Core Performance Indicators for Homeless-Serving Programs Administered by the U.S. Department of Health and Human Services. Overview of the Four Mainstream Programs


Basic characteristics of mainstream program generally quite different in terms of scale and target population. As shown in Exhibit 5-1, the four mainstream programs are quite different on a number of important dimensions from the four homeless-serving programs that are the main focus of this study. In comparison to the four homeless-serving programs, the mainstream programs:

  • Have much greater funding  The largest of the four homeless-serving programs in terms of budget is the Health Care for the Homeless (HCH) program, with an annual budget of slightly more than $100 million. The funding levels of HCH and the other homeless-serving programs pale in comparison to those of the four mainstream programs: Medicaid, with FY 2002 federal assistance to states of $147.3 billion; Head Start, with a FY 2002 budget of $6.5 billion; SAPT, with a FY 2002 budget of $1.7 billion, and the BPHCs Health Centers Cluster, with FY 2002 budget of $1.3 billion (which includes funding for HCH).
  • Serve many more individuals  As might be expected given their greater funding levels and mandates to serve a broader range of disadvantaged individuals, the mainstream programs enroll and serve many more individuals in 2002, Medicaid had nearly 40 million enrolled beneficiaries, far eclipsing the other mainstream and homeless-serving programs. In 2001, the Health Centers Cluster served an estimated 10.3 million individuals, while SAPT served an estimated 1.6 million individuals (in FY 2000) and Head Start enrolled nearly a million (912,345 in FY 2002) children.
  • Serve a generally more broadly defined target population  While similarly targeted on low-income and needy individuals, the mainstream programs extend program services well beyond homeless individuals. Of the four mainstream programs, the two broadest programs are the Medicaid and Health Cluster Centers programs, both focusing on delivery of health care services to low-income and disadvantaged individuals. For example, though there is considerable variation from state to state, individuals may qualify for Medicaid benefits as part of either mandatory or categorically need groups.(17) The Head Start program targets needy and low-income pre-schoolers ages 3 to 5 (90 percent of which must meet low-income guidelines). The program also extends a range of services to the parents of these children to assist them in being better parents and educators of their children. SAPT is primarily targeted on individuals who abuse alcohol and other drugs, but also extends preventive educational and counseling activities to a wider population of at-risk individuals (i.e., not less that 20 percent of block grant funds are to be spent to educate and counsel individuals who do not require treatment and provide activities to reduce risk of abuse).
Exhibit 5-1:
Key Features of the Four DHHS Mainstream Programs
Program Characteristics Head Start Medicaid Substance Abuse Prevention and Treatment Block Grant BPHCs Health Centers Cluster
Authorizing Legislation Head Start Act (42 U.S.C. 9840). Title XIX of Social Security Act (as amended) Public Health Service Act, Title XIX, Part B, Subpart II, as amended, Public Law 106-310; 42 U.S.C. 300x Public Health Service Act, as amended by the Health Centers Consolidation Act of 1996
DHHS Administering Agency Head Start Bureau, Administration on Children, Youth, and Families (ACYF), Administration for Children and Families (ACF) Centers for Medicaid and Medicare Services (CMS) Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) Bureau of Primary Health Care (BPHC), Health Resources and Services Administration (HRSA)
Program Budget (FY2002) $6.5 Billion $147.3 Billion (Federal Share  Assistance to States) $1.7 Billion $1.3 Billion
How Funds Are Allocated
  • Statistical factor used for fund allocation among states (% of children up to age 4 living in families with incomes below poverty)
  • Eligible grantees submit applications for project grants; Regional Offices or ACYF Headquarters review applications and award grants directly to applicants
  • Federal/state governments jointly fund program  federal share determined by formula comparing state per capita income level with national income average
  • Federal funds distributed quarterly (based on estimates of need) to designated state Medicaid agency
  • Formula block grant awarded to states, territories, and tribal organizations
  • Allotments to states based on weighted population factors and a measure reflecting differences among states in costs of providing authorized services
  • Funds distributed on competitive basis in form of project grants for period up to 5 years
  • Eligible organizations submit applications; BPHC makes project grant awards directly to eligible organizations submitting applications
Number and Type of Grantees/Subgrantees Providing Services
  • ~1,565 Head Start grantees (operating 18,500 centers)
  • Public or private, for-profit or nonprofit organizations, Indian Tribes or public school systems are eligible to receive grants to Head Start programs
  • Federal funds must go to designated state Medicaid agency
  • States set own reimbursement levels for wide range of health care providers (e.g., hospitals).
  • Grant awards made to 50 states, District of Columbia, territories, and tribal organizations (grantees submit annual application for allotment)
  • States and other grantees fund over 10,500 CBOs to provide authorized services
-Over 750 health facilities funded serving ~4,000 communities (including Community Health Centers (CHCs), public health dept., hospitals, and CBOs)

-Grants awards made to public or non-profit organizations and limited number of states/local governments

