The Hill-Burton Uncompensated Services Program

CRS Report for Congress
The Hill-Burton Uncompensated
Services Program
Barbara English
Information Research Specialist
Knowledge Services Group
The Hospital Survey and Construction Act of 1946 (P.L. 79-725), commonly
known as the Hill-Burton Act, was enacted to provide federal financial assistance for the
planning, construction, and improvement of health care facilities through grants, loans,
and guaranteed loans under Title VI and later Title XVI of the Public Health Service
Act. Since 1946, the Hill-Burton program has provided assistance to more than 6,900
hospitals and other health care facilities in more than 4,000 communities.
The original legislation stipulated that, in return for assistance, facilities were
required to provide free care for 20 years to eligible persons unable to pay for health
care services. Although there has not been any Title VI funding authority for the
program since FY1974, many facilities that received Hill-Burton funds continue to have
an obligation to provide a certain level of uncompensated care. Facilities funded under
Title XVI must provide uncompensated care in perpetuity.
This report provides information on the act, the obligations and eligibility
requirements for free care, and sources for further information. It will be updated
The Hospital Survey and Construction Act of 1946, known by the names of the
legislation’s initial sponsors, Senators Lister Hill of Alabama and Harold Burton of Ohio,
provided federal assistance for the construction and improvement of hospitals and related
facilities. The program was enacted in response to evidence of an extensive shortage of
hospital facilities around the country, particularly in rural areas, after a long period of
limited hospital construction during the Depression and World War II. It authorized the
states to inventory existing hospitals to assess needs for facilities that could furnish
“adequate hospital, clinic, and similar services to all their people” and then authorized
funds to assist states with the construction of public and nonprofit hospitals to meet these
needs. This included building new facilities and expanding, renovating, and otherwise
altering existing facilities. Later, the Hill-Burton authority was amended to include

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assistance for construction and modernization of nursing homes, rehabilitation facilities,
outpatient facilities, and public and nonprofit health centers.
The program provided for assistance through the Public Health Service Act under
Title VI (Assistance for Construction and Modernization of Hospitals and Other Medical
Facilities). After 1975, assistance was provided under Title XVI (Health Resources
Development). There were three types of aid available: (1) grants to construct or
modernize public or nonprofit health facilities; (2) loan guarantees to nonfederal lenders
on behalf of nonprofit health facilities; and (3) direct loans to public agencies constructing
or modernizing hospitals.
Free Medical Care Under the Hill-Burton Program
Provider Obligations. Health facilities that received grants, loans, or loan
guarantees under the Hill-Burton program have an obligation to provide an annual
minimum dollar volume of uncompensated care to eligible individuals who are unable to
pay for the care. This minimum dollar volume is equal to the lesser of (1) 10% of the
federal assistance they received, adjusted for inflation, or (2) 3% of their annual operating
costs, minus the amount of reimbursement they received from Medicare and Medicaid.
The length of time for which a facility is required to provide free care varies according to
the type of assistance received. Those facilities that received grants under Title VI must
provide the services for 20 years from the time the construction project was completed.
Facilities that received loans must provide the services until the loan is repaid. Those that
received grants under Title XVI must provide services in perpetuity.
A facility that provides more than the minimum required level of uncompensated
care in a year may have the excess credited toward future obligations; one that provides
less is required to make up the deficit in subsequent years, even if this extends their
obligation beyond 20 years. Federal funding for health care facility construction under
Title VI has not been appropriated since FY1974. However, many facilities that received
funds have not yet fulfilled their obligation to provide free care. This could be because
construction on a project was not completed until the 1980s, at which point the 20-year
obligation began, or a facility might be making up a deficit for care not provided
previously. Beginning in 1975, funds for facility construction were provided under Title
XVI. This assistance carried the same qualifying requirements as those under Title VI,
but extended the requirement for uncompensated care indefinitely. As of April 2006,
there were 284 Hill-Burton-obligated facilities. A listing of these facilities can be found
on the Department of Health and Human Services (HHS) website at
Each facility must determine the level of uncompensated services it must provide
annually and arrive at a plan to reach its annual obligation. The facility may decide which
services it will provide free of charge and may specify services it will provide at reduced1
cost. An allocation plan which specifies a description of the services and how they will
be allocated, the dollar amount of services to be provided, the criteria used in determining
eligibility, and an invitation to comment on the plan must be published by the facility in

