|
|
|
|
Health
Centers
|
FY
2007
Actual |
FY
2008
Enacted |
FY
2009
Estimate |
FY
2009 +/-
FY 2008 |
BA |
$1,943,484,000 |
$2,021,737,000 |
$2,047,737,000 |
+$26,000,000
|
FTCA
|
$44,555,000
|
$43,285,000
|
$44,055,000
|
+$770,000
|
Total, HC |
$1,988,039,000
|
$2,065,022,000
|
$2,091,792,000
|
+$26,770,000
|
FTE
|
19
|
20
|
20 |
|
Authorizing
Legislation: Section 330 of the Public Health Service
Act; as amended by Public Law 107-251, the Native
Hawaiian Health Care Act of 1988; as amended by Section
9168 of the Public Law 102-396, and Section 224 of
the Public Health Service Act.
FY
2009 Authorization |
Expired
|
Allocation
Method |
Competitive
Grant |
Program Description and Accomplishments
Health Centers are community-based and patient-directed
organizations that serve populations lacking access
to high quality, comprehensive, and cost-effective
primary health care. These include low income populations,
the uninsured, those with limited English proficiency,
migrant and seasonal farmworkers, individuals and
families experiencing homelessness, and those living
in public housing. For over 40 years, Health Centers
have provided a “health care home” through
the delivery of comprehensive, culturally competent,
quality primary health care that often includes access
to pharmacy, mental health, substance abuse, and oral
health services regardless of a patient’s ability
to pay. The Program targets the nation's neediest
populations and geographic areas and currently funds
over 1,000 Health Center grantees that operate approximately
4,000 service delivery sites in every state, the District
of Columbia, Puerto Rico, the Virgin Islands, and
the Pacific Basin. More than half (53 percent) of
all Health Centers serve rural populations. In 2006,
Health Centers served 15 million patients, providing
over 59 million patient visits, at an average cost
per patient of about $538 dollars (including Federal
and non-Federal sources of funding). Patient services
are supported through Federal health center grants,
Medicaid, Medicare, the State Children’s Health
Insurance Program (SCHIP), other third party, self
pay collections, other Federal grants and State/local/other
resources.
Health Centers serve a diverse patient population:
-
People of all ages: Approximately 37 percent of
patients in 2006 were children (age 19 and younger);
about 7 percent were 65 or older.
- People
without and with health insurance: Four in 10 patients
were without health insurance in 2006. While the
proportion of uninsured patients of all ages has
held steady at nearly 40 percent, the number of
uninsured patients increased from 4 million in 2001
to 6 million in 2006, proportionate to the growth
in Federal health center funding.
-
People of all races and ethnicities: About two-thirds
of Health Center patients are minorities. In 2006,
23 percent of Health Center patients were African
American and 36 percent were Hispanic/Latino —
almost twice the proportion of African Americans
and over two and a half times the proportion of
Hispanics/Latinos reported in the overall U.S. population.
-
Special Populations: Some Health Centers also receive
specific funding to focus on certain special populations
including migrant and seasonal farmworkers, individuals
and families experiencing homelessness, those living
in public housing, and Native Hawaiians. In 2006
Health Centers served over 807,000 migrant and seasonal
farmworkers and their families, nearly 829,000 individuals
experiencing homelessness, over 129,000 residents
of public housing and over 6,000 Native Hawaiians.
-
Migrant Health Centers – In 2006, HRSA-funded
health centers served more than 807,000 migrant
or seasonal farmworkers and their families.
It is estimated that HRSA-funded health center
programs serve more than one quarter of all
migrant and seasonal farmworkers in the United
States. The Migrant Health Center program provides
support to health centers to deliver comprehensive,
high quality, culturally-competent preventive
and primary health services to migrant and seasonal
farmworkers and their families with a particular
focus on the occupational health and safety
needs of this population. Principal employment
for both migrant and seasonal farmworkers must
be in agriculture.
-
Health Care for the Homeless Program –
Homelessness continues to be a pervasive problem
throughout the United States, affecting rural
as well as urban and suburban communities. According
to a recent national survey, it is estimated
that 744,000 people are homeless on a given
night and 2 to 3 million are homeless over the
course of a year. The Health Center for the
Homeless Program is a major source of care for
homeless persons in the United States, serving
patients that live on the street, in shelters,
or in transitional housing. In 2006, HRSA funded
health centers served nearly 829,000 persons
experiencing homelessness. Health Care for the
Homeless grantees recognize the complex needs
of homeless persons and strive to provide a
coordinated, comprehensive approach to health
care including substance abuse and mental health
services.
