First authorized in 1971, the program currently known as HCOP was last reauthorized in 1998. The Secretary of Health and Human Services is authorized to make HCOP grants “for the purpose of assisting individuals from disadvantaged backgrounds . . . to undertake education to enter a health profession.” A wide range of entities are eligible to receive HCOP grants, including, for example, schools of medicine, dentistry, and pharmacy; schools with graduate programs in behavioral and mental health; programs to train physician assistants; and other public or private nonprofit health or educational entities. HCOP grant funds may be used for a variety of activities, such as recruiting individuals from disadvantaged backgrounds interested in health careers; facilitating their entry into health professions schools; providing counseling, mentoring, and other support activities designed to assist them to complete this education; providing information on financial aid; and providing experience in primary health care settings. The 1998 reauthorization of HCOP emphasized the importance of outreach activities by adding a funding preference for HCOP applications for projects that “involve a comprehensive approach by several public or private nonprofit health or educational entities to establish, enhance and expand educational programs that will result in the development of a competitive applicant pool of individuals from disadvantaged backgrounds who desire to pursue health professions careers.” Applications qualifying for this funding preference have an advantage because they must be considered for funding ahead of applications that do not. Projects supported by HCOP grants focus on individuals from disadvantaged backgrounds, and Congress has recognized that such individuals may be members of minority groups. The Public Health Service Act directs the Secretary of Health and Human Services “to the extent practicable, ensure that services and activities are adequately allocated among the various racial and ethnic populations who are from disadvantaged backgrounds.” Section 739 of the Public Health Service Act does not specify any particular populations or methods that HRSA must use to ensure this allocation, leaving these decisions to the agency’s discretion. According to HRSA officials, in the 1990s, the agency allocated additional points to the scores of applications from historically black colleges and universities, Hispanic-serving institutions, and tribal colleges and universities to improve their chances of receiving an HCOP grant. HRSA reported that for 1997 this practice resulted in its awarding eight more HCOP grants to historically black colleges and universities than it had awarded for the previous year. For fiscal years 2002 through 2005, HRSA followed a standard process to award HCOP grant funds, distributing the program’s available funds on a noncompetitive basis to continue funding existing grant projects, then awarding the remaining funds on a competitive basis. For competitive HCOP grants, HRSA published criteria and relied on the assessment of independent reviewers. Grants were awarded in accordance with the applications’ rank order as determined by the independent reviewers. The amount of HCOP funds HRSA distributed each year on a noncompetitive basis to continue funding existing grant projects determined the amount that remained available for competitive grants and, consequently, the number of competitive grants HRSA awarded. For fiscal years 2002 through 2005, the amounts HRSA made available for HCOP grants from its annual appropriations remained relatively stable, with an average of about $34 million a year over the 4 fiscal years. Before making competitive awards, HRSA distributed funds each year on a noncompetitive basis to support existing HCOP grant projects in their second or subsequent years. These noncompetitive continuation awards were subject to HRSA officials’ approval after the agency reviewed each grantee’s annual progress report. Once the noncompetitive continuation awards were made, HRSA awarded the remaining HCOP funds on a competitive basis, including new grants to entities that did not have an HCOP grant for a particular project and competitive continuation grants to entities that applied for continued funding after the end of their authorized HCOP grant period. As shown in figure 1, the amounts distributed on a noncompetitive basis to continue funding existing grant projects varied, from a low of $18 million for fiscal year 2005 to a high of $30 million for fiscal year 2003, and the remaining funds awarded as competitive grants ranged from a low of $4 million for fiscal year 2003 to a high of $15 million for fiscal year 2005. For each of fiscal years 2002 through 2005, HRSA published a notification of upcoming grant opportunities, including those for HCOP grants. This notification provided an overview of the HCOP program, including the entities eligible to receive HCOP grants and a description of the funding preference for projects with a comprehensive approach. For detailed review criteria, the annual notification referred prospective HCOP applicants to the HCOP program guidance available on request or, for fiscal year 2005, through HRSA’s Web site. The review criteria HRSA published in its HCOP program guidance addressed different aspects of a successful HCOP project. Each criterion carried a specified number of potential points, for a maximum total score of 100. For some criteria, the point values differed according to whether the application was for a new grant or a competitive continuation grant. This difference reflected the fact that applications for competitive continuation grants were required to include a summary of the grantee’s management of its previous HCOP grant project and of progress toward meeting its objectives. For all applications for competitive grants—both new and competitive continuations—HRSA assigned the greatest number of potential points to the criterion that addressed plans to implement the HCOP activities authorized in the Public