A NATION S HEALTH AT RISK II:

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1 Special Topics Issue Brief #7 A NATION S HEALTH AT RISK II: A FRONT ROW SEAT IN A CHANGING HEALTH CARE SYSTEM A First Hand Look at How Cost Effective Health Centers Are Affected by Increased Demand and Limited Resources August 2004 National Association of Community Health Centers

2 Special Topics Issue Brief #7 A Nation s Health at Risk II: A Front Row Seat In A Changing Health Care System August 2004 COPYRIGHT NACHC, 2004 ALL RIGHTS RESERVED This material may not be duplicated without expressed written permission from the National Association of Community Health Centers, Inc L Street, N.W., Suite 300 Washington, DC For more information, please contact: Michelle Proser Research and Data Analyst National Association of Community Health Centers, Inc. Department of Federal, State and Public Affairs Office 2001 L Street, N.W. Suite 300 Washington, DC / voice ~ 202/ fax mproser@nachc.com

3 EXECUTIVE SUMMARY In March 2004, the National Association of Community Health Centers began a series of reports looking at the state of health in America as seen through the eyes of health centers, which are the family doctors to 15 million Americans. The first installment, A Nation s Health At Risk, revealed that there are 36 million Americans 12% of the U.S. population who lack access to a regular source of health care. Now, in A Nation s Health At Risk Part II, NACHC attempts to construct a more substantial snap shot of the state of the nation s health care system and examines forces that are impacting access to affordable primary health care in America. Where are the nation s uninsured going to get their health care? How are Community, Migrant, Public Housing and Homeless Health Centers balancing growing demand with tightening revenue? From their unique front row seat in the war against poverty and disease, health centers are buffeted by the trends as they happen: Medicaid cuts in states dealing with budget shortfalls, cuts in direct funding, and a growing uninsured population at health centers in both rural and urban settings. These factors affect health centers even while they actually save money for other safety net programs namely, Medicaid and hospital emergency departments. Nation s Health At Risk Part II looks at costs, care, and the consequences for communities. Highlights of the report, The Nation s Health At Risk Part II, include: Health Centers Provide High Quality, Cost Effective Care Health centers provide care that is equal to or greater than the quality of care provided at other, often more expensive provider types, and greatly improve the health of their patients. By providing regular, continuous care and preventive services to populations who would otherwise go without, health centers are generating significant savings to society through reduced emergency department use and referrals to specialty providers. More Uninsured People at America s Health Centers The number of health center uninsured patients grew by 11% during 2003 alone. Some health centers are experiencing an explosion of uninsured patients as high as 73%, and due to a weakened economy and state budget cuts, no let-up is in sight. In fact, the fastest growing age group that health centers serve is years the age group more at risk for being uninsured than ever before. More Visits to Emergency Rooms In 2002 there were million visits to hospital emergency departments (ED) up from 89.8 million in 1998, despite the fact that the number of hospital EDs in the U.S. fell by 15% during the same time period. Any where between 10 and 50% of all ED visits are for non-urgent and avoidable conditions, and the medically vulnerable are more likely to make such visits. If these patients seeking non-urgent and avoidable care at hospital emergency rooms went to a community National Association of Community Health Centers,

4 health center instead, between $1.6 and $8 billion in annual health care costs could be saved nationally. Too Few Primary Care Doctors For Vulnerable Populations The number of primary care physicians per capita is shrinking, while the number of specialists has been rapidly growing. Fewer doctors open their doors to patients who rely on Medicaid. Onefifth are not accepting any new Medicaid patients. Compounding this access problem are other barriers to care, especially for those needing transportation, case management, translation, and other specialized services to facilitate health care use. Cuts In Direct Funding and Medicaid Challenge Health Centers States are balancing their budgets by cutting health care costs and Medicaid spending. Millions of dollars in direct state funding to health centers have already been cut over the last two years, and additional cuts are likely. Oregon, Texas, Georgia, Wisconsin, Arizona, Colorado, Connecticut, New Hampshire, Rhode Island, South Carolina, Vermont and other states are taking actions on Medicaid and SCHIP that could result in thousands of their residents getting shut out of affordable health care. Loss of support in any form exacerbates the already strained financial condition of health centers, and will result in their inability to serve new patients or even many of their current patients. Health centers are in the midst of a historic expansion initiative, thanks to the support of President Bush and a bipartisan response to Congress to boost federal funding to health centers by at least $2.2 billion through FY So far the expansion initiative has brought affordable and accessible health care to more than 3 million new patients. Nevertheless, there are not enough health centers for the people who need them. Nor are there available resources for communities who apply. This year, less than 1 of every 10 applications for new health center sites has been approved. Yet, existing health centers are able to do much with very little. The average cost of providing comprehensive care at health centers per patient per day is $1.30. At such a modest price, there are healthier newborns in communities lucky enough to have a health center. There are lower minority health disparities including disparities among those with chronic diseases such as diabetes, hypertension and HIV/AIDs, and fewer preventable hospitalizations and visits to the ED. This impressive record of success is why the Office of Management and Budget (OMB) rates community health centers as one of the federal government s most successful programs. Investing in health centers makes good fiscal sense. They create a cycle of good investment strategy: reduce barriers to care, lead to improved health outcomes, and thus trigger a significant cost-savings for society. Nation s Health At Risk: Part II provides extensive evidence of the value and benefits that health centers bring to their patients and communities, to public and private payers, and especially to taxpayers. National Association of Community Health Centers,

