Spreading the Safety Net- Obstacles to the Expansion of Community Health Centers

During the presidency of Bush, his administration's agenda of "compassionate conservatism" with its emphasis on market-based, rather than government-sponsered, approaches to health care services and income support, has been rejected by Democrats innumerable times. This philosophical conflict has resulted in stalemates on many health care issues, and the administration's proposed 2009 budget, which calls for reductions of 200.9$ billion in Medicare and Medicaid spending over the next 5 years, only deepens the political divide. Bush has remained resolute, though, in fulfilling one early campaign pledge that most Democrats enthusiastically embrace: doubling the number of community health centers (CHCs) over a 5 year period so that millions more people who lack insurance or have limited access to private medical care can be treated as publicaly funded facilities. Bush's commitmement persuaded more Republicans to support CHCs, and the result has been a politically effective bipartisanship on this front.

The CHC initiative was launched by Lyndon B. Johnson duirng the administration's War on Poverty and got its inspiration from a South African movement that had offstarted the creation of facilities where poor workers could receive both public healht services and medical care. The primary goals were combining these disparate models and removing financial barriers to access. These goals, along with an emphasis on empowering the community to participate in decision making for CHCs by requiring that the majority of their board members be patients, were build into the centers' operating principles.

Reflecting this "power to the people" philosophy, the funding mechanism for CHCs consists of federal grants that bypass state governments and flow directly to these nonprofit, community-based organiztions. CHCs now number 1200 nationally and operate in some 6000 urban and rural sites in every state and territory and served an estimated 16.3 million people this year. 40% of the patients are uninsured and 35% are covered through Medicaid, with the remainder on Medicare or private insurance. Patients who are uninsured pay according to a sliding scale based on their ability to pay [like Esperanza in North Philly].

2/3 of CHC patients are memebers of racial or ethnic minority groups and many lack proficiency in English. More than 2/3 live on incomes at or below the federal poverty level and more than 92% have incomes below 200% of this threshold. Because their population is relatively young and disproportianly made up of young women and children, there is a high demand for primary care services.

Still, the mix of private and public activities that make up the health care system presents the centers with major challenges. As more people have lost their employer-sponsored or Medicaid coverage and become uninsured, greater demands have been placed on CHCs. Other challenges include recruiting and retaining physicians, nurses, and allied professionals who can provide primary care; securing specialty referrals for uninsured and Medicaid patients; and functioning in the face of budget cutbacks in Medicaid and SCHIP.

The number of doctors providing charity care has dropped significantly over the past decade, increasing the burden on CHCs and ERs. Meanwhile, it is difficult to attract physicians to staff positions at CHCs because hospital medical groups can offer them higher salaries. It is difficult to find specialists willig to treat uninsured patients who have no source of payment.

CHC,s which participate in policy activities largely through the National Association of Community Health Centers (NACHC), are striving to attract more physicians through natoinal, state, and local levels. CHCs meet the definition of a 'medical home' as developed by primary care medical organizations, but we will not be able to reach expansionary goals if we cannot attract a greater number of clinicians to these centers and more federal support from Washington. Despite good intentions on both sides, it remains uncertain whether Congress or the new administration will see the continued expansion of CHCs as a vital step toward reforming the health care system. Clearly, I think it's a vital step.