The State of Unmet Need for Primary Health Care in America

Transcription

1 The State of Unmet Need for Primary Health Care in America March 2012

2 COPYRIGHT MARCH 2012 National Association of Community Health Centers, 2012 Main Office: 7200 Wisconsin Avenue, Suite 210 Bethesda, MD (301) Washington, DC Office: 1400 Eye Street, NW Suite 910 Washington, DC (202) For more information, please This report is available online at Health center photos and stories courtesy of: Jolene Joseph, Health Partners of Western Ohio, Lima, OH and Gale Koch, Quality Health Care Center, Las Vegas, NV Cover design: Holli Rathman, Rathman Design, Keedysville, MD

3 EXECUTIVE SUMMARY The U.S. may have one of the most technologically advanced health care systems in the world, yet millions of residents suffer from unmet health care needs and even preventable deaths. Health Wanted: The State of Unmet Need for Primary Health Care in America describes why so many Americans experience difficulties in accessing primary care, and the far-reaching health and cost consequences when people and communities are shut out of preventive medicine. This report also underscores one proven solution to unmet primary care needs America s Community Health Centers and the overwhelming demand for their services. Indicators of Need Accessing the U.S. health care system is challenging for many people, even if they are insured. Today, barriers of affordability, availability, and accessibility are more daunting than ever. These include lack of insurance, limited income, distance, and other factors that leave many communities without care. When people delay or fail to receive needed preventive services, everyone pays in some measure. People become sicker and many suffer preventable deaths. Caring for a growing population of chronically ill is straining our health care delivery system, and many others have unmet primary care needs. Those without access often wind up in costly Emergency Departments or experience more hospitalizations for care that could have been avoided through timely primary care. The Health Center Solution America s health centers offer a proven solution to these complex problems. Health centers remove multiple barriers to primary care access and improve health outcomes, all in a cost-effective and locally-directed manner. Health centers are required to be open to all residents regardless of ability to pay or insurance status, target medically underserved areas, offer comprehensive primary care services, and be directed by a local patient-majority governing board. Countless studies document that health centers reduce or eliminate barriers to care, improve health, and lower health system costs. Demand for Health Centers Given their effective local model of care, demand for health center services continues to rise. However, demand continues to outpace growth. Among the indicators of need highlighted in Health Wanted, at least 25% of U.S. counties in greatest need do not have a health center. Unfortunately, a recent reduction in health centers federal funding has stymied their growth. Last year, communities across the nation submitted over 1,900 health center grant applications. Less than 10% were funded. These grants would have created new health center sites in communities currently struggling without and expand services at existing health centers. In FY2012, Congress provided $200 million in additional funding that could award some of the 1800-plus pending applications, but many will remain unfunded, their health care needs unaddressed, and additional communities unreached. As barriers to primary care continue to threaten the health and productivity of our nation, health centers stand ready and willing to expand and break down these barriers. The dedicated stream of mandatory funding for health centers enacted under the Affordable Care Act is a promising starting point for continued expansion. Building the nation s primary care system on a strong foundation of health centers is only attainable, however, with sufficient investment to support expansion efforts and to maintain existing operations. A long and detailed history of research and evidence has proven this is an investment well worth making. Health Wanted: The State of Unmet Need for Primary Health Care in America 1

4 INTRODUCTION The U.S. may have one of the most technologically advanced health care systems in the world, yet millions of residents suffer from unmet health care needs and preventable deaths. 1 Lack of access to affordable, accessible primary and preventive care poses significant challenges to our nation s health care system. People have trouble accessing primary care, and even paying for it, even though it remains one of the most reliable means to prevent death and stay healthy. Primary care is critical for identifying and treating health problems, such as chronic disease, averting the deterioration of health, and saving lives. A sufficient primary care infrastructure generates system-wide payoffs through better health outcomes and lower health care costs. Yet persistent health disparities demonstrate that we as a nation have far to go in overcoming obstacles to health care for many families and communities. The greatest gains to our health care system in terms of better health and reduced costs are produced by breaking down access barriers and reducing health disparities. The nation s Health Centers Program is specifically designed to meet the health care needs of those currently without access to care. Health centers offer a comprehensive array of primary and preventive health care services, and provide needed social and enabling services to tackle even the most persistent barriers to care. They are required by federal law to target communities and populations where care is needed but scarce, or where it is plentiful but only for some. The health center model has demonstrated numerous successes in expanding access, improving health outcomes, and reducing health disparities all while yielding significant returns on taxpayer investment and generating local employment opportunities. Despite health center expansion in recent years, tremendous unmet needs exist in communities across America. Although health centers stand ready to meet these needs, previously dedicated funding to support growth has been reduced. Out of 1,900 grant applications for new health center sites or services, only 67 were awarded last year due to the lack of funding. These unfunded applications remain the last great hope of many communities waiting for care. Some of these waiting communities are in rural pockets in America, where the nearest source of care is hours away. Others are located in impoverished urban neighborhoods, where the only chance for primary care is in an Emergency Department because the local provider does not accept Medicaid. Even though the neighborhoods and communities may look different, the circumstances are the same: there are unmet needs for primary care that will continue unabated unless the nation invests in a strong and robust primary care infrastructure. Health Wanted describes why there are unmet needs in America as well as the factors that contribute to this troubling trend and their health and cost consequences. Each case those of barriers to care, poor health outcomes, low rates of preventive services, and preventable use of costly Emergency Departments and hospitals is an indicator of primary health care needs and a growing demand for care. This report will demonstrate how health centers are equipped to meet these needs. Unfortunately, many of the worst off areas do not currently have a health center. Where need is great and health resources lacking, health centers stand as a viable, locally-crafted solution. Health Wanted: The State of Unmet Need for Primary Health Care in America 2

5 100% UNMET NEEDS IN PRIMARY CARE: A Divergence of Supply and Demand Everyone needs health care but not everyone can access it. Millions of Americans, many with elevated health care needs, have limited or no access to a timely, continuous, and regular source of primary and preventive care. Demand for primary care has outpaced supply in many places across the nation. In many of these communities, primary care providers are absent, unaffordable, or otherwise inaccessible due to distance, special health care needs, insurance type or status, or cultural barriers. People who cannot navigate these obstacles are forced to forego or delay seeking care, leaving them with many unmet health care needs. And the problem has worsened; the number of Americans who forgo or delay needed health care has nearly doubled in the past 10 years. 2 FIGURE 1 Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured vs the U.S. Population, 2010 Health Centers U.S. 93% While the barriers are numerous and complex, the consequences are clear. Health status and outcomes deteriorate as individuals delay or fail to receive needed medical care. 3 People without a usual source of health care are likely to have more hospitalizations and Emergency Department (ED) visits and higher costs of care while receiving fewer preventive care services. 4 Greater use of evidence-based preventive services, including screenings, would save lives and billions of dollars. 5 Unfortunately, many communities lack the resources to sustain primary care providers and to ensure their growth and development to meet local needs. With federal and state investment, the nation s Health Centers Program can deliver primary and preventive services to communities that need it and in turn improve public health and reduce health care costs. THE SOLUTION TO UNMET NEEDS: Community Health Centers Health centers actively seek out patients who would otherwise experience unmet health care needs. Also known as Federally Qualified Health Centers (FQHCs), health centers serve more than 20 million patients 6 and operate over 8,100 health care delivery sites in every state and U.S. territory. The majority of their patients have low incomes, are uninsured or publicly-insured, or are members of racial/ethnic minority groups. Health centers provide one-quarter of all primary care visits for the nation s low-income population 7, thereby making up a substantial share of the nation s primary care infrastructure. 80% 60% 40% 20% 0% 38% 16% Uninsured 39% 16% Medicaid 72% 21% At or below 100% of Poverty 40% Under 200% of Poverty Sources: Health Center: Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System. U.S.: Kaiser Family Foundation, State Health Facts Online, Based on U.S. Census Bureau 2009 and 2010 March Current Population Survey. U.S. Census Bureau, Table POV46. Poverty Status by State, August 2010, Annual Social and Economic Supplement, 2010 Current Population Survey. By broadly defining what creates good health and wellness, health centers go above and beyond the traditional role of primary care. They provide services in a team-based approach not typically seen in primary care practices. Among the services health centers provide are dental, mental health and substance abuse, pharmacy, health education, and other services that facilitate access to care, such as translation, transportation, health education, and case management. Health centers not only target health but the social determinants that factor into health status, such as nutrition, poverty, and education. Health Wanted: The State of Unmet Need for Primary Health Care in America 3

6 Millions The promise of improved community health has been the impetus of the Community Health Center Movement since its inception more than 45 years ago. Over time, the model has created healthier communities, reduced or even eliminated disparities, and created system-wide savings. That is why communities seek the presence or expansion of health centers because they recognize that their model of care can address the unmet health care needs of the community. But for this model to effectively work, federal and state investments are a prerequisite for health center growth and financial viability. Over the past 10 years, investments FIGURE 2 The Number of Health Center Patients Has Doubled Since % % % % 15 38% % 17 38% % Source: NACHC analysis of Uniform Data System reports, by Bureau of Primary Health Care, HRSA, DHHS, and estimates for look-alike health centers, % in health centers have allowed them to double the number of patients and communities they serve (Figure 2). The promise of federal funding for health center expansion should fill health care resource shortages in many communities nationwide. Health centers have a dedicated stream of mandatory funding enacted under the Affordable Care Act. However, recent budget cuts to health centers baseline federal funding significantly cut back expansion plans in Fiscal Year That year, only 67 of 810 applications for new health center service sites were funded (Figure 3). The Health Resources and Services Administration (HRSA), the federal agency that oversees the Health Centers Program, had originally anticipated awarding 350 grants before funding was reduced. During the same year, existing health centers submitted nearly 1,100 applications for service expansions based on documented unmet need in local communities. Although HRSA had planned to fund virtually all of the grants, none were funded because of budget cuts. These awards would have expanded care for behavioral health, oral health, pharmacy, vision, and enabling services that make it possible for health center patients to receive comprehensive and coordinated care. They would have also provided health centers resources to expand their hours and hire new staff. The National Association of Community Health Centers estimates that the loss of federal funding to cover these planned expansions has kept 5 million individuals from receiving health center care. FIGURE 3 Community Health Center Grant Application and Awards, Fiscal Year ,096 Grants Awarded Grants Submitted New Health Center Sites Dental 256 Behavioral Expanded Services 213 Enabling 213 Pharmacy 52 Vision Note: The total number of expansion services grants submitted includes medical, dental, behavioral, enabling, pharmacy, and vision grants. Source: Bureau of Primary Health Care, Health Resources and Services Administration, DHHS, Health Wanted: The State of Unmet Need for Primary Health Care in America 4

