Health Resources and Services Administration: Many Underserved	 
Areas Lack a Health Center Site, and the Health Center Program	 
Needs More Oversight (08-AUG-08, GAO-08-723).			 
                                                                 
Health centers funded through grants under the Health Center	 
Program--managed by the Health Resources and Services		 
Administration (HRSA), an agency in the U.S. Department of Health
and Human Services (HHS)--provide comprehensive primary care	 
services for the medically underserved. HRSA provides funding for
training and technical assistance (TA) cooperative agreement	 
recipients to assist grant applicants. GAO was asked to examine  
(1) to what extent medically underserved areas (MUA) lacked	 
health center sites in 2006 and 2007 and (2) HRSA's oversight of 
training and TA cooperative agreement recipients' assistance to  
grant applicants and its provision of written feedback provided  
to unsuccessful applicants. To do this, GAO obtained and analyzed
HRSA data, grant applications, and the written feedback provided 
to unsuccessful grant applicants and interviewed HRSA officials. 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-723 					        
    ACCNO:   A83397						        
  TITLE:     Health Resources and Services Administration: Many       
Underserved Areas Lack a Health Center Site, and the Health	 
Center Program Needs More Oversight				 
     DATE:   08/08/2008 
  SUBJECT:   Cooperative agreements				 
	     Data collection					 
	     Employee training					 
	     Evaluation criteria				 
	     Grant administration				 
	     Grants						 
	     Grants to states					 
	     Health care planning				 
	     Health care policies				 
	     Health care programs				 
	     Health care services				 
	     Health centers					 
	     Health policy					 
	     Managed health care				 
	     Performance measures				 
	     Policy evaluation					 
	     Prices and pricing 				 
	     Program evaluation 				 
	     Program management 				 
	     Standards evaluation				 
	     Strategic planning 				 
	     Training utilization				 
	     program goals or objectives			 
	     Program implementation				 
	     Health Center Program				 

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GAO-08-723

   

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Report to the Ranking Member, Subcommittee on Oversight and 
Investigations, Committee on Energy and Commerce, House of 
Representatives: 

United States Government Accountability Office: 
GAO: 

August 2008: 

Health Resources and Services Administration: 

Many Underserved Areas Lack a Health Center Site, and the Health Center 
Program Needs More Oversight: 

GAO-08-723: 

GAO Highlights: 

Highlights of GAO-08-723, a report to the Ranking Member, Subcommittee 
on Oversight and Investigations, Committee on Energy and Commerce, 
House of Representatives. 

Why GAO Did This Study: 

Health centers funded through grants under the Health Center 
Programï¿½managed by the Health Resources and Services Administration 
(HRSA), an agency in the U.S. Department of Health and Human Services 
(HHS)ï¿½provide comprehensive primary care services for the medically 
underserved. HRSA provides funding for training and technical 
assistance (TA) cooperative agreement recipients to assist grant 
applicants. GAO was asked to examine (1) to what extent medically 
underserved areas (MUA) lacked health center sites in 2006 and 2007 and 
(2) HRSAï¿½s oversight of training and TA cooperative agreement 
recipientsï¿½ assistance to grant applicants and its provision of written 
feedback provided to unsuccessful applicants. To do this, GAO obtained 
and analyzed HRSA data, grant applications, and the written feedback 
provided to unsuccessful grant applicants and interviewed HRSA 
officials. 

What GAO Found: 

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, GAO found wide geographic variation 
in the percentage of MUAs that lacked a health center site in both 
years. Most of the 2007 nationwide decline in the number of MUAs that 
lacked a 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. GAO also found that HRSA lacks 
readily available data on the services provided at individual health 
center sites. 

Figure: Percentages of MUAs That Lacked a Health Center Site, by Census 
Region, 2006 and 2007: 

[See PDF for image] 

This figure is a map of the United States depicting the following data: 

Census Region: Northeast; 
MUAs lacking a health center site, 2006: 39%; 
MUAs lacking a health center site, 2007: 37%. 

Census Region: South; 
MUAs lacking a health center site, 2006: 45%; 
MUAs lacking a health center site, 2007: 40%. 

Census Region: Midwest; 
MUAs lacking a health center site, 2006: 62%; 
MUAs lacking a health center site, 2007: 60%. 

Census Region: West; 
MUAs lacking a health center site, 2006: 32%; 
MUAs lacking a health center site, 2007: 31%. 

Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis 
of HRSA and U.S. Census Bureau data. 

[End of figure] 

HRSA oversees training and TA cooperative agreement recipients, but its 
oversight is limited in key respects and it does not always provide 
clear feedback to unsuccessful grant applicants. HRSA oversees 
recipients using a number of methods, including regular communications, 
review of cooperative agreement applications, and comprehensive on-site 
reviews. However, the agencyï¿½s oversight is limited because it lacks 
standardized performance measures to assess the performance of the 
cooperative agreement recipients and it is unlikely to meet its policy 
goal of conducting comprehensive on-site reviews of these recipients 
every 3 to 5 years. The lack of standardized performance measures 
limits HRSAï¿½s ability to effectively evaluate cooperative agreement 
recipientsï¿½ activities that support the Health Center Programï¿½s goals 
with comparable measures. In addition, without timely comprehensive on-
site reviews, HRSA does not have up-to-date comprehensive information 
on the performance of these recipients in supporting the Health Center 
Program. HRSA officials stated that they are in the process of 
developing standardized performance measures. Moreover, more than a 
third of the written feedback HRSA sent to unsuccessful Health Center 
Program grant applicants in fiscal years 2005 and 2007 contained 
unclear statements. The lack of clarity in this written feedback may 
undermine its usefulness rather than enhance the ability of applicants 
to successfully compete for grants in the future. 

What GAO Recommends: 

GAO is making recommendations to improve HRSAï¿½s oversight of 
cooperative agreement recipients and the clarity of written feedback 
provided to unsuccessful grant applicants. HHS concurred and plans to 
implement these recommendations. However, HHS raised concerns with the 
report scope and another recommendation to collect site-specific data. 
GAO believes that the report scope is appropriate and that additional 
data would benefit HRSA decision making. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-723]. For more 
information, contact Cynthia A. Bascetta at (202) 512-7114 or 
[email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Almost Half of MUAs Lacked a Health Center Site in 2006, and the Types 
of Services Provided by Each Site Could Not Be Determined: 

2007 Awards Reduced the Number of MUAs That Lacked a Health Center 
Site, but Wide Geographic Variation Remained: 

HRSA Oversees Cooperative Agreement Recipients but Oversight Is Limited 
in Key Respects, and Its Feedback to Unsuccessful Applicants Is Not 
Always Clear: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Number and Percentage of Medically Underserved Areas (MUA) 
Lacking a Health Center Site, 2006 and 2007: 

Appendix II: Data on the 2007 High Poverty County New Access Point 
Competition, by Census Region and State: 

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

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Description of Criteria and Maximum Points Awarded for New 
Access Point Grant Opportunities, Fiscal Years 2005 and 2007: 

Table 2: Number of MUAs That Lacked a Health Center Site for 2006 and 
2007, and 2006 to 2007 Decrease in MUAs That Lacked a Health Center 
Site by Number and Percentage, by Census Region: 

Table 3: Number and Percentage of All New Access Point Grants Awarded 
in 2007, by Census Region: 

Table 4: Number and Percentage of New Access Point Grants Awarded in 
Fiscal Year 2007 for the Open New Access Point Competition, by Census 
Region: 

Table 5: Total Number of Distinct Examples of Unclear Feedback by 
Criterion for New Access Point Grant Applications from Fiscal Years 
2005 and 2007: 

Figures: 

Figure 1: Percentage of MUAs That Lacked a Health Center Site, by 
Census Region and State, 2006: 

Figure 2: Percentage of MUAs That Lacked a Health Center Site, by 
Census Region, 2007: 

Figure 3: Geographic Distribution of Counties Targeted and Grants 
Awarded for the 2007 High Poverty County New Access Point Competition: 

Abbreviations: 

HHS: U.S. Department of Health and Human Services: 

HRSA: Health Resources and Services Administration: 

MUA: medically underserved area: 

MUP: medically underserved population: 

PCA: primary care association: 

TA: technical assistance: 

UDS: uniform data system: 

[End of section] 

United States Government Accountability Office: Washington, DC 20548: 

August 8, 2008: 

The Honorable John M. Shimkus: 
Ranking Member: 
Subcommittee on Oversight and Investigations: 
Committee on Energy and Commerce: 
House of Representatives: 

Dear Mr. Shimkus: 

Health centers in the federal Health Center Program 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).[Footnote 1] 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. These grants, along with other 
federal benefits available to health center grantees through the Health 
Center Program, are an important part of successful health center 
operations and viability.[Footnote 2] In 2006, Health Center Program 
grants made up about 20 percent of all health center grantees' 
revenues. A health center grantee may provide services at one or more 
delivery sites--known as health center sites. Not all health center 
sites are required to provide the full range of comprehensive primary 
care services; some health center sites may provide only limited 
services, such as dental and mental health services. In 2006, 
approximately 1,000 health center grantees operated more than 6,000 
health center sites while serving more than 15 million people. 

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.[Footnote 3] 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, though 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 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.[Footnote 4] 

To assist potential health center grantees in applying for new access 
point grants, HRSA provides funds to national, regional, and state 
organizations to promote Health Center Program grant opportunities and 
help applicants secure funding. This funding mechanism is known as a 
training and technical assistance (TA) cooperative agreement. For 
fiscal year 2007, HRSA awarded nearly $53 million in cooperative 
agreements to national organizations--specifically, those that assist 
broadly with health center operations as well as expand access to 
health care for underserved populations--and regional and state primary 
care associations (PCA), organizations that also support health centers 
and other safety net providers in increasing access to primary care 
services. HRSA also assists potential grantees by providing written 
feedback to applicants that apply for, but are not awarded, HRSA grants 
through the Health Center Program. This written feedback--known as 
summary statements--characterizes the strengths and weaknesses of the 
applications. The summary statements are intended to help unsuccessful 
applicants improve the quality--and therefore success--of future grant 
applications. The summary statements are prepared by objective review 
committees selected by HRSA to evaluate health center grant 
applications. Before HRSA releases the statements to unsuccessful 
applicants, the agency removes any internal recommendations made by the 
committee and reviews them for accuracy. 

Given the expansion of the Health Center Program under the President's 
Health Centers Initiative and the High Poverty County Initiative as 
well as HRSA's past challenges in targeting its new access point grant 
awards to serve needy areas, you asked us to examine the extent to 
which MUAs contain health center sites as well as HRSA's management of 
the Health Center Program, specifically, efforts to assist applicants 
for new access point grants. In this report, we examine (1) for 2006, 
the extent to which MUAs lacked health center sites and the services 
provided by each site in an MUA; (2) how new access point grants 
awarded in 2007 changed the extent to which MUAs lacked health center 
sites; and (3) HRSA's oversight of cooperative agreement recipients' 
assistance to new access point applicants and feedback the agency 
provides to unsuccessful applicants. 

To examine the extent to which MUAs lacked health center sites 
nationwide and the services provided by each site in 2006, we 
interviewed HRSA officials and obtained health center site data from 
HRSA's uniform data system (UDS). The UDS provided the zip code 
location of health center sites as of December 31, 2006.[Footnote 5] We 
also obtained from HRSA data on the geographic location of MUAs 
designated for 2006. We linked the location of the MUAs to their 
associated zip codes using a geographic crosswalk file based on U.S. 
Census Bureau data.[Footnote 6] We then compared the location of health 
center sites with the location of MUAs by census region and state. 
[Footnote 7] 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.[Footnote 8] 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[Footnote 9]--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 
from HRSA the applications submitted[Footnote 10] for the new access 
point competitions held in fiscal year 2007 and the list of funded 
applicants for these competitions.[Footnote 11] We reviewed the 
applications to determine the zip code location of proposed new health 
center sites, that is, sites for which the applicants requested 
funding, and the list of funded applicants to determine the location of 
the new health center sites for which grants were awarded in 
2007.[Footnote 12] We also obtained from HRSA data on the location of 
MUAs in 2007. We then compared the location of proposed and funded new 
health center sites in 2007 with the location of MUAs in 2007.[Footnote 
13] As with the 2006 analysis, we limited our review to health center 
sites operated by grantees that requested 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. 
As we did for the 2006 analysis, we obtained from HRSA the location of 
health center look-alike sites in 2007 and compared them to the 
location of MUAs in 2007. 

