oversight

Health Centers: Trends in Revenue and Grants Supported by the Community Health Center Fund

Published by the Government Accountability Office on 2019-07-01.

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

             United States Government Accountability Office
             Report to the Committee on Finance,
             U.S. Senate




             HEALTH CENTERS
May 2019




             Trends in Revenue
             and Grants Supported
             by the Community
             Health Center Fund




GAO-19-496
                                              May 2019

                                              HEALTH CENTERS
                                              Trends in Revenue and Grants Supported by the
                                              Community Health Center Fund
Highlights of GAO-19-496, a report to the
Committee on Finance, U.S. Senate




Why GAO Did This Study                        What GAO Found
In 2017, nearly 1,400 health centers          Health centers’ revenue more than doubled from calendar years 2010 through
provided care to more than 27 million         2017, from $12.7 billion to $26.3 billion. Health centers’ revenue comes from a
people, regardless of their ability to pay.   variety of sources, including reimbursements from Medicaid, Medicare, private
Health centers were established to            insurance, and federal and state grants. While total health center revenue
increase the availability of primary and      increased from 2010 through 2017, the share of revenue from each source
preventive health services for low-           changed in different ways. In particular, revenue from federal and state grants
income people living in medically             decreased from 38.0 percent of total revenue in 2010 to about 30.2 percent of
underserved areas. Health centers rely        total revenue in 2017 while reimbursements from Medicaid, Medicare, and
on revenue from a variety of public and       private insurance increased. Over the same time period, the number of health
private sources, including revenue from       centers increased from 1,124 centers in 2010 to 1,373 centers in 2017. In
CHCF grants. HRSA began awarding
                                              addition, the number of patients served over the same time period increased by
grants funded by the CHCF in fiscal
                                              7.7 million patients, from 19.5 million to 27.2 million.
year 2011.
GAO was asked to review the sources
                                          GAO’s analysis of Health Resources and Services Administration (HRSA) data
and amounts of health center revenue.     shows that from fiscal years 2011 through 2017, health centers received
This report describes (1) trends in healthapproximately $15.8 billion in federal grants funded by the Community Health
centers’ revenue and (2) the purposes     Center Fund (CHCF), which was established by the Patient Protection and
for which CHCF grants have been           Affordable Care Act in 2010. Of this total amount, 79.7 percent—or $12.6
awarded.                                  billion—was awarded for the purpose of maintaining operations at existing health
                                          centers (see figure). According to HRSA officials, these CHCF grants are used to
GAO analyzed HRSA data collected          fill the gap between what it costs to operate a health center and the amount of
from health centers and compiled in its
                                          revenue a health center receives. As such, officials explained, the awards are a
Uniform Data System to identify the
                                          primary means through which health centers provide health care services that
sources and amounts of revenue health
centers received from 2010 through
                                          may be uncompensated, including services for uninsured patients or services not
2017, the most recent data at the time of typically reimbursed by other payers, such as adult dental care. The remaining
GAO’s analysis. GAO also reviewed         $3.2 billion in CHCF grants were made to increase the amount of services
HRSA grant documentation for grants       provided at existing health centers; increase the number of health centers and
funded by the CHCF for fiscal years       sites; and other special initiatives, such as implementing health information
2011-2017—the most recent data at the technology.
time of GAO’s analysis—including
                                          Total Grant Funding from the Community Health Center Fund, Fiscal Years 2011–2017
information on the award amount and
purpose of the grant, and reviewed
published studies that described the
purposes for which CHCF grants have
been made. Additionally, GAO
interviewed HRSA officials, authors of
the published studies, and an
association representing health centers.
GAO provided a draft of this report to
HHS. HHS provided technical
comments, which GAO incorporated as
appropriate.




View GAO-19-496. For more information,
contact Jessica Farb at (202) 512-7114 or
farbj@gao.gov.


                                              ______________________________________ United States Government Accountability Office
Contents


Letter                                                                                  1
               Background                                                               4
               While Health Centers’ Revenue Doubled from 2010 through 2017,
                 the Share of Revenue from Grants Decreased                             7
               HRSA Awarded CHCF Grants Primarily to Support Ongoing
                 Operations and Services at Health Centers                            12
               Agency Comments                                                        19

Appendix I     Information on Health Centers and Patients Served                      20



Appendix II    Sources and Amounts of Revenue for Health Centers, Calendar
               Years 2010 through 2017                                                24



Appendix III   Community Health Center Fund Awards for Health Centers, Fiscal
               Years 2011 through 2017                                                26



Appendix IV    GAO Contact and Staff Acknowledgments                                  29


Tables
               Table 1: Selected Primary Health and Supplemental Services
                       Provided at Health Centers                                       6
               Table 2: Community Health Center Fund New Access Point (NAP)
                       Awards                                                         15
               Table 3: Proportion of Health Center Patients Who are Uninsured
                       or Covered by Medicaid, Medicare, or Private Insurance,
                       Calendar Years 2010 through 2017                               23
               Table 4: Health Center Revenue Sources by Year, Calendar
                       Years 2010 through 2017                                        24
               Table 5: Community Health Center Fund (CHCF) Awards for
                       Health Centers, Fiscal Years (FY) 2011 through FY 2017         26




               Page i                                  GAO-19-496 Community Health Centers
Figures
          Figure 1: Appropriations for Section 330 Federal Grants, Fiscal
                   Years 2011–2017                                                  5
          Figure 2: Health Centers’ Revenue, Calendar Years 2010–2017               8
          Figure 3: Health Center Revenue Sources and Amounts In
                   Calendar Years 2010 and 2017                                     9
          Figure 4: Percentage of Health Center Revenue from Grants,
                   Calendar Years 2010 and 2017                                   10
          Figure 5: Share of Health Center Revenue from Section 330
                   Grants, by State, Calendar Year 2017                           11
          Figure 6: Total Health Resources and Services Administration
                   (HRSA) Section 330 Grants Funded by the Community
                   Health Center Fund (CHCF), Fiscal Years 2011–2017              12
          Figure 7: Locations of New Health Center Sites, Fiscal Years
                   2011–2017                                                      17
          Figure 8: Number and Location of Health Centers, Calendar Year
                   2017                                                           21
          Figure 9: Growth in Health Centers and Sites, 2010–2017                 22
          Figure 10: Growth in Number of Patients Served at Health
                   Centers, 2010–2017                                             23




