Health Care Access: Opportunities to Target Programs and Improve Accountability

Published by the Government Accountability Office on 1997-09-11.

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

                               United States General Accounting Office

GAO                            Testimony
                               Before the Subcommittee on Human Resources,
                               Committee on Government Reform and Oversight,
                               House of Representatives

For Release on Delivery
Expected at 10:00 a.m.
Thursday, September 11, 1997
                               HEALTH CARE ACCESS

                               Opportunities to Target
                               Programs and Improve
                               Statement of Bernice Steinhardt, Director
                               Health Services Quality and Public Health Issues
                               Health, Education, and Human Services Division

Health Care Access: Opportunities to Target
Programs and Improve Accountability

               Mr Chairman and Members of the Subcommittee:

               We are pleased to be here today to expand on our testimony regarding the
               Rural Health Clinic program that we presented to you last February. In
               that testimony, we said that the program did not focus on improving
               access to care in areas that most needed it. Today, we would like to
               discuss our findings in the broader context of our past reviews of federal
               efforts to improve access to primary health care. The federal government
               spends billions of dollars each year on programs like the Rural Health
               Clinic program that, in whole or part, are aimed at achieving this objective.
               I would like to (1) summarize the common problems we found and some
               recent initiatives to address them and (2) discuss how the type of
               management changes called for under the Government Performance and
               Results Act of 1993 (Results Act) can help the Rural Health Clinic and
               related programs improve accountability.

               In brief, our work has identified many instances in which the Rural Health
               Clinic program and other federal programs have provided aid to
               communities without ensuring that this aid has been used to improve
               access to primary care. In some cases, programs have provided more than
               enough assistance to eliminate the defined shortage, while needs in other
               communities remain unaddressed. Our work has identified a pervasive
               cause for this problem: a reliance on flawed systems for measuring health
               care shortages. These systems often do not work effectively to identify
               which programs would work best in a given setting or how well a program
               is working to meet the needs of the underserved once it is in place. For
               several years, the Department of Health and Human Services (HHS) has
               tried unsuccessfully to revise these systems to address these problems.
               The goal-setting and performance measurement discipline available under
               the Results Act, however, appears to offer a suitable framework for
               ensuring that programs are held accountable for improving access to
               primary care.

               All communities contain populations that may have difficulty accessing
Background     primary health care services for reasons such as geographic isolation or,
               more often, inability to pay for care. Multiple federal agencies, often with
               state and local governments as partners, have long supported a broad
               range of programs to remedy these access problems. The largest and best
               known is Medicaid, which spent over $161 billion in fiscal year 1996 on
               health and long-term care for low-income Americans considered to be

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    Health Care Access: Opportunities to Target
    Programs and Improve Accountability

    unable to purchase services.1 However, over 30 other programs exist. (See
    appendix for an overview of some of these programs.) These other
    programs, which collectively spent more than $1 billion a year as of 1996,
    use one of three strategies aimed to ensure that all populations have
    access to care.

•   Providing incentives to health professionals practicing in underserved
    areas. Under the Rural Health Clinic and Medicare Incentive Payment
    programs, providers are given additional Medicare and/or Medicaid
    reimbursement to practice in underserved areas. In 1996, these
    reimbursements amounted to over $400 million. In addition, over
    $112 million was spent on the National Health Service Corps program,
    which supports scholarships and repays education loans for health care
    professionals who agree to practice in designated shortage areas. Under
    another program, called the J-1 Visa Waiver, U.S. trained foreign
    physicians are allowed to remain in the United States if they agree to
    practice in underserved areas.2
•   Paying clinics and other providers caring for people who cannot afford to
    pay. More than $758 million funded programs that provide grants to help
    underwrite the cost of medical care at community health centers and other
    federally qualified health centers. These centers also receive higher
    Medicare and Medicaid payments. Similar providers also receive higher
    Medicare and Medicaid payments as “look-alikes” under the Federally
    Qualified Health Center program.
•   Paying institutions to support the education and training of health
    professionals. Medical schools and other teaching institutions received
    over $238 million in 1996 to help increase the national supply, distribution,
    and minority representation of health professionals through various
    education and training programs under Titles VII and VIII of the Public
    Health Service Act.

