HEALTH CENTER 

PROGRAM

2011 Grant Award 

Process Highlighted 

Need and Special 

Populations and 

Merits Evaluation

Report to Congressional Requesters

May 2012

GAO-12-504

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-504, a report to 

congressional requesters

May 2012

HEALTH CENTER PROGRAM 

2011 Grant Award Process Highlighted Need and 

Special Populations and Merits Evaluation

Why GAO Did This Study

Health centers funded in part by grants 

from HRSA’s Health Center Program, 

under Section 330 of the Public Health 

Service Act, provide comprehensive 

primary care services for the medically 

underserved, including many poor, 

uninsured, and Medicaid patients. 

Legislation enacted in 2009 and 2010 

provided additional funding that could 

significantly expand health center 

capacity over the next several years. 

GAO was asked to review HRSA’s 

process for awarding grants for new 

delivery sites and possible effects of 

health centers, such as competition, on 

other providers. This report examines 

(1) the actions HRSA has recently 

taken to target its grants for new 

delivery sites to health centers in 

communities with demonstrated need 

and the outcome of HRSA’s award 

process in recent years, and (2) the 

extent to which HRSA-funded health 

centers collaborate and compete with 

other health care providers in their 

service area. GAO focused its work on 

NAP grants, HRSA’s primary means of 

establishing new health centers and 

delivery sites, during fiscal years 2008 

through 2011. GAO analyzed HRSA 

documents and interviewed HRSA 

officials, and interviewed officials from 

11 health centers and providers and 

officials in their service areas.

What GAO Recommends

The Secretary of HHS should direct the 

Administrator of HRSA to evaluate the 

fiscal year 2011 NAP grant award 

process for effectiveness and 

transparency, identify lessons learned, 

and incorporate any improvements for 

future funding cycles. HHS agreed with 

GAO’s findings and recommendation 

and said HRSA has begun to take 

action.

What GAO Found

The Department of Health and Human Services’ (HHS) Health Resources and 

Services Administration (HRSA) revised its New Access Point (NAP) competitive 

award process in fiscal year 2011 to increase the emphasis on the need for 

services in the applicant’s proposed service area, and on the three special 

populations—migrant and seasonal farmworkers, homeless people, and 

residents of public housing—designated by the Public Health Service Act. The 

act requires that certain proportions of Health Center Program funding go to 

health centers serving the special populations. To increase the emphasis on 

need, HRSA increased the weight given to need in the application review 

process. To target health centers serving special populations, HRSA gave extra 

points in the application process to applicants proposing to serve them. When 

this was insufficient to meet the required proportions, HRSA moved some 

applicants ahead of others in the award rank order list, a method it had used in 

the past. The effect of HRSA’s actions on the award outcome was magnified in 

fiscal year 2011 because (1) HRSA received less program funding than it had 

anticipated, and (2) it needed to increase the share of grants going to health 

centers serving the special populations because HRSA had not applied the 

statutory proportions when it used American Recovery and Reinvestment Act 

funding to award grants in fiscal year 2009. As a result, HRSA awarded 67 NAP 

grants in fiscal year 2011, 57 of which went to applicants proposing to serve at 

least one special population; 13 of the 57 received grants by being moved ahead 

of other applicants with equal or higher review scores. HRSA announced the 

extra points in application guidance, but not the potential moving of some 

applicants ahead of others. As HRSA has periodically needed to take actions to 

meet its statutory obligations and may need to do so again, evaluating the 

effectiveness and transparency of its most recent New Access Point grant award 

process could help it identify lessons and possible improvements for the future.

Health centers in the communities GAO studied collaborate with other providers 

and generally do not compete with them for patients, but GAO found greater 

potential for competition in rural areas. Health center officials described 

collaborative relationships with other providers that give patients access to 

services not available through the health center. Health centers and other 

providers told GAO they generally do not compete for patients; health centers 

typically serve patients not treated elsewhere, such as uninsured and Medicaid 

patients. However, because the health center grant covers, on average, about 20 

percent of a center’s budget, other funding must also be secured, such as by 

serving insured patients, for the center to be financially sustainable. This can 

result in competition with other providers in its service area. During the award 

process, HRSA takes steps to reduce competition by identifying nearby safety 

net providers and assessing whether the level of unmet need in the area 

warrants a grant for a new health center or delivery site. Greater potential for 

competition exists in rural areas because patients there are more likely to be 

insured and rural health clinics and certain hospitals might seek to serve some of 

the same patients as health centers, although they may not offer all of the 

View GAO-12-504. For more information, services required of health centers.

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-12-504 Health Center Funding

Letter 1 

Background 7

HRSA Revised 2011 Award Process, and Most New Access Point 

Grants Went to Health Centers Serving Special Populations 14

Health Centers and Other Providers Reported Collaboration and 

Little or No Competition, but Rural Areas Have Greater Potential 

for Competition 28

Conclusions 33

Recommendation for Executive Action 34

Agency Comments 35

Appendix I New Access Point Grant Awards, Fiscal Years 2008-2011, and 

Total Health Center Grantees, 2010 37

Appendix II Ratio of Health Center Grantees to Population Living in Poverty, 

by State, 2010 40

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

Appendix IV GAO Contact and Staff Acknowledgments 47

Related GAO Products 48

Tables

Table 1: HRSA’s New Access Point Grants to Health Centers, Fiscal 

Years 2008-2011 10

Table 2: HRSA’s Scoring Criteria and Maximum Base Points 

Awarded for New Access Point Grant Applications, Fiscal 

Years 2008, 2009, and 2011 16

Table 3: Extra Points Awarded by HRSA to New Access Point 

Applicants in Fiscal Year 2011 18

Contents
Page ii GAO-12-504 Health Center Funding

Table 4: Selected Socioeconomic Characteristics for New Access 

Point Grantees’ Delivery Sites, in Aggregate, Compared to 

National Average, Fiscal Years 2008, 2009, and 2011 27

Table 5: New Access Point Grant Awards, Fiscal Years 2008-2011, 

and Number and Percentage of Total Health Center 

Grantees, 2010, by State and Territory 37

Table 6: Ratio of Health Center Grantees to Population Living in 

Poverty, by State, 2010 40

Figures

Figure 1: Insurance Coverage of Health Center Patients, 

Nationwide, 2010 8

Figure 2: Health Center Revenue Sources, Nationwide, 2010 9

Figure 3: HRSA’s New Access Point Grant Award Process in Fiscal 

Year 2011 20

Figure 4: HRSA New Access Point Grant Awards, Fiscal Year 2011, 

and Total Health Center Grantees, 2010 24

Figure 5: Number of New Access Point (NAP) Grants Awarded by 

HRSA and Delivery Sites the Grants Funded, by Fiscal 

Year 26
Page iii GAO-12-504 Health Center Funding

Abbreviations

ACS American Community Survey

HHS Department of Health and Human Services

HPSA health professional shortage area

HRSA Health Resources and Services Administration

MUA medically underserved area

MUP medically underserved population

PCA primary care association

PCO primary care office

PPACA Patient Protection and Affordable Care Act

UDS Uniform Data System

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Page 1 GAO-12-504 Health Center Funding

United States Government Accountability Office

Washington, DC 20548

May 29, 2012

The Honorable Michael B. Enzi

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Richard Burr

Ranking Member

Subcommittee on Children and Families

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Tom Coburn

Ranking Member

Permanent Subcommittee on Investigations

Committee on Homeland Security and Governmental Affairs

United States Senate

The nationwide network of health centers in the federal Health Center 

Program is an important component of the health care safety net for 

vulnerable populations, including Medicaid beneficiaries,1 people who are 

uninsured, and others who may have difficulty obtaining access to health 

care. In 2010, more than 1,100 health centers operated more than 

8,100 delivery sites across all the states2 and served more than 19 million 

people. These health centers provide comprehensive primary health care 

services—preventive, diagnostic, treatment, and emergency services, as 

well as referrals to specialty care—without regard to a patient’s ability to 

pay. Through its Health Center Program, the Department of Health and 

Human Services’ (HHS) Health Resources and Services Administration 

(HRSA) awards grants to eligible health centers under Section 330 of the 

Public Health Service Act.3

 

1

Medicaid is a joint federal and state program that finances health insurance for certain 

low-income adults and children.

HRSA funds the establishment of new health 

2

In this report, “state” refers to the 50 states, the District of Columbia, and Puerto Rico. 

There are also delivery sites in six territories.

3

42 U.S.C. § 254b.

 
 

Page 2 GAO-12-504 Health Center Funding

center delivery sites—for both new and existing grantees—through its 

New Access Point grants.

To be eligible for a grant, an applicant must serve a federally designated 

medically underserved area (MUA) or a federally designated medically 

underserved population (MUP).4 Among other things, HRSA is required to 

ensure that an applicant has made efforts to establish and maintain 

collaborative relationships with other health care providers in its service 

area before awarding a grant.5 The scope of a health center’s activities is 

delineated in its grant application and consists of its services, delivery 

sites, providers, target population, and service area. In addition, 

applicants must describe a specific need for services in the area they plan 

to serve, based on factors such as unique health care needs of the target 

population or particular provider shortages. There are four types of health 

centers funded through the Health Center Program: community health 

centers, funded to serve all members of an underserved community, and 

three types specifically funded to serve designated special populations—

migrant and seasonal farmworkers, homeless people, and residents of 

public housing.