7 IDENTIFYING PRIMARY CARE NEEDS The snapshots that follow in this report illustrate examples of primary care needs. They are organized into three categories: 1. Barriers to Care such as affordability, availability, and accessibility; 2. Poor Health Outcomes often due to a lack of preventive screenings; and 3. Economic Consequences due to using the Emergency Department and hospital rather than primary care. The cases presented here demonstrate access obstacles as well as the limited preventive services, adverse health outcomes, and economic consequences that stem from insufficient access to primary care. Those with unmet needs must navigate barriers of affordability, availability, accessibility. Those with unmet needs miss critical preventive screenings and often suffer from poor health. And those with unmet needs wind up in the Emergency Department (ED) or hospital for costly care that could have been avoided through timely primary care. Each of these cases, then, is an indicator of primary care need. Within each case, the reader will also find accounts of health center successes in meeting the need presented. Health centers overcome the most intractable barriers and ensure their patients receive needed services, from preventive care to management of chronic conditions. They also improve health outcomes and lower the rate of unnecessary ED visits and hospitalizations. Many areas with dramatic indicators of primary care needs do not have a health center. Figure 4 demonstrates just how great the need is, documenting the proportion of counties identified as having the highest rate of primary care need without a health center present. These are the areas where health centers can make a difference. Rural Primary Care Providers Preventable Hospitalizations Uninsured Mammography Screening ED Visits Health Status Diabetes Prevalence Not English Proficent Low-Income Low Birthweight HIV Prevalence FIGURE 4 Health Centers Are Not Present in More than a Quarter of the Counties with Unfavorable Primary Care Needs 25% 33% 36% 36% 34% 38% 42% 50% 47% 54% 53% 63% The examples of primary care needs that follow are not meant to make up an exhaustive list. Case in point, individuals rarely experience just one barrier to care. Moreover, the cases here do not illustrate the severe shortage of dental, behavioral, pharmacy, and other services that also plague our nation. Also, while the majority of the maps demonstrate primary care needs at the county-level, it is essential to note that a community tends to be smaller than a county; therefore, a community s true need may not show in these maps. These examples represent only a few ways to demonstrate the nation s primary care needs. 0% 10% 20% 30% 40% 50% 60% 70% Note: Counties with Unfavorable Primary Care Needs were identified by being in the either bottom or top quintile depending on the primary needs indicator. Source: NACHC analysis of data obtained from University of Wisconsin Population Health Institute County Health Rankings 2011; U.S. Census Bureau; and HRSA. Health Wanted: The State of Unmet Need for Primary Health Care in America 5

8 REMOVING BARRIERS: WHO NEEDS THE CARE OF A HEALTH CENTER? Unmet needs are often caused by barriers to health care and healthy living. The barriers that affect our health care system can be divided into three categories: 1) affordability, 2) availability, and 3) accessibility. Affordability: Health care and insurance costs continue to soar at an alarming rate in the midst of an economic recession when more and more families are struggling to make ends meet. Employer-sponsored insurance coverage remains beyond the reach of the over 12 million people who are currently unemployed and the over 5 million people who have been searching for a job longer than six months. 8 Unemployed workers, many of whom were once comfortably middle class, are priced out of the individual private health insurance market while still being ineligible for Medicaid. 9 Availability: Even if people can afford health care or health insurance, it does not necessarily mean that health care providers are available to them. The U.S. is sorely in need of more primary care providers, especially primary care providers who accept all new patients regardless of insurance status. Most private primary care practices limit their patient intake according to health insurance, with Medicaid patients having a far more difficult time finding a primary care practitioner than privately insured patients. 10 State and national surveys have shown that the number of private, office-based physicians accepting new Medicaid patients has been declining over the past several years, some by as much as 20% since At the same time, there is a continuous decline in the number of physicians who provide charity care. 12 In fact, health care providers in office-based practices are half as likely to accept charity patients compared with health centers. 13 Accessibility: Even if people can afford available providers, they still may not be able to access these providers because of cultural and geographic barriers. Some people may not be able to travel to providers due to long geographic distances and a lack of transportation services. Others may be unable to communicate with or understand their providers or health care because of language or cultural divides. 14 Even when patients overcome all other barriers to find care, they may feel that their condition stigmatizes them in the eyes of the providers, or the provider may not be equipped to deal with their health needs, social circumstances, or language and cultural orientation. This section outlines several barriers to care for each of these three categories and provides evidence of health centers addressing them. Later sections demonstrate the consequences of untimely, forgone, or mismanaged care. Health Wanted: The State of Unmet Need for Primary Health Care in America 6

9 BARRIERS IN A LOCAL COMMUNITY: CLARK COUNTY, NEVADA Although the two million residents of Clark County, Nevada live on the doorstep of Las Vegas, the city s fortunes are beyond the reach of most people living there, especially when it comes to health care. One in five Nevadans lives at or below the Federal Poverty Level (FPL) and 27 percent of children aged 18 and under live in poverty. 119 Sky-rocketing population growth has stretched county and state resources, making it nearly impossible to keep pace with the spiraling demand for health care and social services. Nevada ranks worst in the country with respect to the availability of registered nurses to population, with an average of 520 per 100,000 people (the national average is 798 per 100,000). 120 Primary care services are also in short supply. There are only two Community Health Center organizations in the entire state. Yet over 478,000 Nevadans still lack health insurance and are likely to have little or no access to primary health care services. 121 Nearly 46 percent of Nevadans have had no coverage for two years or longer while 25 percent never had health insurance. 122 Many of these people are employed in workplaces unable to provide insurance, or have simply been priced out of the health insurance market. These individuals and their families are forced to use emergency rooms for routine care because they cannot pay cash for their health care needs, reports the association. Three out of 4 feasibility study focus group respondents found it somewhat or very difficult to access medical services. 123 Large portions of the underserved in Clark County are children living in poverty with little or no access to care. Quality Health Care Center in Clark County currently provides medical, dental, and behavioral and mental health care for children in foster families through a collaboration with The Foundation For Positively Kids and other entities in the local community. However, to better meet the needs of a growing population of children needing primary care, Quality Health Care Center sent in a pending application to open a New Access Point Community Health Center that would provide care spanning a person s lifetime. The health center also planned to expand services to the adult and elderly populations and work with the hospital system to reduce the costs of unnecessary visits to the ER. However, these plans went unrealized when their New Access Point grant was not funded. Without access to a health center providing primary care, thousands of Nevadans will continue to use the emergency room for their routine care. Clark County, Nevada is a bustling area but lacks primary care facilities. Health Wanted: The State of Unmet Need for Primary Health Care in America 7

10 People with Low Incomes Currently, 21% of U.S. households are at 100% or less of the Federal Poverty Level (FPL), measured as an annual income of $22,350 in a family of four in Furthermore, 40% of households are at 200% or less of the FPL. 15 Many low-income families experience barriers to healthy living simply because of where they live. Their neighborhoods may lack areas to exercise or walk, 16 or have grocery stores that sell healthy and affordable food. 17 Low-income adults are more likely to experience chronic medical conditions than those with higher incomes, yet they are less likely to access primary care services, and they receive less than the recommended amount of care regardless of whether they are uninsured or insured through Medicaid. 18 A third of low-income adults lack a stable source of care. 19 The Health Center Solution Health centers are typically located in low-income, resource-poor rural and urban communities. Nearly all of health centers 20 million-plus patients have low incomes (under 200% of FPL). 20 This number has doubled over the last ten years such that health centers now serve 1 out of every 6 low-income Americans and 1 out of every 3 living in poverty. 21 Not surprisingly, health center patients are much more likely than patients of office-based physician practices to live in communities with higher concentrations The Concentration of Low-Income Individuals In Census Tracts More than a third of counties with the highest concentration* of low-income individuals do not have a health center. % Low-Income Population 0.0%-14.7% 14.8%-25.1% 25.2%-37.1% 37.2%-52.6% 52.9%-100% N/A Health Center Delivery Sites Note: Highest rate denotes counties with 52.9%-100% of the population who are low-income. Source: Estimates are by Census tract. NACHC analysis of U.S. Census Bureau s American Community Survey, 5 Year ( ) Estimates. Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 8

