3-31-09, 10:31 am

It was the passage of the landmark Economic Opportunity Act of 1964, the same year that Medicare and Medicaid were enacted, that marked the birth of America's Community Health Centers (also known as Federally Qualified Health Centers). However, there was a lot of political pressure during the 1960s and 1970s to enact more fundamental health system reform. President Nixon, during the early 1970s, viewed community health centers as a way of heading off fundamental reform, and gave them a boost during his administration. In 1975, Congress permanently authorized neighborhood health centers as 'community and migrant health centers,' and in later years added primary health care programs for residents of public housing and the homeless to the portfolio of programs. The Health Centers Consolidation Act of 1996 combined these into the current system

The Irony

The irony is that over the decades the community health centers have grown to play an increasingly important role in the health care safety net precisely because the for-profit forces in the health industry have strengthened their stranglehold on the provision of health care. Nevertheless, the extraordinary precedent of service to all, efficiency, and quality set by the national network of nonprofit community health centers demonstrates the potential of community-governed clinics on the one hand, and the abject failure of the for-profit health care sector on the other. The centers put health care before profits.

Community Health Centers (CHCs) are non-profit, community-directed health care providers serving low income and medically under-served communities across the United States. For over four decades this national network of health centers has provided high-quality, affordable primary and preventive care, as well as dental, mental health, substance abuse, and pharmacy services. CHCs are located in areas where care is needed but scarce, and improve access to care for millions of Americans regardless of their insurance status or ability to pay. Their administrative costs of care rank among the lowest. Currently, around 1,200 health centers deliver care through over 6,600 service delivery sites in every state and territory.

Safety Net for Millions

Health centers currently serve as the medical and health care home for 18 million people nationally, but that number is growing rapidly and is anticipated to grow even more rapidly as mass lay-offs increase across the United States due to the capitalist crisis. Health center patients are among the nation's most vulnerable populations. These are people who, even if insured, remain isolated from medical care because of where they live, the language they speak, and/or their complex health care needs.

Over 70 percent of community health center patients have family incomes at or below the poverty level. Patients also tend to be members of racial and ethnic minority groups. In addition, 39 percent of health center patients are uninsured and another 35 percent are on Medicaid. About half of community health center patients live in rural areas, and half tend to live in economically depressed inner city communities.

Nonprofit and Community Governed

Community Health Centers are required by law to be nonprofits. CHCs and most not-for-profit hospitals have to meet requirements that for-profit health care providers do not. This makes CHCs much more responsive to the working families that need their care, as compared to for-profit health care providers whose main interest is in maximizing profits.

Community Health Centers:

* are located in areas identified by the federal government as having high levels of poverty, higher than average infant mortality, and few primary health care providers;

* see all residents, regardless of whether they have health insurance, and provide free or reduced-cost care based on ability to pay;

* offer important related services such as transportation, translation, case management, health education, and home visits;

* provide services in a linguistically and culturally appropriate setting. For example, nearly a third of all patients are served in languages other than English.

For many patients the health center may be the only source of health care services available. The number of uninsured patients at health centers – who are typically refused health care by for-profit providers – has grown from 3.9 million in 1998 to 7 million today. The centers are also valuable to Medicare recipients; they provide care where physicians refuse to see Medicare patients

Community health center federal regulations require that governing boards include a majority of local patients. Board members directly represent the community served by the clinic, and make decisions on the services provided. This assures responsiveness to local needs in a way that for-profit health care providers are incapable of doing. This also applies to most not-for-profit hospitals. As a result, community health centers provide an unparalleled level of care in the community.

Quality Health Care

For example, CHCs provide preventive services to low-income working families that would otherwise not have access to services such as immunizations, health education, mammograms, pap smears, and other screenings. In addition, studies have found that the quality of care provided at health centers is typically equal to or greater than the quality of care provided elsewhere, and, in stark contrast to people that rely on for-profit health care, disparities in health status do not exist among Community Health Center patients, even after factoring in socio-demographic factors.

Community Health Centers meet or exceed nationally accepted practice standards for treatment of chronic conditions, according to the National Institutes of Medicine and the Government Accountability Office. The community centers are nationally-recognized models when it comes to screening, diagnosing, and managing chronic conditions such as diabetes, cardiovascular disease, asthma, depression, cancer, and HIV.

Communities served by Community Health Centers have infant mortality rates at least 10 percent lower than comparable communities not served by CHCs. Lower-income women who use community health centers have lower rates of low-birth-weight babies compared to all such mothers.

Cost Effective Care and an Economic Boost to Neighborhoods

Care received at health centers is considered among the most cost-effective. For example, several studies have found that the health centers save the Medicaid program around 30 percent in annual spending for health center Medicaid beneficiaries. Furthermore, health centers generate savings for the entire health care system of up $17.6 billion a year. These savings are the result of less use of more costly specialty, inpatient, and emergency room care.

Community Health Centers also bring critical economic benefits to the low-income communities they serve. They produce 143,000 jobs in some of the country's most economically deprived neighborhoods, and have an overall economic impact of nearly $13 billion in those communities.

Despite the fact that Community Health Centers are required by the federal government to serve those who cannot afford health care, on average CHCs receive only 26 percent of their total revenue from federal grants. The largest single source of revenue is Medicaid, representing 36 percent of total revenue. About 13 percent of their revenue comes from state and local funds. Much of the rest comes from private insurance or cash paid by patients.

Looking Down the Road

President Obama signed the Children's Health Insurance Program Re-authorization Act (CHIPRA) 2009 into law on February 4, 2009. The legislation creates a revised payment system for SCHIP patients that allows health centers to provide and expand primary care services to more SCHIP beneficiaries, while ensuring some financial stability for community health centers. This is critically important to the CHCs, since they provide a source of health care and family doctors to nearly 6.5 million children, nearly 400,000 of whom are enrolled in state CHIPs.

The bill also overturns a 5-year ban on eligibility for children who are legal immigrants, and it directs the HHS Secretary to develop a model process for interstate coordination of Medicaid/CHIP enrollment and coverage of eligible individuals such as farmworkers and disaster evacuees, who move from state to state. Moreover, the Obama administration's economic recovery act contained about $1.5 billion specifically earmarked for community health centers, and so far more than $300 million has been released to help fund them over the past month alone.

Thousands of non-profit Community Health Centers are distributed all over the United States. They are governed by people who live in the communities they serve. CHCs are organized by region and nationally. They provide high quality cost-effective health care to millions of Americans. There are no exorbitant salaries or golden parachutes for staff or administrators. The CHCs are a useful example for the bloated not-for-profit hospitals and academic medical centers across the U.S. In the Community Health Centers, patients may be denied or delayed only because of the growing number of patients and the concomitant shortage of resources in the centers. However, no patient is ever denied care in order to maximize profits.

This is a period of tremendous potential for fundamental reform in the organization of health care in the United States. The for-profit health insurance industry is far more efficient at denying health care rather than providing access to it, and for-profit health care providers have excluded tens of millions of residents in the United States from adequate health care. Introducing tough Federal regulations on other health care not-for-profits could help merge them into the existing system of public hospitals and Community Health Centers, which could, in turn, lead to a national health care system

It is time to evaluate the national structure of Community Health Centers as a key element in fundamental health care reform and also as a valuable component in creating a national health service.

--David Lawrence is the co-health editor of Political Affairs.