     Medicaid is a joint federal-state program, which in fiscal year 1996 financed health care for about
    37 million low-income, blind, disabled, and elderly people. The federal contribution to state Medicaid
    programs in that year amounted to $91.9 billion or about 57 percent of the $161.2 billion total. In 1995,
    more than 70 percent of Medicaid expenditures paid for care for the elderly, blind, and disabled and
    for payments to hospitals serving large numbers of Medicaid and low-income patients under the
    Disproportionate Share Hospital program.
     In 1995, 4 federal agencies and 23 states requested waivers to requirements that foreign physicians
    return to their home country after completing U.S. medical training under a J-1 visa.

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                          Health Care Access: Opportunities to Target
                          Programs and Improve Accountability

                          Over the past several years, we have issued a number of reports examining
Programs Need to          most of these programs.3 Our findings show that while the Rural Health
Improve Their Focus       Clinic program and other federal programs have provided resources to
on Access Problems        improve access to primary care, the programs historically have not been
                          held accountable for showing that access has indeed improved. Here are
                          some examples:

                      •   The Rural Health Clinic program—which had an original purpose to
                          subsidize health care in remote rural areas lacking physicians—now costs
                          Medicare and Medicaid more than $295 million a year4 to primarily
                          subsidize care in cities and towns already having substantial health care
                          resources. Our review of a sample of clinics showed that the availability of
                          care did not change appreciably for at least 90 percent of Medicare and
                          Medicaid beneficiaries using the clinics. Staff we interviewed at most
                          clinics said they did not use the subsidies to expand access to underserved
                          portions of the population or need the subsidies to remain financially
                      •   The Medicare Incentive Payment program, created out of concern that
                          physicians would not treat Medicare patients due to low Medicare
                          reimbursement rates, pays all physicians in designated shortage areas a
                          10-percent bonus on Medicare billings. Physicians receive bonus payments
                          now totaling over $100 million each year, even in shortage areas where
                          Medicare patients are not underserved or where low Medicare
                          reimbursement rates are not the cause of underservice.6
                      •   Federal and state programs placing providers in underserved areas have
                          oversupplied some communities and states with providers, while others
                          received none. Considering the National Health Service Corps program
                          alone, at least 22 percent of shortage areas receiving National Health
                          Service Corps providers in 1993 received providers in excess of the

                           We have not reviewed how health center grants or benefits provided to other federally qualified health
                          centers improved access to care. However, we did review HHS budget documentation for programs
                          directed at relieving underservice, including the health center programs.
                           This is the estimated additional cost to the Medicare and Medicaid programs due to higher payment
                          rates to rural health clinics.
                           We reviewed the health care resources of a sample of communities where 144 rural health clinics
                          were certified in 4 states: Alabama, Kansas, New Hampshire, and Washington. We analyzed past access
                          to care for Medicare and Medicaid beneficiaries using 119 of these clinics, and subsequently
                          interviewed staff at 76 of the clinics. See Rural Health Clinics: Rising Program Expenditures Not
                          Focused on Improving Care in Isolated Areas (GAO/HEHS-97-24, Nov. 22, 1996) and related testimony
                          (GAO/T-HEHS-97-65, Feb. 13, 1997).
                          See Health Care Shortage Areas: Designations Not a Useful Tool for Directing Resources to the
                          Underserved (GAO/HEHS-95-200, Sept. 8, 1995).

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                              number needed to remove federal designation as a shortage area,7 while
                              785 shortage areas requesting providers did not receive any providers at
                              all. Of these latter locations, 143 had unsuccessfully requested a National
                              Health Service Corps provider for 3 years or more.8 Taking other provider
                              placement programs into account shows an even greater problem in
                              effectively distributing scarce provider resources. For example, HHS
                              identified a need for 54 physicians in West Virginia in 1994, but more than
                              twice that number—116 physicians—were placed there using the National
                              Health Service Corps and J-1 Visa Waiver programs. We identified eight
                              states where this occurred in 1995.9
                          •   While almost $2 billion has been spent in the last decade on Title VII and
                              VIII education and training programs, HHS has not gathered the information
                              necessary to evaluate whether these programs had a significant effect on
                              changes that occurred in the national supply, distribution, or minority
                              representation of health professionals or their impact on access to care.
                              Evaluations often did not address these issues, and those that did address
                              them had difficulty establishing a cause-and-effect relationship between
                              federal funding under the programs and any changes that occurred. Such a
                              relationship is difficult to establish because the programs have other
                              objectives besides improving supply, distribution, and minority
                              representation and because no common goals or performance measures
                              for improving access had been established.10