6 The four types of health centers were consolidated into a 

single program in 1996;7

 

4

HRSA designates MUAs based on a geographic region, such as a county, and it 

designates MUPs based on a specific population that demonstrates economic, cultural, or 

linguistic barriers to primary care services. Criteria for designating a medically 

underserved area or population include the ratio of primary care physicians per 1,000 

population, infant mortality rate, percentage of the population with incomes below the 

federal poverty level, and percentage of the population age 65 and older. In 1998 and 

again in 2008, HRSA proposed new rules for designation of medically underserved 

communities and populations with health professional shortages and/or high unmet needs 

for health services. In both cases, HRSA received a large volume of critical comments 

upon publication of the proposed rules, and ultimately withdrew them. Subsequently, the 

2010 Patient Protection and Affordable Care Act required the formation of a negotiated 

rulemaking committee to develop a comprehensive methodology and criteria for MUP and 

Health Professional Shortage Area (HPSA) designations. The Negotiated Rulemaking 

Committee on the Designation of MUPs and HPSAs completed its work in October 2011, 

and HRSA is drafting an interim final rule.

prior to the consolidation, the grantees serving 

the three designated special populations were funded through separate 

programs.

5

42 U.S.C. § 254b(k)(3)(B). 

6

HRSA guidance states that to be funded as an organization that serves a special 

population, a health center must devote at least 25 percent of its HRSA funding to serving 

one or more of the three designated special populations. 

7

Health Centers Consolidation Act of 1996, Pub L. No. 104-299, 110 Stat. 3626.
 

Page 3 GAO-12-504 Health Center Funding

For each of fiscal years 2009 and 2010, HRSA allocated almost 

$2.2 billion in annual appropriations to the Health Center Program;8,9 of 

that amount, nearly $2 billion each year was used for health center 

grants.10 In addition, the American Recovery and Reinvestment Act of 

2009 (Recovery Act)11 appropriated $2 billion for health centers to be 

used over those 2 years. In fiscal year 2011, HRSA allocated $1.6 billion 

in annual appropriations to the Health Center Program. This amount 

reflected a reduction of $604 million as a result of a reduction in 

appropriations to HRSA and a rescission of appropriations made for that 

year for nondefense programs; these reductions occurred after the fiscal 

year had begun and resulted in HRSA receiving less funding for the 

Health Center Program than it had anticipated. However, the Patient 

Protection and Affordable Care Act (PPACA), as amended by the Health 

Care and Education Reconciliation Act of 2010, provided an additional 

$11 billion over 5 years—beginning with $1 billion for fiscal year 2011—

for the operation, expansion, and construction of health centers.12

In light of the additional funds provided to the Health Center Program 

through the Recovery Act and PPACA, you asked us to review HRSA’s 

awarding of new grants to communities with a need for services, and 

about possible effects, such as competition, on other providers resulting 

from the increased support for health centers. In this report, we examine 

(1) the actions HRSA has recently taken to target its grants for new 

delivery sites to health centers in communities with demonstrated need, 

and the outcome of HRSA’s award process in recent years; and (2) the 

extent to which federally funded health centers collaborate and compete 

with other health care providers in their service area.

As a 

result, health center capacity is expected to expand significantly over the 

next several years.

 

8

HRSA allocates funds to the Health Center Program out of the annual appropriation 

made to the agency for its programs. 

9

In fiscal year 2008, the Health Center Program’s allocation was nearly $2.1 billion.

10The remainder was used to fund other activities that support the Health Center Program, 

such as cooperative agreements with nonprofit organizations that assist health centers.

11Pub. L. No. 111-5, 123 Stat. 115. 

12Pub. L. No. 111-148, § 10503, 124 Stat.119, 1004 (2010); Pub. L. No. 111-152, § 2303, 

124 Stat. 1029, 1083. In this report, references to “PPACA” are to the Patient Protection 

and Affordable Care Act, as amended by the Health Care and Education Reconciliation 

Act of 2010.
 

Page 4 GAO-12-504 Health Center Funding

To examine the actions HRSA has recently taken to target its grants for 

new delivery sites to health centers in communities with demonstrated 

need and the outcome of HRSA’s award process in recent years, we 

focused our work on New Access Point grants, because these grants are 

HRSA’s primary means of establishing new health centers and delivery 

sites,13 and because applicants are required to demonstrate the need for 

health care services in a newly proposed service area. We reviewed 

HRSA program documents and web-based resources and interviewed 

HRSA officials to obtain information about the agency’s process for 

awarding grants, including any changes HRSA made between fiscal 

years 2008 and 2011 to the New Access Point grant application guidance 

and the criteria used for reviewing and scoring applications. We also 

reviewed applicant scores and rankings during that period. We 

interviewed health center officials and reviewed grant applications from

nine selected health centers that received New Access Point grants 

during fiscal years 2008 through 2011 to obtain the health centers’ 

perspective on their experience applying for a grant and to review the 

information they provided to HRSA.14 We chose the health centers based 

on criteria that included geographic diversity, patient demographics 

(e.g., percentage of population in poverty and insurance status), and sitespecific information (e.g., number of delivery sites operated by the 

grantee and U.S. Census Bureau urban/rural continuum category).15

 

13HRSA can also award funds through a competitive process to a new health center 

grantee to serve an existing grantee’s service area under certain circumstances, such as 

when the existing health center grantee’s grant period expires or when the existing 

grantee is no longer able to serve its service area. 

We 

obtained data used in our selection process from HRSA’s 2010 Uniform 

Data System (UDS) and 2009-2010 Area Resource File (ARF), the most 

14We selected grantees that received grants for new health centers, rather than existing 

grantees that received grants for new delivery sites, to focus on grantees whose 

applications described all their funded delivery sites. The selected grantees were located 

in the following states: California, Florida, Illinois, Kansas, New York, North Carolina, 

Oklahoma, Vermont, and Virginia.

15Because HRSA does not collect data on the population served and types of services 

provided at individual health center sites, we used the grantee’s main address as a proxy 

for the site’s location. We eliminated from consideration grantees for which the main 

address is a site that serves a purely administrative function.
 

Page 5 GAO-12-504 Health Center Funding

recent data available.16 To assess the reliability of the UDS and ARF data

elements that we used in our selection, we performed checks, such as 

examining the data for missing values, and reviewed related 

documentation. We determined that the UDS and ARF data were 

sufficiently reliable for our purposes. We chose three grantees each from 

fiscal years 2008, 2009, and 2011 to represent various funding sources.17

To identify the level of need in the communities served by applicants that 

received New Access Point grants, we also analyzed data on selected 

socioeconomic characteristics (e.g., the percentage of the population 

living in poverty and the unemployment rate) for all delivery site locations 

funded through these grants from fiscal years 2008 through 2011. To do 

this, we determined the county in which each delivery site was located 

based on its zip code, and reviewed and analyzed county-level data from 

the U.S. Census Bureau’s 2006-2010 and 2008-2010 American 

Community Survey (ACS), which contained the most recent available 

data.

(HRSA did not award any New Access Point grants in fiscal year 2010.)

18

To examine the extent to which federally funded health centers 

collaborate and compete with other health care providers in their service 

area, we reviewed HRSA program documentation, policies, and guidance 

To assess the reliability of the ACS data elements that we used in 

our analysis, we performed checks, such as examining the data for 

missing values, and reviewed related documentation. We determined that 

the ACS data were sufficiently reliable for our purposes.

 

16We also obtained data from the 2008 and 2009 UDS for grantees funded in those years. 

The UDS is the Health Center Program’s administrative database, through which all 

grantees are required to submit data on their operations each year, including data on their 

delivery sites, patients, revenues, and expenses. The ARF is a county-based health

resources database that contains data from many sources, including the U.S. Census 

Bureau and the American Medical Association.

17New Access Point grants in fiscal year 2008 were funded by the Consolidation 

Appropriations Act, 2008. Pub. L. No. 110-161, 121 Stat. 1877 (2007). All New Access 

Point grants in fiscal years 2009 and 2011 were funded with Recovery Act and PPACA 

funds, respectively. 

18County-level data may not provide a fully accurate depiction of the socioeconomic 

characteristics for some delivery site locations because the health center’s service area 

may be smaller than the county as a whole, and other locations in the county may have 

different characteristics. This could result in data linked to the delivery site being diluted by 

overall county data and certain characteristics, such as the percentage of the population 

living in poverty, being underestimated. However, county-level data are the best data 

available.
 

Page 6 GAO-12-504 Health Center Funding

related to collaboration and service area overlap and interviewed HRSA 

officials. For this objective, we interviewed officials from the six health 

center grantees selected for our first objective that received New Access 

Point grants in fiscal years 2008 and 2009, but we did not include the 

three 2011 grantees. We did not interview officials from the fiscal year 

2011 grantees because these grantees received their awards in August 

2011 and were not yet fully operational, although we did review their grant 

applications for discussions of collaborative efforts. We also interviewed 

officials from two additional grantees that were funded prior to 2008—

which were selected using criteria similar to those used for the other 

grantees.19 We asked the officials from both groups of health centers

about their relationships with other providers in their communities, 

including any collaboration or competition with them. To obtain 

information on the eight health centers’ communities and their 

relationships with other providers, we also interviewed officials from 

primary care associations (PCA)—nonprofit organizations that support 

health centers at the state or regional level—and state primary care 

offices (PCO)—state government entities that work toward addressing the 

needs of the medically underserved in their states and receive funding 

from HRSA and other sources. We also interviewed representatives of 

hospitals and other providers, such as rural health clinics and private 

physician practices, and officials from community organizations with 

knowledge of the local health care environment in the health centers’ 

communities. The information obtained about individual health centers 

and their communities through our interviews with officials from health 

centers, PCAs, PCOs, hospitals, other providers, and community 

organizations cannot be generalized to other health centers. In addition, 

we interviewed officials from national stakeholder groups, including the 

National Association of Community Health Centers, American Hospital 

Association, National Association of Rural Health Clinics, and National 

Rural Health Association about the extent to which there is collaboration 

and competition between health centers and other providers in general.