5 Introduction For nearly 40 years, the national network of Community, Migrant, and Homeless Health Centers have been delivering high-quality and cost-effective primary and preventive health care to low income and otherwise medically underserved communities. As part of the first line of defense in the war against poverty and disease, health centers hold a unique front row seat to trends impacting the US health care system. Rising numbers of uninsured, cutbacks in Medicaid, and state budget deficits have undoubtedly impacted the health of local communities and similarly buffeted health centers with unprecedented fiscal challenges. Can health centers meet these challenges and yet continue the expansion initiative to double the number of people served? The struggles of health centers often tell a story about what is happening in America, and in the health of its own people. In March 2004, the National Association of Community Health Centers (NACHC) began a series of reports looking at the state of health in America as seen through the eyes of health centers, who are the family doctors to 15 million Americans. The first installment, A Nation s Health At Risk, revealed that there are 36 million Americans 12% of the US population who lack access to basic health care. Now, in Nation s Health At Risk Part II, NACHC examines other trends that are impacting health centers and the communities they serve: a growing uninsured population, a shortage of primary care physicians and other barriers to care, and an increasing strain on hospital emergency rooms from growing demand. In this report, we will examine at length how these forces are impacting access to affordable health care in America and straining the safety net. The Importance of Having a Usual Source of Care Having a place to go for regular care is crucial for patient health outcomes and controlling the cost of health care. Furthermore, access to primary care may contribute to removing the severe adverse impact on income inequalities on health. 1 In order to prevent sickness and manage chronic disease, patients must see doctors before they are sick and require more expensive care. Numerous studies have concluded that having both health insurance coverage and a regular source of care results in improved overall health for the entire population. Indeed, one recent study found that having both coverage and a regular health care provider netted improved access to a variety of preventive services, and noted that improving preventive service delivery to the entire US population requires expanding health insurance coverage and improving access to comprehensive and continuous primary care services. 2 The results for patients with a regular provider are lower health care costs even if the patient is ill, improved health outcomes for specific diseases, and better overall health. 3 1 Shi L, et al. Income Inequality, Primary Care, and Health Indicators Journal of Family Practice 48(4): DeVoe JE, et al. Receipt or Preventive Care Among Adults: Insurance Status and usual Source of Care. May 2003 American Journal of Public Health 93(5): Maeseneer JM, et al. Provider Continuity on Family Medicine: Does It Make a Difference for Total Health Care Costs? Annals of Family medicine 1(3): (September/October 2003). Parchman ML and Burge SK. The Patient-Physician Relationship, Primary Care Attributes, and Preventive Services. January 2004 Family Medicine 36(1): See also Weiss LJ and Blustein J. Faithful Patients: The Effect of Long-Term Patient-Patient Relationships on the Costs and Use of Health Care by Older Americans. December 1996 American Journal of Public Health 86(12): National Association of Community Health Centers,

6 A host of studies conclude that having a regular doctor improves access to primary care and health outcomes more effectively than having insurance coverage or even the ability to pay fully for one s health care alone. Having a regular source of care prevents costlier illness later on, 4 and is associated with improved access and use, better management of chronic diseases, increasing cancer screenings for women by one-third, and even fewer lawsuits against emergency rooms. 5 Primary care is thus essential for people with chronic diseases, such as diabetes or hypertension, and for those who need health screenings, such as mammograms and pap smears. Another study bears out the fact that not having a regular provider is a greater predictor of delay in seeking care than insurance status, and that among insured persons, those with a regular physician enjoyed greater access to care than those without. Patients who have a regular physician are also less likely to go to the emergency room for health care. 6 Thus, improved access to a regular primary care provider leads to longer, healthier lives as well as lowering costs. Having both insurance and a regular source of care results in improved health and only when jointly present can we most effectively narrow health disparities among minorities, the poor, rural residents, and other medically vulnerable populations. The Need for the Safety Net Safety net providers play a crucial role in delivering regular care to vulnerable communities, who often rely on these providers as their only source of primary care. Individuals relying on safety net providers are largely uninsured and publicly insured, 7 and there is a growing need for their services. Yet even under universal insurance there will continue to be a need for safety net providers given that cost is not the only barrier to care. In fact, a recent study found that expanding both insurance coverage and the health center program are needed to improve access to care and that they complement each other, adding that health centers provide services others do not (such as services that facilitate the use of health care), may be the preferred source of care for many patients, and that incentives to promote provider participation in public programs may not encourage their practicing in underserved areas where safety net providers are located. 8 Barriers to health care are interrelated and complex, as described above. A recent NACHC report looked at one particular barrier, the lack of available primary care doctors in communities, and determined that 36 million Americans lack a place of regular care (the socalled medically unserved ) due to this problem. The report notes that the National Center for Health Statistics (NCHS) within the Centers for Disease Control and Prevention (CDC) also 4 For several studies on how primary care is related to improved health outcomes and lower costs, see Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998; Starfield B. Primary Care and Health: A Cross-National Comparison October 1991 JAMA 266(16): ; and Starfield B. Is Primary Care Essential? October (8930): Lambrew J. et al The Effects of Having a Regular Doctor on Access to Primary Care. Medical Care. 34(2): February Sox C, et al Insurance or Regular Physician: Which is the Most Powerful Predictor of Health Care? March 1998American Journal of Public Health. 88(3): IOM. America s Health Care Safety Net: Intact but Endangered. National Academy of Sciences Press, Cunningham P and Hadley J. Expanding Care Versus Expanding Coverage: How to Improve Access to Care. July/August 2004 Health Affairs 23(4): National Association of Community Health Centers,

