Caring for the Poor in the 21st Century: Enabling Community Health Centers for a New Era

Caring for the Poor in the 21st Century:Enabling Community Health Centers for a New Era Kevin Fiscella, MD, MPH (bio) and H. Jack Geiger, MD (bio) Community health centers (CHCs) represent the largest system for primary care to poor and undeserved patients in the U.S. Since Jack Geiger and Count Gibson founded the first CHC, Columbia Point Health Center in Boston in 1965,1 CHCs have proven remarkably resilient and effective. For half a century, they have weathered, seven economic recessions, nine U.S. Presidents, federal government shut downs, and sequestrations, and the rise and fall of managed care. In the face of these historic challenges CHCs have provided high quality care while minimizing health care disparities and costs.2–6 In an era of gigantic health care systems, independently operated CHCs are the little engines that could. Their patient governing boards, community focus, diverse staff and provision of high quality, patient-centered, efficient and equitable care represent a model for the U.S. health system. CHC’s success likely reflects their grass roots governing structures, savvy leadership, passionate commitment to care for the underserved and community health, unique payment structures, and support through the National Health Service Corps and various state loan repayment programs.7–10 Throughout their history, CHCs have received almost continuous bipartisan support in Congress, from both red and blue states. This support has enabled remarkable growth over five decades to more than 1,200 CHCs serving some 23 million low income patients. While FQHC have survived against the odds, they often generate narrow financial operating margins and limited cash reserves.11 Among CHCs, there is wide variation in fiscal health.11 The rapidly changing landscape of health care reform in the United States poses important opportunities and unique threats to CHCs.12 Wright et al report results from a survey of CHC executive directors in Iowa regarding CHC capacity and demands and organizational readiness for change. Nearly three out of four CHC directors anticipate [End Page 2044] increases in their patient population with a corresponding shortage of primary care clinicians and nurses. Only half of directors report their CHC has the resources to respond to health reform challenges. Most report significant need for behavioral providers. In short, most CHC directors perceive a mismatch between future health demands and the capacity of their CHC to meet those demands. Wright et al are careful to note limitations of their findings. Only Iowa CHC directors were surveyed. Some of the challenges confronted by CHCs within rural states differ from those in more urban areas.13 Some might dismiss these findings as executive angst about an uncertain health care future. However, a recent national survey of hospital executives revealed starkly different results. Most hospital executives expressed optimism regarding the future of health care and 93% anticipated that the quality of care provided by their own system would improve.14 Thus, it seems that CHC directors’ responses reflect more than just angst regarding a rapidly changing landscape. CHC Opportunities The opportunities confronting CHC are more evident than the threats. Twenty seven states including the District of Columbia have opted for expanded coverage of Medicaid to 138% of the federal poverty line for US citizens.15 This Medicaid expansion, which will likely continue to grow, will undoubtedly provide additional revenue for CHCs in affected states.16 In addition, the recent change in the Medicare prospective payment system (PPS) implemented October 1, 2014 will help, but Medicare is a relatively small source of revenue.16 Federal funding for expansion of CHCs, largely for construction and renovation, has improved the reach of CHCs,17 but this brick and mortar funding will not necessarily improve operating margins. Experiences from insurance expansion in Massachusetts suggests that expansions has increased not decreased demand for care through CHCs.18 This increased demand results not only from more patients being able to afford primary care, but also because patients view CHCs as providing affordable and convenient care as opposed to representing a provider of last resort.18 CHC Threats The threats to CHCs are less visible and less well documented. These include potential erosion of the Medicaid PPS, failure of many states to expand Medicaid, the...