          Page ii                                  GAO-19-496 Community Health Centers
Abbreviations

CHCF              Community Health Center Fund
HHS               Department of Health and Human Services
HRSA              Health Resources and Services Administration
NAP               New Access Point
PHSA              Public Health Service Act
PPACA             Patient Protection and Affordable Care Act
UDS               Uniform Data System




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Page iii                                            GAO-19-496 Community Health Centers
                       Letter




441 G St. N.W.
Washington, DC 20548




                       May 30, 2019

                       The Honorable Chuck E. Grassley
                       Chairman
                       The Honorable Ron Wyden
                       Ranking Member
                       Committee on Finance
                       United States Senate

                       Health centers were established to increase the availability of primary and
                       preventive health care services for low-income people living in medically
                       underserved areas. These outpatient facilities receive federal funding and
                       serve as an important safety net provider as the majority of their patients
                       are uninsured or enrolled in Medicaid. The majority of health centers
                       serve the general population within a designated area, while other types
                       of health centers provide care to more specific populations, including the
                       homeless, residents of public housing, and migrant and seasonal
                       farmworkers. 1 Regardless of type, health centers are required to provide
                       health care to individuals who are members of the health center’s target
                       population or to all individuals located in the health center’s service area,
                       regardless of their ability to pay. In some communities, these centers may
                       be the only primary care providers available to certain vulnerable
                       populations. In 2017, nearly 1,400 health centers operated more than
                       11,000 sites that provided care to more than 27 million people in the
                       United States, including 1 in 9 children; 1 in 5 rural residents; 1 in 3 living
                       in poverty; and more than 355,000 veterans. 2

                       Health centers rely on revenue from a variety of public and private
                       sources, including federal, state, and local governments; and payments
                       for services from Medicaid, Medicare, private insurance, and patients.
                       This revenue includes grants awarded by the Health Resources and
                       Services Administration (HRSA) through its Health Center Program. In
                       2010, the Patient Protection and Affordable Care Act (PPACA)
                       established an additional source of funding for the Health Center



                       1
                        In this report, the term “health centers” refers to all types of health centers unless
                       otherwise indicated.
                       2
                        Most health centers operate facilities at several locations—referred to as sites.




                       Page 1                                                 GAO-19-496 Community Health Centers
Program’s grants: the Community Health Center Fund (CHCF). 3 The
CHCF supports a variety of grants to health centers for health care
services for low-income populations.

You asked us to review health centers’ revenue, including its sources and
uses. In this report we describe

1. trends in health centers’ revenue from 2010 through 2017; and
2. the purposes for which CHCF grants have been awarded.

To describe trends in health centers’ revenue, we analyzed data from
HRSA’s Uniform Data System for calendar years 2010 through 2017, the
most recent data at the time of our analysis. 4 These data include data
reported annually by health centers on their patient-related revenue, such
as payments from Medicaid and Medicare, as well as other revenue
provided from HRSA grants, other federal grants, and non-federal grants
or contracts. All revenue data are reported as nominal dollars. We also
interviewed HRSA officials about the sources of revenue provided to
health centers since 2010, including how those sources may or may not
have changed over time.

To describe the purposes for which CHCF grants have been awarded, we
reviewed HRSA policy and grant documentation, such as HRSA grant
funding announcements that outline the purpose of the grants funded by
the CHCF. We also reviewed a list provided by HRSA that includes all 52
awards funded through 28 CHCF grants from fiscal years 2011 through
2017. This list included the award purpose and funding amount. 5 Each

3
 Pub. L. No. 111-148, § 10503, 124 Stat. 119, 1004 (2010), as amended by Health Care
and Education Reconciliation Act of 2010, Pub. L. No. 111-152, § 2303, 124 Stat. 1029,
1083 (2010); Medicare Access and CHIP Reauthorization Act of 2015, Pub. L. No. 114-
10, § 221, 129 Stat. 87, 154 (2015); Bipartisan Budget Act of 2018, Pub. L. No. 115-123, §
50901, 132 Stat. 64, 282 (2018) (codified at 42 U.S.C. § 254b-2). The CHCF also
supports the National Health Service Corps, a scholarship and loan repayment program
that places providers in underserved areas, including at health centers. From fiscal year
2012 through fiscal year 2018, the CHCF was that program’s sole funding source.
4
 The Uniform Data System (UDS) includes data reported annually by health center grant
awardees. UDS consists of data relating to patients, visits, staffing and utilization, quality
of care indicators, health outcomes and disparities, financial costs, and revenue. UDS
revenue is the gross receipts on a cash basis for each year collected by health centers,
regardless of the period in which the paid for services were rendered. Data are reported in
UDS by calendar year, rather than fiscal year.
5
 Some grants were funded in multiple fiscal years.




Page 2                                                GAO-19-496 Community Health Centers
grant could represent multiple awards to health centers. To corroborate
the list of awards provided by HRSA, we reviewed descriptions of the
grants contained in the funding opportunity announcements and grant
award announcements for a random sample of 10 percent of the 52
awards made, including those for the largest grants. We also analyzed
information on health center sites reported by health centers to HRSA—
known as Form 5 B Service Site data—to determine the number and
location of new health centers from fiscal years 2011 through 2017. 6
These data show the location of each health center site. We reviewed
some published studies identified through web searches that describe
how the CHCF has been used since fiscal year 2011, such as studies
published by the Congressional Research Service and George
Washington University’s Milken Institute, and we interviewed the studies’
authors. 7 Lastly, we interviewed HRSA officials and the National
Association of Community Health Centers—an organization representing
health centers—about the use of CHCF grant funding.

We assessed the reliability of the Uniform Data System and Form 5 B
Service Site data used in this report by reviewing relevant documentation
and interviewing officials knowledgeable about the data. Based on these
steps, we found the data were sufficiently reliable for the purpose of our
reporting objectives.

We conducted this performance audit from November 2018 to May 2019
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.