Limitations of Existing       Our work has shown that these programs share a common problem: HHS
Approaches Used to            does not have a way to effectively match the various programs with the
Measure Need and Target       specific kinds of access problems that exist. Its systems for identifying
                              underservice are so general that they often are of little help in identifying
Assistance                    who is underserved and why. Likewise, these systems are often of little
                              use in measuring whether a program, once applied, is having any effect on

                               In creating the federal health professional shortage area designation system, federal intervention was
                              considered justified only if the number of health care providers was significantly less than adequate,
                              indicating that the needs of these areas were not being met through free-market mechanisms or
                              reimbursement programs.
                               See National Health Service Corps: Opportunities to Stretch Scarce Dollars and Improve Provider
                              Placement (GAO/HEHS-96-28, Nov. 24, 1995).
                               For these eight states, the number of J-1 visa physicians for whom waivers were processed in 1994
                              and 1995, combined with the number of National Health Service Corps physicians in service at the end
                              of 1995, exceeded the number of physicians to remove health professional shortage area designations
                              in the state. See Foreign Physicians: Exchange Visitor Program Becoming Major Route to Practicing in
                              U.S. Shortage Areas (GAO/HEHS-97-26, Dec. 30, 1996).
                               See Health Professions Education: Role of Title VII/VIII Programs in Improving Access to Care is
                              Unclear (GAO/HEHS-94-164, July 8, 1994) and Health Professions Education: Clarifying the Role of
                              Title VII and VIII Programs Could Improve Accountability (GAO/HEHS-97-117, Apr. 25, 1997).
                              Page 4                                                                          GAO/T-HEHS-97-204
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    the problem. Despite 3 decades of federal efforts, the number of areas HHS
    has classified as underserved using these systems has not decreased.

    HHS uses two systems to identify and measure underservice: the Health
    Professional Shortage Area (HPSA) system and the Medically Underserved
    Area (MUA) system. First used in 1978 to place National Health Service
    Corps providers, the HPSA system is based primarily on provider-to-
    population ratios. In general, HPSAs are self-defined locations with fewer
    than one primary care physician for every 3,500 persons.11 Developed at
    about the same time, the MUA system more broadly identifies areas and
    populations considered to have inadequate health services, using the
    additional factors of poverty and infant mortality rates and percentage of
    population aged 65 or over.

    We previously reported on the long-standing weaknesses in the HPSA and
    MUA systems in identifying the types of access problems in communities
    and in measuring how well programs focus services on the people who
    need them, including the following:

•   The systems have relied on data that are old and inaccurate. About half of
    the U.S. counties designated as medically underserved areas since the
    1970s would no longer qualify as such if updated using 1990 data.12
•   Formulas used by the systems, such as physician-to-population ratios, do
    not count all primary care providers available in communities, overstating
    the need for additional physicians in shortage areas by 50 percent or more.
    The systems fail to count the availability of those providers historically
    used by the nation to improve access to care, such as National Health
    Service Corps physicians and U.S. trained foreign physicians, as well as
    nurse practitioners, physician assistants, and nurse midwives.

    One result of such problems is the sheer number of HPSAs and MUAs that
    now exist, minimizing the usefulness of the systems in targeting
    assistance. Eighty-eight percent of all U.S. counties had HPSAs, MUAs, or
    both as of June 1995. Even when the systems accurately identify needy
    areas, they often do not provide the information needed to decide which
    programs are best suited to an area’s particular need. Designations are
    generally made for broad geographic areas without considering the

     Under certain circumstances, the ratio used to designate a primary care HPSA may be 1 to 3,000. HHS
    has different criteria for dental and mental health HPSAs.
     MUAs are designated based on a relative ranking of all U.S. counties, minor civil divisions, and
    census tracts that occurred in 1975 and 1976. All areas that ranked below the county median combined
    score for the four criteria were designated as MUAs. MUAs have been added since then on the basis of
    newer data and the same cutoff score.

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    demand for services. As a result, the systems do not accurately identify
    whether access problems are common for everyone living in the area, or
    whether only specific subpopulations, such as the uninsured poor, have
    difficulty accessing primary care resources that are already there but
    underutilized. Without additional criteria to identify the type of access
    barriers existing in a community, programs may not benefit the specific
    subpopulation with insufficient access to care.