- Public
Housing Primary Care Health Centers –
The Public Housing Primary Care Program provides
residents of public housing with increased access
to comprehensive primary health care services
through the direct provision of health promotion,
disease prevention, and primary health care
services. Services are provided on the premises
of public housing developments or at other locations
immediately accessible to residents. In 2006,
HRSA funded health centers served over 129,000
residents of public housing.
Native Hawaiians – The Native Hawaiian
Health Care Program, funded within the health
center appropriation, improves the health status
of Native Hawaiians by making health education,
health promotion, and disease prevention services
available through the support of the Native
Hawaiian Health Care Systems. Native Hawaiians
face cultural, financial, social, and geographic
barriers that prevent them from utilizing existing
health services. In addition, health services
are often unavailable in the community. The
Native Hawaiian Health Care Systems use a combination
of outreach, referral, and linkage mechanisms
to provide or arrange services. Services provided
include nutrition programs, screening and control
of hypertension and diabetes, immunizations,
and basic primary care services. In 2006, Native
Hawaiian Systems provided medical and enabling
encounters to more than 6,163 people.
Allocation Method: Public and non-profit
private entities, including tribal, faith-based and
community-based organizations are eligible to apply
for funding under the Health Center Program. All Health
Center grants are awarded based on a competitive process
that includes an assessment of need and merit. In
addition, Health Center grantees are required to compete
for their existing service areas at the completion
of every project period (generally every 3 to 5 years).
Grant opportunities are announced nationally and applications
are then reviewed by objective review committees,
composed of experts who are qualified by training
and experience in particular fields related to the
Program.
Funding decisions are made based on committee assessments,
announced funding preferences and program priorities.
In addition to the Objective Review Committee (ORC)
score, various statutory awarding factors are applied
in the selection of Health Center grants. These include
funding preferences for applications serving a sparsely
populated area; consideration of the rural and urban
distribution of awards (no more than 60 percent and
no fewer than 40 percent of people served come from
either rural or urban areas); and a requirement for
continued proportionate distribution of funds to the
special populations served under the Health Center
Program.
Health Centers demonstrate performance by increasing
access, improving quality of care and health outcomes,
and promoting efficiency.
Increasing Access: Health Centers continue
to serve an increasing number of the Nation’s
medically underserved. The number of Health Center
patients served in 2006 was 15 million, exceeding
the annual target. This increased access beyond the
10.3 million patients served in 2001 represents over
a 46 percent increase within a 5-year period. Of these
15 million patients served, 92 percent were at or
below 200 percent of the Federal poverty level, 64
percent were from racial/ethnic minority groups, and
40 percent were uninsured. Success in increasing the
number of patients served has also been due in large
part to the development of new Health Centers, new
satellite sites, and expanded capacity at existing
clinics. Through FY 2007, the President’s Health
Centers Initiative, which began in FY 2002, has impacted
over 1,200 communities including the addition of 337
new access points and significantly expanded sites
in FY 2007. Health Center expansion exceeded targeted
goals for each year of the Presidential Initiative.
Improving Quality of Care and Health Outcomes:
Health centers continue to provide quality primary
and related health care services, improving the health
of the Nation’s underserved communities and
vulnerable populations. For example, by monitoring
timely entry into prenatal care, the program assesses
both quality of care as well as Health Center outreach
efforts. Identifying maternal disease and risks for
complications of pregnancy or birth during the first
trimester can also help improve birth outcomes. Results
over the past few years demonstrate improved performance
as the percentage of pregnant Health Center patients
that began prenatal care in the first trimester grew
from 57.8 percent in 2000 to 61.3 percent in 2006
virtually meeting the target of 61.4 percent. It should
also be noted that Health Centers serve a higher risk
prenatal population than seen nationally, making progress
on this measure a particular accomplishment.
Appropriate prenatal care management can also have
a significant effect on the incidence of low birth
weight (LBW), the risk factor most closely associated
with neonatal mortality. Monitoring birth weight rates
reflects both on quality of care and health outcomes
for Health Center women of child-bearing age, a key
group served by the Program. This measure is benchmarked
to the national rate to demonstrate how Health Center
performance compares to the performance of the nation
overall. In 2005, 7.3 percent of Health Center patients
had LBW infants, a rate that was 11 percent lower
than seen nationally (8.2 percent - 2005 national
LBW rate). The rate of LBW in Health Centers in 2006
fell slightly to 7.2 percent, as compared to the preliminary
national LBW of 8.3 percent. Health Center LBW rates
have continued to follow a steady pattern at about
7 percent, while increases have been observed in the
national rate (Source: Hamilton BE, Martin JA, Ventura
SJ. Births: Preliminary data for 2006. National vital
statistics reports; vol 56 no 7. Hyattsville, MD:
National Center for Health Statistics. 2007).