6
 We analyzed HRSA’s Federal Office of Rural Health Policy eligible zip code data files to
determine whether the location of a new site was in a rural area. For more information see
https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. We assessed the
reliability of this data and determined they were sufficiently reliable for the purpose of our
reporting objectives.
7
 See for example, Congressional Research Service, The Community Health Center Fund:
In Brief (Washington, D.C., July 5, 2018); Congressional Research Service, Federal
Health Centers: An Overview (Washington, D.C., May 19, 2017); and P. Shin, J. Sharac,
R. Gunsalus, and S. Rosenbaum, Policy Research Brief #49: What are the Possible
Effects of Failing to Extend the Community Health Center Fund?” September 21, 2017.




Page 3                                                GAO-19-496 Community Health Centers
             The federal Health Center Program was established in the mid-1960s in
Background   an effort to help low-income individuals gain access to health care
             services. The Health Center Program, authorized in Section 330 of the
             Public Health Service Act, is administered by HRSA’s Bureau of Primary
             Health Care and makes grants—known as Section 330 grants—to four
             types of health centers that primarily serve low-income populations:

             1. Community health centers. These health centers serve the general
                population with limited access to health care. They are required to
                provide primary health services to all residents who reside in the
                center’s service area. More than three-quarters of health centers are
                community health centers.
             2. Health centers for the homeless. These health centers provide
                primary care services to individuals who lack permanent housing or
                live in temporary facilities or transitional housing. These centers are
                required to provide substance abuse services and supportive services
                targeted to the homeless population.
             3. Health centers for residents of public housing. These health centers
                provide primary health care services to residents of public housing
                and individuals living in areas immediately accessible to public
                housing.
             4. Migrant health centers. These health centers provide primary care to
                migratory agricultural workers (individuals whose principal
                employment is in agriculture and who establish temporary residences
                for work purposes) and seasonal agricultural workers (individuals
                whose principal employment is in agriculture on a seasonal basis but
                do not migrate for the work).
             HRSA’s Section 330 grants are funded by a combination of discretionary
             appropriations and, since 2011, mandatory appropriations provided from
             the CHCF. 8 From fiscal years 2010 through 2017, total funding
             appropriated for Section 330 grants—which includes funding from
             discretionary appropriations and the CHCF—increased from about $2.1
             billion to $4.9 billion (see fig. 1).



             8
              Discretionary appropriations are generally made through the annual appropriations
             process. Mandatory appropriations are generally created and funded in the same law in a
             multiyear or permanent basis and not through the annual appropriations process.
             Although created in 2010 under PPACA, the first year of CHCF funding was fiscal year
             2011.




             Page 4                                            GAO-19-496 Community Health Centers
Figure 1: Appropriations for Section 330 Federal Grants, Fiscal Years 2011–2017




According to HRSA data, approximately 70 percent of appropriations for
Section 330 awards in fiscal year 2017—or about $3.5 billion—were
funded by the CHCF. HRSA officials also told us that the total amount of
CHCF appropriations may differ from the total amount of awards funded
because, for example, appropriations may be (1) used for administrative
costs, (2) reduced because of sequestration, or (3) carried over between
fiscal years.

Health centers are required to provide comprehensive primary health
services, including preventive, diagnostic, treatment, and emergency
health services. (See table 1.) All services that health centers provide
must be available to patients at the center regardless of patient payment
source or ability to pay and must be available (either directly or under a
referral arrangement) to patients at all health center service sites.
Services are provided by clinical staff—including physicians, nurses,
dentists, and mental health and substance abuse professionals—or
through contracts or cooperative arrangements with other providers.




Page 5                                         GAO-19-496 Community Health Centers
Table 1: Selected Primary Health and Supplemental Services Provided at Health Centers

 Category                                         Examples of services provided
 Primary health services                          Primary health services include basic health services including those related to family
                                                  medicine, internal medicine, pediatrics, obstetrics, or gynecology.
 Preventive health services                       Required preventive services include
                                                  •  Well-child care
                                                  •  Prenatal and perinatal care
                                                  •  Immunizations
                                                  •  Voluntary family planning
                                                  •  Preventive dental care
 Emergency medical services                       Required services that are provided through defined arrangements with outside providers for
                                                  medical emergencies during and after centers regularly scheduled hours.
 Enabling services                                Required services include, but are not limited to
                                                  •  Translation services
                                                  •  Health education
                                                  •  Transportation for individuals residing in a center’s service area who have difficulty
                                                     accessing the center
 Supplemental services                            Additional services that are not primary health services but are appropriate to meet the health
                                                                                                                                                  a
                                                  needs of the service population, such as behavioral health and environmental health services.
                                                  Health centers are not required to provide these services.
Source: Public Health Service Act. | GAO-19-496
                                                       a
                                                        Mental health services include the services of psychiatrists, psychologists, and other appropriate
                                                       mental health professionals. Environmental services can include the detection and alleviation of
                                                       unhealthful conditions associated with water supply and lead exposure, among other things.


                                                       In addition to the services they provide, health centers are also required
                                                       to document the unmet health needs of the residents in their service area
                                                       and to periodically review their service areas to determine whether the
                                                       services provided are available and accessible to area residents promptly
                                                       and as appropriate. Health centers also must 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. 9 HRSA determines whether health center grantees meet




                                                       9
                                                        HRSA may waive the patient majority board composition governance requirement for
                                                       certain centers, such as health centers for the homeless, upon a showing of good cause.




                                                       Page 6                                                     GAO-19-496 Community Health Centers
                        these and other health center program requirements when making award
                        determinations. 10


                        Our analysis shows that total revenue received by health centers
While Health Centers’   nationwide more than doubled from calendar years 2010 through 2017—
Revenue Doubled         from about $12.7 billion to $26.3 billion (see fig. 2). 11 Over the same time
                        period, both the number of health centers and the number of patients
from 2010 through       served also increased. The number of health centers increased from
2017, the Share of      1,124 centers in 2010—operating 6,949 sites—to 1,373 centers in 2017—
                        operating 11,056 sites. 12 In addition, the total number of patients served
Revenue from Grants     at health centers over the same time period increased by 7.7 million
Decreased               patients, from 19.5 million to 27.2 million. See appendix I for additional
                        information.