11 Percent Growth Over 10 Years 100% 80% 60% 40% 100% 80% 60% 40% 20% 0% FIGURE 6 Health Center Uninsured Patients Receive More Preventive Services Compared to the Uninsured Nationally 78% FIGURE 5 The Number of Health Center Uninsured Patients Has Grown Twice as Fast as Their National Counterparts 71% 89% Health Center Uninsured Patient Population 86% 77% 52% 38% 26% U.S. Uninsured Population Source: Health Center: NACHC analysis of Bureau of Primary Health Care, HRSA, DHHS, 2000 and 2010 Uniform Data System. U.S.: Kaiser Family Foundation, State Health Facts Online, Based on U.S. Census Bureau 2000 and 2010 March Current Population Survey. Health Center Uninsured U.S. Uninsured 73% 62% of poverty. 22 As more of a state s low-income population is served by health centers, racial and ethnic health disparities in key areas are reduced across the state. 23 The Uninsured There are 50 million uninsured Americans 24, many of whom live in low-income households 25 that are having difficulty paying for basic monthly expenses such as rent, food and utilities. Nearly one-quarter (24%) of workingage adults an estimated 43 million reported that they and/or their spouse had lost their job within the past two years, according to a recent Commonwealth Fund survey, and nearly half of those reporting recent unemployment lost their health insurance. 26 Low- and moderate-income adults who were uninsured during the year were much less likely to have a regular source of health care than people in the same income range who were insured all year. 27 The uninsured are less likely to seek out primary care and preventive services than those with insurance and are also more likely to have unmet health care needs and delay seeking care due to costs. 28 As a result, if they develop a medical problem, it is more likely to progress to an acute condition than it would be if they had insurance. In addition, uninsured low-income adults were more likely than insured adults in the same income group to cite factors other than medical emergencies as reasons for going to the emergency room. These included needing a prescription drug, not having a regular doctor, or saying that other places cost too much % 0% Mammograms* Pap Tests** STDs Screening Smoking Cessation Counselling *% of Women 40+ and <200% FOL Receiving Mammograms. ** % of Women 18+ and <200% FPL Receiving Pap Smears in Last 3 Years Source: Shi, L and Stevens, GD. The Role of Community Health Centers in Delivering Primary Care to the Underserved. April-June 2007 J Ambulatory Care Manage 30(2): Health Wanted: The State of Unmet Need for Primary Health Care in America 9

12 The Percent of Population who are Uninsured in Counties Half of the counties with the highest rate* of uninsured population are without a health center. % Uninsured 3.3%-13.2% 13.3%-16.6% 16.7%-19.5% 19.6%-23.0% 23.1%-42.8% N/A Health Center Delivery Sites Note: Highest rate denotes counties with uninsurance rates between 23.1%-42.8%. Source: NACHC. Data Source: U.S. Census Bureau, Small Area Health Insurance Estimates, Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, The Health Center Solution Thirty-eight percent of health center patients are uninsured 1 in 7 uninsured Americans 30. The health center uninsured population continues to grow faster than the national uninsured population (Figure 5). Health centers also accept more uninsured patients than other primary care providers. 31 Health centers deliver results: uninsured health center patients are twice as likely as other uninsured Americans to seek out timely and needed care and to refill prescriptions. 32 They are also more likely than their national counterparts to receive many preventive services (Figure 6). Health Wanted: The State of Unmet Need for Primary Health Care in America 10

13 FTEs 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Communities that Lack Sufficient Primary Care Providers Many communities do not have enough primary care providers physicians, nurse practitioners, physician assistants, certified nurse midwives, nurses and others to support their health care needs. Physicians, for example, are also curtailing the number of hours per week they will see patients. The reduction in physician capacity is exacerbated by the fact that more physicians are working part time and only a third offer evening and weekend hours. 33 FIGURE 7 The Number of Health Center Medical Providers Has More Than Doubled 4,803 9,592 Physicans 6,362 6,378 2, ,365 19,310 43,830 NP, PA, CNM Nurses Total Medical Care Providers Note: NP, PA, CNM stands for Nurse Practitioner, Physician Assistants, Certified Nurse Midwives. Total Medical Care Providers includes physicians, NP,s PA, CNM, nurses, and other medical personnel. Source: NACHC analysis of NACHC analysis of Bureau of Primary Health Care, HRSA, DHHS, 2000 and 2010 Uniform Data System (UDS). Sixty million Americans do not have adequate access to primary care because of shortages of such physicians in their communities. The problem reaches even those with insurance, but it disproportionately affects low-income, uninsured, and minority populations. 34 Many communities are also impacted by shortages of other primary care professionals, including nurse practitioners, physician assistants, certified nurse midwives, and nurses. Those living in areas with too few primary care resources are forced to travel long distances to receive care, and often find themselves delaying or foregoing care. Where demand outweighs provider supply, providers are forced to limit their practices. They also spend less time with patients, curtailing the number of preventive services that should be furnished. 35 Patients suffer with poorer outcomes and often wind up turning to costlier Emergency Departments and inpatient care for problems that could be prevented or treated through timely primary care. Even where there are sufficient numbers of primary care providers, there is widespread evidence of primary care practices restricting the patients they accept based on insurance. 36 Medicaid patients and the uninsured have a far more difficult time finding a primary care practitioner than privately insured patients do. The Health Center Solution Health centers serve as an anchor for primary care resources, setting up the infrastructure that brings in many clinicians dedicated to caring for the underserved. For example, they are currently the place of employment for 40% of all National Health Service Corps (NHSC) program participants, who receive scholarships or loan repayment to serve in areas needing additional professionals. 37 Additionally, nearly 80 percent of health centers are engaged in training health professionals. 38 Research shows that health center-trained physicians are more than twice as likely as their non-health center trained counterparts to work in an underserved area. 39 Workforce placement and training programs have helped the health center medical provider population grow (Figure 7). Health Wanted: The State of Unmet Need for Primary Health Care in America 11

14 The Rate of Primary Care Providers Per 10,000 Population in Counties Over half of the counties with the lowest* primary care provider rates do not have a health center. Primary Care Providers (per 10,000 person N/A Health Center Delivery Sites Note: The lowest rate denotes counties with primary care providers per 10,000 persons. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: Health Resources and Services Administration, Area Resource File (ARF), 2008, Primary Care Providers. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Not only are health centers located in areas where there is a shortage of available providers, their unique delivery model utilizes multiple health professionals with varied skills to increase capacity and thereby amplify access to primary care in underserved communities. Compared with other provider settings, they are twice as likely to employ at least one non-physician clinician. 40 Also critical to health centers success is their dedication to serving all without regard to insurance status or ability to pay. More than 85% of their patients are uninsured or publicly-insured. 41 Health Wanted: The State of Unmet Need for Primary Health Care in America 12

15 Communities that Need Culturally Competent Care Cultural competence in health care incorporates the awareness of health beliefs and behaviors, disease prevalence and incidence, and treatment outcomes for different patient populations. It is a component of health care delivery that receives greater attention as the U.S. population becomes more culturally diverse. Efforts to increase cultural competency are aimed at eliminating health care disparities and improving medical outcomes. Research suggests that health care providers need to do a better job acknowledging and understanding their patients cultural and linguistic differences, how these differences might affect care, and how best to meet all their patients health care needs. 42 This research finds that compared with whites, minority respondents feel less welcomed by the health care system, have more reservations about the benefits and value of health care, and are more likely to face significant language barriers. Research on health disparities suggests that patients who receive culturally sensitive care are likely to show an increased level of adherence to medical advice and to report satisfaction with their care providers. 43 For example, language accessibility is critical in ensuring that providers fully understand their patients health concerns and that The Percent of the Population Not English Proficient in Counties More than 1 in 3 counties with the highest percentage* of the population not proficient in English do not have a health center. % Not Proficient in English 0.0%-0.7% 0.8%-1.3% 1.4%-2.4% 2.5%-0.7% 5.2%-61.0% N/A Health Center Delivery Sites Note: Highest percent denotes counties with 5.2%-61.0% of population not proficient in English. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: U.S. Census Bureau, American Community Survey 5- year Estimates, 2009, Percent Not English Proficient. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 13

16 patients understand their health care. 44 Language barriers can cause people to delay or forgo care, or, for those who do access care, may lead to misunderstandings about their health or health care, failure to comply with treatments, and lower satisfaction with their care. 45 The Health Center Solution Over 63% of health center patients are racial or ethnic minorities. Health centers report higher patient satisfaction ratings compared to the general population. 46 Some research suggests that the absence of disparities at health centers may be related to their culturally competent practices and community involvement, features that are often lacking at other primary care settings. 47 Health centers blend cultural practices into their health care delivery model, delivering alternative healing approaches that complement mainstream medicine. To combat language barriers for their Limited English Proficiency (LEP) patients, over 95% of health centers provide translation services. 48 A NACHC survey found that health centers use a variety of staffing models that utilize bilingual clinical, non-clinical staff and staff interpreters who speak over 55 languages to meet patients needs. 49 This is critical to ensuring that health center patients receive appropriate and necessary care. People Living in Rural America Rural residents number approximately 50 million nationwide 50. In general, they have a higher prevalence of elderly individuals, poverty, and incidence of chronic disease 51 and a lower rate of transportation access than urban residents. 52 Residents of rural areas are also more likely to report their health status as fair or poor than urban residents (20% vs. 16%). 53 While they face some of the same obstacles to health care as urban dwellers, including cost, cultural and linguistic differences, and transportation, rural residents also face barriers unique to their geographic location, including fewer options for health care facilities and greater distances to travel to reach them. Inadequate access has been amplified by the shortage of physicians in non-metropolitan areas, with 37% of rural residents having insufficient access due to low physician presence compared to just 21% of urban residents. 54 Furthermore, those who live in rural areas, especially the elderly, do not visit care providers as often and, therefore, receive less primary care on average. 55 Health Wanted: The State of Unmet Need for Primary Health Care in America 14

17 The Health Center Solution In total, 48% of all health centers serve rural populations, providing care for 1 in 7 rural residents. 56 In addition to providing comprehensive services in rural areas health centers also provide supportive services, such as transportation, home visits, interpreters, case management, and health education that increase access in rural areas. To cater to their large elderly population, rural health centers also commonly provide nursing home placement and home visiting services. These rural health center services have led to: 25% fewer uninsured Emergency Department visits for ambulatory care sensitive conditions compared to rural counties without a health center, 57 $5 billion annually returned to rural communities through employment and supplier purchases, 58 Increased rates of pap smears among rural health center female patients compared to rural women nationally, 59 and Lower rates of low birth weight among rural health center patients than among patients of other providers. 60 The Percent of the Population Living in Rural Communities More than two-thirds of the most rural counties* do not have a health center. % Population Living in Rural Areas 0.0%-30.4% 30.5%-51.6% 51.7%-69.8% % 100% N/A Health Center Delivery Sites Note: Most rural counties denotes 100% of population living in rural areas. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: U.S. Census Bureau, Percent Rural. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 15

