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Appendix B
HRSA-Supported Primary Care
Systems and Health Departments
T
he statement of task directed the committee to explicitly consider
HRSA-supported primary care systems and health departments. This
appendix provides an overview of these entities.
HRSA-SUPPORTED PRIMARY CARE SYSTEMS
While most primary care in the United States is delivered outside of
HRSA-supported primary care systems, these systems served 19.5 million
patients in 2010 (HRSA, 2011j) and play a critical strategic role in ad-
dressing health disparities. The most widely recognized of these primary
care systems are the health centers funded under the Health Center Pro-
gram or designated as federally qualified health center (FQHC) look-alikes.
These centers are community-based and patient-directed organizations that
provide comprehensive primary care and preventive services in medically
underserved communities for vulnerable populations with limited access to
health care. In addition, HRSA supports other primary care systems as well.
Health Centers
HRSA supports two classes of health centers (HRSA, 2011k). The
first are Health Center Program grantees or federally funded health cen-
ters. These are public and private nonprofit health care organizations that
meet certain criteria under the Medicare and Medicaid programs (Sec-
tions 1861[(aa)][(4)] and 1905[(l)][(2)][(B)], respectively, of the Social Se-
curity Act) and receive funds under Section 330 of the Public Health
163
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164 PRIMARY CARE AND PUBLIC HEALTH
Service Act. They include community health centers, migrant health centers,
Healthcare for the Homeless centers, and Public Housing Primary Care
centers. These health centers are required to report administrative, clinical,
and other information to the Bureau of Primary Health Care within HRSA.
The second class of health center comprises federally qualified health
center (FQHC) look-alikes, health centers that do not receive grant fund-
ing under Section 330 but have been identified by HRSA and certified by
the Centers for Medicare & Medicaid Services (CMS) as meeting Section
330 requirements. Although FQHC look-alikes do not receive Section 330
funding, they report to the Bureau of Primary Health Care and are eligible
for other FQHC1 benefits through CMS.
As mentioned in Chapter 3, this report uses the term “health center”
to refer to Health Center Program grantees and FQHC look-alike organi-
zations. The term does not refer to FQHCs that are sponsored by tribal
or urban Indian health organizations, except for those that receive Health
Center Program grants.
All HRSA-supported health centers are required to meet certain criteria
to maintain their health center designation. Health centers must meet per-
formance and accountability requirements established by HRSA. They must
be governed by a community board, at least 51 percent of whose members
represent the population served by the center. Additionally, health centers
must provide comprehensive primary health care and supportive services
and use a sliding-scale system to charge patients without health insurance.
These services include well-child care, nutritional assessment and referral
services, blood pressure and weight management, clinical breast examina-
tion, and prenatal services. Most important, health centers must be located
in a medically underserved area or serve a specified medically underserved
population (HRSA, 2011b).
Migrant health centers are a strong example of health centers that serve
a medically underserved population, focusing on communities of migrant
and seasonal farm workers who face unique health care challenges. These
challenges may be due to a relatively small number of individuals requir-
ing care over a large geographic area, the transient nature of migrant and
seasonal farm work, and/or the inability of existing health centers to handle
the cyclical nature of seasonal work and the influx and outflow of patients.
Approximately 90 percent of migrant health centers are funded as Health
Center Program grantees serving special populations; the remaining 10 per-
1 The term FQHC is a designation determined and used by CMS to indicate that an entity
can be reimbursed using specific methodologies statutorily designed for FQHCs. Here the
term FQHC is used to indicate these CMS-designated entities, and includes designated Health
Center Program grantees, FQHC look-alikes, and outpatient health clinics associated with
tribal or urban Indian health organizations that are not administered or overseen by HRSA.
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165
APPENDIX B
cent operate under migrant health voucher programs in which primary care
services for migrant workers are subcontracted to existing local providers
(National Center for Farmworker Health, 2011a,b).
FQHCs (and rural health clinics, described next) are reimbursed by
Medicare through a Prospective Payment System (PPS). This system estab-
lishes a fee to be paid to the provider regardless of the service rendered,
and is designed to encourage comprehensive care. There is no limit on the
number of visits each patient can make per year. The reimbursement is
based on yearly cost reports, which take into account the overall cost of
operations relative to clinical production. Medicare and Medicaid PPS rates
are set by the respective agencies but are generally similar.