 

19We added the two additional grantees that were initially funded prior to 2008 because 

they had been in operation longer than the other selected grantees and could provide the 

perspective of grantees with more years of experience. These two grantees had been 

funded through the Health Center Program for 28 and 29 years, respectively. The two 

additional grantees were located in Alabama and New York.
 

Page 7 GAO-12-504 Health Center Funding

We conducted this performance audit from July 2011 to May 2012 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Health centers are private, nonprofit community-based organizations or, 

less commonly, public organizations such as public health department 

clinics. Section 330 of the Public Health Service Act, which authorizes the 

Health Center Program, requires health centers to provide a 

comprehensive set of primary health care services, including enabling 

services—such as language translation and transportation—that facilitate 

access to health care. Among other things, health centers are also 

required to have a sliding fee scale based on a patient’s ability to pay and 

to be governed by a community board of which at least 51 percent of the 

members are patients of the health center.20

In 2010, nearly 93 percent of all health center patients had incomes at or 

below 200 percent of the federal poverty level, and nearly 72 percent had 

incomes at or below 100 percent.21

 

20HRSA may waive the governing board requirement for certain centers upon a showing 

of good cause. For information on HRSA’s oversight of the Health Center Program, see 

GAO, Health Center Program: Improved Oversight Needed to Ensure Grantee 

Compliance with Requirements, 

About 39 percent of patients were 

insured by Medicaid, and nearly 38 percent were uninsured. See figure 1 

for more information on insurance coverage of health center patients.

GAO-12-546 (Washington, D.C.: May 29, 2012). 

21The characteristics of individual health centers’ patient populations—such as insurance 

coverage and income level—vary.

Background 

Health Center Patients, 

Revenue, and Grants
 

Page 8 GAO-12-504 Health Center Funding

Figure 1: Insurance Coverage of Health Center Patients, Nationwide, 2010

Notes: The most recent available data on health center patients’ insurance coverage come from the 

2010 Uniform Data System (UDS). 

Children covered under the State Children’s Health Insurance Program (CHIP)—a joint federal and 

state insurance program for certain low-income, uninsured children whose family income is too high 

for Medicaid eligibility—are included in either the Medicaid or Other public categories.

Health center revenue comes from multiple sources, including public and 

private insurance and grants from federal, state, and local governments 

and private organizations. The single largest source of health center 

revenue is Medicaid, which provided nearly 38 percent of health center 

revenue in 2010. (See fig. 2.) Together, HRSA Health Center Program 

grants funded through annual appropriations and grants funded through 

the Recovery Act constituted about 21 percent of total health center 

revenue in that year.22

 

22The revenue from grants funded through annual appropriations accounted for 

15.7 percent of the total, and the revenue from grants funded through the Recovery Act 

accounted for 5.7 percent of the total.
 

Page 9 GAO-12-504 Health Center Funding

Figure 2: Health Center Revenue Sources, Nationwide, 2010

Note: The most recent available data on health centers’ revenue sources come from the 2010 

Uniform Data System (UDS).

a

The Recovery Act is the American Recovery and Reinvestment Act of 2009. Pub. L. No. 111-5, 

123 Stat. 115 (Feb. 17, 2009).

The Health Center Program provides several types of grants, and New 

Access Point grants are used to establish new health center delivery 

sites—whether for a new health center grantee or an existing grantee.23

 

23Other types of competitive grants that the Health Center Program provides include 

grants to expand the types of services available at a given delivery site and planning 

grants to assist organizations in planning a potential HRSA-supported health center. In 

addition, HRSA has provided competitive grants to health centers to support construction 

and renovation, which were funded through the Recovery Act and PPACA.

Grantees may request funding to operate one or more types of health 

centers, such as a community health center and one serving migrant and 

seasonal farmworkers. Once a health center is an established grantee, it 

must compete periodically to maintain its grant funding for its specific 

service area. The vast majority of health center grant funds distributed 
 

Page 10 GAO-12-504 Health Center Funding

each year by HRSA—for example, 96 percent in fiscal year 2008—are 

used to support continuing operations for established grantees and their 

existing delivery sites; New Access Point grants made up about 1 percent 

of the funds distributed in fiscal year 2008, the last year these grants were 

funded through annual appropriations. In fiscal years 2009 and 2011, 

HRSA used additional resources provided through the Recovery Act and 

PPACA, respectively, to fund New Access Point grants. See table 1 for 

more information on the New Access Point grants HRSA awarded in 

fiscal years 2008 through 2011.

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

2011

Fiscal year

Number of New Access 

Point grant awards

Total dollar amount provided 

through New Access Point grants

2008 41 $22.0 million

2009 126 $154.9 million a

2010 None N/A b

2011 67 $28.8 million c

Source: GAO analysis of HRSA data.

a

In fiscal year 2009, HRSA used Recovery Act funds for all New Access Point grants.

b

In fiscal year 2010, HRSA did not award any New Access Point grants.

c

In fiscal year 2011, HRSA used PPACA funds for all New Access Point grants.

HRSA has cooperative agreements with PCAs to provide training and 

technical assistance to health centers and other safety net providers, 

support the development of health centers in their state, and enhance the 

operations and performance of health centers. PCAs also assist in 

planning for the growth of health centers in their states and help 

communities apply for and obtain funds for new health centers and 

delivery sites. HRSA also relies on PCAs to identify underserved areas 

and populations in their state/region.
 

Page 11 GAO-12-504 Health Center Funding

HRSA uses a competitive process to award New Access Point grants.24

Announcement and Assistance. After announcing a funding opportunity 

via its website and Grants.gov, HRSA issues grant application guidance, 

which includes the forms applicants need to submit and a detailed 

description of the application review criteria and process. HRSA also 

provides applicants with access to technical assistance during the 

development of grant applications. For example, through cooperative 

agreements with HRSA, PCAs and the National Association of 

Community Health Centers offer training sessions on topics such as 

proposal writing and conducting a community assessment, which may 

include an analysis of the other providers in an area and any unmet 

health care needs.

Application Preparation and Submission. Applicants must prepare and 

submit the application materials to HRSA through Grants.gov and the 

agency’s website. The application materials include several narrative 

sections as outlined in the guidance from HRSA, as well as attachments 

such as a proposed budget, organizational chart, and summary of any 

current or proposed contracts to provide services outlined in the 

application.

Eligibility. Grant applications undergo an initial review for eligibility in 

which HRSA screens applications based on specific criteria, as described 

in the funding announcement. For example, the applicant must be 

applying for a grant for which it is eligible (e.g., certain HRSA grants are 

available only to existing grantees), and the application must include all 

required documents.

Review. Independent reviewers who are not affiliated with the Health 

Center Program, but have experience in a field relevant to the program, 

are selected by HRSA to review and score all eligible applications against 

established criteria, each of which has a specified point range. (We 

discuss the review criteria and point ranges in greater detail below.) For 

example, reviewers assess the description of the specific need for 

services in the area the applicant plans to serve—including the 

characteristics of its target population, the availability of services from 

 

24The process HRSA uses to award New Access Point grants is generally the same 

process it uses for its other competitive grant awards.

HRSA’s Award Process for 

New Access Point Grants
 

Page 12 GAO-12-504 Health Center Funding

other providers, and any gaps in the availability of services—as well as 

the applicant’s capacity and readiness to initiate the proposed services. 

After reviewers score the applications, all applicants are ranked in an 

initial rank order list, which is provided to HRSA officials for grant award 

consideration.

Assessment of Service Area Overlap. Once applications have been 

scored and ranked, HRSA conducts a review of the potential for service 

area overlap between proposed delivery sites and certain existing safety 

net providers, including hospitals.25

Award Decisions. The Associate Administrator for Primary Health Care 

in HRSA makes final award decisions.

HRSA has a policy describing this 

process. HRSA first identifies the existing safety net providers and the 

patient population in the area to determine whether there is any unmet 

need. This step includes determining the size of the population with 

incomes below 200 percent of the federal poverty level and the size of the 

population without health insurance. HRSA then assesses the applicant’s 

ability to fill any service gaps identified in the area. On rare occasions, 

HRSA may also conduct a site visit to an area to collect additional 

information to inform its decision. After its assessment, the agency may 

determine that there is not sufficient unmet need in the area to warrant a 

grant award or it may choose to award a grant despite service area 

overlap if it determines that the level of unmet need exceeds the capacity 

of existing providers.

• Basis of Award Decisions. The Associate Administrator bases 

award decisions on the ranked application scores, while also taking 

into account a variety of factors such as whether the applicant is 

located in a sparsely populated rural area, the urban/rural mix of grant 

 

25According to HRSA, the safety net providers included in its review are federally qualified 

health centers, public hospitals/health department primary care clinics, critical access 

hospitals with primary care capacity, and rural health clinics. Generally, critical access 

hospitals are small hospitals—with no more than 25 inpatient beds—in rural communities. 

Rural health clinics provide primary care services similar to those provided by health 

centers in underserved rural communities; however, they are not required to provide the 

range of services offered by health centers or to serve all individuals. Both critical access 

hospitals and rural health clinics are certified as such by the Centers for Medicare & 

Medicaid Services and receive enhanced payments for the services they provide to 

Medicare and Medicaid patients. Rural health clinics receive enhanced payments that are 

lower than the rate health centers receive.
 

Page 13 GAO-12-504 Health Center Funding

awards,26 and the distribution of funds across the different types of 

health centers.

