Community Health Centers In The United States - Community Health Center

The community health center (CHC) in the United States is the dominant model for federal grant funding for primary care in the country's health care safety net. The U.S. safety net consists of health care professionals willing to provide services to the nation’s uninsured and underserved population. According to the U.S. Census Bureau, 50.7 million people in the country (16.7% of the population) were uninsured in 2009. Many more Americans lack adequate coverage or access to health care. To receive health care services, this group of people must use providers who are either personally chosen or are legally required to provide care despite the patients being unabl e to pay. CHCs represent a provider group for this group.

CHCs are organized as non-profit clinical care providers that operate under comprehensive federal standards. The two types of clinics that meet CHC requirements are those that receive federal funding under Section 330 of the Public Health Service Act and those that meet all requirements applicable to federally funded health centers and are supported through state and local grants. Both types of CHCs are designated as “Federally Qualified Health Centers” (FQHCs), which grants them special payment rates under Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). To receive Section 330 grant funds, CHCs must meet the following qualifications:^[1][4]

• Be located in a federally designated medically under-served area (MUA) or serve medically under-served populations (MUP)
• Provide comprehensive primary care
• Adjust charges for health services on a sliding fee schedule according to patient income
• Be governed by a community board of which a majority of members are patients at the CHC

Uniquely in community health centers, at least 51% of all governing board members must be patients there. A sliding fee scale based on income is implemented to decrease the cost of care. The purpose of these stipulations is to ensure that health centers improve access to care and serve the community.

Integration of health care services is a major focus. Administrative and health care personnel meet regularly to focus on location health care needs. Services are provided that vary depending upon the site including primary care, dental care, counseling services, women's health, health promotion and education, podiatry, physiotherapy, case management, advocacy and intervention. The mission of community health centers depends on collaborative relationships with industry, government, hospitals and other health services.

Community health centers that receive federal funding through the Health Resources and Services Administration, HHS, are also called "Federally Qualified Health Centers." There are now more than 1,250 federally supported FQHCs with more than 8,000 service delivery sites. They are community health centers, migrant health centers, health care for the homeless centers, and public housing primary care centers that deliver primary and preventive health care to more than 20 million people in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin.

History

According to historian John Duffy, the concept of community health centers in the United States can be traced to infant milk stations in New York City in 1901. In November, 1914, the city established the first district health center in New York at 206 Madison Avenue, serving 35,000 residents of Manhattan's lower east side. The staff consisted of one medical inspector and three nurses stationed permanently in the district who, through a house card system, developed a complete health record of each family. In 1915, the system expanded, adding four district centers in Queens. Wartime and political pressures ended this development in New York City, but privately funded clinics through the New York Association for Improving the Condition of the Poor were started in 1916 (Bowling Green Neighborhood Association), 1917 (Columbus Hill Health Center), 1918 (Mulberry Street Health Center) and 1921 (Judson Health Center). Founded by Eleanor A. Campbell in Greenwich Village, the Judson Health Center became the largest health center in the U.S. by 1924.

The official establishment of community health centers was caused by the civil rights movement of the 1960s. The Office of Economic Opportunity (OEO) established what was initially called “neighborhood health centers” as a War on Poverty demonstration program.^[1] The aim of these clinics was to provide access points to health and social services to medically under-served and disenfranchised populations. The health centers were intended to serve as a mechanism for community empowerment. Accordingly, federal funds for the clinics went directly to nonprofit, community-level organizations. ^[1] The health centers were designed and run with extensive community involvement to ensure that they remained responsive to community needs.

Under the modern definition, the first community health center in the United States was the Columbia Point Health Center in Dorchester, Massachusetts, which opened in December 1965. The center was founded by two medical doctors - H. Jack Geiger, who had been on the faculty of Harvard University and later at Tufts University, and Count Gibson, also from Tufts University. Geiger had previously studied the first community health centers and the principles of community-oriented primary care with Sidney Kark and colleagues while serving as a medical student in rural Natal, South Africa. The federal government's Office of Economic Opportunity (OEO) funded the Columbia Point Health Center, which served the poor community living in the Columbia Point Public Housing Projects located on an isolated peninsula far away from Boston City Hospital. On its twenty-fifth anniversary in 1990, the center was rededicated as the Geiger-Gibson Community Health Center and is still in operation.^[11]

At about the same time, Geiger and Gibson also established a rural community health center, the Delta Health Center, in Mound Bayou, Bolivar County, Mississippi to serve the poverty-stricken counties of Bolivar, Coahoma, Sunflower, and Washington. This center was also set up in conjunction with Tufts University with a grant from the OEO. While the Columbia Point Health Center was set in an urban community, the Delta Health Center represented a rural model. The War on Poverty enlisted many idealistic men, such as Leon Kruger, the first Director of the CHC at Mound Bayou. As a result, many families such as his, were drafted in the War on Poverty, often at their own risk.

