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The Hill-Burton
Free Care Program
In 1946, Congress passed P.L.
79-725, the Hospital Survey and Construction Act, sponsored by Senators
Lister Hill and Harold Burton, widely known as the Hill-Burton Act. It
was the Nation's major health facility construction program under Title
VI of the Public Health Service Act. Originally designed to provide Federal
grants to modernize hospitals which had become obsolete due to lack of
capital investment throughout the period of the Great Depression and World
War II (1929 to 1945), the program has changed over time to address other
types of infrastructure needs. Since 1946, more than $4.6 billion in Hill-Burton
grant funds as well as $1.5 billion in loans have aided nearly 6,800 health
care facilities in over 4,000 communities. In return for Federal funds,
facilities agreed to provide free or reduced charge medical services to
persons unable to pay. In 1970, direct loans and loan guarantees with
interest subsidies to facilities were authorized, and in 1972, a 20-year
limit on the provision of uncompensated services and specific requirements
for providing uncompensated services were initiated.
In 1975, Congress enacted
Title XVI of the Public Health Service Act, an amendment to the Hill-Burton
Program which established Federal grants, loan guarantees and interest
subsidies for health facilities. Facilities assisted under Title XVI must
provide uncompensated services in perpetuity. Title XVI transferred the
enforcement responsibilities from States to the Federal government, and
required more stringent investigation, monitoring and compliance standards.
The Act also empowered the Government to recover
grant funds in certain situations when the facility is sold, transferred
to an ineligible entity, or ceases to be used for an eligible purpose
within the 20-year obligation period. In 1979, regulations established
compliance levels (adjusted by the change in the Consumer
Price Index (CPI) for medical care) eligibility (based solely on the
Federal Poverty Guidelines), record
maintenance, and reporting requirements.
In the 1980s, a substantial
compliance review process was initiated to more quickly identify and certify
credit to facilities operating compliant programs, having no or only minor
technical violations. This procedure permitted limited staff resources
to be concentrated on those facilities operating noncompliant programs.
Also, compliance
alternatives were established for: publicly or quasi-publicly owned
and operated facilities, the Public Facility Compliance Alternative (PFCA);
facilities with annual compliance levels of not more than $10,000, the
Small Annual Obligation Compliance Alternative (SAOCA); and federally
supported health centers, the Community Health Centers , Migrant Health
Centers and certain National Health Service Corps Sites Compliance Alternative.
The Charitable Facility Compliance Alternative (CFCA) was added in the
mid-1990s for facilities which are supported by state, local and philanthropic
contributions. Procedural and reporting requirements are reduced for facilities
which qualify under an alternative. Also in the mid-1990s, nursing homes
were permitted to increase the Hill-Burton income-eligibility limits to
three times the Federal poverty guidelines.
The Division provides technical
assistance to obligated facilities; and provides information to the public
through the Directory
of Obligated Facilities, the Hill-Burton
Hotline, and other means.
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