7 found that a similar number of Americans reported being without regular care (possibly taking other barriers to care, such as language and insurance status, into account). 9 Based on these findings, one in eight Americans 12 percent of the population lacks a usual source of care, yet in some states, the unserved account for a much higher percentage of the population. The map below displays the states according to their proportions of unserved populations. In two states (Louisiana and Mississippi), the unserved account for one of every three state residents, and in ten others (Alabama, Arkansas, Georgia, Idaho, Kentucky, Nebraska, Nevada, North Carolina, Tennessee, and Wyoming) at least one in five residents have no regular provider of care. Map 1 Percent of State Population Without a Usual Source of Health Care, 2003 DC National = 12% Less than 10% 10-19% 20-29% 30% or Greater Note: Based on a private practice provider to patient ratio for each county. Residents left over (i.e., not in the ratio) are considered without access to a regular doctor, and these county estimates are totaled for each state. Patients of Federally-Qualified Health Centers are then subtracted from each state estimate. Source: National Association of Community Health Centers, A Nation s Health at Risk, The number of people without access to a usual source of care may actually reflect a maldistribution of health care providers within each state or region. Despite this, lack of available physicians is a very real crisis for the US health care system. Private, office-based physicians do not tend to locate in low income areas where health care services are severely lacking, and even if they did, only half of physicians are willing to accept all new Medicaid patients, and one-fifth are not accepting any. 10 Other research has found that too many private providers that do accept Medicaid are limiting the number of Medicaid beneficiaries they care for, thereby narrowing affordable access for beneficiaries. 11 Compounding all this is the fact that there are fewer practicing primary care physicians, where most Americans receive their 9 NACHC. A Nation s Health at Risk: A National and State Report on America s 36 Million People Without A Regular Healthcare Provider. March Cunningham PJ. Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, Center for Studying Health System Change, Tracking Report No. 6, December Zuckerman S et al. Changes in Medicaid Physician Fees, : Implications for Physician Participation. 23 June 2004 Health Affairs Web Exclusive W4: Cunningham, Berman, et al. Factors that Influence the Willingness of Private Primary Care Pediatricians to Accept More Medicaid Patients. August 2002 Pediatrics 110(2): Perloff JD et al. Medicaid Participation Among Urban Primary Care Physicians. Feb 1997 Med Care 35(2): National Association of Community Health Centers,

8 formal health care and preventive services. The Robert Graham Center, which provides analysis concerning family practice and primary care, reports that the number of primary care physicians per capita has been steadily shrinking, while the number of specialists has been rapidly growing accounting for more than three-quarters of the growth in per capita physicians from 1980 to This fact was recently noted by Elizabeth James Duke, Administrator of the Health Resources and Services Administration (HRSA) at the National Farmworker Health Conference last May. We have enough Park Avenue surgeons, Duke told attendees. We need health care staff in the real America. The lack of doctors or providers willing or able to care for vulnerable or medically underserved populations remains a critical access problem in the US. John Hopkins University researchers have found that mortality is related to a lack of primary care physicians. 13 Beyond and distinct from the number of available physicians, other barriers to care still exist, especially for those needing transportation, case management, translation, and other specialized services to facilitate health care use. Such services are especially important for certain populations, such as the homeless, farmworkers, and rural residents. Health centers, the largest national network of safety net primary care services, were established to eliminate most or all of these interrelated and complex barriers to care in order to guarantee that the medically vulnerable have a usual source of care, as well as access to dental, mental health, substance abuse, vision, hearing, and pharmacy services many of which may not be covered for insured patients. The Community Health Centers Program Health centers are local, non-profit, community-owned health care providers with a shared mission to improve access to regular health care for Americans regardless of their insurance status or ability to pay. Also known as Federally-Qualified Health Centers (FQHCs), they provide assessable, affordable, and appropriate primary care and preventive medical and health-related services, and often provide on-site dental, pharmaceutical, and mental health and substance abuse services to 15 million mostly uninsured or publicly insured Americans, making them a major provider of safety net services. Their mission and characteristics make them unique among all health care providers, as they: are located in medically underserved areas where health care options are few; are open to all patients regardless of ability to pay or whether they possess an insurance card; offer comprehensive medical as well as health care facilitation services tailored to meet individual community needs; and are governed by a patient-majority board to ensure that the health center is responsive to the community it serves. 12 The Robert Graham Center. The US Primary Care Physician Workforce: Minimal Growth, One-Pager Number 22, October Shi L, et al. The Relationship Between Primary Care, Income Inequality, and Mortality in the US States, September/October Journal of the American Board of Family Practice 16(5): Shi L and Starfield B. Primary Care, Income Inequality, and Self-Rated Health in the United States: A Mixed-Level Analysis International Journal of Health Services 30(3): Shi L, et al. Income Inequality, Primary Care, and Health Indicators. April 1999 Journal of Family Practice 48(4): National Association of Community Health Centers,