    The Rural Health Clinic program, established to improve access in remote
    rural areas, illustrates this problem. Under the program, all providers
    located in rural HPSAs, MUAs, and HHS-approved state-designated shortage
    areas can request rural health clinic certification to receive greater
    Medicare and Medicaid reimbursement. However, if the underserved
    group is the uninsured poor, such reimbursement does little or nothing to
    address the access problem. Most of the 76 clinics we surveyed said the
    uninsured poor made up the majority of underserved people in their
    community, yet only 16 said they offered health services on a sliding-fee
    scale based on the individual’s ability to pay for care. Even if rural health
    clinics do not treat the group that is actually underserved, they receive the
    higher Medicare and Medicaid reimbursement, without maximum payment
    limits if operated by a hospital or other qualifying facility. These payment
    benefits continue indefinitely, regardless of whether the clinic is no longer
    in an area that is rural and underserved.

    Last February, we testified before this Subcommittee that improved cost
    controls and additional program criteria were needed for the Rural Health
    Clinic program. In August of this year, the Balanced Budget Act of 1997
    made changes to the program that were consistent with our
    recommendations. Specifically, the act placed limits, beginning next
    January, on the amount of Medicare and Medicaid payments made to
    clinics owned by hospitals with more than 50 beds. The act also made
    changes to the program’s eligibility criteria in the following three key

•   In addition to being located in a rural HPSA, MUA, or HHS-approved
    state-designated shortage area, the clinic must also be in an area in which
    the HHS Secretary determines there is an insufficient number of health care
•   Clinics are allowed only in shortage areas designated within the past 3

     The act also contains provisions related to quality assurance, staffing requirements, and payment for
    physician assistant services. In addition, the act allows states to begin limiting the higher Medicaid
    payments to rural health clinics starting in fiscal year 2000.

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                        •   Existing clinics that are no longer located in rural shortage areas can
                            remain in the program only if they are essential for the delivery of primary
                            care that would otherwise be unavailable in the area, according to criteria
                            that the HHS Secretary must establish in regulations by 1999.

                            Limiting payments will help control program costs. But until, and
                            depending on how, the Secretary defines the types of areas needing rural
                            health clinics, HHS will continue to rely on flawed HPSA and MUA systems
                            that assume providing services to anyone living in a designated shortage
                            area will improve access to care.

                            HHS  has been studying changes needed to improve the HPSA and MUA
                            systems for most of this decade, but no formal proposals have been
                            published. In the meantime, new legislation continues to require the use of
                            these systems, thereby increasing the problem. For example, the newly
                            enacted Balanced Budget Act authorizes Medicare to pay for telehealth
                            services—consultative health services through telecommunications with a
                            physician or qualifying provider—for beneficiaries living in rural HPSAs.
                            However, since HPSA qualification standards do not distinguish rural
                            communities that are located near a wide range of specialty providers and
                            facilities from truly remote frontier areas, there is little assurance that the
                            provision will benefit those rural residents most in need of telehealth

                            To make the Rural Health Clinic program and other federal programs more
Implementation of the       accountable for improving access to primary care, HHS will have to devise
Government                  a better management approach to measure need and evaluate individual
Performance and             program success in meeting this need. If effectively implemented, the
                            management approach called for under the Results Act offers such an
Results Act Provides        opportunity. Under the Results Act, HHS would ask some basic questions
an Opportunity to           about its access programs: What are our goals and how can we achieve
                            them? How can we measure our performance? How will we use that
Address Identified          information to improve program management and accountability? These
Problems                    questions would be addressed in annual performance plans that define
                            each year’s goals, link these goals to agency programs, and contain
                            indicators for measuring progress in achieving these goals. Using
                            information on how well programs are working to improve access in
                            communities, program managers can decide whether federal intervention
                            has been successful and can be discontinued, or if other strategies for
                            addressing access barriers that still exist in communities would provide a
                            more effective solution.

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                            Health Care Access: Opportunities to Target
                            Programs and Improve Accountability

Establishing                The Results Act provides an opportunity for HHS to make sure its access
Results-Oriented            programs are on track and to identify how efforts under each program will
Performance Goals and       fit within the broader access goals. The Results Act requires that agencies
                            complete multi-year strategic plans by September 30, 1997, that describe
Measures                    the agency’s overall mission, long-term goals, and strategies for achieving
                            these goals.14 Once these strategic plans are in place, the Results Act
                            requires that for each fiscal year, beginning fiscal year 1999, agencies
                            prepare annual performance plans that expand on the strategic plans by
                            establishing specific performance goals and measures for program
                            activities set forth in the agencies’ budgets. These goals are to be stated in
                            a way that identifies the results—or outcomes—that are expected, and
                            agencies are to measure these outcomes in evaluating program success.
                            Establishing performance goals and measures such as the following could
                            go far to improve accountability in HHS’ primary access programs.