                        10
                           In 2017 HRSA issued the Health Center Program Compliance Manual which outlines 18
                        program requirements. The Health Center Program Compliance Manual is the
                        consolidated resource to assist in understanding and demonstrating compliance with the
                        Health Center Program requirements found in the Health Center Program’s authorizing
                        legislation and implementing regulations, as well as certain applicable grants regulations.
                        For information on the Health Center Program Compliance Manual see
                        https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html..
                        11
                         In real terms, the growth in revenue is less. Specifically, the inflation-adjusted increase
                        was about 85 percent instead of 107 percent.
                        12
                          In addition to these totals, some organizations choose not to apply for funding under the
                        Health Center Program, but seek to be recognized by HRSA as health center look-alikes.
                        With this recognition, they may become eligible to receive other federal benefits, such as
                        enhanced Medicare and Medicaid payment rates and reduced drug pricing. In 2017, there
                        were 56 look-alikes that served 721,922 patients, a decrease from 93 look-alikes that
                        served 951,242 patients in 2012. For more information on Health Center Program look-
                        alikes, see https://bphc.hrsa.gov/uds/lookalikes.aspx?year=2017.




                        Page 7                                                GAO-19-496 Community Health Centers
Figure 2: Health Centers’ Revenue, Calendar Years 2010–2017




Notes: Revenue in the Uniform Data System is defined as the gross receipts on a cash basis for each
year collected by health centers, regardless of the period in which the paid for services were
rendered. Dollars are nominal.

While the total revenue received by health centers more than doubled
from 2010 through 2017, the share of revenue received from grants—
including Section 330 grants and other federal and non-federal grants—
decreased, from 38.0 percent of total revenue in 2010 to about 30.2
percent in 2017. 13 During the same time period, the share of revenue
health centers received from Medicaid, Medicare, and private health




13
  Grants in HRSA’s Uniform Data System include three categories of revenue: (1) Section
330 grants, such as Health Center Program grants; (2) other federal grants, such as
Medicare and Medicaid Electronic Health Record Incentive grants; and (3) non-federal
grants or contracts, such as amounts from contracts that are not tied to the delivery of
services and amounts received from state and local indigent care programs. The federal
grants health centers receive are awarded in part to support services provided to the
uninsured. The decrease in the share of health center revenue from grants corresponds to
a decrease in health centers’ uninsured patient population. By 2017, about 23 percent of
the overall patient population of health centers were uninsured—a decrease from about 38
percent in 2010. See table 3 in appendix I.




Page 8                                                   GAO-19-496 Community Health Centers
insurance increased (see fig. 3). 14 (See app. II for more information on
health centers’ revenue from 2010 through 2017.)

Figure 3: Health Center Revenue Sources and Amounts In Calendar Years 2010 and
2017




14
  In 2017, the amount of revenue health centers received from Medicaid generally aligned
with the size of the Medicaid patient population. While revenue from Medicaid made up
about 44 percent of health centers’ revenue, about 49 percent of the patients served by
health centers were covered by Medicaid. See table 3 in appendix I.




Page 9                                            GAO-19-496 Community Health Centers
                                        Notes: Revenue in the Uniform Data System is defined as the gross receipts on a cash basis for each
                                        year collected by health centers, regardless of the period in which the paid for services were
                                        rendered. Dollars are nominal. Percentages may not add to 100 due to rounding.
                                        a
                                         Other revenue includes two categories in the Uniform Data System: (1) other public insurance and
                                        (2) non-patient related revenue not reported elsewhere, such as revenue from fund-raising, rent from
                                        tenants, medical record fees, and vending machines.
                                        b
                                         Grants in HRSA’s Uniform Data System include three categories of revenue: (1) Section 330 grants,
                                        such as Health Center Program grants; (2) other federal grants, such as Medicare and Medicaid
                                        Electronic Health Record Incentive grants; and (3) non-federal grants or contracts, such as amounts
                                        from contracts that are not tied to the delivery of services and amounts received from state and local
                                        indigent care programs.


                                        While the share of health centers’ total revenue coming from all grants
                                        decreased from 2010 to 2017, the share of revenue from one type of
                                        grant—Section 330 grants—increased. Specifically, the share of revenue
                                        health centers received from Section 330 grants—a portion of which are
                                        funded by the CHCF—increased from 15.7 percent of health centers’ total
                                        revenue in 2010 to 18.0 percent in 2017 (see figure 4).

Figure 4: Percentage of Health Center Revenue from Grants, Calendar Years 2010 and 2017




                                        Notes: Total revenue for health centers in 2010 was about $12.7 billion and in 2017 was about $26.3
                                        billion. Dollars are nominal.
                                        a
                                         Grants in HRSA’s Uniform Data System include three categories of revenue: (1) Section 330 grants,
                                        such as Health Center Program grants; (2) other federal grants, such as Medicare and Medicaid
                                        Electronic Health Record Incentive grants; and (3) non-federal grants or contracts, such as amounts
                                        from contracts that are not tied to the delivery of services and amounts received from state and local
                                        indigent care programs.




                                        Page 10                                                    GAO-19-496 Community Health Centers
                                         Our analysis also shows that the share of revenue health centers receive
                                         from Section 330 grants varies by state. As figure 5 below shows, in
                                         2017, health centers in 2 states received more than 40 percent of their
                                         total revenue from Section 330 grants, while health centers in 18 states
                                         received less than 20 percent of total revenue from these grants.

Figure 5: Share of Health Center Revenue from Section 330 Grants, by State, Calendar Year 2017




                                         Page 11                                        GAO-19-496 Community Health Centers
                       Our analysis of HRSA data shows that for the 7-year period from fiscal
HRSA Awarded           years 2011 through 2017, HRSA provided health centers with about
CHCF Grants            $15.8 billion in Section 330 grants funded by the CHCF. 15 Most of this
                       funding—$12.6 billion, or nearly 80 percent of all grants awarded through
Primarily to Support   the CHCF during this period—was awarded for the purpose of service
Ongoing Operations     area funding, which supports ongoing operations and services across the
                       nearly 1,400 health centers nationwide (see fig. 6). The remaining $3.2
and Services at        billion in CHCF grants were awarded to increase the amount of services
Health Centers         provided at existing health centers; to increase the number of health
                       centers and sites; and for other special initiatives, such as initiatives to
                       support health information technology.

                       Figure 6: Total Health Resources and Services Administration (HRSA) Section 330
                       Grants Funded by the Community Health Center Fund (CHCF), Fiscal Years 2011–
                       2017




                       15
                         As previously noted, Section 330 grants funded by the CHCF are a subset of all Section
                       330 grants. For fiscal years 2011 through 2017, Congress appropriated about $16.4 billion
                       for the CHCF. HRSA officials told us that the amount of Section 330 grants health centers
                       received may be less than the total amount appropriated for the CHCF because of factors
                       such as administrative costs, sequestration, or monetary carryover between fiscal years.




