[Congressional Record Volume 143, Number 148 (Wednesday, October 29, 1997)]
[House]
[Pages H9713-H9724]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
ACCOMPLISHMENT OF THE HEALTH CENTER PROGRAMS
The SPEAKER pro tempore. Under the Speaker's announced policy of
January 7, 1997, the gentleman from Illinois [Mr. Davis] is recognized
for 60 minutes as the designee of the minority leader.
General Leave
Mr. DAVIS of Illinois. Mr. Speaker, I ask unanimous consent that all
Members may have 5 legislative days within which to revise and extend
their remarks on the subject of my special order.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Illinois?
There was no objection.
Mr. DAVIS of Illinois. Mr. Speaker, about 30 years ago, there emerged
on the American scene, as a result of the civil rights movement,
demonstrations, marches, protests, action on the part of the United
States Congress, initiation of the war on poverty, there emerged a new
set of health service delivery mechanisms, something that we today know
as community health centers. They started out with the name
neighborhood health centers as part of the OEO antipoverty program.
Every community that OEO would go into, making an assessment to look
at the issue of poverty, there would always emerge the issue of a lack
of
[[Page H9714]]
health care resources, the issue of there not being services available
to the people who lived in inner cities and rural communities. As a
result of that, these pioneering centers came on the scene.
Today I rise to underscore that they are indeed a vital component of
our health care system and one that focuses on providing the access to
primary and preventive health care services that coverage alone cannot
assure. As we all know too well from our experience over the years with
Medicaid, the possession of an insurance card will not necessarily
guarantee Americans access to health care. Nowhere is this more true
than in our inner city and rural, medically underserved communities.
I had the good fortune of taking a job at the Martin Luther King, Jr.
Neighborhood Health Center in the City of Chicago as its director of
training, which sharpened my interest in health care, and ultimately
continued to work in that area and had the good fortune to see the
emergence and development of this group of inner-city, rural migrant
health programs throughout the country, got involved and eventually
became, after the group had developed, a national association which
even to this day still exists, is very vibrant, viable and a valuable
part of the American health care delivery system.
Every place that we went we found that underserved communities
desperately need the health care system to deliver three things:
One, the presence of a medical home that offers high quality care
regardless of a person's health or social status or his or her ability
to pay for services and that is accessible in terms of location of
hours of service for those who do not have private transportation or
cannot take time off from the workday.
Second, adequate numbers of highly trained, culturally competent
health professionals to staff these facilities; and, thirdly, the
assurance that their medical home will not be driven out of business
due to excessive financial risk or inadequate reimbursement simply
because they care for those who are the sickest and hardest to reach.
I strongly believe that our health system should be built and should
build on what works. Among the programs that have worked best for the
underserved are the community migrant and homeless health center
programs. Over the past 30 years, these centers have established an
unparalleled, uniquely successful record of providing quality, cost-
effective primary and preventive care to the hardest-to-reach
populations across the Nation, recruiting and retaining health
professionals where they are most needed and empowering communities to
develop long-range solutions to their health needs.
Health reform should invest in such success by preserving and
building upon these programs in preparation for the implementation of
reform so that universal coverage will truly guarantee access to
quality care for everyone.
One of the things that I liked best about the community health center
movement is that they have spurred the development of so many
individuals. I am certain without a doubt that I would not be standing
here today as a Member of the United States Congress had I not gotten
involved with the community health center movement in my community that
not only brought services, but also provided opportunities for
individuals to be trained, for individuals who had never been in the
health business to develop careers.
I remember some of the great training programs that the association
developed where individuals could go off to the University of Michigan
and acquire a master's degree in public health on the weekends while
working in their local centers.
{time} 2200
Or they could go out to the University of California for six-week
periods at a time and acquire Master's degrees in health administration
while retaining the job that they had back in their local communities.
So I am so pleased that one of the real people who have seen these
developments is also here to join with me this evening, in the person
of the esteemed Representative from the State of South Carolina [Mr.
Clyburn]. We will be delighted to have him join and share with us.
Mr. CLYBURN. Mr. Speaker, I am pleased to be here this evening with
my good friend, the gentleman from Illinois [Mr. Davis] and to thank
him for all of his historical work in the field of community health
centers.
I want to say to him tonight that one of the most pleasant things for
me to find out was, as I was working my congressional district a few
months ago, to find out from so many of my constituents that he is
considered a real hero among the people in this field. I am honored
that he has asked me to join with him tonight in this special order.
Community health centers have long been the sole means of medical
attention for millions of Americans. For that reason alone, we should
be very careful to afford them the resources needed to continue their
services. Community health centers offer a wide range of services,
including dental care, health education, community outreach,
transportation, and various support programs. In many communities,
health centers work in collaboration with other organizations such as
the local schools, Head Start programs, and homeless shelters, just to
name a few.
As events of the past few days have proven, many of us are driven by
numbers, so let me share some numbers with you concerning community
health centers of the last year alone. Nine hundred forty community
health centers served almost 10 million people nationwide. In my home
State of South Carolina, there are 17 community health centers which
are private, not-for-profit businesses owned and run by the local
communities.
In 1996 they provided primary and preventive health care services at
more than 60 locations. These health clinics served more than 152,000
patients, many of whom would not have otherwise received medical care.
More than 50,000 children, 85,000 adults, and 15,000 elderly South
Carolinians depended on the health professionals in their community
health centers for their medical care and made over a half million
visits to them.
In the Sixth Congressional District, which I am proud to represent,
there were over 68,000 people in community health centers last year.
Many of these people are children, some pregnant women, many uninsured,
many minorities, many from rural areas, many from low-income
households, and many Medicaid recipients.
In my district, the Franklin C. Fetter Family Health Center in
Charleston County had over 100,000 visits last year, the highest in the
State. Another center in my district, the Family Health Center,
Incorporated, in Orangeburg, served over 34,000 individual patients,
another record high in the State.
Now, I share these numbers with my colleagues to illustrate the value
my constituents place on these local health centers. Nationwide, over
50,000 people are employed in community health centers. In South
Carolina, that translates into more than 900 jobs and over $53 million
being pumped into the State's economy. There is tremendous return on
our investment in health centers. Every $100 million invested brings an
additional $200 million in other resources into our communities. I
think that my colleagues will agree with me that that is an investment
worth making.
Mr. Speaker, community health centers play a vital role in our
Nation, our States and, more importantly, in our local communities. I
am pleased to join tonight with my good friend the gentleman from
Illinois [Mr. Davis] to ask that this Congress continue to work toward
the adequate funding of these unique and vital community institutions.
I thank the gentleman for allowing me the time.
Mr. DAVIS of Illinois. Thank you so much. I really appreciate your
being here.
You mentioned Franklin C. Fetter. I remember when that center
started, and I remember that it had a director who was there for a long
period of time, just an outstanding gentleman. I am thinking of people
that I knew then in South Carolina, like Georgia Goode and Tom
Barnwell, I mean, people who were so committed and so dedicated and
gave so much of themselves to make sure that these centers got started
and that they continue.
Who was the gentleman I am trying to think of?
[[Page H9715]]
Mr. CLYBURN. Mr. Speaker, if the gentleman will yield, he may recall
that that movement in South Carolina started with an effort in Beaufort
County, the Beaufort-Jasper Comprehensive Health Care Center. That
occupied significant amounts of our time trying to pull all of that
together, and it finally got put together. Tom Barnwell, as you know,
for many, many years directed that effort. It came about because
Senator Hollings took it upon himself to go and visit rural Beaufort
County and drew the Nation's attention to the health care problems in
rural South Carolina.
When that attention was focused, a lot of people were a bit upset,
thinking that this was a negative for Beaufort. But when the Congress
saw, it responded, and what looked like a negative turned out to be a
tremendous positive not just for Beaufort County, but then it moved
from there to Franklin Fetter.
I think my colleague may be talking about Dr. Leroy Anderson.
Mr. DAVIS. Dr. Leroy Anderson.
Mr. CLYBURN. He directed that for a long period of time, and of
course the Franklin Fetter Center started out working with migrants. It
was my opportunity to serve for a number of years as the director of
the South Carolina Commission for Farm Workers, and of course part of
our work was on James Island and Johns Island and Yonges and Edisto
Islands, trying to work with migrants who came into the area following
the stream up from Florida, as well as seasonal farm workers. We found
tremendous health needs among this rural part of Charleston county.
Of course, Franklin Fetter was born there, and from there it has
moved to Charleston's east side to focus on the urban aspects of these
problems. The center is still there, enjoying a tremendous work and, of
course, working with us now, we are about to establish a similar center
in north Charleston. Thanks to the mayor and the council of north
Charleston there, they have come forward to provide the building for us
to put the center in.
When we see these kind of efforts, it is not just about health care,
it is about getting communities to work together, getting people to
focus on needs that go beyond health, health being the method by which
we get them organized. I think that your work with my friends in South
Carolina, and of course I better mention, because also in my district,
in fact, I spent last Saturday afternoon with the people in Eastover,
where we have a similar center. Mr. Brown, who directs that, they were
very pleased with the recent grant they got to help with their work.
So I want to thank my colleague because, as I move throughout the
district, I am amazed at the number of people. I am glad he lives in
Illinois. Do not move to South Carolina, because I find it a little bit
difficult, people think so much of you there for the work that you have
done in this field.
I think that health care is so fundamental to everything that we do,
so I want to just thank my colleague for all that he has done.
Mr. DAVIS of Illinois. Mr. Speaker, reclaiming my time, the gentleman
from South Carolina [Mr. Clyburn] is just so on target, and again, I
want to compliment him. I also want to compliment him because we
recently just finished an outstanding legislative weekend of the
Congressional Black Caucus, and he was the chairperson of that
activity. Every place that I go back in my district in Chicago and out
in the suburban areas and throughout the country, there are people who
tell me what an outstanding weekend they thought it was, and I always
say to them, ``Well, one the reasons is the fact that we had an
outstanding chairman.'' So I commend him for that.
Mr. CLYBURN. Thank you.
Mr. DAVIS of Illinois. My colleague jogged my memory, he started
talking about Dr. Anderson and I remembered other people, like Dr.
Stephen Joseph; Jack Geiger; Count Gibson; Jerry Ashford out of Boston,
who became the first director of the association; Dr. Sam Rodgers from
Kansas City, where they eventually named a center there for him; Dr.
