 applications HRSA received. Of the
                            810 applications, 210—about 26 percent—proposed serving at least one
                            of the three designated special populations. HRSA officials said the
                            number of applications proposing to serve the special populations was
                            the largest the agency had ever received. Fifty-seven of the 67 successful
                            applicants proposed serving one or more of these populations. 41 Of the
                            10 remaining successful applicants, 3 received either one or two extra
                            points for serving a high-poverty area and an additional 1 received the
                            five extra points for being in a sparsely populated area.

                            All of the grantees receiving New Access Point awards in fiscal year 2011
                            had high scores that placed them at or near the top of the rank order list,
                            including the 57 grantees seeking to serve one or more designated



                            40
                              The National Health Service Corps program, administered by HRSA, offers school loan
                            repayment and scholarships to primary care providers who serve in underserved areas.
                            Awards are made to providers in locations designated as health professional shortage
                            areas.
                            41
                               An applicant can propose to use at least 25 percent of its grant to serve one or more of
                            the three designated special populations. In total, 39 percent of successful applicants in
                            fiscal year 2011 proposed serving the homeless population, 37 percent proposed serving
                            migrant and seasonal farmworkers, and 21 percent proposed serving residents of public
                            housing. Of the 57 applicants that proposed serving one or more of the special
                            populations, 9 received additional extra points for serving a high-poverty area and
                            2 received additional extra points for serving a sparsely populated area.




                            Page 22                                                  GAO-12-504 Health Center Funding
special populations. 42 However, because HRSA’s awarding of extra
points was not sufficient to ensure that it met its statutorily required
funding proportion for serving the migrant farmworker population, 13 of
the
57 grantees received awards by being moved ahead of other applicants
to meet the required proportion of funds awarded for serving this
population; all of these 13 grantees also served the general health center
population with a portion of their funding. Although these 13 grantees had
high-scoring applications, they were placed ahead of 177 other applicants
with the same or higher scores on the rank order list.

Another outcome of the fiscal year 2011 award process was that all New
Access Point grants went to applicants in 24 states. (See fig. 4.) Most of
these states had either 1 or 2 successful applicants; California had
20 successful applicants, or 30 percent of all grants. (See app. I.)
HRSA officials told us that if the program had been able to award the
$250 million for New Access Point grants officials had anticipated rather
than the $28.8 million the program did award, the geographic dispersion
of grants would have been different. For example, in one potential
scenario HRSA shared with us, applicants in 46 states and one territory
might have received funding. Although California applicants received
the largest share of all New Access Point grants in fiscal year 2011—and
10 percent of all health centers nationwide in 2010 were located in
California 43—the state has a low ratio of health centers to the population
in poverty, a measure of the availability of care for the medically
underserved. Compared to the other states, California ranks 36. 44 (See
app. II for information on the ratio of health centers to the population in
poverty, by state.)




42
  Successful applicants had final scores ranging from 95 to 114 points, including
applicants that were moved ahead of other applicants in the rank order list to meet
statutory requirements for the designated special populations.
43
  The total number of health centers is based on 2010 UDS data, which include health
centers funded through fiscal year 2009 and represent the states and the territories.
44
 The California poverty estimate is based on the 2006-2010 ACS.




Page 23                                                 GAO-12-504 Health Center Funding
Figure 4: HRSA New Access Point Grant Awards, Fiscal Year 2011, and Total Health Center Grantees, 2010




                                        Note: In this map, “state” refers to the 50 states, the District of Columbia, and Puerto Rico.
                                        a
                                         In fiscal year 2011, HRSA awarded 67 New Access Point grants—10 to establish new health centers
                                        and 57 to establish new delivery sites for existing grantees. In total, 108 delivery sites were funded
                                        through the 67 grants.
                                        b
                                         The total number of health center grantees includes the states and the territories. The counts are
                                        based on 2010 Uniform Data System (UDS) data—the most current available data on health center
                                        grantees—and include new health center grantees funded through fiscal year 2009, but do not
                                        include the 10 new health center grantees funded in fiscal year 2011.




                                        Page 24                                                           GAO-12-504 Health Center Funding
HRSA officials told us that they plan to award New Access Point grants in
fiscal year 2012, and instead of offering a new grant award competition,
they plan to use the fiscal year 2011 rank order list of applicants to make
about $145 million to $150 million in awards to approximately
220 applicants that were approved in that year but did not receive an
award. 45 HRSA had used a similar process for its fiscal year 2009 New
Access Point grant awards, when additional funding became available
through the Recovery Act. Specifically, HRSA funded 126 applicants that
had initially applied in fiscal year 2008 but had not received one of the
41 grants awarded that year. In 2008, all eligible applicants that did not
receive a grant were notified that their application would remain active for
a year, with the possibility of a grant award if HRSA received additional
funding. 46 The agency used the 2008 rank order list to provide grants to
additional applicants in 2009 without soliciting and reviewing new
applications, which enabled HRSA to quickly award Recovery Act
funding.

