1. Presented by: Terry Glasscock, Senior Project Consultant, Capital Link Health Choice Network Of Florida June 2014 Capital Financing: Strategies and Tools For Success

2. In truth, there has never been a better time to initiate a capital project. Nor will there likely be a better time for years to come.

3. Window of Opportunity Lowest Interest rates Stagnated building costs Strategic Changes Ahead (Medicare and Medicaid) Government Financing Programs NMTC and FDA

4. #1. Interest Rates

5. Interest Rates Fed Funds – 0% TE Bond -.25% Prime – 3.25% Inflation - 0% Rates TodayFive Years Ago Fed Funds – 3.00% TE Bond -4.5% Prime – 5.0% Inflation – 4% I’ll bet Five Years From Now???won’t see lower interest rates in your life time

6. #2. Building Costs

7. Building Costs Inflation rate – 1% Construction bids – at or under budget Building Costs

8. #3. Strategic Changes Ahead

9.  1900 – 3% GDP (Gross Domestic Product).  1964 – 6% GDP.  1994 – 15% GDP.  2020 – 25% GDP.  Per person expenditure for healthcare:  1965 - $205  2000 - $4637  2010 - $8233 Healthcare Costs Office of Economic and Cooperative Development

10. Social Security, Medicare & Medicaid Outlays as a Percentage of GDP 1990-2075 Source: C. Eugene Steurle and Adam Carasso, (Budget Crisis at the Door), The Urban Institute, 2003. Based on data from the Congressional Budget Office, “A 125Year Picture of the Federal Government’s Share of the Economy, 1950- 2075,” July 3, 2002, table 2.

11. Influences: Federal Receipts vs Entitlement Spending Source: C. Eugene Steurle and Adam Carasso, (Budget Crisis at the Door), The Urban Institute, 2003 Based on data from Budget of the U.S. Government, FY 2004 and CBO’s “Analysis of the President’s Budget, FY 2004.” (As percent of GDP)

12. Federal Government Spending Medicaid Medicare S.S. 43% Medicaid Medicare S.S. 20%

13. Congress’ own Commission on Entitlement Reform reported that SS, Medicare, Medicaid and interest on the national debt will exceed all federal income by 2030

14. Entitlement programs cannot be sustained at current levels! Medicaid, Medicare, S.S. Will be altered! The Window of Opportunity Will Close.

15. So, How Can I Do This?  Business Plan  Financial Forecasting  Funding Considerations  Financing Options

16. Business Plan and Financial Forecast Critical!

17. Components of a Business Plan CHC description and background Market analysis and Growth potential Organizational experience and structure Project Details Financial history and forecast

18. Business Plan: Financial Section  Financial Feasibility  Historical Performance (three years audited)  5-7 year Forecast  Project budget  Sources and Uses  Financing Structure

19. Modeling the Impact of Your Capital investment Project  How will the project enhance your ability to be financially successful over the long- term?  Increased Volumes  Higher cost reimbursement  Higher profile/fundraising  Improved recruitment/retention/ productivity

25. Sources & Uses Of Project Funds

27. Health Center Cash Reserves Federal Government: ACA, CDBG, EDA, USDA, OCS, NMTC State/Local Government Grants/Appropriations Foundation Grants— Private or Corporate Hospital or Other Partners Community Capital Campaigns In-Kind Gifts, e.g. Donated Land/Equipment, $1.00/Year Lease for 99 years Equity/ Grant Funding

28. Financing Components TE Bonds Bank Loan HRSA LGP USDA 28 Fed Grant CCHN Ventures Loan Foundation State Funds NMTC Grants/Gifts

29. Combining the Best Financing Sources Structure considerations mean big financial differences!

30. Let’s assume a $10,000,000 project.

31. Conventional Bank Loan

32. Conventional Bank Loan Loan 80% of project value - $8,000,000 Interest rate 6.5% with 25 year amortization Where will the remaining $2,000,000 come from? – Sale of existing building? – Hospital contribution? – State? – Capital Campaign? – Government grant

33. Conventional Bank Loan Sources of Funds: Bank Loan…….$8,000,000 Other……….….$2,000,000 Total……………$10,000,000 Annual Debt Service (P&I)…..$ 655,032

34. New Markets Tax Credits

35. NMTC Magic!

36. NMTC Hypothetical CHC Project Assumes $10 million in Project Costs Equity Investor CDE LLC Equity investment ~ $3 million Eligible CHC or “Special Purpose Entity” established by CHC Fees & Reserves ~$1 million NMTC Fund LLC $11 million investment into CDE $10 million in loans Bank or TE Bond Debt “A Loan”: $8 million “B Loan”: $2 million $8 million Leverage Loan $4.29 million in tax credits (39% over 7 years) Lender Weighted Average Cost of Capital ~ 5.2% in current market; ~$520,000 interest-only for 7 yrs; refi $8 million after 7 years Tax credits & distributions to pay Leverage Lender Loan payments

37. New Markets Tax Credits “Investment” that isn’t repaid 20% of total project cost Finding a Community Development Entity (CDE) Application and awards 37

38. Bank Loan and NMTC NMTC investment approximately 20% of project cost Bank loan for the balance - $8,000,000 interest only for 7 years – same rate $2,000,000 in “free” money!

39. Bank Loan: NMTC – Interest Only Sources of Funds: Bank Loan……..$8,000,000 NMTC….……….$2,000,000 Total…………….$10,000,000 Annual Debt Service………….$ 520,000

40. USDA Usable with other options Population 20,000 or under Loan guarantee 90% Direct Loan 3.5% for 40 years 40

41. USDA Direct Loan Structure Loan will be 80% of project Cost - $8,000,000. Roughly 3.5% interest rate with 40 year amortization. Where will the remaining $2,000,000 come from?

42. USDA Direct Loan Sources of Funds: USDA Loan……..$ 8,000,000 Other…………….$ 2,000,000 Total……………...$10,000,000 Annual Debt Service………..$ 371,982

43. Tax Exempt Bonds With other options NMTC State issuing authority Private Purchase by Bank 43

44. Tax Exempt Bonds and NMTC NMTC investment approximately 20% of project cost - $2,000,000 TE Bonds for the balance - $8,000,000 interest only for 7 years Interest rate – 3.9% (fixed 10 years) No need for additional financing

45. TE Bond: NMTC Sources of Funds: TE Bonds…..…..$ 8,000,000 NMTC….……….$ 2,000,000 Total………….….$10,000,000 Annual Debt Service…………..$ 312,000

46. Foundation PRI Program Related Investment With NMTC HRSA LG Private Purchase (Non-profit Foundations) 46

47. Foundation and NMTC NMTC investment approximately 20% of project cost - $2,000,000 80% federal guarantee No need for additional financing Loan for the balance - $8,000,000 interest only for 7 years Interest rate – 3.0%

48. Foundation: HRSA LG and NMTC Sources of Funds: Tax Bonds……...$ 8,000,000 NMTC….……….$ 2,000,000 Total……………..$10,000,000 Annual Debt Service………..$ 240,000

49. Project Feasibility Analysis Paid for by HRSA Will analyze using the examples shown above with your financial and project information Will show how much you can comfortably borrow under each scenario. What we will need from you: – Description of the project – 3 years of audits – Price of project – Street address of site Business and Market analysis loans also available through CCHN Ventures.

50. Terry Glasscock tglasscock@caplink.org Terry Glasscock tglasscock@caplink.org