Charles Swett out of Chicago; Clifton Cole out of Los Angeles, who
became the first president of our association; Dr. Batcheler from
Detroit; a woman named Earline Lindsey out of Chicago; another lady,
Delores Lindsey out of Cincinnati; and Pepper Jacques out of Detroit;
and Eloise Westbrook from out in San Francisco; and Harvey Holzberg out
of New York; and Tom van Koffenen, who now directs the association, who
came on and has been there I guess now 25 years or so, continuing to
advocate, continuing to develop, to plan, to orchestrate and to provide
technical assistance and help these centers to grow.
Because even though we have experienced a tremendous amount of
success, there are still 43 million medically underserved people in
this country, and these are people who do not have adequate access to
health care services and often have poor health status. It is critical
that health reform include special measures to meet their needs if our
goal of cost containment is to be realized.
The underserved are exactly the ones who end up on emergency room
doorsteps. Studies have shown, for example, that up to 80 percent of
emergency room visits in underserved visits are non-urgent care. If the
underserved do not have their preventive and primary health care needs
met in health reform, then our goal of cost containment will be
unattainable.
Health centers have shown that we give top quality care and
constrained cost for our communities. For example, inpatient hospital
admission rates for health center patients have been up to 67 percent
lower than for those served by other providers, including hospital
outpatient departments or private physicians. I do not know if you can
get much better than that.
The length of stay for hospital patients served by health centers has
been found to be only one-third as long as that for patients who are
seen by outpatient departments and half as long as that of outpatients
served by private physicians. Studies have also shown that regular use
of a health center has produced a 33-percent savings to Medicaid on
both per case and per person yearly basis. This is for total costs for
all services.
{time} 2215
Health centers are among the few Federal programs that empower
communities to craft long-range solutions to their health problems. By
law, of course, health centers must be governed by a board of
directors, a majority of whom must be patients of the facility. Only
through the health center programs are consumers in the driver's seat
of their primary care delivery site. And only through health centers
are underserved communities assured that their primary care provider
will respond to their specific needs. It is for these reasons and
others that health centers have attracted such broad bipartisan
support.
Virtually all major health reform proposals introduced in the
Congress over the past few years have included funding and other
provisions for community health centers. That means that a majority of
the Members of this House, whether they be Democrats or Republicans or
Independents, have stated that they think health centers are the best
hope for addressing the needs of the underserved populations. When it
comes to access to care, health centers are something we can all
support.
Most of these legislative proposals have called for efforts to
respond to the needs of underserved Americans in 3 very important ways.
First, they have called for an expansion of the community health center
program, including flexible authority to make grants to other community
based providers and to establish community owned and operated networks
and plans consistent of safety net providers.
Secondly, they have included provisions encouraging managed care
plans to include health centers in their provider networks and to make
sure that these providers are not put at undue risk. This will preserve
the existing safety net primary care infrastructure in underserved
areas and assure their full participation in the new health system.
Thirdly, they have encouraged the inclusion of health centers in
health professions education and training. This will ensure that
primary health care professionals are trained and practice in
underserved areas where they are most needed. This is a critical point
in the history of the health center movement. It demonstrates that to
get health care to the people who cannot afford it, the Federal
Government
[[Page H9716]]
must chip in a critical share. It comes in the form of health center
operating grants. The best action we can take for those health
professionals who want to give something back to their communities is
to ensure a broad base of federally assisted community based providers
in underserved areas. This will give these professionals a place to
train and practice with the quality care environment and all the
supports they will need.
The health centers in my home State are all jewels. As a matter of
fact, they are indeed worth their weight in gold. They are cost
effective, responsive to community needs, and the patients just love
them. I cannot think of much more that we could ask of a group of
providers. And so I would certainly want to urge this Congress and all
of my colleagues to continue to provide the support that has been
provided over the years and let us continue with one of the most
effective programs that we have ever seen for the provision of quality
comprehensive health care to large numbers of poor people in this
country.
I really thank the gentleman from South Carolina [Mr. Clyburn] for
sharing. It is also an indication of caring. If the gentleman has got
some other comments, please go right ahead.
Mr. CLYBURN. I thank the gentleman so much. I am just pleased to be a
part of this because, as we have discussed in passing, this is
something I very much have been involved in over the years. I was just
so pleased to find that the gentleman had such a rich and hands-on
involvement. To have someone like the gentleman as an advocate in this
area is something that makes me feel much more comfortable with our
efforts. I just want to thank the gentleman for letting me be here
tonight to join with him and to call upon our colleagues to continue
this great work.
Mr. DAVIS of Illinois. I thank the gentleman. I will just make a
little special recognition to a few of the community health centers
that operate in my district. I always say that I have the most
fascinating district in the United States of America. These people have
simply gone above and beyond being just good providers of primary care.
For example, under the tireless leadership of Berniece Mills-Thomas,
executive director of the Near North Health Service Corporation which
provides primary care to women, infants, school age children and their
parents, we have seen that infant mortality has gone down significantly
in the area that they service around Cabrini Housing Development.
Actually they have reduced infant mortality over the years from 26.6
per 1,000 live births to now 12.8 per 1,000 live births. That is an
outstanding indicator of the impact, of the effectiveness.
The Winfield Moody, I can remember traveling around the country with
Mrs. Moody as they were getting that community's health center started.
And we have the Erie Family Center under the strong leadership of
Rupert Evans, who is the executive director. This center has done an
outstanding job of providing care to the communities in and around it,
Humboldt Park, West Town. Plus the Erie integrated care program is the
only bilingual primary care provider serving HIV and HIV/AIDS infected
patients in the city of Chicago. They have a great pediatric program.
We also have a number of other centers, such as the Daniel Hale
Williams Center, the Mercy Diagnostic, the Sinai Family Centers, which
just received a substantial grant of $8 million not very long ago to
continue its great work, the Alivio Medical Center, Circle Family
Center, the Mill Square Health Center, Komed, New City, the Cook County
Network. All of these are centers that provide not only the best of
care but also opportunities for people to work, for people to have
jobs, for people to plan, for people to serve on the boards of
directors, to make decisions, to decide what their neighborhoods and
communities will be.
And so in its 30th year, I just thought that this would be an
excellent time to stop and pause and pay tribute to this great group of
centers that are operating and remember some of the individuals who
made it happen, people out of New York like Paul Mejias and Janice
Robinson, Curtis Owens from Philadelphia, Dan Cantrell from Chicago,
Dave Simmons from Boston, Aaron Shirley from Jackson, Mississippi,
Melba McAfee from Jackson, Mississippi, and other people from all over
the country. I just hope that some historian who has been involved in
the efforts is writing a history so that 100 years from now when we
look back and look at where health care has come and look at our health
care delivery systems, we will recognize the tremendous role that the
community health center movement has played.
Mr. Speaker, I would like to include some additional documents here
that I would like to insert:
``The American Health Care Revolution and the Critical Role of Health
Centers.''
``Health Centers Are Unique in Structure and Mission.''
``Why Health Centers Work for the Nation.''
``Community, Migrant & Homeless Health Centers.''
``And from the Bureau of Primary Health Care, its depiction of what
the health center movement has meant to primary care services in the
country.''
``The material referred to is as follows:
The American Health Care Revolution and the Critical Role of Health
Centers
A revolution in the American health care system is well
underway and by all accounts will dramatically transform that
system over the next few years. More than two-thirds of
privately-insured individuals, or 120 million people, are
already enrolled in some form of managed care, with
continuing substantial annual increases in managed care
enrollment.\1\ This revolution has been driven by employers'
and insurers' demands that costs be held down or even
reduced, and that providers share financial risk. Managed
care plans have willingly complied with those demands,
bargaining for significant reductions in provider charges or
rates. Though doubts continue to persist as to the long-term
ability of managed care systems in holding down health care
costs, data from 1994 and 1995 show medical cost inflation
rates in the single digits for the first time in over a
decade. Clearly, the era of open-ended, fee-for-service
medicine is over.
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Footnotes at end of article.
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While public insurance programs have moved more slowly,
they too--especially Medicaid--are now outpacing the private
sector in their rates of managed care enrollment. In 1990, a
little over 2 million Medicaid beneficiaries were enrolled in
managed care plans; that number jumped to an estimated 11
million by the end of 1995 \2\. Most of that growth has been
accomplished through the use of Medicaid waivers, which the
current Administration has granted to more than a dozen
states under Section 1115 of the Social Security Act,
allowing those states to bypass Medicaid law requirements in
establishing state managed care initiatives and other
reforms. The recently-enacted Balanced Budget Act of 1997
contains far-reaching provisions that give states substantial
flexibility to re-structure their Medicaid programs in order
to enroll most of their Medicaid populations in managed care
plans.\3\
Under the right circumstances, the American health care
revolution can significantly improve both the availability
and quality of health care for most Americans while
containing costs by reducing the provision of unnecessary or
inappropriate care. However, the success of both private
market and public financing reforms could be significantly
undermined if adequate attention is not given to two other
key factors:
The recent acceleration in the use of Medicaid managed care
raises questions as to whether the managed care industry has
the capacity and infrastructure to absorb millions of
patients who differ dramatically in socioeconomic and health
status, education and health care needs from their
traditional enrollees, and experience numerous barriers to
access to health care services--making them among the most
difficult-to-reach and needy patients in the health care
system.\4\ Medicaid beneficiaries and other low income
Americans have higher rates of illness and disability than
other Americans, and thus accumulate significantly higher
costs of medical care.\5\ By contrast, most managed care
organizations have, until recently, principally focused their
enrollment and infrastructure in reasonably affluent,
healthy, well-educated suburban patient bases. Therefore, in
implementing Medicaid managed care programs, states are
moving millions of individuals into health care delivery
systems which have had little experience in providing care to
them. Without an adequate infrastructure, this difficult-to-
reach and needy population may be denied access to basic
health care.
At the same time, more than 43 million Americans have no
health insurance and that number is rising by more than
100,000 each month.\6\ A recent report found that the
uninsured are almost twice as likely to lack a regular source
of care, have fewer ambulatory visits, and have a higher rate
of medical emergencies, than those who have insurance. They
frequently depend on hospitals and emergency rooms for even
basic care often due to severe shortages of appropriate
primary health services in their communities \7\.
[[Page H9717]]
As more privately-insured Americans join managed care plans,
and as plans increasingly demand maximum cost-efficiency from
their providers, providers will be less able to provide care
to individuals who are uninsured or whose insurer pays less
than the cost of care that is provided (as is true of both
Medicare and Medicaid today).