Overall, during fiscal years 2008 through 2011, HRSA awarded a total of
234 New Access Point grants, with 77 grants to establish new health
centers and 157 grants to fund existing health centers to establish new
delivery sites. (See fig. 5.) New Access Point applicants, regardless of
whether they are seeking to establish a new health center or a new
delivery site for an existing grantee, may propose to serve their area with
one or more delivery sites. In total, 355 new delivery sites were funded in
fiscal years 2008 through 2011. A greater percentage of grants—about 85
percent—went to existing health centers to establish one or more new
delivery sites in fiscal year 2011 than in fiscal years 2008 and 2009—
about 63 percent and 59 percent, respectively.




45
  HRSA officials told us that they plan to take into account the statutory funding
requirements for special populations when they award grants in fiscal year 2012.
46
  HRSA sent a comparable letter to all 2011 eligible applicants that did not receive a
grant.




Page 25                                                  GAO-12-504 Health Center Funding
Figure 5: Number of New Access Point (NAP) Grants Awarded by HRSA and
Delivery Sites the Grants Funded, by Fiscal Year




Note: HRSA did not make any New Access Point grant awards in fiscal year 2010.
a
 New Access Point grantees may have received funding for more than one delivery site. The grant
application asks applicants to provide information on each delivery site it proposes to use in serving
its target population.


HRSA awarded grants in the fiscal years we studied to health centers
serving areas with unemployment and poverty rates higher than the
national average. (See table 4.) HRSA also awarded grants in these fiscal
years in areas where patients were more likely to be uninsured or to
receive Medicaid, compared to the national average. Over 36 percent of
the population was below 200 percent of the federal poverty level in areas
receiving New Access Point grants in fiscal year 2011, compared with
about 31 percent nationwide. For example, of the grantees whose
applications we reviewed, one successful applicant in Brooklyn, New
York, applied for extra points for serving a high-poverty area because,
according to its application, more than 34 percent of the residents in the
local community live below 100 percent of the federal poverty level and



Page 26                                                          GAO-12-504 Health Center Funding
                                            more than 56 percent live below 200 percent of the federal poverty level.
                                            Another successful applicant, in rural North Carolina, serves three
                                            counties whose combined population has an average uninsured rate of
                                            20 percent, in comparison to the national rate of 15 percent.

Table 4: Selected Socioeconomic Characteristics for New Access Point Grantees’ Delivery Sites, in Aggregate, Compared to
National Average, Fiscal Years 2008, 2009, and 2011

                                                                      Fiscal year 2008                   Fiscal year 2009               Fiscal year 2011
                                                                   New Access Point                   New Access Point               New Access Point
                                                                      grantee delivery                   grantee delivery               grantee delivery
Selected characteristic              National average              sites, in aggregate                sites, in aggregate            sites, in aggregate
Percentage of population below
100 percent of the federal poverty
                 a
level, 2006-2010                                   13.5                                 14.8                               14.7                    16.8
Percentage of population below
200 percent of the federal poverty
                 a
level, 2006-2010                                   31.2                                 34.5                               34.3                    36.2
                               a
Unemployment rate, 2006-2010                         7.9                                  8.4                                  8.6                  8.6
Percentage of population
                     b
uninsured, 2008-2010                               15.0                                 19.7                               19.4                    17.1
Percentage of population with
                              b
Medicaid coverage, 2008-2010                       16.0                                 18.6                               18.3                    21.6
                                            Source: GAO analysis of U.S. Census Bureau American Community Survey (ACS) data.

                                            Note: For each grantee delivery site, we used the site’s zip code as a proxy for the location where the
                                            services would be provided, matched each zip code to the county where the majority of the zip code
                                            fell, and analyzed county-level data from the ACS. We used the 2006-2010 ACS when possible,
                                            which had the most recent data for all counties, and used the 2008-2010 ACS for selected
                                            characteristics for which data were not available in the 2006-2010 ACS; the 2008-2010 ACS had
                                            recent data only for counties with populations of 20,000 or more. The socioeconomic characteristics
                                            for which we used the 2008-2010 ACS did not include data for 31 counties, and these communities
                                            were subsequently excluded from our aggregate analysis.
                                            a
                                             The selected socioeconomic characteristic comes from the 2006-2010 ACS, which includes data for
                                            all counties.
                                            b
                                             The selected socioeconomic characteristic comes from the 2008-2010 ACS, which includes data for
                                            counties with populations of 20,000 or more.