                       Page 12                                            GAO-19-496 Community Health Centers
Notes: Section 330 grants funded by the CHCF are a subset of all Section 330 grants. Percentages
may not add to 100 due to rounding. Dollars across fiscal years are nominal.


Service area funding. From fiscal years 2011 through 2017, HRSA used
the CHCF to provide health centers with approximately $12.6 billion in
grants for service area funding, which supports ongoing operations and
service delivery. 16 HRSA officials told us that these CHCF grants are
used to fill the gap between what it costs to operate a health center and
the amount of revenue a health center receives. As such, the awards are
a primary means through which health centers provide health care
services that may be uncompensated, including services for patients who
are uninsured or services not typically reimbursed by other payers, such
as adult dental care, or other services such as transportation and
nutritional education. These awards can cover uncompensated care costs
for patients with incomes low enough to qualify for sliding fee assistance,
which reduces or waives the cost of services for patients based on their
ability to pay. In addition, these awards can cover patients who have
private insurance but face substantial deductibles and cost-sharing.
Officials we interviewed from the Congressional Research Service,
George Washington University’s Milken Institute, and the National
Association of Community Health Centers similarly noted that CHCF
grants support services not typically covered by public health insurance,
such as adult dental care services not generally covered by Medicare or
Medicaid.

Increasing services at existing health centers. From fiscal years 2011
through 2017, HRSA used the CHCF to provide health centers with about
$1.2 billion in grants to help increase the amount of services offered at
existing health centers that chose to apply for an award. This amount
included funding to increase the availability of specific health care
services, such as dental care, as well as funding to support health
centers’ efforts to extend service hours or increase the number of
available providers. Specifically, these grants were awarded for the
following:

•    Behavioral and mental health, substance abuse. Three grants totaling
     about $400.8 million were awarded to expand access to behavioral
     health, mental health, and substance abuse services. These awards
     focused primarily on integrating primary care and behavioral health

16
  These grants are known as service area competitions and yearly budget period
renewals.




Page 13                                                 GAO-19-496 Community Health Centers
      care services and expanding substance use services at existing
      health centers, such as medication-assisted treatment for opioid-use
      disorder. 17
•     Oral health. A grant for about $155.9 million was awarded to increase
      access to oral health services and improve oral health outcomes by
      funding new onsite providers and supporting the purchase and
      installation of dental equipment.
•     Expanding Services. Two grants—one in fiscal year 2014 for $295.6
      million and another in fiscal year 2015 for about $349.6 million—were
      made to increase access to comprehensive primary health care in
      various ways, at the discretion of individual health centers. At existing
      sites, health centers may have chosen to expand service hours,
      increase the number of health care providers, or expand services
      such as oral health, behavioral health, pharmacy, and vision services.
Increasing the number of health centers and sites. From fiscal years 2011
through 2017, HRSA awarded about $1.1 billion—or about 7 percent of
total CHCF funds—to organizations to help establish new health centers
or new sites at existing health centers. Specifically, HRSA awarded
grants for the following purposes:

•     New Access Point (NAP) Awards. Most of the funding to increase
      access to health centers—about $648.5 million of the $1.1 billion—
      was provided through what are called NAP awards. According to
      HRSA officials, there are two primary ways these funds can be
      used—either to allow a new organization to become a health center
      (about 30 percent of grant applicants) or for an existing health center
      to add one or more service sites (about 70 percent of grant
      applicants). 18 HRSA officials told us that they funded 1,059 NAP
      awards to new and existing health centers from fiscal year 2011
      through 2017 for a combined total of 1,609 proposed new health
      centers or sites. 19 These awards included 295 awards to new
      organizations and 764 awards to existing health centers adding one or
      more service sites. (See table 2 below for more information on the
17
  Medication-assisted treatment is an approach that combines behavioral therapy and the
use of certain medications, such as methadone and buprenorphine. See GAO-16-833,
Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted
Treatment Access (Washington, D.C.: Sept. 27, 2016).
18
  Grant recipients could apply to establish a single site or multiple sites as part of one
grant.
19
    HRSA did not make NAP awards in fiscal year 2016.




Page 14                                               GAO-19-496 Community Health Centers
       increase in health centers resulting from NAP awards.) Among the
       1,609 total proposed new health centers or sites, 686 were in rural
       areas, including 191 new health centers and 495 additional sites at
       existing centers.
•      Construction Grants. HRSA awarded construction grants totaling
       about $411.3 million through the Health Infrastructure Investment
       Program to help existing health centers alter, renovate, expand, or
       construct a facility. 20 According to HRSA officials, construction grants
       may increase the number of health center sites or may result in the
       consolidation of sites while still expanding access to care.
•      Health Center Planning Grants. HRSA awarded a Health Center
       Planning grant in fiscal year 2011 for about $10.3 million to support
       planning and development of comprehensive primary care health
       centers.

Table 2: Community Health Center Fund New Access Point (NAP) Awards

                                                                 Number of new
                            Total number of                      centers or sites         Total NAP award
                                          a                                     b
    Fiscal year               NAP awards                    proposed by grantee         funding ($ million)
    2011                                        67                                125                 28.8
    2012                                       219                                344                128.6
    2013                                        32                                 49                 19.6
    2014                                       236                                367                150.7
    2015                                       430                                632                269.8
    2017                                        75                                 92                   51
    Total                                   1,059                               1,609                648.5
Source: Health Resources and Services Administration (HRSA). | GAO-19-496

Note: HRSA did not make NAP awards in fiscal year 2016.
a
These awards include those for new health centers or new sites at existing health centers.
b
 Grantee proposals may include establishing multiple sites using one grant. These figures reflect the
number of sites HRSA approved upon review of grant applications. According to HRSA officials, this
number is subject to change.




20
  These construction grants are separate from the $1.5 billion appropriated by PPACA to
fund construction associated with health centers.