Health Service Act. Table 1 summarizes the criteria used by reviewers to assess HCOP applications for fiscal year 2005. The HCOP program guidance also included information on how to apply for, and receive, the funding preference for projects involving a comprehensive approach. To receive the funding preference, applicants were required to meet all four of the following statutory requirements: Demonstrate a commitment to a comprehensive approach through formal signed agreements that specify common objectives and establish partnerships with institutions of higher education, school districts, and other community-based entities. Enter into formal signed agreements reflecting the coordination of educational activities and support services and the consolidation of resources within a specific area. Design activities that establish a competitive health professions applicant pool of individuals from disadvantaged backgrounds by focusing on both academic and social preparation for health careers. Describe educational activities that focus on developing a culturally competent health care workforce to serve needy populations in the geographic area. HRSA’s HCOP program guidance for fiscal years 2002 through 2005 specified that, to receive the funding preference, copies of formal agreements between applicants and community-based partners must be included with the application. For fiscal years 2002 through 2005, HRSA’s standard process for awarding competitive HCOP grants relied on independent reviewers to assess applications against the agency’s published review criteria. HRSA officials generally limited their own review of applications for competitive HCOP grants to screening for applicant eligibility and compliance with technical requirements such as format and length. After determining which applications met basic eligibility requirements, HRSA officials forwarded all eligible HCOP applications to the agency’s Division of Independent Review to arrange for assessment and scoring. To assess HCOP applications, the division selected reviewers with health- related educational, counseling, academic, or project management experience who were not employed by HRSA and who were free from conflicts of interest, including employment or consulting arrangements with any entity that was applying for an HCOP grant for that fiscal year. The division sent each reviewer about eight applications to read in advance, then convened multiple panels in which reviewers met to discuss the merits of those applications. The reviewers were instructed to apply the published HCOP review criteria and reach consensus within each panel on their funding recommendations. The reviewers did not recommend for approval those applications they determined were not responsive to the review criteria. For each application recommended for approval, the reviewers assigned a score and determined whether the application qualified for the funding preference. The reviewers also had the opportunity to comment on applications’ proposed budgets and to recommend adjustments for reasonableness. After the independent reviewers completed their assessments, HRSA officials used a statistical method to standardize the results from all HCOP review panels for a given year into a single ranked list, placing all applications receiving the funding preference ahead as a group, from highest to lowest score, followed by applications without the funding preference, from highest to lowest score. HRSA officials used this rank- order list as their basis for recommending which applications should receive grants for a given fiscal year and the amount of each award. The HRSA officials’ recommendations were included in memorandums to the HRSA Administrator, who made the final award decisions for fiscal years 2002 through 2005. Figure 2 provides an overview of the process for awarding competitive HCOP grants. When awarding HCOP grants, HRSA had the discretion to consider additional factors, such as geographic diversity, targeted health professions, and the allocation of HCOP-funded services and activities among minority populations who are disadvantaged. According to a HRSA official responsible for administering the HCOP program, the agency could have used this discretion to depart from the rank-order list resulting from the independent review process but did not do so for fiscal years 2002 through 2005. This official said that 80 percent of HCOP program participants in fiscal year 2004 came from disadvantaged minority groups, regardless of the entity that received the HCOP grants, and that HRSA had concluded that no divergence from the rank-order list was required since the allocation of HCOP-funded activities among minority populations was consistent with the Public Health Service Act. For fiscal year 2004, however, HRSA reduced all competitive HCOP grant budgets by 10 percent—an action that enabled the agency to fund five additional grants, including three at historically black colleges and universities that would not otherwise have been funded. For fiscal years 2002 through 2005, HRSA reviewed a total of 439 applications for competitive HCOP grants and awarded 99 HCOP grants. The number of competitive HCOP grants awarded depended on the availability of funds each year, and HRSA was unable to fund many high- scoring applications that received the funding preference. Over the 4 fiscal years, minority-serving institutions submitted 25 percent of the applications for competitive HCOP grants and received 30 percent of the awards. Both the number of applications and the number of competitive grants awarded varied from year to year (see table 2). Overall, for fiscal years 2002 through 2005, applications for new HCOP grants outnumbered applications for competitive continuations by nearly three to one, but applications for new grants received about the same number of awards as applications for competitive continuation grants. The number of competitive grants awarded in a given year depended more on the availability of funds for competitive HCOP grants than on the applications’ scores. Each year, the score of the lowest-scoring application receiving a grant differed little from the score of the next application on the list, which did not receive a grant. While all applications that received grants for fiscal years 2002 through 2005 qualified for the funding preference for comprehensive projects, the preference did not guarantee that an application would be funded. In some years, applications that received the funding preference and scored in the 80s (out of 100 possible points) were not funded. As shown in figure 3, the majority of applications that were approved for funding by the independent reviewers received the funding preference, but not all were funded. For fiscal years 2002 through 2005, minority-serving institutions submitted a total of 25 percent of all applications for competitive HCOP grants and received about 30 percent of awards. Although minority-serving institutions received awards in greater proportion than their representation among all applications for HCOP grants over the 4 fiscal years, the proportions varied from year to year. For fiscal years 2002, 2004, and 2005, minority-serving institutions were represented among grantees in the same, or in greater, proportion than they were among applications, submitting 25–28 percent of applications and receiving 25–35 percent of grants. Fiscal year 2003 stands out because of the smaller number of competitive grants awarded; that year, 10 competitive HCOP grants were awarded, 1 of which was awarded to a minority-serving institution (see table 3). The smaller number of competitive grants was mainly due to the relatively high number of noncompetitive continuation grants that received funding for that fiscal year. Among minority-serving institutions, historically black colleges and universities submitted the most applications and received the most awards, followed by Hispanic-serving institutions (see table 4). Some entities submitted more than one application over the 4 fiscal years of our review, and a given entity may have received more than one grant. For example, an entity may have applied for an HCOP grant for fiscal year 2002 and failed to receive a grant, then tried again in subsequent years. A new fiscal year 2002 grantee would have had to apply for a competitive continuation grant for fiscal year 2005 after the end of its 3-year project period. It is also possible for the same entity to have had more than one HCOP grant at the same time, provided that each grant had a distinct purpose and budget. In written comments on a draft of this report (see app. III), HRSA stated that the report met the goals of describing the award process and outlining the number and characteristics of HCOP applicants and grantees. HRSA suggested that, due to the small number of grantees, the summary of findings on our Highlights page present the numbers, rather than percentages, of minority institutions that were awarded grants between 2005 and 2006. For the summary, we believe it is appropriate to use percentages to convey that applications from minority-serving institutions generally received grants in greater proportion than all applications. As noted in the draft report, the percentages we present are for the 4-year period of fiscal years 2002 through 2005. HRSA provided two other comments suggesting revisions to clarify our discussion, which we generally incorporated. In addition, HRSA provided technical comments which we incorporated as appropriate. We are sending copies of this report to the Administrator of HRSA and appropriate congressional committees. We will also provide copies to others upon request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff members have any questions about this report, please contact me at (312) 220-7600 or aronovitzl@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. We determined whether Health Careers Opportunity Program (HCOP) applicants and grantees were minority-serving institutions by using statutory definitions, lists of institutions that fall under these statutory definitions, and data from the Department of Education. The term “minority-serving institution” refers to an accredited institution of higher education eligible for federal support under title III or title V of the Higher Education Act of 1965; this support is administered by the Department of Education. These institutions include historically black colleges and universities, American Indian tribally controlled (or tribal) colleges and universities, Hispanic-serving institutions, Native Hawaiian–serving institutions, and Alaska Native–serving institutions. For our review, we defined historically black colleges and universities and tribal colleges and universities as institutions that met certain statutory definitions for institutions eligible to receive federal support under title III of the Higher Education Act of 1965. To identify an HCOP applicant or grantee as a historically black college or university, we compared a list of historically black colleges and universities published by the White House Initiative on Historically Black Colleges and Universities with the data we obtained from the Health Resources and Services Administration (HRSA) on HCOP grant applicants and recipients. To identify HCOP applicants and grantees that were designated as a tribal college or university, we compared a list published by the White House Initiative on Tribal Colleges and Universities with the data we obtained from HRSA on HCOP grant applicants and recipients. Hispanic-serving institutions, Native Hawaiian–serving institutions, and Alaska Native–serving institutions are eligible for federal funding under title III or title V of the Higher Education Act of 1965. Unlike historically black colleges and universities and tribal colleges and universities, however, eligibility of these institutions for funding is based on the percentage of enrolled minority students. As a result, the number of institutions that qualify as Hispanic-serving institutions, Native Hawaiian– serving institutions, and Alaska Native–serving