• Required Funding Proportions for Designated Special 

Populations. The Public Health Service Act requires that HRSA 

ensure that a certain proportion of the total annual appropriation 

allocated to the Health Center Program is made available for grants 

serving each of the three designated special populations—migrant 

and seasonal farmworkers, homeless people, and residents of public 

housing.27 These populations are particularly vulnerable and often 

have specific health and access problems. The proportions of funding 

that must be maintained are 8.6 percent for health centers serving 

migrant and seasonal farmworkers, 8.7 percent for health centers 

serving homeless people, and 1.2 percent for health centers serving 

residents of public housing.28 These proportions were established 

when the Health Center Program was consolidated in 1996 and were 

generally maintained in subsequent legislation authorizing

appropriations for the Health Center program. Most recently, 

legislation authorizing appropriations in 2008 and 2010 did not alter 

these proportions.29

 

26HRSA is required to make awards so that 40 to 60 percent of patients expected to be 

served reside in rural areas. 42 U.S.C. § 254b(k)(4).

2742 U.S.C. § 254b(r)(2)(B).

28In previous years, HRSA has taken actions when making New Access Point grant 

awards to ensure that these proportions were met. For example, in fiscal year 2004, it 

chose to award grants only to applicants requesting funding to serve migrant and 

homeless populations. See GAO, Health Centers: Competition for Grants and Efforts to 

Measure Performance Have Increased, GAO-05-645 (Washington, D.C.: July 13, 2005), 

40.

29The proportional funding requirement was established when the Health Center Program 

was consolidated in 1996 to maintain for fiscal year 1997 the proportions of funding that 

previously were provided for these same designated populations when they were funded 

through separate programs. HRSA was permitted to increase or decrease these 

proportions by 10 percent for fiscal years 1998 and 1999, but during those years HRSA 

maintained the 1997 proportions without adjusting them, and HRSA continued to award 

grants in the same proportions in fiscal years 2000 and 2001. In 2002, legislation 

authorizing appropriations for the Health Center Program required that the proportions be 

maintained going forward.
 

Page 14 GAO-12-504 Health Center Funding

• Required Consideration of Sparsely Populated Areas. The Public 

Health Service Act also requires that HRSA give special consideration 

to applicants in sparsely populated areas.30 HRSA defines these as 

areas with seven or fewer residents per square mile.

Funding for Grant Awards. For New Access Point grants, HRSA 

approves funding for a 2-year project period; prior to fiscal year 2009, the 

project period for New Access Point grants was up to 3 years. HRSA 

provides an initial grant for the first year of the project; a health center 

grantee obtains grants for each subsequent year in the project period 

through a noncompetitive process in which the grantee must demonstrate 

that it has made satisfactory progress in providing services.31 A grantee 

demonstrates its progress by submitting a progress report for HRSA’s 

review. At the end of the New Access Point project period, new health 

center grantees compete to continue receiving Health Center Program 

funding to serve their service area; the project period for these 

competitive continuing operations grants is typically 3 or 5 years.32

HRSA revised its New Access Point award process for fiscal year 2011 to 

increase the emphasis on need and on the designated special 

populations. As a result of these changes and HRSA’s receiving less 

fiscal year 2011 funding than it had anticipated, a high proportion of 

grants went to health centers serving the designated special populations.

 

3042 U.S.C. § 254b(p).

31Noncompetitive continuation funding is also contingent on the availability of funds.

32These competitive continuing operations grants are known as Service Area Competition 

grants.

HRSA Revised 2011 

Award Process, and 

Most New Access 

Point Grants Went to 

Health Centers 

Serving Special 

Populations 
 

Page 15 GAO-12-504 Health Center Funding

HRSA revised the New Access Point grant application and award process 

for fiscal year 2011. According to HRSA officials, it did so to better target 

resources to communities with high need because it found that the 

previous process did not adequately factor need into the application 

score, and because past applicants and grantees expressed concerns 

about this issue. One step HRSA took was to increase the need score 

from 10 to 30 points, out of a maximum of 100 base points. (See table 2.) 

Twenty of the 30 points are available for applicant responses provided on 

an attached form that documents barriers to access to care and various 

health indicators in the proposed service area, and the remaining 

10 points are available based on the applicant’s narrative describing 

health care need.33

 

33Independent reviewers assess only the 10 points from the application’s narrative on 

need. The 20 points from the attached form are based on data submitted by the applicant 

and converted to predetermined point values as detailed in HRSA’s application guidance. 

HRSA Increased Weight 

Given to Need and 

Emphasized Special 

Populations in 2011 Award 

Process
 

Page 16 GAO-12-504 Health Center Funding

Table 2: HRSA’s Scoring Criteria and Maximum Base Points Awarded for New Access Point Grant Applications, Fiscal Years 

2008, 2009, and 2011

Scoring criterion Description

Maximum base points for 

fiscal years 2008 and 2009

Maximum base points for 

fiscal year 2011

Need The applicant’s description of health care need 

in the proposed service area.

10 30

Response The applicant’s proposal to respond to the 

health care need.

30 20

Collaboration The applicant’s plans for coordinating services 

with other providers in its proposed service area.

N/A 10 a

Evaluative measures The applicant’s ability to measure its own 

performance.

10 5 

Impact The applicant’s justification for requested 

funding and explanation of how it will increase 

access to care.

10 5 

Resources/Capabilities The applicant’s organizational and financial plan 

and past accomplishments.

15 10

Support requested The applicant’s budget. 10 10

Governance The applicant’s plans for establishing a 

governing board.

10 10

Readiness The applicant’s ability to begin providing 

services.

5 N/Ab

Total 100 100

Source: GAO analysis of HRSA documents.

Note: HRSA did not award any New Access Point grants in fiscal year 2010.

a

For fiscal year 2011 New Access Point applications, HRSA included a separate criterion for 

Collaboration that formerly was part of the Response criterion in fiscal year 2008 and 2009 

applications.

b

For fiscal year 2011 New Access Point applications, HRSA eliminated the Readiness criterion; some 

of the Readiness provisions became a part of the Resources/Capabilities criterion.

HRSA also revised its award process in fiscal year 2011 to award extra 

points, which HRSA calls priority points, over the maximum 100 base 

points to applicants seeking to serve the three designated special 

populations and sparsely populated areas. HRSA did this to help it 

continue to meet the Public Health Service Act requirements regarding 

these populations.34

 

3442 U.S.C. §§ 254b(r)(2)(B), (p).

In addition, HRSA decided to award extra points to 

applicants seeking to serve high-poverty areas to further increase the 

emphasis on need in the award process. This was the first time HRSA 
 

Page 17 GAO-12-504 Health Center Funding

awarded such extra points, and the application guidance described how 

the points would be awarded, providing transparency for this aspect of the 

process. (See table 3.) HRSA officials applied the extra points to 

applicants’ base scores out of 100;35 these adjusted scores were used to 

update and finalize the rank order list of all applicants. HRSA awarded 

from 5 to 10 extra points for serving one or more of the designated 

special populations, 5 extra points for serving a sparsely populated area, 

and up to 5 extra points for serving a high-poverty area.

 

35For each application, HRSA averages the scores assigned by each reviewer in the 

panel. Depending on the number of applications it receives, HRSA may use multiple 

review panels during a funding cycle. When this occurs, HRSA uses a statistical method 

to adjust the scores for variation among different review panels. This process could result 

in adjusted scores of over 100 before extra points have been awarded. 
 

Page 18 GAO-12-504 Health Center Funding

Table 3: Extra Points Awarded by HRSA to New Access Point Applicants in Fiscal Year 2011

Source: GAO analysis of HRSA application guidance.

Note: The Public Health Service Act requires that HRSA award a certain proportion of funds to serve 

each of the designated special populations, and that it give special consideration to applicants in 

sparsely populated areas when making awards.

a

Applicants that met the sparsely populated area description received 5 extra points. HRSA did not 

offer a range for this population.

In fiscal year 2011, HRSA also used a method it had used before to 

produce its final list of applicants awarded funding—moving certain 

applicants proposing to use at least 25 percent of their grant funding to 

serve one or more of the designated special populations ahead of other 

applicants in the rank order list. HRSA used this method to ensure that it 

met the statutory requirement that the specified proportion of funds be 

provided to applicants serving the three designated special populations. 

HRSA’s application guidance in fiscal years 2008 and 2011 stated that 

HRSA would consider the need to meet proportional requirements for the 

designated special populations and would give special consideration to 

Population served Description

Percentage of funding 

to be used to serve 

special populations Extra points awarded

Designated special populations The applicant intends to serve one or 

more of the three designated special 

populations—migrant and seasonal 

farmworkers, homeless, or public 

housing—with at least 25 percent of 

its HRSA funding.

≥25% - 35% 5 

>35% - 45% 6 

>45% - 55% 7 

>55% - 65% 8 

>65% - 75% 9 

>75% 10

Sparsely populated area The applicant is located in a sparsely 

populated area of seven or fewer 

people per square mile.

N/A 5 a

Percentage of population 

at or below 100 percent of 

the federal poverty level

High-poverty area The applicant serves a high-poverty 

area—over 30 percent of the population 

is at or below 100 percent of the federal 

poverty level.

>30% - 42% 1 

>42% - 46.6% 2 

>46.6% - 50.9% 3 

>50.9% - 56% 4 

>56% 5 
 

Page 19 GAO-12-504 Health Center Funding

applicants serving them in making awards.36 However, the guidance did 

not specifically describe the method that HRSA would use to do so, 

limiting the transparency of this aspect of the award process. HRSA had 

used this method for the designated special populations in fiscal year 

2008, as well as in the past. In addition, in fiscal year 2008 HRSA gave a 

preference to applicants in sparsely populated areas, which moved these 

applicants ahead of others in the rank order list; HRSA eliminated the 

preference for the fiscal year 2011 funding cycle.37

 

36HRSA took action in fiscal year 2011 to encourage applications from organizations 

proposing to serve these special populations by highlighting the topic in its application 

guidance, describing the new extra points in its national conference calls with potential 

applicants to discuss grant opportunities, and working with partners such as national 

organizations focused on migrant farmworkers and the homeless.

(See fig. 3 for a 

depiction of the award process in fiscal year 2011.)

