CAP was originally funded by Congress and implemented by the Health Resources and Services Administration (HRSA) in September 2000. In 2002, Congress passed authorizing legislation creating HCAP, which began in fiscal year 2003 (Health Care Safety Net, 2002). From 2000 through 2006, HCAP provided grants to local communities to strengthen the health care safety net that served the uninsured and underinsured. Congressional funding for CAP began with a $25 million appropriation in the Fiscal Year (FY) 2000 budget, used to make grants to 23 coalitions of community organizations and safety net providers. Additional funding provided to HRSA for the program comprised approximately $500 million from FY 2001 through FY 2005. The program was unfunded for FY 2006.
In total, HRSA awarded 260 grants in 45 states and the District of Columbia and the Virgin Islands. Most grantees received an initial grant of $750,000 to $1 million in the first year, with additional, but reduced, funding for two additional years. Although federal and foundation grants have long supported safety net providers’ efforts to increase access to care and the quality of care for underserved populations, the HCAP program distinguished itself on three fronts: first, by requiring collaboration—grants were given only to consortia of local providers, not to individual institutions; second, the funds were to be directed to infrastructure development, rather than direct service provision; and, third, the program afforded grantees wide latitude to formulate programs based on their communities’ specific needs. Through these design features, the program sought to overcome the fragmented nature of safety net care by bringing the major players together and providing funds to address problems that cannot adequately be addressed by individual providers or organizations.
HCAP coalitions focused on a variety of activities, including service integration, expansion of the delivery system, cultural competency, provider education, community and patient education, disease detection and prevention, service integration, and new health insurance plans for the uninsured, among others. The outcomes of their grants were documented in an evaluation of the HCAP program conducted by NORC in 2006, including:
- A total of over 640,000 people were enrolled in Medicaid and SCHIP;
- About 156,000 were enrolled in private insurance or a new program for the uninsured;
- Over 560,000 individuals were assigned to a medical home;
- Over 1.2 million individuals were assigned to a primary care provider;
- 483,000 and 438,000 patients were referred to primary and specialty care, respectively;
- A total of 650,000 patients were reached through care coordination or navigation systems; and
- Over 500,000 patients were reached through programs targeting appropriate use of the emergency department.
The 2006 evaluation also identified several lessons learned related to collaboration and sustainability:
- A broad consortium of diverse members was critical to developing a successful program. In many of the more successful HCAP coalitions, a history of collaboration and shared experiences provided a solid foundation on which to undertake additional endeavors.
- The HCAP community collaboration model supported increased integration of services and coordination of care. The development of shared infrastructure contributed to increased communication and collaboration, administrative efficiencies, and improvements in coordination of care and health care access for the under- and uninsured.
- Planning for sustainability at the outset and documenting program results were key to securing ongoing funding and creating lasting improvements to the safety net. The most successful HCAP grantees worked towards securing funds from the beginning of their programs, pursuing a variety of funding sources, including foundations, other community organizations, or the use of internal funds. Being able to demonstrate results (in terms of grantees’ access or health outcomes) and, in particular, cost savings was frequently instrumental in gaining financial support.
Using the HCAP grantees as a lens to explore sustainability of community coalitions is particularly important today given new federal investments in clinical and community-based strategies. Signed into law in February 2009, the American Recovery and Reinvestment Act (ARRA) provided funding for community-based health strategies through a Prevention and Wellness fund. A year later, in March 2010, the Patient Protection and Affordable Care Act (Affordable Care Act) was signed into law, expanding coverage and access to health services for Americans. HHS has implemented several programs that build on ARRA and the Affordable Care Act—including the Communities Putting Prevention to Work (CPPW) Initiative and the Community Transformation Grants (CTGs). These programs are creating policy, systems and environmental changes, and demonstrate the federal government’s investment in innovative community-based strategies to improve health outcomes. Understanding the facilitators and barriers to community coalition sustainability is an issue of paramount importance both for the multi-sectorial community coalitions that are implementing this work as well as their funders.