Appendix A

Health Resources and Services
Administration (HRSA) and Centers for
Disease Control and Prevention (CDC)

In recent years, the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have articulated a vision of how their work can impact the broader determinants of health (Frieden, 2010; HRSA, 2010). To understand how this work can be accomplished within and between the agencies, it is important to understand the current organization of each agency and how funding flows into and through their networks. This appendix provides a brief overview of each agency and reviews their macro-level funding streams as they relate to primary care and public health opportunities.

WITHIN THE CONTEXT OF THE DEPARTMENT
OF HEALTH AND HUMAN SERVICES

The Department of Health and Human Services (HHS) is the principal agency charged with protecting the health of all Americans, and in fiscal year 2010, it spent $854 billion in pursuit of that goal (see Table A-1 for details). It is notable that together, HRSA and CDC account for less than 2 percent of the department’s budget. In contrast, the National Institutes of Health accounts for 3.65 percent of the HHS budget, the Administration for Children and Families for 6.1 percent, and the Centers for Medicare & Medicaid Services (CMS) for fully 86.5 percent (HHS, 2011).

While HRSA and CDC operate on less than 0.5 percent of total federal outlays, they are responsible for the provision of primary care for tens of millions of vulnerable individuals and for oversight of the public health of the nation, respectively, and thus are positioned to facilitate the integration



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Appendix A Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) I n recent years, the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have articulated a vision of how their work can impact the broader de- terminants of health (Frieden, 2010; HRSA, 2010). To understand how this work can be accomplished within and between the agencies, it is important to understand the current organization of each agency and how funding flows into and through their networks. This appendix provides a brief overview of each agency and reviews their macro-level funding streams as they relate to primary care and public health opportunities. WITHIN THE CONTEXT OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES The Department of Health and Human Services (HHS) is the principal agency charged with protecting the health of all Americans, and in fiscal year 2010, it spent $854 billion in pursuit of that goal (see Table A-1 for details). It is notable that together, HRSA and CDC account for less than 2 percent of the department’s budget. In contrast, the National Institutes of Health accounts for 3.65 percent of the HHS budget, the Administration for Children and Families for 6.1 percent, and the Centers for Medicare & Medicaid Services (CMS) for fully 86.5 percent (HHS, 2011). While HRSA and CDC operate on less than 0.5 percent of total federal outlays , they are responsible for the provision of primary care for tens of millions of vulnerable individuals and for oversight of the public health of the nation, respectively, and thus are positioned to facilitate the integration 153

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154 PRIMARY CARE AND PUBLIC HEALTH TABLE A-1 HHS Outlays by Operating Division (Fiscal Year 2010) Outlays Percentage of Operating Division (in millions of $) Total Outlays Centers for Medicare & Medicaid Services 732,896 85.80 Administration for Children and Families 56,370 6.60 National Institutes of Health 33,052 3.87 Health Resources and Services 8,569 1.00 Administration Centers for Disease Control and Prevention 6,957 0.81 Public Health and Social Services Emergency 4,890 0.57 Fund Indian Health Service 4,350 0.51 Substance Abuse and Mental Health Services 3,325 0.39 Food and Drug Administration 2,117 0.25 Administration on Aging 1,512 0.18 Program Support Center 575 0.07 Departmental Management 497 0.06 Agency for Healthcare Research and Quality 80 0.01 Office of the National Coordinator 115 0.01 Medicare Hearings and Appeals 64 0.01 Office of Inspector General 91 0.01 Office for Civil Rights 34 0.00 Prevention and Wellness 10 0.00 Health Insurance Reform Implementation 21 0.00 Fund World Trade Center Health Program Fund 0 0.00 Offsetting Collections –1,351 –0.16 Total Health and Human Services 854,174 100.00 SOURCE: HHS, 2011. of primary care and public health. Yet, while they share certain objectives, HRSA and CDC are two very different agencies, and located more than 600 miles apart; they have very different responsibilities for fostering the health of the U.S. population. Among HHS agencies, HRSA and CDC have especially important roles to play in improving population health. HRSA plays a strategic role in helping to ensure access to health services for uninsured and vulnerable populations. Among its other activities, it provides funding to support the provision of primary care services at community health centers, Ryan White clinics, and rural health clinics, as well as training programs for the primary care workforce and maternal and child health care programs. And with its focus on health promotion, prevention, and preparedness, CDC is recognized as a global leader in public health. The agency works with local and state health departments on a number of efforts, including implement- ing disease surveillance systems, preventing and controlling infectious and