To examine HRSA's oversight of cooperative agreement recipients' 
assistance to new access point applicants, we first interviewed HRSA 
officials and representatives from organizations that had training and 
TA cooperative agreements with HRSA for fiscal year 2007 to provide 
assistance to applicants for health center grants. Specifically, we 
interviewed representatives of the eight national organizations that 
target assistance to new access point applicants[Footnote 14] and a 
judgmental sample of 10 geographically diverse state PCAs. We reviewed 
copies of the organizations' notices of grant awards, work plans 
(documents detailing health center training and technical assistance 
activities), and semiannual and annual progress reports submitted to 
HRSA.[Footnote 15] We examined documents obtained from HRSA relating to 
its review of these cooperative agreement recipients' fiscal year 2007 
annual noncompeting continuation applications[Footnote 16] and periodic 
comprehensive on-site reviews conducted by HRSA. To evaluate HRSA's 
feedback to unsuccessful applicants, we obtained from HRSA the summary 
statements that were issued to unsuccessful applicants in connection 
with each of the three new access point grant competitions held in 
fiscal years 2005 and 2007.[Footnote 17] We selected a random sample of 
30 percent of the summary statements based on application score. This 
resulted in a sample of 69 summary statements out of the universe of 
230 sent to unsuccessful applicants. The results of our analysis are 
generalizable to this universe. For each summary statement, we reviewed 
the information provided on the application's strengths and weaknesses 
for each of the eight criteria used to evaluate new access point grant 
applications. 

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 our 
work 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. 

Results in Brief: 

In 2006, 47 percent of MUAs nationwide lacked a health center site; 
however, the percentage of MUAs lacking a health center site varied 
widely across census regions and states. For example, more than 60 
percent of MUAs in the Midwest census region lacked a health center 
site while approximately 30 percent of MUAs in the West census region 
lacked a health center site. In addition, in some states, such as 
Nebraska and Iowa, more than 80 percent of MUAs lacked a health center 
site, while in other states, including Mississippi and California, less 
than 25 percent of the MUAs lacked a health center site. 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 provided by health center sites 
is unknown. 

New access point awards made by HRSA in 2007 reduced the number of MUAs 
that lacked a health center site nationwide by about 7 percent. As a 
result, 43 percent of MUAs lacked a health center site in 2007. Wide 
geographic variation in the percentage of MUAs lacking a health center 
site remained. The West and Midwest census regions continued to show 
the lowest and highest percentages of MUAs that lacked health center 
sites, respectively. In addition, three of the census regions showed a 
1 or 2 percentage point change since 2006, while the South census 
region showed a 5 percentage point change. 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 in 2007 was concentrated in the South census region, which 
received the largest proportion of the awards made in 2007. 

HRSA oversees training and TA cooperative agreement recipients that 
assist new access point applicants using a number of methods, but its 
oversight is limited in certain key respects, and its feedback to 
unsuccessful applicants is not always clear. HRSA oversees recipients 
using a number of methods, including regular communications, review of 
cooperative agreement applications, and comprehensive on-site reviews. 
However, the agency's oversight of cooperative agreement recipients has 
limitations because the agency does not have standardized performance 
measures to evaluate recipients' performance of training and technical 
assistance activities. For example, HRSA does not require that 
recipients be held to a performance measure that would report the 
number of successful applicants each assisted. Without standardized 
measures, HRSA cannot effectively assess recipients' performance and 
compare the extent to which recipients' activities support the goals of 
the Health Center Program. HRSA officials told us that they are 
developing standardized measures to help the agency assess the 
performance of its cooperative agreement recipients but provided no 
details on specific measures they may implement. HRSA's oversight is 
also limited because it is unlikely to meet its policy goal timeline of 
conducting comprehensive on-site reviews of the recipients every 3 to 5 
years. HRSA has conducted comprehensive on-site reviews for fewer than 
one-quarter of its training and TA cooperative agreement recipients 
that target assistance to new access point applicants since the agency 
implemented these reviews in 2004. These reviews evaluate the overall 
operations of cooperative agreement recipients and are intended to 
improve the performance of HRSA programs. HRSA officials stated that 
they had limited resources each year to review cooperative agreement 
recipients. Moreover, to help unsuccessful applicants, HRSA sends 
summary statements detailing the strengths and weaknesses of the 
applications. However, 38 percent of the summary statements sent to 
unsuccessful applicants for new access point grant competitions held in 
fiscal years 2005 and 2007 contained unclear feedback. The lack of 
clarity in the summary statements may undermine the usefulness of the 
feedback for these applicants rather than enhance their ability to 
successfully compete for new access point grants in the future. 

To help improve the Health Center Program, we recommend that HRSA take 
the following actions. First, to improve the agency's ability to 
measure access to comprehensive primary care services in MUAs, we 
recommend that HRSA collect and maintain readily available data on the 
types of services provided at each health center site. Second, to 
enhance the agency's oversight of training and TA cooperative agreement 
recipients that assist grant applicants, we recommend that HRSA develop 
and implement standardized performance measures for those recipients, 
including a measure of the number of grant applicants an organization 
assisted. Third, given HRSA's concerns about resources to conduct 
comprehensive on-site reviews of cooperative agreement recipients each 
year, we recommend that HRSA reevaluate its policy of reviewing 
training and TA cooperative agreement funding recipients every 3 to 5 
years and consider targeting its available resources to focus on 
comprehensive on-site reviews for cooperative agreement recipients that 
are most likely to benefit from such oversight. Finally, to improve the 
clarity of the feedback the agency provides to unsuccessful grant 
applicants, we recommend that HRSA identify and take appropriate action 
to ensure that the discussion of applicants' strengths and weaknesses 
in all summary statements is clear. 

In commenting on a draft of this report, HHS raised concerns regarding 
the scope of the report and one of our recommendations and concurred 
with the other three recommendations. HHS stated that its most 
significant concern was that we did not include MUPs in our analysis. 
Our research objective was to determine the location of health center 
sites that provide services to residents of an MUA and not to assess 
how well areas or populations were served. Therefore, MUPs were beyond 
the scope of our work. Moreover, in our MUA analysis, we covered the 
health center sites of 90 percent of all Health Center Program 
grantees. With regard to our recommendation that HRSA collect and 
maintain data on the services provided at each health center site, 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. We believe that having site-specific information on services 
provided would help HRSA better measure access to comprehensive primary 
health care services in MUAs when considering the placement of new 
health center sites and facilitate the agency's ability to evaluate 
service area overlap in MUAs. 

Background: 

The Health Center Program is governed by section 330 of the Public 
Health Service Act.[Footnote 18] By law, grantees with community health 
center funding must operate health center sites that: 

* serve, in whole or in part, an MUA or MUP; 

* provide comprehensive primary care services as well as enabling 
services, such as translation and transportation, that facilitate 
access to health care; 

* are available to all residents of the health center service area, 
with fees on a sliding scale based on patients' ability to pay; 

* are governed by a community board of which at least 51 percent of the 
members are patients of the health center; and: 

* meet performance and accountability requirements regarding 
administrative, clinical, and financial operations. 

HRSA's MUA Designation Criteria: 

HRSA may designate a geographic area--such as a group of contiguous 
counties, a single county, or a portion of a county--as an MUA based on 
the agency's index of medical underservice, composed of a weighted sum 
of the area's infant mortality rate, percentage of population below the 
federal poverty level, ratio of population to the number of primary 
care physicians, and percentage of population aged 65 and over. 

In previous reports, we identified problems with HRSA's methodology for 
designating MUAs, including the agency's lack of timeliness in updating 
its designation criteria.[Footnote 19] HRSA published a notice of 
proposed rule making in 1998 to revise the MUA designation system, but 
it was withdrawn because of a number of issues raised in over 800 
public comments.[Footnote 20] In February 2008, HRSA published a 
revised proposal and the period for pubic comment closed in June 2008. 
[Footnote 21] 

HRSA's New Access Point Grant Process: 

HRSA uses a competitive process to award Health Center Program grants. 
There are four types of health center grants available through the 
Health Center Program, but only new access point grants are used to 
establish new health center sites.[Footnote 22] Since 2005, HRSA has 
evaluated applications for new access point grants using eight criteria 
for which an application can receive a maximum of 100 points (see table 
1). 

Table 1: Description of Criteria and Maximum Points Awarded for New 
Access Point Grant Opportunities, Fiscal Years 2005 and 2007: 

Criterion: Need; 
Description: The applicant's description of need in the proposed 
service area; 
Maximum points for the 2005 and 2007 open new access point competition: 
10; 
Maximum points for the 2007 high poverty county new access point 
competition: 35. 

Criterion: Response; 
Description: The applicant's proposal to respond to the health care 
need; 
Maximum points for the 2005 and 2007 open new access point competition: 
30; 
Maximum points for the 2007 high poverty county new access point 
competition: 20. 

Criterion: Evaluative measures; 
Description: The applicant's ability to measure its own performance; 
Maximum points for the 2005 and 2007 open new access point competition: 
10; 
Maximum points for the 2007 high poverty county new access point 
competition: 5. 

Criterion: Impact; 
Description: The applicant's justification of requested funding and how 
it will increase access to care; 
Maximum points for the 2005 and 2007 open new access point competition: 
10; 
Maximum points for the 2007 high poverty county new access point 
competition: 6. 

Criterion: Resources/capabilities; 
Description: The applicant's organizational and financial plan and past 
accomplishments; 
Maximum points for the 2005 and 2007 open new access point competition: 
15; 
Maximum points for the 2007 high poverty county new access point 
competition: 11. 

Criterion: Support requested; 
Description: The applicant's budget; 
Maximum points for the 2005 and 2007 open new access point competition: 
10; 
Maximum points for the 2007 high poverty county new access point 
competition: 8. 

Criterion: Governance; 
Description: The applicant's plans for establishing a governing board; 
Maximum points for the 2005 and 2007 open new access point competition: 
10; 
Maximum points for the 2007 high poverty county new access point 
competition: 10. 

Criterion: Readiness; 
Description: The applicant's ability to begin providing services; 
Maximum points for the 2005 and 2007 open new access point competition: 
5; 
Maximum points for the 2007 high poverty county new access point 
competition: 5. 

Total: 
Maximum points for the 2005 and 2007 open new access point competition: 
100; 
Maximum points for the 2007 high poverty county new access point 
competition: 100. 

Source: GAO analysis of HRSA's new access point health center 
application guidance from fiscal years 2005 and 2007. 

[End of table] 

Grant applications are evaluated by an objective review committee--a 
panel of independent experts, selected by HRSA, who have health center- 
related experience. The objective review committee scores the 
applications by awarding up to the maximum number of points allowed for 
each criterion and prepares summary statements that detail an 
application's strengths and weaknesses in each evaluative criterion. 
The summary statements also contain the committee's recommended funding 
amounts and advisory comments for HRSA's internal use; for example, the 
committee may recommend that HRSA consider whether the applicant's 
budgeted amount for physician salaries is appropriate. The committee 
develops a rank order list--a list of all evaluated applications in 
descending order by score. HRSA uses the internal comments--recommended 
funding amounts and advisory comments--from the summary statements and 
the rank order list when making final funding decisions. In addition, 
HRSA is required to take into account the urban/rural distribution of 
grants, the distribution of funds to different types of health centers, 
and whether a health center site is located in a sparsely populated 
rural area.[Footnote 23] HRSA also considers the geographic 
distribution of health center sites--to determine if overlap exists in 
the areas served by the sites--as well as the financial viability of 
grantees.[Footnote 24] After the funding decisions are made, HRSA 
officials review the summary statements for accuracy, remove the 
recommended funding amounts and any advisory comments, and send the 
summary statements to unsuccessful applicants as feedback. 