In 2010, 1,124 health centers served more than 19 million patients.
Approximately one-third of these patients were individuals aged 18 or
younger, 7.3 million were uninsured, and nearly 863,000 were migrant or
seasonal farm workers and their families (HRSA, 2011j). Table B-1 presents
more detailed information on health centers.
TABLE B-1 Snapshot of Health Centers
Characteristic Number Percentage
Total Patients 19,469,467
Patients by Age
Children (<18) 6,251,866 32.11
Adults (18-64) 11,885,206 61.05
Geriatric patients (65 and over) 1,332,395 6.84
Number of Patients by Insurance Status
Uninsured 7,308,655 37.54
Uninsured children (0-19) 1,393,640 7.16
Medicaid/CHIP 7,505,047 38.55
Medicare 1,461,485 7.51
Other third party 2,699,183 13.86
Patients below the poverty level 10,726,964 55.10
Staffing
Total staff 131,660.23
Primary care physicians 9,592.10
Nurse practitioners 3,807.86
Physician assistants 2,034.20
Certified nurse midwives 520.28
Dentists 2,881.89
NOTE: CHIP = Children’s Health Insurance Program.
SOURCE: HRSA, 2011j.
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166 PRIMARY CARE AND PUBLIC HEALTH
Rural Health Clinics
Another HRSA-supported clinical service is the rural health clinic pro-
gram, initiated to increase primary care services for Medicaid and Medicare
patients in rural communities. As of August 2011, more than 3,800 rural
health clinics were in operation across the United States, with 28 states
containing more than 50 such centers (CMS Rural Health Center, 2011).
Rural health clinics must meet certain criteria to maintain their rural
health clinic designation. They must be located in a nonurbanized medically
underserved or health professional shortage area. They must utilize a team
of physicians and other practitioners, such as nurse practitioners, physician
assistants, and certified nurse midwives, and must be staffed at least 50 per-
cent of the time by nonphysician practitioners. Rural health clinics are not
required to provide any preventive health, preventive dental health, or case
management services. The scope of their services is limited to emergency
care; outpatient primary care; and basic laboratory services such as urine
testing by stick or tablet, blood sugar tests, and the collection of cultures
for transmittal to a certified laboratory for analysis (HRSA, 2006).
Disease-Specific Health Centers
HRSA supports a number of disease-specific health centers. These
centers focus on serving populations with particular diseases or areas with
concentrated rates of a particular disease resulting from geographic prox-
imity to exposures and other factors. The most renowned of these centers
are Ryan White clinics, which exist as a part of the Ryan White Program.
That program, the largest federal program focused exclusively on HIV/
AIDS care, was designed to increase federal funding for centers providing
primary care to HIV/AIDS patient (HRSA, 2011a).
The Ryan White Program has six parts. Part A funds are used to pro-
vide care for people living with HIV, including outpatient and ambulatory
medical care, oral health care, mental health services, substance abuse
outpatient care, and assistance with health insurance premiums and cost
sharing for low-income individuals (HRSA, 2011e). Part B provides grants
to states and U.S. territories to improve the quality, availability, and or-
ganization of HIV/AIDS health care and support services (HRSA, 2011f).
Part C gives grants directly to service providers to support outpatient HIV
early intervention services, and provide primary care and ambulatory care
(HRSA, 2011g). Part D focuses on services to families and awards funds to
public and private organizations for such activities as community outreach,
prevention programs, primary and specialty medical care, and psychosocial
services. It also supports efforts to improve access to clinical trials and re-
search for vulnerable populations (HRSA, 2011h). Finally, Part F provides
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APPENDIX B
funds for a variety of programs, including the Special Projects of National
Significance Program, the AIDS Education and Training Centers Program,
dental programs, and the Minority AIDS Initiative (HRSA, 2011i). In 2010,
the Ryan White Program was funded at approximately $2.2 billion (HRSA,
2011d).