18 POOR HEALTH OUTCOMES: HEALTH CENTERS PROVIDE NEEDED CARE AND IMPROVE HEALTH Individuals who face barriers to health care and healthy living are at risk of developing poor health outcomes. More and more Americans are experiencing morbidity as the prevalence of chronic disease and disabilities rises. Morbidity not only affects the length and quality of a person s life but also their economic stability if they have to take time off from work or spend costly sums on health care. Diseases do not discriminate. They affect everyone regardless of age, gender, race/ethnicity, income, insurance status, and geographic location. Barriers to care, on the other hand, tend to disproportionately affect these populations. As a result, significant health disparities exist. The impact of these poor health outcomes is costly. Poor health outcomes can be mitigated and even prevented through the use of effective primary care, which includes disease management. Unfortunately, many of these services are lacking in too many areas. Screening rates for various diseases are too low in too many counties while disease management services are also palpably absent in many areas. The following section demonstrates a second way to gauge health care needs. This series of needs highlights examples of poor health outcomes, the importance of prevention, and the role of health centers in providing preventive and disease management services. Health Wanted: The State of Unmet Need for Primary Health Care in America 16

19 POOR HEALTH OUTCOMES IN A COMMUNITY IN NEED: HARDIN COUNTY, OHIO Residents living in Hardin County, Ohio are much in need of primary care services but have to drive over 33 miles to a neighboring county to gain access to care, a round trip of over 60 miles. All of Hardin County is federally designated as a Primary Medical Care Health Professional Shortage Area and a Dental Health Shortage Area. 124 Hardin County ranks 53 rd out of the state s total 88 counties in overall health outcomes and 73 rd for premature death. 125 Heart disease and stroke are a major cause of death and disabilities, as well as cancer. 126 In 2008, 26% of children did not receive recommended immunizations. 127 Methamphetamine use is also a huge problem. Over 7% of students in Ohio report using the drug. It is an even bigger problem in Hardin County according to local school officials and hospital ER reports. the unintentional drug death rate was per 100,000 in Hardin County, compared with per 100,000 in the State of Ohio. 128 In addition to its poor health outcomes, Hardin County is also very poor. It remains one of the five poorest counties in Ohio without a health center and has been further battered by the economic recession with factory closings and an unemployment rate that hovers around 9%. The percentage of the population living in poverty has risen sharply in recent years. Among the hardest hit are children: 65% live at or below 200 percent FPL, the highest percentage of children living in poverty in Northwest Ohio. 129 Not surprisingly, a large portion of Hardin County residents (49%) do not own cars while those who do often cannot afford escalating gas prices. 130 When gas prices in 2008 spiked to over $4.00 a gallon in Northwest Ohio, many patients reported they did not have the money for gas to drive to their appointments or pick up prescriptions, 131 an occurrence that could happen again with today s high gas prices. To make health care accessible to Hardin County residents and meet their health care needs, Health Partners of Western Ohio Community Health Center, which operates two sites in nearby counties, applied for a new access point in Hardin County. Even though their own center has seen an increase in the number of patients traveling long distances for care and an increase in the demand for services overall in an area that is sorely in need of primary care, the application for the New Access Point in Hardin County remains unfunded. Future intended site for Health Partners new health center that went unfunded. Health Wanted: The State of Unmet Need for Primary Health Care in America 17

20 People with Poor Health Status Health status serves as an important indicator of health care needs. 61 These individuals require a high level of health care services, coordinated by a regular source of primary and preventive care. More than 1 in 7 U.S. adults report that his/her health status is fair or poor. 62 The likelihood of reporting fair or poor health increases with age and poverty status. Racial/ethnic minorities, Medicaid beneficiaries, and the uninsured have higher rates of fair/poor health status than their non-minority and privately insured counterparts. 63 Studies indicate that those who self-rate their health as fair or poor are at significantly higher risk of mortality compared to those who report their health as excellent. The risk is twice as high for those with poor health. 64 The Health Center Solution Access to high quality primary care, characterized by enhanced accessibility and care continuity, is associated with reducing racial and ethnic disparities in self-reported health status, particularly among those living in poverty. 65 Although health center patients have lower health status compared to the general population, disparities in health status do not exist within health centers, even after controlling for socio-demographic factors. 66 The Percent of Population Reporting Fair or Poor Health Status in Counties Health centers are absent in nearly 4 in 10 counties with the highest percent* of population living in poor/fair health. % Reporting Fair/Poor Health 2.1%-11.9% 11.91%-14.6% 14.61%-17.8% 17.81%-21.6% 21.61%-44.8% N/A Health Center Delivery Sites Note: Highest percent denotes counties with 21.61%-44.8% of population reporting poor/ fair health. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: Behavioral Risk Factor Surveillance System (BRFSS), , Percent of adults reporting fair or poor health. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 18

21 Mothers and Babies at Risk for Low Birth Weight Low Birth Weight (LBW) is a primary contributor to infant mortality. It can also lead to a variety of long-term debilitating and costly health conditions for children, including cerebral palsy, developmental disabilities, and vision and hearing impairments. 67 However, not all consequences are immediately apparent. LBW has been linked to an increased risk of cardiovascular diseases like myocardial infarction, coronary revascularization, and stroke, which do not develop until adulthood. 68 Women of low-income status run a higher risk of delivering babies at LBW compared to women with higher incomes. 69 While rates of LBW continually decreased in the 1900s, by the latter part of the century, the progress halted and even reversed, with the national rate increasing from 6.8% to 8.3% between 1981 and During the same period, preterm birth, which often results in LBW, rose from 9.4% to 12.8%. 70 LBW is preventable with timely access to prenatal care. Yet only 77% of African-American mothers and 77% of Hispanic mothers received prenatal care in the first trimester, compared to the national average of 84%. 71 The Health Center Solution Health center patients account for 1 out of every 6 lowincome births nationally. 72 Yet, while health centers treat a high risk demographic, their rate of LBW among deliveries is consistently below the national average. 73 As Figure 8 illustrates, health center births have lower rates of LBW than all births nationally, despite serving patients at higher risk. This trend holds true across different racial/ethnic groups. Thanks to health centers, there are 17,100 fewer LBW African-American infants annually. 74 The benefits of lowering LBW are economic as well as health-related. Health centers save the state and federal governments billions of dollars. For example, one study of the health center Clinica Family Health Services in Colorado reported that this specific health center alone saved $2.1 million in costs related to LBW by preventing 43 premature births just in FIGURE 8 Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts U.S. U.S. Low Income Health Center 15% 13.0% 14.9% 10.7% 10% 5% 7.7% 8.2% 7.5% 7.5% 7.5% 6.6% 6.5% 6.0% 5.6% 6.8% 9.1% 7.4% 0% Total Asian Black Hispanic White Source: Shi, L., et al. America s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes Health Services Research, 39(6), Part I, Health Wanted: The State of Unmet Need for Primary Health Care in America 19

22 The Percent of Low Birth Weight Infants in Counties A health center is not present in a third of the counties with the highest percent* of low birth weight babies. % Low Birthweight Infants % 6.6%-7.3% 7.4%-8.2% 8.3%-9.5% 9.6%-16.5% N/A Health Center Delivery Sites Note: Highest percent denotes counties with 9.6%-16.5% of infants who are low birth weight. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: National Center for Health Statistics (NCHS), Percent of live births with low birthweight (< 2500 grams). Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 20

23 12% 10% 8% 6% 4% 2% 0% 80% 60% 40% 20% People with Chronic Disease and Diabetes Prevalence The nation is burdened with an increasing prevalence and continuous demand for care and management of chronic illness. 76 Seven out of ten deaths among Americans each FIGURE 9 Individuals with Chronic Conditions Are More Likely to Seek Care at Health Centers than Other Providers Health Centers Primary Care Offices 9% FIGURE 10 Health Center Diabetes Patients Receive More Care than Other Low-Income Diabetics 63% 5% Mental Disorders 52% 7% 26% 23% 3% 3% 78% 67% 62% 60% Health Center Patients Low-Income Nationally 0% Eye Exam Foot Exam FluShot** Pneumovax** ** Age 65 years Source: A review of community health issues and opportunities: Hearings before the Energy and Commerence, Subcommitteeon Oversight and Investigations, 109th Cong. (2005) (testimony of Leiyu Shi). Based on Community Health Center User, 2002; and National Health Interview Survey, % 11% 4% Diabetes Asthma Hypertension Source: Kaiser Family Foundation. Community Health Centers: Opportunities and Challenges of Health Reform. August Available at Based on Private Physicians from 2006 NAMCS (CDC National Center for Health Statistics, 2008). Health Centers from UDS, year are from chronic diseases. 77 People living in rural areas are more at risk compared with their urban counterparts. 78 Diabetes in particular places a heavy burden on the U.S. health care system. Diabetes affects over 25 million people (8%) in the U.S. and over one-quarter (27%) of those over age 65. Another 79 million adults (35%) with prediabetes are at high risk of developing the disease over the next decade. 79 The disease is the seventh leading cause of death and is associated with other major chronic disease. In 2007, estimated costs associated with diabetes totaled more than $174 billion. Medical expenses for people with diabetes are more than two times higher than for people without diabetes. 80 The Health Center Solution Among reports of primary reasons for a visit to a health center, chronic illness (including behavioral health) makes up more than one-quarter. Diabetes is one of the most prevalent chronic diseases among health center patients (Figure 9). In 2010, diabetes was the primary reason for more than 3.7 million visits. 81 Despite the difficulties associated with diabetes, health centers provide effective and comprehensive management services to prevent the onset of diabetes-related illness, such as blindness, kidney failure, limb amputations, and heart disease (Figure 10). Many health centers have participated in the Health Disparities Collaboratives, an innovative health program from HRSA designed to improve health outcomes for chronic diseases through patient-centered approaches. As a result, health centers perform better than physician offices on several process of care measures, including laboratory tests such as glycohemoglobin (blood sugar) tests, especially for uninsured, Medicaid, Hispanic/Latino and African American patients. 82 Health centers provision of clinical, education, and outreach services has helped reduce the complications associated with diabetes 83 and the health care costs of diabetes-related illnesses. 84 Their chronic care management activities have significantly improved clinical processes of care in just one to two years and clinical outcomes in two to four years. 85 These positive results make health centers presence vitally important in managing diabetes and preventing its onset. Health Wanted: The State of Unmet Need for Primary Health Care in America 21

