• Community Health Centers and Resource Allocation

    Aaron posted yesterday on the impact of cuts to expanded money for community health centers (CHCs). CHCs have typically been areas of bipartisan agreement, even for those who might be against larger scale reforms, but they were unable to escape cuts to expansions put in place by the ACA in the current political context.

    This Wednesday and Thursday will be the final meeting of the Negotiated Rulemaking Committee that is revising the method of designating medically underserved areas (MUA) and health professional shortage areas (HPSA), that are essentially unchanged since the 1970s. Being a MUA makes an area/populations eligible for federal resources such as those enabling the work of CHCs. I know, I know, the September meeting was also supposed to be the last one for this committee, but work expands to fill the time until deadlines (the committee is disbanded as I understand it, on October 31, 2011, so this actually is it). Where things stand:

    • The biggest source of committee disagreement remains the meta-role of such designations. Is it to identify expansively those areas/populations that could be helped by extra resources, or to focus designations on the worst-off areas due to the limited resources available to respond?
    • There is an inevitable triage of areas/populations given finite resources and always has been; the question we are wrestling with is to what degree should this be acknowledged when making areas/populations eligible for such resources?
    • A worry of some is that expansive designation means that better off areas will prevail in the scramble for finite resources. A worry for others is that we should identify those places in which there are groups with access barriers, even if we cannot ameliorate them all.
    • Under the Negotiated Rulemaking Act of 1990 that guides the work of the committee, the definition of consensus is unanimous agreement, and getting there with 28 people is very difficult.
    • If we reach a unanimous agreement, our decisions will become the essence of a draft interim final rule.
    • If we do not reach a unanimous agreement, the Sec. of HHS can move ahead to publish a rule to change these designation procedures in the manner of her choosing, following the normal processes. So, some change in the designation method seems likely.

    In any event, this is a big week for our country’s safety net, as the means of designating areas and populations as eligible to receive federal resources such as those provided via CHCs is likely to be changed one way or another by the actions of this committee.


    • With luck, and perhaps just due to fatigue, all will agree on your proposed approach. The trouble is, any formula will inevitably miss some places and people who need resources that depend on designation and the complexity of the process will make it hard for other places and people to make their case–that is inevitable and will continue to create agitation for change. What is good is that more and more people have become involved and been given the responsibility to join the decision process. That’s good in and of itself.

      The designation system and the establishment of CHCs has put “facts on the ground” that are hard to ignore. The idea that we will have to continuously recognize “underservice” where programs are successful and where conditions change is an awkward reality for the foreseeable future. The CHC structure is now a permanent feature of our health care delivery and financing system–it is no longer the stop-gap for “market failure/” Given this, the process of designation and subsequent grant seeking has become one of continuous priority setting and funding. This is now becoming a re-distributive process (taking from some other programs)–as opposed to a distributive one (new money for need). This transition will change everything, as they say.

      • @Tom Ricketts
        yes to all you say. The transition from old designation regime to new regime will be especially hard to get straight. All methods we have considered produce substantial changes (new designations, old ones losing out, etc.). It is also much more difficult to measure ‘underservice’ and operationalize a response to it than it is provider shortage as well.