Health Center patients, including low-income individuals,
racial/ethnic minority groups and persons who are
uninsured, are more likely to suffer from chronic
diseases such as hypertension and diabetes. Clinical
evidence indicates that access to appropriate care
can improve the health status of patients with chronic
diseases and thus reduce or eliminate health disparities.
Two measures focus on quality of care and improved
health outcomes for these two highly prevalent chronic
conditions among Health Center patients.
Controlling blood pressure (hypertension) can reduce
the health risk associated with conditions such as
heart disease and stroke. However, with increasing
rates of hypertension, effective control is a particularly
ambitious undertaking as improvements in such a chronic
condition often requires treatment with both lifestyle
modifications, usually as the first step, and, if
needed, with medications. According to CDC data for
1999-2002, only 32 percent of adults nationally demonstrated
adequate high blood pressure control while the actual
performance for the Health Center Program in 2006
not only met, but also exceeded the annual target
at 44.4 percent. A second, health outcome measure
for Health Centers that focuses on control of diabetes
is developmental. Clinical evidence indicates that
controlling blood glucose through activities such
as chronic care management provided in Health Centers,
benefits people with either type-1 or type-2 diabetes.
Future progress on this developmental measure will
be monitored and reported annually by all grantees
via the Uniform Data System (UDS) beginning in 2009.
Promoting Efficiency: Health centers provide
cost effective, quality primary health care services.
The Program’s efficiency measure focuses on
maximizing the number of Health Center patients served
per dollar as well as keeping cost increases below
annual national health care cost increases while maintaining
access to high quality services. In looking at growth
in total cost per patient, the full complement of
services (medical, dental, mental health, pharmacy,
outreach, translation, etc.) that make Health Centers
a "health care home" are captured. In 2005,
the average cost per patient served at Health Centers
grew by only 2.1 percent. In 2006, costs grew at a
slightly higher rate (4.6 percent), but performance
was under the target growth rate of 5.4 percent. This
is about 33 percent below the 6.8 percent projected
growth rate for national health expenditures in 2006.
In fact, in the past 4 years, cost increases at Health
Centers have been at least 20 percent below national
cost increases. By restraining increases in the cost
per individual served at Health Centers below national
per capita health care cost increases, the Program
has served a volume of patients that otherwise would
have required additional funding to serve annually
and demonstrates that it delivers its high quality
services at a more cost-effective rate. Success in
achieving cost-effectiveness may in part be related
to Health Centers’ use of a multi and interdisciplinary
team that treats the “whole patient.”
This, in turn, is associated with the delivery of
high quality, culturally competent and comprehensive
primary and health care services that not only increases
access and reduces health disparities, but promotes
more effective care for Health Center patients. Evaluation
studies demonstrate that Medicaid beneficiaries receiving
care from a Health Center were less likely to be hospitalized
than Medicaid beneficiaries receiving care elsewhere
and were also less likely to inappropriately visit
the emergency room when compared to Medicaid beneficiaries
with another provider as their usual source of care.
Program Assessment Rating Tool: An Office
of Management and Budget (OMB) Program Assessment
Rating Tool (PART) reassessment of the Health Center
Program was conducted in 2007, and the Program received
the highest possible rating of Effective. The review
found that evaluations of the Program demonstrate
that it is effective at extending access and delivering
high quality health care to underserved populations
and that the Program has demonstrated progress in
meeting long-term and short-term performance goals.
It also found that collaboration with programs that
share common goals has been improved since the initial
PART assessment in 2002. In addition, the Program
is implementing improvements that include: 1) completion
of a national survey of Health Center patients to
expand and update information on program performance
and impact; and 2) program-wide collection of core
quality of care and health outcome performance measures,
such as hypertension and diabetes-related outcomes,
from all grantees by 2009.
External Evaluation: In addition to internal
monitoring of Health Center performance, peer reviewed
literature and major reports continue to document
that Health Centers successfully increase access to
care, promote quality and cost-effective care, and
improve patient outcomes, especially for traditionally
underserved populations.
Health Center uninsured patients are more likely to
have a usual source of care than the uninsured nationally
(98 percent vs. 75 percent) (Carlson et al. Journal
of Ambulatory Care Management 24, 2001, Starfield
and Shi. Pediatrics 113, 2004).
