Health Resources and Services Administration: Many Underserved Areas Lack a Health Center Site, and Data Are Needed on Service Provision at Sites
Published: 2009-04-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Health centers funded through grants under the Health Center Program--managed by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)--provide comprehensive primary care services for the medically underserved. The statement GAO is issuing today summarizes an August 2008 report, Health Resources and Services Administration: Many Underserved Areas Lack a Health Center Site, and the Health Center Program Needs More Oversight (GAO-08-723). In that report, GAO examined to what extent medically underserved areas (MUA) lacked health center sites in 2006 and 2007. To do this, GAO obtained and analyzed HRSA data and grant application
section_title: What GAO Found
paragraphs: In its August 2008 report, which is summarized in this statement, GAO found the following: (1) Grant awards for new health center sites in 2007 reduced the overall percentage of MUAs lacking a health center site from 47 percent in 2006 to 43 percent in 2007. (2) There was wide geographic variation in the percentage of MUAs that lacked a health center site in both years. (3) Most of the 2007 nationwide decline in the number of MUAs that lacked a health center site occurred in the South census region, in large part because half of all awards made in 2007 for new health center sites were granted to the South census region. (4) HRSA lacked readily available data on the services provided at individual health center sites. GAO concluded that from 2006 to 2007, HRSA's grant awards to open new health center sites reduced the number of MUAs that lacked a site by about 7 percent. However, in 2007, 43 percent of MUAs continued to lack a health center site, and the grants for new sites awarded that year had little impact on the wide variation among census regions and states in the percentage of MUAs lacking a health center site. GAO reported that HRSA's grants to open new health center sites increased access to primary health care services for underserved populations in needy areas, including MUAs. However, HRSA's ability to place new health center sites in locations where they are most needed was limited because HRSA does not collect and maintain readily available information on the services provided at individual health center sites. Because each health center site may not provide the full range of comprehensive primary care services, having readily available information on the services provided at each site is important for HRSA's effective consideration of need when distributing federal resources for new health center sites.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work on the extent to which  health centers in the federal Health Center Program are located in areas  having a shortage of health care services. Health centers provide  comprehensive primary health care services—preventive, diagnostic,  treatment, and emergency services, as well as referrals to specialty care— to federally designated medically underserved populations (MUP), or  those individuals residing in federally designated medically underserved  areas (MUA). The people served by health centers include Medicaid  beneficiaries, the uninsured, and others who may have difficulty obtaining  access to health care. To fulfill the Health Center Program’s mission of  increasing access to primary health care services for the medically  underserved, the Health Resources and Services Administration (HRSA)— the agency within the U.S. Department of Health and Human Services  (HHS) that administers the Health Center Program—provides grants to  health centers. A health center grantee may provide services at one or  more delivery sites—known as health center sites. HRSA does not require  all health center sites to provide the full range of comprehensive primary  care services; some health center sites may provide only limited services,  such as dental or mental health services. In 2006, approximately 1,000  health center grantees operated more than 6,000 health center sites that  served more than 15 million people. Additional people may need to rely on  health centers for their care during the current economic period.
Beginning in fiscal year 2002, HRSA significantly expanded the Health  Center Program under a 5-year effort—the President’s Health Centers  Initiative—to increase access to comprehensive primary care services for  underserved populations, including those in MUAs. Under the initiative,  HRSA set a goal of awarding 630 grants to open new health center sites— such grants are known as new access point grants—and 570 grants to  expand services at existing health center sites by the end of fiscal year  2006. New access point grants fund one or more new health center sites  operated by either new or existing health center grantees. In July 2005, we  reported challenges HRSA encountered during this expansion of the  Health Center Program. In particular, we found that HRSA’s process for  awarding new access point grants might not sufficiently target  communities with the greatest need for services, although we concluded  that changes HRSA had made to its grant award process could help the  agency appropriately consider community need when distributing federal  resources. We also reported that HRSA lacked reliable information on the  number and location of the sites where health centers provide care, and  we recommended, among other things, that HRSA collect this information.  In response to our recommendation, HRSA took steps to improve its data  collection efforts in 2006 to more reliably account for the number and  location of health center sites funded under the Health Center Program.
By the end of fiscal year 2007, HRSA had achieved its grant goals under the  original President’s Health Centers Initiative and launched a second  nationwide effort, the High Poverty County Presidential Initiative. In fiscal  year 2007, HRSA held two new access point competitions, one focused on  opening new health center sites in up to 200 HRSA-selected counties that  lacked a health center site—part of the High Poverty County Presidential  Initiative—and one that was an open competition.
My statement today is based largely on our August 2008 report entitled  Health Resources and Services Administration: Many Underserved  Areas Lack a Health Center Site, and the Health Center Program Needs  More Oversight. In the August 2008 report, we examined, among other  things, (1) for 2006, the extent to which MUAs lacked health center sites  and the services provided by individual sites in MUAs, and (2) how new  access point grants awarded in 2007 changed the extent to which MUAs  lacked health center sites.