                                            Page 27                                                                     GAO-12-504 Health Center Funding
                         Health centers in the communities we studied collaborate with other
Health Centers and       providers in their service area. Health centers and other providers said
Other Providers          they generally did not compete for patients, but we found greater potential
                         for competition in rural areas.
Reported
Collaboration and
Little or No
Competition, but
Rural Areas Have
Greater Potential for
Competition
Health Centers in        Health centers in the communities we studied collaborate with other
Communities We Studied   providers to meet the health care needs of patients in the health center’s
Collaborate with Other   service area. Officials we interviewed from each of the health centers
                         described at least one collaborative relationship with another provider—
Providers                such as local hospitals and specialty care providers—to provide access to
                         services not available through the health center. For example, officials
                         from one of the health centers told us they collaborate with specialists
                         such as a pediatric cardiologist, podiatrist, and ophthalmologist. In
                         addition, officials from several hospitals said that collaborating with health
                         centers is important because the centers help reduce the non-urgent use
                         of hospital emergency departments. 47 However, in some of the rural
                         communities we studied we also found that the relationship between the
                         health center and a nearby hospital was strained. For example, officials
                         from a hospital in one community we studied told us that the health center
                         did not always send the medical records of admitted patients in a timely
                         way.

                         HRSA has encouraged health centers to collaborate with other providers
                         in their service area. HRSA issued a Program Assistance Letter in fiscal
                         year 2011 that provides guidance to health centers on collaborating and
                         establishing contractual agreements with other providers to maximize



                         47
                           We previously reported on strategies health centers have implemented that may help
                         reduce the non-urgent use of emergency departments. See GAO, Hospital Emergency
                         Departments: Health Center Strategies That May Help Reduce Their Use, GAO-11-414R
                         (Washington, D.C.: Apr. 11, 2011).




                         Page 28                                              GAO-12-504 Health Center Funding
resources and efficiencies in their service area. For example, the letter
includes a list of suggested resources to help health centers maximize
collaboration with other safety net providers, such as the UDS Mapper
tool, PCAs, and HRSA project officers, who are responsible for
overseeing health centers and providing technical assistance.

For fiscal year 2011, HRSA added a collaboration component to the New
Access Point application scoring to encourage collaboration by health
centers. The fiscal year 2008 and 2009 applicants had been required to
include a written description of existing collaborative relationships with
other providers and had also been encouraged to submit letters of
support, but these were not scored separately. However, in fiscal year
2011, applicants could receive up to 10 points for submitting letters of
support—from other providers or community organizations—and a written
description of their existing and proposed efforts to establish collaborative
relationships with other providers in their proposed service area. During
the period included in our study, letters of support were written by, among
others, neighboring health centers, local hospitals, private physicians,
local government agencies, and PCAs. The letters of support generally
included similar types of information—such as a description of the specific
health care needs of the community and support for the applicant’s efforts
to care for underserved patients—regardless of the type of organization
expressing support. A few letters included information about specific
support the writer had provided or planned to provide to a health center,
such as pediatric or obstetrical care to health center patients.

PCAs often work with applicants and grantees to help them develop
collaborative relationships. Officials from several PCAs told us they used
applicants’ requests to the PCA for a letter of support as an opportunity to
assist them in developing relationships with other providers. For example,
officials from one PCA told us that for the fiscal year 2011 New Access
Point award cycle, they hosted over 20 town hall meetings in applicants’
communities to facilitate community involvement, collaboration, and
understanding of the Health Center Program. Several PCAs told us they
also work with potential applicants to determine whether it would be better
for them to combine efforts with an existing health center grantee or to
establish a new health center. Officials from one PCA explained that it
may be better for a new organization to become a satellite site of an
existing organization because existing organizations already have the
resources and infrastructure in place to operate a health center.




Page 29                                        GAO-12-504 Health Center Funding
                            Officials we interviewed identified various factors that contribute to
                            successful collaboration between health centers and other providers.
                            Officials from hospitals, other providers, and community groups said that
                            leadership commitment to collaboration, community participation in
                            developing a new health center, and other providers’ understanding of the
                            role of health centers are important factors that contribute to successful
                            collaboration. For example, officials from one hospital and a community
                            group in the same area noted improved collaboration as a result of a new
                            director coming to a health center. They told us that the previous director
                            was difficult to collaborate with and did not acknowledge the abilities of
                            other primary care providers to serve the safety net population. These
                            officials also said that the current relationship is much more collaborative
                            and that the health center and hospital share a board member and a
                            physician. In addition, officials from one PCA told us that a former state
                            government official had, over many years, discouraged hospitals from
                            collaborating on efforts to establish new health centers in their
                            communities, warning the hospitals that they could lose patients to the
                            health centers. Regarding the importance of community participation,
                            officials from one hospital said that the hospital led the effort to develop
                            the health center in its community, because previously physicians
                            voluntarily provided services for low-income patients two evenings a
                            week, and that effort was unsustainable.