Local Variability
Like local health departments (discussed below), HRSA-supported pri-
mary care systems vary widely. Health centers and rural health clinics serve
a variety of populations and population sizes. Nationally, for example,
health centers serve an average of 2,416 patients per center site; however,
this number varies from 488 patients per site in Alaska to 3,408 patients
per site in Washington state and 5,972 patients per site in the U.S. territory
of Puerto Rico (National Association of Community Health Centers, 2011).
This variability results from a number of factors, including the size of the
overall population and the geographic distribution of both the general and
underserved populations, the degree of stability of these populations, the
number and location of the centers, and the presence of alternative sources
of care in the community.
While health centers may vary from program to program, there is some
standardization for entities within each funding program. As noted earlier,
for instance, rural health clinics must meet a number of requirements to
receive that designation. These requirements not only set minimum service
levels, but also include services that these clinics cannot provide using
program funds. Additional sources of funding may impose further require-
ments or allow centers to provide additional services. For example, some
centers may be associated with academic institutions and may use the center
as a teaching environment for medical interns and residents. These centers
may provide expanded services using institutional funding. The presence of
auxiliary staff, such as social workers, mental health and substance abuse
personnel, and community health workers,2 varies from center to center
as well.
HEALTH DEPARTMENTS
Health departments have primary responsibility for the provision of
essential public health services. The governmental public health system,
embodied in health departments, evolved in response to the hunger, malnu-
2 A community health worker is defined as a person who links members of the community to
health services. The designation encompasses promotores de salud (community health workers
in Spanish) and patient navigators (who work with specific patients), as well as other terms.
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168 PRIMARY CARE AND PUBLIC HEALTH
trition, scurvy, and infectious diseases that were epidemic in the American
colonies. Early public health interventions often were based in policy, with
colonies enacting laws to regulate waste disposal and the quarantining of
ships. Smallpox inoculation was another early demonstration of the effec-
tiveness of public health interventions, dramatically reducing the mortality
rate from that disease among the vaccinated (Novick and Mays, 2005).
Since the colonial period, health departments have evolved to meet the
public’s changing needs and grown in influence. Currently, federal health
agencies can set a national health policy agenda and steer the system by al-
locating resources across the designated priorities. While national agendas
are set at the federal level, states play a pivotal role in the system, often
acting as intermediaries between the federal government and local munici-
palities (Novick and Mays, 2005). Local health departments often are the
primary entities implementing public health activities in local communities.
State Health Departments
State health departments provide essential expertise and other support
for local public health departments and in 26 states act as the local public
health department for some or all of their state’s communities. These health
departments are responsible for the state’s public health—including preven-
tive, protective, and wellness services—and the allocation of public health
resources according to local needs.
Structure and Governance
Some state health departments are independent organizations, while
others operate within an umbrella agency that is also responsible for
such functions as Medicaid, services for the elderly, and public assistance
(ASTHO, 2011a). Public health agencies are more likely to be independent
in states with larger populations: this is the case in 71 percent of states with
medium-sized populations and 65 percent of those with large populations
(ASTHO, 2011a).
Governance relationships between state and local agencies vary, and
these variations affect the way public health services are delivered. In 14
states, governance is wholly or largely centralized such that the state gov-
ernment has primary responsibility for leading local agencies, including
decision-making authority in most matters related to budget, the issuance
of public health orders, and the appointment of local health officials. In five
states, a shared governance model is used whereby either local or state gov-
ernments may lead local agencies, with responsibility for decisions regard-
ing budget, the issuance of public health orders, and the appointment of
local health officials (ASTHO, 2011a). Finally, 27 states have a governance
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APPENDIX B
structure that is wholly or largely decentralized. Mainly local employees
lead the local agencies, and local governments have some decision-making
authority.
Expenditures and Revenues
For fiscal year (FY) 2009, state health department revenues were re-
ported for 48 states; they totaled $31.5 billion. If revenues are estimated
for the two remaining states and the District of Columbia, the total is about
$34 billion. State health department revenues come from federal sources
(45 percent); state general funds (23 percent); other state funds (16 per-
cent); fees and fines (7 percent); Medicare and Medicaid (4 percent); and
other sources (5 percent), such as tobacco settlement funds, payment for
direct clinical services (other than Medicare and Medicaid), foundations,
and other private donations. Average revenue per capita was $126 in FY
2009 (ASTHO, 2011a).