In carrying out the work for our August 2008 report examining the extent  to which MUAs lacked health center sites and the services provided by  individual sites in 2006, we interviewed HRSA officials and obtained health  center site data from HRSA’s uniform data system (UDS), and then  compared the location of health center sites with the location of MUAs by  census region and state. We limited our analysis to health center sites  operated by grantees that received community health center funding—the  type of funding that requires sites to provide services to all residents of the  service area regardless of their ability to pay. In addition, because HRSA  takes into account the location of federally qualified health center look- alike sites—facilities that operate like health center sites but do not  receive HRSA funding—when deciding where to award new access point  grants, we obtained from HRSA the location of health center look-alike  sites in 2006 and compared them with the location of MUAs. To examine  how new access point grants awarded in 2007 changed the extent to which  MUAs lacked health center sites nationwide, we obtained data from HRSA  and compared the location of proposed and funded new health center sites  in 2007 with the location of MUAs in 2007. As with the 2006 analysis, we  limited our review to health center sites operated by grantees that  requested community health center funding, and we obtained from HRSA  the location of health center look-alike sites in 2007 and compared them to  the location of MUAs in 2007. We discussed our data sources with  knowledgeable agency officials and performed data reliability checks,  such as examining the data for missing values and obvious errors, to test  the internal consistency and reliability of the data. After taking these steps,  we determined that the data were sufficiently reliable for our purposes.  We conducted the performance audit for the August 2008 report from April  2007 through July 2008, 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. A  detailed explanation of our methodology is included in our August 2008  report.
In brief, we found that grant awards for new health center sites in 2007  reduced the overall percentage of MUAs lacking a health center site from  47 percent in 2006 to 43 percent in 2007. In addition, we found wide  geographic variation in the percentage of MUAs that lacked a health center  site in both years. We reported that, for 2006, we could not determine the  types of services provided by individual health center sites in MUAs  because HRSA does not collect and maintain data on the types of services  provided at each site. Because HRSA lacks readily available data on the  types of services provided at individual sites, the extent to which  individuals in MUAs have access to the full range of comprehensive  primary care services is unknown. In reporting on geographic variation,  we found that, for 2007, the West and Midwest census regions continued to  show the lowest and highest percentages, respectively, of MUAs that  lacked health center sites. In addition, three of the four census regions  showed a 1 or 2 percentage point decrease since 2006 in MUAs that lacked  a health center site, while the South census region showed a 5 percentage  point decrease. The minimal impact of the 2007 awards on geographic  variation overall was due, in large part, to the fact that the majority of the  decline in MUAs that lacked a health center site was concentrated in the  South census region, which received the largest proportion of the awards  made in 2007. To help improve the agency’s ability to measure access to  comprehensive primary care services in MUAs, we recommended that  HRSA collect and maintain readily available data on the types of services  provided at each health center site. In commenting on a draft of our  report, HHS raised concerns regarding this recommendation. HHS  acknowledged that site-specific information would be helpful for many  purposes, but said collecting this information would place a significant  burden on grantees and raise the program’s administrative expenses.
While we acknowledge that effort and cost are involved in program  management activities, we believe that having site-specific information on  services provided is essential to help HRSA better measure access to  comprehensive primary health care services in MUAs when considering  the placement of new health center sites and to facilitate the agency’s  ability to evaluate service area overlap in MUAs.
subsections: section_title: Almost Half of MUAs Lacked a Health Center Site in 2006, and Types of Services Provided by Each Site Could Not Be Determined
paragraphs: In August 2008, we reported that almost half of MUAs nationwide—  47 percent, or 1,600 of 3,421—lacked a health center site in 2006, and  there was wide variation among the four census regions and across states  in the percentage of MUAs that lacked health center sites. (See fig. 1.) The  Midwest census region had the most MUAs that lacked a health center site  (62 percent), while the West census region had the fewest MUAs that  lacked a health center site (32 percent). More than three-quarters of the  MUAs in 4 states—Nebraska (91 percent), Iowa (82 percent), Minnesota  (77 percent), and Montana (77 percent)—lacked a health center site. (See  app. I for more detail on the percentage of MUAs in each state and the U.S.  territories that lacked a health center site in 2006.) In 2006, among all  MUAs, 32 percent contained more than one health center site; among  MUAs with at least one health center site, 60 percent contained multiple  health center sites, with about half of those containing two or three sites.  Almost half of all MUAs in the West census region contained more than  one health center site, while less than one-quarter of MUAs in the Midwest  contained more than one site. The states with three-quarters or more of  their MUAs containing more than one health center site were Alaska,  Connecticut, the District of Columbia, Hawaii, New Hampshire, and Rhode  Island. In contrast, Nebraska, Iowa, and North Dakota were the states  where less than 10 percent of MUAs contained more than one site.