Clearly, the long-term success of the American health care
revolution will depend upon steps to assure the availability,
and encourage the use, of cost-effective preventive and
primary health care for uninsured low income working
families; and the key to the longer-term survival of managed
care organizations will be the adequacy of their Medicare and
Medicaid enrollees' access to lower-cost primary and
preventive care, as well as their expertise in managing
enrollee costs. To be successful in these efforts, the new
American health care system and its managed care plans will
need the resources and know-how of providers that have a
history of cost-effective, quality service to Medicaid
beneficiaries and other low income populations--providers
such as America's Health Centers.
why health centers?
For more than 30 years, Health Centers have served as
``managed care'' providers for publicly-insured and uninsured
families. Nationwide, 2700 local health center service sites
currently deliver preventive and primary health care to more
than 10 million people--including 3.8 million Medicaid
recipients, 1 million Medicare beneficiaries, and 4.2 million
people who have no health insurance--in urban and rural
underserved communities across the country. The underlying
goal of the health center programs has been to help
communities and their people to take responsibility for their
health; toward that end, the programs have facilitated the
flow of public and private resources, enabling the
communities themselves to establish and operate health
centers and to develop innovative programs to meet their
health needs.
Health Centers have historically operated with very limited
budgets and have developed considerable expertise in managing
patients with significant health needs in low cost settings,
providing access to primary and preventive health services.
With literally thousands of communities across the country
suffering from acute shortages of cost-effective preventive
and primary health care service providers, with the numbers
of uninsured Americans rising each month, and with cost
controls making it increasingly impossible for other
providers to continue offering care to those without
coverage, health center programs are today, more than ever,
critical to the success of the new American health care
system. This is especially true because health centers:
Are, by law, located exclusively in rural and inner city
communities that have been designated as ``medically
underserved,'' because they have far too few ``front-line''
providers and poor health status indicators. I these
communities, health centers are frequently the only available
and accessible primary care provider.
Care for those whom other providers do not serve because of
their high costs and complex health needs.
Offer high quality preventive and primary health care under
one roof, in a ``one-stop caring'' system.
Have had a major impact on the health of their communities
and provide care in a highly cost-effective fashion.
health centers are a private sector alternative
Although health centers have a broad, prevention-focused
perspective on many health problems, they are much like
private medical practices, staffed by physicians, nurses, and
other health professionals. They differ from private medical
practices, however, by their broader range of services, such
as social service and health education, and by their
management structure. Health centers are owned and operated
by communities through volunteer governing boards composed of
leaders and residents of the communities they serve. They
function as non-profit businesses with professional managers;
purchase goods and services; provide employment; and make an
economic impact within their community.
Because they exist to serve their communities, health
centers are committed to seeking out and combining resources
from a variety of sources to ensure that access to primary
health care services is made available to all community
residents, regardless of their financial or insurance status.
Patients who can afford to pay are expected to pay. Medicare
and Medicaid patients are always welcome. And insurance
companies are billed on behalf of patients with coverage. The
centers' Board and staff also work to obtain support from
other sources, such as local governments and foundations, to
ensure that care is available for all patients based on
ability to pay.
In order to maximize limited resources, these private, non-
profit community practices have developed community linkages
with local health departments, hospitals, nursing homes,
pharmacists and others to ensure that services are
coordinated and to eliminate duplication of effort. Although
some services may not be available on-site, the health center
does coordinate care and referrals to other providers in a
way that assures true ``one stop caring'' for its patients.
health centers are found where they're needed most
By law, all Health Centers must be located in and serve
medically underserved areas and/or populations--and their
2,700 sites are split evenly between rural and urban
communities. The residents of these communities suffer from
the most profound shortage of accessible primary health care
services and, not surprisingly, exhibit some of the most
severe health problems and the poorest health status of all
American communities.
More than 43 million people, living in these inner-city and
rural communities, remain seriously medically underserved
because of special needs or circumstances \8\:
They are overwhelmingly members of low income families, and
are disproportionately young.
Many are uninsured, but 60 percent of them already have
some form of insurance (including Medicare and Medicaid).
Many live and work in areas with too few providers of care,
while others face serious non-financial barriers to care
(such as language or physical disabilities), or have complex
health and social problems.
In simplest terms, the medically underserved are people who
can't get care when they need it, and when it is most
appropriate--to prevent the onset of a health problem or
illness, or to diagnose and treat a condition in its earliest
stages--because of who they are, where they live, or because
of their health status. Two recent reports found that, even
when insured, these Americans continue to face significant
barriers to care, especially to primary and preventive health
services, and as a result have measurably poorer health
outcomes and overall health status.\9\
health centers serve the most vulnerable of all
Health center patients are almost universally among the
most vulnerable of all underserved people in America today--
persons who even if insured, nonetheless remain isolated from
traditional forms of medical care because of where they live,
who they are, and their frequently far greater levels of
complex health care needs:
Fifty percent reside in isolated rural areas; the other
half live in economically depressed inner city communities.
Virtually all patients have family incomes below 200
percent of the federal poverty level ($28,700 annually for a
family of four in 1994).
Nearly one in two is completely uninsured, either publicly
or privately, and more than one-third depend on Medicaid.
44 percent of all patients are children under 18, and
thirty percent are women of childbearing age (nearly one in
ten is pregnant). Health centers delivered over 400,000
babies last year--10 percent of all births and 1 in 5 low
income births \10\.
Because of factors such as poverty or homelessness, and
other social-environmental threats that permeate low income/
underserved communities, health center patients are at higher
risk for serious and costly conditions (such as asthma,
tuberculosis, or high-risk pregnancies) than the general
population, and require unique health services not typically
offered by traditional providers, including most managed care
entities.
health centers are clinically effective
Health centers provide more than just care for illness or
episodic conditions. They offer a ``health care home'' for
all residents of an underserved area. Like any good family
doctor's office, they provide ongoing care and health
management for families and individuals through all life
stages. Care is provided in the office whenever possible;
physicians are on the medical staffs of their local
hospitals; and referrals to other providers are made whenever
needed.
Health center practices are staffed by a team of board
certified or board eligible physicians, physician's
assistants, nurses, dentists, social workers and other health
professionals. In rural areas, physicians are typically
family practitioners, while larger urban centers are usually
staffed with interdisciplinary teams of internists,
pediatricians, and obstetricians. Almost 98% of the more than
5,000 health center physicians are board-certified or
eligible \11\, and all are required to have hospital
admitting privileges.
The hallmarks of effective primary health care are the
entry point it provides into the entire system of care, its
comprehensiveness, continuity, and responsiveness to the
needs of the patients served. Because primary care must be
patient-centered to be effective, it is not the same for
everyone--one size cannot fit all. Local centers have
developed special intervention programs for significant
health care needs in their community, including strong
obstetrical practices to fill a gap in their community or a
special focus on patients with diabetes, or hypertension or
AIDS. Many centers have developed special outreach programs
to help overcome the cultural and language barriers faced by
people who speak little or no English in obtaining primary
health care access \12\.
Centers also emphasize services designed to enhance the
effectiveness of the medical care provided, such as community
outreach, health/nutrition education, and case management.
Some 98 percent of health centers offer health education
services; over 90 percent offer case management services;
more than three-quarters offer preventive dental services and
in-house laboratory services. All health centers employ
outreach and patient relations workers from the communities
they serve \13\.
Health centers are required by the U.S. Public Health
Service (PHS) to update their
[[Page H9718]]
quality assurance program and health care plan in response to
annual community need assessments, and are required to report
to PHS outcome measures, including immunization rates, low
birth weight reduction, hospital admission and length of stay
\14\.
Available literature provides extensive documentation of
the quality and effectiveness of care offered by health
centers, using factors such as patient health outcomes,
satisfaction and health status of the community. These
studies provide strong evidence that where there is a health
center, the level of health of the community is dramatically
improved. For instance:
Infant mortality: Communities served by health centers have
been shown to have infant mortality rates from ten to forty
percent lower than communities not served by health centers.
The provision of health center services also has been linked
to improvements in the use of prenatal care and reductions in
the incidence of low birthweight \15\.
Incidence of disease/hospitalization: Health centers have
been shown to reduce rheumatic fever and untreated middle ear
infections in children and have significantly increased the
proportion of children who are immunized against preventable
disease \16\.
Use of preventive care: Health centers have increased the
use of preventive health services such as Pap smears and
physical exams \17\.
Effectiveness of care: Health center patients have been
shown to have lower hospital admission rates, shorter lengths
of stay and make less inappropriate use of emergency room
services \18\.
Two recent (1994 and 1995) system-wide studies of thousands
of Medicaid patient medical records in Maryland found that
health centers scored highest among all providers for the
proportion of their pediatric patients who had received
preventive services, including immunizations; and that health
centers consistently scored at or near the highest in 21
separate measures of quality assessment, even though their
costs of care were among the lowest of the various provider
types reviewed \19\.
Health center patients are also overwhelmingly satisfied
with their care and treatment. According to a 1993-1994
nationwide study of health center patients conducted by the
Picker/Commonwealth Fund: 96% of health center patients were
very satisfied or satisfied with the quality of their
care; 97% would recommend the health center to friends and
family; 95% receive regular health care services, even
when they are not sick (preventive and primary care
services); 87% have never had a concern or complaint.
Health Center Cost-Effectiveness Is Second to None
Health centers are subject to ongoing Federal scrutiny of
their cost-effectiveness and quality of care. Cost screens
applied to health centers by the U.S. Public Health Service
and the Health Care Financing Administration, such as
administrative costs and costs per patient visit, are
virtually unparalleled in the health care industry. The
result is that health centers provide quality, comprehensive
primary care to some of the hardest-to-reach patients in the
health system at a price second to none. Several recent
studies have found that Medicaid patients who regularly use
health centers cost significantly less than those who use
private primary care providers, such as HMO's, hospital
outpatient units or private physicians. For instance:
In Washington state in 1992, health center patients were
found to be 36% less expensive for all services than patients
of other primary care providers and used 31% fewer emergency
room services \20\;
In California in 1993, health center patients were 33% less
expensive overall (controlling for maternity services), and
had 27% less total hospital costs \21\;
In Maryland in 1993, health center patients had lowest
total payments; lowest ambulatory visit cost; lowest
incidence of inpatient days and lowest inpatient day cost;
health center patients were one-third as likely as hospital
outpatient unit patients to be admitted on an inpatient basis
and were half as likely to have unstable chronic medical
diagnoses as patients of other providers \22\;
In New York in 1994, health center patients were 22-30%
less expensive overall, and had 41% lower total inpatient
costs; diabetics and asthmatics who were regular health
center uses had 62% and 44% lower inpatient costs,
respectively \23\.
