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On March 23, 2010, forty-five years after the first community health centers opened their doors in Mound Bayou, Mississippi, and Boston’s Columbia Point housing projects, President Obama signed into law arguably the most sweeping overhaul of the nation’s health insurance system ever attempted. Unlike Medicare and Medicaid, the Patient Protection and Affordable Care Act (ACA) does not merely fill the chasms created by voluntary health insurance.1 Instead, it tackles the fundamental problems that arise in a system that gives healthy individuals the freedom to opt out, bars coverage for the sick, and allows private insurers to select the healthiest customers and then walk away when the tide turns. The ACA addresses these problems by creating a five-pillar approach to health reform. First, as of January 1, 2014, the law eliminates health insurers’ ability to choose only the healthiest risks by barring various types of discriminatory practices including, among others, rescissions of coverage, discrimination based on health status, and application of preexisting condition exclusions.2 Second, by requiring virtually all individuals who can afford to do so to obtain coverage, the law creates the national pool of healthy lives essential to any viable, stable approach to universal coverage.3 Third, to ensure that coverage is affordable, the legislation creates a system of refundable tax credits and cost-sharing subsidies.4 Fourth, the legislation creates a more robust individual and small-group market for health insurance coverage through the establishment of state health insurance exchanges.5 Finally, the law restructures Medicaid to ensure coverage of the poorest individuals.6 Reinventing a Classic Community Health Centers and the Newly Insured Chapter 3 67 Sara Rosenbaum But even as the ACA establishes a new foundational base for health insurance , it pretty much leaves untouched the organization and practice of health care. Important pilot efforts are authorized that aim to use Medicare and (at state option) Medicaid to incentivize greater quality and efficiency among health care providers.7 But these pilots do not alter providers’ freedoms to select the patients they wish to treat, practice in what they perceive to be desirable locations, reject patients considered too difficult to manage, or specialize in accordance with the practice area of their own choosing. Nothing in the law compels physicians—the gateway into the health care system—to locate in poor communities, to accept Medicaid beneficiaries or uninsured people, to learn to speak multiple languages, or to become skilled in caring for patients whose health burdens extend far beyond a relatively simple set of presenting clinical symptoms. By contrast, adaptation of health care to medically underserved communities and populations is the hallmark of the health center program.8 The ACA makes a number of major investments in community health centers. A primary purpose of these investments is to address the chronic shortage of health care professionals to serve the low-income and medically underserved populations who are the principal beneficiaries of health reform. An additional purpose is to prepare for the surge in health care use that can be expected to flow from a major expansion of insurance (Kessler 2009) to thirtytwo million persons, including the sixteen million mostly adult poor people who will gain Medicaid eligibility.9 The aim of these reforms is to more than double the size of the program by 2019, growing health centers from the twenty million patients served in 2009 (NACHC 2009) into a health care gateway for some fifty million medically underserved children and adults by 2019 (Rosenbaum, Jones, and Shin 2010). Most of these patients will be insured, but more than one in five is projected to remain without health insurance as a result of gaps in coverage, the lack of affordable options, or legal status (ibid.). This is to be expected, of course, given the mission of health centers. How health centers respond to this updated mission and the opportunities and challenges that lie ahead are the focus of this chapter. The chapter begins with an overview of the health centers program and its key characteristics. It then describes the major elements of the law that will help shape their ability to achieve this expanded gateway mission. It also discusses broader currents moving through the health care system as a whole—including the pressures toward clinical and financial integration—that ultimately will bear directly on health centers’ success in opening a window onto the entire health care system for their patients. 68 Sara Rosenbaum Overview Health Centers’ Origins and...


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