24 The Percent of Population with Diabetes in Counties Over a third of the counties with the highest prevalence* of diabetes do not have a health center. % Population with Diabetes 3.0%-8.2% 8.3%-9.3% 9.4%-10.3% 10.4%-11.7% 11.8%-18.2% N/A Health Center Delivery Sites Note: Highest prevalence denotes counties with 11.8%-18.2% of population with Diabetes. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: Centers for Disease Control (CDC), Small Area Obesity Estimates, 2008, Percent Diabetic. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 22

25 People with HIV and AIDS HIV affects and continues to plague every region, age range, and ethnic group in the U.S. At least 1.2 million Americans are living with HIV, with an estimated 50,000 additional new cases each year. Populations that are disproportionately affected by the disease include African Americans (14% of the population and 44% of new infections) and Hispanics (16% of the population and 20% of new infections). HIV is a leading cause of death for African-American men and women aged and Hispanic/Latina females of the same age. 86 People living in poor urban settings are at particularly high risk for HIV. These individuals are also disproportionately affected by limited health care access, substance abuse, and incarceration all of which impact receipt of HIV testing and prevention services. 87 Some of the same factors that impede HIV testing also hamper the receipt of treatment services. For example, patients without adequate insurance are less likely to be on antiretroviral therapy. 88 Too many are diagnosed late in their infection and consequently fail to benefit from early treatment and prevention that can delay diagnosis of or death from AIDS. 89 HIV patients also require other primary care preventive services, such as cancer screenings, but still often fail to receive them. 90 The Rate of HIV Per 100,000 in Counties A quarter of the counties with the highest prevalence* of HIV do not have a health center. HIV Rate (per 100,000 persons) N/A Health Center Delivery Sites Note: Highest rate denotes counties with cases per 100,000 persons. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: National Center for Hepatitis, HIV, STD and TB Prevention, 2007, HIV Rate. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 23

26 The Health Center Solution Primary care providers are essential sources of care for patients with or at risk of HIV/AIDS. These providers can promote prevention, evaluate risk, identify infected patients, and share in the delivery of effective HIV treatment services. Moreover, as HIV-positive patients live longer due to effective treatments, primary care providers can manage their other chronic illnesses, such as cardiovascular disease, hypertension, and diabetes. Effective primary care can reduce the need for costly specialty services for HIV patients. 91 Health centers are a major source of HIV prevention, care, and treatment in America s safety net. Health centers provided HIV testing to nearly 800,000 patients in Some health centers are integrating rapid testing protocols into their practice and are seeing the number of HIV tests provided increase as much as five-fold in just one year. 92 Many health centers provide HIV/STD risk reduction counseling and psychosocial evaluation onsite. Approximately 1 in 4 HIV-infected patients were new patients over the previous year, according to a 2003 survey of health centers. 93 Health Wanted: The State of Unmet Need for Primary Health Care in America 24

27 % of Women 40+ and <200% FPL Receiving Mammograms 100% 80% 60% 40% 20% 0% People Without Disease Prevention and Preventive Screenings Disease prevention is a growing national imperative, particularly as more families struggle with the personal and financial implications of chronic illness. Individuals who receive preventive care, including immunizations and cancer screenings, have better health and lower health care costs. 94 Screenings are an important step to diagnosing health conditions, like diabetes and cancer, before they progress. However, screenings are often not being performed as primary care providers compensate for large patient caseloads by spending less time per patient. 95 Research demonstrates that with an increase in evidencebased clinical preventive services utilization, as many as 100,000 lives can be saved annually. 96 For example, the risk of developing severe breast cancer symptoms can be reduced through regular breast cancer screenings, such as mammograms. FIGURE 11 Health Centers Reduce Disparities in Access to Mammograms 76% 48% Hispanic 61% 49% 82% 56% Health Centers Nationally Healthy People % 49% African-American Medicaid Uninsured Source: Shi, L and Stevens, GD. The Role of Community Health Centers in Delivering Primary Care to the Underserved. April-June 2007 J Ambulatory Care Manage 30(2): Politzer R, Yoon J, Shi L, Hughes R, Regan J, and Gaston M. Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care Medical Care Research and Review 58(2): The Health Center Solution Although many women never receive mammograms due to access and cost barriers, health centers provided 319,262 mammograms to 299,516 patients in 2010 alone. 97 Several studies have shown that health center patients have higher breast cancer screening rates than Medicaid, uninsured, low-income, and minority patients seen elsewhere (Figure 11). 98 Additionally, uninsured patients are more likely to receive pap tests, screening for sexually transmitted diseases or infections, and smoking cessation counseling than the uninsured nationally. 99 As part of their commitment to provide comprehensive primary care services, health centers also provide these and other preventive screenings: Screening for communicable diseases, Pediatric dental, hearing, and vision screening, Cholesterol screening, Cancer screenings, Screenings for elevated blood lead level, HIV tests, and Mental health and substance abuse screenings. Health Wanted: The State of Unmet Need for Primary Health Care in America 25

28 The Percent of Female Medicare Enrollees that Receive Mammography Screening in Counties Health Centers are not present in nearly half of the counties with the lowest mammography screenings. % Receiving Mammography Screening 19.1%-55.0% 55.1%-60.9% 61.0%-65.4% 65.5%-70.6% 70.7%-100% N/A Health Center Delivery Sites Note: Lowest percent counties with 19.1%-55% of female Medicare enrollees receiving mammography screenings. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: Medicare claims/dartmouth Atlas, , Percent of Female Medicare Enrollees that Receive Mammography Screening. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 26

29 UNNECESSARY EXPENSES: HEALTH CENTERS SAVE MONEY Faced with barriers to timely, regular care and poor health, many individuals default to costlier Emergency Departments (EDs) to address their primary health needs. Many also wind up in the ED or even in the hospital when they are forced to delay care for an ambulatory care need until it becomes severe. Many others utilize expensive specialty care for primary care treatable services. These circumstances drastically inflate health care costs. If everyone made appropriate use of primary care, the U.S. health care system would save $67 billion annually. 100 Continuous access to primary care is critical to rein in health care costs and prevent the health care system from becoming overloaded and misused. Numerous studies have documented the savings that result from using primary care as opposed to tertiary levels of care. For example, health centers overall medical expenditures per patient are 24% less than the overall medical costs for patients who did not use health centers, while their per-patient ambulatory care expenditures are 25% less, their hospital inpatient expenditures are 18% less, and their emergency expenditures are 18% less. 101 These per-person savings add up. Health centers save $1,263 per person per year (Figure 12), which totals $24 billion annually in overall health care savings. 102 Health centers reduce unnecessary, avoidable, and wasteful use of health resources and ultimately lower costs across the health care delivery system. This section details yet another marker of health care needs. What follows is a depiction of how the U.S. health care system is becoming overloaded as the result of avoidable use of costlier forms of care and how health centers are helping the system to get back on track. FIGURE 12 Health Centers Save $1,263 Per Patient Per Year $6,000 $5,306 $5,000 $4,000 $4,043 $3,000 $2,000 $1,000 $0 Health Center Users Non-Health Center Users Hospital Emergency Department Hospital Inpatient. Ambulatory Other Services Source: NACHC analysis based on Ku L et al. Using primary Care to Bend the Cure. Estimating the Impact of a Health Center GWU Department of Health Policy. Policy ResearchBrief No. 14. September Health Wanted: The State of Unmet Need for Primary Health Care in America 27

30 Avoidable Emergency Department Visits Because hospital emergency departments (EDs) are open 24 hours a day, 7 days a week, and are generally required to medically screen all people regardless of ability to pay, a growing proportion of people who lack a usual source of care use EDs for their health care. 103 As more EDs close, those that remain open experience higher patient volume and overcrowding, and patients experience longer wait times. 104 As many as 30% of ED visits are considered nonurgent or could have been treated in a primary care setting. 105 In a majority of these visits (about 65 percent), patients arrived in the emergency department at times and days when primary care providers are likely to be closed after business hours on weekdays and on the weekends. The Health Center Solution Research shows that health centers reduce the rate of ED use, as shown by several independent studies. Much of this has to do with providing preventive care to populations who would otherwise rely on the ED for their primary care, or would wind up in the ED after an untreated ambulatory-treatable condition became life-threatening. In fact, greater health center capacity lowers ED utilization The Rate of Emergency Department Visits in Counties Health centers are absent in more than 40 percent of the counties with the highest rate* of ED visits. Emergency Department Visits (per 1,000 persons) N/A Health Center Delivery Sites Note: Highest rate counties with ED visits per 1,000 persons. Source: Health Resources and Services Administration, Area Resource File (ARF), , Hospital Emergency Department Visits. Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 28