These findings are consistent with those from dozens of
previous studies on the cost-effectiveness and quality of
care provided through the health center model, and in
particular addressing the health centers' demonstrated and
historic savings to state Medicaid programs. Taken together,
these studies have found that:
Use of health centers led to lower utilization of more
costly emergency rooms, ranging from 13 percent to 38 percent
in the case of pediatric emergency room use. \24\
Health centers have reduced inpatient admission rates for
their patients by anywhere from 22 percent to 67 percent,
reduced the number of patients admitted per year and the
length of stay among those who were admitted. \25\
Health centers have achieved such tremendous success
because, like managed care organizations, they are a first
point of entry for their patients into the health care
delivery system, and they manage their patients' care to keep
them healthy and out of costly emergency rooms, hospitals,
and specialists' offices. They are also experienced in the
management of health care costs, since they must run their
programs within a limited annual budget.
Health centers are well tested and highly successful models
of community-based health care. They are partnerships of
people, governments, and communities working together to meet
local health care needs in an culturally competent, effective
and efficient way. Health centers develop primary care
infrastructure in areas of the nation that need it most with
limited Federal assistance. Federal grants to health centers
average less than $100 annually per patient. This represents
a small investment for what centers accomplish in
strengthening community health and fostering prevention and
health education.
The Health of Each Health Center is Always Leadership And
Accountability
Health centers are professional health care organizations
providing a comprehensive range of high quality services for
their community. But their most distinctive feature is that
the health centers are developed and run by their
communities, and are dedicated to the needs of their people.
Health center governing boards are composed of local
community leaders and residents who care about the primary
health care access needs of their community and are committed
to working together to make a difference. Federally funded
centers are required to have patients as a majority of their
governing board members.
The empowerment and involvement of local citizens in
planning and governance has been the essential characteristic
that has made in possible for health centers to make a real
difference in underserved communities, in terms of both the
sense of ownership they help foster and the tangible benefits
they yield. In recent years, the role of community governance
has achieved increased recognition and respect, especially
because it promotes direct involvement by local residents in
developing the services they use. Because of their commitment
to their local communities, health centers have become an
effective solution for primary health care access in
thousands of communities across the nation, affirming their
vital role in America's future health care system.
The Health Center Experience: Limited Investment Generates Outstanding
Success
Health center achievements over the past 30 years show how
much is known about how to make a difference in the health of
the poor and how far even a modest investment will go.
Every Federal dollar invested in health centers leverages
another two dollars in other revenues--in addition to the
Medicare and Medicaid savings they produce. Health centers
understand and respond to their communities' most urgent
health care needs. Health centers care for those whom other
providers cannot or will not serve. Health centers offer high
quality medical care. Health centers have had a major impact
on the health of their communities and provide care in a
highly cost-effective fashion. There is no better health care
bargain anywhere--public or private.
Perhaps the greatest testament to the unique ability of
health centers to design services that are accessible to
their patients is that, ironically, health centers report
that for every 10 patients currently served there are another
3 on local centers' waiting lists who are seeking care there
\26\. And those on health center waiting lists do not even
begin to take into account the far larger number of persons
who need the services of health centers but who do not have a
center within reach--particularly in the nearly 1,000
underserved U.S. counties that today have no health center
\27\.
Health Centers Can Do So Much More
As policy makers consider options for improving the reach
and effectiveness of America's health care system, they would
do well to seriously consider including steps to:
Expand the network of health centers to ultimately reach
all medically underserved people and communities. With
current funding, health centers are able to reach just 9
million of the 43 million medically underserved Americans who
would benefit from their services. This effort could be
accomplished incrementally over several years, with each
additional $100 million in funding for health centers
extending services to an additional 1 million people in some
400 communities.
Assist health centers to fully participate in managed care,
by allowing them to form or join Provider Sponsored Networks
as fully integrated partners, and by ensuring that any
Medicaid or Medicare reforms include supplemental payments to
health centers--in addition to other reimbursements from
Medicare or Medicaid, or from managed care plans--for the
purpose of making sure that health centers receive sufficient
funds to adequately care for their Medicaid patients. Without
sufficient resources to meet the needs of their patients,
centers and clinics would be forced to substantially reduce
their services and patient loads (mostly uninsured patients),
and many could go out of business.
Involve health centers in the training of the enhanced
primary care workforce required for the future, by making
teaching health centers eligible for direct payment of their
health professions teaching costs. The Council on Graduate
Medical Education (COGME), as well as the Institute of
Medicine, and the Physician Payment Review
[[Page H9719]]
Commission, have recommended revision of current GME policies
to support expanded primary care and ambulatory training
programs; and health centers represent the ideal site for
training in comprehensive preventive and primary ambulatory
health care, because they have an established history of
functioning as interdisciplinary care environments, providing
quality, comprehensive primary and preventive care.
Health centers provide comprehensive, continuous care to
their patients regardless of insurance status or ability to
pay. It is this ability to offer continuous care that makes
the health centers unique and particularly valuable. Health
centers form a critical base on which to build managed care
systems for low-income and medically underserved populations.
Already, health centers are managed care providers for over
1.5 million Medicaid patients, and that number is expected to
more than double over the next year or two.
The road to long-term managed care plan viability and
effectiveness can be made smoother by the inclusion of health
centers in managed care networks. As experienced and
effective health care providers to the medically underserved,
health centers can provide the primary care infrastructure
network which managed care systems need to provide cost
efficient quality health care. Health centers have much to
offer managed care systems and stand ready to collaborate
with them.
notes
\1\ ``Market Strategies and the Growth of Managed Care'',
Paper Presented by Howard Bailit, D.M.D., Ph.D., Senior Vice
President for Health Services Research, Aetna Health Plans,
to the Annual Meeting of the Association of Academic Health
Centers, September 29, 1994.
\2\ Testimony of Bruce Vladeck, Administrator, Health Care
Administration (HCFA), before the House Committee on
Government Reform and Oversight, January, 1996.
\3\ See Subtitle H of Title IV of P.L. 105-33, the Balanced
Budget Act of 1997.
\4\ Holahan, Liska and Obermaier, Medicaid Expenditures and
Beneficiary Trends, 1988-1993; Report to the Kaiser
Commission on the Future of Medicaid by The Urban Institute,
September 1994.
\5\ Health Insurance of Minorities in the U.S., Report by the
Agency for Health Care Policy and Research, U.S. Department
of Health and Human Services, 1992 and Green Book, Overview
of Entitlement Programs Under the Jurisdiction of the Ways
and Means Committee, U.S. House of Representatives, 1994.
\6\ Employee Benefits Research Institute, Sources of Health
Insurance and Characteristics of the Uninsured, EBRI Special
Report and Issue Brief No. 158, February, 1995.
\7\ Baker, Laurence, and Baker, Linda, ``Excess Costs of
Emergency Department Visits for Nonurgent Care,'' Health
Affairs, Winter 1994: 162-171.
\8\ Hawkins, Daniel, and Rosenbaum, Sara, Lives in the
Balance: A National, State and County Profile of America's
Medically Underserved (National Association of Community
Health Centers, 1993).
\9\ Grumback, Kevin, et al, Primary Care Resources and
Preventable Hospitalization in California, CPS Report,
California Policy Seminar, May 1995; and Kohrs, Francis P.,
MD, and Mainous, Arch G., PhD, ``The Relationship of Health
Professional Shortage Areas to Health Status, Archives of
Family Medicine, Vol. 4, August 1995: 681-685.
\10\ Data from 1995 health center reports to the Bureau of
Primary Health Care, HHS.
\11\ Data from Bureau of Primary Health Care, 1994.
\12\ See Community and Migrant Health Centers; Critical
Components of Health Reform (National Association of
Community Health Centers, 1993).
\13\ Lewin-ICF, 1991 Survey of Health Centers.
\14\ See Program Expectations for Community and Migrant
Health Centers, Bureau of Primary Health Care, HHS (1994).
\15\ Grossman, Michael, and Goldman, Fred, ``An Economic
Analysis of Community Health Centers,'' National Bureau of
Economic Research (1983); see also Schwartz, Rachel, and
Poppen, Paul, Measuring the Impact of Community Health
Centers on Pregnancy Outcomes, Abt Associates (1982), and
M.B. Wingate, et al, ``Obstetric Care in a Family-Health
Oriented Neighborhood Health Center, ``Medical Care'' 14, 4
(April 1976): 315-325.
\16\ Mary E. Biscoe et al, ``Follow-up Study of the Impact of
Rural Preventive Care Outreach Program on Children's Health
and Use of Medical Services'', American Journal of Public
Health 70, 2 (February 1980); 151-156; Theodore J. Columbo et
al, ``The Effect of Outreach Workers' Educational Efforts on
Preschool Children's Use of Preventive Services'', American
Journal of Public Health 69, 5 (May 1979): 465-468; and David
L. Cowan et al, ``Impact of a Rural Preventive Care Outreach
Program on Children's Health,'' American Journal of Public
Health 68, 5 (May 1978: 471-476; and Leon Gordis,
``Effectiveness of Comprehensive Care Programs in Preventing
Rheumatic Fever'', New England Journal of Medicine 289, 7
(August 16, 1973): 331-335.
\17\ Sheils A. Gorman and Hannah Nelson, ``Meeting the Data
Needs of Neighborhood Health Centers,'' (Presented at the
102nd meeting of the American Public Health Association,
1984); and John C. Hershey and John R. Moore, ``The Use of an
Information System for Community Health Services Planning and
Management,'' 13 Medical Care (February 1975): 114. See also
Joel J. Alpert, et al, ``Effective Use of Comprehensive
pediatric Care'', American Journal of Diseases of Children
116 (November 1968): 529-533; and Theodore J. Columbo, et al,
``The Effect of Outreach Workers' Education Efforts on Use of
Preventive Services by a Poverty Population,'' (Presented at
the 104th meeting of the American Public Health Association,
1976).
\18\ De Prez, Ronald, et al, ``The Substitutability of
Outpatient Primary Care in Rural Community Health Centers for
Inpatient Hospital Care,`` Health Services Research 22,2
(June 1987): 207-233; Gretchen V. Fleming and Ronald M.
Anderson, ``The Municipal Health Services Program: Improving
Access to Primary Care with Increasing Expenditures,''
Medical Care 24,7 (July 1986): 565-579; Howard E. Freeman, K.
Jill Kiecolt, and Harris M. Allen, ``Community Health
Centers: An Initiative of Enduring Utility'', Milbank
Memorial Fund Quarter 60,2 (Spring 1982): 245-267; Marsha R.