37HRSA did not use the method of moving applicants ahead of others in the rank order list 

for any of these populations in fiscal year 2009.
 

Page 20 GAO-12-504 Health Center Funding

Figure 3: HRSA’s New Access Point Grant Award Process in Fiscal Year 2011

a

During the application scoring process, HRSA averages the scores assigned by each independent 

reviewer in the panel. Depending on the number of applications it receives, HRSA may use multiple 

review panels during a funding cycle. When this occurs, HRSA uses a statistical method to adjust the 

scores for variation among different review panels. This process could result in adjusted scores of 

over 100 before extra points have been awarded. This illustration does not reflect this process.

b

For fiscal year 2011 New Access Point applications, grantees were able to score over the maximum 

100 base points by indicating that they intended to serve: any of the three designated special 

populations—migrant and seasonal farmworkers, homeless people, and residents of public housing—

and sparsely populated or high-poverty areas.
 

Page 21 GAO-12-504 Health Center Funding

In part, HRSA needed to target the designated special populations when 

awarding fiscal year 2011 New Access Point grants because of its fiscal 

year 2009 award funding process and results. HRSA did not apply the 

Public Health Service Act’s funding proportions to the New Access Point

grants awarded in fiscal year 2009.38

In addition to making application and award process changes in fiscal 

year 2011, HRSA used a new tool in assessing service area overlap. In 

2010, HRSA began using a web-based tool—UDS Mapper—in its 

assessment of potential service area overlap between proposed delivery 

sites and certain existing safety net providers, to better facilitate its ability 

to target New Access Point awards to areas with need and to minimize 

service area overlap. The agency uses UDS Mapper to identify existing 

safety net providers, including hospitals, in the service area of an 

applicant’s proposed delivery site.

Few of these grants went to 

applicants proposing to serve the designated special populations. When 

the fiscal year 2009 New Access Point project periods ended in fiscal 

year 2011, continuing operations grants for the fiscal year 2009 grantees 

were funded through PPACA. HRSA applied the required funding 

proportions for designated special populations to the fiscal year 2011 

grants made with PPACA funding, including grants for continued 

operations and New Access Point grants. As a result, HRSA determined 

that in fiscal year 2011 it needed to increase the share of New Access 

Point grant funding dedicated to special populations to help the agency 

meet the required funding proportions. This need influenced HRSA’s 

decision to award extra points to applicants proposing to serve these 

special populations. HRSA officials told us that they made the grants 

funded through PPACA in the same manner they would have if they used 

annual appropriations, and, as a result, had to take the required funding 

proportions into account.

39

 

38HRSA determined at that time that the proportions were not required for grants made 

with Recovery Act funding.

UDS Mapper includes data from 

federal sources such as HRSA’s UDS, the U.S. Census Bureau, and the 

Centers for Medicare & Medicaid Services. However, UDS Mapper does 

not include information about private physician practices, except for those 

39In addition to safety net hospitals, UDS Mapper also includes the locations of non-safety 

net hospitals.
 

Page 22 GAO-12-504 Health Center Funding

participating in the National Health Service Corps program.40 HRSA 

officials told us this information is challenging to obtain because there is 

no good data source on such providers and their patient populations. 

HRSA officials said that in its service area overlap assessment, the 

agency relies in part on information submitted by applicants about the 

locations of private physician practices.

As a result of the increased focus on designated special populations and 

HRSA’s receiving less fiscal year 2011 funding than it had anticipated, 

HRSA awarded over 80 percent of fiscal year 2011 New Access Point 

grants to applicants seeking to serve the designated special populations. 

HRSA had announced that it expected to award about 350 New Access 

Point grants in fiscal year 2011, based on increased funding from 

PPACA, but after the total amount of funding the agency anticipated 

being available was reduced, it instead awarded 67 grants, which 

represented 8 percent of the 810 applications HRSA received. Of the 

810 applications, 210—about 26 percent—proposed serving at least one 

of the three designated special populations. HRSA officials said the 

number of applications proposing to serve the special populations was 

the largest the agency had ever received. Fifty-seven of the 67 successful 

applicants proposed serving one or more of these populations.41

All of the grantees receiving New Access Point awards in fiscal year 2011 

had high scores that placed them at or near the top of the rank order list, 

including the 57 grantees seeking to serve one or more designated 

Of the 

10 remaining successful applicants, 3 received either one or two extra 

points for serving a high-poverty area and an additional 1 received the 

five extra points for being in a sparsely populated area.

 

40The National Health Service Corps program, administered by HRSA, offers school loan 

repayment and scholarships to primary care providers who serve in underserved areas. 

Awards are made to providers in locations designated as health professional shortage 

areas.

41An applicant can propose to use at least 25 percent of its grant to serve one or more of 

the three designated special populations. In total, 39 percent of successful applicants in 

fiscal year 2011 proposed serving the homeless population, 37 percent proposed serving 

migrant and seasonal farmworkers, and 21 percent proposed serving residents of public 

housing. Of the 57 applicants that proposed serving one or more of the special 

populations, 9 received additional extra points for serving a high-poverty area and 

2 received additional extra points for serving a sparsely populated area.

HRSA’s Increased Focus on 

Special Populations and 

Receipt of Less Funding 

than It Had Anticipated 

Resulted in Large 

Proportion of 2011 Awards 

Going to Health Centers 

Serving These Populations
 

Page 23 GAO-12-504 Health Center Funding

special populations.42

Another outcome of the fiscal year 2011 award process was that all New 

Access Point grants went to applicants in 24 states. (See fig. 4.) Most of 

these states had either 1 or 2 successful applicants; California had 

20 successful applicants, or 30 percent of all grants. (See app. I.) 

HRSA officials told us that if the program had been able to award the 

$250 million for New Access Point grants officials had anticipated rather 

than the $28.8 million the program did award, the geographic dispersion 

of grants would have been different. For example, in one potential 

scenario HRSA shared with us, applicants in 46 states and one territory 

might have received funding. Although California applicants received 

the largest share of all New Access Point grants in fiscal year 2011—and 

10 percent of all health centers nationwide in 2010 were located in 

California

However, because HRSA’s awarding of extra 

points was not sufficient to ensure that it met its statutorily required 

funding proportion for serving the migrant farmworker population, 13 of 

the 

57 grantees received awards by being moved ahead of other applicants 

to meet the required proportion of funds awarded for serving this 

population; all of these 13 grantees also served the general health center 

population with a portion of their funding. Although these 13 grantees had 

high-scoring applications, they were placed ahead of 177 other applicants 

with the same or higher scores on the rank order list.

43—the state has a low ratio of health centers to the population 

in poverty, a measure of the availability of care for the medically 

underserved. Compared to the other states, California ranks 36.44

 

42Successful applicants had final scores ranging from 95 to 114 points, including 

applicants that were moved ahead of other applicants in the rank order list to meet 

statutory requirements for the designated special populations.

(See 

app. II for information on the ratio of health centers to the population in 

poverty, by state.)

43The total number of health centers is based on 2010 UDS data, which include health 

centers funded through fiscal year 2009 and represent the states and the territories.

44The California poverty estimate is based on the 2006-2010 ACS. 
 

Page 24 GAO-12-504 Health Center Funding

Figure 4: HRSA New Access Point Grant Awards, Fiscal Year 2011, and Total Health Center Grantees, 2010

Note: In this map, “state” refers to the 50 states, the District of Columbia, and Puerto Rico.

a

In fiscal year 2011, HRSA awarded 67 New Access Point grants—10 to establish new health centers 

and 57 to establish new delivery sites for existing grantees. In total, 108 delivery sites were funded 

through the 67 grants.

b

The total number of health center grantees includes the states and the territories. The counts are 

based on 2010 Uniform Data System (UDS) data—the most current available data on health center 

grantees—and include new health center grantees funded through fiscal year 2009, but do not 

include the 10 new health center grantees funded in fiscal year 2011.
 

Page 25 GAO-12-504 Health Center Funding

HRSA officials told us that they plan to award New Access Point grants in 

fiscal year 2012, and instead of offering a new grant award competition, 

they plan to use the fiscal year 2011 rank order list of applicants to make 

about $145 million to $150 million in awards to approximately 

220 applicants that were approved in that year but did not receive an 

award.45 HRSA had used a similar process for its fiscal year 2009 New 

Access Point grant awards, when additional funding became available 

through the Recovery Act. Specifically, HRSA funded 126 applicants that 

had initially applied in fiscal year 2008 but had not received one of the 

41 grants awarded that year. In 2008, all eligible applicants that did not 

receive a grant were notified that their application would remain active for 

a year, with the possibility of a grant award if HRSA received additional 

funding.46

Overall, during fiscal years 2008 through 2011, HRSA awarded a total of 

234 New Access Point grants, with 77 grants to establish new health 

centers and 157 grants to fund existing health centers to establish new 

delivery sites. (See fig. 5.) New Access Point applicants, regardless of 

whether they are seeking to establish a new health center or a new 

delivery site for an existing grantee, may propose to serve their area with 

one or more delivery sites. In total, 355 new delivery sites were funded in 

fiscal years 2008 through 2011. A greater percentage of grants—about 85 

percent—went to existing health centers to establish one or more new 

delivery sites in fiscal year 2011 than in fiscal years 2008 and 2009—

about 63 percent and 59 percent, respectively.

The agency used the 2008 rank order list to provide grants to 

additional applicants in 2009 without soliciting and reviewing new 

applications, which enabled HRSA to quickly award Recovery Act 

funding.

 

45HRSA officials told us that they plan to take into account the statutory funding 

requirements for special populations when they award grants in fiscal year 2012.

46HRSA sent a comparable letter to all 2011 eligible applicants that did not receive a 

grant.
 