31 among low-income populations. 106 As noted earlier, one major study found that rural counties with a health center have 25% fewer ED visits for uninsured patients with ambulatory care sensitive conditions than rural counties without a health center. 107 Also, Medicaid beneficiaries who rely on health centers for usual care are 19% less likely to use the ED for ambulatory care sensitive conditions compared to beneficiaries relying on other providers. 108 Health centers achieve these results in two ways: first, their accessibility, including providing care during evening and weekend clinic hours when many ED visits take place, and their effective management of chronic disease; and second, through ED care coordination strategies, often in collaboration with a hospital. These initiatives provide usual care through a health center to those at risk of avoidable ED visits. They typically do so by educating patients on the appropriate use of the ED, informing them about the services offered at the health center, and arranging follow-up appointments at or referrals to the participating health center. 109 Due to these promising strategies and results, the Government Accountability Office (GAO) recognizes that health centers may serve as a less costly alternative to EDs, particularly for individuals with non-urgent conditions. Based on their report, the GAO found that the average amount paid for a nonemergency visit to the ED was seven times more than that for a health center visit ($792 vs. $108). 110 Health Wanted: The State of Unmet Need for Primary Health Care in America 29

32 Preventable Hospitalizations Every day in America, there are people hospitalized for conditions that could have been prevented or treated in a primary care setting. The irony is that many hospitalizations or rehospitalizations are preventable with better primary care, discharge planning, and transitional and follow-up care. Two studies that analyzed hospital admissions rates for ambulatory-care sensitive conditions (ACSCs) found that individuals who reported poor access to medical care had higher hospitalization rates for ACSCs. 111 The Health Center Solution Evidence shows that a higher density of primary care providers can lower that probability of hospitalization for ambulatory-care sensitive conditions. 112 Several studies have documented the positive impact health centers have on reducing hospitalization rates. For example, the rate of hospitalizations associated with conditions related to ambulatory care is 12 to 16% lower in rural areas with at least one health center, compared with rural areas where there are no health centers. This relationship is especially strong among adult populations. 113 Health center Medicaid beneficiaries are also 19% less likely to be hospitalized for an ACSC than Medicaid beneficiaries who receive their care elsewhere. 114 The Hospitalization Rate for Ambulatory-Care Sensitive Conditions Per 1,000 Medicare Enrollee in Counties More than half of counties with the highest rate* of hospitalizations for ambulatory care sensitive conditions do not have a health center. Hospitalization Rate of Ambulatory Care Sensitive Conditions (per 1,000 Medicare Enrollees) N/A Health Center Delivery Sites Note: Highest rate denotes counties with hospitalizations per 1,000 Medicare enrollees. Source: University of Wisconsin Population Health Institute. County Health Rankings Data Source: Medicare claims/dartmouth Atlas, , Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees. Accessible at Health Center Site Locations: HRSA Data Warehouse, January 20, Health Wanted: The State of Unmet Need for Primary Health Care in America 30

33 HOW HEALTH CENTERS ADDRESS UNMET NEEDS The health center model of care is rooted in their federal program requirements, 115 yet customized to meet the specific needs of their diverse communities. In this way health centers take responsibility for the health of entire communities, not just their patients. This section draws attention to the elements that make the federal Health Center Program successful and accountable to community needs. Each component is an essential part of fulfilling unmet health care needs, but it is the full package that best improves health. Consumer-Directed, Not-for-Profit Care All health centers must be nonprofit. Key to health centers accomplishments is patient involvement in service delivery and design. Health centers are required to be directed by patient-majority governing boards. Board members reflect the communities being served and manage health center operations, scope of services, and location decisions. Health center governing boards go beyond the role of advisory boards. Federal law requires that they meet at least monthly, be involved in planning and assessment of health care needs, directly hire and evaluate the performance of the executive director, establish general policies, evaluate patient utilization and satisfaction, monitor local market trends and long term goals, assess the health center s finances, ensure laws and regulations are met, and not be controlled by third parties. Empowering patients to actively manage their own care and advocate on behalf of their communities helps assure responsiveness to local needs. Enhanced Access to Care Getting patients in the door is a vital first step in improving health and generating savings for the health system. Health centers anchor primary care practices in communities unable to attract or sustain sources of stable, highquality of care. They excel in reaching the very sick, the hard-to-serve, and those unfamiliar with the health care system. Health centers remove common barriers to care by serving communities that otherwise confront financial, geographic, language, cultural and other barriers, making them different from most private, office-based physicians. They do so in the following ways: Locate in or serve high-need areas. Health centers are mandated to serve federally-designated Medically Underserved Areas and Populations (MUA/Ps). Across urban and rural communities, these areas are recognized has having elevated poverty, worse than average health outcomes, and where too few primary care resources locate. Be open to all residents, regardless of insurance or income status. Health centers offer free or reducedcost care based on ability to pay. Operate during hours that maximize accessibility. Health centers stay open past normal business hour and even have weekend hours. They are required to provide professional coverage when the center is closed. Deliver linguistically and culturally appropriate care. Health center providers often speak the same language as their patients, and services are designed to reflect the community s cultural views. Actively seek out patients. Health centers reach out to patients through outreach services, community health fairs, regular needs assessments, and mobile health care units that drive to hard-to-reach patients. Offer services that help their patients access health care, such as transportation, translation, case management, health education, and home visitation. Health Wanted: The State of Unmet Need for Primary Health Care in America 31

34 Enhanced Delivery of Care Beyond improving access to care, improving community health involves identifying unmet health needs, shaping health care around needs and community preferences, and delivering high-quality, evidence-based care. Health center patients are more at risk than the general population and therefore require a more intensive level of care. 116 Health centers enhance the delivery of care in the following ways. The result is care that is comprehensive, coordinated, continuous, and centered around patients and communities unique needs. Approach health broadly and provide comprehensive services. Beyond providing a broad array of primary and preventive care, as well as enabling services that facilitate access to care, health centers frequently offer dental, mental health and substance abuse, pharmacy, nutritional, educational, social, and other services. These services fill an otherwise critical gap in care, and many aim to alleviate the underlying causes of poor health. Deliver team-based, multidisciplinary care. An expanded definition of health necessitates integrating a diverse health professional workforce into primary care. Such team-based settings involve physicians, nurse practitioners, physician assistants, nurses, social workers, case managers, behavioral health specialists, dental providers, health educators, outreach workers, and others. Conduct ongoing needs and quality improvement assessments. Health centers carry out regular and formal assessments of community health needs and engage in continuous quality improvement activities. They run quality assurance programs to assess utilization and quality of services provided. Health centers chronic disease management programs rapidly incorporate evidence-based guidelines into clinical practices. 117 Coordinate care. Staffing arrangements must support coordination of services for health center patients, including coordination of hospital-provided services to their patients. Collaborate with other health and social service providers. Health centers partner with other community partners to extend their comprehensive array of services. Maintain data reporting systems. Data management supports clinical and operational decision-making. Health Wanted: The State of Unmet Need for Primary Health Care in America 32

35 HEALTH CENTERS ARE RISING TO THE CHALLENGE, BUT GREAT NEEDS REMAIN In caring for more than 20 million of the most traditionally underserved and at-risk populations, health centers stand as a locally-tailored solution to the nation-wide state of unmet need. Were it not for health centers, the number of individuals with unmet health care needs would be far greater. Health centers provide needed primary care, as well as dental, behavioral, pharmacy, and other services that fill community gaps in health care resources. Health centers also offer services that specifically help their patients navigate difficult circumstances in order to utilize high-quality care. These include transportation, translation, health education, outreach, case management, and other services that break down barriers to care. Because of their success in building healthier communities, mitigating health disparities, and expanding access to highquality, cost-effective care, the Health Centers Program was rated one of the most effective federal programs by the Office of Management and Budget (OMB). 118 Both research and recent health center grant applications from communities nationwide demonstrate that the need for access to primary care far outweighs available resources in many corners of our country. As the series of maps in this report illustrates, navigating complex and compounding barriers requires an enhanced level of services beyond medical care to address the social, environmental, and economic determinants of health. A more complete list of unmet needs would highlight barriers to care and indicators of need relevant to oral health care, mental health and substance abuse services, pharmacy, vision and other services that health centers successfully integrate into their model of care. As the research highlighted in this report has documented, taking this comprehensive approach to primary care through the health center model improves health and lowers health system costs significantly. The Health Centers Program has benefitted from longstanding bipartisan support due to this proven effectiveness. Today, health centers have a dedicated stream of mandatory funding enacted under the Affordable Care Act, providing still further opportunity for continued expansion to meet the persistent access needs documented in this report. However, in FY2011, only 67 of 1,900-plus health center grant applications submitted were awarded due to funding cuts. In FY2012, Congress has provided $200 million in additional funding that should allow for some of the over 1,800-plus unfunded and pending application to be awarded, but many will remain unfunded even as new communities lacking primary care continue to be identified. Building the nation s primary care system on a strong foundation of health centers is only attainable with sufficient investment to support expansion efforts and to maintain existing operations. A long and detailed history of research and evidence has proven this is an investment well worth making for the health and productivity of our nation. Health Wanted: The State of Unmet Need for Primary Health Care in America 33

