The Community Health Center Fund: In Brief

The Health Center Program, which is administered by the Health Resources and Services Administration within the Department of Health and Human Services, awards grants to outpatient health care facilities that provide care to medically underserved populations. The program’s annual funding has more than tripled between FY2002 and FY2018, which has, in turn, increased the number of centers operating, the number of patients they see, and the volume and type of services available.

The program’s funding increase occurred partially because of the Community Health Center Fund (CHCF), a mandatory multibillion dollar fund established in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). This fund is available between FY2011 and FY2019; although it was intended to increase health center appropriations; the fund has partially replaced the program’s annual appropriations.

CHCF funds have been used to support a number of Health Center Program activities, including funding new health centers, increasing services provided at existing health centers, and implementing care coordination initiatives. The CHCF has also been used to fund emergent needs, including funding health centers in Zika-affected areas and providing supplemental funding for opioid treatment at health centers. The CHCF represents more than 70% of the Health Center Program’s FY2018 funding. Since its inception, the CHCF has been extended twice; first, it was extended for FY2016 and FY2017 in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10), which provided $3.6 billion for FY2016 and FY2017. The second extension was in the Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123), which provided $3.8 billion in FY2018 and $4.0 billion in FY2019 for the CHCF.

This report provides information on the CHCF. Specifically, it presents data on the relative contribution of the CHCF to the Health Center program’s budget, data on the types of grants awarded, and data on the amount of CHCF funds that facilities in each state received.

The Community Health Center Fund: In Brief

Updated July 5, 2018 (R43911)

Background

The Health Center Program, which is administered by the Health Resources and Services Administration within the Department of Health and Human Services, awards grants to outpatient health care facilities that provide care to medically underserved populations.1 The program's annual funding has more than tripled between FY2002 and FY2018, increasing from $1.3 billion to $5.3 billion. This funding increase—a result of both increases in annual discretionary appropriations and supplemental funding2—has resulted in more health centers, more patients seen, and more services available to these patients.3 The program's funding increase is due, in part, to the Community Health Center Fund (CHCF),4 a mandatory multibillion-dollar fund established in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) and extended in subsequent laws. The most recent two-year extension was included in the Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123). The fund was established in 2011 and is currently available through FY2019. When the fund was established it was intended to increase health center appropriations above the level the program received in FY2008;5 however, the CHCF has partially supplanted annual appropriations since it began. The CHCF also supports the National Health Service Corps, a scholarship and loan repayment program that places providers in underserved areas including at health centers. From FY2012 through FY2018, the CHCF was that program's sole funding source.6

CHCF funds have been used for a range of health center activities including funding new health centers, increasing services provided at existing health centers, and implementing care coordination initiatives.7 CHCF funds have also been used to fund health centers in need of immediate funding, such as those in Flint, MI, which had acute health service needs due to the discovery of lead in its water supply; those in Puerto Rico and other territories, which had additional health service needs related to the Zika virus; and those in areas most affected by the opioid crisis.8

The CHCF represents more than 70% of the Health Center Program's FY2018 funding. Since its inception, the CHCF has been extended twice: first, it was extended for FY2016 and FY2017 in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10); second, it was extended in the Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123), which provided FY2018 and FY2019 funding. MACRA provided $3.6 billion to the CHCF for each of FY2016 and FY2017 ($7.2 billion total), while BBA 2018 provided $3.8 billion for FY2018 and $4.0 billion for FY2019 ($7.8 billion total).

This report provides information on the CHCF. Specifically, it includes information on the types of grants awarded, total funds disbursed, and the amount of CHCF funds that centers in each state and territory received.

CHCF as a Percentage of Health Center Funding

The CHCF as a total percentage of federal funding for health centers has increased from 40% to 72% from FY2011 through F2018 (see Figure 1).

Figure 1. The CHCF and Health Center Funding

(Dollars in Millions, CHCF and Discretionary labeled with percent of total)

Source: CRS analysis of HRSA's Congressional Budget Justifications and P.L. 115-123.

CHCF Grants Awarded

ACA's language creating the CHCF specified rather broad purposes—that the fund be used to "provide for expanded and sustained national investment in community health centers."9 CHCF funds have been used to support operating grants at existing health centers, including grants that are awarded competitively to existing health centers at the end of their grant cycle that seek continued funding.10 The CHCF has also been used to support a number of specific initiatives that seek to expand services and to improve the care provided by health centers (see Table 1).11

Table 1. CHCF-Supported Grant Programs

Name

Description

Funds Awarded

Beacon Community Supplemental Funding

Grants to support health center HIT adoption so as to improve health outcomes, improve care quality, and achieve cost efficiencies.