We could not determine the types of primary care services provided at  individual health center sites because HRSA did not collect and maintain  readily available data on the types of services provided at individual sites.  While HRSA requests information from applicants in their grant  applications on the services each site provides, in order for HRSA to  access and analyze individual health center site information on the  services provided, HRSA would have to retrieve this information from the  grant applications manually. HRSA separately collects data through the  UDS from each grantee on the types of services it provides across all of its  health center sites, but HRSA does not collect data on services provided at  each site. Although each grantee with community health center funding is  required to provide the full range of comprehensive primary care services,  HRSA does not require each grantee to provide all services at each health  center site it operates. HRSA officials told us that some sites provide  limited services—such as dental or mental health services. Because HRSA  lacks readily available data on the types of services provided at individual  sites, it cannot determine the extent to which individuals residing in MUAs  have access to the full range of comprehensive primary care services  provided by health center grantees. This lack of basic information can  limit HRSA’s ability to assess the full range of primary care services  available in needy areas when considering the placement of new access  points and can also limit the agency’s ability to evaluate service area  overlap in MUAs.
section_title: 2007 Awards Reduced the Number of MUAs That Lacked a Health Center Site, but Wide Geographic Variation Remained
paragraphs: In August 2008, we reported that our analysis of new access point grants  awarded in 2007 showed that these awards reduced the number of MUAs  that lacked a health center site by about 7 percent. Specifically, 113 fewer  MUAs in 2007—or 1,487 MUAs in all—lacked a health center site when  compared with the 1,600 MUAs that lacked a health center site in 2006.  (See app. I.) As a result, 43 percent of MUAs nationwide lacked a health  center site in 2007. Despite the overall reduction in the percentage of  MUAs nationwide that lacked health center sites in 2007, regional variation  remained. The West and Midwest census regions continued to show the  lowest and highest percentages of MUAs that lacked health center sites,  respectively. (See fig. 2.) Three of the four census regions showed a 1 or   2 percentage point decrease since 2006 in the percentage of MUAs that  lacked a health center site, while the South census region showed a   5 percentage point decrease.
We found that the minimal impact of the 2007 awards on regional variation  was due, in large part, to the fact that more than two-thirds of the  nationwide decline in the number of MUAs that lacked a health center  site—77 out of the 113 MUAs—occurred in the South census region. In  contrast, only 24 of the 113 MUAs were located in the Midwest census  region, even though the Midwest had nearly as many MUAs that lacked a  health center site in 2006 as the South census region. While the number of  MUAs that lacked a health center site declined by 12 percent in the South  census region, the other census regions experienced declines of about   4 percent. The South census region experienced the greatest decline in the  number of MUAs lacking a health center site in 2007 in large part because  it was awarded more new access point grants that year than any other  region. Specifically, half of all new access point awards made in 2007— from the two separate new access point competitions—went to applicants  from the South census region. For example, when we examined the High  Poverty County new access point competition, in which 200 counties were  targeted by HRSA for new health center sites, we found that 69 percent of  those awards were granted to applicants from the South census region.  The greater number of awards made to the South census region may be  explained by the fact that nearly two-thirds of the 200 counties targeted  were located in the South census region. When we examined the open new  access point competition, which did not target specific areas, we found  that the South census region also received a greater number of awards  than any other region under that competition. Specifically, the South  census region was granted nearly 40 percent of awards; in contrast, the  Midwest received only 17 percent of awards.
section_title: Concluding Observations
paragraphs: In our August 2008 report, we noted that awarding new access point grants  is central to HRSA’s ongoing efforts to increase access to primary health  care services in MUAs. From 2006 to 2007, HRSA’s new access point  awards achieved modest success in reducing the percentage of MUAs that  lacked a health center site nationwide. However, in 2007, 43 percent of  MUAs continued to lack a health center site, and the new access point  awards made in 2007 had little impact on the wide variation among census  regions and states in the percentage of MUAs lacking a health center site.  The relatively small effect of the 2007 awards on geographic variation may  be explained, in part, because the South census region received a greater  number of awards than other regions, even though the South was not the  region with the highest percentage of MUAs lacking a health center site in  2006.
We reported that HRSA awards new access point grants to open new  health center sites, which increase access to primary health care services  for underserved populations in needy areas, including MUAs. However,  HRSA’s ability to target these awards and place new health center sites in  locations where they are most needed is limited because HRSA does not  collect and maintain readily available information on the services provided  at individual health center sites. Having readily available information on  the services provided at each site is important for HRSA’s effective  consideration of need when distributing federal resources for new health  center sites, because each health center site may not provide the full range  of comprehensive primary care services. This information could also help  HRSA assess any potential overlap of services provided by health center  sites in MUAs.
Mr. Chairman, this concludes my prepared statement. I would be happy to  answer any questions that you or Members of the Committee may have.
section_title: GAO Contacts and Staff Acknowledgments
paragraphs: For further information about this statement, please contact Cynthia A.  Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Key contributors to this statement were Helene  Toiv, Assistant Director; Stella Chiang; Karen Doran; and Karen Howard.
section_title: Appendix I: Number and Percentage of Medically Underserved Areas (MUA) Lacking a Health Center Site, 2006 and 2007
subsections: section_title: Total number of MUAs
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