Health Centers provide continuous and high quality
primary care and reduce the use of costlier providers
of care, such as emergency departments and hospitals
(Proser M. Journal of Ambulatory Care Management 28(4),
2005).
Uninsured people living within close proximity to
a Health Center are less likely to have an unmet medical
need (Hadley J and Cunningham P. Health Services Research
39(5): 2004).
Health Centers have demonstrated success in chronic
disease management. A high proportion of Health Center
patients receive appropriate diabetes care (Maizlish
et al. American Journal of Medical Quality 19(4),
2004).
Medicaid beneficiaries receiving care from a Health
Center were less likely to be hospitalized than Medicaid
beneficiaries receiving care elsewhere (Falik M. et
al. Medical Care 39(6), 2001).
Health Center Medicaid patients were 11 percent less
likely to be inappropriately hospitalized and 19 percent
less likely to visit the emergency room inappropriately
than Medicaid beneficiaries who had another provider
as their usual source of care (Falik M. et al. Journal
of Ambulatory Care Management 29, 2006).
Health Centers have been found to improve patient
outcomes and reduce racial and ethnic disparities
in health care (O'Malley AS, et al. Health Affairs
24(2): 2005, Shin P, Jones K, and Rosenbaum S. George
Washington University: 2003, Shi, L., J. Regan, R.
Politzer, and J. Luo. International Journal of Health
Services 31(3): 2001).
Health Center low birth weight rates continue to be
lower than national averages for all infants. In particular,
the Health Center low birth weight for African American
patients is lower than the rate observed among African
Americans nationally (10.7 percent vs. 14.9 percent
respectively) (Shi et al. Health Services Research,
39:2004).
Health Center patient rates of blood pressure control
were better than rates in hospital affiliated clinics,
the Veterans Affairs health system, or in commercial
managed care populations (Hicks LS. et al. Health
Affairs 25, 2006). Funding includes costs associated
with grant reviews, processing of grants through the
Grants Administration Tracking and Evaluation System
(GATES) and HRSA’s electronic handbook, and
follow-up performance reviews.
Funding History
FY
2004 |
$1,617,629,000
|
FY
2005 |
$1,734,810,000 |
FY
2006 |
$1,785,076,000 |
FY
2007 |
$1,988,039,000
|
FY
2008 |
$2,065,022,000 |
Budget Request
The
FY 2009 Request of $2,091,792,000 is an increase of
$26,770,000 over the FY 2008 Enacted level. This funding
level will continue support to over 1,000 health center
grantees that provide comprehensive, culturally competent,
quality primary health care services through over
4,000 service delivery sites to an estimated 17.05
million medically underserved, low income patients
around the nation. The request includes $26,000,000
for the President’s goal of placing health centers
in high poverty areas. This will fund up to 40 new
access point grants in high poverty areas around the
Nation without a health center site. Priority points
will be available for applicants demonstrating that
they will serve areas (or populations) with a significant
percent of the population at or below 200 percent
of the Federal Poverty Level (FPL). This option would
maintain the Administration’s focus on highlighting
the needs of the highest poverty areas, by creating
an additional incentive to serve high poverty areas
where there is no existing health center. This would
allow for open competition at a national level –
and applicants would be eligible from all States.
In addition, this level will fund up to 25 planning
grants to community-based organizations for projects
to plan and develop Health Centers in high poverty
areas across the country. This support will enable
community-based entities in areas without the benefit
of a Health Center to enhance their readiness to implement
a health services delivery grant, and in some cases
provide an inducement for an organization to address
the health care needs of the underserved in a high
poverty area where there would otherwise be no expansion
activity.
The entire FY 2009 budget request will support the
Program’s achievement of its ambitious performance
targets. The Program will continue its central goal
of increasing access to care for more underserved
and vulnerable populations. Based on the final FY
2008 appropriation amounts, Health Centers are projected
to serve 16.75 million patients by the end of 2008
and increase further to 17.05 million patients by
the end of 2009.
As part of the Program’s efforts to improve
quality of care and health outcomes, the Health Center
program has established ambitious FY 2009 and out-year
targets. For low birth weight, the Program seeks to
be at least 11 percent below the national rate. While
the measure maintains the current ratio in the next
five years, it is ambitious because Health Centers
continue to serve a higher risk prenatal population
than represented nationally in terms of socio-economic,
health status and other factors that predispose Health
Center patients to greater risk for low birth weight
and adverse birth outcomes. The FY 2009 target for
the Program’s hypertension measure is to increase
the rate of adult patients with diagnosed hypertension
whose blood pressure is under adequate control to
43 percent. This target will be challenging to achieve
because improvements in a chronic condition require
treatment with lifestyle modifications, usually as
the first step, and, if needed, with medication. The
Program is developing a fourth measure related to
effective management of diabetes for which it will
begin collecting data in 2009. Consequently, it does
not yet have targets.