Gold and Robert G. Rosenburg, ``Use of Emergency Room
Services by the Population of a Neighborhood Health Center'',
Health Service Report 89,1 (January-February 1974): 65-70;
Louis I. Hochheiser, Kenneth Woodward, and Evan Charney,
``Effect on Neighborhood Health Center on the Use of
Pediatric Emergency Departments in Rochester, New York'', The
New England Journal of Medicine 285,3 (July 15, 1971): 148-
152; Gordon T. Moore, Rosemary Bonanno, and Roberta
Bernstein, ``Effect of a Neighborhood Health Center on
Emergency Room Use'', Medical Care 10,3 (May-June 1972): 240-
247; and Elliot Sussman, et al, ``Can Primary Care
Deliver?'', Journal of Ambulatory Care Management 2,3 (August
1979): 29-39.
\19\ Starfield, Barbara, et al, ``Costs vs. Quality in
Different Types of Primary Care Settings,'' Journal of the
American Medical Association 272,24 (December 28, 1994);
1903-1908; and Stuart, Mary e., et al, ``Improving Medicaid
Pediatric Care,'' Journal of Public Health Management
Practice 1(2) (Spring, 1995): 31-38.
\20\ Braddock, Dennis, et al, Using Medicaid Fee-For-Service
Data to Develop Health Center Policy, Washington Association
of Community Health Centers and Group Health Cooperative of
Puget Sound (1994).
\21\ Health Services Utilization and Costs to Medicaid of
AFDC Recipients in California Served and Not Served by
Community Health Centers, Center for Health Policy Studies/
SysteMetrics (1993).
\22\ Steinwachs, Donald M., and Stuart, Mary E., (Johns
Hopkins Univ. School of Public Health and Hygiene),
``Patient-Mix Differences Among Ambulatory Providers and
Their Effects on Utilization and Payments for Maryland
Medicaid Users,'' Medical Care 34,12 (December 1993): 1119-
1137.
\23\ Utilization and Costs to Medicaid of AFDC Recipients in
New York Served and Not Served by Community Health Centers,
Center for Health Policy Studies (1994).
\24\ Hockheiser, L., Woodward, K., and Charney, E., ``Effect
of the Neighborhood Health Center on the use of Pediatric
Emergency Departments in Rochester, New York,'' 285 New
England Journal of Medicine 148 (July 15, 1971).
\25\ ``Final Report for Community Health Center Cost
Effectiveness Evaluation,'' JRB Associates for U.S.
Department of Health and Human Services, Contract No. 100-78-
0138 (1981). See also Davis, Karen and Schoen, Cathy, Health
and the War on Poverty: A Ten-Year Appraisal (Brookings
Institution, Washington, D.C., 1977).
\26\ Lewin-ICF, 1991 Survey of Health Centers.
\27\ Hawkins, Daniel, and Rosenbaum, Sara, op cit.
____
America's Health Centers are comprised of Community,
Migrant and Homeless Health Centers and other federally-
qualified community-based providers. In a thirty-year
history, they have shown the value and strength of a health
system rooted in community partnership and built on the
delivery of accessible, quality primary care to Americans in
need. Today, this growing nationwide network delivers primary
and preventive care to more than 10 million medically
underserved people--spanning urban and rural communities in
all fifty states, the District of Columbia, Puerto Rico, Guam
and the Virgin Islands.
health centers are unique in structure and mission
Health centers are public-private partnerships. They are
nonprofit, private corporations, which are locally-owned and
operated by the communities they serve.
Health Centers serve in medically underserved communities--
America's inner cities, migrant farmworker communities, and
isolated rural areas. They are defined areas with few or no
physicians--suffering high levels of poverty, infant
mortality, elderly, and poor health.
Health centers are governed by consumer boards--composed of
51 percent patients who represent the community served. This
is a powerful link to the community. Consumer governance
gives patients and local citizens a voice in the workings of
their center--and ensures that care is patient-centered and
responsive to diverse cultures and needs within the
community.
Health center revenues are multi-sourced. Federal grants on
average represent 36 percent of a health center budget.
Reimbursement from Medicaid and Medicare constitutes 38
percent. The remainder is leveraged from state and local
governments, insurance, and patient fees.
Health centers provide care to all who seek their service.
Patients are charged on a sliding fee scale to ensure that
income or lack of insurance is not a barrier to care. Federal
grants received by centers subsidize the cost of care
provided to the uninsured--and the cost of services not
covered by Medicare or Medicaid or private insurance.
why health centers work for the nation
Health centers fill critical gaps in health care. Health
centers serve low-income working families, the uninsured as
well as high-risk populations such as the homeless, the frail
elderly, migrant farmworkers, and poor women and children.
They are people who confront barriers to care and whose unmet
health needs represent a huge and growing cost to the nation.
Health Center Patient Profile: Virtually all health center
patients have family incomes below 200 percent of the federal
poverty level. More than two in five are completely
uninsured. More than one-third depend on Medicaid. 70 percent
of health center patients are children and poor women of
childbearing age. 60 percent of health center patients are
members of racial and ethnic minorities at high risk. Nearly
half a million of our patient population are migrant
farmworkers and their families.
Health Centers are built by community initiative. A limited
federal grant program provides seed money. The purpose: to
empower communities themselves to find partners and resources
to develop centers--to hire doctors and needed health
professionals--and to build their own points of entry into
the nation's health care delivery system.
Health centers focus on wellness and prevention--the keys
to cost savings in health care. Through innovative programs
in outreach, education, and prevention centers reach out and
energize communities to meet critical health needs and
promote greater personal responsibility for good health.
[[Page H9720]]
Health centers produce savings. Their skills and experience
are unsurpassed as providers of quality, cost-effective
health care to high-risk and vulnerable populations.
health centers make a difference
Cost effectiveness: Health centers provide cost-effective
high quality care--second to none. Total health care costs
for center patients are on average 40 percent lower than for
other providers serving the same populations. Centers also
achieve significant savings by reducing the need for hospital
admissions and costly emergency care.
Improving Access: Health centers bring needed health
services and facilities to areas of greatest need--often not
served by traditional providers. They train, recruit, and
retain highly-skilled health professional in acute shortage
areas.
Quality Managed care: Health centers provide comprehensive
primary and preventive care. Ninety-eight percent of health
center physicians are board certified/eligible. Centers are
linked to hospitals, health departments, nursing homes, and
other providers as well as social service agencies to ensure
that patients have access not only to primary care but a
continuum of coordinated care, including special treatment
and support services.
Accountability: Health centers meet high uniform standards
of accountability and performance. Health centers demonstrate
the effective utilization of public and private investment as
reflected in positive health outcomes; a 40 percent reduction
in infant mortality; improved immunization and prenatal care
rates; and increased use of preventive health services.
OTHER KEY FACTORS
Health Centers empower Communities. They provide jobs and
generate new investment into devastated and poor communities.
Health centers employ over 50,000 community residents. They
are the nation's leading trainer and health career path for
minority health professionals. Their total operating budget
of $2.8 billion leverages over $14 billion in economic
development in needy urban and rural areas--Which translates
into jobs, facilities and contracts.
Health Centers are vital safety net providers for millions
of poor Americans. They are frontline providers of care
helping communities attack costly and compelling health
problems such as AIDS, substance abuse, teenage pregnancy,
and crime. But, they are more than just providers. They are
catalysts--empowering communities with the resources, jobs/
education--and leadership--that can improve health and bring
new promise to America's disadvantaged.
____
Community, Migrant and Homeless Health Centers and other
community-based providers comprise America's Health Centers.
In a thirty year history, they have shown the value and
strength of a health system rooted in community partnership--
and built on the delivery of accessible, quality primary care
to Americans in need. Today, this growing nationwide network
delivers primary and preventive care to more than 9 million
medically underserved people--spanning urban and rural
communities in all fifty states, the District of Columbia,
Puerto Rico, Guam and the Virgin Islands.
WHY HEALTH CENTERS WORK FOR THE NATION
Health centers fill critical gaps in health care delivery.
Health centers serve low-income working families, the
uninsured as well as high-risk populations such as the
homeless, the frail elderly, the disabled, migrant
farmworkers, and poor women and children and others. They are
people who confront barriers to health care--and whose unmet
health needs represent a huge and growing cost to the nation.
Health centers are built by community initiative. A limited
federal grant program provides seed money. The purpose: to
empower communities themselves to find partners and resources
to develop centers--to hire doctors and needed health
professionals--and to build their own points of entry into
the nation's health care delivery system.
Health centers focus on wellness and prevention--the keys
to cost savings in health care. Through innovative programs
in outreach, education and prevention--centers reach out and
energize communities and their people to meet critical health
needs and promote greater personal responsibility for good
health.
Health centers produce savings--in Medicare and Medicaid--
and preventive care. Their skills and experience are
unsurpassed as providers of quality, cost-effective health
care to vulnerable populations. A track record of
accomplishment demonstrates that prevention and primary care
works: It keeps people healthy--It saves tax dollars--It
builds stronger communities.
Community Partnership is the dynamic that drives the
success of America's Health Centers. Health centers are
partnerships of people, governments, businesses, communities
working together to expand access and to improve health.
HOW HEALTH CENTERS ARE UNIQUE--IN STRUCTURE AND MISSION
Health centers are public/private partnerships. They are
nonprofit, private corporations, which are locally owned and
operated by the people and communities they serve.
Health centers are governed by consumer boards--composed of
51 percent patients--who represent the community served. This
is a powerful link to the community. It not only gives
patients and local citizens a voice in the workings of their
center--but ensures that care is patient centered and
responsive to diverse cultures and needs within the
community.
Health centers revenues are multi-sourced. Federal grants
on average represent 36 percent of a health centers budget.
Reimbursements from Medicaid and Medicare constitute 38
percent. There remainder is leveraged from state and local
governments, private contributions, insurance and patient
fees.
Health centers serve in medically underserved communities--
America's inner cities--migrant farmworker communities--and
isolated rural areas. They are defined areas with few or no
physicians--suffering high levels of poverty, infant
mortality, elderly and poor health.
Health centers provide care to all people who seek their
services. Patients are charged on a sliding fee scale to
ensure that income or lack of insurance is not a barrier to
care. All patients pay something toward the cost of their
care. Medicare and Medicaid as well as private insurance are
billed for those with coverage. Federal grants received by
centers subsidize the cost of care provided to the
uninsured--and the cost of services not covered by public or
private insurance.
Health center care is patient centered and community
directed. Centers provide additional services of outreach--
transportation and translation--education, and case
management--to maximize effectiveness in producing long-term,
positive health outcomes for high-risk populations. Health
centers also deal with costly community health problems such
as teenage pregnancy, infant mortality, homelessness,
substance abuse, AIDS and others.
