Having worked with Community Health Centers as a major part of my day job for the past 16 years, I would like to follow-up on Joan’s front page article Republican budget would end community health center funding.
As Joan notes, expansion of Community Health Centers (CHCs) is a major part of PPACA, so it might seem that these called for cuts by Republicans is just partisan business as usual. But in fact it is quite startling when put into historical context.
Even though they started as lefty idea, were implemented as part of LBJ’s Great Society programs, and were originally out of the Office of Economic Opportunity, CHCs have from the beginning and down through the George W. Bush administration had strong bipartisan support. Indeed one of the few compassionate parts of Bush's original campaign 2000 "compassionate conservatism" that was ever implemented (more or less for real) was a doubling of the number of CHC sites!
Below is more of the CHC story:
The underlying problems Community Health Centers (CHCs) are meant to address are as follows:
1. If you do not have health insurance then a visit to the doctor or dentist, for you or your family or kids, may be too expensive to pay out of pocket.
2. Even if you have health insurance, especially if you have public health insurance such as Medicare and especially if you have Medicaid, there may not be any doctors (and especially few dentists) who take it as payment in full.
3. Indeed, and perhaps most importantly to the CHC story, if you live in the poor parts of the inner city, or in any rural areas, there may not be any doctors at all. These so called Health Professional Shortage Areas, Medically Underserved Areas and Medically Underserved Populations are what CHCs serve. If there is no health care provider, no health care facility near where you live, then even if you have insurance you do not have access. As I have pointed out before, UnderServed is still a bigger problem than OverTreated.
Although there are of course exceptions, doctors and other health professionals tend disproportionately, to not want to live in rural or frontier areas. It turns out that as bad as access can be in poor inner cities, it is if anything even more problematic in rural areas. From the beginning, the CHCs have always been cleverly divided approximately half-and-half in urban and rural areas. If the only health care provider in your district is a CHC, then you tend to be in favor of that program, even if you are otherwise an "anti-big-guvmint" Republican.
And, so, despite part of their image being clinics for urban poor people of color, in fact CHCs have always served a truly diverse population, and have always (until now I guess) had pretty strong bipartisan support.
CHCs must be located in one of those shortage areas. They are also required to take all public insurance (Medicare, Medicaid, CHIP, etc.) as payment in full. And they are required to take the uninsured on an income based sliding fee scale.
It should also be noted that CHCs are actually independent non-profit community based organizations. They are NOT government entities. The must have a board of directors from the local community, at least half of whom use the CHC as their own place of care. The board hires an executive director, who in turn is in charge of the CHC, hiring the medical director and other staff. The physicians are not in charge. Indeed the physicians and other clinicians are salaried, typically with a base salary and a bonus based on both productivity and quality. CHCs are to a great extent what HMOs were originally (back in the 1970s) supposed to be, and what are now being talked about in terms of Accountable Care Organizations and Patient Centered Medical Homes.
Although most of the staff are long-term, the CHC program does work in partnership with the one of HRSA's other programs the National Health Service Corps (which is also expanded under the last years ARRA stimulus, and is supposed to expanding with PPACA). Over half of NHSC clinicians work at CHCs. And over half of them stay on after their payback service is done.
In essence, there are two types of the federal grants for the CHC:
1. There is a starter upper grant for new programs or expansion of a program to make new site.
2. There is the ongoing annual grant, which actually amounts to anywhere from as little as 15 to rarely more than 40% of the annual budget. The main purpose of the grants is to offset the fact that these sites are required to see all persons even those without health insurance. Those who are self-pay without insurance, may pay a sliding fee scale based on their income. It used to be a sliding fee scale went down to zero, but in recent years there is supposed to be a minimal fee, typically $20 or $30 per visit, which covers everything including all procedures and lab tests at that visit.
These are longtime stable entities. They differ from many of the "free clinics" in that they are providing reliable, high quality (lost of monitoring), ongoing (and emergency) care, day-in and day-out, year-in and year-out. They have regular hours. They have extended hours including evenings and weekends. They provide whole range of "wrap-around" social services in addition to having primary care doctors and dentists, some specialty care, often podiatry and optometry, and of course mental health care.
In addition to the main program of general primary care health centers, there are also separate special population subprograms that fund the Migrant Health Centers, Health Care for the Homeless Program, School-based health programs, and health care in Public Housing.
As data from the Health Resources and Services Administration , the agency within HHS that administers the Health Center program, in 2009, the health center program made the following impact:
1,131 grantee organizations with over 7,000 sites - half of which are located in rural areas.
Served 18.8 million unique patients, who made 74 million visits.
92% below 200% poverty
71% below 100% poverty
38% uninsured
1,018,000 homeless individuals
865,000 migrant/seasonal farmworkers
165,000 residents of public housing
Employed more than 123,000 staff
9,100 physicians
5,800 nurse practitioners, physicians assistants, and certified nurse midwives
Although this particular data analysis does not mention it, I should add that most of the health centers also have dentists.
As the National Association of Community Health Centers points out, CHCs save the national health care system between $9.9 billion and $17.6 billion a year by helping patients avoid emergency rooms and making better use of preventive services.
The quality of care provided by CHCs is on par or superior with that from regular private providers, and superior to that of other predominantly Medicaid providers. We know this from numerous academic peer-review published studies, comparison to ongoing external datasets such as the NCQA HEDIS program, and from internal program-based monitoring of clinical measures. There are a lot more quality improvement and quality assurance activities going on at the facilities then at your typical private doctor's office.
And I would be remiss if I did not provide you with the look-up tool to find a Health Center near you.
I wanted to get this up quickly in response to Joan’s FP piece, but am happy to answer questions in comments.