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Almost sixty million Americans—about one in five—go without regular primary care (NACHC 2009a; AHRQ 2006). Lack of access is not simply a matter of insurance status; the difficulty of finding a primary care provider is a massive barrier to the use of primary care. Traditionally, charity care for the medically indigent has existed outside of government channels. From the early 1900s, local and county governments experimented with funding, coordinating, and even providing ambulatory care; none of these efforts survived attacks by local physicians. But beginning in the mid-1960s the federal government began funding a new mode of primary care delivery: community health centers. Community health centers are not-for-profit entities serving residents of areas designated by the Department of Health and Human Services (HHS) as “medically underserved.” Subsisting on third-party reimbursements (mainly Medicaid), competitive federal grants and loan guarantees awarded by the HHS, and some state and local governmental support and philanthropic funding , they provide comprehensive ambulatory care, either free or on a sliding scale. Centers also offer different mixes of “enabling” services, from case management and transportation to and from the facility, to translation services, and to substance abuse programs, immunizations, and screenings. In addition, all centers regularly assess community health problems and conduct health education and outreach programming; some target specific populations, such as migrant workers, public housing residents, homeless individuals, and elementary and secondary school children. Today, more than 1,100 centers provide what is considered cost-effective and high-quality care to more than twenty million Americans at more than Dr. StrangeRove; or, How Conservatives Learned to Stop Worrying and Love Community Health Centers Chapter 2 21 Robert W. Mickey 7,900 delivery sites. Health centers improve access and use for the underserved , and reduce ethnic and racial disparities in health outcomes. About one-third of their patients are Hispanic (most of whom rely on bilingual staff), and another quarter are African American. Seventy percent of patients are poor. Fully 60 percent of users have some form of health insurance.1 The health centers program constitutes the country’s largest primary care system. With annual expenditures of more than $7 billion (not including additional funding through FY 2015 provided through the Patient Protection and Affordable Care Act of 2010 [Affordable Care Act, or ACA]), community health centers now occupy a central role in America’s safety net of health care provision . Combining primary care with some public health functions—a departure from the traditional bifurcation of medical care from public health—health centers also feature a quite radical governance structure begun during the program’s origins during the War on Poverty: a majority of each center’s governing board must consist of active patients residing nearby (Brandt and Gardner 2000). Excluding state and local sources, patient payments, and third-party reimbursements, HHS spends more than $2 billion per year on the program (figure 2.1). Relying more than other health facilities on nurse practitioners, physicians’ assistants, and other non-MD health professionals, health centers are also heavily dependent on the National Health Service Corps and other federal medical workforce programs. Just over one-half of health centers are in rural areas while just over one-half of all patients reside in urban areas. Health centers exist in every state, in more than 90 percent of congressional districts, but in only about one-quarter of those areas designated by HHS as medically underserved (Iglehart 2010, 343). The program is managed by HHS’s wellregarded Health Resources and Services Administration (HRSA), and for more than three decades a highly effective national lobby and its state affiliates have played a critical role in the program’s survival and its recent, strange expansion. Begun as a demonstration project during the War on Poverty, the program has until recently remained in the shadows of the health care system. Uncontroversial and of low salience to members of Congress, it muddled through for three decades. Targeted by Republican administrations and conservatives for reduction or elimination through budget cuts or conversion into block grants, it survived but never experienced the massive expansion for which its proponents long hoped. The Clinton administration was also strangely uninterested in it, and it grew during the 1990s only due to the initiative of a bipartisan coalition in Congress and improved financing arrangements. In the past decade, a massive expansion has occurred, but under the unlikely stewardship of the George W. Bush administration. While many other programs for the poor...


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MARC Record
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