Page 26 GAO-12-504 Health Center Funding

Figure 5: Number of New Access Point (NAP) Grants Awarded by HRSA and 

Delivery Sites the Grants Funded, by Fiscal Year

Note: HRSA did not make any New Access Point grant awards in fiscal year 2010.

a

New Access Point grantees may have received funding for more than one delivery site. The grant 

application asks applicants to provide information on each delivery site it proposes to use in serving 

its target population.

HRSA awarded grants in the fiscal years we studied to health centers 

serving areas with unemployment and poverty rates higher than the 

national average. (See table 4.) HRSA also awarded grants in these fiscal 

years in areas where patients were more likely to be uninsured or to 

receive Medicaid, compared to the national average. Over 36 percent of 

the population was below 200 percent of the federal poverty level in areas 

receiving New Access Point grants in fiscal year 2011, compared with 

about 31 percent nationwide. For example, of the grantees whose 

applications we reviewed, one successful applicant in Brooklyn, New 

York, applied for extra points for serving a high-poverty area because, 

according to its application, more than 34 percent of the residents in the 

local community live below 100 percent of the federal poverty level and 
 

Page 27 GAO-12-504 Health Center Funding

more than 56 percent live below 200 percent of the federal poverty level. 

Another successful applicant, in rural North Carolina, serves three 

counties whose combined population has an average uninsured rate of 

20 percent, in comparison to the national rate of 15 percent.

Table 4: Selected Socioeconomic Characteristics for New Access Point Grantees’ Delivery Sites, in Aggregate, Compared to 

National Average, Fiscal Years 2008, 2009, and 2011

Selected characteristic National average

Fiscal year 2008 

New Access Point 

grantee delivery 

sites, in aggregate

Fiscal year 2009 

New Access Point 

grantee delivery 

sites, in aggregate

Fiscal year 2011 

New Access Point 

grantee delivery 

sites, in aggregate

Percentage of population below 

100 percent of the federal poverty 

level, 2006-2010 13.5 a 14.8 14.7 16.8

Percentage of population below 

200 percent of the federal poverty 

level, 2006-2010 31.2 a 34.5 34.3 36.2

Unemployment rate, 2006-2010 7.9 a 8.4 8.6 8.6

Percentage of population 

uninsured, 2008-2010 15.0 b 19.7 19.4 17.1

Percentage of population with 

Medicaid coverage, 2008-2010 16.0 b 18.6 18.3 21.6

Source: GAO analysis of U.S. Census Bureau American Community Survey (ACS) data.

Note: For each grantee delivery site, we used the site’s zip code as a proxy for the location where the 

services would be provided, matched each zip code to the county where the majority of the zip code 

fell, and analyzed county-level data from the ACS. We used the 2006-2010 ACS when possible, 

which had the most recent data for all counties, and used the 2008-2010 ACS for selected 

characteristics for which data were not available in the 2006-2010 ACS; the 2008-2010 ACS had 

recent data only for counties with populations of 20,000 or more. The socioeconomic characteristics 

for which we used the 2008-2010 ACS did not include data for 31 counties, and these communities 

were subsequently excluded from our aggregate analysis.

a

The selected socioeconomic characteristic comes from the 2006-2010 ACS, which includes data for 

all counties.

b

The selected socioeconomic characteristic comes from the 2008-2010 ACS, which includes data for 

counties with populations of 20,000 or more.
 

Page 28 GAO-12-504 Health Center Funding

Health centers in the communities we studied collaborate with other 

providers in their service area. Health centers and other providers said 

they generally did not compete for patients, but we found greater potential 

for competition in rural areas.

Health centers in the communities we studied collaborate with other 

providers to meet the health care needs of patients in the health center’s 

service area. Officials we interviewed from each of the health centers 

described at least one collaborative relationship with another provider—

such as local hospitals and specialty care providers—to provide access to 

services not available through the health center. For example, officials 

from one of the health centers told us they collaborate with specialists 

such as a pediatric cardiologist, podiatrist, and ophthalmologist. In 

addition, officials from several hospitals said that collaborating with health 

centers is important because the centers help reduce the non-urgent use 

of hospital emergency departments.47

HRSA has encouraged health centers to collaborate with other providers 

in their service area. HRSA issued a Program Assistance Letter in fiscal 

year 2011 that provides guidance to health centers on collaborating and 

establishing contractual agreements with other providers to maximize 

However, in some of the rural 

communities we studied we also found that the relationship between the 

health center and a nearby hospital was strained. For example, officials 

from a hospital in one community we studied told us that the health center 

did not always send the medical records of admitted patients in a timely 

way.

 

47We previously reported on strategies health centers have implemented that may help 

reduce the non-urgent use of emergency departments. See GAO, Hospital Emergency 

Departments: Health Center Strategies That May Help Reduce Their Use, GAO-11-414R

(Washington, D.C.: Apr. 11, 2011).

Health Centers and 

Other Providers 

Reported 

Collaboration and 

Little or No 

Competition, but 

Rural Areas Have 

Greater Potential for 

Competition 

Health Centers in 

Communities We Studied 

Collaborate with Other 

Providers
 

Page 29 GAO-12-504 Health Center Funding

resources and efficiencies in their service area. For example, the letter 

includes a list of suggested resources to help health centers maximize 

collaboration with other safety net providers, such as the UDS Mapper 

tool, PCAs, and HRSA project officers, who are responsible for 

overseeing health centers and providing technical assistance.

For fiscal year 2011, HRSA added a collaboration component to the New 

Access Point application scoring to encourage collaboration by health 

centers. The fiscal year 2008 and 2009 applicants had been required to 

include a written description of existing collaborative relationships with 

other providers and had also been encouraged to submit letters of 

support, but these were not scored separately. However, in fiscal year 

2011, applicants could receive up to 10 points for submitting letters of 

support—from other providers or community organizations—and a written 

description of their existing and proposed efforts to establish collaborative 

relationships with other providers in their proposed service area. During 

the period included in our study, letters of support were written by, among 

others, neighboring health centers, local hospitals, private physicians, 

local government agencies, and PCAs. The letters of support generally 

included similar types of information—such as a description of the specific 

health care needs of the community and support for the applicant’s efforts 

to care for underserved patients—regardless of the type of organization 

expressing support. A few letters included information about specific 

support the writer had provided or planned to provide to a health center, 

such as pediatric or obstetrical care to health center patients.

PCAs often work with applicants and grantees to help them develop 

collaborative relationships. Officials from several PCAs told us they used 

applicants’ requests to the PCA for a letter of support as an opportunity to 

assist them in developing relationships with other providers. For example, 

officials from one PCA told us that for the fiscal year 2011 New Access 

Point award cycle, they hosted over 20 town hall meetings in applicants’ 

communities to facilitate community involvement, collaboration, and 

understanding of the Health Center Program. Several PCAs told us they 

also work with potential applicants to determine whether it would be better 

for them to combine efforts with an existing health center grantee or to 

establish a new health center. Officials from one PCA explained that it 

may be better for a new organization to become a satellite site of an 

existing organization because existing organizations already have the 

resources and infrastructure in place to operate a health center.
 

Page 30 GAO-12-504 Health Center Funding

Officials we interviewed identified various factors that contribute to 

successful collaboration between health centers and other providers. 

Officials from hospitals, other providers, and community groups said that 

leadership commitment to collaboration, community participation in 

developing a new health center, and other providers’ understanding of the 

role of health centers are important factors that contribute to successful 

collaboration. For example, officials from one hospital and a community 

group in the same area noted improved collaboration as a result of a new 

director coming to a health center. They told us that the previous director 

was difficult to collaborate with and did not acknowledge the abilities of 

other primary care providers to serve the safety net population. These 

officials also said that the current relationship is much more collaborative 

and that the health center and hospital share a board member and a 

physician. In addition, officials from one PCA told us that a former state 

government official had, over many years, discouraged hospitals from 

collaborating on efforts to establish new health centers in their 

communities, warning the hospitals that they could lose patients to the 

health centers. Regarding the importance of community participation, 

officials from one hospital said that the hospital led the effort to develop 

the health center in its community, because previously physicians 

voluntarily provided services for low-income patients two evenings a 

week, and that effort was unsustainable.

In the communities we studied, health centers and other providers in their 

service area generally do not compete for patients. HRSA and PCA 

officials told us that health centers typically serve patients not treated 

elsewhere, such as uninsured and Medicaid patients. Nationwide, 

37.5 percent of health center patients are uninsured, and for the eight 

health centers we studied, the rate of uninsured patients averaged 

30.4 percent. Similarly, Medicaid patients make up 38.5 percent of health 

center patients nationwide, and 35 percent in the health centers we 

studied. Officials from most of the PCAs we spoke with said health 

centers and other providers generally do not compete for uninsured 

patients; some also noted that other providers rarely provide care for 

uninsured patients. Similarly, officials from one health center told us that 

Medicaid patients in their area had difficulty finding other providers that 

would accept them. We have previously reported on the difficulties certain 

Health Centers and Other 

Providers Generally Did 

Not Encounter Significant 

Competition for Patients, 

but Rural Areas Have 

Greater Potential for 

Competition 
 

Page 31 GAO-12-504 Health Center Funding

Medicaid patients, such as children, face in finding providers who are 

willing to serve them.48

HRSA’s service area overlap policy is designed to help the agency avoid 

awarding grants for new delivery sites in areas where other safety net 

providers are already serving the population’s need, and this may reduce 

competition between health centers and other safety net providers. The 

agency did not award grants to two applicants in fiscal years 2008 and 

2009—one in each year—because awarding grants to these applicants 

would have resulted in overlap with existing providers that had the 

capacity to meet the needs of the area. HRSA officials told us that they 

did not find any significant service area overlap during the fiscal year 

2011 award cycle. They also said that since the agency increased its 

emphasis on collaboration—and applicants have increased their outreach 

in their communities—it has received fewer complaints from other safety 

net providers about service area overlap than it received in prior years.49

Because the health center grant covers, on average, about 20 percent of 

a health center’s budget, health centers also must secure other funding, 

such as by serving privately insured and Medicaid patients, to be 

financially sustainable;50

 

48See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children but Have 

Difficulty Referring Them for Specialty Care, 

this necessity can occasionally result in 

competition with and complaints from other providers in their service area. 