Page 15                                                                 GAO-19-496 Community Health Centers
Collectively, a total of 5,536 new health center sites were added in the
United States from fiscal year 2011 through 2017. 21 Of these new sites,
3,838 were in urban locations and 1,698 were in rural locations. 22 While
many of these new health center sites were from NAP awards, as
previously described, other grants either funded by the CHCF or by
discretionary appropriations may have contributed to the establishment of
new health center sites. For example, HRSA officials told us that health
center sites may be added through a change of scope to their service
area competition award or through other types of grants funded by the
CHCF, such as grants to increase adult dental services. However,
according to HRSA officials, the data do not allow for directly associating
the number of new sites with those grants, as the grants may be used for
multiple purposes. Figure 7 below shows the locations of health center
sites added during this time period that are active as of February 2019.




21
  This number reflects new health center sites in the 50 states and the District of
Columbia that were still active as of February 2019. In addition to these sites, 67 new
health center sites were added in other areas.
22
   The number of new sites reported (5,536) here differs from the number of sites reported
elsewhere in this report, including in figure 9 in appendix I. According to HRSA officials,
differences are the result of the two methodologies used to generate these numbers.
Specifically, the number of new sites reported here reflect new sites added to scope in
fiscal year 2011 through fiscal year 2017, excluding sites added prior to fiscal year 2011
and sites terminated during this time period. Data reported elsewhere represent the net
increase in total active sites as of the end of calendar year 2017.




Page 16                                              GAO-19-496 Community Health Centers
Figure 7: Locations of New Health Center Sites, Fiscal Years 2011–2017




                                         Note: Each dot represents a zip code where one or more health centers are located.


                                         Other special initiatives. From fiscal years 2011 through 2017, HRSA
                                         awarded about $898.9 million of CHCF funds for grants to health centers
                                         to support other special initiatives and to address identified priorities or
                                         emerging health care needs. Specifically, HRSA awarded grants to those
                                         health centers that chose to apply for the following purposes:




                                         Page 17                                                  GAO-19-496 Community Health Centers
•    Health information technology. Three grants totaling about $243.4
     million were awarded to advance the adoption and implementation of
     health information technology. For example, the purpose of one
     grant—the Health Center Controlled Networks—was to advance the
     adoption, implementation, and optimization of health information
     technology. Another grant provided supplemental funding to improve
     the electronic reporting capabilities of health centers in Beacon
     Communities. 23
•    HIV. Two grants totaling about $23.8 million were awarded with the
     goal to increase access to HIV care and services. One specifically
     targeted prevention and treatment services in those communities
     most affected by HIV.
•    Outreach and enrollment. $222.0 million in grant funding was awarded
     to support health centers in raising awareness of affordable insurance
     options and providing eligibility and enrollment assistance to
     uninsured patients of health centers and residents in their approved
     service areas.
•    Patient-Centered Medical Home. About $84.6 million in grant funding
     was awarded to support HRSA efforts to expand the number of
     patient-centered medical homes with a particular focus of improving
     quality of care, access to services, and reimbursement
     opportunities. 24
•    Quality improvement. Approximately $305.1 million in grant funding
     was awarded to support health centers that displayed high quality
     performance so they can continue to strengthen quality improvement
     efforts. Specifically, the funds were to support health centers to further
     improve the quality, efficiency, and effectiveness of health care
     delivered to the communities served.
•    Training and technical assistance. Two grants totaling about $14.3
     million were awarded to support training and technical assistance for
     health centers in order to support programmatic, clinical, and financial
     operations. One grant focused on the delivery of training and technical

23
  The Beacon Community Agreement Program is a cooperative agreement program
administered by HHS’s Office of the National Coordinator for Health Information
Technology. The program provides funding to 17 selected communities throughout the
United States with strong health information technology infrastructure, including high rates
of electronic health record adoption.
24
  A patient-centered medical home is an approach to provide comprehensive primary care
by facilitating partnerships between individual patients, their physicians, and when
appropriate, the patient’s family.




Page 18                                              GAO-19-496 Community Health Centers
                      assistance by national organizations and the other grant was based
                      on statewide and regional needs.
                  •   Zika. A grant for about $5.7 million was awarded to health centers that
                      chose to apply to expand their existing activities to strengthen the
                      response to the Zika virus in Puerto Rico, the U.S. Virgin Islands, and
                      American Samoa. These activities included outreach, patient
                      education, screening, voluntary family planning services, and/or
                      treatment services.
                  See appendix III for a complete list of all grants awarded through CHCF
                  by category.


                  We provided a draft of this report to HHS. HHS provided technical
Agency Comments   comments, which we incorporated as appropriate.


                  As agreed with your offices, unless you publicly announce the contents of
                  this report earlier, we plan no further action until 30 days from the report
                  date. At that time, we will send copies of this report to the Secretary of
                  Health and Human Services and other interested parties. In addition, the
                  report will be available at no charge on GAO’s website at
                  http://www.gao.gov.

                  If you or your staff have any questions about this report, please contact
                  me at (202) 512-7114 or at farbj@gao.gov. Contact points for our Office
                  of Congressional Relations and Office of Public Affairs can be found on
                  the last page of this report. GAO staff who made key contributions to this
                  report are listed in appendix IV.




                  Jessica Farb
                  Director, Health Care




                  Page 19                                     GAO-19-496 Community Health Centers
Appendix I: Information on Health Centers
              Appendix I: Information on Health Centers and
              Patients Served



and Patients Served

              This appendix provides information on health centers and patients
              served. Specifically,

              •   figure 8 illustrates the number and location of health centers in 2017;
              •   figure 9 illustrates the growth in health centers and sites since 2010;
              •   figure 10 illustrates the growth in patients served at health centers
                  since 2010; and
              •   table 3 provides information on how the payer mix for patients served
                  at health centers has changed since 2010.