Target Population
  • Primarily low-income pre-schoolers, ages 3 to 5
  • At least 90% of children must meet low-income guidelines, except for programs operated by Indian tribes
  • Not less than 10% of enrollment shall be available to children with disabilities
  • Low-income and needy individuals, including low-income families with children meeting TANF eligibility, SSI recipients, infants born to Medicaid-eligible women, low-income children and pregnant women, recipients of adoption assistance and foster care, and certain Medicare beneficiaries.
  • States have some discretion on which groups the program will cover and financial criteria for eligibility (i.e., mandatory versus categorically needy groups
  • Grants primarily focused on individuals who abuse alcohol & other drugs
  • Several additional targets: not less than 20% of grants are to be spent to educate and counsel individuals not requiring treatment and for activities to reduce risk of abuse; not less than 5 percent of grants are to be spent on services to pregnant women & women with dependent children
  • Low-income and needy individuals, especially those unable to obtain medical care and treatment for substance abuse problems
  • Includes underserved and vulnerable populations, such as underinsured, underserved, low income, women and children, homeless persons, migrant farm workers, and people living in frontier and rural areas
Estimate of Number of Individuals Served 912,345 Children (FY 2002) 39 million (Estimated Enrollees, FY 2002) 1.6 Million (FY 2000) 10.3 million (FY 2001)
Key Program Goals
  • Increase the school readiness and social competence of young children in low-income families. Social competence includes social, emotional, cognitive, and physical development.
  • Provide financial assistance to states for payments of medical assistance on behalf of mandatory and categorically eligible needy individuals
  • Improve the health care status of low-income and needy adults and children
  • Provide financial assistance to states/territories to support projects for alcohol and drug abuse prevention, treatment, and rehabilitation
  • Projects aim to prevent/ reduce alcohol and other drug abuse and dependence
  • Increase access to primary and preventive care and improve the health status of underserved and vulnerable populations
  • Develop/support systems and providers of high quality, community-based, culturally competent care
Main Program Services
  • Head Start Bureau provides grants to organizations to establish and operate Head Start Centers
  • Head Start grantee and delegate agencies provide a range of individualized services in the areas of education and early childhood development, medical, dental, and mental health, nutrition, and parent involvement. Services are responsive and appropriate to each child/familys developmental, ethnic, cultural, and linguistic heritage and experience.
  • Head Start also engages parents in role as the primary educators and nurturers/advocates for their children
  • Medicaid is medical/health insurance program that pays providers on fee-for-services basis or through various prepayment arrangements (e.g., HMOs)
  • Types of services covered vary from state-to-state; generally states must cover:
  • in- and out-patient hospital services, prenatal care, vaccines for children, physician services, nursing facility services, family planning services /supplies, rural health clinic services, home health care (for persons over age 21), laboratory and x-ray services, pediatric and family nurse practitioner services, nurse-midwife services, federally-qualified health center services, and EPSDT services (for persons under age 21)
  • States may also cover optional services, such as dental care, eyeglasses, and prescription drugs
  • SAPT seeks to support development and implementation of prevention, treatment, and rehabilitation activities directed to diseases of alcohol and drug abuse, including: (1) comprehensive prevention programs directed at at-risk individuals not in need of treatment; (2) interim services or interim substance abuse services to reduce adverse health effects of abuse prior to admittance to substance abuse treatment; (3) early intervention services related to HIV; and (4) services for pregnant women and women with dependent children
  • Generally, no expenditures allowed for inpatient hospital substance abuse treatment
  • Health Centers Cluster includes following programs: Community Health Centers, Migrant Health Centers, HCH, Outreach and Primary Health Services for Homeless Children, and Public Housing Primary Care Programs
  • CHC accounts for ~3/4 of Clusters expenditures
  • Health Centers Cluster emphasizes multi-disciplinary approach to delivery of care to needy individuals, combining street outreach with integrated systems of primary care, mental health and substance abuse services, case management, and client advocacy

Despite some differences, there are commonalities in terms of program goals and services offered by mainstream and homeless-serving programs. Three of the four mainstream programs (Medicaid, SAPT, the Health Centers Cluster) focus program services primarily on improving health care status of low-income individuals through provision of treatment and preventative care. Two of the programs  Medicaid and the Health Centers Cluster  are aimed directly at delivery of health care services to improve health care status of low-income and needy individuals. Though more narrowly targeted on homeless individuals, HCH and PATH are similarly aimed at improving health care status of the disadvantaged individuals. The third mainstream program  SAPT aims at improving substance abuse treatment and prevention services. Under SAPT, block grants funds are distributed to states, territories, and tribes aimed at the development and implementation of prevention, treatment, and rehabilitation activities directed to diseases of alcohol and drug abuse. Program services sponsored under SAPT (i.e., the treatment services) are perhaps most similar to the Treatment for Homeless Persons and PATH programs (though PATH has additional focus on provision of mental health services).

In terms of program goals and services, the fourth mainstream program  Head Start  is quite different from the three other mainstream programs and the four homeless-serving programs. The Head Start program is aimed principally at increasing school readiness and social competence of young children in low-income families. The program promotes school readiness by enhancing the social and cognitive development of children through the provision educational, health, nutritional, social, and other services. Head Start also engages parents in their children's learning and assists parents in making progress toward their educational, literacy, and employment goals.(18)

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