WASHINGTON -- Organ transplants, medical school loan repayments, maternal and child health services -- it's all in a day's work for one government agency: the Health Resources and Services Administration (HRSA).
What do all of those areas have in common? Earl Fox, MD, MPH, who served as HRSA administrator from 1997 to 2001, figured that out when he first arrived at the agency. "We started looking around at all the programs in HRSA; there's one common theme, and it's access," he said in a phone interview. "Whether it's provided directly through federally qualified health centers (FQHCs) or indirectly through a well-trained workforce or the Maternal and Child Health Bureau, all of it is about access."
As a result, Fox and his colleagues branded HRSA as the "access agency ... We said our mantra was 100% access and 0% disparities."
Four Funding Areas
The work of the little-known agency, headquartered in Rockville, Md., falls primarily into four areas:
- FQHCs, commonly referred to as community health centers: HRSA funds a nationwide network of FQHCs, which provide care for 24 million people across more than 10,000 sites
- Workforce Training: The agency funds various training programs for physicians, including graduate medical education at children's hospitals and primary care training programs. The most well-known program in this arena is the National Health Service Corps, which provides repayment of medical school loans to physicians who agree to serve in medically underserved areas
- Maternal and Child Health: The Maternal and Child Health Bureau gives block grants to states to help them provide comprehensive primary care for pregnant women, as well as programs to reduce teen pregnancy and infant mortality. "HRSA has played a critical role in helping bring infant mortality rates down," said Anand Parekh, MD, chief medical advisor at the Bipartisan Policy Center here
- Ryan White HIV/AIDS Program: There are about one million people with HIV AIDS [in the U.S.]; Ryan White is providing support for at least half that population," said Parekh. In 2015, 83.4% of Ryan White program clients were virally suppressed; the national average is 55%, noted HRSA spokesman Marty Kramer. "Obviously, the program is doing something correctly."
No Stranger to Controversy
In addition to those four areas -- which account for the bulk of the agency's $10.5 billion annual budget, the agency also oversees the operation of the United Network for Organ Sharing, which matches organ donors with organ recipients. That is one of several HRSA programs that has not escaped controversy, according to Fox.
When Fox worked at HRSA under then-Health and Human Services Secretary Donna Shalala, " there was an ongoing discussion about allocation of solid organs -- mainly livers, but others too -- 'Is [the matching system] fair?' Donna was convinced the answer to that was no, they were not allocated on a fair basis," Fox said. "So she wanted to change the rules."
For one thing, under the system then, there was no sharing of organs across regional lines, "so if you were in Region 1 and at the top of the transplant list, and you were out playing golf but not mortally ill, while right across the river, someone was in a hospital bed dying, and [if the call came in Region 1], you get the liver," said Fox. "So we started a process of rulemaking to try to make changes to make sure it was 'sickest first,' as long as ... we could reasonably expect the person to survive if they receive a transplant." The result? "We managed to make everybody mad -- hospitals, surgeons, and the Society of Transplant Physicians."
Another hot-button area that HRSA touches is family planning services. The agency disburses $300 million in family planning funds, which serve almost five million people, mostly women, "and it provides a host of important family planning services and also preventive screenings, as well as sexually transmitted disease screenings," said Parekh, who was formerly deputy assistant secretary for health in the Obama administration. One of the providers receiving funding through the program is Planned Parenthood, which has been targeted for defunding by congressional Republicans because it also provides abortions.
Planned Parenthood supporters note that the abortion part of the organization's services is not funded with federal funds because of the Hyde Amendment, which prohibits any federal money from being used for abortions. Critics of Planned Parenthood counter that since the money is fungible, the federal government is funding abortions indirectly by giving any money at all to the organization. And, they say, the services Planned Parenthood is providing could be provided instead by the community health centers.
The community health centers, however, don't necessarily agree with that second point: "We would feel much more comfortable if Planned Parenthood and other family planning programs were continued," said Dan Hawkins, senior vice president for public policy and research at the National Association of Community Health Centers, in a phone interview. "They have unique expertise in women's health issues."
Although community centers do serve women -- in fact, they make up more than half of the centers' patients -- providers such as Planned Parenthood "are located in communities where care is scarce and needs to be continued," he said. Hawkins noted that Congress at one point considered defunding Planned Parenthood and turning the $400 million it was getting over to HRSA to fund health center expansions.
"With that amount [of money], Planned Parenthood served about 4.5 million women," he continued. "But because community health centers must be open to everyone ... we can't discriminate by gender or age -- the cost of [serving that same population] would be multiple times the $400 million they were going to take from Planned Parenthood."
Funding Issues on the Horizon
HRSA also provides funding to so-called 340B hospitals, which serve low-income patients. "Most recently, the Trump administration just unveiled [proposed] reductions in payments to these [hospitals]," said Parekh. "It almost seems like it's making the life of these providers that much harder."
Community health centers are also facing funding issues -- their HRSA funding expires at the end of September. Members of Congress are already considering reauthorizing funding for the Children's Health Insurance Program -- whose funding is slated to run out at the same time -- and there has been talk of reauthorizing the health centers' funding as well.
"From a timing perspective ... it would make sense to put [the FQHCs] with CHIP," a senior Republican House aide told 51˶ at a breakfast briefing Thursday. "When you think about orders of magnitude, CHIP and FQHCs are multiple billions of dollars -- not insignificant," while some other programs such as the National Health Service Corps "are not unimportant, but they're much smaller, so it's a little easier to think about plugging them in and offsetting them; that's less tricky than some of the bigger costs. I expect we'll do more conversations with members and stakeholders, [but] there tends to be a lot of support from members for those types of [programs]."
Looking at HRSA today, Fox said there are a few things he would like to see the agency improve on. "HRSA [spends] a minority of its money -- $771 million -- for the healthcare workforce. When I was there, this country had an extreme shortage of physicians trained to take care of geriatric patients. That's gotten worse, not better," he said.
"The funding part of geriatric training programs at HRSA is minuscule ... We've got an aging population, but we're not training people to specialize in geriatric care and not taking the people out there now and training them about how to provide [it]." And, because geriatricians don't make a lot of money and there are other disincentives for going into geriatric training, "it's a huge problem."
The public health workforce overall is another area that concerns Fox: "People are retiring at a faster rate than they are being replenished, and the public health training budget is $10 million for the whole country. The Affordable Care Act [ACA] has a provision for a workforce commission to look at these issues, but Congress has consistently blocked it. They've made threats to HRSA that if any steps were taken to implement that part of the ACA, there would be severe repercussions."
That's too bad, because HRSA's Bureau of Primary Health Care has operating agreements with every state to perform workforce analyses on the need for providers in underserved areas, and the 50 centers -- one in each state -- that do this analysis "could be expanded to look not just at medically underserved areas, but also at nurses, physicians, dentists, and on down the line," he said. "If you don't have an adequately deployed or distributed workforce, you're in a mess of trouble."