Total state health department expenditures for FY 2009 for the 48
states for which data are available were $22.5 billion. If revenues are
estimated for the two states without expenditure data and the District of
Columbia, the total is about $25 billion. Almost half of these expenditures
were for either the Special Supplemental Nutrition Program for Women, In-
fants, and Children (WIC) (24 percent of the total) or improving consumer
health (also 24 percent), a category that includes access to care programs
and direct clinical services, such as tuberculosis treatment, adult day care,
early childhood programs, and local health clinics. Thirteen percent of state
health department expenditures were for infectious disease programming,
while 8 percent was dedicated to chronic disease prevention. Six percent
went to improving the quality of health care and 5 percent to each of the
following: all-hazards preparedness, environmental protection, adminis-
tration, and other. A small portion was spent on health laboratories (2
percent), injury prevention (2 percent), health data (1 percent), and vital
statistics (1 percent) (ASTHO, 2011a).
Workforce
In 2010, state (including the District of Columbia) health departments
were estimated to have about 107,000 full-time employees. Of these, more
than 27,000 were assigned to local health departments and another 17,000
to regional or district offices. The greatest numbers of these employees were
administrative and clerical personnel, followed by public health nurses. On
average, state health departments had about 288 vacant positions but were
recruiting for only about 15 percent of these—likely as a result of hiring
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170 PRIMARY CARE AND PUBLIC HEALTH
freezes in many states (87 percent of states have had such a freeze in effect
since 2008).
As one would expect, state health departments serving larger popu-
lations employed larger numbers of full-time equivalents. The average
number of employees in the state health departments serving the smallest
populations was 876, while those serving midsized populations had an
average of 2,045 employees and those serving the largest populations an
average of 3,537. Considered on a per capita basis, smaller states employed
more staff: 82 per 100,000 persons, compared with 47 for midsized states
and 27 for large states (ASTHO, 2011b).
Priorities and Responsibilities
Top priorities cited by state health leaders included improving infra-
structure and increasing capacity in terms of technology and workforce
capacity (17 percent of states); quality improvement (9 percent); health
promotion and prevention (8 percent); obesity, nutrition, and physical ac-
tivity (6 percent); and emergency preparedness (6 percent). Responsibilities
of state health departments included vaccine order management and inven-
tory distribution, behavioral risk factor surveillance, reportable diseases,
vital statistics, and testing of likely bioterrorism agents (ASTHO, 2011a).
Local Health Departments
Local health departments are formed at the discretion of the state or
local jurisdiction and often perform a broad range of services depending
on the jurisdiction. To address some of this variability, in 2005 the Na-
tional Association of County and City Health Officials (NACCHO) led the
development of the “Operational Definition of a Functional Local Health
Department” (NACCHO, 2005). This definition identifies the essential
functions a citizen should expect a state, local, tribal, or territorial health
department to perform. Furthermore, standards for local public health
have been established, and voluntary accreditation for local health depart-
ments started in 2011. The Public Health Accreditation Board, a national
nonprofit organization, based the public health standards on the 10 essen-
tial public health services (see Box 1-2 in Chapter 1) and the NACCHO
definition. This accreditation is endorsed by NACCHO and is encouraged
as a way of ensuring consistent and quality local public health services for
all communities across the United States. Nonetheless, great variability re-
mains among local health departments in terms of population size served,
jurisdiction, and governance; expenditures and revenues; workforce; role
and scope of services; and information technology.
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APPENDIX B
Population Size, Jurisdiction, and Governance
The majority of local health departments serve small populations. Ap-
proximately 63 percent serve fewer than 50,000 people, and only 5 percent
serve 500,000 or more. The population size served often is governed by the
department’s geographic jurisdiction. In 2010, 68 percent of health depart-
ments served county systems, 21 percent served cities or towns, 8 percent
served multiple counties, and 4 percent served multiple cities or a county
and a city located outside of the county line (NACCHO, 2011a). Many
health departments (75 percent) also are associated with one or more local
boards of health, which serve to represent local perspectives and needs, in-
stitute public health regulations, set and impose fees, and administer other
activities (NACCHO, 2011a).