                        •   The Rural Health Clinic program currently tracks the number of clinics
                            established, while the Medicare Incentive Payment program tracks the
                            number of physicians receiving bonuses and dollars spent. To focus on
                            access outcomes, HHS will need to track how these programs have
                            improved access to care for Medicare and Medicaid populations or other
                            underserved populations.
                        •   Success of the National Health Service Corps and health center programs
                            has been based on the number of providers placed or how many people
                            they served. To focus on access outcomes, HHS will need to gather the
                            information necessary to report the number of people who received care
                            from National Health Service Corps providers or at the health centers who
                            were otherwise unable to access primary care services available in the

                            Establishing performance goals will also help clarify how each program
                            “fits” into HHS’ overall portfolio of programs to improve access to primary
                            care. HHS has established national outcome-based goals and objectives for
                            the year 2000 through its Healthy People 2000 initiative,15 including the
                            objective of increasing the proportion of Americans with a usual source of
                            primary care from 84 percent in 1994 to 95 percent in the year 2000. HHS
                            uses the results from its National Health Interview Survey, an existing

                             The results of our review of HHS’ draft strategic plan can be found in The Results Act: Observations
                            on the Department of Health and Human Services’ April 1997 Draft Strategic Plan
                            (GAO/HEHS-97-173R, July 11, 1997).
                               Healthy People 2000 is the U.S. Public Health Service’s national public health initiative to improve the
                            health of all Americans. In consultation with stakeholders, other government agencies, and the public
                            health community, the Public Health Service developed a series of outcome-based public health goals
                            and measures.

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                            Health Care Access: Opportunities to Target
                            Programs and Improve Accountability

                            survey, to measure progress toward this goal by counting the number of
                            people across the nation who do and do not have a usual source of
                            primary care. For those people without a usual source of primary care, the
                            survey categorizes the reasons for this problem that individual programs
                            may need to address, such as people’s inability to pay for services, their
                            perception that they do not need a physician, or the lack of provider

                            Although HHS officials have started to look at how individual programs fit
                            under these national goals, they have not yet established links between the
                            programs and national goals and measures. Such links are important so
                            resources can be clearly focused and directed to achieve the national
                            goals. For example, HHS’ program description, as published in the Federal
                            Register, states that the health center programs directly address the
                            Healthy People 2000 objectives by improving access to preventive and
                            primary care services for underserved populations. While HHS’ fiscal year
                            1998 budget documents contain some access-related goals for health
                            center programs, it also contains other goals, such as creating 3,500 jobs in
                            medically underserved communities. Although creating jobs may be a
                            desirable by-product of supporting health center operations, it is unclear
                            how this employment goal ties to national objectives to ensure access to
                            care. Under the Results Act, HHS has an opportunity to clarify the
                            relationships between its various program goals and define their relative
                            importance at the program and national levels.

Developing Better           Viewing program performance in light of program costs—such as
Information on the          establishing a unit cost per output or outcome achieved—can help HHS and
Cost-Effectiveness of Its   the Congress make informed decisions on the comparative advantage of
                            continuing current programs.16 For example, HHS and the Congress could
Programs                    better determine whether the effects gained through the program were
                            worth their costs—financial and otherwise—and whether the current
                            program was superior to alternative strategies for achieving the same
                            goals. Unfortunately, in the past, information needed to answer these
                            questions has been lacking or incomplete, making it difficult to determine
                            how to get the “biggest bang for the buck.”

                            This is not just a theoretical point. Our work has shown the value of
                            analyzing and comparing costs. For example, our review of the National
                            Health Service Corps program showed the benefits of using comparative

                             We previously reported on the type of information needed to oversee and evaluate federal programs;
                            see Program Evaluation: Improving the Flow of Information to the Congress (GAO/PEMD-95-1, Jan. 30,

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             Health Care Access: Opportunities to Target
             Programs and Improve Accountability

             cost information to allocate resources between its scholarship and loan
             repayment programs. While both of these programs pay education
             expenses for health professionals who agree to work in underserved areas,
             by law, at least 40 percent of amounts appropriated each year must fund
             the scholarship program and the rest may be allocated at the HHS
             Secretary’s discretion. However, our analysis found that the loan
             repayment program costs the federal government at least one-fourth less
             than the scholarship program for a year of promised service and was more
             successful in retaining providers in these communities. Changing the law
             to allow greater use of the loan repayment program would provide greater
             opportunity to stretch program dollars and improve provider retention.
             Comparisons between different types of programs may also indicate areas
             of greater opportunity to improve access to care. However, the per-person
             cost of improving access to care under each program is unknown.
             Collecting and reporting reliable information on the cost-effectiveness of
             HHS programs is critical for HHS and the Congress to decide how to best
             spend scarce federal resources.