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155 APPENDIX A chronic diseases, reducing injuries, eliminating workplace hazards, and addressing environmental health threats. This appendix examines HRSA and CDC in greater detail. HEALTH RESOURCES AND SERVICES ADMINISTRATION Established in 1980, HRSA is the primary federal agency responsible for ensuring access to health care services for people who are uninsured, isolated, or medically vulnerable, including those living with HIV/AIDS, mothers and children, and those living in rural areas. HRSA’s vision is “Healthy Communities, Healthy People,” and its mission is “to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs” (HRSA, 2011a). HRSA has established four goals to help achieve its vision and mission: to improve (1) access to quality care and services, (2) the health workforce, (3) healthy communities, and (4) health equity (HRSA, 2011a). At its highest level, HRSA is organized into 6 bureaus and 10 offices (Figure A-1) (HRSA, 2011c). Each bureau provides clinical and preventive services to vulnerable populations. For instance, the Bureau of Primary Health Care funds health centers in underserved communities that provide comprehensive primary and preventive health care for medically under- served populations regardless of their ability to pay (HRSA, 2011b), while the Maternal and Child Health Bureau functions to improve the health of mothers, infants, and children and aims to reduce health disparities relat- ing to such issues as infant mortality, access to pre- and postnatal care, and health care for children with special health care needs (HRSA, 2011d). Among other efforts, HRSA functions to improve health by funding health care initiatives and systems such as health clinics, maternal and child health initiatives, and workforce programs including training and loan reimbursement programs. HRSA supports 70 programs that provide funding to such entities as academic institutions, community health centers, public health departments, and local communities. HRSA programs and their funding share some key features. HRSA programs include few flex- ible funding sources and include only one block grant—the Maternal and Child Health Block Grant. In contrast with the CDC programs discussed below, 10 of the HRSA programs allocate funds based on a formula, and 12 of the HRSA project grants are funded through cooperative agreements which allows HRSA to be substantially involved in local activities. Despite this variability, the majority of HRSA awards are project grants designated for a specified use or project (Federal Funds Information for States, 2011). Additionally, HRSA programs have some specific funding restrictions. Fifteen of the programs impose some type of matching requirement, and 22 have a maintenance-of-effort provision. These may require that additional

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156 O ce of the Administrator Bureau of Maternal O ce of Bureau of Bureau of Healthcare Clinician and Child HIV/AIDS Rural Health Primary Health Systems Recruitment Health Bureau Policy Health Care Professions Bureau and Service Bureau O ce of O ce of O ce of O ce of Equal O ce of O ce of Federal Special O ce of O ce of O ce of Opportunity, Planning Women's Regional Assistance Communications Civil Rights, Health Legislation Operations Analysis and Health Operations Management and Diversity A airs Evaluation Management FIGURE A-1 Organizational structure of HRSA. SOURCE: HRSA, 2011c. Figure A-1.eps landscape

