National Association of Counties
Washington, D.C.


 Brooks negotiates new rules to define medical under-service; billions at stake

By Paul V. Beddoe


Roy C. Brooks
Tarrant County, Texas

Tarrant County, Texas Commissioner Roy C. Brooks has been appointed by Health and Human Services Secretary Kathleen Sebelius to serve on a negotiated rulemaking committee, chartered to develop a new system for designating medically underserved areas (MUAs), medically underserved populations (MUPs) and health professional shortage areas (HPSAs) for the Health Resources and Services Administration (HRSA).

The 28 members of the committee represent a broad range of stakeholders including state primary care offices, state offices of rural health, organizations representing federally qualified health centers (FQHC), rural health centers and other health care providers and others representing minority communities and people with disabilities.

Section 5602 of the new health reform law, the Patient Protection and Affordable Care Act (P.L. 111-148), directed HHS to use this rarely used regulatory process because two previous attempts to update HRSA’s designation of MUAs, MUPs and HPSAs in 1998 and in 2008 had been scuttled by the widespread dissatisfaction of the stakeholders. Some of the criteria used to assign designations include population-to-provider ratios, percent of population below poverty level, infant mortality rates and ability to pay for health services.

MUA and MUP designation is required for HRSA community health center program grants and enhanced payments. HPSA designation qualifies providers in an area for National Health Service Corps scholarship and loan repayment. One or more of these designations is used by several other federal programs with billions of dollars available if other requirements are met.

Brooks, who chairs NACo’s Health Steering Committee Subcommittee on Health Reform, is the only elected official appointed to the committee and the only representative of local government. In his opening statement at the organizational meeting in September, he explained the wide range of responsibilities that counties fulfill in America’s health system.

He also outlined NACo’s goals for the negotiations. Alluding to the famous Hippocratic oath, he asked that the committee "first, do no harm" to existing local safety-net systems, to the extent possible. He also suggested that the new designation system should maximize local-level decision making and use of available sub-county-level data, noting that some counties, like Tarrant County, may not be underserved at the county level but have pockets of severe under-service.

Finally he threw down a policy marker, declaring that this rulemaking would not be enough, and that NACo believes additional changes to the law are needed to allow county public health and hospital systems, including networks of clinics and behavioral health providers, to be reimbursed at the same rates as the FQHCs.

After the organizational session, the committee began substantive discussions at its Oct. 13–14 meeting, planning to meet monthly at least through April. If the committee can report to the secretary that it is on track to achieve consensus by April, it may continue to work up to July 1, 2011.

If the committee can reach consensus on a new designation system, the secretary will publish the designations immediately as an interim final rule. Interim final rules have the full force of law, but remain open to comment and possible change. Committee members have agreed that if consensus is reached neither they nor the organizations they represent would file adverse comments on the interim final rule.

Brooks and NACo staff welcome input from interested counties. For more information or to pass along your comments, contact Paul Beddoe, associate legislative director, at 202.942.4234 or