36 1 Nolte, E., & McKee, C.M. (2011). Variations in Amenable Mortality Trends in 16 High-Income Nations. Health Policy, 103(1): National Center for Health Statistics. (2011). Health, United States, 2010: With Special Feature on Death and Dying. 3 Diamant, A.L., et al.(2004). Delays and Unmet Need for Health Care among Adult Primary Care Patients in a Restructured Urban Public Health System. Am J Public Health, 94(5): ; National Center for Health Statistics. (2011). Health, United States, Starfield, B. & Shi, L. (2004). The Medical Home, Access to Care, and Insurance: A Review of Evidence. Ped, 113(5 Suppl): Maciosek, M.V., et al. (2010). Greater Use of Preventative Services in US Health Care Could Save Lives at Little or No Cost. Health Aff, 29(9): Bureau of Primary Health Care (BPHC), Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS). (2010). Uniform Data System (UDS) [NACHC analysis]. Includes all patients of federally funded health centers as reported through the Uniform Data System, as well as NACHC data on non-federally funded health centers, and expected growth through BPHC, HRSA, HHS. (2009). UDS [NACHC Analysis]; Agency for Healthcare Research and Quality (AHRQ), HHS. (2008). Medical Expenditures Panel Survey: Tables of Expenditures by Health Care Services. *Low-income is defined by 200% of Federal Poverty Level (FPL), as measured by the HHS poverty guidelines. 8 U.S. Bureau of Labor Statistics, The Employment Situation January 2012, News release (Washington, D.C.: BLS, Feb. 2012). 9 Schwatz, K. & Streeter, S. (June, 2011). Kaiser Commission on Medicaid and the Uninsured: Health Coverage for the Unemployed. Kaiser Family Foundation. Retrieved from 10 Bodenheimer, T. & Hoangmai, H. (2010). Primary Care: Current Problems and Proposed Solutions. Health Aff, 29(5): Texas Medical Association. (2006). Survey of Texas Physicians Research Findings; Nelson, J., Banning, T., Kroll, C., & Bailey, C.J. (December, 2006). Fractured: The State of Health Care in Texas. Primary Care Coalition, Austin, TX; Vermont Department of Health. (November, 2007) Physicians Survey: Statistical Report. Retrieved from Vermont Department of Health. (March, 2005) Physician Survey: Statistical Report. Retrieved from: Public Sector Consultants, Inc. (December, 2009). Michigan Department of Community Health Survey of Physicians: Survey Findings, 2009; Cunningham, P.J. & O Malley, A.S. (2009). Do Reimbursement Delays Discourage Medicaid Participation by Physicians? Health Aff, 28(1):w17-w Cunningham, P.J., & May, J.H. (2006). A Growing Hole in the Safety Net: Physician Charity Care Declines Again. Center for Studying Health System Change, Tracking Report No Hing, E., Hooker, R., & Ashman, J. (June, 2011). Primary Health Care in Community Health Centers and Comparison with Office- Based Practice. J Comm Health, 36(3): Carrillo, E., et al. (2011). Defining and Targeting Health Care Access Barriers. J of Health Care for the Poor and Underserved, (22): Urban Institute. Kaiser Commission on Medicaid and the Uninsured. Kaiser Family Foundation. Retrieved from (Estimates based on the Census Bureau s March 2010 and 2011 Current Population Surveys). *Persons in poverty are defined here as those living in health insurance units with incomes less than 100% of the FPL. 16 Rundle, A., et al. (2008). Personal and Neighborhood Socioeconomic Status and Indices of Neighborhood Walkability Predict Body Mass Index in New York City. Social Science & Medicine, 67(12): ; Zick, C.D., et al. (2009). Running to the Store? The Relationship between Neighborhood Environments and the Risk of Obesity. Soc Sci Med,69(10): Franco, M., et al. (2008). Neighborhood Characteristics and Availability of Healthy Foods in Baltimore. Am J Prev Med,35: ; Morenoff, J.D., Diez Roux, A.V., Hansen, B.B., & Osypuk, T.L. (2006). Residential Environments and Obesity: What Can We Learn about Policy Interventions from Observational Studies? Presentation at the National Poverty Center s Health Effects of Non-Health Policy Conference. Retrieved from /events/healtheffects_agenda/morenoff.pdf. 18 Bodenheimer, T., Chen, E., & Bennett, H.D. (February, 2012). Confronting the Growing Burden of Chronic Disease: Can the U.S. Healthcare Workforce Do the Job? Health Aff, 31(2): National Center for Health Statistics, CDC, HHS. (2011). Health, United States, 2010: With Special Feature on Death and Dying. 20 BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. 21 BPHC, HRSA, HHS. ( ). UDS. [NACHC analysis]. 22 Shi, L., Lebrun, L.A., Tsai, J., & Zhu, J. (2010). Characteristics of Ambulatory Care Patients and Services: A Comparison of Community Health Centers and Physician Offices. J Health Care for the Poor and Underserved,21(4): Shin, P., Jones, K., & Rosenbaum, S. (September, 2003). Reducing Racial and Ethnic Health Disparities: Estimating the Impact of High Health Center Penetration in Low-Income Communities. Prepared for the National Association of Community Health Centers. Retrieved from 24 U.S. Census Bureau. (2011). Income, Poverty, and Health Insurance Coverage in the United States: Hoffman, C. & Schwartz, K. (October, 2008). Trends in Access to Care Among Working-Age Adults, Kaiser Commission on Medicaid and the Uninsured, No. 7824; Hoffman, C. & Schwartz, K. (2008). Eroding Access among Nonelderly U.S. Adults with Chronic Conditions: Ten Years of Change. Health Aff, 27(5):w Collins, S.R, Doty, M.M., Robertson R., & Garber, T. (March, 2011). Help on the Horizon: How the Recession Has Left Millions of Workers without Health Insurance, and How Health Reform Will Bring Relief. The Commonwealth Fund. Retrieved from 486_Collins_help_on_the_horizon_2010_biennial_survey_report_FINAL_31611.pdf 27 Collins, S., Roberston, R., Garber, T., & Doty, M.M. (February, 2012). The Income Divide in Health Care: How the Affordable Care Act Will Help Restore Fairness to the U.S. Health System. The Commonwealth Fund, Tracking Trends in Health System Performance, 3. Health Wanted: The State of Unmet Need for Primary Health Care in America 34

37 28 Hoffman, C. & Schwartz, K. (October, 2008),. Trends in Access; to Care Among Working-Age Adults, Kaiser Commission on Medicaid and the Uninsured (#7824; October); Hoffman, C. and & Schwartz, K. (2008). Eroding Access Among Nonelderly U.S. Adults with Chronic Conditions: Ten Years of Change. Health Aff 27(5):w Collins, S.R., Robertson, R., Garber, T., & and Doty, M.M. (2012). The Income Divide in Health Care. 30 BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. *NACHC, Includes all patients of federally-funded health centers, nonfederally funded health centers, and expected patient growth for Data on federally-funded health centers from Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System (UDS). Proportion of all US residents does not account for health centers located in U.S. territories. 31 Hing, E., Hooker, R.S., & Ashman, J.J. (June, 2011). 32 O Malley, A.S., et al. (2005). Health Center Trends, : What Do They Portend for the Federal Growth Initiative? Health Aff, 24(2): American Medical Group Association. (March, 2008) Physician Retention Survey (Supplemental edition). Retrieved from: SE_web.pdf. 34 NACHC. (March, 2009). Primary Care Access: An Essential Building Block of Health Reform. Retrieved from 35 Zyzanski, S.J., Stange, K.C., Langa, D., & Flocke, S.A. (May, 1998). Trade-offs in High-volume Primary Care Practice. J Fam Pract, 46(5): Cunningham, P. J., & Hadley, J. (2008). Effects of Changes in Incomes and Practice Circumstances on Physicians Decisions to Treat Charity and Medicaid Patients. The Milbank Quarterly, 86(1): HRSA, HHS. Justification of Estimates for Appropriations Committees, Fiscal Year NACHC. (March, 2012). An Assessment of Community Health Centers Involvement in Health Professions and Residency Training (Chartbook). 39 Morris, et al. (2008). Training Family Physicians in Community Health Centers: A Health Workforce Solution. Fam Med, 40(4): Hing, Hooker, & Ashman, (June, 2011). 41 BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. 42 Commonwealth Fund (2002). Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. nd%20report/2002/mar/diverse%20communities%20%20common%20concerns%20%20assessing%20health%20care%20qual ity%20for%20minority%20americans/collins_diversecommun_52 3%20pdf.pdf. 43 Chenowethm, L., Jeon, Y.H., Goff, M., et al. (2006). Cultural competency and nursing care: an Australian perspective. Int Nurs Rev. 53: Cook, C.T., Omofolasade, K., Richard, O.B. (2005). Satisfaction with and perceived cultural competency of healthcare providers: the minority experience. J Natl Med Assoc. 97: Wolosin, S., Schwartz, L.M., Katz, S.J., & Welch, H.G. (1997). Is Language A Barrier to the Use of Preventive Services? J Gen Intern Med, 12, Derose, K.P., & Baker, D.W. (2000). Limited English Proficiency and Latinos Use of Physician Services. Med Care Res Rev, 57(1), Feinberg, E., Swartz, K., Zaslavsky, A.M., Gardner, J., & Walker, D.K. (2002). Language Proficiency and the Enrollment of Medicaid-Eligible Children in Publicly Funded Health Insurance Programs. Maternal and Child Health Journal, 6(1), David, R.A., & Rhee, M. (1998). The Impact of Language as a Barrier to Effective Health Care in an Underserved Urban Hispanic Community. Mount Sinai Journal of Medicine, 65, Proser, M. (2005). Deserving the Spotlight: Health Centers Provide High-quality and Cost-effective Care. J Ambul Care Manage, 28(4), Shi, L., Regan, J., Politzer, R., & Luo, J. (2001). Community Health Centers and Racial/Ethnic Disparities in Healthy Life. Int J Health Serv, 31(3): NACHC, Patient Experience Evaluation Report (PEER) Data, NACHC. (2007). Serving Patients with Limited English Proficiency: Results of a Community Health Center Survey. 50 Kaiser Family Foundation. (2009). Population Distribution by Metropolitan Status, States ( ), U.S. State Facts. Retrieved from 51 Agency for Healthcare Research and Quality (AHRQ), HHS. (2009). Health Care in Urban and Rural Areas, Combined Years MEPS Chartbook, No. 13. Retrieved from 52 The National Advisory Committee on Rural Health and Human Services. (April, 2005). The 2005 Report to the Secretary: Rural Health and Human Services Issues. 53 Bennett, K., et al. (2008). Health Disparities: A Rural-Urban Chartbook. Rural Health Research and Policy Centers. 54 The Robert Graham Center s analysis of medically disenfranchised populations. For more information, see NACHC & RGC. (2007). Access Denied. Retrieved from 55 AHRQ, HHS. (2009). Health Care in Urban and Rural Areas, Combined Years MEPS Chartbook, No. 13. Retrieved from 56 BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. 57 Rust,G., et al, (2009), Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties. J Rural Health (1): Based on 2007 revenue and applies an average economic multiplier for rural health centers of 1.3. Developed with input from Capital Link. 59 Regan, J., et al. (2003). The Role of Federally Funded Health Centers in Serving the Rural Population. J Rural Health, 19(2): Rust, G., et al. (2009). 61 DeSalvo, K., et al. (2006) Mortality Prediction with a Single General Self-rated Health Question. J Gen Intern Med, 21: Centers for Disease Control and Prevention (CDC), HHS. (2010). Behavioral Risk Factor Surveillance System Survey Data. Retrieved from HS&yr=2010&qkey=4414&state=All. Health Wanted: The State of Unmet Need for Primary Health Care in America 35