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157 APPENDIX A TABLE A-2 HRSA Fiscal Year 2010 Budget Authority Funding Level Activity (in millions of $) Percent of Total HIV/AIDS 2,315 30.90 Primary Care 2,253 30.07 Health Workforce 1,230 16.42 Maternal and Child Health 984 13.13 Other Activities 837 11.17 Health Care Systems 267 3.56 Rural Health 185 2.47 Less Funds from Other Sources −579 −7.73 TOTAL 7,492 100.00 SOURCE: HHS, 2011. funds be generated by the program or through other grants. Many of these programs have a supplantation provision requiring that the grantee use the funds to supplement, not supplant, existing funding for specified grant ac- tivities. These provisions are in addition to funding restrictions, such as on the use of funds for the delivery of health care services, indirect costs, and facility construction (Federal Funds Information for States, 2011). In fiscal year 2010, HRSA was appropriated $7.5 billion (Table A-2). It received nearly equal funding for its HIV/AIDS and primary care initiatives (30.9 and 30.1 percent, respectively), while 16 percent of its funding was dedicated to health workforce development and maintenance (HHS, 2011). CENTERS FOR DISEASE CONTROL AND PREVENTION Established in 1942, CDC is perhaps the most well known of Depart- ment of Health and Human Services (HHS) agencies. The agency pursues its mission of “Health Protection … Health Equity” through collaboration with nationwide and global partners to “monitor health, detect and inves- tigate health problems, conduct research to enhance prevention, develop and advocate sound public health policies, implement prevention strategies, promote healthy behaviors, foster safe and healthful environments, and provide leadership and training” (CDC, 2010). At its highest level, CDC is organized into five offices, the Center for Global Health, and the National Institute for Occupational Safety and Health (Figure A-2). Three of these offices—the Office of Infectious Dis- eases; the Office of Noncommunicable Disease, Injury, and Environmental Health; and the Office of Surveillance, Epidemiology and Laboratory Ser- vices—are further divided into national centers and program offices (CDC, 2011b). These centers and offices are further partitioned into divisions

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O ce of the Director 158 O ce of Public Health National Institute for O ce for State, Tribal, Center for Preparedness and Occupational Safety Local and Territorial Global Health Response and Health Support O ce of Noncommunicable O ce of Surveillance, O ce of Diseases, Injury and Epidemiology and Infectious Diseases Environmental Health Laboratory Services National Center on Birth Public Health National Center for National Center for Defects and Surveillance Immunization and Health Statistics Developmental Disabilities Program O ce Respiratory Diseases National Center for National Center for Laboratory Science Epidemiology and Chronic Disease Prevention Emerging and Zoonotic Policy and Practice Analysis Program O ce and Health Promotion Infectious Diseases Program O ce National Center for Public Health Informatics Scientific Education and National Center for Injury HIV/AIDS, Viral Hepatitis, and Technology Professional Prevention and Control STD and TB Prevention Program O ce Development O ce National Center for Environmental Health/ Agency for Toxic Substances and Disease Registry FIGURE A-2 Organizational structure of CDC. SOURCE: CDC, 2011b. Figure A-2.eps landscape

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159 APPENDIX A and then branches, which are narrowly focused on health topic areas. For instance, the National Center for Chronic Disease Prevention and Health Promotion comprises nine divisions: the Division of Adolescent and School Health; the Division of Cancer Prevention and Control; the Division of Adult and Community Health; the Division of Diabetes Translation; the Division of Nutrition, Physical Activity and Obesity; the Division of Repro- ductive Health; the Office of Smoking and Health; the Division for Heart Disease and Stroke Prevention; and the Division of Oral Health (CDC, 2011a). Each division, center, and office is headed by a director who ulti- mately reports to the director of CDC and the secretary of HHS. CDC functions to improve the health of all Americans through vari- ous public health initiatives, such as vaccine promotion, infectious disease prevention, and management of chronic disease. While organizing many of its own campaigns, CDC functions largely through its grant-making programs. These programs cover a broad spectrum and share several fea- tures. Only one program—the Preventive Health and Health Services Block Grant—provides flexible funding to states that can be used for a variety of activities, from clinical services to data surveillance. The remaining CDC programs provide funding through project grants, whereby the funding is competitive and restricted to a specified use or project. Twenty-nine of these project grants operate as cooperative agreements between the federal government and recipient(s) (Federal Funds Information for States, 2011). Programs in the CDC inventory also are similar in their funding restric- tions. Most have general restrictions that apply to all CDC grants. These restrictions generally entail use limitations, which allow funding only for reasonable program costs and exclude the use of funds for the purchase of equipment and construction and for rehabilitative services or clinical care. These restrictions also require the recipient to play a substantial role in car- rying out the project objectives and do not allow for the reimbursement of pre-award costs. In addition to these general restrictions, some programs impose matching or maintenance-of-effort requirements. For example, state health departments must match $1 for every $4 they receive under coopera- tive agreements for state-based diabetes control programs and evaluation of surveillance systems. Additionally, while some programs have specific maintenance-of-effort requirements, others have supplantation provisions (Federal Funds Information for States, 2011). In fiscal year 2010, CDC was appropriated nearly $6.5 billion in dis- cretionary funds (Table A-3). At 23.5 percent, the largest portion of this funding was dedicated to public health preparedness and response. This was followed by funding for prevention of HIV/AIDS, viral hepatitis, sexu- ally transmitted diseases (STDs), and tuberculosis (17.3 percent) and $949 million for chronic disease prevention and health promotion (HHS, 2011). The primary uses of these funds are to support public health through state