Health Centers and Other    In the communities we studied, health centers and other providers in their
Providers Generally Did     service area generally do not compete for patients. HRSA and PCA
Not Encounter Significant   officials told us that health centers typically serve patients not treated
                            elsewhere, such as uninsured and Medicaid patients. Nationwide,
Competition for Patients,   37.5 percent of health center patients are uninsured, and for the eight
but Rural Areas Have        health centers we studied, the rate of uninsured patients averaged
Greater Potential for       30.4 percent. Similarly, Medicaid patients make up 38.5 percent of health
Competition                 center patients nationwide, and 35 percent in the health centers we
                            studied. Officials from most of the PCAs we spoke with said health
                            centers and other providers generally do not compete for uninsured
                            patients; some also noted that other providers rarely provide care for
                            uninsured patients. Similarly, officials from one health center told us that
                            Medicaid patients in their area had difficulty finding other providers that
                            would accept them. We have previously reported on the difficulties certain




                            Page 30                                        GAO-12-504 Health Center Funding
Medicaid patients, such as children, face in finding providers who are
willing to serve them. 48

HRSA’s service area overlap policy is designed to help the agency avoid
awarding grants for new delivery sites in areas where other safety net
providers are already serving the population’s need, and this may reduce
competition between health centers and other safety net providers. The
agency did not award grants to two applicants in fiscal years 2008 and
2009—one in each year—because awarding grants to these applicants
would have resulted in overlap with existing providers that had the
capacity to meet the needs of the area. HRSA officials told us that they
did not find any significant service area overlap during the fiscal year
2011 award cycle. They also said that since the agency increased its
emphasis on collaboration—and applicants have increased their outreach
in their communities—it has received fewer complaints from other safety
net providers about service area overlap than it received in prior years. 49

Because the health center grant covers, on average, about 20 percent of
a health center’s budget, health centers also must secure other funding,
such as by serving privately insured and Medicaid patients, to be
financially sustainable; 50 this necessity can occasionally result in
competition with and complaints from other providers in their service area.
For example, HRSA officials told us that some private dentists have
complained about competing with health centers for Medicaid patients;
the officials added that many patients might have to go without dental




48
  See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children but Have
Difficulty Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.: June 30,
2011). The report notes that physicians participating in Medicaid and the State Children’s
Health Insurance Program (CHIP)—a joint federal and state insurance program for certain
low-income, uninsured children whose family income is too high for Medicaid eligibility—
are generally more willing to accept privately insured children as new patients than
Medicaid and CHIP children. For example, about 79 percent were accepting all privately
insured children as new patients, while about 47 percent were accepting children in
Medicaid and CHIP as new patients.
49
  HRSA does not maintain records of all the complaints the agency receives that are
related to competition and service area overlap.
50
 See GAO, Community Health Centers: Adapting to Changing Health Care Environment
Key to Continued Success, GAO/HEHS-00-39 (Washington, D.C.: Mar. 10, 2000).




Page 31                                                 GAO-12-504 Health Center Funding
care if health centers did not offer these services, because some dentists
are unwilling to serve Medicaid patients. 51

Greater potential for competition exists in rural areas, where in general a
higher proportion of health center patients are insured and therefore more
likely to be a source of competition with other providers. Among the
health centers we studied, the rate of insured patients was higher in rural
areas than in urban areas. For example, more than 76 percent of patients
served by the health centers we studied in rural areas had some type of
insurance coverage, 52 compared to about 61 percent of the patients at the
health centers in urban areas.

Competition may exist between health centers and hospitals in rural
areas under certain circumstances. For example, a recent HRSA report
discussed the potential for competition between health centers and critical
access hospitals. 53 It suggested that duplicative services by health
centers and critical access hospitals (e.g., primary care and laboratory
services) could lead to detrimental competition, but that both types of
providers would benefit if they collaborated with each other instead of
competing. The report also said that health centers and critical access
hospitals can benefit from sharing resources that foster infrastructure,
access, and quality of care improvements. In addition, while most hospital
officials we interviewed said their hospitals do not compete with health
centers, officials from the hospitals in rural communities we studied told
us that health centers receive certain benefits that could lead to increased
competition with their local hospital. For example, officials from a few
hospitals in rural communities said that hospitals generally finance
construction or renovation costs on their own, but health centers may



51
  We previously reported that obtaining dental care for children remains a challenge
because most dentists treat few or no Medicaid and CHIP patients. See GAO, Oral
Health: Efforts Under Way to Improve Children’s Access To Dental Services, but
Sustained Attention Needed to Address Ongoing Concerns, GAO-11-96 (Washington,
D.C.: Nov. 30, 2010).
52
  Insurance coverage for patients served by the health centers we studied includes
coverage by Medicaid, CHIP, Medicare, other public insurance (such as state insurance
programs), and private insurance.
53
 HMS Associates, A Manual on Effective Collaboration Between Critical Access
Hospitals and Federally Qualified Health Centers, a report prepared for the U.S.
Department of Health and Human Services, Health Resources and Services
Administration, Office of Rural Health Policy (Getzville, N.Y.: April 2010).