The Program will also continue to promote efficiency
and aims to keep cost per patient increases at least
20 percent below annual national health care cost
increases, as forecasted by the Center for Medicare
and Medicaid Services' National Health Expenditure
Projections. By benchmarking the Health Center efficiency
to national per capita health care cost increases,
the measure takes into account changes in the health
care marketplace while demonstrating the Program’s
ability to deliver services at a more cost-effective
rate. The target for FY 2009 is a 5.8 percent increase,
a rate that is 20 percent below the projected national
growth rate of 7.3 percent. To assist in areas of
cost-effectiveness, the program offers technical assistance
to grantees to review costs and revenues and develop
plans to implement effective cost containment strategies.
The budget request will also support the Program’s
ongoing involvement in an agency-wide effort to improve
quality and accountability in all HRSA-funded programs
that deliver direct health care. One of the key steps
the Health Center Program has taken in this area is
to establish a core set of clinical performance measures
for all Health Centers. The Program has aligned its
new required clinical performance measures that all
Health Center grantees will begin to report in 2009
with those of national quality measurement organizations,
such as the Ambulatory Care Quality Alliance and the
National Quality Forum, and are consistent with the
overarching goals of Healthy People 2010. Core measures
will include: Immunizations; Prenatal care; Cancer
screenings; Cardiovascular Disease/Hypertension; and
Diabetes.
In addition to tracking these core health outcome
indicators, Health Centers will also report data on
some of the measures (Low Birth Weight, Diabetes and
Hypertension) by race/ethnicity in order to demonstrate
progress towards eliminating health disparities in
health outcomes. To support quality improvement across
all Health Centers, the Program will continue to support
National and State-level technical and training programs
that promote quality improvements in health center
data and quality reporting, clinical and quality improvement,
and implementation of innovative quality activities.
The Program continues to promote the integration of
Health Information Technology (HIT) into Health Centers
as part of HRSA’s strategy to assure that key
safety-net providers are not left behind as this technology
advances. In addition to supporting funding opportunities
around HIT, HRSA will continue its partnership with
the Agency for Healthcare Research and Quality (AHRQ)
on the HRSA HIT Community Portal designed exclusively
for Health Centers, Primary Care Associations and
Primary Care Offices to access information about HIT,
share best practices, and support collaborative efforts
to expand access to HIT services.
Funding will also allow the Program to continue to
coordinate and collaborate with related Federal, State,
local, and private programs in order to further leverage
and promote efforts to expand and improve Health Centers.
The Program will continue to work with the AHRQ on
HIT, the Centers for Disease Control and Prevention
(CDC) to address Migrant Stream Farmworker issues
and HIV prevention initiatives, and the National Institutes
of Health (NIH) on US-Mexico Border health issues,
among others. In addition, the Program will continue
to coordinate with the Centers for Medicare and Medicaid
Services (CMS) to jointly review section 1115 Medicaid
Demonstration Waivers to address any concerns for
Health Centers within States. The Program will also
work closely with the Department of Justice on the
Federal Tort Claims Act (FTCA) program, which provides
medical malpractice liability protection to Section
330 supported Health Centers.
SOURCES OF REVENUE |
|
FY
2007
Enacted
|
FY
2008
President’s Budget |
FY
2009
Request |
Health
Centers |
$1,943.5
1/ |
$2,021.7 |
$2,047.7
|
Other Sources: |
|
|
|
Medicaid
|
3,025.0
|
3,145.0
|
3,185.0
|
Medicare
|
500.0 |
520.0 |
530.0 |
SCHIP |
180.0 |
190.0
|
190.0 |
Other
Third Party |
650.0 |
675.0 |
685.0 |
Self
Pay Collections |
550.0
|
575.0
|
585.0 |
Other
Federal Grants |
225.0
|
235.0 |
235.0
|
State/Local/Other
|
1,565.0
|
1,625.0 |
1,650.0 |
TOTAL
|
$8,638.5
|
$8,986.7 |
$9,107.7 |
1/ Excludes funding for Tort Claims: FY 2007 - $44.6
million, FY 2008 – $43.3 million, FY 2009 –
$44.1 million.
See Chart
|