1 Services not covered under the Hill-Burton program include private physician fees, pharmacy
fees, and Medicare deductibles and copayments.

a local newspaper. In addition, a written individual notice must be provided to anyone
seeking services at the facility. The notice must state the facility’s obligation to provide
free or reduced-cost care to individuals unable to pay, the eligibility criteria to be met,
where application for care must be made, and the time frame within which a written
determination will be provided to the applicant. Finally, posted notices in English and
Spanish (and other languages as necessary) must be conspicuously displayed in
appropriate areas of the facility stating that uncompensated services will be provided for
those who cannot pay.
Eligibility for Uncompensated Services. The federal poverty guidelines
published by HHS annually in the Federal Register are used as the basis for determining
eligibility for free or reduced-cost health care under the Hill-Burton program. Services
cannot be denied on the basis of race, creed, color, or national origin, regardless of
citizenship or residency status.2 Facilities must provide the services listed in their
allocation plans free to persons with incomes up to the guideline amounts (Category A).
Facilities have the option of offering free or reduced-cost services to persons with
incomes up to twice the guidelines (Category B) or, in the case of nursing homes, up to
three times the guidelines (Category C). Services that are fully covered by third-party
insurance or a governmental program are not eligible for Hill-Burton coverage.
2006 Poverty Guidelines. The poverty guidelines are published annually in the
Federal Register by HHS and are used as criteria for determining eligibility for a number
of federal programs, including the Hill-Burton program. The 2006 guidelines were
published on January 24, 2006 (71 Federal Register 3848), and went into effect for the
Hill-Burton program on March 25, 2006.
Table 1. 2006 Federal Poverty Guidelines
Size of Family UnitAll Other StatesAlaska Hawaii
1$ 9,800$12,250$11,270
2 13,200 16,500 15,180
3 16,600 20,750 19,090
4 20,000 25,000 23,000
5 23,400 29,250 26,910
6 26,800 33,500 30,820
7 30,200 37,750 34,730

8 33,600 42,000 38,640

2 An applicant must have lived in the United States for at least three months to be determined
eligible under the program.

Additional Information
Information on the Hill-Burton program, including a list of obligated facilities in a
state, can be obtained by phoning the Hill-Burton toll-free Hot Line at 1-800-638-0742
(Maryland residents phone 1-800-492-0359). Information is also available on HHS
website at [].
The program is administered by the Health Resources and Services Administration
(HRSA) within HHS. Individuals may contact the regional HRSA offices at the following
addresses and phone numbers.
HRSA Field Office/Cluster Contacts
Region 1: Boston, MA Region 2: New York
(Connecticut, Maine, Massachusetts,(New Jersey, New York, Puerto Rico,
New Hampshire, Rhode Island,U.S. Virgin Islands)
Ronald Moss, MPH
Gina CapraTelephone: 212-264-4498
Field Director
Telephone: 617-565-1420
Region 3: PhiladelphiaRegion 4: Atlanta
(Delaware, District of Columbia,(Alabama, Georgia, Florida, Kentucky,
Maryland, Pennsylvania, Virginia, WestMississippi, North Carolina, South
Virginia)Carolina, Tennessee)
Bruce RiegelKetty M. Gonzalez, MD
Telephone: 215-861-4411Telephone: 404-562-7972
Region 5: ChicagoRegion 6: Dallas, TX
(Illinois, Indiana, Michigan, Minnesota,(Arkansas, Louisiana, New Mexico,
Ohio, Wisconsin)Oklahoma, Texas)
Rick WilkShirley Henley
Telephone: 312-353-6835Telephone: 214-767-3872
Region 7: Kansas City, MORegion 8: Denver
(Iowa, Missouri, Nebraska, Kansas)(Colorado, Montana, North Dakota,
South Dakota, Utah, Wyoming)
Hollis HensleyAngela Powell
Telephone: 816-426-5226Telephone: 303-844-3203
Region 9: San FranciscoRegion 10: Seattle
(Arizona, California, Hawaii, Nevada)(Alaska, Idaho, Oregon, Washington)
Wayne SausedaSharrion Jones
Telephone: 415-437-8090Telephone: 206-615-2490