Today, a cost-conscious nation is looking to the success of
the U.S. health center model, which has produced the markers
to an effective alternative in accessible, affordable
community based care. This model has shown that it takes more
than governments to solve the problems in health care; that
people and community partners must be involved to protect
health--to realize cost savings--and to make health care
delivery work for more Americans.
How Health Centers Make A Difference
Cost Effectiveness. Health centers provide cost-effective,
high-quality health care--second to none. Total health care
costs for center patients are on average 30 percent lower
than for other providers serving the same populations.
Centers also achieve significant savings by reducing the need
for hospital admissions and costly emergency care.
Improving Access. Health centers bring needed health care
services and facilities to areas of greatest need--often, not
served by traditional providers. They train, recruit, and
retain highly skilled health professionals in acute shortage
areas.
Quality Managed Care. Health centers provide comprehensive
primary and preventive health care. Ninety-eight percent of
health center physicians are board certified/eligible.
Centers are linked to hospitals, health departments, nursing
homes and other providers as well as social service agencies
to ensure that patients have access not only to primary care,
but a continuum of coordinated care, including specialized
treatment and support services. Numerous independent studies
document that health centers improve the health of their
communities--reducing preventable deaths, costly disability,
and communicable disease.
Accountability. Health centers meet high, uniform standards
of accountability in terms of cost effectiveness and quality
care under the Public Health Service Act. Centers are subject
to periodic reviews and federal audits, and are required to
submit comprehensive health plans detailing health services
in their geographic area, demonstrating need and demand, and
showing the impact of their intervention. Health centers
demonstrate effective use of resources and public and private
funds.
Empowerment. Health centers empower communities to take
charge and meet health needs. They engage citizen
participation and involvement--facilitate the flow of public
and private investment into communities--and generate jobs
and new community development.
Opportunity. Health centers contribute to the well being
and strength of communities. By providing cost-effective
prenatal care--health centers reduce the high costs
associated with adverse pregnancy outcomes. By keeping
children healthy--centers enable them to stay in school and
train for the future as responsible members of the community.
By keeping workers healthy--health centers reduce absenteeism
and help workers remain productive and contributing citizens.
Investment. Health centers yield a substantial return on
public and private investment. They are more than providers.
Health centers are community assets that improve health--
provide jobs--strengthen schools--stabilize neighborhoods--
and enhance community pride.
____
Community, Migrant and Homeless Health Centers--United States
(Presented by: Thomas J. Van Coverden, president and chief executive
officer, National Association of Community Health Centers, Inc.)
Historical Background and Development
Community and Migrant Health Center programs were
established by the federal
[[Page H9721]]
government in the decade of the sixties. Conceived as part of
a war on poverty, the programs were a major social experiment
joining the resources of the federal government and local
communities to expand quality and accessible health care to
Americans in need.
Health centers were the product of two powerful forces.
Social unrest was erupting in riots for lack of jobs,
opportunities, and health care in inner cities. Reform-minded
physicians and nurses were calling for a better way to
deliver health care by reaching out into communities in need
and attacking the problems underlying poverty.
This step in U.S. health care was historically significant.
For the first time, resources were committed by the federal
government to assist local communities in development of a
community-based primary care infrastructure to serve
medically underserved populations. Experimentation with a new
model of health care marked recognition of large gaps in
America's health delivery system. It confronted the reality
that even with expansion of public health insurance to cover
broad segments of the poor and elderly, millions of Americans
and their families would still lack access to doctors and
basic health services because of poverty, cultural, and
geographic barriers. Moreover, it conceded that a national
war on poverty to help all Americans to education and job
opportunities and a better standard of living would never be
won without a frontal assault on the problems of inadequate
health care.
Federal grants to public and nonprofit entities for the
development and operation of neighborhood health centers
(later called community health centers) were made available
in 1965 under the Office of Economic Opportunity (OEO). The
first two neighborhood health centers opened in rural
Mississippi and in a public housing project in Boston,
Massachusetts. While services were directed to the poor and
near poor, centers also provided care to individuals who
could pay all or part of the cost of their health care.
During the early years, grants were awarded to established
medical entities such as hospitals, health departments, and
medical schools. Later this orientation was to change to
nonprofit community groups, which reinforced independent,
local control over health centers; community management; and
a focus on tailoring health services to specific community
needs.
A similar program of grants for the development of migrant
health centers was authorized by the U.S. Congress with
enactment of the Migrant Health Act in 1962. Centers were to
provide medical and essential support services such as
translation, outreach, and social service linkages to the
nation's migrant and seasonal farmworkers and their families.
Steadily and with growing local and congressional support,
both the migrant and neighborhood health center programs took
root. By the mid-1970's and phaseout of the OEO, about 100
neighborhood health centers were in operation, mainly in
poverty-stricken inner cities and isolated rural areas.
phases of health center development
1965-1975: a period of demonstration projects, with
authority broadly defined, but calling for targeted focus on
the needs of the poor, accessible health care services plus
outreach and full integration and coordination with community
resources, and community participation.
1975-1980: a period of growth with enactment of permanent
legislation laying the foundation for community health
centers with establishment of standards of clinical practice
and administrative efficiencies related to fee schedules,
billings and collections, patient care, administrative cost
limitations, productivity, and hospital linkages as well as
consumer board involvement.
1981-1990: a period of retrenchment and consolidation for
health centers fending off reduced funding and conversion of
health center grants to state block grants until 1986.
1990-Present: a period of expansion and public recognition
with changes in federal reimbursement policy for health
centers requiring full cost-reimbursement for services
rendered to Medicaid and Medicare patients, and federal
malpractice coverage for centers and their clinical staffs.
Health centers have evolved through the years into a
dynamic and expanding network of locally-owned, nonprofit
community-based health providers. Their mission is a provide
comprehensive primary and preventive care to America's poor
and underserved. America's health center network, today, is
comprised of federally-assisted community and migrant, and
homeless health centers as well as other community-based
health centers, which are qualified under the Medicare and
Medicaid laws.
Nationwide 2200 health center service sites deliver primary
and preventive health care to almost 8.8 million people in
urban and rural underserved communities. More than 7.5
million people obtain care from health centers that receive
funding from the four principal health center grant programs
administered by the U.S. Public Health Service: Community
Health Centers; Migrant Health; Health Care for the Homeless;
and Health Service for Residents of Public Housing. Another
1.3 million persons receive care from other federally
qualified centers that do not receive federal grant funds.
Health centers are located in all fifty states including the
District of Columbia and the American territories of Guam,
Puerto Rico, and the Virgin Islands.
In Fiscal Year 1995, Congress appropriated $757 million for
the support of America's health center programs. It is a
modest sum in public investment given that health centers
have been given the challenging task of providing care for
some of America's poorest, sickest, and hard-to-reach
populations. The typical budget of an urban health center is
$3.7 million; a typical rural health center budget is $1.6
million. The average health center operates with a main
facility and three to four satellite delivery sites, which
are all located in the center's service area. The collective
budget of the nation's health centers, inclusive of grants,
Medicare and Medicaid reimbursements, and other revenues
approximate $2 billion annually, which is less than one-
fourth of one percent of total U.S. health care expenditures.
In structure, health centers are public/private
partnerships. They nonprofit corporations, locally owned and
operated by the people and communities they serve. Their
revenue base is multisourced. Federal grants, on average,
represent 36 percent of a health center's budget.
Reimbursements from Medicaid, the public insurance program
which pays for the care of many low-income and poor, on
average, accounts for 33 percent of a health center's budget.
Medicare, which insures the nation's elderly, is
approximately 5 percent of a health center's budget. State
and local government contributions as well as foundation and
private donations average about 11 percent of a health center
budget. Eight percent of a health center budget is derived
from private insurance and about 7 percent is from patient
fees.
service characteristics
The health center mission is to promote high quality,
comprehensive health care that is accessible, culturally and
linguistically competent, and community directed for all
medically underserved populations.
Health centers are required to provide a broad range of
primary and preventive health services including physician,
physician assistant and nurse clinician services; diagnostic
laboratory and radiology services; perinatal services,
immunizations, preventive dental care, disease screening and
control, case management, emergency medical services, and
family planning services, and hospital referrals.
The focus of health centers is prevention and health care
access. Centers emphasize services that are designed to
enhance access and the effectiveness of medical care through
outreach, transportation services, heath/nutrition education
and case management. Some 98 percent of health centers offer
health education services; over 90 percent offer case
management service; more than three-quarters offer preventive
dental services and in-home laboratory services. All health
centers employ outreach and patient relations workers from
the communities they serve. Health centers recognize that the
risk factors and pervasive needs of patients from low-income
underserved communities require health services not typically
offered by traditional providers.
Health centers promote community directed responsive,
patient-centered care. Special intervention programs are
frequently developed by local health centers to address
significant community health needs such as teenage pregnancy/
infant mortality, AIDS, substance abuse, hypertension,
diabetes. Centers also organize the provision of services to
ensure that medical care is available at convenient times,
and in locations that take into account the special needs of
the populations they serve. Many centers offer evening and
weekend hours for working families; provide care at multiple
sites; use mobile clinics to reach rural and homeless
patients, and employ multi-lingual staffs or translators to
overcome barriers faced by people who speak little or no
English. Bilingual physicians are available at 63% of health
centers. All health centers have a 24 hour system for after-
hours calls and emergencies.
Health Centers are appropriately linked to hospitals,
health departments, nursing homes, and other providers and
social service agencies for emergency and specialty referrals
as well as counseling and other assistance as may be needed
by patients. The goal is to ensure that patients have access
not only to primary care, but a continuum of coordinated
care, including specialized treatment and support services.
Health centers serve in areas of greatest need. By law
health centers are mandated to serve urban and rural
communities that have been designated as ``medically
underserved''--areas suffering acute physician shortages,
with high levels of poverty, elderly, infant mortality, and/
or poor health status. Health centers are equally distributed
between urban and rural areas. Half are located in isolated
rural areas, the other half in economically-depressed inner
cities. In these locations, they are often the only available
and accessible primary care providers for the patients they
serve.
America's health centers are able to reach 20 percent of
America's 43 million medically underserved. They are
America's poor and vulnerable--persons who even if insured,
nonetheless remain isolated from traditional forms of medical
care because of where they live, who they are, and
frequently, their far greater levels of complex health care
needs.
Virtually all patients have family incomes below 200
percent of the federal poverty levels ($28,700 annually for a
family of four in 1994).