HRSA's Training and TA Cooperative Agreements: 

For fiscal year 2007, HRSA funded 60 training and TA cooperative 
agreements with various national, regional, and state organizations to 
support the Health Center Program, in part, by providing training and 
technical assistance to health center grant applicants.[Footnote 25] 
Cooperative agreements are a type of federal assistance that entails 
substantial involvement between the government agency--in this case, 
HRSA--and the funding recipient--that is, the national, regional, and 
state organizations. HRSA relies on these training and TA cooperative 
agreement recipients to identify underserved areas and populations 
across the country in order to assist the agency in increasing access 
to primary care services for underserved people. In addition, these 
cooperative agreement recipients serve as HRSA's primary form of 
outreach to potential applicants for health center grants. 

For each cooperative agreement recipient, HRSA assigns a project 
officer who serves as a recipient's main point of contact with the 
agency. The duration of a cooperative agreement, known as the project 
period, is generally 2 or 3 years, with each year known as a budget 
period. As a condition of the cooperative agreements, HRSA project 
officers and the organizations jointly develop work plans detailing the 
specific training and technical assistance activities to be conducted 
during each budget period. Activities targeted to new access point 
applicants can include assistance with assessing community needs, 
disseminating information in underserved communities regarding health 
center program requirements, and developing and writing grant 
applications. After cooperative agreement recipients secure funding 
through a competitive process, they reapply for annual funding through 
what is known as a noncompeting continuation application each budget 
period until the end of their project period. These continuation 
applications typically include a work plan and budget for the upcoming 
budget period and progress report on the organization's current 
activities. 

HRSA policy states that cooperative agreement recipients will undergo a 
comprehensive on-site review by agency officials once every 3 to 5 
years. During these comprehensive on-site reviews, HRSA evaluates the 
cooperative agreement recipients using selected performance measures-- 
developed in collaboration with the organizations--and requires 
recipients to develop action plans to improve operations if necessary. 
The purpose of these reviews is for the agency to evaluate the overall 
operations of all its funding recipients and improve the performance of 
its programs. 

Almost Half of MUAs Lacked a Health Center Site in 2006, and the Types 
of Services Provided by Each Site Could Not Be Determined: 

Almost half of MUAs nationwide lacked a health center site in 2006. The 
percentage of MUAs that lacked a health center site varied widely 
across census regions and states. We could not determine the types of 
primary care services provided by health center sites in MUAs because 
HRSA does not maintain data on the types of services offered at each 
site. Because of this, the extent to which individuals in MUAs have 
access to the full range of comprehensive primary care services 
provided by health center sites is unknown. 

Almost Half of MUAs Nationwide Lacked Health Center Sites in 2006, and 
the Percentage of MUAs Lacking Sites Varied Widely by Census Region and 
State: 

Based on our analysis of HRSA data, we found that 47 percent of MUAs 
nationwide--1,600 of 3,421--lacked a health center site in 2006. 
[Footnote 26] We found wide variation among census regions-- Northeast, 
Midwest, South, and West--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). 

Figure 1: Percentage of MUAs That Lacked a Health Center Site, by 
Census Region and State, 2006: 

[See PDF for image] 

This figure is a map of the United States depicting the following data 
with number of MUAs in a state in parenthesis: 

Northeast Region: Regional average: 39%; 
* Percentage of MUAs that lacked a health center site: 0%: 
State: Rhode Island: (7). 

* Percentage of MUAs that lacked a health center site: 1-25%: 
State: Connecticut: (17); 
State: Massachusetts: (40); 
State: New Hampshire: (5); 
State: New Jersey: (28). 

* Percentage of MUAs that lacked a health center site: 26-50%: 
State: Maine: (30); 
State: New York: (115); 
State: Pennsylvania: (137); 

* Percentage of MUAs that lacked a health center site: 51-75%: 
State: Vermont: (16). 

* Percentage of MUAs that lacked a health center site: 76-100%: 
None. 

South Region: Regional average: 45%; 

* Percentage of MUAs that lacked a health center site: 0%: 
State: Delaware: (4); 
State: District of Columbia: (9). 

* Percentage of MUAs that lacked a health center site: 1-25%: 
State: Alabama: (96); 
State: Mississippi: (91); 
State: South Carolina: (68); 
State: West Virginia: (57). 

* Percentage of MUAs that lacked a health center site: 26-50%: 
State: Arkansas: (82); 
State: Florida: (35); 
State: Maryland: (38); 
State: Tennessee: (101); 
State: Virginia: (92). 

* Percentage of MUAs that lacked a health center site: 51-75%: 
State: Georgia: (147); 
State: Kentucky: (78); 
State: Louisiana: (73); 
State: North Carolina: (107); 
State: Oklahoma: (65); 
State: Texas: (282). 

* Percentage of MUAs that lacked a health center site: 76-100%: 
None. 

Midwest Region: Regional average: 62%; 

* Percentage of MUAs that lacked a health center site: 0%: 
None. 

* Percentage of MUAs that lacked a health center site: 1-25%: 
None. 

* Percentage of MUAs that lacked a health center site: 26-50%: 
State: Illinois: (145); 
State: Michigan: (89); 
State: Ohio: (111). 

* Percentage of MUAs that lacked a health center site: 51-75%: 
State: Indiana: (61); 
State: Kansas: (66); 
State: Missouri: (118); 
State: North Dakota: (55); 
State: South Dakota: (65); 
State: Wisconsin: (67); 

* Percentage of MUAs that lacked a health center site: 76-100%: 
State: Iowa: (73); 
State: Minnesota: (96); 
State: Nebraska: (82). 

West Region: Regional average: 362%; 

* Percentage of MUAs that lacked a health center site: 0%: 
State: Alaska: (17); 
State: Hawaii: (4). 

* Percentage of MUAs that lacked a health center site: 1-25%: 
State: California: (165); 
State: Colorado: (42); 
State: New Mexico: (36); 

* Percentage of MUAs that lacked a health center site: 26-50%: 
State: Arizona: (33); 
State: Idaho: (35); 
State: Nevada: (8); 
State: Oregon: (42); 
State: Utah: (17); 
State: Washington: (31); 

* Percentage of MUAs that lacked a health center site: 51-75%: 
State: Wyoming: (11). 

* Percentage of MUAs that lacked a health center site: 76-100%: 
State: Montana: (44). 

Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis 
of HRSA and U.S. Census Bureau data. 

Note: U.S. territories are not included in this map. 

[End of figure] 

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; in contrast, fewer than one- 
quarter of the MUAs in 13 states--including Colorado (21 percent), 
California (20 percent), Mississippi (20 percent), and West Virginia 
(19 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. 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 multiple 
health center sites. 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 multiple sites. 

The Types of Services Provided at Individual Sites Could Not Be 
Determined Because Data Were Not Readily Available: 

We could not determine the types of primary care services provided at 
each health center site because HRSA does not collect and maintain 
readily available data on the types of services provided at individual 
health center 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 it 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, it is not required 
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 in MUAs have access to the 
full range of comprehensive primary care services provided by health 
center sites. 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 limit the 
agency's ability to evaluate service area overlap in MUAs. 

2007 Awards Reduced the Number of MUAs That Lacked a Health Center 
Site, but Wide Geographic Variation Remained: 

Our analysis of new access point grants awarded in 2007 found 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. As a result, 43 percent 
of MUAs nationwide lacked a health center site in 2007.[Footnote 27] 

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 census regions showed a 1 or 2 
percentage point change since 2006, while the South census region 
showed a 5 percentage point change. 

Figure 2: Percentage of MUAs That Lacked a Health Center Site, by 
Census Region, 2007: 

[See PDF for image] 

This figure is a map of the United States depicting the following data: 

Census Region: Northeast; 
MUAs lacking a health center site, 2006: 39%; 
MUAs lacking a health center site, 2007: 37%. 

Census Region: South; 
MUAs lacking a health center site, 2006: 45%; 
MUAs lacking a health center site, 2007: 40%. 

Census Region: Midwest; 
MUAs lacking a health center site, 2006: 62%; 
MUAs lacking a health center site, 2007: 60%. 

Census Region: West; 
MUAs lacking a health center site, 2006: 32%; 
MUAs lacking a health center site, 2007: 31%. 

Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis 
of HRSA and U.S. Census Bureau data. 

[End of figure] 

The minimal impact of the 2007 awards on regional variation is 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. (See table 2.) 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. Overall, while 
the South census region experienced a decline of 12 percent in the 
number of MUAs that lacked a health center site, the other census 
regions experienced declines of approximately 4 percent. 

Table 2: Number of MUAs That Lacked a Health Center Site for 2006 and 
2007, and 2006 to 2007 Decrease in MUAs That Lacked a Health Center 
Site by Number and Percentage, by Census Region: 

Census region: Northeast; 
Number of MUAs that lacked a health center site: 2006: 153; 
Number of MUAs that lacked a health center site: 2007: 147; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Number: 6; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Percentage: 4. 

Census region: Midwest; 
Number of MUAs that lacked a health center site: 2006: 641; 
Number of MUAs that lacked a health center site: 2007: 617; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Number: 24; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Percentage: 4. 

Census region: South; 
Number of MUAs that lacked a health center site: 2006: 651; 
Number of MUAs that lacked a health center site: 2007: 574; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Number: 77; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Percentage: 12. 

Census region: West; 
Number of MUAs that lacked a health center site: 2006: 155; 
Number of MUAs that lacked a health center site: 2007: 149; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Number: 6; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Percentage: 4. 

Census region: Nationally; 
Number of MUAs that lacked a health center site: 2006: 1,600; 
Number of MUAs that lacked a health center site: 2007: 1,487; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Number: 113; 
Decrease in MUAs that lacked a health center site, 2006 to 2007: 
Percentage: 7. 

Source: GAO analysis of HRSA data. 

[End of table] 

The South census region experienced the greatest decline in the number 
of MUAs lacking a health center site in 2007 compared to other census 
regions, in large part, because it was awarded more new access point 
grants that year than any other region. (See table 3.) Specifically, 
half of all new access point awards made in 2007--from two separate new 
access point competitions--went to applicants from the South census 
region. 

Table 3: Number and Percentage of All New Access Point Grants Awarded 
in 2007, by Census Region: 

Census region: Midwest; 
Grants awarded: Number: 39; 
Grants awarded: Percentage: 19. 

Census region: Northeast; 
Grants awarded: Number: 15; 
Grants awarded: Percentage: 7. 

Census region: South; 
Grants awarded: Number: 101; 
Grants awarded: Percentage: 50. 

Census region: West; 
Grants awarded: Number: 47; 
Grants awarded: Percentage: 23. 

Census region: Total; 
Grants awarded: Number: 202; 
Grants awarded: Percentage: 100[A]. 

Source: GAO analysis of HRSA data. 

[A] Percentages do not add to 100 because of rounding. 

[End of table] 

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. (See fig. 3.) The greater 
number of awards made to the South census region for this competition 
may be explained by the fact that nearly two-thirds of the 200 counties 
targeted were located in the South census region. (For detail on the 
High Poverty County new access point competition by census region and 
state, see app. II.) 

Figure 3: Geographic Distribution of Counties Targeted and Grants 
Awarded for the 2007 High Poverty County New Access Point Competition: 

[See PDF for image] 

This figure is a multiple vertical bar graph depicting the following 
data: 

Source: GAO analysis of HRSA data. 

[End of figure] 

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. (See table 4.) 

