Health Center Program: 2011 Grant Award Process Highlighted Need and Special Populations and Merits Evaluation
Published: 2012-05-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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 services required of health centers.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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, people who are  uninsured, and others who may have difficulty obtaining access to health  care. In 2010, more than 1,100 health centers operated more than   8,100 delivery sites across all the states 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   HRSA funds the establishment of new health  Public Health Service Act.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). 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. 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. The four types of health centers were consolidated into a  single program in 1996; prior to the consolidation, the grantees serving  the three designated special populations were funded through separate  programs.
For each of fiscal years 2009 and 2010, HRSA allocated almost   $2.2 billion in annual appropriations to the Health Center Program; of  that amount, nearly $2 billion each year was used for health center  grants. In addition, the American Recovery and Reinvestment Act of  2009 (Recovery Act) 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. As a  result, health center capacity is expected to expand significantly over the  next several years.
In light of the additional funds provided to the Health Center Program  through the Recovery Act and PPACA, you asked us to review HRSA’s  awarding of new grants to communities with a need for services, and  about possible effects, such as competition, on other providers resulting  from the increased support for health centers. In this report, we examine  (1) the actions HRSA has recently taken to target its grants for new  delivery sites to health centers in communities with demonstrated need,  and the outcome of HRSA’s award process in recent years; and (2) the  extent to which federally funded health centers collaborate and compete  with other health care providers in their service area.
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, 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. We chose the health centers based  on criteria that included geographic diversity, patient demographics   (e.g., percentage of population in poverty and insurance status), and site- specific information (e.g., number of delivery sites operated by the  grantee and U.S. Census Bureau urban/rural continuum category). 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  recent data available. 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.(HRSA did not award any New Access Point grants in fiscal year 2010.)
To identify the level of need in the communities served by applicants that  received New Access Point grants, we also analyzed data on selected  socioeconomic characteristics (e.g., the percentage of the population  living in poverty and the unemployment rate) for all delivery site locations  funded through these grants from fiscal years 2008 through 2011. To do  this, we determined the county in which each delivery site was located  based on its zip code, and reviewed and analyzed county-level data from  the U.S. Census Bureau’s 2006-2010 and 2008-2010 American  Community Survey (ACS), which contained the most recent available  data. To assess the reliability of the ACS data elements that we used in our analysis, we performed checks, such as examining the data for  missing values, and reviewed related documentation. We determined that  the ACS data were sufficiently reliable for our purposes.
To examine the extent to which federally funded health centers  collaborate and compete with other health care providers in their service  area, we reviewed HRSA program documentation, policies, and guidance  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. 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.
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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Health Center Patients, Revenue, and Grants
paragraphs: 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.insured by Medicaid, and nearly 38 percent were uninsured. See figure 1  for more information on insurance coverage of health center patients.
section_title: HRSA Revised 2011 Award Process, and Most New Access Point Grants Went to Health Centers Serving Special Populations
paragraphs: 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.
subsections: section_title: HRSA Increased Weight Given to Need and Emphasized Special Populations in 2011 Award Process
paragraphs: 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.
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.applicants seeking to serve high-poverty areas to further increase the  emphasis on need in the award process. This was the first time HRSA   In addition, HRSA decided to award extra points to  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; 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.
section_title: Health Centers and Other Providers Reported Collaboration and Little or No Competition, but Rural Areas Have Greater Potential for Competition
paragraphs: 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.
subsections: section_title: Health Centers in Communities We Studied Collaborate with Other Providers
paragraphs: 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. However, in some of the rural  communities we studied we also found that the relationship between the  health center and a nearby hospital was strained. For example, officials  from a hospital in one community we studied told us that the health center  did not always send the medical records of admitted patients in a timely  way.
HRSA has encouraged health centers to collaborate with other providers  in their service area. HRSA issued a Program Assistance Letter in fiscal  year 2011 that provides guidance to health centers on collaborating and  establishing contractual agreements with other providers to maximize  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.
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.
section_title: Health Centers and Other Providers Generally Did Not Encounter Significant Competition for Patients, but Rural Areas Have Greater Potential for Competition
paragraphs: 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  Medicaid patients, such as children, face in finding providers who are  willing to serve them.
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.
See GAO, Community Health Centers: Adapting to Changing Health Care Environment  Key to Continued Success, GAO/HEHS-00-39 (Washington, D.C.: Mar. 10, 2000). care if health centers did not offer these services, because some dentists  are unwilling to serve Medicaid patients.
Insurance coverage for patients served by the health centers we studied includes  coverage by Medicaid, CHIP, Medicare, other public insurance (such as state insurance  programs), and private insurance. 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. 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.
section_title: Conclusions
paragraphs: 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  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.
section_title: Recommendation for Executive Action
paragraphs: 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  publicly available, and incorporate any improvements identified into the  award process for that funding opportunity.
section_title: Agency Comments
paragraphs: 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.
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.
section_title: Appendix I: New Access Point Grant Awards, Fiscal Years 2008-2011, and Total Health Center Grantees, 2010
paragraphs: 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.
section_title: Appendix II: Ratio of Health Center Grantees to Population Living in Poverty, by State, 2010
paragraphs: 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.)
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: 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.
section_title: Related GAO Products
paragraphs: 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.