Page 32                                                GAO-12-504 Health Center Funding
              receive grant funding for construction or renovations, which gives them a
              competitive advantage. They said the health centers might be better able
              to attract insured patients because of the improved facilities or might be
              able to attract staff because these grant funds free up resources that can
              be used for higher salaries.

              PCA and health center officials we interviewed more frequently raised
              concerns about the potential for competition between health centers and
              rural health clinics, in part because there are more similarities in the
              services they provide to patients in rural communities. 54 For example,
              several PCA officials told us that while there is no competition between
              health centers and rural health clinics for serving uninsured patients, they
              do compete for patients with insurance, including Medicaid and Medicare.
              Although patients in rural areas often face access barriers because of a
              shortage of providers, HRSA officials said the addition of a health center
              to an area can increase competition for insured patients when such
              patients seek treatment from a health center that is more conveniently
              located than other providers. HRSA officials also told us that they may
              award grants in rural areas where there are other providers if those
              providers do not fully meet the needs of the safety net population. For
              example, existing providers may not offer a sliding fee scale or be willing
              to serve uninsured people.


              Health centers funded by HRSA’s Health Center Program are a critical
Conclusions   component of the nation’s health care safety net, and New Access Point
              grants provide the agency with an important means for increasing access
              to health care for vulnerable populations—those who may have difficulty
              obtaining needed health care services because of financial or other
              limitations. To better target resources to communities with a high need for
              health center services, in fiscal year 2011 HRSA increased the weight of
              the criterion assessing the need for services in the New Access Point
              grant application. Certain populations—migrant and seasonal
              farmworkers, homeless people, and residents of public housing—are
              particularly vulnerable and often have specific health and access
              problems. In its 1996 consolidation of the Health Center Program,
              Congress began requiring that specific proportions of the program’s funds



              54
                Rural health clinics are not required to provide the full range of services that health
              centers must provide or to accept all patients regardless of their ability to pay.




              Page 33                                                    GAO-12-504 Health Center Funding
                     be used to serve these populations. Over the years, HRSA has taken
                     various actions to ensure it was meeting the required funding proportions.
                     During its fiscal year 2011 New Access Point award process, HRSA for
                     the first time gave extra points to applicants serving these designated
                     special populations. Congress also requires HRSA to give special
                     consideration to organizations serving sparsely populated areas, and in
                     fiscal year 2011 HRSA also gave extra points to applicants serving
                     sparsely populated and high-poverty areas. HRSA’s approach of
                     assigning these extra points—and its description in its application
                     guidance of how the points would be awarded—increased the
                     transparency of the grant award process compared to previous years.
                     However, because the extra points were not sufficient to ensure that
                     HRSA met its statutorily required funding proportion for migrant health
                     centers, HRSA also moved applicants serving this population ahead of
                     other applicants to ensure the required proportion was met, a step that
                     was not specifically described in the application guidance. Although
                     HRSA had used such an approach before, the effect in fiscal year 2011
                     was magnified by the combined effect of the reduction in program funding
                     and HRSA’s need to increase the share of funding awarded to the
                     designated special populations as a result of not applying the proportions
                     when awarding grants with Recovery Act funds in fiscal year 2009. HRSA
                     has periodically needed to take actions to meet its statutory obligations
                     and may face such a situation in the future. Evaluating the effectiveness
                     and transparency of the New Access Point grant award process it used
                     most recently could help HRSA identify lessons learned and possible
                     improvements that it could apply to future funding cycles to ensure the
                     most effective use of limited Health Center Program resources.


                     To ensure that in the future HRSA can effectively target limited Health
Recommendation for   Center Program resources through a transparent grant award process,
Executive Action     the Secretary of HHS should direct the Administrator of HRSA to evaluate
                     the fiscal year 2011 New Access Point grant award process to identify
                     lessons learned and potential improvements for future funding cycles,
                     including consideration of (1) the effect of the change in the need score
                     on targeting grants to communities with demonstrated need, (2) the effect
                     of actions taken to target grants to applicants proposing to serve the
                     designated special populations and sparsely populated and high-poverty
                     areas, and (3) the transparency of the process to applicants, Congress,
                     and the public. The Secretary should also direct the Administrator of
                     HRSA to complete the evaluation before the next New Access Point
                     funding opportunity is announced, make the results of the evaluation



                     Page 34                                       GAO-12-504 Health Center Funding
                  publicly available, and incorporate any improvements identified into the
                  award process for that funding opportunity.