$8.4 million (FY2011)

Behavioral Health Integration

Grants to expand behavioral health services by increasing the number of providers and services offered.

$54.6 million (FY2014); $51.3 million (FY2015)

Expanded Services

Grants for hiring new staff to extend hours and expand care that a health center provides.

$295 million (FY2014); $6.4 million (FY2015); $7 million (FY2016); $156 million (FY2016 for oral health)

Facility Improvement

Grants for construction and renovations to increase the number of patients served.

$260 million (FY2016)

Health Center Controlled Network-Health Information Technology (HIT)

Grants to expand the use of advanced HIT.

$21 million (FY2013); $123 million (FY2016)

Health Center Outreach and Enrollment Assistance

Grants to hire staff for in-person enrollment and eligibility assistance to uninsured individuals.

$150 million (FY2013); $58 million (FY2014)

HIV Service Integration

Grants to support HIV services with primary care service integration.

$5 million (FY2012); $6.2 million (FY2014)

New Access Points

Grants to support new health center sites.

$28.8 million (FY2011); $128.6 million (FY2012); $19 million (FY2013); $150 million (FY2014); $270 million (FY2015); $51 million (FY2017)

Opioid and Heroin Treatment

Grants to expand substance abuse services at health centers.

$94 million (FY2016); $350 million (FY2018)

Patient-Centered Medical Homes (PCMH)

Grants to assist facilities with meeting the requirements (including facility-related requirements) to be certified as a PCMH.

$32 million (FY2011); $44 million (FY2012); $35.7 million (FY2014); $8.6 million (FY2016)

Planning and Development

Grants to support organizations to plan and become health centers.

$10 million (FY2011)

Quality Improvement/ Base Adjustment

Adjustments to health center base funding for ongoing operations and quality improvement activities.

$48 million (FY2013); $63 million (FY2015); $100 million (FY2016)

State and Regional Primary Care Association

Cooperative agreements with state and regional organizations to provide health center training and technical assistance.

$5.2 million (FY2011); $6.4 million (FY2013)

Training and Technical Assistance

Cooperative agreements to provide technical assistance to organizations that support health centers.

$2.8 million (FY2011)

Sources: CRS analysis of data from the HRSA data warehouse; CRS communication with HRSA's Office of Legislation, January 5, 2015, December 30, 2016, and May 15, 2018; and HRSA and HHS press releases obtained by searching http://www.hrsa.gov and http://www.hhs.gov/news/. FY2016 funds were also used to fund health centers in Flint, MI, and the territories for Zika virus related health services.

CHCF funds were awarded from FY2011 through FY2017 to facilities and organizations in each of the 50 states, the District of Columbia, and the territories (see Table 2).

Table 2. CHCF Funds Awarded, by State and Territory

(Dollars in Thousands)