In the early 1970s, the health centers program was transferred to the Department of Health, Education, and Welfare (HEW). The HEW has since become the U.S. Department of Health and Human Services (HHS). Within HHS, the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC) currently administers the program.^[1]

Patients

Community health centers primarily provide health care to patients who are uninsured or covered by Medicaid. In 2007, almost 40% of all CHC patients lacked insurance, and 35% were Medicaid patients.^[4] Compared with patients who receive care from private providers, CHC patients are almost three times more likely to seek care for serious and chronic conditions. However, with the exception of those with private insurance, CHC patients are also more likely to meet referral obstacles than comparable patients treated by private physicians.^[3] Although they are able to provide comprehensive primary care, CHCs are limited in their ability to provide specialty care due to a lack of providers. The people affected most by this scarcity in services are the uninsured and Medicaid patients.^[4]

In 2008, 1,080 CHCs provided comprehensive primary care to more than 17.1 million people.^[3] CHC patients typically have low family incomes, live in medically under-served communities, and have complicated health conditions. 70% of CHC patients in 2007 had family incomes of no more than 100% of the federal poverty level; more than 90% of patients had family incomes at or below twice the poverty level.^[4] Health center patients are also ethnically diverse. In 2007, half of all CHC patients were minorities, a third of whom were Hispanic.^[4] All together, CHCs serve one in four low-income, minority residents.^[4] CHC patients are more likely to reside in rural areas relative to the rest of the population. They tend to be younger in age and are more likely to be female. In 2008, 36% of all CHC patients were children, and almost three in five patients were female.

Financing

Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations. The sources of funding for health centers have changed significantly over time. Public Health Service Act grants under Section 330 were once a prominent source of funding for CHCs. Although 330 grants remain important to the financial viability of health centers, federal reimbursement policy under Medicaid has become their largest source of revenue. In 2008, Public Health Service Act grants comprised 18.3% of all CHC revenues.^[3] The expansion of CHCs has instead been largely funded by the growth in Medicaid resulting from eligibility expansions, coverage reforms, and modified payment rules. In 1985, Medicaid patients made up 28% of all CHC patients but only 15% of CHC revenues.^[4] By 2007, the share of Medicaid patients matched their share of revenues. In the same time period, grants for the uninsured dec reased from 51% to 21%.^[4] In 2008, Medicaid payments had grown to account for 37% of all CHC revenues.^[3]

In 1989, Congress created the Federally Qualified Health Center (FQHC) program, which established a preferential payment policy for health centers by requiring “cost-based” reimbursement for both Medicaid and Medicare.^[1] The policy designated FQHC services as a mandatory Medicaid service that all states must cover and reimburse on a cost-related basis, using the Medicaid prospective payment system. The aim of these payment changes was to prevent health centers from using Section 330 and other grants (intended for the uninsured) to subsidize low Medicaid payment rates. The resulting payment structure reimbursed health centers on the basis of their actual costs for providing care, not by a rate negotiated with the state Medicaid agency or set by Medicare.

Medicaid’s shift to a managed care delivery system in the 1990s required CHCs to again modify their financial structure. Health centers largely lost money in their early experiences of contracting and assuming risk for Medicaid managed care patients. In 1997, to protect health centers under managed care, Congress mandated that state Medicaid agencies make a “wrap-around” payment to FQHCs to cover the difference between their costs for providing care and the rates they were receiving from managed care organizations (MCOs).^[1]

The economic recession in the United States continues to pose significant challenges for community health centers. In 2002, President Bush launched the Health Center Expansion Initiative, to significantly increase access to primary health care services in 1,200 communities through new or expanded health center sites. In 2008, the Health Care Safety Net Act reauthorized the health centers program for four years with the expectation of expanding the program by 50% over the time period.^[4] In 2009, the American Recovery and Reinvestment Act (ARRA) appropriated $2 billion for investment in health center expansion.^[4] By 2010, assisted by funding received through the ARRA, health centers had expanded to serve more than 18 million people. The health center program’s annual federal funding grew from $1.16 billion in the 2001 fiscal year to $2.6 billion in the 2011 fiscal year. With new funding provided through the Patient Protection and Affordable Care Act of 2010 , health centers are projected to serve up to 44 million people by 2015.^[3]