                  We provided a draft of this report to HHS for review, and HHS provided
Agency Comments   written and oral comments. (HHS’s written comments are printed in
                  app. III.) HHS agreed with our findings and recommendation. In its
                  general comments, HHS restated and provided additional information on
                  our discussion of the Health Center Program and the New Access Point
                  grant process. HHS said that the increased score for need and use of
                  extra points improved the agency’s awarding of New Access Point grants
                  in fiscal year 2011 by targeting resources to higher need communities
                  and populations while still ensuring that organizations with sound health
                  center service delivery plans were funded. HHS also noted that increased
                  emphasis on collaboration contributed to health centers and other area
                  providers maximizing available resources while enhancing the service
                  delivery system to better address the community’s primary health care
                  needs. HHS said that these factors support HRSA’s goal to expand the
                  current safety net on a national basis by creating new delivery sites in
                  areas not currently served by federally funded health centers. Regarding
                  the GAO recommendation, HHS said HRSA is taking steps to evaluate
                  the effects of the change in the need score and other actions taken to
                  target grants, including for special populations. According to HHS, HRSA
                  plans to use the findings from its evaluation to improve the New Access
                  Point application guidance and will make its findings available to the
                  public. In its oral comments, HHS suggested that the title of the draft
                  report did not fully reflect the contents of the report, which provides a
                  detailed discussion of the changes HRSA made to its fiscal year 2011
                  New Access Point grant award process, including increased weight given
                  to need. We revised the report title to reflect this. HHS also provided
                  technical comments, and we incorporated information from its general
                  and technical comments as appropriate.


                  As agreed with your offices, unless you publicly announce the contents of
                  this report earlier, we plan no further distribution until 30 days from the
                  report date. At that time, we will send copies to the Secretary of HHS and
                  the Administrator of HRSA. The report also will be available at no charge
                  on the GAO website at http://www.gao.gov.




                  Page 35                                        GAO-12-504 Health Center Funding
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this report
are listed in appendix IV.




Debra A. Draper
Director, Health Care




Page 36                                       GAO-12-504 Health Center Funding
Appendix I: New Access Point Grant Awards,
                                        Appendix I: New Access Point Grant Awards,
                                        Fiscal Years 2008-2011, and Total Health
                                        Center Grantees, 2010


Fiscal Years 2008-2011, and Total Health
Center Grantees, 2010
                                        Table 5 shows the distribution of New Access Point grants awarded to
                                        applicants in each state and territory in fiscal years 2008 through 2011. It
                                        also shows the number of grantees in each state and territory and the
                                        percentage of total grantees in each state and territory in 2010.

Table 5: New Access Point Grant Awards, Fiscal Years 2008-2011, and Number and Percentage of Total Health Center
Grantees, 2010, by State and Territory

                                         New Access Point grant awards
                                                                                                         Total health center
                                                                                                                         a
                     Fiscal year 2008             Fiscal year 2009           Fiscal year 2011             grantees, 2010
State/Territory    Number     Percentage      Number      Percentage       Number        Percentage     Number     Percentage
Alabama                   0             0             3              2               2            3           14                1
Alaska                    0             0             1              1               1            1           25                2
American Samoa            0             0             1              1               0            0            1               <1
Arizona                   0             0             3              2               0            0           16                1
Arkansas                  0             0             3              2               0            0           12                1
California                9             22          12               10         20               30         118                10
Colorado                  2             5             1              1               2            3           15                1
Connecticut               1             2             4              3               1            1           13                1
Delaware                  0             0             1              1               1            1            4               <1
District of
Columbia                  0             0             0              0               0            0            5               <1
Federated States
of Micronesia             0             0             0              0               0            0            2               <1
Florida                   5             12            8              6               2            3           44                4
Guam                      0             0             0              0               0            0            1               <1
Georgia                   1             2             4              3               0            0           27                2
Hawaii                    0             0             0              0               0            0           14                1
Idaho                     0             0             0              0               1            1           11                1
Illinois                  2             5             4              3               2            3           36                3
Indiana                   0             0             2              2               0            0           19                2
Iowa                      0             0             1              1               0            0           13                1
Kansas                    0             0             2              2               2            3           13                1
Kentucky                  0             0             4              3               0            0           19                2
Louisiana                 1             2             7              6               0            0           24                2
Maine                     0             0             2              2               0            0           18                2
Marshall Islands          0             0             0              0               0            0            1               <1