Table 4: Number and Percentage of New Access Point Grants Awarded in 
Fiscal Year 2007 for the Open New Access Point Competition, by Census 
Region: 

Census region: Midwest; 
Grants awarded: Number: 21; 
Grants awarded: Percentage: 17. 

Census region: Northeast; 
Grants awarded: Number: 12; 
Grants awarded: Percentage: 9. 

Census region: South; 
Grants awarded: Number: 49; 
Grants awarded: Percentage: 39. 

Census region: West; 
Grants awarded: Number: 45; 
Grants awarded: Percentage: 35. 

Census region: Total; 
Grants awarded: Number: 127; 
Grants awarded: Percentage: 100. 

Source: GAO analysis of HRSA data. 

[End of table] 

HRSA Oversees Cooperative Agreement Recipients but Oversight Is Limited 
in Key Respects, and Its Feedback to Unsuccessful Applicants Is Not 
Always Clear: 

HRSA oversees cooperative agreement recipients, but the agency's 
oversight is limited because it does not have standardized performance 
measures to assess the performance of the cooperative agreement 
recipients in assisting new access point applicants and the agency is 
unlikely to meet its policy timeline for conducting comprehensive on- 
site reviews. Although HRSA officials told us that they were developing 
standardized performance measures, they provided no details on the 
specific measures that may be implemented. Moreover, more than a third 
of the summary statements sent to unsuccessful applicants for new 
access point competitions held in fiscal years 2005 and 2007 contained 
unclear feedback. 

HRSA Oversees Cooperative Agreement Recipients but Lacks Standardized 
Performance Measures and Likely Will Not Complete All Comprehensive On- 
site Reviews in a Timely Manner: 

HRSA oversees the activities of its cooperative agreement recipients 
using a number of methods. HRSA officials told us that over the course 
of a budget period, project officers use regular telephone and 
electronic communications to discuss cooperative agreement recipients' 
activities as specified in work plans, review the status of these 
activities, and help set priorities.[Footnote 28] According to HRSA 
officials, there is no standard protocol for these communications, and 
their frequency, duration, and content vary over the course of a budget 
period and by recipient. HRSA staff also reviews annual noncompeting 
continuation applications to determine whether the cooperative 
agreement recipients provided an update on their progress, described 
their activities and challenges, and developed a suitable work plan and 
budget for the upcoming budget period. The progress reports submitted 
by cooperative agreement recipients in these annual applications serve 
as HRSA's primary form of documentation on the status of cooperative 
agreement recipients' activities.[Footnote 29] 

HRSA's oversight of training and TA cooperative agreement recipients is 
based on performance measures tailored to the individual organization 
rather than performance measures that are standardized across all 
recipients. Specifically, HRSA uses individualized performance measures 
in cooperative agreement recipients' work plans and comprehensive on-
site reviews to assess recipients' performance. For cooperative 
agreement recipients' work plans, recipients propose training and 
technical assistance activities in response to HRSA's cooperative 
agreement application guidance, in which the agency provides general 
guidelines and goals for the provision of training and technical 
assistance to health center grant applicants. The guidance requires 
recipients to develop performance measures for each activity in their 
work plans.[Footnote 30] When we analyzed the work plans of the 8 
national organizations and 10 PCAs with training and TA cooperative 
agreements, we found that these measures varied by cooperative 
agreement recipient. For example, we found that for national 
organizations, performance measures varied from (1) documenting that 
the organization's marketing materials were sent to PCAs to (2) 
recording the number of specific technical assistance requests the 
organization received to (3) producing monthly reports for HRSA 
detailing information about potential applicants. For state PCAs, 
measures varied from (1) the PCA providing application review as 
requested to (2) holding specific training opportunities--such as 
community development or board development--to (3) identifying a 
specific number of applicants the PCA would assist during the budget 
period. Because these performance measures vary for cooperative 
agreement recipients' activities, HRSA does not have comparable 
measures to evaluate the performance of these activities across 
recipients. 

HRSA's oversight of cooperative agreement recipients is limited in some 
key respects. One limitation is that the agency does not have 
standardized measures for its assessment of recipients' performance of 
training and technical assistance activities. Without standardized 
performance measures, HRSA cannot effectively assess the performance of 
its cooperative agreement recipients with respect to the training and 
technical assistance they provide to support Health Center Program 
goals. For example, HRSA does not require that all training and TA 
cooperative agreement recipients be held to a performance measure that 
would report the number of successful applicants each cooperative 
agreement recipient helped develop in underserved communities, 
including MUAs. Standardized performance measures could help HRSA 
identify how to better focus its resources to help strengthen the 
performance of cooperative agreement recipients. 

HRSA officials told us that they are developing performance measures 
for the agency's cooperative agreement recipients, which they plan to 
implement beginning with the next competitive funding announcement, 
scheduled for fiscal year 2009. However, HRSA officials did not provide 
details on the particular measures that it will implement, so it is 
unclear to what extent the proposed measures will allow HRSA to assess 
the performance of cooperative agreement recipients in supporting 
Health Center Program goals through such efforts as developing 
successful new access point grant applicants. 

HRSA's oversight is also limited because the agency's comprehensive on- 
site reviews of cooperative agreement recipients do not occur as 
frequently as HRSA policy states.[Footnote 31] According to HRSA's 
stated policy, the agency will conduct these reviews for each 
cooperative agreement recipient every 3 to 5 years. The reviews are 
intended to assess--and thereby potentially improve--the performance of 
the cooperative agreement recipients in supporting the overall goals of 
the Health Center Program. This support can include helping potential 
applicants apply for health center grants, identifying underserved 
areas and populations across the country, and helping HRSA increase 
access to primary care services for underserved populations. 

As part of the comprehensive on-site reviews, HRSA officials consult 
with the relevant project officer, examine the scope of the activities 
cooperative agreement recipients have described in their work plans and 
reported in their progress reports, and develop performance measures in 
collaboration with the recipient. Similar to the performance measures 
in cooperative agreement recipients' work plans, the performance 
measures used during comprehensive on-site reviews are also 
individually tailored and vary by recipient. For example, during these 
reviews, some recipients are assessed using performance measures that 
include the number of training and technical assistance hours the 
recipients provided; other recipients are assessed using measures that 
include the number of applicants that were funded after receiving 
technical assistance from the recipient or the percentage of the 
state's uninsured population that is served by health center sites in 
the Health Center Program. 

After an assessment, HRSA asks the recipient to develop an action plan. 
In these action plans, the reviewing HRSA officials may recommend 
additional activities to improve the performance of the specific 
measures they had identified during the review. For example, if the 
agency concludes that a cooperative agreement recipient needs to 
increase the percentage of the state's uninsured population served by 
health center sites in the Health Center Program, it may recommend that 
the recipient pursue strategies to develop a statewide health 
professional recruitment program and identify other funding sources to 
improve its ability to increase access to primary care for underserved 
people. 

Although HRSA's stated policy is to conduct on-site comprehensive 
reviews of cooperative agreement recipients every 3 to 5 years, HRSA is 
unlikely to meet this goal for its training and TA cooperative 
recipients that target assistance to new access point applicants. In 
the 4 years since HRSA implemented its policy for these reviews in 
2004, the agency has evaluated only about 20 percent of cooperative 
agreement recipients that provide training and technical assistance to 
grant applicants. HRSA officials told us that they have limited 
resources each year with which to fund the reviews. However, without 
these reviews, HRSA does not have a means of obtaining comprehensive 
information on the performance of cooperative agreement recipients in 
supporting the Health Center Program, including information on ways the 
recipients could improve the assistance they provide to new access 
point applicants. 

HRSA Provided Unclear Written Feedback to More Than a Third of 
Unsuccessful Applicants: 

More than a third of summary statements sent to unsuccessful applicants 
from new access point grant competitions held in fiscal years 2005 and 

2007 contained unclear feedback. Based on our analysis of 69 summary 
statements, we found that 38 percent contained unclear feedback 
associated with at least one of the eight evaluative criteria, while 13 
percent contained unclear feedback in more than one criterion. We 
defined feedback as unclear when, in regard to a particular criterion, 
a characteristic of the application was noted as both a strength and a 
weakness without a detailed explanation supporting each conclusion. We 
found that 26 summary statements contained unclear feedback. We found 
41 distinct examples of unclear feedback in the summary statements. 
(See table 5.) HRSA's stated purpose in providing summary statements to 
unsuccessful applicants is to improve the quality of future grant 
applications. However, if the feedback HRSA provides in these 
statements is unclear, it may undermine the usefulness of the feedback 
for applicants and their ability to successfully compete for new access 
point grants. 

Table 5: Total Number of Distinct Examples of Unclear Feedback by 
Criterion for New Access Point Grant Applications from Fiscal Years 
2005 and 2007: 

Criterion: Need; 
Total number of distinct examples of unclear feedback: 11. 

Criterion: Response; 
Total number of distinct examples of unclear feedback: 7. 

Criterion: Impact; 
Total number of distinct examples of unclear feedback: 5. 

Criterion: Support requested; 
Total number of distinct examples of unclear feedback: 5. 

Criterion: Evaluative measures; 
Total number of distinct examples of unclear feedback: 4. 

Criterion: Governance; 
Total number of distinct examples of unclear feedback: 4. 

Criterion: Readiness; 
Total number of distinct examples of unclear feedback: 3. 

Criterion: Resources/capabilities; 
Total number of distinct examples of unclear feedback: 2. 

Criterion: Total; 
Total number of distinct examples of unclear feedback: 41. 

Source: GAO analysis of a sample of HRSA summary statements from new 
access point competitions from fiscal years 2005 and 2007. 

[End of table] 

Based on our analysis, the largest number of examples of unclear 
feedback was found in the need criterion, in which applications are 
evaluated on the description of the service area, communities, target 
population--including the number served, encounter information, and 
barriers---and the health care environment. For example, one summary 
statement indicated that the application clearly demonstrated and 
provided a compelling case for the significant health access problems 
for the underserved target population. However, the summary statement 
also noted that the application was insufficiently detailed and brief 
in its description of the target population. 

Seven of the examples of unclear feedback were found in the response 
criterion, in which applications are evaluated on the applicant's 
proposal to respond the target population's need. One summary statement 
indicated that the application detailed a comprehensive plan for health 
care services to be provided directly by the applicant or through its 
established linkages with other providers, including a description of 
procedures for follow-up on referrals or services with external 
providers. The summary statement also indicated that the application 
did not provide a clear plan of health service delivery, including 
accountability among and between all subcontractors. 

Conclusions: 

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 recent new access point awards achieved modest success 
in reducing the percentage of MUAs nationwide that lacked a health 
center site. However, in 2007, 43 percent of MUAs continue 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. 

HRSA awards new access point grants to open new health center sites, 
thus increasing 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 can 
also help HRSA assess any potential overlap of services provided by 
health center sites in MUAs. 

HRSA could improve the number and quality of grant applications it 
receives--and thereby broaden its potential pool of applicants--by 
better monitoring the performance of cooperative agreement recipients 
that assist applicants and by ensuring that the feedback unsuccessful 
applicants receive is clear. However, limitations in HRSA's oversight 
of the training and TA cooperative agreement recipients hamper the 
agency's ability to identify recipients most in need of assistance. 
Because HRSA does not have standardized performance measures for these 
recipients--either for their work plan activities or for the 
comprehensive on-site reviews--the agency cannot assess recipients' 
performance using comparable measures and determine the extent to which 
they support the overall goals of the Health Center Program. One 
standardized performance measure that could help HRSA evaluate the 
success of cooperative agreement recipients that assist new access 
point applicants is the number of successful grant applicants each 
cooperative agreement recipient develops; this standardized performance 
measure could assist HRSA in determining where to focus its resources 
to strengthen the performance of cooperative agreement recipients. 

