The community health center (CHC) in the United States is the dominant model for providing integrated primary care and public health services for the low-income and uninsured, and represents one use of federal grant funding as part of the country's health care safety net. The health care safety net can be defined as a group of health centers, hospitals, and providers willing to provide services to the nation’s uninsured and underserved population, thus ensuring that comprehensive care is available to all, regardless of income or insurance status. According to the U.S. Census Bureau, 29 million people in the country (9.1% of the population) were uninsured in 2015. Many more Americans lack adequate coverage or access to health care. These groups are sometimes called "underinsured." CHCs represent one method of accessing receiving health and medical care for both underinsured and uninsured communities.
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:
CHCs place great value in being patient-centered. Uniquely in community health centers, at least 51% of all governing board members must be patients of the clinic. This policy creates interesting implications in terms of how "participatory" CHCs are, as governing board members become directly invested in the quality of the clinic. A sliding fee scale based on income is implemented so that the cost of care is commensurate to the patient's ability to pay. The purpose of these stipulations is to ensure that CHCs work alongside the community, instead of serve the community, in order to improve access to care.
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.
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.[page needed] 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. 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. 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.[page needed] On its twenty-fifth anniversary in 1990, the center was rededicated as the Geiger-Gibson Community Health Center and is still in operation.[page needed]
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.[page needed]
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.
Since the Affordable Care Act's expansion of Medicaid, a challenge facing community health centers — and the health care safety net as a whole — is how to attract newly insured patients who now have more options in terms of where to seek care in order to remain financially viable.
The evolution of the terminology used to describe what are now called "community health centers" is crucial to understanding their history and how they are contextualized in the United States social safety net. When they were titled "neighborhood health centers," heavy emphasis was placed on grassroots community involvement and empowerment. Since, the terms have shifted to "community health centers" and "Federally Qualified Health Centers," indicating how these clinics have transformed into government provisions, and are now subject to bureaucratization. While CHCs still retain their historical commitment to responding to community needs, through mechanisms such as requiring at least 51% of governing board members to be patients at the health center, their positioning as a government provision makes CHCs responsible for meeting federal requirements as well.
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. In 2008, 1,080 CHCs provided comprehensive primary care to more than 17.1 million people. 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. Health center patients are also ethnically diverse. In 2007, half of all CHC patients were minorities, a third of whom were Hispanic. All together, CHCs serve one in four low-income, minority residents. 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.
Integration of health care services is a major focus, in addition to the provision of preventive and comprehensive care. Services provided can vary depending upon the site, but frequently include primary care, dental care, counseling services, women's health services, podiatry, mental and behavioral health services, substance abuse services, and physiotherapy. Often, CHCs are the only local source of dental, mental health, and substance abuse care available to low-income patients.
Because patients can come from a diverse range of socioeconomic, educational, cultural, and linguistic backgrounds, CHCs offer additional public health services such as health promotion and education, advocacy and intervention, translation, public benefit registration, and case management.
CHCs place great emphasis on meeting community needs. To meet this goal, administrative and health care personnel meet regularly to focus on the health care needs of the particularly community. Individual CHCs will often provide specialized programs tailored to the populations they serve. These populations could include specific minority groups, seniors and the elderly, or those facing homelessness. To determine what the community's needs may be, CHC staff may decide to engage in community-based participatory research. The mission of community health centers depends on collaborative relationships with community members, industry, government, hospitals and other health care services and providers.
Quality of care at CHCs can be assessed through many measurements and indices, including the availability of preventative services, treatment and management of chronic diseases, other health outcomes, cost effectiveness, and patient satisfaction. According to several studies, the quality of care at community health centers is comparable to the quality of care provided by private physicians. Nevertheless, community health centers face numerous challenges in light of their source of funding and the vulnerability of the population they serve. As CHCs primarily treat the low-income and uninsured, many of their patients do not regularly see a primary care physician, which can lead to poorer health outcomes. It is crucial for CHCs to evaluate the quality of care they provide in order to meet federal requirements and to fulfill their mission of eliminating health disparities based on socio-economic and insurance status.
From 2002 to 2004, the Agency for Healthcare Research and Quality (AHRQ) and HRSA jointly monitored CHC providers, finding that CHCs often operated independently and haphazardly, with little communication or cohesion between groups of providers. Since this program ended, there has been no federal system in place to monitor and evaluate the progress and success of CHCs.
Community health center patients are less likely to seek medical care consistently, as many of these patients tend to be from vulnerable populations in terms of socioeconomic background and insurance status. Nevertheless, those who use community health centers as a regular source of care are likely to have a positive patient experience and receive high-quality preventative services.
Studies have indicated that CHCs provide preventive services at similar rates to private physicians. Preventative services studied included cancer screenings, diet and exercise counseling, and immunizations. CHCs performing higher than private providers in terms of immunization rates, but lower in terms of diet and exercise counseling.
Although CHCs are able to provide comprehensive primary care, they 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. In areas with a high uninsurance rate, which tend to be the medically underserved areas where CHCs operate, there is often a lack of availability of specialty care.
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. In one study investigated management of diabetes in CHCs, a majority of patients exhibited signs or symptoms of diabetes, but relatively few received comprehensive monitoring and management. Moreover, adherence to treatment protocols was low in CHCs, speaking both to the effectiveness of CHCs and to the social determinants of health that make CHC patients so vulnerable.
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. 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. By 2007, the share of Medicaid patients matched their share of revenues. In the same time period, grants for the uninsured decreased from 51% to 21%. In 2008, Medicaid payments had grown to account for 37% of all CHC revenues.
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. 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. The implementation of managed care in Medicaid was intended to curb costs while providing patients with greater freedom to choose where they access care. However, the shift had adverse financial implications on safety net providers. Health centers largely lost money in their early experiences of contracting and assuming risk for Medicaid managed care patients. Uncertainty about financial viability also lead to concerns about the ability of CHCs to continue serving the uninsured. 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). Since the initial shift to managed care, Medicaid has helped a wider group of patients access consistent medical care.
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. However, these funds furthered disparity between CHCs, as they primarily benefitted larger, financially stable CHCs, rather than expanding and improving care in smaller clinics. 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. In 2009, the American Recovery and Reinvestment Act (ARRA) appropriated $2 billion for investment in health center expansion. 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. Health centers served 24,295,946 patients in 2015.
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