9 Armed with a solid record of achievement and experience, health centers have vastly reduced complicated and multiple barriers to health care for vulnerable populations and have changed the health care landscape to provide more affordable options. Not only have health centers successfully improved access to primary and preventive services, they effectively manage chronic disease, reduce racial and ethnic health disparities, decrease infant mortality, create jobs and stimulate economic growth. Their costs of care rank among the lowest, and they reduce the need for more expensive in-patient, emergency, and specialty care. Moreover, redirecting non-urgent and primary care treatable emergency department visits to health centers could save up to $8 billion annually. Who Health Centers Serve Located where care is needed but scarce, over 1,000 health centers currently serve 3,600 urban and rural communities in every state and territory. These communities are typically low income inner-city neighborhoods or resource-poor rural communities. Health centers are open to everyone in their communities but have a special focus on making care available and accessible to those who are uninsured and publicly insured, and to other vulnerable groups, such as farmworkers and homeless individuals. Speaking to this mission, they currently serve: 1 of every 8 uninsured Americans and 1 in 5 low income uninsured; 1 of every 9 Medicaid beneficiaries; 1 of every 7 people of color, including more than 20% of minority populations in most southern states; 1 of every 10 rural Americans; and 1 of every 5 low income children. In addition, in 2003 health centers served nearly 700,000 migrant farmworkers and nearly 680,000 homeless persons. The Appendix provides more information on the number of patients served in every state in 2003, plus the proportion of minority, low income, uninsured, and Medicaid-enrolled patients in every state. Health center patients are disproportionately low-income, uninsured or publicly insured, racial and ethnic minorities. While 12% of all Americans were at or below poverty in 2002, 14 as Figure 1 illustrates, 90% of health center patients are low income, and 70% of health center patients have family incomes at or below poverty ($15,260 annual income for a family of three in 2003). Moreover, as Figure 2 demonstrates, nearly 40% of health center patients are uninsured, 36% depend on Medicaid, and another 10% rely on Medicare and other forms of public insurance. In comparison, 15% of the national population was uninsured and another 12% had Medicaid during the previous year US Census Bureau. Poverty in the United States: Current Population Reports, P September US Census Bureau. Health Insurance Coverage in the United States: Current Population Reports, P September National Association of Community Health Centers,

10 Figure 1 Health Center Patients By Income Level, % FPL 6.3% % FPL 14.3% Over 200% FPL 10.4% Note: Federal Poverty Level (FPL) for a family of three in 2003 was $15,260. (See Source: Bureau of Primary Health Care, 2003 Uniform Data System 100% FPL and Below 69.0% Figure 2 Health Center Patients By Insurance Status, 2003 Other Public 2.8% Medicare 7.2% Uninsured 39.3% Private 14.8% Note: Percentages do not total 100% due to rounding. Source: Bureau of Primary Health Care, 2003 Uniform Data System. Medicaid 35.8% As the map below shows, by the end of last year, health centers in three states (Alaska, South Dakota, and West Virginia) and the District of Columbia provide care for at least half of their states low-income uninsured populations, while in another 10 states (Colorado, Connecticut, Hawaii, Massachusetts, Mississippi, Montana, New Mexico, North Dakota, Rhode Island, and Washington) they serve more than one in three low income uninsured residents. Nationally, health centers serve 1 in 5 low income uninsured people. Map 2 Percent of Low Income Uninsured Served by Health Centers, 2003 DC National = 20% Less than 20% % % 50% or Greater Note: Low income is defined as at or under 200% of poverty. While total low income uninsured includes non-elderly, health center uninsured patients are predominately non-elderly. Source: National Association of Community Health Centers, A Nation s Health at Risk, Health centers are vital providers of care to the uninsured, whose numbers have been rising nationally during the recent economic slowdown. Health center uninsured patients grew 11% during 2003 alone, and health centers are reporting growing numbers of new uninsured patients as well as rising uninsurance among their existing patients as high as 73%. This is because health centers are located in those areas likely to be hardest hit during the economic National Association of Community Health Centers,