For example, HRSA officials told us that some private dentists have 

complained about competing with health centers for Medicaid patients; 

the officials added that many patients might have to go without dental 

GAO-11-624 (Washington, D.C.: June 30, 

2011). The report notes that physicians participating in Medicaid and the State Children’s 

Health Insurance Program (CHIP)—a joint federal and state insurance program for certain 

low-income, uninsured children whose family income is too high for Medicaid eligibility—

are generally more willing to accept privately insured children as new patients than 

Medicaid and CHIP children. For example, about 79 percent were accepting all privately 

insured children as new patients, while about 47 percent were accepting children in 

Medicaid and CHIP as new patients. 

49HRSA does not maintain records of all the complaints the agency receives that are 

related to competition and service area overlap.

50See GAO, Community Health Centers: Adapting to Changing Health Care Environment 

Key to Continued Success, GAO/HEHS-00-39 (Washington, D.C.: Mar. 10, 2000).
 

Page 32 GAO-12-504 Health Center Funding

care if health centers did not offer these services, because some dentists 

are unwilling to serve Medicaid patients.51

Greater potential for competition exists in rural areas, where in general a 

higher proportion of health center patients are insured and therefore more 

likely to be a source of competition with other providers. Among the 

health centers we studied, the rate of insured patients was higher in rural 

areas than in urban areas. For example, more than 76 percent of patients 

served by the health centers we studied in rural areas had some type of 

insurance coverage,52

Competition may exist between health centers and hospitals in rural 

areas under certain circumstances. For example, a recent HRSA report 

discussed the potential for competition between health centers and critical 

access hospitals.

compared to about 61 percent of the patients at the 

health centers in urban areas.

53

 

51We previously reported that obtaining dental care for children remains a challenge 

because most dentists treat few or no Medicaid and CHIP patients. See GAO, Oral 

Health: Efforts Under Way to Improve Children’s Access To Dental Services, but 

Sustained Attention Needed to Address Ongoing Concerns, 

It suggested that duplicative services by health 

centers and critical access hospitals (e.g., primary care and laboratory 

services) could lead to detrimental competition, but that both types of 

providers would benefit if they collaborated with each other instead of 

competing. The report also said that health centers and critical access 

hospitals can benefit from sharing resources that foster infrastructure, 

access, and quality of care improvements. In addition, while most hospital 

officials we interviewed said their hospitals do not compete with health 

centers, officials from the hospitals in rural communities we studied told 

us that health centers receive certain benefits that could lead to increased 

competition with their local hospital. For example, officials from a few 

hospitals in rural communities said that hospitals generally finance 

construction or renovation costs on their own, but health centers may 

GAO-11-96 (Washington, 

D.C.: Nov. 30, 2010). 

52Insurance coverage for patients served by the health centers we studied includes 

coverage by Medicaid, CHIP, Medicare, other public insurance (such as state insurance 

programs), and private insurance.

53HMS Associates, A Manual on Effective Collaboration Between Critical Access 

Hospitals and Federally Qualified Health Centers, a report prepared for the U.S. 

Department of Health and Human Services, Health Resources and Services 

Administration, Office of Rural Health Policy (Getzville, N.Y.: April 2010).
 

Page 33 GAO-12-504 Health Center Funding

receive grant funding for construction or renovations, which gives them a 

competitive advantage. They said the health centers might be better able 

to attract insured patients because of the improved facilities or might be 

able to attract staff because these grant funds free up resources that can 

be used for higher salaries.

PCA and health center officials we interviewed more frequently raised 

concerns about the potential for competition between health centers and 

rural health clinics, in part because there are more similarities in the 

services they provide to patients in rural communities.54 For example, 

several PCA officials told us that while there is no competition between 

health centers and rural health clinics for serving uninsured patients, they 

do compete for patients with insurance, including Medicaid and Medicare. 

Although patients in rural areas often face access barriers because of a 

shortage of providers, HRSA officials said the addition of a health center 

to an area can increase competition for insured patients when such 

patients seek treatment from a health center that is more conveniently 

located than other providers. HRSA officials also told us that they may 

award grants in rural areas where there are other providers if those 

providers do not fully meet the needs of the safety net population. For 

example, existing providers may not offer a sliding fee scale or be willing 

to serve uninsured people.

Health centers funded by HRSA’s Health Center Program are a critical 

component of the nation’s health care safety net, and New Access Point 

grants provide the agency with an important means for increasing access 

to health care for vulnerable populations—those who may have difficulty 

obtaining needed health care services because of financial or other 

limitations. To better target resources to communities with a high need for 

health center services, in fiscal year 2011 HRSA increased the weight of 

the criterion assessing the need for services in the New Access Point 

grant application. Certain populations—migrant and seasonal 

farmworkers, homeless people, and residents of public housing—are 

particularly vulnerable and often have specific health and access 

problems. In its 1996 consolidation of the Health Center Program, 

Congress began requiring that specific proportions of the program’s funds 

 

54Rural health clinics are not required to provide the full range of services that health 

centers must provide or to accept all patients regardless of their ability to pay.

Conclusions 
 

Page 34 GAO-12-504 Health Center Funding

be used to serve these populations. Over the years, HRSA has taken 

various actions to ensure it was meeting the required funding proportions. 

During its fiscal year 2011 New Access Point award process, HRSA for 

the first time gave extra points to applicants serving these designated 

special populations. Congress also requires HRSA to give special 

consideration to organizations serving sparsely populated areas, and in 

fiscal year 2011 HRSA also gave extra points to applicants serving 

sparsely populated and high-poverty areas. HRSA’s approach of 

assigning these extra points—and its description in its application 

guidance of how the points would be awarded—increased the 

transparency of the grant award process compared to previous years. 

However, because the extra points were not sufficient to ensure that 

HRSA met its statutorily required funding proportion for migrant health 

centers, HRSA also moved applicants serving this population ahead of 

other applicants to ensure the required proportion was met, a step that 

was not specifically described in the application guidance. Although 

HRSA had used such an approach before, the effect in fiscal year 2011 

was magnified by the combined effect of the reduction in program funding 

and HRSA’s need to increase the share of funding awarded to the 

designated special populations as a result of not applying the proportions 

when awarding grants with Recovery Act funds in fiscal year 2009. HRSA 

has periodically needed to take actions to meet its statutory obligations 

and may face such a situation in the future. Evaluating the effectiveness 

and transparency of the New Access Point grant award process it used 

most recently could help HRSA identify lessons learned and possible 

improvements that it could apply to future funding cycles to ensure the 

most effective use of limited Health Center Program resources.

To ensure that in the future HRSA can effectively target limited Health 

Center Program resources through a transparent grant award process, 

the Secretary of HHS should direct the Administrator of HRSA to evaluate 

the fiscal year 2011 New Access Point grant award process to identify 

lessons learned and potential improvements for future funding cycles, 

including consideration of (1) the effect of the change in the need score 

on targeting grants to communities with demonstrated need, (2) the effect 

of actions taken to target grants to applicants proposing to serve the 

designated special populations and sparsely populated and high-poverty 

areas, and (3) the transparency of the process to applicants, Congress, 

and the public. The Secretary should also direct the Administrator of 

HRSA to complete the evaluation before the next New Access Point 

funding opportunity is announced, make the results of the evaluation 

Recommendation for 

Executive Action
 

Page 35 GAO-12-504 Health Center Funding

publicly available, and incorporate any improvements identified into the 

award process for that funding opportunity.

We provided a draft of this report to HHS for review, and HHS provided 

written and oral comments. (HHS’s written comments are printed in 

app. III.) HHS agreed with our findings and recommendation. In its 

general comments, HHS restated and provided additional information on 

our discussion of the Health Center Program and the New Access Point 

grant process. HHS said that the increased score for need and use of 

extra points improved the agency’s awarding of New Access Point grants 

in fiscal year 2011 by targeting resources to higher need communities 

and populations while still ensuring that organizations with sound health 

center service delivery plans were funded. HHS also noted that increased 

emphasis on collaboration contributed to health centers and other area 

providers maximizing available resources while enhancing the service 

delivery system to better address the community’s primary health care 

needs. HHS said that these factors support HRSA’s goal to expand the 

current safety net on a national basis by creating new delivery sites in 

areas not currently served by federally funded health centers. Regarding 

the GAO recommendation, HHS said HRSA is taking steps to evaluate 

the effects of the change in the need score and other actions taken to 

target grants, including for special populations. According to HHS, HRSA 

plans to use the findings from its evaluation to improve the New Access 

Point application guidance and will make its findings available to the 

public. In its oral comments, HHS suggested that the title of the draft 

report did not fully reflect the contents of the report, which provides a 

detailed discussion of the changes HRSA made to its fiscal year 2011 

New Access Point grant award process, including increased weight given 

to need. We revised the report title to reflect this. HHS also provided 

technical comments, and we incorporated information from its general 

and technical comments as appropriate. 

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of HHS and 

the Administrator of HRSA. The report also will be available at no charge 

on the GAO website at http://www.gao.gov. 

Agency Comments
 

Page 36 GAO-12-504 Health Center Funding

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made major contributions to this report 

are listed in appendix IV. 