             Although the Rural Health Clinic program and other federal programs help
Conclusion   to provide health care services to many people, the magnitude of federal
             investment creates a need to hold these programs accountable for
             improving access to primary care. The current HPSA and MUA systems are
             not a valid substitute for developing the program criteria necessary to
             manage program performance along these lines. The management
             discipline provided under the Results Act offers direction in improving
             individual program accountability. Once it finalizes its strategic plan, HHS
             can develop in its annual performance plans individual program goals for
             the Rural Health Clinic program and other programs that are consistent
             with the agency’s overall access goals, as well as outcome measures that
             can be used to track each program’s progress in addressing access

             This program performance information can assist HHS’ operating divisions,
             such as the Health Care Financing Administration (HCFA) and the Health
             Resources and Services Administration (HRSA), in better managing its
             programs toward a common goal. In addition, this information can assist
             in determining whether strategies such as providing higher Medicare and
             Medicaid reimbursement rates under the Rural Health Clinic program are
             still needed to improve access to care, or whether directing federal dollars
             to other strategies, such as those addressing the inability to pay for

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services, would have greater effect in achieving HHS’ national primary care
access goals.

Mr. Chairman, this concludes my prepared statement. I would be pleased
to respond to any questions you or members of the Subcommittee may

Page 11                                                    GAO/T-HEHS-97-204

Selected Federal Programs Addressing
Medical Underservice

                        Overall strategy to                                        Program strategy used
Total FY96 federal      address cause of            Program (amount of             to address cause of             Agency administering
funding (in millions)   underservice                federal funding)               underservice                    program
$514                    Providing incentives to     Rural Health Clinic            Pay higher Medicare and HCFA
                        health professionals in     ($295)a                        Medicaid rates to
                        underserved areas                                          physicians and
                                                                                   nonphysicians in
                                                                                   underserved areas

                                                    Medicare Incentive Pay         Provide 10% bonus on     HCFA
                                                    ($107)                         Medicare payments to all
                                                                                   physicians in shortage

                                                    National Health Service        Pay education costs of          HRSA and states
                                                    Corps ($112)                   providers agreeing to
                                                                                   locate in shortage areas

                                                    J-1 Visa Waiver ($0)           Allow foreign physicians        Multiple federal agencies
                                                                                   (exchange-visitors) to          and states
                                                                                   remain in the U.S. if they
                                                                                   practice in shortage
$758+                   Paying clinics and          Health Centers Grantsb         Subsidize certain               HRSA
                        providers caring for        ($758)                         providers willing to see
                        people unable to pay                                       patients regardless of
                                                                                   their ability to pay

                                                    Federally Qualified            Higher Medicare and             HCFA
                                                    Health Centerc                 Medicaid payments to
                                                                                   certain providers willing
                                                                                   to see patients
                                                                                   regardless of their ability
                                                                                   to pay
$238                    Paying institutions to      Title VII/VIII Health          Pay health professions          HRSA
                        support education and       Education and Training         schools to support
                        training of health          Programsd ($238)               training of health
                        professionals                                              professionals
                                          Estimated additional cost to Medicare and Medicaid programs due to higher payment rates to
                                         rural health clinics.
                                          Includes four health center programs: Community, Migrant, Homeless, and Residents of Public
                                         Housing. Prior to the Health Center Consolidation Act of 1996 (P.L. 104-299, Oct. 11, 1996), these
                                         programs were authorized under sections 329, 330, 340, and 340A of the Public Health Service
                                          Includes health center grantees, as well as health centers that qualify for a federal grant but do
                                         not receive one. Medicare and Medicaid costs associated with this program are unknown.
                                          Includes 30 programs for increasing the supply, distribution, and minority representation of
                                         health professionals.

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           Selected Federal Programs Addressing
           Medical Underservice

(108311)   Page 13                                GAO/T-HEHS-97-204
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