              Page 20                                         GAO-19-496 Community Health Centers
                                        Appendix I: Information on Health Centers and
                                        Patients Served




Figure 8: Number and Location of Health Centers, Calendar Year 2017




                                        Page 21                                         GAO-19-496 Community Health Centers
                                         Appendix I: Information on Health Centers and
                                         Patients Served




Figure 9: Growth in Health Centers and Sites, 2010–2017




                                         Page 22                                         GAO-19-496 Community Health Centers
Appendix I: Information on Health Centers and
Patients Served




Figure 10: Growth in Number of Patients Served at Health Centers, 2010–2017




Table 3: Proportion of Health Center Patients Who are Uninsured or Covered by
Medicaid, Medicare, or Private Insurance, Calendar Years 2010 through 2017

                                                      Percentage                    Percentage
                     Percentage           Percentage covered by                     covered by
                     covered by           covered by other public                       private           Percentage
                                                                a
    Year               Medicaid             Medicare  insurance                      insurance             uninsured
    2010                        38.5                   7.5                  2.5                13.9                  37.5
    2011                        39.3                   7.8                  2.4                14.1                  36.4
    2012                        39.6                   8.0                  2.3                14.0                  36.0
    2013                        40.6                   8.4                  2.0                14.1                  34.9
    2014                        46.7                   8.6                  1.3                15.6                  27.9
    2015                        48.9                   8.9                  1.0                16.8                  24.4
    2016                        49.2                   9.2                  1.0                17.2                  23.4
    2017                        49.1                   9.4                  1.0                17.6                  22.9
Source: GAO analysis of Health Resources and Services Administration (HRSA) Uniform Data System data. | GAO-19-496
a
 HRSA’s Uniform Data System defines other public insurance as state and/or local government
programs, such as Washington’s Basic Health Plan or Massachusetts’ Commonwealth plan, that
provide a broad set of benefits for eligible individuals. It can also include the Children’s Health
Insurance Program.




Page 23                                                                 GAO-19-496 Community Health Centers
Appendix II: Sources and Amounts of
                                                              Appendix II: Sources and Amounts of Revenue
                                                              for Health Centers, Calendar Years 2010
                                                              through 2017


Revenue for Health Centers, Calendar Years
2010 through 2017
Table 4: Health Center Revenue Sources by Year, Calendar Years 2010 through 2017

                                             2010                                  2011                             2012                      2013
                                                   Percent of                             Percent                       Percent of                Percent of
                                Millions                total           Millions           of total         Millions         total    Millions         total
 Source                        of dollars            revenue           of dollars         revenue          of dollars     revenue    of dollars     revenue
 Total Medicaid                      4,780                  37.7             5,288              38.1           5,744          38.3       6,302          39.6
 Total Medicare                      740.3                    5.8            799.6                   5.8       897.6           6.0       969.9           6.1
 Total other public                  339.5                    2.7            333.6                   2.4       383.4           2.6       355.7           2.2
           a
 insurance
 Total private                       864.2                    6.8            951.3                   6.9       1,086           7.2       1,197           7.5
 insurance
 Self-pay                            744.2                    5.9            818.2                   5.9       912.7           6.1       977.6           6.1
 Total federal                       1,993                  15.7             2,295              16.5           2,614          17.4       2,832          17.8
 Section 330
        b
 Grants
 Total other federal                 950.3                    7.5            1,010                   7.3       750.6           5.0       478.5           3.0
        c
 Grants
 Total non-federal                   1,880                  14.8             1,940              14.0           2,050          13.7       2,164          13.6
 grants and
           d
 contracts
                     e
 Other revenue                       399.5                    3.1            444.6                   3.2       561.5           3.7       647.2           4.1
 Total revenue                      12,691                100.0            13,880             100.0           15,001        100.0       15,923        100.0
                                             2014                                  2015                             2016                      2017
 Total Medicaid                      7,632                  42.4             9,327              44.4          10,289          43.3      11,478          43.6
 Total Medicare                      1,098                    6.1            1,386                   6.6       1,692           7.1       1,974           7.5
 Total other public                  276.3                    1.5            257.3                   1.2       256.2           1.1       280.7           1.1
           a
 insurance
 Total private                       1,467                    8.2            1,805                   8.6       2,228           9.4       2,569           9.8
 insurance
 Self-pay                            942.9                    5.2            930.2                   4.4       1,005           4.2       1,109           4.2
 Total federal                       3,210                  17.8             3,701              17.6           4,422          18.6       4,732          18.0
 Section 330
        b
 Grants
 Total other federal                 481.0                    2.7            459.1                   2.2       457.2           1.9       509.7           1.9
        c
 Grants
 Total non-federal                   2,150                  12.0             2,305              11.0           2,460          10.4       2,701          10.3
 grants and
           d
 contracts
                     e
 Other revenue                       729.8                    4.1            831.2                   4.0       943.8           4.0       983.2           3.7
 Total revenue                      17,987                100.0            21,001             100.0           23,753        100.0       26,337        100.0
Source: Health Resources and Services Administration (HRSA) Uniform Data System data. | GAO-19-496

                                                              Notes: Dollars are nominal. Percentages may not equal 100 due to rounding.




                                                              Page 24                                                      GAO-19-496 Community Health Centers
Appendix II: Sources and Amounts of Revenue
for Health Centers, Calendar Years 2010
through 2017




a
 HRSA’s Uniform Data System defines other public insurance as state and/or local government
programs, such as Washington’s Basic Health Plan or Massachusetts’ Commonwealth plan, that
provide a broad set of benefits for eligible individuals.
b
    Total federal Section 330 grants includes Health Center Program grants.
c
Other federal grants in HRSA’s Uniform Data System include Medicare and Medicaid Electronic
Health Record Incentive grants.
d
 HRSA’s Uniform Data System defines non-federal grants and contracts as revenue from contracts
that are not tied to the delivery of services and revenue received from state and local indigent care
programs.
e
 HRSA’s Uniform Data System defines other revenue as non-patient related revenue not reported
elsewhere. Examples include revenue from fund-raising, rent from tenants, medical record fees, and
vending machines.




