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.