Following the Money: Do Block Grant Resources Reach Rural Communities?

The overarching goal of this project was to document the distribution of block grant resources from federal agencies through states to local communities, particularly rural communities. We worked closely with the Federal Office of Rural Health Policy (FORHP) to identify two or three block grant programs for inclusion. The project primarily consisted of two sets of analyses. First, we conducted a secondary data analysis to explore the distribution of block grant resources based on multiple dimensions of state-level rurality across all 50 states. We further examined the relationships between resource allocation and state-level structural and other community characteristics. State-level data from multiple sources were combined to create a national dataset for the analysis.

Key sources included:

• Documentation of funding amounts allocated to each state for selected block grant programs (2018, 2019)
• American Community Survey data (e.g., state-level data on indicators such as percentage of population below the poverty level)
• U.S. Census Bureau data on indicators such as state-level population estimate and population density
• Information on state public health governance structure and health agency structure from Association of State and Territorial Health Officials' 2019 Profile.

Additional secondary data was integrated as appropriate, such as state-level mortality data available through the National Vital Statistics System. Second, we conducted a case study analysis using quantitative and qualitative methods to explore the distribution of block grant resources from states to the local level, comparing distributions and allocation strategies between rural versus non-rural jurisdictions, in up to six states. We applied a data-driven approach to purposefully select states. For each selected state, we requested quantifiable information on the distribution of block grant funding from the state to local levels, comparing urban and rural distributions using Rural-Urban Community Area (RUCA) code definitions. These data were supplemented through structured interviews with key informants in each state. We combined the quantitative results and qualitative findings to generate a robust understanding of the dynamics of federal resource distribution in local communities.

We tested the hypotheses listed below, with analyses to include per capita funding as appropriate.

1. The amount of block grant resources allocated to states may differ by state-level rurality, public health governance structure (i.e., centralized/decentralized/mixed/shared), state health agency structure (i.e., freestanding or part of combined health and human services agency), and/or other community characteristics.
2. The amount of block grant resources allocated from states to local jurisdictions may differ by rurality, local public health governance, state health agency structure, and/or other community characteristics.
3. Block grant resources will be allocated disproportionately to non-rural communities.
4. The allocation of block grant resources to local communities will vary by the total amount of block grant resources allocated to states, with smaller block grants more likely to skew towards non-rural communities.

In addition to the secondary data analysis and case study analysis, we conducted a targeted and rigorous review of the Notice of Funding Opportunities (NOFOs; 2018, 2019) for block grant programs (2018, 2019). We worked closely with FORHP to select block grant programs for inclusion and secure copies of the NOFOs for review. Findings may guide the development of recommendations for how NOFOs could be improved to promote equitable distribution of block grant resources to rural populations.

Publications

• State Priorities and Needs: The Role of Block Grants
  Journal Article
  ETSU/NORC Rural Health Research Center
  Date: 11/2023
  This study looks at state-level funding allocations for 5 federal block grant programs from 2015-2019, and associations with state-level measures of need that align with the purposes of each block grant program.