HRSA's allocation of available resources has made it unlikely that it 
will meet its goal of conducting comprehensive on-site reviews of each 
cooperative agreement recipient every 3 to 5 years. Without these 
reviews, HRSA does not have comprehensive information on the 
effectiveness of training and TA cooperative agreement recipients in 
supporting the Health Center Program, including ways in which they 
could improve their efforts to help grant applicants. Given the 
agency's concern regarding available resources for its comprehensive on-
site reviews, developing and implementing standardized performance 
measures for training and TA cooperative agreement recipients could 
assist HRSA in determining the cost-effectiveness of its current 
comprehensive on-site review policy and where to focus its limited 
resources. 

HRSA could potentially improve its pool of future applicants by 
increasing the extent to which it provides clear feedback to 
unsuccessful applicants on the strengths and weaknesses of their 
applications. HRSA intends for these summary statements to be used by 
applicants to improve the quality of future grant applications. 
However, the unclear feedback HRSA has provided to some unsuccessful 
applicants in fiscal years 2005 and 2007 does not provide those 
applicants with clear information that could help them improve their 
future applications. This could limit HRSA's ability to award new 
access point grants to locations where such grants are needed most. 

Recommendations for Executive Action: 

We recommend that the Administrator of HRSA take the following four 
actions to improve the Health Center Program: 

* Collect and maintain readily available data on the types of services 
provided at each health center site to improve the agency's ability to 
measure access to comprehensive primary care services in MUAs. 

* Develop and implement standardized performance measures for training 
and TA cooperative recipients that assist applicants to improve HRSA's 
ability to evaluate the performance of its training and TA cooperative 
agreements. These standardized performance measures should include a 
measure of the number of successful applicants a recipient assisted. 

* Reevaluate its policy of requiring comprehensive on-site reviews of 
Health Center Program training and TA cooperative agreement recipients 
every 3 to 5 years and consider targeting its available resources at 
comprehensive on-site reviews for cooperative agreement recipients that 
would benefit most from such oversight. 

* Identify and take appropriate action to ensure that the discussion of 
an applicant's strengths and weaknesses in all summary statements is 
clear. 

Agency Comments and Our Evaluation: 

In commenting on a draft of this report, HHS raised concerns regarding 
the scope of the report and one of our recommendations and concurred 
with the other three recommendations. (HHS's comments are reprinted in 
app. III.) HHS also provided technical comments, which we incorporated 
as appropriate. 

HHS said its most significant concern was with our focus on MUAs and 
the exclusion of MUPs from the scope of our report. In our analysis, we 
included the health center sites of 90 percent of all Health Center 
Program grantees. We excluded from our review sites that were 
associated with the remaining 10 percent of grantees that received HRSA 
funding to serve specific MUPs only because they are not required to 
serve all residents of the service area.[Footnote 32] Given our 
research objective to determine the location of health center sites 
that provide services to residents of an MUA, we excluded these 
specific MUPs and informed HRSA of our focus on health center sites and 
MUAs. We agree with HHS's comment that it could be beneficial to have 
information on the number of grants awarded to programs serving both 
MUAs and MUPs generally to fully assess the coverage of health center 
sites. 

HHS also commented that our methodology did not account for the 
proximity of potential health center sites located outside the boundary 
of an MUA. While we did not explicitly account for the proximity of 
potential health center sites located outside an MUA, we did include 
the entire area of all zip codes associated with an MUA. As a result, 
the geographic boundary of an MUA in our analysis may be larger than 
that defined by HRSA, so our methodology erred on the side of 
overestimating the number of MUAs that contained a health center site. 

With regard to our reporting on the percentage of MUAs that lacked a 
health center site, HHS stated that this indicator may be of limited 
utility, because not all programs serving MUAs and MUPs are comparable 
to each other due to differences in size, geographic location, and 
specific demographic characteristics. Specifically, HHS commented that 
our analysis presumed that the presence of one health center site was 
sufficient to serve an MUA. In our work, we did not examine whether 
MUAs were sufficiently served because this was beyond the scope of our 
work. Moreover, since HRSA does not maintain site-specific information 
on services provided and each site does not provide the same services, 
we could not assess whether an MUA was sufficiently served. HHS also 
noted that a health center site may not be the appropriate solution for 
some small population MUAs; however, we believe it is reasonable to 
expect that residents of an MUA--regardless of its size, geographic 
location, and specific demographic characteristics--have access to the 
full range of primary care services. 

With regard to our first recommendation that HRSA collect and maintain 
site-specific data on the services provided at each health center site, 
HHS acknowledged that site-specific information would be helpful for 
many purposes, but it said collecting this information would place a 
significant burden on grantees and raise the program's administrative 
expenses. We believe that having site-specific information on services 
provided would help HRSA better measure access to comprehensive primary 
health care services in MUAs when considering the placement of new 
health center sites and facilitate the agency's ability to evaluate 
service area overlap in MUAs. 

HHS concurred with our three other recommendations. With regard to our 
second recommendation, HHS stated that HRSA will include standardized 
performance measures with its fiscal year 2009 competitive application 
cycle for state PCAs and that HRSA plans to develop such measures for 
the national training and TA cooperative agreement recipients in future 
funding opportunities. With regard to our third recommendation, HHS 
commented that HRSA has developed a 5-year schedule for reviewing all 
state PCA grantees. HHS also stated that HRSA is examining ways to 
better target onsite reviews for national training and TA cooperative 
agreement recipients that would most benefit from such a review. 
Finally, HHS agreed with our fourth recommendation and stated that HRSA 
is continuously identifying ways to improve the review of applications. 

As arranged with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution of it until 30 
days after its issue date. At that time, we will send copies of this 
report to the Secretary of HHS, the Administrator of HRSA, appropriate 
congressional committees, and other interested parties. We will also 
make copies of this report available to others upon request. In 
addition, the report will be available at no charge on the GAO Web site 
at [hyperlink, http:///www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or [email protected]. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. Staff members who made major 
contributions to this report are listed in appendix IV. 

Sincerely yours, 

Cynthia A. Bascetta: 
Director, Health Care: 

[End of section] 

Appendix I: Number and Percentage of Medically Underserved Areas (MUA) 
Lacking a Health Center Site, 2006 and 2007: 

Midwest census region; 
Total number of MUAs: 2006: 1,027; 
Total number of MUAs: 2007: 1,029; 
Number of MUAs lacking a health center site: 2006: 641; 
Number of MUAs lacking a health center site: 2007: 617; 
Percentage of MUAs lacking a health center site: 2006: 62; 
Percentage of MUAs lacking a health center site: 2007: 60. 

Midwest census region; Illinois; 
Total number of MUAs: 2006: 146; 
Total number of MUAs: 2007: 143; 
Number of MUAs lacking a health center site: 2006: 71; 
Number of MUAs lacking a health center site: 2007: 63; 
Percentage of MUAs lacking a health center site: 2006: 49; 
Percentage of MUAs lacking a health center site: 2007: 44. 

Midwest census region; Indiana; 
Total number of MUAs: 2006: 61; 
Total number of MUAs: 2007: 61; 
Number of MUAs lacking a health center site: 2006: 35; 
Number of MUAs lacking a health center site: 2007: 34; 
Percentage of MUAs lacking a health center site: 2006: 57; 
Percentage of MUAs lacking a health center site: 2007: 56. 

Midwest census region; Iowa; 
Total number of MUAs: 2006: 73; 
Total number of MUAs: 2007: 73; 
Number of MUAs lacking a health center site: 2006: 60; 
Number of MUAs lacking a health center site: 2007: 56; 
Percentage of MUAs lacking a health center site: 2006: 82; 
Percentage of MUAs lacking a health center site: 2007: 77. 

Midwest census region; Kansas; 
Total number of MUAs: 2006: 66; 
Total number of MUAs: 2007: 71; 
Number of MUAs lacking a health center site: 2006: 49; 
Number of MUAs lacking a health center site: 2007: 52; 
Percentage of MUAs lacking a health center site: 2006: 74; 
Percentage of MUAs lacking a health center site: 2007: 73. 

Midwest census region; Michigan; 
Total number of MUAs: 2006: 89; 
Total number of MUAs: 2007: 89; 
Number of MUAs lacking a health center site: 2006: 44; 
Number of MUAs lacking a health center site: 2007: 43; 
Percentage of MUAs lacking a health center site: 2006: 49; 
Percentage of MUAs lacking a health center site: 2007: 48. 

Midwest census region; Minnesota; 
Total number of MUAs: 2006: 96; 
Total number of MUAs: 2007: 97; 
Number of MUAs lacking a health center site: 2006: 74;
Number of MUAs lacking a health center site: 2007: 75; 
Percentage of MUAs lacking a health center site: 2006: 77; 
Percentage of MUAs lacking a health center site: 2007: 77. 

Midwest census region; Missouri; 
Total number of MUAs: 2006: 116; 
Total number of MUAs: 2007: 116; 
Number of MUAs lacking a health center site: 2006: 62; 
Number of MUAs lacking a health center site: 2007: 58; 
Percentage of MUAs lacking a health center site: 2006: 53; 
Percentage of MUAs lacking a health center site: 2007: 50. 

Midwest census region; Nebraska; 
Total number of MUAs: 2006: 82; 
Total number of MUAs: 2007: 82; 
Number of MUAs lacking a health center site: 2006: 75; 
Number of MUAs lacking a health center site: 2007: 73; 
Percentage of MUAs lacking a health center site: 2006: 91; 
Percentage of MUAs lacking a health center site: 2007: 89. 

Midwest census region; North Dakota; 
Total number of MUAs: 2006: 55; 
Total number of MUAs: 2007: 55; 
Number of MUAs lacking a health center site: 2006: 40; 
Number of MUAs lacking a health center site: 2007: 39; 
Percentage of MUAs lacking a health center site: 2006: 73; 
Percentage of MUAs lacking a health center site: 2007: 71. 

Midwest census region; Ohio; 
Total number of MUAs: 2006: 111; 
Total number of MUAs: 2007: 110; 
Number of MUAs lacking a health center site: 2006: 48; 
Number of MUAs lacking a health center site: 2007: 42; 
Percentage of MUAs lacking a health center site: 2006: 43; 
Percentage of MUAs lacking a health center site: 2007: 38. 

Midwest census region; South Dakota; 
Total number of MUAs: 2006: 65; 
Total number of MUAs: 2007: 65; 
Number of MUAs lacking a health center site: 2006: 40; 
Number of MUAs lacking a health center site: 2007: 40; 
Percentage of MUAs lacking a health center site: 2006: 62; 
Percentage of MUAs lacking a health center site: 2007: 62. 

Midwest census region; Wisconsin; 
Total number of MUAs: 2006: 67; 
Total number of MUAs: 2007: 67; 
Number of MUAs lacking a health center site: 2006: 43; 
Number of MUAs lacking a health center site: 2007: 42; 
Percentage of MUAs lacking a health center site: 2006: 64; 
Percentage of MUAs lacking a health center site: 2007: 63. 

Northeast census region; 
Total number of MUAs: 2006: 395; 
Total number of MUAs: 2007: 400; 
Number of MUAs lacking a health center site: 2006: 153; 
Number of MUAs lacking a health center site: 2007: 147; 
Percentage of MUAs lacking a health center site: 2006: 39; 
Percentage of MUAs lacking a health center site: 2007: 37. 

Northeast census region; Connecticut; 
Total number of MUAs: 2006: 17; 
Total number of MUAs: 2007: 17; 
Number of MUAs lacking a health center site: 2006: 1; 
Number of MUAs lacking a health center site: 2007: 1; 
Percentage of MUAs lacking a health center site: 2006: 6; 
Percentage of MUAs lacking a health center site: 2007: 6. 

Northeast census region; Maine; 
Total number of MUAs: 2006: 30; 
Total number of MUAs: 2007: 32; 
Number of MUAs lacking a health center site: 2006: 10; 
Number of MUAs lacking a health center site: 2007: 11; 
Percentage of MUAs lacking a health center site: 2006: 33; 
Percentage of MUAs lacking a health center site: 2007: 34. 