11 downturn. While the Census reports that there are 43.6 million people in the US who are uninsured, conventional estimates of the uninsured do not take into account people who lose their insurance for a portion of a year. Families USA estimates that one of three people in the US went without health insurance for all or part of a two year period from approximately 81.8 million people. Cutbacks in Medicaid eligibility compound the rising numbers of patients without steady jobs who are likely to fluctuate in their insurance status. A slow economic recovery, compounded by state budget deficits, Medicaid cutbacks and other factors, are helping to fuel a growing uninsured population in the US and especially at health centers. 16 As one example, Washington State community and migrant health centers saw a dramatic rise in the number of uninsured patients an increase of 50% between January 2002 and December 2003, and the number of patient visits for the uninsured grew by 46% over the same time. In contrast, insured health center patients grew by only 10%, and visits among the insured grew by only 5%. 17 Two-thirds of health center patients are members of racial and ethnic minorities, as shown in Figure 3. In 2003, Hispanic/Latinos made up the largest minority group at 35% of all patients, while African Americans made up nearly a quarter of all patients. Comparatively, Hispanic/Latinos and African Americans each represent about 12% of the total US population, and by 2050 the percentage of Hispanic/Latino US residents will have doubled (Figure 4). Figure 3 Health Center Patients By Race/Ethnicity, 2003 American Indian/ Alaska Native 1.1% African American 24.1% Hispanic/ Latino 35.4% Note: Percentages do not total 100% due to rounding. Source: Bureau of Primary Health Care, 2003 Uniform Data System. White 36.2% Asian/Pacific Islander 3.3% Figure 4 Percent Distribution of US Population by Race/Ethnicity, 2000 and % 52.8% 24.3% 12.5% 3.7% 12.1% 13.2% 1.8% 0.7% 0.8% 8.9% White, Non-Latino Latino African American Asian/Pacific Islander Other American Indian/Alaska Native Note: Other was only recorded in 2000 and represents non-latino individuals who reported some other race or two or more races. Source: Kaiser Family Foundation. Key Facts: Race, Ethnicity & Medical Care. June Health centers provide comprehensive care to all ages. As Figure 5 demonstrates, nearly 40% of health center patients are under age 20, and a quarter are over the age of 45. Notably, patients ages 45 to 64 are the fast growing age group health centers serve, a trend that underscores their role as safety net providers for those most at risk for being uninsured. 16 Rosenbaum S, Shin P and Darnell J. Economic Stress and the Safety Net: A Health Center Update. Kaiser Commission on Medicaid and the Uninsured. June Kavoussi R and Burchfield E. Stretching the Safety Net: The Rising Uninsured at Washington s Community Health Centers. Community Health Network of Washington. May National Association of Community Health Centers,

12 Figure 5 Health Center Patients By Age, 2003 Ages % Under % Ages % Ages % Ages % Ages % Ages % Note: Percentages do not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2003 Uniform Data System Unique Community Providers Removing Barriers to Care The health centers program began as part of President Lyndon Johnson s War on Poverty. It was designed as a unique public-private partnership, with federal resources funneled directly to community organizations for the development and operation of local health care systems. Unlike other community safety net programs, federal program rules mandate that a majority of the membership on each local health center s governing board must consist of individuals who receive their health care at that center and who represent the community being served; in other words, a patient democracy. In this way, communities in need are given the resources to address their most pressing health problems, and they are then held accountable for doing so. No other health care provider in America provides their patients this empowering opportunity to decide how their health care provider is run. These patient-majority governing boards oversee health center operations as well as direct the creation and operation of programs tailored to serve their communities specific needs, such as parenting education classes, job training, weight reduction programs, smoking session classes, and housing assistance programs. This direct patient involvement in service delivery is key to health centers accomplishments in serving their communities. Active patient oversight of health centers assures responsiveness to local needs, and helps guarantee that health centers improve their patients quality of life. In addition to the patient-majority governing boards, health centers have other common and often unique features designed to remove multiple barriers to health care that make them different from other community-based health care providers, as well as and most private, officebased physicians. These unique characteristics are rooted in their program requirements and are central to their mission and success. Health centers and their services are customized to confront and deal with the complexities of the low income communities who rely on them for care National Association of Community Health Centers,

13 places where residents typically face more than one barrier to health care. As described below, health center remove geographic, financial, language, cultural and other common barriers to care. First, health centers must be located in high-need areas identified by the federal government as having elevated poverty, higher than average infant mortality, and where too few physicians practice. By locating in these medically underserved areas, health centers improve access for people who traditionally confront geographic barriers to health care, such as rural or homeless patients. Accessibility of patient-centered care is a priority. Thus, many health centers operate during evening or weekend hours, at multiple sites, and through mobile clinics to reach those most in need. Second, health centers must be open to all residents, regardless of insurance status or income, and provide free or reduced cost care based on ability to pay. Health centers charge sliding scale fees for out-of-pocket payments based on an individual s or family s income and ability to pay, yet patients unable to meet sliding scale fees are never turned away and many qualify for free care. In fact, health centers nationally only collected 20% of charges to self-pay patients and costsharing requirements from insured patients in Thus, health centers eliminate financial barriers to care. For many patients, the health center may be the only source of health care services available. The number of uninsured patients at health centers is rapidly growing from over 3.5 million in 1998 to over 5.9 million today. Third, health centers must provide comprehensive primary care and offer services that help their patients access health care, so-called enabling services. Health centers understand that these services are necessary to remove multiple barriers to care. Accordingly, the vast majority of health centers offer outreach to identify potential patients and facilitate access to care, as well as translation, case management, health education, and eligibility assistance for health and social service public assistance programs, including Medicaid, the State Children s Health Insurance Program (SCHIP), cash assistance, food stamps, and the Special Supplemental Food Program for Women, Infants and Children (WIC). In addition, more than half of all health centers provide transportation to and from their center, parenting education, and home visitation. Undeniably, health centers are providing services that go above and beyond normally provided medical care. Table 1 below lists examples of services health centers provide. Table 1 Examples of Services Provided at Health Centers Health Services Primary and Preventive Health Care Obstetrical and Gynecological Care Dental Services Mental Health/Substance Abuse Services X-Rays and Lab Pharmacy Hearing/Vision Screening Testing for Blood Lead Levels Enabling Services Case Management Health Education Parenting Education Nutrition Education Outreach Interpretation/Translation Services Transportation Home Visiting National Association of Community Health Centers,