institutions can vary from year to year. For our review, we defined Hispanic-serving institutions as those that received grants through the Developing Hispanic-Serving Institutions Program under title V of the Higher Education Act of 1965 for fiscal years 2002 through 2005. That is, we determined an institution’s status as a Hispanic-serving institution for a particular fiscal year on the basis of whether the institution had a title V grant that year. To identify HCOP applicants and grantees that were Hispanic-serving institutions at the time of our review, we obtained lists of title V grantees for the Developing Hispanic-Serving Institutions Program from the Department of Education’s Web site for fiscal years 1999 through 2005. We cross-checked the title V grantee lists with the membership of the Hispanic Association of Colleges and Universities and with lists of schools with significant Hispanic enrollment from the Department of Education’s Office of Civil Rights. We compared these lists with the data we obtained from HRSA on HCOP grant applicants and recipients. In addition, we counted all HCOP applicants and grantees located in Puerto Rico as Hispanic-serving institutions. Because not all institutions that could be eligible for grants under title V of the Higher Education Act of 1965 apply for or receive title V grants, our counts of Hispanic-serving institutions at a given time are likely to be conservative. Likewise, we defined Native Hawaiian–serving institutions and Alaska Native–serving institutions as those that were eligible to receive grants under title III of the Higher Education Act of 1965 and that received such grants for fiscal years 2002 through 2005. As noted above, the exact number of entities designated as minority- serving institutions may vary from year to year. While we were able to classify the HCOP applicants and grantees for fiscal years 2002 through 2005, table 5 summarizes the different minority-serving institution designations and provides approximate counts for fiscal year 2005, the most recent year for which total counts were available. Table 6 shows, by location, applications and awards for competitive HCOP grants for fiscal years 2002 through 2005. The numbers represent applications, rather than individual applicant entities. An entity may have applied for a competitive HCOP grant more than once, and a single entity may have had more than one HCOP grant for separate and distinct HCOP projects. The locations are those of the grant applicants, although partnerships may cross state lines and result in HCOP-funded activities and services in more than one state. In addition to the contact named above, Kim Yamane, Assistant Director; Matt Byer; Ellen W. Chu; Karlin Richardson; Suzanne Rubins; and Hemi Tewarson made key contributions to this report. Health Professions Education Programs: Action Still Needed to Measure Impact. GAO-06-55. Washington, D.C.: February 28, 2006. Low-Income and Minority-Serving Institutions: Department of Education Could Improve its Monitoring and Assistance. GAO-04-961. Washington, D.C.: September 21, 2004. Health Professions Education: Clarifying the Role of Title VII and VIII Programs Could Improve Accountability. GAO/T-HEHS-97-117. Washington, D.C.: April 25, 1997.

Summary: To support the education and training of health professionals, the Health Resources and Services Administration (HRSA), in the Department of Health and Human Services (HHS), administers health professions education programs authorized under title VII of the Public Health Service Act. One of these programs, the Health Careers Opportunity Program (HCOP), provides grants to health professions schools and other entities to help students from disadvantaged backgrounds prepare for health professions education and training. Funding preference is given to grant applications that demonstrate a comprehensive approach involving other educational or health-related partners. Congressional committees have encouraged HRSA to give priority to applications from schools with a historic mission of educating minority students for health professions. In 2004, the appropriations conference committee asked GAO to review HRSA's process for awarding grants. This report addresses, for fiscal years 2002 through 2005, (1) HRSA's process for awarding HCOP grants and (2) the number and characteristics of HCOP applicants and grantees. GAO reviewed data from HRSA, interviewed HRSA officials, and reviewed relevant federal laws and agency documents from HHS and the Department of Education. HRSA followed a standard process to award HCOP grants, distributing funds on a noncompetitive basis to continue funding existing HCOP grants within their approved project periods, and then awarding the remaining funds on a competitive basis. For each of fiscal years 2002-05, HRSA competitively awarded between $4 million and $15 million from the approximately $34 million annually available for HCOP. To award competitive grants, HRSA used independent reviewers who assessed applications against published criteria, scored applications that met minimum criteria, and determined if they qualified for the funding preference. HRSA ranked the applications from highest to lowest score--putting those with the funding preference first--and awarded grants in decreasing rank order until the available funds were exhausted. Although HRSA had discretion to award grants out of rank order, the agency did not do so for fiscal years 2002-05. For fiscal years 2002-05, HRSA awarded a total of 99 competitive HCOP grants from 439 grant applications reviewed. Overall, minority-serving institutions submitted about 25 percent of the applications reviewed and received about 30 percent of the competitive grants; historically black colleges and universities were the most numerous grantees among minority-serving institutions, followed by Hispanic-serving institutions. HRSA commented that a draft of this report met the goals of describing the award process and outlining the number and characteristics of HCOP applicants and grantees.