                                        Page 37                                                 GAO-12-504 Health Center Funding
                                      Appendix I: New Access Point Grant Awards,
                                      Fiscal Years 2008-2011, and Total Health
                                      Center Grantees, 2010




                                      New Access Point grant awards
                                                                                                       Total health center
                                                                                                                       a
                   Fiscal year 2008             Fiscal year 2009           Fiscal year 2011             grantees, 2010
State/Territory   Number    Percentage      Number      Percentage       Number        Percentage     Number     Percentage
Maryland               1              2             0              0               1            1           16                1
Massachusetts          0              0             1              1               0            0           36                3
Michigan               0              0             2              2               0            0           29                3
Minnesota              0              0             1              1               0            0           15                1
Mississippi            0              0             1              1               0            0           21                2
Missouri               0              0             2              2               1            1           21                2
Montana                1              2             1              1               0            0           15                1
Nebraska               1              2             0              0               0            0            6                1
Nevada                 0              0             1              1               0            0            2               <1
New Hampshire          0              0             1              1               0            0           10                1
New Jersey             1              2             2              2               1            1           20                2
New Mexico             1              2             0              0               1            1           15                1
New York               3              7             6              5               8           12           51                5
North Carolina         1              2             2              2               2            3           27                2
North Dakota           0              0             0              0               0            0            4               <1
Northern
Mariana Islands        0              0             0              0               0            0            0                0
Ohio                   2              5             5              4               2            3           32                3
Oklahoma               1              2             6              5               0            0           17                2
Oregon                 1              2             0              0               3            4           25                2
Palau                  0              0             0              0               0            0            1               <1
Pennsylvania           0              0             6              5               2            3           35                3
Puerto Rico            0              0             2              2               2            3           19                2
Rhode Island           0              0             2              2               0            0            8                1
South Carolina         0              0             0              0               0            0           20                2
South Dakota           0              0             1              1               1            1            6                1
Tennessee              1              2             2              2               1            1           23                2
Texas                  0              0           11               9               4            6           64                6
Utah                   1              2             0              0               0            0           11                1
Vermont                1              2             1              1               0            0            8                1
Virgin Islands         0              0             0              0               0            0            2               <1
Virginia               2              5             5              4               0            0           25                2
Washington             2              5             1              1               4            6           25                2
West Virginia          0              0             1              1               0            0           28                2
Wisconsin              0              0             0              0               0            0           16                1




                                      Page 38                                                 GAO-12-504 Health Center Funding
                                       Appendix I: New Access Point Grant Awards,
                                       Fiscal Years 2008-2011, and Total Health
                                       Center Grantees, 2010




                                        New Access Point grant awards
                                                                                                                      Total health center
                                                                                                                                      a
                   Fiscal year 2008                Fiscal year 2009                  Fiscal year 2011                  grantees, 2010
State/Territory   Number    Percentage          Number          Percentage        Number        Percentage           Number        Percentage
Wyoming                0               0                 0                   0            0                  0               6              1
Total                 41              100             126                   100          67               100            1124             100
                                       Source: GAO analysis of HRSA data.

                                       Note: In this table, “state” refers to the 50 states, the District of Columbia, and Puerto Rico.
                                       Percentages do not total 100 due to rounding.
                                       a
                                       The number of total health centers comes from HRSA’s UDS. The most recently available UDS data
                                       were for calendar year 2010.




                                       Page 39                                                            GAO-12-504 Health Center Funding
Appendix II: Ratio of Health Center Grantees
              Appendix II: Ratio of Health Center Grantees to
              Population Living in Poverty, by State, 2010



to Population Living in Poverty, by State,
2010
              We calculated the ratio of total health center grantees to the population
              living in poverty for every state, a measure of the availability of care for
              the medically underserved. We then ranked them in order from highest to
              lowest ratio. (See table 6.)

              Table 6: Ratio of Health Center Grantees to Population Living in Poverty, by State,
              2010

                                                                Ratio of health centers to population
               Ranking        State                                    living in poverty (per 100,000)
               1              Alaska                                                            38.91
               2              Vermont                                                           11.99
               3              Wyoming                                                           11.47
               4              Hawaii                                                            11.23
               5              Maine                                                             11.09
               6              Montana                                                           10.86
               7              New Hampshire                                                     10.05
               8              West Virginia                                                      9.02
               9              Rhode Island                                                       6.48
               10             South Dakota                                                       5.67
               11             Massachusetts                                                      5.47
               12             Idaho                                                              5.41
               13             North Dakota                                                       5.10
               14             District of Columbia                                               4.91
               15             Oregon                                                             4.84
               16             Delaware                                                           4.26
               17             New Mexico                                                         4.15
               18             Connecticut                                                        4.14
               19             Utah                                                               3.88
                                     a
               20             Iowa                                                               3.84
                                         a
               21             Kansas                                                             3.84
               22             Mississippi                                                        3.48
               23             Maryland                                                           3.36
               24             Washington                                                         3.21
               25             Virginia                                                           3.20
               26             Louisiana                                                          3.08
               27             Oklahoma                                                           2.95
               28             Nebraska                                                           2.91
               29             South Carolina                                                     2.79