14 Fourth, health centers tailor their services to fit the special needs and priorities of their communities, and provide services in a linguistically and culturally appropriate setting, thereby removing language and cultural barriers. Center staff are often bi- or multi-lingual, patient materials are written in multiple languages, and staff are sensitive to the specific needs and cultural beliefs of their patients. In fact, approximately one-third of all patients are best served in languages other than English. A 2001 NACHC survey of health center patients found that 95% reported their doctor speaks the same language as they do, and of those reporting their doctor does not speak the same language, over half stated someone at the health center translates. Such tailored services help avoid under-use of preventive services and substantial treatment disparities. 18 Beyond providing services in culturally appropriate settings, health centers offer programs beyond medical care suited to specific community needs, such as weight management programs, health education programs for adolescents, nutrition counseling, and 24-hour crisis counseling. Finally, health centers must follow rigorous performance and accountability requirements regarding their administrative, clinical, and financial operations. Federally-funded centers are required to report to the federal government information each year on utilization, patient demographics, insurance status, managed care, prenatal care and birth outcomes, diagnoses, and financing. While this reporting does not directly remove barriers to care for patients, it establishes a means of health center accountability for doing so and ensures quality of care. Providers of High Quality Care Despite its own wealth and cutting edge technological advancements in health care, the US is still plagued with higher mortality rates and illnesses among minorities than those of nonminorities even when income, insurance status and medical conditions are equal, 19 as well as inconsistent delivery of high-quality health care, creating a system of care that does not produce the best possible outcomes for patients. 20 Access to primary care is an important first step in reducing health care disparities and improving health outcomes. Community-based primary health care that includes access to other social services effectively improves health outcomes at an individual and community level. Health centers are exemplary models of such care. 21 Research has shown that health centers generally provide care that is equal to or greater than the quality of care provided at other, often more expensive provider types. 22 Speaking to the quality 18 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academy Press, See also IOM, 2002 (citing Grumbach K, Vranizan K, and Bindman A. Physician Supply and Access to Care in Urban Communities Health Affairs16(1):71-86.). 19 Institute of Medicine (IOM). Unequal Treatment: Confronting Racial and Ethnic disparities in Healthcare. National Academy of Sciences Press, March IOM. Crossing the Quality Chasm: A New Health System for the 21 st Century. National Academy of Sciences Press, March Politzer RM, Schempf AH, Starfield B, and Shi L. The Future Role of Health Centers in Improving National Health Journal of Public Health Policy 24(3/4): Starfield B, et al. "Costs vs. Quality in Different Types of Primary Care Settings," 28 December 1994 Journal of the American Medical Association 272(24): National Association of Community Health Centers,

15 of their care, 99% of surveyed health center patients report they were satisfied with the care received at health centers. 23 Improving Access to Preventive Services Health centers provide improved access to continuous, primary care and preventive services to vulnerable populations who would otherwise not have access to certain services, such as immunizations, health education, mammograms, pap smears, and other screenings. Examples of how health centers improve access to health care services are described below. Usual Source of Care. Low income, uninsured health center patients are much more likely to have a usual source of care than the uninsured nationally, even though health center uninsured patients are more likely to live in poverty-stricken areas, be poorly educated, and be members of a minority group. In fact, 98% of health center patients report having a usual source of care, compared to 75% of all uninsured patients nationally. This difference is likely due to the fact that health center patients face fewer barriers to care than the uninsured in general. 24 Timely Care. Health centers are improving access to timely screening and preventive services for low income and minority patients who would not otherwise have access to certain services. 25 When compared to uninsured patients who do not receive care at health centers, health center uninsured patients are much less likely to delay seeking care because of costs, go without needed care, or fail to fill prescriptions for needed medicine. 26 Health Education. Uninsured adults at health centers are more likely than other US uninsured adults to receive health promotion counseling on diet, physical activity, smoking, drugs, alcohol, and sexually transmitted diseases. 27 Well-Child Care and Immunizations. Health centers are major providers of pediatric care, serving 1 in 5 low income children. Compared to office-based physicians, outpatient departments, emergency rooms, and other providers, health centers score highest in the proportion of Medicaid pediatric patients who receive preventive services. 28 They have also successfully improved childhood immunization rates, especially for the more recently recommended Hib and Hepatitis B NACHC, Patient Experience Evaluation Report (PEER) Data, Carlson BL et al. Primary Care of Patients without Health Insurance by Community Health Centers. April 2001 Journal of Ambulatory Care Management 24(2): Frick KD and Regan J. Whether and Where Community Health Centers Users Obtain Screening Services. November 2001 Journal of Healthcare for the Poor and Underserved 12(4): Politzer R, et al. Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care Medical Care Research and Review 58(2): Carlson, Stuart ME, et al. "Improving Medicaid Pediatric Care." Spring 1995 Journal of Public Health Management Practice 1(2): Schempf AH, Politzer RM, and Wulu J. Immunization Coverage of Vulnerable Children: A Comparison of Health Center and National Rates. March 2003 Medical Care Research and Review 60(1): National Association of Community Health Centers,