State

FY2011

FY2012

FY2013

FY2014

FY2015

FY2016

FY2017

Totala

Alaska

$15,176

$17,176

$21,855

$31,370

$45,789

$48,670

$53,611

$233,648

Alabama

$19,803

$23,584

$29,280

$39,000

$58,662

$55,617

$58,600

$284,546

Arkansas

$11,634

$13,671

$16,951

$23,823

$37,286

$34,559

$39,961

$177,885

American Samoa

$1,089

$901

$1,146

$1,899

$1,348

$2,360

$2,384

$11,127

Arizona

$19,016

$20,195

$24,729

$37,004

$52,156

$63,647

$64,899

$281,647

California

$120,943

$140,459

$178,975

$275,331

$445,460

$494,221

$493,092

$2,148,482

Colorado

$25,431

$29,535

$37,523

$45,921

$62,087

$72,845

$75,681

$349,023

Connecticut

$12,973

$15,168

$18,923

$22,080

$35,906

$45,680

$42,957

$193,687

District of Columbia

$5,211

$5,852

$6,465

$9,744

$18,315

$20,258

$21,357

$87,202

Delaware

$3,290

$4,372

$6,164

$6,280

$7,459

$10,225

$10,283

$48,073

Florida

$48,992

$59,567

$73,398

$117,934

$165,216

$170,243

$169,526

$804,876

Federated States of Micronesia

$423

$438

$476

$1,123

$1,836

$2,136

$2,934

$9,367

Georgia

$21,338

$26,182

$37,181

$47,576

$73,665

$83,684

$86,411

$376,037

Guam

$501

$519

$683

$1,059

$1,460

$1,361

$1,350

$6,934

Hawaii

$6,880

$6,795

$8,606

$13,448

$21,135

$23,212

$22,050

$102,126

Iowa

$8,507

$9,537

$12,555

$16,899

$27,913

$28,002

$28,604

$132,017

Idaho

$9,029

$10,223

$13,255

$18,743

$32,664

$33,182

$33,898

$150,994

Illinois

$41,748

$50,739

$64,450

$88,207

$132,420

$144,843

$145,608

$668,016

Indiana

$12,420

$13,746

$17,216

$28,441

$48,338

$58,643

$59,062

$237,867

Kansas

$7,414

$9,633

$13,030

$18,278

$28,237

$34,513

$34,203

$145,308

Kentucky

$13,705

$17,800

$21,803

$31,162

$49,267

$54,770

$58,258

$246,765

Louisiana

$17,792

$19,320

$24,680

$43,095

$66,806

$74,742

$77,796

$324,231

Massachusetts

$24,757

$26,155

$32,222

$54,646

$81,352

$95,352

$90,527

$405,011

Maryland

$13,066

$12,880

$15,336

$26,574

$34,035

$40,760

$40,902

$183,552

Maine

$8,751

$9,965

$11,100

$17,724

$30,805

$32,886

$31,988

$143,219

Marshall Islands

$295

$306

$338

$704

$785

$808

$756

$3,992

Michigan

$23,770

$27,289

$33,868

$55,030

$89,391

$97,298

$92,650

$419,296

Minnesota

$8,829

$10,938

$13,775

$18,646

$28,149

$29,128

$30,680

$140,145

Missouri

$20,096

$22,840

$28,811

$45,233

$68,839

$83,065

$79,128

$348,012

Mississippi

$18,939

$19,205

$23,681

$34,055

$49,672

$49,916

$52,336

$247,804

Montana

$8,669

$10,250

$13,772

$18,292

$27,698

$29,685

$31,574

$139,940

North Carolina

$26,443

$31,974

$42,027

$57,132

$95,453

$91,974

$102,757

$447,760

North Dakota

$1,989

$1,818

$2,447

$4,211

$7,262

$7,445

$8,393

$33,566

Nebraska

$3,830

$4,891

$6,211

$9,385

$12,291

$16,670

$15,322

$68,600

New Hampshire

$4,280

$4,927

$7,340

$10,909

$16,817

$18,452

$20,493

$83,218

New Jersey

$18,036

$18,534

$25,263

$37,524

$53,364

$62,578

$59,840

$275,139

New Mexico

$17,132

$19,064

$25,423

$32,981

$43,138

$55,949

$54,541

$248,229

Nevada

$3,963

$3,802

$7,030

$6,265

$11,065

$15,349

$16,079

$63,553

New York

$54,434

$69,550

$84,597

$114,257

$177,512

$194,513

$196,883

$891,746

Northern Mariana Islands

$608

$732

$738

$906

$1,041

$1,166

$5,191

Ohio

$27,236

$32,877

$37,969

$60,811

$100,662

$108,040

$114,226

$481,821

Oklahoma

$12,270

$15,626

$19,901

$22,992

$39,075

$43,577

$42,123

$195,564

Oregon

$18,770

$23,679

$29,405

$41,563

$62,124

$67,299

$68,314

$311,154

Palau

$358

$31,807

$40,399

$55,918

$811

780.218

732.931

$130,807

Pennsylvania

$27,426

$24,701

$30,063

$38,782

$86,292

$89,813

$88,928

$386,005

Puerto Rico

$19,894

$371

$292

$577

$56,486

$67,430

$62,928

$207,978

Rhode Island

$7,259

$6,713

$7,671

$11,673

$20,470

$20,970

$21,034

$95,790

South Carolina

$20,082

$23,988

$31,938

$37,320

$49,574

$60,102

$60,766

$283,770

South Dakota

$4,150

$4,523

$5,597

$8,434

$12,625

$12,131

$13,339

$60,798

Tennessee

$17,968

$21,473

$26,400

$36,560

$59,695

$62,397

$60,329

$284,822

Texas

$60,674

$68,428

$86,323

$121,729

$184,926

$179,902

$186,745

$888,727

Utah

$6,805

$6,834

$10,814

$16,712

$25,117

$29,516

$30,641

$126,440

Virginia

$19,223

$22,149

$27,601

$38,361

$56,120

$64,809

$65,272

$293,535

Virgin Islands

$673

$789

$959

$1,339

$2,368

$2,351

$2,280

$10,759

Vermont

$3,791

$4,126

$5,439

$10,222

$12,865

$22,564

$18,788

$77,794

Washington

$27,932

$30,811

$40,902

$57,496

$94,593

$95,990

$95,116

$442,840

Wisconsin

$8,327

$11,069

$13,051

$18,617

$32,303

$35,536

$33,162

$152,064

West Virginia

$13,499

$15,001

$20,198

$29,218

$46,687

$52,842

$51,149

$228,595

Wyoming

$1,730

$1,921

$2,386

$3,999

$6,319

$6,038

$6,188

$28,581

Totalb

$978,659

$1,137,296

$1,440,620

$2,075,045

$3,191,077

$3,502,371

$3,530,603

$15,855,677

CHCF Allocationc

$1,000,000

$1,200,000

$1,465,000c

$2,145,000c

$3,510,000c

$3,600,000

$3,516,000c

$16,436,000

Source: CRS analysis of HRSA's Datawarehouse (at http://www.hrsa.gov/data-statistics/index.html) and of data obtained from HRSA, personal communication, February 8, 2018.

