Tuesday, December 30, 2008

Community Health Centers

Boxing Day, December 26, 2008, the New York Times has a shortage of news, and its featured right-hand column page 1 story is “For Bush, a rise in health clinics shapes a legacy”. While scarcely “news”, the article addresses an important topic: the expansion of Community Health Centers during the Bush years, arguably the only contribution that the outgoing administration made to health and health care. The first paragraph notes that the legacy is in “bricks and mortar”, with creation or expansion of 1,297 clinics in medically underserved areas. As one reads on, the article documents the problems: there are still too few, the demand still exceeds the supply, and the funding for them (beyond the physical expansion of “bricks and mortar”) is inadequate. In addition, it notes an issue that has been addressed on this blog: there are not currently enough primary care physicians to staff them, and given the rate of entry of students in to primary care, the problem is likely to get worse.

Community Health Centers originated in the Great Society program of the Johnson years. Contrary to false claims that the War on Poverty didn’t work, it did; while poverty surely was not eliminated, its impact was reduced. Of course, the funding for the programs suffered with the expansion of the Vietnam war, and the Reagan administration decimated most of the programs. (Poverty rates in the US dropped from about 20% in the early 1960s to less than 10% in the early 1970s, to rise again through the 80s and 90s.)[1] Known as “330 clinics” because they were established under Title 330 of the Public Health Service Act,[2] and currently know as Federally Qualified Health Centers (FQHCs), these Community Health Centers (and their “cousins”, the Title 329 Migrant Health Centers) provide sliding scale fee-for-service care to the urban and rural underserved. T[3]hese terms are clearly and simply explained in a University of North Dakota publication. In exchange for meeting a variety of service and reporting requirements, including management by a Board that is at least 51% consumers (clinic clients), these clinics get enhanced reimbursement from Medicare and Medicaid at rates far higher than ordinary doctors or clinics. They also get “grant funds” intended to help them care for the uninsured who are not eligible for one of these federal (Medicare) or federal-state match (Medicaid) programs. (There is also a class of clinics called FQHC-“look alikes” that have to meet the same criteria and get the same Medicare and Medicaid reimbursement, but do not get the cash grant.) Of course, these are the funds that are grossly insufficient for most clinics; the needs of the number of working poor who do not have health insurance and do not qualify for Medicaid, which is the fastest growing portion of our population, far exceed the funding.

According to the Times article, “As governor of Texas, Mr. Bush came to admire the missionary zeal and cost-efficiency of the not-for-profit community health centers.” This is admirable, and I am certainly glad that this admiration has resulted in his expansion of the program. But there remain issues to be addressed, hopefully, by the incoming administration, related to this admiration. First, as we and the article have noted, is the need for additional funding so that these centers, as zealous and cost-efficient as they may be, can begin to meet the health care needs that exist. Second, there need to be programs – unquestionably tied to increased reimbursement – to encourage more young physicians to enter primary care so that there are physicians to staff these clinics. The Bush administration has been less concerned about this issue, continuing to oppose funding for Title VII of the Public Health Service act that funds training of primary care doctors, as well as other programs including physician’s assistant training.[4]

Another issue concerns our expectation that those caring for the poor should sacrifice, be volunteers, be less well paid, than those caring for the insured or more affluent, who we expect to earn as much as possible. The Times article notes that CHCs often start their primary care doctors at $120,000 a year. While there is some regional variation, and it is difficult to get sympathy from people who are losing their jobs for someone “only” making $120,000 a year, this is a salary that is far lower than even primary care doctors make in practices serving the insured, and an amount significantly lowered by the medical school debt accumulated by many of the same committed doctors who wish to work in such settings. And this is “good”, that is, these are at least living-wage jobs for physicians; in many settings that do not have CHCs or publically-funded (usually county or city) clinics, those caring for the poor are actually much closer to being “volunteers”. In my town, the Missouri side of the Kansas City area has a (inadequately) county-supported hospital and two large FQHCs. The Kansas side has neither public hospital or public clinic or its own FQHC. Wyandotte, the poor county, has a high rate of uninsured people and has two one-doctor branches of the Missouri FQHC, 3 volunteer-doctor clinics, and a clinic that works because all the staff including the physicians earn $12/hour. And depends on grants. Johnson County, one of the richest in the nation, has just over 1/3 the uninsurance rate of Wyandotte, but with over 3 times the population, has more uninsured, and poor, people in total. And it has 2 volunteer clinics, with a half-time medical director. So, for the nearly ¾ million people in these two counties there are about 3-4 jobs that pay anything close to a reasonable wage for physicians; in these circumstances it would not matter if a lot more graduating physicians wanted to serve the underserved; the jobs are not there. Johnson County, in particular, with a high income population and a smaller percentage of poor and uninsured, deserves censure for not having a publically funded clinic system, not to mention hospital.

A two-class health system is not desirable, but it is better than when the lower “class” can get no care at all. Those working in CHCs, public clinics, and public hospitals, chronically underfunded, rightly bemoan their inability to truly meet the health needs of their patients, but there are many places where even that level of care is simply not available. CHCs may be excellent models for health care delivery for all people, but while we laud and honor those who work in volunteer clinics and public hospitals, we cannot consider this the solution. Martin Luther King, Jr., said “Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary.” (More pithy, Jonathan Kozol: “Charity is not a good substitute for justice.”) We must never stop struggling against this injustice.

If we ever achieve a national health system, where financial barriers are eliminated and hospitals and physicians are paid the same for the care of a homeless person as a millionaire, we will be much closer. Sure, some hospitals and doctors will still try to avoid caring for the homeless and poor but then, at least, without the financial disincentive, we can correctly identify them as what they are (? how about “scum”?) Until then, we depend on volunteerism and sacrifice to try – very incompletely – to meet the health needs of our most needy. Tudor Hart’s inverse care law again validated.

[1] US Census Bureau, Historic Poverty Tables, http://www.census.gov/hhes/www/poverty/histpov/hstpov2.html
[2] http://bphc.hrsa.gov/about/legislation/section330.htm
[3] Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs) http://ruralhealth.und.edu/pdf/hpsa.pdf
[4] Freeman J, Kruse J “Title VII: Our Loss, Their Pain” Annals of Family Medicine 4:465-466 (2006).

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