16 Cancer Screening. Health center women are more likely to receive mammograms, clinical breast exams, and pap smears than comparable women not using health centers. Figure 6 shows that 88% of Hispanic health center women needing mammograms received them compared to 79% nationally, and 86% of African American health center women patients needing mammograms received them compared to 78% nationally. Health center uninsured women and Medicaid beneficiaries needing mammograms are also more likely than their counterparts to receive them. Also noteworthy is the fact that health centers far exceed the Healthy People 2010 goal of 70% set by the Department of Health and Human Services. Figure 6 Percent of Women Receiving Mammograms at Health Centers vs. Nationally 88% 86% 79% 78% 96% 75% 78% 71% Healthy People 2010 Target (70%) Health Centers Nationally Hispanic African American Medicaid Uninsured Note: For women over age 40. Compares health center women to all women under 200% of poverty nationally. Source: Bureau of Primary Health Care, HRSA, DHHS. Based on 2002 Health Center User Survey and 2000 National Health Interview Survey. Reducing Infant Mortality and Low Birth Weight Health centers are important providers of prenatal care for low income women. In fact, nearly 30% of all patients and half of all female patients are women of childbearing age. In 2003, health centers provided prenatal care to over 330,000 women. Communities served by health centers have infant mortality rates between 10 and 40% lower than communities without a health center. 30 As Figure 7 demonstrates, health centers have lower rates of low birth weight (LBW) among their patients than nationally (7.0 vs. 7.8, respectively), and this gap has widened over the last few years as health center LBW rates have dropped while national LBW rates have climbed. 30 Goldman F and Grossman M. The Impact of Public Health Policy: The Case of Community Health Centers Eastern Economic Journal 14(1): Gorman S and Nelson H. "Meeting the Data Needs of Neighborhood Health Centers." Presented at the 102nd meeting of the American Public Health Association, Grossman M and Goldman F. An Economic Analysis of Community Health Centers. National Bureau of Economic Research, Schwartz R and Poppen P. Measuring the Impact of Community Health Centers on Pregnancy Outcomes. Abt Associates, National Association of Community Health Centers,

17 Figure 7 Low Birth Weight at Health Centers vs. Nationally, United States Rate Health Centers Source: Bureau of Primary Health Care, HRSA, DHHS. Based on Uniform Data System and Centers for Disease Control and Prevention, DHHS, Health, US Gaps in LBW are more dramatic for racial and ethnic minorities. Nationally, 13% of African American women give birth to low birth weight infants, compared to 9.9% of all African American women at health centers and 7.4% of rural African American health center patients in This statistic is noteworthy, considering the fact that health center women are more likely to be at greater risk for adverse pregnancy outcomes. 31 Effective Management of Chronic Disease Nationally, 26% of all health center medical encounters are for chronic diseases, including asthma, diabetes, hypertension, HIV/AIDS, and mental health and substance abuse conditions. Health centers meet or exceed nationally accepted practice standards for chronic conditions. Ninety percent of African American and Hispanic health center patients with hypertension reported that their blood pressure is under control. This is more than triple that of a comparable national group and nearly double the Healthy People 2000 goal of 50% set by the Department of Health and Human Services. Also, health center diabetics were more then twice as likely to have their glyco-hemoglobin tested on schedule than the national population. 32 Approximately 500 health centers nationwide are participating in an initiative that aims to improve health outcomes for chronic conditions among the medically vulnerable, particularly minorities. Known as the Health Disparities Collaboratives, 33 and overseen by the federal Bureau of Primary Health Care, the initiative was designed to improve the skills of clinical staff, strengthen the process of care through the development of extensive patient registries that improve clinicians ability to monitor the health of individual patients, and effectively educate 31 Politzer, Politzer, For more information on how health centers meet or exceed practice standards, see Ulmer, C et al. Assessing Primary Care Content: Four Conditions Common in Community Health Center Practice. January 2000 Journal of Ambulatory Care Management. 23(1): For more information on the Health Disparities Collaboratives, see National Association of Community Health Centers,

18 patients on self-management of their conditions. Approximately 175,000 health center patients with chronic disease are enrolled in electronic registries for diabetes, cardiovascular disease, asthma, depression, prevention, cancer, and HIV. Eventually, every health center will be participating in at least one Collaborative. The map below provides a visual display of health centers operating at least one Collaborative. Map 3 Location of Health Centers Participating in Health Disparities Collaboratives, 2002 Total N= > 500 of 845 grantees Source: Bureau of Primary Health Care, HRSA, DHHS. The Collaboratives increase screenings for registered patients and have led to improved health outcomes for registered health center patients, helping to diminish the health gaps for racial and ethnic minorities as well as the poor in the US. A recent study found that the diabetes Collaboratives at 19 Midwestern health centers had improved measures of diabetes-related health outcomes and quality (e.g., HbA1c measurement, eye examination referral, foot examination, and lipid assessment). Moreover, the researchers found that surveyed health center staff considered the Collaboratives successful. The authors conclude that the model employed by the Collaboratives improved diabetes care at the health centers in just one year. 34 The Collaboratives have great potential for reducing the costs of treating patients with chronic disease. A study in South Carolina compared total costs for diabetic patients enrolled in the state employees health plan at different providers, and found that patients treated at a specialist or family practitioner cost more than three times as much as those who were treated at a health center Chin MH, et al. Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative. January 2004 Diabetes Care 27(1): Lewis AM. Improving Care for Diabetic Patients. CareSouth Carolina Community Health Center. Presentation at the Seventh Annual Eye Health Education Conference for the National Institutes of Health s National Eye Institute, Charleston, SC, March 3, National Association of Community Health Centers,