Northeast census region; Massachusetts; 
Total number of MUAs: 2006: 40; 
Total number of MUAs: 2007: 40; 
Number of MUAs lacking a health center site: 2006: 10; 
Number of MUAs lacking a health center site: 2007: 9; 
Percentage of MUAs lacking a health center site: 2006: 25; 
Percentage of MUAs lacking a health center site: 2007: 23. 

Northeast census region; New Hampshire; 
Total number of MUAs: 2006: 5; 
Total number of MUAs: 2007: 5; 
Number of MUAs lacking a health center site: 2006: 1; 
Number of MUAs lacking a health center site: 2007: 1; 
Percentage of MUAs lacking a health center site: 2006: 20;
Percentage of MUAs lacking a health center site: 2007: 20. 

Northeast census region; New Jersey; 
Total number of MUAs: 2006: 28; 
Total number of MUAs: 2007: 28; 
Number of MUAs lacking a health center site: 2006: 1; 
Number of MUAs lacking a health center site: 2007: 1; 
Percentage of MUAs lacking a health center site: 2006: 4; 
Percentage of MUAs lacking a health center site: 2007: 4. 

Northeast census region; New York; 
Total number of MUAs: 2006: 115; 
Total number of MUAs: 2007: 116; 
Number of MUAs lacking a health center site: 2006: 56; 
Number of MUAs lacking a health center site: 2007: 53; 
Percentage of MUAs lacking a health center site: 2006: 49; 
Percentage of MUAs lacking a health center site: 2007: 46. 

Northeast census region; Pennsylvania; 
Total number of MUAs: 2006: 137; 
Total number of MUAs: 2007: 139; 
Number of MUAs lacking a health center site: 2006: 63; 
Number of MUAs lacking a health center site: 2007: 61; 
Percentage of MUAs lacking a health center site: 2006: 46; 
Percentage of MUAs lacking a health center site: 2007: 44. 

Northeast census region; Rhode Island; 
Total number of MUAs: 2006: 7; 
Total number of MUAs: 2007: 7; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

Northeast census region; Vermont; 
Total number of MUAs: 2006: 16; 
Total number of MUAs: 2007: 16; 
Number of MUAs lacking a health center site: 2006: 11; 
Number of MUAs lacking a health center site: 2007: 10; 
Percentage of MUAs lacking a health center site: 2006: 69; 
Percentage of MUAs lacking a health center site: 2007: 63. 

South census region; 
Total number of MUAs: 2006: 1,435; 
Total number of MUAs: 2007: 1,441; 
Number of MUAs lacking a health center site: 2006: 651; 
Number of MUAs lacking a health center site: 2007: 574; 
Percentage of MUAs lacking a health center site: 2006: 45; 
Percentage of MUAs lacking a health center site: 2007: 40. 

South census region; Alabama; 
Total number of MUAs: 2006: 96; 
Total number of MUAs: 2007: 96; 
Number of MUAs lacking a health center site: 2006: 24; 
Number of MUAs lacking a health center site: 2007: 19; 
Percentage of MUAs lacking a health center site: 2006: 25; 
Percentage of MUAs lacking a health center site: 2007: 20. 

South census region; Arkansas; 
Total number of MUAs: 2006: 92; 
Total number of MUAs: 2007: 93; 
Number of MUAs lacking a health center site: 2006: 38; 
Number of MUAs lacking a health center site: 2007: 33; 
Percentage of MUAs lacking a health center site: 2006: 41; 
Percentage of MUAs lacking a health center site: 2007: 35. 

South census region; Delaware; 
Total number of MUAs: 2006: 4; 
Total number of MUAs: 2007: 4; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

South census region; District of Columbia; Total number of MUAs: 2006: 
9; Total number of MUAs: 2007: 8; 
Number of MUAs lacking a health center site: 2006: 1; 
Number of MUAs lacking a health center site: 2007: 1; 
Percentage of MUAs lacking a health center site: 2006: 11; 
Percentage of MUAs lacking a health center site: 2007: 13. 

South census region; Florida; 
Total number of MUAs: 2006: 35; 
Total number of MUAs: 2007: 35; 
Number of MUAs lacking a health center site: 2006: 17; 
Number of MUAs lacking a health center site: 2007: 15; 
Percentage of MUAs lacking a health center site: 2006: 49; 
Percentage of MUAs lacking a health center site: 2007: 43. 

South census region; Georgia; 
Total number of MUAs: 2006: 147; 
Total number of MUAs: 2007: 149; 
Number of MUAs lacking a health center site: 2006: 88; 
Number of MUAs lacking a health center site: 2007: 78; 
Percentage of MUAs lacking a health center site: 2006: 60; 
Percentage of MUAs lacking a health center site: 2007: 52. 

South census region; Kentucky; 
Total number of MUAs: 2006: 78; 
Total number of MUAs: 2007: 78; 
Number of MUAs lacking a health center site: 2006: 51; 
Number of MUAs lacking a health center site: 2007: 45; 
Percentage of MUAs lacking a health center site: 2006: 65; 
Percentage of MUAs lacking a health center site: 2007: 58. 

South census region; Louisiana; 
Total number of MUAs: 2006: 73; 
Total number of MUAs: 2007: 73; 
Number of MUAs lacking a health center site: 2006: 39; 
Number of MUAs lacking a health center site: 2007: 33; 
Percentage of MUAs lacking a health center site: 2006: 53; 
Percentage of MUAs lacking a health center site: 2007: 45. 

South census region; Maryland; 
Total number of MUAs: 2006: 38; 
Total number of MUAs: 2007: 38; 
Number of MUAs lacking a health center site: 2006: 11; 
Number of MUAs lacking a health center site: 2007: 10; 
Percentage of MUAs lacking a health center site: 2006: 29; 
Percentage of MUAs lacking a health center site: 2007: 26. 

South census region; Mississippi; 
Total number of MUAs: 2006: 91; 
Total number of MUAs: 2007: 91; 
Number of MUAs lacking a health center site: 2006: 18; 
Number of MUAs lacking a health center site: 2007: 17; 
Percentage of MUAs lacking a health center site: 2006: 20; 
Percentage of MUAs lacking a health center site: 2007: 19. 

South census region; North Carolina; 
Total number of MUAs: 2006: 107; 
Total number of MUAs: 2007: 108; 
Number of MUAs lacking a health center site: 2006: 59; 
Number of MUAs lacking a health center site: 2007: 55; 
Percentage of MUAs lacking a health center site: 2006: 55; 
Percentage of MUAs lacking a health center site: 2007: 51. 

South census region; Oklahoma; 
Total number of MUAs: 2006: 65; 
Total number of MUAs: 2007: 66; 
Number of MUAs lacking a health center site: 2006: 34; 
Number of MUAs lacking a health center site: 2007: 30; 
Percentage of MUAs lacking a health center site: 2006: 52; 
Percentage of MUAs lacking a health center site: 2007: 45. 

South census region; South Carolina; 
Total number of MUAs: 2006: 68; 
Total number of MUAs: 2007: 69; 
Number of MUAs lacking a health center site: 2006: 17; 
Number of MUAs lacking a health center site: 2007: 15; 
Percentage of MUAs lacking a health center site: 2006: 25; 
Percentage of MUAs lacking a health center site: 2007: 22. 

South census region; Tennessee; 
Total number of MUAs: 2006: 101; 
Total number of MUAs: 2007: 101; 
Number of MUAs lacking a health center site: 2006: 38; 
Number of MUAs lacking a health center site: 2007: 35; 
Percentage of MUAs lacking a health center site: 2006: 38; 
Percentage of MUAs lacking a health center site: 2007: 35. 

South census region; Texas; 
Total number of MUAs: 2006: 282; 
Total number of MUAs: 2007: 283; 
Number of MUAs lacking a health center site: 2006: 167;
Number of MUAs lacking a health center site: 2007: 145; 
Percentage of MUAs lacking a health center site: 2006: 59; 
Percentage of MUAs lacking a health center site: 2007: 51. 

South census region; Virginia; 
Total number of MUAs: 2006: 92; 
Total number of MUAs: 2007: 93; 
Number of MUAs lacking a health center site: 2006: 38; 
Number of MUAs lacking a health center site: 2007: 34; 
Percentage of MUAs lacking a health center site: 2006: 41; 
Percentage of MUAs lacking a health center site: 2007: 37. 

South census region; West Virginia; 
Total number of MUAs: 2006: 57; 
Total number of MUAs: 2007: 56; 
Number of MUAs lacking a health center site: 2006: 11; 
Number of MUAs lacking a health center site: 2007: 9; 
Percentage of MUAs lacking a health center site: 2006: 19; 
Percentage of MUAs lacking a health center site: 2007: 16. 

West census region; 
Total number of MUAs: 2006: 485; 
Total number of MUAs: 2007: 487; 
Number of MUAs lacking a health center site: 2006: 155; 
Number of MUAs lacking a health center site: 2007: 149; 
Percentage of MUAs lacking a health center site: 2006: 32; 
Percentage of MUAs lacking a health center site: 2007: 31. 

West census region; Alaska; 
Total number of MUAs: 2006: 17; 
Total number of MUAs: 2007: 17; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

West census region; Arizona; 
Total number of MUAs: 2006: 33; 
Total number of MUAs: 2007: 33; 
Number of MUAs lacking a health center site: 2006: 13; 
Number of MUAs lacking a health center site: 2007: 13; 
Percentage of MUAs lacking a health center site: 2006: 39; 
Percentage of MUAs lacking a health center site: 2007: 39. 

West census region; California; 
Total number of MUAs: 2006: 165; 
Total number of MUAs: 2007: 167; 
Number of MUAs lacking a health center site: 2006: 33; 
Number of MUAs lacking a health center site: 2007: 31; 
Percentage of MUAs lacking a health center site: 2006: 20; 
Percentage of MUAs lacking a health center site: 2007: 19. 

West census region; Colorado; 
Total number of MUAs: 2006: 42; 
Total number of MUAs: 2007: 42; 
Number of MUAs lacking a health center site: 2006: 9; 
Number of MUAs lacking a health center site: 2007: 9; 
Percentage of MUAs lacking a health center site: 2006: 21; 
Percentage of MUAs lacking a health center site: 2007: 21. 

West census region; Hawaii; 
Total number of MUAs: 2006: 4; 
Total number of MUAs: 2007: 4; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

West census region; Idaho; 
Total number of MUAs: 2006: 35; 
Total number of MUAs: 2007: 35; 
Number of MUAs lacking a health center site: 2006: 15; 
Number of MUAs lacking a health center site: 2007: 14; 
Percentage of MUAs lacking a health center site: 2006: 43; 
Percentage of MUAs lacking a health center site: 2007: 40. 

West census region; Montana; 
Total number of MUAs: 2006: 44; 
Total number of MUAs: 2007: 44; 
Number of MUAs lacking a health center site: 2006: 34; 
Number of MUAs lacking a health center site: 2007: 33; 
Percentage of MUAs lacking a health center site: 2006: 77; 
Percentage of MUAs lacking a health center site: 2007: 75. 

West census region; Nevada; 
Total number of MUAs: 2006: 8; 
Total number of MUAs: 2007: 8; 
Number of MUAs lacking a health center site: 2006: 4; 
Number of MUAs lacking a health center site: 2007: 4; 
Percentage of MUAs lacking a health center site: 2006: 50; 
Percentage of MUAs lacking a health center site: 2007: 50. 

West census region; New Mexico; 
Total number of MUAs: 2006: 36; 
Total number of MUAs: 2007: 36; 
Number of MUAs lacking a health center site: 2006: 5; 
Number of MUAs lacking a health center site: 2007: 4; 
Percentage of MUAs lacking a health center site: 2006: 14; 
Percentage of MUAs lacking a health center site: 2007: 11. 

