Grants help strongest, most capable communities

Federal grants under Community Health Center expansion and the Community Access Program have helped some communities strengthen their health care safety-net services, but only work best in communities that already have a solid infrastructure, strong leadership, and additional sources of income.

That’s the finding from a Center for Studying Health System Change analysis of grant use in 12 nationally representative communities involved in the center’s 2002-2003 site visits. (Every two years, center researchers visit 12 representative metropolitan communities — Boston; Cleveland; Greenville, SC; Indianapolis; Lansing, MI; Little Rock, AR; Miami; northern New Jersey; Orange County, CA; Phoenix; Seattle; and Syracuse, NY — to track changes in local health care markets. The researchers interview individuals in each community who are involved directly or indirectly in providing safety-net services to low-income people, including representatives of safety-net hospitals, community health centers, local health departments, and government officials, academics, and advocates.)

According to a center issue brief, Federal Aid Strengthens Health Care Safety Net: The Strong Get Stronger, written by John F. Hoadley, et al., federal funds helped many communities expand preventive and primary care services and increase coordination among community health centers and other safety-net providers, especially hospitals.

But, the researchers caution, "generally, communities with existing safety nets tended to be more successful in obtaining grants, while some communities with less well-established safety nets have not reaped as much benefit from the additional federal aid."

Community Health Center expansion grants were launched by the Bush administration in 2002 to help new or existing health centers add preventive and primary care services. Consistent with the ability of centers to treat more people in need, the administration’s goal has been to increase the number of patients treated at community health centers from about 10 million in 2001 to more than 16 million in 2006. Nationally, about 460 grants were awarded in 2002 covering $175 million in new spending and expanding community health centers’ reach to about 1.6 million new patients. Nearly half of the eligible community health centers in the 12 communities surveyed received grants in 2002 ranging from $100,000 to $787,500.

Mr. Hoadley, et al., say there are several types of expansion grants that fund new centers or sites, expand medical capacity at existing centers, or add new dental, mental health, substance abuse, or pharmacy services. They say the community health center expansion grants "have played a significant role in strengthening the reach of community health centers in the eight communities studied that received at least one grant." Some centers opened new facilities. For instance, community health centers in Phoenix opened two new centers and expanded hours to include evenings and Saturdays. A northern New Jersey center was able to open a new site to replace one that had closed. And in other communities, grants have allowed health centers to add workers. In Miami, for example, one community health center used grant money to hire a dentist, dental hygienists, and a clinical social worker.

With a limited amount of new money available, some communities expressed concern about the intense competition for funds and also raised questions about sustainability of activities started through the federal grants. In Boston, for example, many community health centers used the federal expansion money to expand dental coverage with a commitment from the state to support dental services through Medicaid. Centers spent about $7 million to build dental capacity, only to have the state eliminate coverage of adult dental services in early 2002. "Even though the new federal funds likely will continue," says Mr. Hoadley, "they alone may be inadequate to maintain the program."

The grants appear to have had less impact in communities lacking a pre-existing strong network of safety-net institutions. The report says that in several of the 12 communities visited, the safety net has faced serious challenges in meeting the needs of uninsured people. Yet there were no clear examples of a fragile community health center becoming significantly stronger as a result of the new federal grants.

Across the 12 center sites, communities such as Boston with relatively large safety-net capacity appeared more likely to receive expansion and CAP grants than communities with smaller, struggling safety nets such as Little Rock.

"Financially viable safety-net organizations were more likely to receive grants than those experiencing financial problems or other weaknesses," the researchers say. "A number of factors contributed to this overall pattern, including strong infrastructure, leadership, financial viability, and the ability to demonstrate ongoing needs in the community."

Safety-net organizations with a stronger infrastructure often have the staffing and expertise needed to prepare grant applications and evaluate their success in serving more people or achieving efficiencies. As a result, Mr. Hoadley writes, they likely are more able to develop a compelling grant proposal to start a new site, expand services, or develop new approaches for outreach or collaboration with other providers.

The role of community health center leadership also is examined, with the researchers finding that safety-net organizations led by talented directors who actively seek new funding are more skilled at gaining support and grants. Because long-term sustainability of a project is a critical factor in grant awards, financially stable community health centers with multiple revenue sources and less reliance on direct federal funds are likely to have a better chance of receiving a grant. Further, safety-net organizations have to show there is a need.

Mr. Hoadley, et al. say the grant programs have been a success for many communities but they are not a panacea for bridging significant gaps in safety-net infrastructure or for filling some of the largest holes in services for low-income people.

They tell policy-makers that if they want to bolster safety nets in some of the nation’s neediest communities, changes will be needed. Since, for instance, safety-net organizations with less established infrastructure and fewer resources could benefit from technical assistance to apply for, obtain, and use grants, ways must be found to make that assistance available.

[Contact Mr. Hoadley at (202) 484-5261. Download the issue brief from]