Expenditures and Revenues
Local health departments vary greatly in their expenditures and reve-
nues. According to NACCHO’s 2010 National Profile (NACCHO, 2011a),
roughly one-third of all local health departments had total expenditures of
less than $1 million, another third had expenditures of $1-$4.99 million,
and under 20 percent had expenditures of $5 million or more (it should be
noted that 19 percent of health departments did not provide this informa-
tion). Smaller health departments tended to spend more per person than
larger ones ($48 for those serving fewer than 25,000 people versus $37 for
those serving more than 1 million). Health departments governed by both
state and local authorities reported higher median expenditures per person
than those governed solely by state or local governments ($67 versus $46
and $38, respectively). This trend also pertains to local health department
revenues. Smaller health departments reported median revenues of $54 per
person, whereas median revenues for larger health departments were the
same as median expenditures ($37 per person). Health departments operat-
ing under a shared governance model also experienced a higher median per
capita than those governed solely by state or local governments ($67 versus
$52 and $39, respectively), a trend that echoes local health department
expenditures organized by these categories (NACCHO, 2011b).
Local health departments varied by population size in revenue sources
as well. Federal direct and pass-though funds accounted for approximately
20 percent of revenues for local health departments serving fewer than
500,000 persons and for nearly 30 percent of those for departments serving
populations of 500,000 or more. The percentage of revenues derived from
Medicaid funding differed the most by population size. Larger local health
departments serving more than 500,000 people received only 9 percent of
their revenues from Medicaid, which accounted for more than 20 percent
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172 PRIMARY CARE AND PUBLIC HEALTH
of revenues for those serving fewer than 25,000 people (NACCHO, 2011a).
Many, regardless of size, received just less than 50 percent of their revenues
from state and local sources.
Workforce
The differences among local health departments are further exempli-
fied by their workforces. While 87 percent of local health departments
had fewer than 100 full-time employees in 2010, the median number
ranged from 4 (for local health departments serving populations of fewer
than 10,000) to 530 (for local health departments serving populations of
1 million or more). The percentage of full-time employees rose with the
population size (73 percent for those serving populations of fewer than
10,000 to nearly 100 percent for those serving populations of 1 million
or more). Most local health departments employed a range of personnel.
Positions in at least 50 percent of local health departments included ad-
ministrative personnel (97 percent), public health nurses and managers (96
and 85 percent, respectively), environmental health workers (81 percent),
emergency preparedness staff (65 percent), health educators (57 percent),
and nutritionists (55 percent). At the median, local health departments
employed 17 full-time employees, 4 administrative or clerical personnel, 4
public health nurses, 2 environmental health workers, and 1 public health
manager (NACCHO, 2011a).
Role and Scope of Services
Local health departments provided a variety of services directly or
through contracts with service providers in 2010 (NACCHO, 2011a). Lo-
cal health departments offered the following 10 services most frequently:
adult immunization, communicable disease surveillance, childhood im-
munization, tuberculosis screening, food service establishment inspection,
environmental health surveillance, food safety education, tuberculosis treat-
ment, school/child care facility inspection, and population-based nutrition
services. Other common roles included monitoring and health surveillance,
the development and enforcement of health policies and regulations, emer-
gency response, communication of health issues, and mobilization of com-
munities around important health issues (NACCHO, 2011a). Additional
roles included serving as the source of primary and preventive care for a
large portion of the uninsured population and Medicaid recipients, devel-
oping and training the county’s health workforce, and linking the public to
appropriate health services.
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APPENDIX B
Information Technology
Local health departments reported using information technology (IT)
to varying degrees (NACCHO, 2011a). One issue of concern is interoper-
ability with other IT systems. While 52 percent of local health depart-
ments could share some data, only 14 percent had IT systems that were
fully compatible (NACCHO, 2010). Immunization registries were the most
commonly used form of IT, followed by electronic health records, practice
management systems, health information exchanges, and nationwide health
information networks. Many local health departments reported using elec-
tronic syndromic surveillance systems for such activities as the detection of
influenza-like and foodborne illnesses, the establishment of case definitions,
and the evaluation of interventions (NACCHO, 2011a).
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