19 As a result of their success, the Institute of Medicine (IOM) commended health centers for providing chronic care management that is at least as good as, and in many cases superior to, the overall health system in terms of better quality and lower costs, and recommended health centers as models for reforming the delivery of primary health care. 36 The General Accounting Office (GAO) also recently recognized the Collaboratives as a promising federal program targeting health disparities that should be expanded. 37 Reducing Racial and Ethnic Health Disparities Health centers also reduce or even eliminate racial and ethnic health disparities, as many of the examples provided above already indicate. Health centers largely do this through their mission and grant requirements. In other words, through their very nature: they are located in underserved areas often with large minority populations, they are open to all, and they provide comprehensive, culturally sensitive care that is customized to fit the needs of the communities they serve. Moreover, health center patients are predominately minority, making health centers key players in delivering quality, needed care to reduce disparities. A recent study found that disparities in health status do not exist among health center users even after controlling for socio-demographic factors. In fact, non-white Hispanic health center users experienced healthier life than white users, and there are no significant differences between white and African American users. Conversely, among non-health center users, whites experienced significantly healthier life than African Americans and Hispanics. The authors concluded that the absence of disparities at health centers may be related to their culturally sensitive practices and community involvement, features that other primary care settings often lack. 38 Health centers are also associated with reducing disparities at the state level. A landmark report from last year found that as health centers serve more low income in a state, the state s black/white and Hispanic/white health disparity narrows (i.e., declines) in such key areas as infant mortality, prenatal care, tuberculosis case rates, and age-adjusted death rates. 39 Because of their success in removing barriers to care, the IOM and the GAO have each recognized the success of health centers in reducing or even eliminating the health gaps for racial and ethnic minorities, as well as for low income populations. It is noteworthy that the IOM specifically recognized the importance of community health centers, stating that the community health center model has proven effective not only in increasing access to care, but also in improving health outcomes for the often higher-risk populations they serve IOM. Fostering Rapid Advances in Health Care: Learning from System Demonstrations. National Academy of Sciences Press, November General Accounting Office (GAO). Health Care: Approaches to Address Racial and Ethnic Disparities. GAO R. July 8, Based on self-reported healthy life. Shi L, et al. Community Health Centers and Racial/Ethnic Disparities in Healthy Life International Journal of Health Services 31(3): Shin P, Jones K, and Rosenbaum S. Reducing Racial and Ethnic Health Disparities: Estimating the Impact of High Health Center Penetration in Low-Income Communities. The George Washington University Center for Health Services Research and Policy, September IOM, 2003, p GAO, National Association of Community Health Centers,

20 Cost Effective Care Health centers improve the health of the patients they serve and do so inexpensively and cost-effectively. The average cost of providing comprehensive care at health centers per day per patient served was $1.30 in Total medical cost per patient last year was $352 (not including dental and enabling services) significantly less than the national average. In fact, medical care at health centers is around $250 less than the average annual expenditure for an office-based primary care provider. 41 As stated above, research has shown that continuity of care saves money. By providing regular care and preventive services to populations who would otherwise go without, health centers are generating significant savings to society through reduced emergency department use and referrals to specialty providers. Medicaid Savings Generated by Health Centers An extensive amount of literature has found that health centers save states and, by extension, the federal government money on their Medicaid programs. They do this by providing effective and regular primary, preventive care that translates into reduced hospitalizations, visits to emergency departments (EDs), and visits to costly specialists. Reviews of Medicaid claims data have found that health centers provide care that is equal to or greater than the quality of care provided at other, often more expensive provider types, 42 and it is this high quality care that prevents the need for other, costlier care. Falik, et al found that Medicaid beneficiaries in five states who receive care at health centers were significantly less likely than other Medicaid beneficiaries to be hospitalized or visit EDs for ambulatory care sensitive conditions (ACSC) that are avoidable through timely primary care. The researchers also found that health center Medicaid beneficiaries are more likely to have at least one primary care office visit than beneficiaries seen elsewhere. The study concluded that health centers as a regular source of care can significantly reduce the likelihood of hospitalizations and ED visits for ACSCs, and that increased office visits did not appear to offset possible savings from ACSC avoidable events. These savings could potentially result in far fewer hospitalizations and ER visits among Medicaid enrolled children and non-elderly adults. 43 Several other studies have found that health centers save the Medicaid program in annual spending due to reduced specialty care referrals and fewer hospital admissions. Reviews of 41 Based on a comparison of 2000 data, the most recent available. Health center per person expenditure comes from the 2000 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. US average expenditure for office-based visits does include clinics. See Olin GL. National Health Care Expenses in the US Community Population, Statistical Brief #27. Agency for Health Care Research and Quality, DHHS Starfield, Stuart ME, et al. "Improving Medicaid Pediatric Care." Spring 1995 Journal of Public Health Management Practice 1(2): Falik M, et al. Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using Federally Qualified Health Centers Medical Care 39(6): National Association of Community Health Centers,