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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-
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2011).
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