Notes: Blank cells indicate that no funds were received by that state or territory in that year.

a. Total indicates the cumulative amount a state has received from the CHCF since the fund began in FY2011.

b. Total indicates amount of grants awarded; it is lower than the amount appropriated to the CHCF as some funds are used by HRSA to administer these grant programs.

c. The FY2013, FY2014, FY2015, and FY2017 amounts were reduced by the sequester required under the Budget Control Act (P.L. 112-25). For more information, see CRS Report R43937, Federal Health Centers: An Overview.

Author Contact Information

[author name scrubbed], Specialist in Health Services ([email address scrubbed], [phone number scrubbed])

Acknowledgments

LaTiesha Cooper, former CRS Research Assistant, and Clarissa Cooper, CRS Research Assistant, prepared the tables and figures included in this report.

Footnotes

1.

For more information on health centers, see CRS Report R43937, Federal Health Centers: An Overview.

2.

Annual discretionary appropriations during this time period and the American Recovery and Reinvestment Act (P.L. 111-5) provided supplemental funding in FY2009 and FY2010. See Table 3 in CRS Report R43937, Federal Health Centers: An Overview, and CRS Report R40181, Selected Health Funding in the American Recovery and Reinvestment Act of 2009.

3.

Peter Shin et al., Community Health Centers: A 2012 Profile and Spotlight on Implications of State Medicaid Expansion Decisions, The Kaiser Commission on Medicaid and the Uninsured, Issue Brief, Washington, DC, September 2014.

4.

Section 10503 of the Patient Protection and Affordable Care Act (ACA) established the CHCF. Though the fund is named for community health centers (the most common type of health center), its funds are available for use by all four types of health centers: (1) community health centers, (2) health centers for the homeless, (3) migrant health centers, and (4) health centers for residents of public housing.

5.

The FY2008 appropriation was $2.1 billion; see Table 3 in CRS Report R43937, Federal Health Centers: An Overview.

6.

CRS Report R44970, The National Health Service Corps. In FY2018, the National Health Service Corps received discretionary appropriations for the first time since FY2012.

7.

See Table 1.

8.

U.S. Department of Health and Human Services, Health Resources and Services Administration, press releases, "HHS Awards $500,000 in Funding to Flint Health Centers," https://www.hhs.gov/about/news/2016/02/18/hhs-awards-500000-funding-flint-health-centers.html; "HHS Awards $5 Million to Puerto Rico Health Centers to Fight the Spread of Zika Virus," April 26, 2016, https://www.hhs.gov/about/news/2016/04/26/hhs-awards-5-million-to-puerto-rico-health-centers.html; and "HHS Awards More than $742,000 to Health Centers in American Samoa and the Virgin Islands to Fight Zika," June 23, 2016, https://www.hhs.gov/about/news/2016/06/23/hhs-awards-more-742000-health-centers-american-samoa-and-virgin-islands-fight-zika.html; "FY2016 Substance Abuse Service Expansion Awards," https://bphc.hrsa.gov/programopportunities/fundingopportunities/substanceabuse/2016awards/index.html; and "HHS Makes $350 Million Available to Fight the Opioid Crisis in Community Health Centers Nationwide," https://www.hhs.gov/about/news/2018/06/15/hhs-makes-350-million-available-to-fight-opioid-crisis-community-health-centers.html.

9.

ACA Section 10503(a).

10.

These are referred to as "service area competitions." Under these awards, HRSA specifies geographic areas eligible to apply. These awards may be competing continuations (where existing grantees must apply at the end of their grant cycle) or may be competitions for new areas. See U.S. Department of Health and Human Services, Health Resources and Services Administration, "Service Areas Competition," https://bphc.hrsa.gov/programopportunities/fundingopportunities/default.aspx?id=dcb72c18-c136-411b-bce5-c69a548f6283.

11.

The ACA also provided, for use between FY2011 and FY2015, $1 billion dollars for health center construction and renovation. Grant awards from this program were made in FY2011 and FY2012 and supported 398 projects at 190 centers; see CRS Report R42433, Federal Health Centers.