Nearly one in two is completely uninsured, either publicly
or privately, and more than one-third depend on Medicaid.
[[Page H9722]]
44 percent of all patients are children under 18, and 30
percent are women of childbearing age (nearly one in ten is
pregnant).
Over 60 percent of health center patients are members of
racial or ethnic minorities, compared to 26.3 percent for the
nation's population as a whole.
Health Centers improve access to care. Within available
resources, health centers must serve all who seek their
services. Patients are charged on a sliding fee scale to
ensure that income or lack of insurance is not a barrier to
care. All patients pay something toward the cost of their
care. Medicare and Medicaid as well as private insurance are
billed for those with coverage. Federal grants received by
health centers subsidize the cost of care furnished to the
uninsured, and additional services not covered by public or
private insurance.
organization and administration
Health centers recruit, train, and retain health
professionals. They bring physicians and health professionals
and needed services and health facilities to people not
served by traditional providers. Health center practices are
staffed by a team of board certified or board eligible
physicians, nurses, physician's assistants, nurses
practitioners, nurse mid-wives, dentists, social workers and
other health professionals. In rural areas, physicians are
typically family practitioners, while larger urban centers
are usually staffed with multi-disciplinary teams of
internists, pediatricians and obstetricians.
Health centers employ 5000 physicians. Almost 98 percent
are board certified or eligible and all are required to have
hospital admitting privileges. The number of other health
professions serving the nation's health centers is
approximately 6200.
Health center physicians and staff are salaried employees.
Salaries are negotiated and paid out of budget by the
individual health center entity. In some cases, staff
services may be contracted. The National Health Service Corps
(NHSC) also provides a source of doctors and other health
care professionals who serve in health centers in partial
obligation to repay government student loans and/or
educational scholarships. Approximately 1900 NHSC primary
care providers serve in underserved/shortage areas. Health
center employment for Community and Migrant Health Centers
alone is more than 35,700 with a total health center payroll
of $1.4 billion.
Health centers are governed by volunteer consumer boards,
composed of leaders and residents of the communities they
serve. A unique and distinguishing feature of health center
boards is that a majority of board members (51 percent) must
be patients of the center and who, as a group, represent the
community of patients served. The remaining members of the
board must be individuals who are actively engaged in the
community with local government, finance and banking, legal
affairs, business and/or cultural and social endeavors. At
present, there are a total of 12,500 health center community
board members.
Health center boards foster community ownership and local
participation. Health center boards meet on a regular basis
and are responsible for the approval of the health center
budget; financial management practices; the establishment of
center policies and priorities; personnel policies, including
the hiring and firing of the executive director; evaluation
of center activities, including program services and patient
satisfaction; and health center compliance with applicable
federal, state, and local laws and regulations. Health
centers are managed by a team led by an executive director or
chief executive officer, including a clinical/medical
director responsible or clinical programs and a chief
financial officer with responsibility for fiscal affairs.
Health centers meet high national standards of
accountability. They are subject to ongoing federal scrutiny
of their cost effectiveness and quality of care. Health
centers are required to periodically report to the government
on services, utilization, quality measures (for perinatal,
pediatric, adolescent, adult and geriatric services, low
birthweight, and infant mortality, and hospital admissions
and length of stay), financial management and status,
billings and collections, and patient satisfaction. In
addition, they are required to submit comprehensive health
plans for their geographic area detailing services,
demonstrating need and demand, and showing the impact of
their intervention.
Health centers hold an unparalleled 30 year track record of
providing quality and cost-effective care. Studies
demonstrate that health care costs for health center patients
are on average 30 percent lower than for other providers
serving the same populations. Health centers also achieve
significant cost savings by reducing the need for hospital
admissions and costly emergency care. The federal grant cost
for each patient cared for by health centers is less than
$100 annually; and the total cost of health center services
amounts to less than $300 when compared to other providers
serving similar populations.
Independent studies further document the success of health
centers in achieving positive health outcomes. Communities
served by health centers have cut infant mortality rates 10-
40 percent as compared to those that are not served by health
centers. In addition, centers have increased the proportion
of children who are immunized and have increased the use of
preventive health services such as Pap smears and physical
exams. Patients also have expressed overwhelming satisfaction
with the care they receive in health centers.
community partnership
Health Centers Empower the Community. The empowerment and
involvement of local citizens in planning and governance has
been the basic characteristic that has made it possible for
health centers to make a difference in medically underserved
communities in terms of the community ownership they foster
and the tangible benefits they yield. The community is
directly involved in every aspect of center operations--from
setting policy to staffing vital services, from providing
information on community needs to determining whether the
center is properly responding to those needs.
Health center governing boards, composed of community
leaders and patients/residents, engage citizen participation
and responsiveness to local health needs. In turn, health
centers are an integral part of their communities--providing
meaningful jobs for local residents, a means to attract
investment and other business and forms of community/economic
development, a base for community advocacy and action, and a
source for developing community leaders and giving them
recognition and stature in the community.
Health center board members and staff are vital to building
community ties and partnerships. They are actively involved
with schools, hospitals, state and local health departments,
community groups, businesses, churches and others in
developing health/education programs, identifying community
health needs, and creating integrated health networks to
enhance service capacity. They reach out to the greater
community leveraging support, additional resources, and
investment in health center programs. Successful
collaborative efforts, for example, are currently helping 337
health centers access free prescription drugs for low-income
patients. Center ties with universities and medical schools
are fostering the training of leaders in community-based
health care and promoting health centers as recognized
environments for the training of needed primary care
physicians.
Health centers are advocates for the patients and the
communities they serve. As a nationwide network, they are
using their experience, expertise and ideas to help
communities and governments leaders find solutions to health
care needs. Through education, communication, and
interaction, they are telling their remarkable story of
success in serving medically underserved populations--making
this nation aware that programs in primary care, outreach and
prevention work are essential to expanding access and
building stronger and healthier communities.
summary
America's health centers are tested models of community
based care. They are partnerships of people, governments, and
communities working together to meet health needs. In three
decades of growth and development, health centers have become
an integral part of America's health delivery system serving
as a safety net for the nation's poor and medically
underserved.
America's health centers have yielded a substantial return
on public and private investment. They have proven that the
special needs of high-risk and vulnerable populations can be
met with quality, dignity, and cost-effective health care. In
their committed work, they have produced compelling evidence
showing the dollar value of their programs, the cost savings
to communities, and the positive case-by-case outcomes of
primary care intervention.
Yet, health centers confront serious challenge as the
health care industry rapidly consolidates to contain costs
and the federal government moves to reduce public spending
and shift greater responsibility for health care and other
social programs to the states and private sector. The reality
is that health centers are being thrust into a price-driven,
competitive health care market. In a new managed care
environment, centers are being forced to compete not only for
scarce resources, but for paying/insured patients and market
base, which are vital to their financial viability and their
continued ability to serve the poor and uninsured.
While America's health centers are determined to survive,
the problem is that they face large and well-financed
providers such as HMOs and other conglomerates, who are now
tapping the Medicaid market and competing for lucrative and
exclusive managed care contracts with States. In some cases,
centers are being forced to contract with purchasers and
providers for health care whose bottom line is cost and who
have little or no interest in paying for a broad range of
social and other support services that have traditionally
characterized the health center mission, and which have been
the hallmark of their success in achieving quality and
containing health care costs.
The looming question is whether, in the process of
integrating into a managed care market, health centers will
be able to retain their unique identity as health care
providers. Will health centers be able to access the capital
and sources of investment needed for growth and development;
improved organizational frameworks to leverage strength and
capacity as providers; management and financial skills and
advanced technologies to sustain a competitive position? Will
health centers have access to adequate resources to
[[Page H9723]]
compete for doctors and other health professional staff? Will
the federal government continue to support the health center
mission to the extent that appropriate funding and safeguards
are provided to ensure a level playing field of competition?
Today, health centers are aggressively moving to be part of
the evolving health care system. In states and communities
across the country, health centers are taking steps to form
networks and full managed care plans with other local
providers, to negotiate subcontracts with other managed care
plans, and to develop the financial, legal, and business
acumen necessary to effectively function in the new
environment.
Health centers hold many strengths. They are low-cost
providers in high-risk markets. Their skills and experience
are unsurpassed as providers of patient-centered care to
vulnerable populations. They are locally owned businesses and
community driven in their approach to meeting health care
needs. Health center programs in primary care offer
accountability, quality, efficiency and cost savings. In
addition, they hold tremendous assets in a nationwide solid
infrastructure ready for fast-track development to meet
growing health needs.
America's health centers stand prepared to build on their
heritage and compete and endure in the future.
references
Access to Community Health Care--A State & National
Databook. National Association of Community Health Centers,
Inc., Washington, DC, 1995.
America's Essential Providers: The Foundation of Our
Nation's Health System. Gage, Larry S., National Association
of Public Hospitals; Willson, Peters D., National Association
of Children's Hospitals and Related Institutions; Finerfrock,
Bill and Thometz, Alice, National Association of Rural Health
Clinics. Jointly published, 1995.
America's Health Centers. National Association of Community
Health Centers, Inc., Washington, DC, 1995.
America's Health Centers: Value in Health Care. National
Association of Community Health Centers, Inc., Washington,
DC, 1995.
Basic Information--Community & Migrant Health Centers.
National Association of Community Health Centers, Inc.,
Washington, DC, 1992.
Community and Migrant Health Centers: A Key Component of
the U.S. Health Care System--Overview and Status Report.
National Association of Community Health Centers, Inc.,
Washington, DC, 1991.
Community Health Centers: Engines for Economic Growth.
National Association of Community Health Centers Inc.,
Washington, DC, 1994.
Improving Access to Care for Hard-to-Reach Populations.
National Association of Community Health Centers Inc.,
Washington, DC, 1992.
Lives In The Balance: The Health Status of America's
Medically Underserved Populations. National Association of
Community Health Centers Inc., Washington, DC, March 1993.
____
Bureau of Primary Health Care: 43 Million People Lack Access to Primary
Health Care
unmet need
Forty-three million persons without access to a primary
care provider; 41 million persons are uninsured; minority
health status disparities.
pressures facing the safety net
Reduced Medicaid revenue from managed care: reimbursement
rates down; reduction in Medicaid eligibles.