West census region; Oregon; 
Total number of MUAs: 2006: 42; 
Total number of MUAs: 2007: 42; 
Number of MUAs lacking a health center site: 2006: 17; 
Number of MUAs lacking a health center site: 2007: 16; 
Percentage of MUAs lacking a health center site: 2006: 40; 
Percentage of MUAs lacking a health center site: 2007: 38. 

West census region; Utah; 
Total number of MUAs: 2006: 17; 
Total number of MUAs: 2007: 17; 
Number of MUAs lacking a health center site: 2006: 7; 
Number of MUAs lacking a health center site: 2007: 7; 

Percentage of MUAs lacking a health center site: 2006: 41; 
Percentage of MUAs lacking a health center site: 2007: 41. 

West census region; Washington; 
Total number of MUAs: 2006: 31; 
Total number of MUAs: 2007: 31; 
Number of MUAs lacking a health center site: 2006: 12; 
Number of MUAs lacking a health center site: 2007: 12; 
Percentage of MUAs lacking a health center site: 2006: 39; 
Percentage of MUAs lacking a health center site: 2007: 39. 

West census region; Wyoming; 
Total number of MUAs: 2006: 11; 
Total number of MUAs: 2007: 11; 
Number of MUAs lacking a health center site: 2006: 6; 
Number of MUAs lacking a health center site: 2007: 6; 
Percentage of MUAs lacking a health center site: 2006: 55; 
Percentage of MUAs lacking a health center site: 2007: 55. 

U.S. territories; 
Total number of MUAs: 2006: 79; 
Total number of MUAs: 2007: 79; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

U.S. territories; American Samoa; 
Total number of MUAs: 2006: 4; 
Total number of MUAs: 2007: 4; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

U.S. territories; Guam; 
Total number of MUAs: 2006: 0; 
Total number of MUAs: 2007: 0; 
Number of MUAs lacking a health center site: 2006: n/a; 
Number of MUAs lacking a health center site: 2007: n/a; 
Percentage of MUAs lacking a health center site: 2006: n/a; 
Percentage of MUAs lacking a health center site: 2007: n/a. 

U.S. territories; Northern Mariana Islands; 
Total number of MUAs: 2006: 0; 
Total number of MUAs: 2007: 0; 
Number of MUAs lacking a health center site: 2006: n/a; 
Number of MUAs lacking a health center site: 2007: n/a; 
Percentage of MUAs lacking a health center site: 2006: n/a; 
Percentage of MUAs lacking a health center site: 2007: n/a. 

U.S. territories; Puerto Rico; 
Total number of MUAs: 2006: 72; 
Total number of MUAs: 2007: 72; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

U.S. territories; U.S. Virgin Islands; 
Total number of MUAs: 2006: 3; 
Total number of MUAs: 2007: 3; 
Number of MUAs lacking a health center site: 2006: 0; 
Number of MUAs lacking a health center site: 2007: 0; 
Percentage of MUAs lacking a health center site: 2006: 0; 
Percentage of MUAs lacking a health center site: 2007: 0. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) and U.S. Census Bureau data. 

[End of table] 

[End of section] 

Appendix II Data on the 2007 High Poverty County New Access Point 
Competition, by Census Region and State: 

Midwest census region; 
Counties targeted by HRSA: Number: 56; 
Counties targeted by HRSA: Percentage: 28; 
Applications submitted: Number: 25; 
Applications submitted: Percentage: 22; 
Awards received: Number: 18; 
Awards received: Percentage: 24. 

Midwest census region; Illinois; 
Counties targeted by HRSA: Number: 7; 
Counties targeted by HRSA: Percentage: 4; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

Midwest census region; Indiana; 
Counties targeted by HRSA: Number: 10; 
Counties targeted by HRSA: Percentage: 5; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

Midwest census region; Iowa; 
Counties targeted by HRSA: Number: 4; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

Midwest census region; Kansas; 
Counties targeted by HRSA: Number: 2; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Midwest census region; Michigan; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

Midwest census region; Minnesota; 
Counties targeted by HRSA: Number: 5; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Midwest census region; Missouri; 
Counties targeted by HRSA: Number: 11; 
Counties targeted by HRSA: Percentage: 6; 
Applications submitted: Number: 6; 
Applications submitted: Percentage: 5; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

Midwest census region; Nebraska; 
Counties targeted by HRSA: Number: 3; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

Midwest census region; North Dakota; 
Counties targeted by HRSA: Number: 2; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

Midwest census region; Ohio; 
Counties targeted by HRSA: Number: 5; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 4; 
Applications submitted: Percentage: 4; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

Midwest census region; South Dakota; 
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Midwest census region; Wisconsin; 
Counties targeted by HRSA: Number: 3; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

Northeast census region; 
Counties targeted by HRSA: Number: 11; 
Counties targeted by HRSA: Percentage: 6; 
Applications submitted: Number: 6; 
Applications submitted: Percentage: 5; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

Northeast census region; Connecticut; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; Maine; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; Massachusetts; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; New Hampshire; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; New Jersey; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; New York; 
Counties targeted by HRSA: Number: 6; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 4; 
Applications submitted: Percentage: 4; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

Northeast census region; Pennsylvania; 
Counties targeted by HRSA: Number: 5; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 2; 
Applications submitted: Percentage: 2; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

Northeast census region; Rhode Island; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Northeast census region; Vermont; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

South census region; 
Counties targeted by HRSA: Number: 128; 
Counties targeted by HRSA: Percentage: 64; 
Applications submitted: Number: 79; 
Applications submitted: Percentage: 70; 
Awards received: Number: 52; 
Awards received: Percentage: 69. 

South census region; Alabama; 
Counties targeted by HRSA: Number: 4; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 4; 
Applications submitted: Percentage: 4; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

South census region; Arkansas; 
Counties targeted by HRSA: Number: 3; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

South census region; Delaware; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

South census region; Florida; 
Counties targeted by HRSA: Number: 6; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 4; 
Applications submitted: Percentage: 4; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

South census region; Georgia; 
Counties targeted by HRSA: Number: 19; 
Counties targeted by HRSA: Percentage: 10; 
Applications submitted: Number: 12; 
Applications submitted: Percentage: 11; 
Awards received: Number: 10; 
Awards received: Percentage: 13. 

South census region; Kentucky; 
Counties targeted by HRSA: Number: 13; 
Counties targeted by HRSA: Percentage: 7; 
Applications submitted: Number: 7; 
Applications submitted: Percentage: 6; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

South census region; Louisiana; 
Counties targeted by HRSA: Number: 13; 
Counties targeted by HRSA: Percentage: 7; 
Applications submitted: Number: 8; 
Applications submitted: Percentage: 7; 
Awards received: Number: 5; 
Awards received: Percentage: 7. 

South census region; Maryland; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

South census region; Mississippi; 
Counties targeted by HRSA: Number: 2; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

South census region; North Carolina; 
Counties targeted by HRSA: Number: 16;
Counties targeted by HRSA: Percentage: 8; 
Applications submitted: Number: 10; 
Applications submitted: Percentage: 9; 
Awards received: Number: 4; 
Awards received: Percentage: 5. 

South census region; Oklahoma; 
Counties targeted by HRSA: Number: 3; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 3; 
Awards received: Percentage: 4. 

South census region; South Carolina; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

South census region; Tennessee; 
Counties targeted by HRSA: Number: 3; 
Counties targeted by HRSA: Percentage: 2; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

South census region; Texas; 
Counties targeted by HRSA: Number: 30; 
Counties targeted by HRSA: Percentage: 15; 
Applications submitted: Number: 14; 
Applications submitted: Percentage: 12; 
Awards received: Number: 10; 
Awards received: Percentage: 13. 

South census region; Virginia; 
Counties targeted by HRSA: Number: 14; 
Counties targeted by HRSA: Percentage: 7; 
Applications submitted: Number: 6; 
Applications submitted: Percentage: 5; 
Awards received: Number: 6; 
Awards received: Percentage: 8. 

South census region; West Virginia; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 2; 
Applications submitted: Percentage: 2; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

West census region; 
Counties targeted by HRSA: Number: 5; 
Counties targeted by HRSA: Percentage: 3; 
Applications submitted: Number: 3; 
Applications submitted: Percentage: 3; 
Awards received: Number: 2; 
Awards received: Percentage: 3. 

West census region; Alaska; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Arizona; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; California; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Colorado; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 0; 
Awards received: Percentage: 0. 

West census region; Hawaii; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Idaho; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

West census region; Montana; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Nevada; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; New Mexico; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Oregon; 
Counties targeted by HRSA: Number: 1; 
Counties targeted by HRSA: Percentage: 1; 
Applications submitted: Number: 1; 
Applications submitted: Percentage: 1; 
Awards received: Number: 1; 
Awards received: Percentage: 1. 

West census region; Utah; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Washington; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

West census region; Wyoming; 
Counties targeted by HRSA: Number: 0; 
Counties targeted by HRSA: Percentage: 0; 
Applications submitted: Number: 0; 
Applications submitted: Percentage: 0; 
Awards received: Number: n/a; 
Awards received: Percentage: n/a. 

Source: GAO analysis of HRSA and U.S. Census Bureau data. 

[End of table] 

[End of section] 

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

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

July 10, 2008: 

Cynthia A. Bascetta: 
Director, Health Care: 
441 G Street NW: 
U.S. Government Accountability Office: 
Washington, D.C. 20548: 

Dear Ms. Bascetta: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Health Resources 
and Services Administration: Many Underserved Areas Lack a Health 
Center Site, and the Consolidated Health Centers Program Needs More 
Oversight" (GAO 08-723). 

The Department appreciates the opportunity to comment on this draft 
before its publication. 

Sincerely, 

Signed by: 

Jennifer R. Luong, for: 

Vincent J. Ventimiglia, Jr. 
Assistant Secretary for Legislation: 

Attachment: 

General Comments for The Department of Health and Human Services' 
Comments on Government Accountability Office's Draft Report: "Health 
Resources And Services Administration: Many Underserved Areas Lack a 
Health Service Site, and the Consolidated Health Centers Program Needs 
More Oversight" (GAO-08-723): 

The Department of Health and Human Services (HHS) appreciates the 
opportunity to comment on the Government Accountability Office's (GAO) 
draft report. 

The most significant issue/concern with the report, which cannot be 
corrected easily, is that the GAO did not investigate the extent to 
which new projects were awarded to programs serving Medically 
Underserved Populations (MUPs), as opposed to Medically Underserved 
Areas (MUAs). This may be the result of the specific request from 
Congress. MUPs may be within MUAs but also may be populations such as 
uninsured and/or Medicaid recipients who are living within an area that 
is not geographically an MUA, and it may be considerably easier for an 
applicant to meet the MUP test. Knowing the breakdown between grants 
awarded to MUAs versus MUPs would be useful information for planning 
and for policy analysis purposes for HRSA. While it would be difficult 
for the GAO to go back and gather that information now, it might be 
beneficial to provide a footnote that explains why this study focuses 
on geography, rather than population. 

Please see below our comments on each of GAO's four recommendations. 

GAO Recommendation #1: 

GAO recommends that, in order to improve the agency's ability to ensure 
access to comprehensive primary care services in MUAs, HRSA collect and 
maintain readily available data on the types of services provided at 
each health center site. 

HHS Response: 

The Health Center Program collects information on services by grantee, 
not by individual site. While having available site specific 
information would be useful for many purposes, collecting such 
information at this level of detail would place a significant burden on 
grantees and added administrative expenses on the program. 

Site Data Collection: 

Health centers arc required by statute to assure that all services 
provided by the centers are available and accessible to patients served 
by them. Even in cases where health centers have established service 
delivery sites that provide more limited services, the health center 
must still assure that all patients receiving care at any site have 
access to the full range of services offered. For example, patients 
seen at one site and found to have a need for services not available 
there are referred to one of the other health center sites in the 
center's service area for the specific service needed. 

