Updated Unmet Need Score (UNS) Frequently Asked Questions (FAQs)

Below are common questions and corresponding answers related to the updated Unmet Need Score (UNS) or UNS 2.0. For detailed information on the Service Area Needs Assessment Methodology (SANAM) and UNS 2.0, please see the Unmet Need Score and Service Area Status Resource Guide (PDF - 561 KB).

Questions

Does HRSA plan to use the UNS 2.0 outside of New Access Point funding competitions?

HRSA conducted a stakeholder webinar (PDF - 660 KB) on UNS 2.0 in September 2020 and has considered feedback received since then. We do not currently have an open New Access Point (NAP) competition in which to implement UNS 2.0, but in the event we receive funding for new access points, we will use this version of the UNS to support the Need section of the NAP funding opportunity. We do not currently have plans to use the UNS 2.0 outside of NAP funding opportunities.

Are there updates to the data sources in the UNS 2.0 since the September 2020 webinar?

Yes. In December 2020, following our UNS 2.0 webinar (PDF - 660 KB), the U.S. Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation released the PLACES Project data, which provide small area estimates for some health measures. Data for seven measures (Dental Visit in Past Year (previously, No Dentist in Past Year), Cervical Cancer Screening (previously, Pap Smear Screening), Asthma, Diabetes, Poor Mental Health, Poor Physical Health (previously, Poor or Fair Health), Obesity, and Smoking) were previously obtained from the Behavioral Risk Factor and Surveillance Survey (BRFSS), County Health Rankings Exit Disclaimer (CHR), and UDS Mapper Exit Disclaimer. Simple extrapolations were then performed on the data from BRFSS and CHR to obtain ZIP Code-level estimates. These data are now being obtained from the PLACES Project because it provides estimates for smaller geographic units than the BRFSS and CHR do and eliminates the need for extrapolation.

The Unintentional Injury Mortality measure that was included in UNS 1.0 was removed in UNS 2.0. How are injuries that typically fall under unintentional injury mortality captured in UNS 2.0?

Mortality due to unintentional injuries will continue to be captured in UNS 2.0 as part of the All-cause Mortality measure, as well as the Estimated Drug Poisoning measure.

How does HRSA define the Estimated Drug Poisoning Mortality measure? Does it align with CDC’s definition of poisoning mortality?

Estimated Drug Poisoning Mortality is the estimated number of all drug poisoning deaths per 100,000 population. The definition and primary data are from the CDC’s National Vital Statistics System (NVSS). We considered this measure for UNS 1.0, but at that time there was a lack of available data in many areas of the United States. The CDC has since developed new estimates that address the data limitations.

Why did HRSA add the Limited Access to Healthy Foods measure and does it include data on food insecurity?

HRSA examined four possible measures to address food insecurity: Food Deserts (U.S. Department of Agriculture (USDA)); Limited Access to Healthy Foods (USDA); Food Insecurity (Map the Meal Gap); and Food Environment Index (County Health Rankings).

HRSA selected USDA’s Limited Access to Healthy Foods measure (defined as % of population that are low-income [below 200% FPL] AND do not live close [more than 10 miles for rural and 1 mile for non-rural] to a grocery store [convenience stores are not counted]) based on its availability at a more granular geographic level (i.e., census tract), because it addresses accessibility and affordability, and captures the neighborhood and built environment.

Why did HRSA replace Physical Inactivity with Adult Obesity?

We replaced Physical Inactivity with Adult Obesity because obesity is a better predictor of area-level burden of illness than Physical Inactivity. Obesity is also a better predictor of health service utilization and a top cause of morbidity and mortality in the United States. Our goal is to keep the UNS to a reasonable number of measures and to include measures that provide new information and that do not highly correlate with each other.

What are the new measures “Nonwhite Concentration Index” and “Foreign-born Concentration Index” and why are they included in UNS 2.0?

The Nonwhite Concentration Index uses a validated method Exit Disclaimer that compares the concentration difference between low-income nonwhite populations and high-income white populations within a ZIP Code. The Foreign-born Concentration Index compares the concentration difference between low-income foreign-born and high income native-born within a ZIP Code. Disparities in access to health services and health care utilization have been attributed to stigmatization, fear of deportation, absence of culturally sensitive care and health information, and difficulty navigating complex health insurance systems. The inclusion of these measures along with the other 26 measures will further support the ability of the UNS to identify unmet need for primary and preventive health care services.

Why did HRSA not adjust for state differences in cost of living in the Foreign-born Concentration and Nonwhite Concentration Index measures?

The UNS is a tool designed to aid decision-making for the national Health Center Program, so it includes a set of measures to allow for consistent comparisons of current and potential health center service areas across the nation. The UNS 2.0 continues to include the Housing Stress measure that provides a proxy for cost of living through relative housing costs.

Why does the UNS continue to emphasize uninsured populations and not account for Medicaid populations?

The Health Center Program has a statutory mandate to serve medically underserved populations, for which the Uninsured measure is a critical component. Health Center Program grant dollars are meant to fill the gap between what it costs to provide care and other revenues, including Medicaid. Therefore, HRSA continues to weigh the Uninsured measure as one of the highest weighted measures to consistently assess this need across the nation.

Why did HRSA select the Broadband Access measure?

We believe the Broadband Access measure is the best available measure to capture those areas where a lack of broadband access may signal a greater need for an in-person service delivery site.

We considered digital literacy and access to cell phones/computers/devices along with broadband access to capture barriers to accessing telehealth services. There were no nationally available data on digital literacy rates, and many factors that are associated with lower digital literacy skills are included in the current measure sets (e.g., education level). Additionally, we considered access to cell phones/computers/devices, but were concerned that a device access measure would over-estimate availability among populations who might have a device but lack consistent internet service in order to reliably connect to telehealth services. Another factor in the decision to include only Broadband Access was the goal to keep the set of measures to a reasonable number.

For broadband availability, we considered two other measures—Broadband Availability (Federal Communications Commission) and Broadband Usage (Microsoft Airband)—before choosing Broadband Access from the American Community Survey) because of its availability at the ZIP Code-level versus county level data for the other two measures.

Why is the UNS calculated for ZIP Codes and not census tracts?

The Health Center Program defines health center service areas by ZIP Code, so the UNS is designed at the ZIP Code level to ensure consistency with service areas. We did examine the differences between UNS values calculated for ZIP Codes and UNS values calculated for census tracts. For the ZIP Codes that have been proposed in recent NAP funding opportunities, ZIP Code and census tract scores tended to be similar. In addition, most ZIP Code scores overall are similar to the scores of overlapping census tracts.

How does SANAM/UNS provide a greater understanding of need than what is available from the UDS Mapper?

UDS Mapper provides data on health centers, including the number of health center patients served in each ZIP Code. It also provides population demographic measures including poverty, race, and health insurance coverage. The UDS Mapper is an important data source for the UNS, but it does not provide data for a number of access measures (e.g., Preventable Hospital Stays, Housing Stress), non-access measures (e.g., Violent Crime, Limited Access to Healthy Foods), and direct health status measures (e.g., Poor Mental Health and Physical Health) that are included in the UNS and important to assessing both health and access to health services in a community.

Date Last Reviewed:  September 2021