Increase in the number of uninsured served; e.g. health
center uninsured up 46% from 1990-96 (national up 16%)
Mergers/Privatization decrease capacity: reduced outpatient
provider capacity.
health centers
Private, not-for-profit organizations: true safety net
providers, obligated to serve all patients without regard to
ability to pay; community-based governing boards, and
community supported; located in underserved areas; provide
comprehensive care services and enabling services; improve
health outcomes and decrease Medicaid costs; 685 center
grantees; services provided at 3,032 sites (incl. NHSC); over
10 million uninsured and vulnerable patients served; 33
million encounters in 1996; and 5,500 primary care providers.
health center patient characteristics
42% children; 32% women of child-bearing age; 65% minority;
41% uninsured; and 85% poor and near poor.
chcs as ``economic engines''--the economic benefit of chcs
CHCs as ``employers'': CHCs are often one of the largest
employers within their immediate service area.
CHCs as ``purchasers'': CHCs are often one of the largest
purchasers of goods and services within their service area.
CHCs represent a significant and vital source of economic
inertia for local communities which is consistent with the
objectives of emerging economic development initiatives.
response of health centers to managed care
Individual contracts with managed care organizations;
Formation of health center-owned health plans and MCOs; and
Development of integrated service networks to contract with
managed care organizations.
market share--health center-owned managed care plans in 12 states
Number of States: first in market share: Connecticut; New
York; California; Massachusetts; Colorado; and Washington
Second in market share: Rhode Island.
Third in market share: Maryland and Oregon.
Fourth in market share: Ohio; Hawaii; and Missouri.
solutions not business as usual
Increased partnerships; integrated networks/delivery
systems; innovative models of care; and document impact.
health centers
Agents of care.
Agents of change: Integrated delivery system; making system
responsive to local needs; and giving communities control.
health centers as solutions
Serve everyone regardless of ability to pay; guaranteed
access through enabling services; empower communities;
improve health outcomes and lower Medicaid costs; and
economic engines and create jobs.
The ``Community'' in Health Care Centers
The most frequently mentioned aspect of consumer
involvement in the health center programs is the fact that a
majority of each center's policy, or governing board must
consist of persons who are patients of the center and who, as
a group, represent the community of patients served there. We
use many terms to describe this characteristic of the health
centers: consumer-controlled, consumer-directed, community-
responsive, and so on. Their majority status on the health
center policy boards gives patients control in determining
how the centers operate: what services are provided, the
locations and hours of operation, the sliding scale fee
discount system, the annual budget and program plans. But the
real value of this patient-majority governance system lies in
the fact that, as a result of it, the community is given a
true sense of ``ownership'' over the health centers; and this
feeling of ownership makes the centers a course of community
empowerment, in which the centers serve as the basis and
focal point for a whole host of activities that serve the
community and its people. When the community is empowered in
this fashion, they will actively involve themselves in being
a part of its work (a part of the solution, not the problem).
They will care for and nurture ``their'' system of care, and
they will fight like hell to keep it going. This experience
plays itself out in any number of ways, such as:
Creating a forum for bringing real and immediate problems
to the table for action. This clearly happens as a natural
part of the regular policy board meetings; but most health
centers also reach out to the whole community as part of
their needs assessment process. For Asian Health Services, in
Oakland, CA, this has meant community meetings conducted in 6
different languages to involve each of the population
subgroups they serve: Korean, Japanese, Chinese, Laotian,
Cambodian, and Pacific Islander. Their efforts have been
rewarded with high community turnout and solid input from the
residents.
Getting feedback on the acceptability and appropriateness
of services and the centers' program plans. Here again the
policy boards provide a vehicle for evaluating the center's
responsiveness to the community's needs. Consumer board
members bring the community's needs and concerns and
complaints about the health center to the board for
consideration. This is perhaps the most important role they
can play.
Providing a training ground for community leaders and
spokespersons--including board members and center employees--
and giving them credibility, recognition, and stature in
advancing or advocating community needs or concerns.
Providing a means and forum for involving community
residents, and the community itself, in the political process
and system--at the local, state, and national levels. The
critical value of this point is that several individuals in
the health center movement have--for perhaps the first time
in their lives--involved themselves actively in our American
political system. This has helped the movement itself, which
has survived and benefitted from their advocacy.
Through NACHC and the State Primary Care Associations,
community residents have found an invaluable mechanism for
taking on critical health policy issues, and winning for
their communities. As a direct result of their experience,
many health center representatives have become quite
involved in local, state, and national politics--for
example, former board member Danny Davis is now a Member
of Congress; community representative Lenny Walker is now
a Rhode Island state representative; and former center
Director Harvey Sloane has served as Mayor of Louisville
and almost became Kentucky's junior U.S. Senator.
Serving as a conduit of important information to and from
the community. Whether this involves information on how to
avoid common childhood injuries or potentially serious
agricultural accidents, warnings about unsafe water supply
sources or the emerging incidence of an infectious disease,
or whether the community provides information that the center
needs to better serve its needs, the centers can serve as a
vital communications link for the entire community. For
example, a Brownsville, TX health center brought considerable
national attention to a growing local controversy, reported
in the New York Times and on ABC's Prime Time
[[Page H9724]]
Live, involving the center's report of an abnormally high
number of births to babies with severe anencephaly and a
possible connection to certain airborne toxins being emitted
from nearby chemical plants. Here, obviously, the center is
serving both as an information source and as an advocate for
its community.
Generating action in response to community needs, even in
case where those needs might not appear to be health-related.
Whether it is the affordable, low income housing developed by
health centers in Boston and Wood River, RI, or the community
water supply and sewer systems spawned by centers in Beaufort
County, SC, and the lower Rio Grande Valley of Texas, health
centers all over the country have played key roles in
organizing their communities to address pressing local needs.
Providing jobs and meaningful employment for community
residents. In particular, when respected community people are
employed and trained by the health center as outreach or
community health workers, or as patient advocates, or in any
of the dozens of clinical and administrative positions, it
can be the start of a long and rewarding health career. Many
health center directors today are community residents who
have worked their way up the ladder at the health center over
the past 15 or 20 years. Employees with the longest tenure at
health centers--often dating back to the center's founding--
are local community residents. One such person recently
stated, ``It's been a wonderful experience, working at a
great place like a health center, serving the community and
helping my neighbors and friends--and being paid a decent
salary to boot!''
Serving as a source of information and inspiration--
complete with role models--for the community's youth,
encouraging them to pursue a health professions career, and
showing them how (and where) they could put that professional
training to good use by coming back to serve their old
neighborhood or town. Dr. Jack Geiger, one of the founding
fathers of the health center movement, recently spoke of what
he saw as the real successes of one of the country's first
centers, in Mound Bayou, MS. In doing so, he noted that the
center had either trained or assisted in helping to train the
county's first black sanitarian, several of the physicians
now working at the health center, and literally dozens of
other professionals working there and at other centers across
the country.
Serving as an ``anchor'' in their communities, helping by
their presence to attract or retain other local businesses--
including other physicians, diagnostic services, pharmacies
or other health providers--or to bring in other forms of
community or economic development. In a very real sense, many
health centers have played pivotal roles in sustaining a
sense of ``community'' in neighborhoods or towns that
otherwise might well have completely disintegrated, giving
its residents a feeling of pride and a ``can-do'' attitude,
which in turn has led to significant neighborhood or
community revitalization.
Thus, the critical, distinguishing factor that separates
the health center model of community empowerment from other,
less successful models, is that the community has been
directly involved in virtually every aspect of the center's
operations--from setting policy to staffing vital services,
from providing information on community needs to determining
whether the center is properly responding to those needs,
and, in turn, the health centers have become an integral part
of their communities--providing meaningful jobs for local
residents, a means to attract other businesses and other
forms of community/economic development, information and
opportunities for pursuing health professions careers, a base
for community advocacy and action, and a source for
developing community leaders and giving them recognition and
stature in the community. The greater the degree of community
involvement in the health center, the greater the center's
role and strength as a vital part of the community itself.
Today, we are in the midst of sweeping changes in the way
health care is both financed and delivered, all across the
country. As the numbers of uninsured have reached levels not
seen since before the creation of Medicare and Medicaid, and
as health care costs continue to skyrocket, health care has
reached the ``hot button'' level as a public policy issue.
The growth in HMOs, PPOs, institutional networks, financing
bureaucracies, consolidated services, hospital closings and
transitions, self-funded insurance plans--all these thing
point to major, fundamental shifts in our health care system.
By the end of the decade, there will be no more Marcus
Welbys, even in group practice form. Every provider--
physician, dentist, midlevel--will work for ``the man''. For
us, the big question is who will ``the man'' be? Will it be
the government, an HMO, an institutional network--or the
community.
The health center model is our last, best hope for
community-directed, community-responsive health care. Health
centers may well be the closest things to Marcus Welby in the
21st century--the last real opportunity for the community to
have a voice in how its health care system functions and
meets their needs. We in the health center movement--yes, we
still see it as a movement--have our plan, our Access 2000
plan, to bring top quality health care to all 43 million
medically underserved Americans by the turn of the century.
It's a hefty order, to be sure, but we are committed to that
vision, that struggle; and yet, we cannot succeed without an
equally committed band of health professionals--and we need
to find and train them in record numbers, if we are to have
any chance at success. As our health center movement expands
and grows, we will continue to need the best and brightest
clinicians, to provide care and leadership.
Mr. TOWNS. Mr. Speaker, I rise to day to urge my colleagues to
support Community, Migrant and Homeless Health Centers and other
community-based providers that comprise successful models for health
care delivery across this Nation.
Community health centers benefit the residents and the areas where
they are located in many ways. First, with the partnerships between
business, government and the people, community residents have a greater
sense of control over the quality of health care and the means of
gaining health care. This is particularly shown in the health centers
that are governed by consumer boards. These boards, where more than
half of the board members are patients, represent the community served
and give local residents a voice regarding the programs and center's
services. With community representation on these boards, responsiveness
is no longer a concern--who best knows what services communities need
than the people who reside in the community?
Second, health centers service communities which are traditionally
and chronically underserved. Often, the inner cities, migrant
farmworker communities, and isolated rural areas benefit greatly from
these health care services. These often forgotten populations also now
have access to quality managed care; health centers provide
comprehensive primary and preventive health care. All patients,
especially women with their particular health care concerns, can look
forward to up-to-date yearly medical exams. We know that the key to
health care is taking preventative measures. With community health
centers, we can do this by low-income seeing patients early and
regularly.
Finally, health centers save money. In total, they provide cost-
effective, high-quality health care. The total costs for patients are
on average 30 percent lower than for other providers serving the same
populations.
Mr. Speaker, I urge my colleagues to support community health
centers. In my district these centers have played a vital role, as I am
sure they have done in other districts, and we should support them as
they continue to support our communities.
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