Also, regarding the second paragraph on page 16 of the report, HRSA 
does not ask grantees for site level services information in an 
application; therefore, data are not available to collect/analyze. HRSA 
collects this information at the grantee level. 

Percentage of MUAs that Lack a Health Center Site: 

As stated in the draft report, Health Center Program grantees are 
required to serve a federally designated MUA or MUP. This requirement 
is implemented via HRSA's policy that a health center must serve, in 
whole or in part, an MUA, but does not have to be physically located in 
the MUA to serve it. The methodology to demonstrate MUAs served does 
not take into account this HRSA policy. Therefore, HRSA suggests that 
the study examine account for the proximity of a health center site to 
the MUA in a standardized method in order to more accurately reflect 
the HRSA policy for determining eligibility. 

Further, the indicator "Percentage of MUAs that Lack a Health Center 
Site" may be of limited utility, and analysis of this indicator by 
State or Census Region may produce results that are misleading. This is 
because all MUAs/MUPs are not necessarily comparable to each other. 
Some MUAs arc whole counties; some arc groups of townships or other 
census county subdivisions in rural areas; some are groups of census 
tracts within metropolitan or micropolitan areas; and MUPs are 
population groups, such as the low-income population of a particular 
geographic area. Some MUA/Ps may have very small populations, others 
very large; and a health center may not be the appropriate solution for 
some small population MUAs. 

Further, throughout the draft report, there is reference to the 
agency's inability to evaluate service area overlap in MUAs, which does 
not consider that service area overlap may be avoidable in serving a 
MUA given its population and/or geographic size. Thus, it is not always 
a fair comparison of MUAs and health center sites in MUAs, since there 
is an assumption by GAO of a one-for-one ratio, i.e., that one site is 
sufficient to serve one MUA. 

GAO Recommendation #2: 

GAO recommends that the agency, in order to enhance its oversight of 
training and technical assistance (TA) cooperative agreement 
recipients, develop and implement standardized performance measures for 
those recipients, including a measure of the number of grant applicants 
an organization assisted. 

HHS Response: 

HRSA concurs with this recommendation, and has developed standardized 
performance measures that will be included as part of the competitive 
FY 2009 application cycle for Primary Care Associations (PCAs). The 
measures are designed to provide HRSA with the ability to measure 
performance across the PCAs in providing training and TA to health 
centers. As this application is still under review and clearance, HRSA 
cannot share the measures at this time. HRSA also plans to develop 
standardized performance measures for the national cooperative 
agreements for inclusion in future funding opportunities. 

GAO Recommendation #3: 

GAO recommends that HRSA re-evaluate its policy of reviewing training 
and TA cooperative agreement funding recipients every 3 to 5 years and 
consider targeting its available resources to focus on comprehensive 
onsite reviews for cooperative agreement recipients that are most 
likely to benefit from such oversight. 

HHS Response: 

HRSA has developed a 5-year schedule for reviewing all State PCA 
grantees through its State strategic partnership reviews. For national 
cooperative agreements, HRSA is examining ways to better target on-site 
reviews to those organizations that would most benefit from such a 
review. 

GAO Recommendation #4: 

GAO recommends that, to improve the clarity of the feedback the agency 
provides to unsuccessful grant applicants, HRSA identify and take 
appropriate action to ensure that the discussion of applicants' 
strengths and weaknesses in all summary statements is clear. 

HHS Response: 

HRSA agrees with this recommendation and is continuously identifying 
ways to improve the review of applications, including summary review 
statements. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Cynthia A. Bascetta, (202) 512-7114 or [email protected]: 

Acknowledgments: 

In addition to the contact named above, Nancy Edwards, Assistant 
Director; Stella Chiang; Krister Friday; Karen Howard; Daniel Ries; 
Jessica Cobert Smith; Laurie F. Thurber; Jennifer Whitworth; Rachael 
Wojnowicz; and Suzanne Worth made key contributions to this report. 

[End of section] 

Footnotes: 

[1] The Health Resources and Services Administration designates MUAs 
based on a geographic area, such as a county, while MUPs are based on a 
specific population that demonstrates economic, cultural, or linguistic 
barriers to primary care services. The people served by health centers 
include Medicaid beneficiaries, the uninsured, and others who may have 
difficulty obtaining access to health care. 

[2] Other federal benefits include enhanced Medicaid and Medicare 
payment rates and reduced drug pricing. 

[3] GAO, Health Centers: Competition for Grants and Efforts to Measure 
Performance Have Increased, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-645] (Washington, D.C.: July 13, 2005). 

[4] This new access point competition is described as open because 
applicants were not required to be located in certain geographic areas 
in order to apply but were required to demonstrate in the proposal that 
the health center and its associated sites would serve, in whole or in 
part, an MUA or MUP. 

[5] Although grant competitions are scheduled according to the fiscal 
year, the UDS reflects health center data as of December 31 of a 
calendar year. 

[6] Although only a portion of the geographic area of a zip code may be 
included within the geographic boundary of an MUA, we included the 
whole area of all zip codes associated with an MUA because we could not 
identify geographic areas smaller than a zip code. As a result, in our 
analysis, the geographic boundary of an MUA may be larger than that 
defined by HRSA and a health center site may appear to be located in an 
MUA when it is located outside the MUA. Therefore, we may overestimate 
the number of MUAs that contain a health center site. 

[7] In this report, we consider the District of Columbia a state. 

[8] 42 U.S.C. ï¿½ 254b(a)(1). In contrast, HRSA grantees that operate 
health center sites targeting migrant farmworkers, public housing 
residents, and the homeless are not required to serve all residents of 
their service areas. 42 U.S.C. ï¿½ 254b(a)(2). Because the UDS does not 
allow separate identification of individual health center sites for 
grantees that receive a combination of community health center funding 
and health center funding to target migrant farmworkers, public housing 
residents, or the homeless (27 percent of all grantees in 2006), we 
could not distinguish sites supported exclusively by community health 
center funding from sites supported exclusively by health center 
funding for migrant farmworkers, public housing residents, or the 
homeless. Therefore, we included all sites associated with health 
center grantees that received, at a minimum, community health center 
funding (90 percent of all grantees in 2006). As a result, some health 
center sites included in our analysis are not sites exclusively 
supported by community health center funding. 

[9] Some organizations choose not to apply for funding under the Health 
Center Program; however, they seek to be recognized by HRSA as 
federally qualified health center look-alikes, in large part, so that 
they may become eligible to receive other federal benefits, such as 
enhanced Medicare and Medicaid payment rates and reduced drug pricing. 
Federally qualified health center look-alike sites are referred to in 
this report as health center look-alike sites. 

[10] HRSA screens grant applications for eligibility, completeness, and 
responsiveness to application and program requirements; those 
applications not meeting these requirements are not considered for the 
competition. Of 387 applications submitted for fiscal year 2007 new 
access point competitions, 363 were found to be eligible for 
consideration; our review was limited to these 363 applications. 

[11] All new access point grants awarded in 2007 were made through two 
new access point competitions held during fiscal year 2007, one of 
which was an open competition and one of which limited applicants to 
200 HRSA-selected counties as part of the High Poverty County 
Presidential Initiative. 

[12] We could not obtain those data from the UDS because it had not yet 
been updated for 2007 at the time of our review. 

[13] Because the UDS had not been updated for 2007 at the time of our 
review, we could not determine whether any health center sites that 
were in operation in 2006 were no longer operating in 2007; therefore, 
we assumed that all health center sites operating in 2006 were still 
operating in 2007. 

[14] Although HRSA had training and TA cooperative agreements with 17 
national organizations for fiscal year 2007, only 8 of these national 
organizations targeted assistance to grant applicants. 

[15] HRSA notifies cooperative agreement recipients of their funding 
through a notice of grant award. Notices of grant awards are issued 
according to a budget period. 

[16] Noncompeting continuation applications that include work plans, 
budgets, and progress reports are submitted annually by cooperative 
agreement recipients for the duration of their cooperative agreements, 
usually 2 to 3 years. 

[17] HRSA awarded new access point grants in fiscal year 2006 based on 
applications that had been submitted and reviewed under the fiscal year 
2005 new access point competition. In order to examine unsuccessful new 
access point applicants associated with fiscal year 2006, we reviewed 
summary statements issued beginning in fiscal year 2005. 

[18] Pub. L. No. 104-299, 110 Stat. 3626 (codified, as amended, at 42 
U.S.C. ï¿½ 254b). 

[19] GAO, Health Professional Shortage Areas: Problems Remain with 
Primary Care Shortage Area Designation System, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-84] (Washington, D.C.: Oct. 
24, 2006), and Health Care Shortage Areas: Designations Not a Useful 
Tool for Directing Resources to the Underserved, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-200] (Washington, D.C.: 
Sept. 8, 1995). 

[20] 63 Fed. Reg. 46,538 (Sept. 1, 1998). 

[21] 73 Fed. Reg. 11,232 (Feb. 29, 2008). 

[22] The other three types of Health Center Program grants are (1) 
expanded medical capacity--to fund the expansion of an existing health 
center or delivery site in order to significantly increase the 
provision of comprehensive primary care services in areas of high need; 
(2) service expansion--to provide opportunities for existing health 
centers to expand and improve access to specialty health care services, 
such as mental health and substance abuse, oral health, pharmacy, or 
quality care management services; and (3) service area competition--to 
open competition for an existing service area when a grantee's project 
period, or the duration of its grant before it must compete to retain 
its funding, is about to expire. 

[23] 42 U.S.C. ï¿½ 254b(k)(4), (r)(2)(B), (p). 

[24] Center applications must demonstrate financial responsibility by 
the use of accounting procedures as prescribed by HRSA. 42 U.S.C. ï¿½ 
254b(k)(3)(D). 

[25] For fiscal year 2007, HRSA funded training and TA cooperative 
agreements with 52 regional and state organizations and 8 national 
organizations that target assistance to grant applicants. 

[26] When we included the 294 health center look-alike sites operating 
in 2006, we found that the percentage of MUAs lacking either a health 
center site or health center look-alike site in 2006 was 46 percent (or 
1,564 MUAs). 

[27] When we included the 265 health center look-alike sites operating 
in 2007, we found that 1,462 MUAs lacked a health center site or health 
center look-alike site in 2007, which did not change the overall 
percentage (43 percent) of MUAs in 2007 that lacked a health center 
site. 

[28] For the Health Center Program, HRSA has five project officers 
assigned to 17 national training and TA cooperative agreement 
recipients--of which eight organizations target assistance to grant 
applicants--and nine project officers for the 52 regional and state 
PCAs with training and TA cooperative agreements. 

[29] In addition to annual reports, HRSA also uses semiannual reports 
and midyear assessments to monitor the progress of cooperative 
agreement recipients. Semiannual reports were discontinued in 2006 for 
state PCAs, and semiannual progress reports were required for only four 
of the eight national organizations that provided training and 
technical assistance to health center applicants for the budget period 
of 2006-2007. According to HRSA officials, semiannual reports for state 
PCAs were phased out in 2006 because of their limited usefulness and 
the reporting burden they posed to cooperative agreement recipients, 
and they intend to oversee cooperative agreement recipients primarily 
through reports provided on an annual basis. In addition, HRSA may 
conduct midyear assessments if there are concerns with a cooperative 
agreement recipient's performance. According to HRSA officials, only 
two midyear assessments have been conducted for training and TA 
cooperative agreement recipients since 2005 and no cooperative 
agreements have been terminated for fiscal years 2006 and 2007 for 
issues with performance. 

[30] The work plan is further refined by both HRSA and the recipient in 
accordance with the Health Center Program's priorities. 

[31] According to HRSA policy, the agency conducts periodic 
comprehensive on-site reviews of all funding recipients that support 
the agency's programs. 

[32] The specific populations served by these grantees are migrant 
farmworkers, public housing residents, and homeless persons. 

[End of section] 

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