Debra A. Draper

Director, Health Care
Appendix I: New Access Point Grant Awards, 

Fiscal Years 2008-2011, and Total Health 

Center Grantees, 2010

Page 37 GAO-12-504 Health Center Funding

Table 5 shows the distribution of New Access Point grants awarded to 

applicants in each state and territory in fiscal years 2008 through 2011. It 

also shows the number of grantees in each state and territory and the 

percentage of total grantees in each state and territory in 2010.

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

Grantees, 2010, by State and Territory

New Access Point grant awards

Fiscal year 2008 Fiscal year 2009 Fiscal year 2011

Total health center 

grantees, 2010

State/Territory 

a

Number Percentage Number Percentage Number Percentage Number Percentage

Alabama 0 0 3 2 2 3 14 1 

Alaska 0 0 1 1 1 1 25 2 

American Samoa 0 0 1 1 0 0 1 <1

Arizona 0 0 3 2 0 0 16 1 

Arkansas 0 0 3 2 0 0 12 1 

California 9 22 12 10 20 30 118 10

Colorado 2 5 1 1 2 3 15 1 

Connecticut 1 2 4 3 1 1 13 1 

Delaware 0 0 1 1 1 1 4 <1

District of 

Columbia 0 0 0 0 0 0 5 <1

Federated States 

of Micronesia 0 0 0 0 0 0 2 <1

Florida 5 12 8 6 2 3 44 4 

Guam 0 0 0 0 0 0 1 <1

Georgia 1 2 4 3 0 0 27 2 

Hawaii 0 0 0 0 0 0 14 1 

Idaho 0 0 0 0 1 1 11 1 

Illinois 2 5 4 3 2 3 36 3 

Indiana 0 0 2 2 0 0 19 2 

Iowa 0 0 1 1 0 0 13 1 

Kansas 0 0 2 2 2 3 13 1 

Kentucky 0 0 4 3 0 0 19 2 

Louisiana 1 2 7 6 0 0 24 2 

Maine 0 0 2 2 0 0 18 2 

Marshall Islands 0 0 0 0 0 0 1 <1

Appendix I: New Access Point Grant Awards, 

Fiscal Years 2008-2011, and Total Health 

Center Grantees, 2010
Appendix I: New Access Point Grant Awards, 

Fiscal Years 2008-2011, and Total Health 

Center Grantees, 2010

Page 38 GAO-12-504 Health Center Funding

New Access Point grant awards

Fiscal year 2008 Fiscal year 2009 Fiscal year 2011

Total health center 

grantees, 2010

State/Territory 

a

Number Percentage Number Percentage Number Percentage Number Percentage

Maryland 1 2 0 0 1 1 16 1 

Massachusetts 0 0 1 1 0 0 36 3 

Michigan 0 0 2 2 0 0 29 3 

Minnesota 0 0 1 1 0 0 15 1 

Mississippi 0 0 1 1 0 0 21 2 

Missouri 0 0 2 2 1 1 21 2 

Montana 1 2 1 1 0 0 15 1 

Nebraska 1 2 0 0 0 0 6 1 

Nevada 0 0 1 1 0 0 2 <1

New Hampshire 0 0 1 1 0 0 10 1 

New Jersey 1 2 2 2 1 1 20 2 

New Mexico 1 2 0 0 1 1 15 1 

New York 3 7 6 5 8 12 51 5 

North Carolina 1 2 2 2 2 3 27 2 

North Dakota 0 0 0 0 0 0 4 <1

Northern 

Mariana Islands 0 0 0 0 0 0 0 0 

Ohio 2 5 5 4 2 3 32 3 

Oklahoma 1 2 6 5 0 0 17 2 

Oregon 1 2 0 0 3 4 25 2 

Palau 0 0 0 0 0 0 1 <1

Pennsylvania 0 0 6 5 2 3 35 3 

Puerto Rico 0 0 2 2 2 3 19 2 

Rhode Island 0 0 2 2 0 0 8 1 

South Carolina 0 0 0 0 0 0 20 2 

South Dakota 0 0 1 1 1 1 6 1 

Tennessee 1 2 2 2 1 1 23 2 

Texas 0 0 11 9 4 6 64 6 

Utah 1 2 0 0 0 0 11 1 

Vermont 1 2 1 1 0 0 8 1 

Virgin Islands 0 0 0 0 0 0 2 <1

Virginia 2 5 5 4 0 0 25 2 

Washington 2 5 1 1 4 6 25 2 

West Virginia 0 0 1 1 0 0 28 2 

Wisconsin 0 0 0 0 0 0 16 1 
Appendix I: New Access Point Grant Awards, 

Fiscal Years 2008-2011, and Total Health 

Center Grantees, 2010

Page 39 GAO-12-504 Health Center Funding

New Access Point grant awards

Fiscal year 2008 Fiscal year 2009 Fiscal year 2011

Total health center 

grantees, 2010

State/Territory 

a

Number Percentage Number Percentage Number Percentage Number Percentage

Wyoming 0 0 0 0 0 0 6 1 

Total 41 100 126 100 67 100 1124 100

Source: GAO analysis of HRSA data.

Note: In this table, “state” refers to the 50 states, the District of Columbia, and Puerto Rico. 

Percentages do not total 100 due to rounding.

a

The number of total health centers comes from HRSA’s UDS. The most recently available UDS data 

were for calendar year 2010.
Appendix II: Ratio of Health Center Grantees to 

Population Living in Poverty, by State, 2010

Page 40 GAO-12-504 Health Center Funding

We calculated the ratio of total health center grantees to the population 

living in poverty for every state, a measure of the availability of care for 

the medically underserved. We then ranked them in order from highest to 

lowest ratio. (See table 6.)

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

2010

Ranking State 

Ratio of health centers to population 

living in poverty (per 100,000)

1 Alaska 38.91

2 Vermont 11.99

3 Wyoming 11.47

4 Hawaii 11.23

5 Maine 11.09

6 Montana 10.86

7 New Hampshire 10.05

8 West Virginia 9.02

9 Rhode Island 6.48

10 South Dakota 5.67

11 Massachusetts 5.47

12 Idaho 5.41

13 North Dakota 5.10

14 District of Columbia 4.91

15 Oregon 4.84

16 Delaware 4.26

17 New Mexico 4.15

18 Connecticut 4.14

19 Utah 3.88

20 Iowa 3.84 a

21 Kansas 3.84 a

22 Mississippi 3.48

23 Maryland 3.36

24 Washington 3.21

25 Virginia 3.20

26 Louisiana 3.08

27 Oklahoma 2.95

28 Nebraska 2.91

29 South Carolina 2.79

Appendix II: Ratio of Health Center Grantees 

to Population Living in Poverty, by State, 

2010
Appendix II: Ratio of Health Center Grantees to 

Population Living in Poverty, by State, 2010

Page 41 GAO-12-504 Health Center Funding

Ranking State 

Ratio of health centers to population 

living in poverty (per 100,000)

30 Minnesota 2.77

31 Missouri 2.62

32 Kentucky 2.58

33 Colorado 2.57 a

34 New Jersey 2.57 a

35 Wisconsin 2.51

36 California 2.40

37 Arkansas 2.39

38 Pennsylvania 2.32

39 Illinoisa 2.29

40 Tennessee 2.29 a

41 Indiana 2.26

42 Ohio 2.02

43 Michigan 2.01

44 North Carolina 1.93

45 New York 1.92

46 Georgia 1.87

47 Alabama 1.78

48 Florida 1.76

49 Arizona 1.71

50 Texas 1.61

51 Puerto Rico 1.13

52 Nevada 0.65

Source: GAO analysis of HRSA and U.S. Census Bureau American Community Survey (ACS) data.

Notes: In this table, “state” refers to the 50 states, the District of Columbia, and Puerto Rico. ACS 

poverty data were not available for the territories. The population living in poverty is that below 

100 percent of the federal poverty level, using population estimates from the 2006-2010 ACS. The 

number of health centers is from HRSA’s UDS and was last updated with calendar year 2010 data.

a

In cases where states had the same ratio, they are listed in alphabetical order.
Appendix III: Comments from the Department 

of Health and Human Services

Page 42 GAO-12-504 Health Center Funding

Appendix III: Comments from the 

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

of Health and Human Services

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

of Health and Human Services

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

of Health and Human Services

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

of Health and Human Services

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

Staff Acknowledgments

Page 47 GAO-12-504 Health Center Funding

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Helene F. Toiv, Assistant 

Director; Giselle Hicks; Coy J. Nesbitt; Roseanne Price; Julie T. Stewart; 

E. Jane Whipple; Jennifer Whitworth; and Monique Williams made key 

contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Acknowledgments 
Related GAO Products

Page 48 GAO-12-504 Health Center Funding

Health Center Program: Improved Oversight Needed to Ensure Grantee 

Compliance with Requirements. GAO-12-546. Washington, D.C.: May 29, 

2012.

Hospital Emergency Departments: Health Center Strategies That May 

Help Reduce Their Use. GAO-11-643T. Washington, D.C.: May 11, 2011.

Hospital Emergency Departments: Health Center Strategies That May 

Help Reduce Their Use. GAO-11-414R. Washington, D.C.: April 11, 

2011.

Health Resources and Services Administration: Many Underserved Areas 

Lack a Health Center Site, and Data Are Needed on Service Provision at 

Sites. GAO-09-667T. Washington, D.C.: April 30, 2009.

Health Resources and Services Administration: Many Underserved Areas 

Lack a Health Center Site, and the Health Center Program Needs More 

Oversight. GAO-08-723. Washington, D.C.: August 8, 2008.

Health Centers: Competition for Grants and Efforts to Measure 

Performance Have Increased. GAO-05-645. Washington, D.C.: July 13, 

2005.

Community Health Centers: Adapting to Changing Health Care 

Environment Key to Continued Success. GAO/HEHS-00-39. Washington, 

D.C.: March 10, 2000.

Related GAO Products

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