Page 25                                                     GAO-19-496 Community Health Centers
Appendix III: Community Health Center Fund
                                             Appendix III: Community Health Center Fund
                                             Awards for Health Centers, Fiscal Years 2011
                                             through 2017


Awards for Health Centers, Fiscal Years
2011 through 2017
Table 5: Community Health Center Fund (CHCF) Awards for Health Centers, Fiscal Years (FY) 2011 through FY 2017

                                                                              Amount in millions of dollars
Name of award         Purpose of funding               FY 2011     FY 2012    FY 2013       FY 2014   FY 2015   FY 2016     FY 2017
Service area funding
Base Adjustment for Increase health center’s                   -          -       48.2        110.4       165          -           -
Continued           annual ongoing base funding
Operations
Funding for           Ensure continued access to          891.3      960.6       1,200        1,400     2,000      2,700      3,100
continued             primary health care services
operations (Service   for communities currently
area competition or   served by the Health Center
budget period         Program
renewal)*
Increase services at existing health centers
Behavioral and Mental Health, Substance Abuse
Access Increases      Expand access to mental                  -          -           -           -         -          -      200.5
for Mental Health     health and substance abuse
and Substance         services with a focus on
Abuse Services        treatment, prevention, and
(AIMS)                awareness of opioid abuse
Behavioral Health     Increase coordination,                   -          -           -        55.1      51.3          -           -
Integration           collaboration, and integration
                      of primary and behavioral
                      health care services
Substance Abuse       Improve and expand delivery              -          -           -           -         -       93.9           -
Service Expansion     of substance abuse services
                      at existing health centers,
                      including medication-assisted
                      treatment
Expanding services
Expanding Services Increase access to primary                  -          -           -       295.6         -          -           -
                                        a
(ES) – FY2014      care health services
Expanding Services Increase access to primary                  -          -           -           -     349.6          -           -
                                        a
(ES) – FY2015      care health services
Oral health
Oral Health           Increase access to oral                  -          -           -           -         -      155.9           -
                      health services and improve
                      oral health outcomes, such
                      as by hiring new providers
                      and purchasing dental
                      equipment




                                             Page 26                                              GAO-19-496 Community Health Centers
                                              Appendix III: Community Health Center Fund
                                              Awards for Health Centers, Fiscal Years 2011
                                              through 2017




                                                                               Amount in millions of dollars
Name of award          Purpose of funding               FY 2011     FY 2012    FY 2013       FY 2014   FY 2015   FY 2016     FY 2017
Increase the number of health centers and sites
               b
Construction
Health                 Funding for                              -          -           -           -     148.9      262.4           -
Infrastructure         alteration/renovation,
Investment Program     expansion, or construction of
(HIIP)                 a facility at existing health
                       centers
Increase number of health centers
Health Center          Increase in number of health         10.3           -           -           -         -          -           -
Planning Grants        centers (organizations or
                       sites at existing centers)
New Access Point       Increase in number of health         28.8      128.6        19.6        150.7     269.8          -         51
(NAP)                  centers (organizations or
                       sites at existing centers)
Other special initiatives
Health information technology
Beacon                 Supplemental funding to               8.5           -           -           -         -          -
Communities            improve the quality of care
                       and electronic reporting
                       capabilities of health centers
                       in Beacon Communities
Health Center       Advance the adoption,                       -          -       21.1          21       32.8       36.3       36.3
Controlled Networks implementation and
(HCCN)              optimization of health
                    information technology
Delivery System        Support strategic                        -          -           -           -         -       87.4           -
Health Information     investments in health
Investment (DSHII)     information technology to
                       support quality improvement
HIV
                   c
HIV Supplement         Increase access to HIV care              -        5.1         6.3           -         -          -           -
                       and treatment services
Partnerships for       Expand provision of HIV                  -          -           -         6.3         3        3.1           -
Care*                  prevention and care services
                       within communities most
                       impacted by HIV
Outreach and enrollment
Outreach and           Expand current outreach and              -          -        150         58.7       6.3          7           -
enrollment             enrollment activities
Patient-Centered Medical Home
Patient-Centered       Improve quality of care,             31.6        44.4           -           -         -        8.6           -
Medical Home           access to services, and
                       reimbursement opportunities




                                              Page 27                                              GAO-19-496 Community Health Centers
                                                              Appendix III: Community Health Center Fund
                                                              Awards for Health Centers, Fiscal Years 2011
                                                              through 2017




                                                                                                              Amount in millions of dollars
Name of award                  Purpose of funding                           FY 2011         FY 2012           FY 2013    FY 2014   FY 2015    FY 2016       FY 2017
Quality improvement
Quality                        Support health centers that                             -                  -          -         -       99.6     100.2          105.3
Improvement                    displayed high levels of
                               quality performance
Training and technical assistance
National Training               Support the delivery of                             2.9                   -          -         -          -           -              -
and Technical                   training and technical
Assistance                      assistance by national
Cooperative                     organizations to maintain
Agreements (NCA)*               fiscal and operational
                                excellence, engage in
                                effective workforce
                                development activities, and
                                appropriately structure
                                health care services.
State and Regional              Provide technical assistance                          5                   -       6.4          -          -           -              -
Primary Care                    based on statewide and
Association (PCA)               regional needs to help
Cooperative                     health centers improve
Agreements*                     programmatic, clinical, and
                                financial performance and
                                operations.
Zika
Zika                           Expansion of existing                                   -                  -          -         -          -        5.7               -
                               activities to strengthen
                               response to Zika in Puerto
                               Rico, the U.S. Virgin Islands,
                                                      d
                               and American Samoa
Source: GAO analysis of Health Resources and Services Administration (HRSA) documentation. | GAO-19-496

                                                              Notes: An “*” indicates that this grant was also funded through discretionary appropriations. Award
                                                              amounts in the table are only CHCF funds. Dollars are nominal.
                                                              a
                                                               Expanding services grants provided supplemental funding to support expanded service hours,
                                                              increased numbers of medical providers, increased availability of medical services, and, optionally,
                                                              the provision of services such as oral health, behavioral health, pharmacy, and/or vision service at
                                                              existing health center sites.
                                                              b
                                                                  The capital improvement awards included in this table are those funded by the CHCF.
                                                              c
                                                              HIV supplement grants were a joint effort by HRSA’s HIV/AIDS Bureau and Bureau of Primary
                                                              Health Care.
                                                              d
                                                               Existing activities include outreach, patient education, screening, voluntary family planning services,
                                                              and/or treatment services.




                                                              Page 28                                                          GAO-19-496 Community Health Centers
Appendix IV: GAO Contact and Staff
                  Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments


                  Jessica Farb, (202) 512-7114 or farbj@gao.gov
GAO Contact
                  In addition to the contact named above, Kristi Peterson, Assistant
Staff             Director; Amy Leone, Analyst-in-Charge; Margot Bolon, Krister Friday,
Acknowledgments   Jeff Tamburello, and Eric Wedum made key contributions to this report.
                  Also contributing were Vikki Porter, Rotimi Adebonojo, Giselle Hicks, and
                  Jennifer Whitworth.




(103183)
                  Page 29                                   GAO-19-496 Community Health Centers
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