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160 PRIMARY CARE AND PUBLIC HEALTH TABLE A-3 CDC Fiscal Year 2010 Budget Authority Funding Level Activity (in millions of $) Percent of Total Public Health Preparedness and Response 1,522 23.51 HIV/AIDS, Viral Hepatitis, STD, and TB 1,119 17.28 Prevention Chronic Disease Prevention and Health 949 14.66 Promotion Immunization and Respiratory Diseases 721 11.14 Public Health Scientific Services 441 6.81 Occupational Safety and Health 430 6.64 Business Support Services 367 5.67 Global Health 354 5.47 Emerging and Zoonotic Infectious Diseases 281 4.34 Public Health Leadership and Support 194 3.00 Environmental Health 181 2.80 Injury Prevention and Control 149 2.30 Child Health, Disabilities, and Blood Disorders 144 2.22 Preventive Health and Health Services Block 100 1.54 Grant Agency for Toxic Substances and Disease 100 1.54 Registry Buildings and Facilities 69 1.07 User Fees 2 0.03 Less Funds from Other Sources −649 −10.02 TOTAL 6,474 100.00 NOTE: STD = sexually transmitted disease; TB = tuberculosis. SOURCE: HHS, 2011. and local health departments and to sponsor nationwide public health re- search and programming. REFERENCES CDC (Centers for Disease Control and Prevention). 2010. About CDC: Vision, mission, core values, and pledge. http://www.cdc.gov/about/organization/mission.htm (accessed November 1, 2011). CDC. 2011a. Chronic disease prevention and health promotion: Organizational chart. http:// www.cdc.gov/chronicdisease/about/org_chart.htm (accessed November 1, 2011). CDC. 2011b. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/maso/pdf/CDC_Chart_wNames.pdf (accessed November 1, 2011). Federal Funds Information for States. 2011 (unpublished). Inventory of federal funding streams: A detailed review of HRSA and CDC funds. Washington, DC: Institute of Medicine.

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161 APPENDIX A Frieden, T. R. 2010. A framework for public health action: The health impact pyramid. Ameri- can Journal of Public Health 100(4):590-595. HHS (Department of Health and Human Services). 2011. Advancing the health, safety, and well-being of our people: FY 2012 president’s budget for HHS. Washington, DC: HHS. HRSA (Health Resources and Services Administration). 2010. Public Health Steering Com- mittee recommendations (draft). Washington, DC: HRSA. HRSA. 2011a. About HRSA. http://www.hrsa.gov/about/index.html (accessed November 1, 2011). HRSA. 2011b. Bureau of Primary Health Care. http://www.hrsa.gov/about/organization/ bureaus/bphc/index.html (accessed November 1, 2011). HRSA. 2011c. Bureaus and offices. http://www.hrsa.gov/about/organization/bureaus/index. html (accessed November 1, 2011). HRSA. 2011d. Maternal and Child Health Bureau. http://www.hrsa.gov/about/organization/ bureaus/mchb/index.html (accessed November 1, 2011).

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