              Page 40                                                GAO-12-504 Health Center Funding
Appendix II: Ratio of Health Center Grantees to
Population Living in Poverty, by State, 2010




                                                                   Ratio of health centers to population
    Ranking         State                                                 living in poverty (per 100,000)
    30              Minnesota                                                                         2.77
    31              Missouri                                                                          2.62
    32              Kentucky                                                                          2.58
                                 a
    33              Colorado                                                                          2.57
                                     a
    34              New Jersey                                                                        2.57
    35              Wisconsin                                                                         2.51
    36              California                                                                        2.40
    37              Arkansas                                                                          2.39
    38              Pennsylvania                                                                      2.32
                             a
    39              Illinois                                                                          2.29
                                     a
    40              Tennessee                                                                         2.29
    41              Indiana                                                                           2.26
    42              Ohio                                                                              2.02
    43              Michigan                                                                          2.01
    44              North Carolina                                                                    1.93
    45              New York                                                                          1.92
    46              Georgia                                                                           1.87
    47              Alabama                                                                           1.78
    48              Florida                                                                           1.76
    49              Arizona                                                                           1.71
    50              Texas                                                                             1.61
    51              Puerto Rico                                                                       1.13
    52              Nevada                                                                            0.65
Source: GAO analysis of HRSA and U.S. Census Bureau American Community Survey (ACS) data.

Notes: In this table, “state” refers to the 50 states, the District of Columbia, and Puerto Rico. ACS
poverty data were not available for the territories. The population living in poverty is that below
100 percent of the federal poverty level, using population estimates from the 2006-2010 ACS. The
number of health centers is from HRSA’s UDS and was last updated with calendar year 2010 data.
a
In cases where states had the same ratio, they are listed in alphabetical order.




Page 41                                                                    GAO-12-504 Health Center Funding
Appendix III: Comments from the
             Appendix III: Comments from the Department
             of Health and Human Services



Department of Health and Human Services




             Page 42                                      GAO-12-504 Health Center Funding
Appendix III: Comments from the Department
of Health and Human Services




Page 43                                      GAO-12-504 Health Center Funding
Appendix III: Comments from the Department
of Health and Human Services




Page 44                                      GAO-12-504 Health Center Funding
Appendix III: Comments from the Department
of Health and Human Services




Page 45                                      GAO-12-504 Health Center Funding
Appendix III: Comments from the Department
of Health and Human Services




Page 46                                      GAO-12-504 Health Center Funding
Appendix IV: GAO Contact and Staff
                             Appendix IV: GAO Contact and
                             Staff Acknowledgments



Acknowledgments

                  Debra A. Draper, (202) 512-7114 or draperd@gao.gov
GAO Contact
                  In addition to the contact named above, Helene F. Toiv, Assistant
Acknowledgments   Director; Giselle Hicks; Coy J. Nesbitt; Roseanne Price; Julie T. Stewart;
                  E. Jane Whipple; Jennifer Whitworth; and Monique Williams made key
                  contributions to this report.




                  Page 47                                        GAO-12-504 Health Center Funding
Related GAO Products
                       Related GAO Products




             Health Center Program: Improved Oversight Needed to Ensure Grantee
             Compliance with Requirements. GAO-12-546. Washington, D.C.: May 29,
             2012.

             Hospital Emergency Departments: Health Center Strategies That May
             Help Reduce Their Use. GAO-11-643T. Washington, D.C.: May 11, 2011.

             Hospital Emergency Departments: Health Center Strategies That May
             Help Reduce Their Use. GAO-11-414R. Washington, D.C.: April 11,
             2011.

             Health Resources and Services Administration: Many Underserved Areas
             Lack a Health Center Site, and Data Are Needed on Service Provision at
             Sites. GAO-09-667T. Washington, D.C.: April 30, 2009.

             Health Resources and Services Administration: Many Underserved Areas
             Lack a Health Center Site, and the Health Center Program Needs More
             Oversight. GAO-08-723. Washington, D.C.: August 8, 2008.

             Health Centers: Competition for Grants and Efforts to Measure
             Performance Have Increased. GAO-05-645. Washington, D.C.: July 13,
             2005.

             Community Health Centers: Adapting to Changing Health Care
             Environment Key to Continued Success. GAO/HEHS-00-39. Washington,
             D.C.: March 10, 2000.




(290951)
             Page 48                                    GAO-12-504 Health Center Funding
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