After nearly a year of heated debate about health care reform, Americans are used to hearing about the millions of their fellow citizens who are living without access to affordable medical care. But now that a version of reform has passed, what will happen to the institutions that have helped the poor and uninsured cope: community clinics and health centers?
The Role of Community Clinics
The first not-for-profit health centers were founded in 1965, with roots in the War on Poverty and the civil rights movement. Their goal was to provide an open door to health care for poor and underserved neighborhoods, while also supporting community empowerment. Since then, community health centers have proliferated and become an integral part of the nation’s health care safety net.
Last year, according to the National Association of Community Health Centers, clinics provided care to more than 18 million patients in over 6,300 communities across the country. Those individuals are disproportionately poor, uninsured, and publicly insured. More than 70 percent of clinic patients have family incomes at or below the federal poverty level. Clinics serve an ethnically diverse population, and they pride themselves on providing culturally proficient care in multiple languages and in easily accessible locations within their communities.
The demand for clinic services has nearly doubled in the past ten years, and the recent economic downturn has resulted in a spike in newly uninsured patients seeking care. Federal support for community health centers has also increased significantly, to $2.19 billion in 2009 (up from $1.34 billion in 2002). Clinic appropriations have historically benefited from bipartisan congressional support, and their important role in the health care system was also acknowledged in the recent federal health reform legislation.
Among the many provisions of the Patient Protection and Affordable Care Act was the creation of an $11 billion Health Center Trust Fund to support clinic operations and capital expansion. This year alone, payments from the Fund will essentially provide a 50 percent increase in federal support for clinics. The legislation also permanently authorizes the community health center program, which once had to be reauthorized every five years.
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The National Health Service Corps (an important provider of physicians to community clinics) is also slated for a $1.5 billion increase in funding over the next five years, essentially tripling its resources for attracting primary care doctors to work in medically underserved areas. When the new legislation’s insurance exchanges come on line in 2014, private insurers will be required to contract with “essential community providers” and to pay them no less than their current Medicaid rate per patient visit.
Clearly, an important role is envisioned for community health centers in a post-health reform America (assuming that efforts to repeal the legislation are not successful). But even with all this new federal funding, their future is not entirely assured.
We know that this legislation, even when fully implemented, will leave millions of individuals and families uninsured (including new immigrants and undocumented immigrants). If the experience of Massachusetts is any guide, clinics will be the main health care providers for a disproportionate share of uninsured individuals—other parts of the health care system will have no incentive to take care of these patients.
Capacity to provide primary care is going to be a particular problem throughout the health care system, but particularly so in the case of community health centers. Even with the increase in funding for the National Health Service Corps, the nation’s medical schools are simply not producing enough primary care physicians to fill the need. Clinics could be confronted with as many as 20 million new patients over the next five years—but with many clinics already experiencing long waiting lists for care in the current economic climate, even the substantial new funding available may only be a down payment on what will actually be needed to meet the demand for services.
And many of the clinics on which poor and uninsured patients depend—as many as half of the nation’s not-for-profit community health centers—do not benefit from federal grant funding, including funding from the recent legislation. That includes free clinics, women’s clinics and other providers of reproductive health care, and faith-based clinics, which are often supported by volunteer labor and individual charitable contributions. They play an essential role in the safety net, but they’re not included in the ambitious plans for clinic expansion. Neither the substantial stimulus money that has already flowed to federally-funded clinics nor the forthcoming funding for Information Technology will reach these key providers.
This landmark legislation has accomplished something many thought was not possible in this political environment. When fully implemented, it will bring us much closer to the ultimate goal of universal coverage. Just the expansion of the Medicaid program is noteworthy in and of itself. It’s the largest single piece of social legislation in a generation. That said, however, the jury is still out on whether we’re actually going to end up with a “reformed” health care system that better serves poor people and that can help reduce historic health inequities.
Just because many more poor people will have health insurance does not mean that they will be able to navigate the system without help. It also does not mean that they are guaranteed access to a health care provider that speaks their language and understands their culture and can provide them with a high quality medical home. There’s a lot of work to be done over the next few years to help ensure that we get the most we can out of this legislation, while pushing for refinements and improvements (e.g. a public insurance option) that were not included in the final version of the bill.
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