38 63 NCHS, CDC, HHS. (January, 2012). Summary Health Statistics for US Adults: National Health Interview Survey, Vital and Health Statistics 10(252). Retrieved from 64 DeSalvo, et al, (2006). 65 Shi, L., Starfield, B., Politzer, R., & Regan, J. (June, 2002). Primary Care, Self-Rated Health, and Reductions in Social Disparities in Health. Health Services Research, 37(3):529-50; Shi, L., Green, L.H., & Kazakova, S. (2007) Primary Care Experience and Racial Disparities in Self-reported Health Status. J Am Board Fam Pract, 17(6): Shi, L., Regan, J. Politzer, R., & Luo, J. (2001). * Healthy life includes both perceived health status and activity limitations. 67 HRSA, HHS. (2009). Child Health USA Retrieved from 68 Shi, L., et al. (2004). America s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes. Health Serv Res, 39(6), Part I, HRSA. (2009). Child Health USA Kenney, M.K., et al. (2012). Federal Expenditures on Maternal and Child Health in the United States. Maternal and Child Health J, 16(2): HHS. (June, 2006). Fact Sheet: Preventing Infant Mortality. Retrieved from 72 Shi, L., et al. (2004). America s Health Centers: Reducing Racial and Ethnic Disparities in Perinatal Care and Birth Outcomes. Health Services Research, 39(6):Part I, Shi, L., et al. (2004). 74 Shi, L., et al,. (2004). 75 Feder, J.L. (2011). Restructuring Care in a Federally Qualified Health Center to Better Meet Patients Needs. Health Aff, 30(3): Russo, C. & Andrews, R. (September, 2006). The National Hospital Bill: The Most Expensive Conditions, by Payer, Healthcare Cost and Utilization Project, AHRQ, Statistical Brief No Kung, H.C., Hoyert, D.L., Xu, J.Q., & Murphy, S.L. (2008). Deaths: Final Data for National Vital Statistics Reports, 56(10). Retrieved from 78 Ziller, E.C., et al. (October, 2003). Health Insurance Coverage in Rural America. Kaiser Commission on Medicaid and the Uninsured. Retrieved from Committee on the Future of Rural Health Care. (2005). Quality through Collaboration: The Future of Rural Health. Institute Of Medicine. 79 CDC, HHS. (2011). National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States. 80 American Diabetes Association. (2007). Economic Costs of Diabetes in the U.S. in Diabetes Care, 31(3): BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. 82 Shi, L., et al. (2012). U.S. Primary Care Delivery after the Health Center Growth Initiative: Comparison of Health Centers, Hospital Outpatient Departments, and Physicians Offices. Journal of Ambulatory Care Management, 35(1): Chin, M.H. (2010). Quality Improvement Implementation and Disparities: The Case of the Health Disparities Collaboratives. Medical Care,48(80): Huang, E., et al. (2007). The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers. Health Services Research,42(6): Hing, E., Hooker, R. S., & Ashman, J. J. (2011). 86 CDC, HHS. (August, 2011). HIV in the United States: An Overview. Retrieved from 87 CDC, HHS. (July, 2010). Press Release: New CDC Analysis Reveals Strong Link between Poverty and HIV Infection. Retrieved from 88 Lillie-Blanton, M., et al. (August, 2010). Association of Race, Substance Abuse, and Health Insurance Coverage with Use of Highly Active Antiretroviral Therapy among HIV-infected Women, Am J Public Health, 100(8): CDC. (August, 2011). HIV in the United States : An Overview. 90 Sheth, A.N., Moore, R.D., Gebo, K.A. (2006). Provision of General and HIV-specific Health Maintenance in Middle Aged and Older Patients in an Urban HIV Clinic. AIDS Patient. Reinhold, J.P., et al. (2005). Colorectal Cancer Screening in HIV-infected Patients 50 Years of Age and Older: Missed Opportunities for Prevention. Am J Gastroenterol, 100: Frame, P.T. (March, 2003). HIV Disease in Primary Care. Prim Care, 30(1): Myers, J.J., et al. (March, 2010). Routine Rapid HIV Screening in Six Community Health Centers Serving Populations at Risk. J Gen Intern Med, 25(3): Charlebois, E.D., et al. (2003). National Survey of Health Center HIV Testing, Prevention, Care and Treatment Practices. AIDS Policy Research center & Center for AIDS Prevention Studies; AIDS Research Institute, U of California. Retrieved from CHC_2003_Final_Report.pdf. 94 U.S. Preventive Services Task Force, AHRQ, HHS. (April, 2004). Guide to Clinical Preventive Services; Shenson, D., Bolen, J., Adams, M., Seeff, L., Blackman, D. (2005). Are Older Adults Upto-date with Cancer Screening and Vaccinations? Preventing Chronic Disease: Public Health Research, Practice, and Policy, CDC, 2(3). 95 Zyzanski, S.J., Stange, K.C., Langa, D., Flocke, S.A. (May, 1998). Trade-offs in High-volume Primary Care Practice. J Fam Pract,46(5): USPSTF, AHRQ, HHS. (2009). Guide to Clinical Preventive Services. 97 BPHC, HRSA, HHS. (2010). UDS. [NACHC analysis]. 98 Dor, A., et al. (2008). Uninsured and Medicaid Patients Access to Preventive Care: Comparison of Health Centers and Other Primary Care Providers. RHCN Community Health Foundation, Research Brief No. 4; Shi, L., & Stevens, G.D. (2007). The Role of Community Health Centers in Delivering Primary Care to the Underserved. J Ambul Care Manage, 30(2): ; Politizer, R., et al. (2001). Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care. Med Care Res Rev, 58(2): ; Regan, J., Lefkowitz, B., & Gaston, M.H. (1999). Cancer Screening Among Community Health Centers Women: Eliminating the Gaps. J Ambul Care Manage 22(4): Shi, L & Stevens, GD. (2007). The Role of Community Health Centers in Delivering Primary Care to the Underserved. J Ambul Care Manage, 30(2): Health Wanted: The State of Unmet Need for Primary Health Care in America 36

39 100 Spann, S. (2004). Report on Financing the New Model of Family Medicine. Ann of Fam Med, 2(3):S Richard, P., et al. (2012). Cost Savings Associated with the Use of Community Health Centers. J of Ambul Care Manage, 35(1): Ku L,et al. (June, 2010). Strengthening Primary Care to Bend the Cost Curve: The Expansion of Community Health Centers Through Health Reform. Geiger Gibson/RCHN Community Health Foundation Collaborative at the George Washington University, Policy Research Brief No Pitts, S.R., Niska, R.W., Xu, J., Burt, C.W. (2008). National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Reports, NCHS, No Institute of Medicine. (2006). Hospital-based Emergency Care: At the Breaking Point; Newton, M.F., et al. (2008). Uninsured Adults Presenting to U.S. Emergency Departments: Assumptions Vs Data. JAMA, 300(16): Cunningham, P. (July, 2006). What Accounts for Differences in the Use of Hospital Emergency Departments Across U.S. Communities? Health Aff, 25:W324-W336; McCaig, L. & Nawar, E. (June, 2006). National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary. Vital and Health Statistics, NCHS, No Retrieved from Choudry, L., et al. (April, 2007). The Impact of Community Health Centers & Community-Affiliated Health Plans on Emergency Department Use. NACHC & Association for Community Affiliated Plans. Retrieved from Cunningham, (July, 2006). What Accounts for Differences in the Use of Hospital Emergency Departments Across U.S. Communities? 107 Rust, G., et al. (2009). 108 Falik, M., Needleman J, Herbert R, et al. (2006). Comparative Effectiveness of Health Centers as Regular Source of Care. J Ambul Care Manage 29(1): Government Accountability Office. (GAO) (April, 2011). Hospital Emergency Departments: Health Center Strategies That May Help Reduce Their Use. Retrieved from GAO, (April, 2011). 111 Ansari, Z., Laditka, J.N., & Laditka, S.B. (2006). Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev, 63: ; Bindman, A.B., et al. (1995). Preventable Hospitalizations and Access to Health Care. JAMA, 274: Basu, J., Friedman, B., & Burstin, H. (2002). Primary Care, HMO Enrollment, and Hospitalization for Ambulatory Care Sensitive Conditions: A New Approach. Med Care, 40: Probst, J.C., Laditka, J.N., & Laditka, S.B. (July, 2009). Association between Community Health Center and Rural Health Clinic Presence and County-level Hospitalization Rates for Ambulatory Care Sensitive Conditions: An Analysis across Eight US States. BMC Health Services Research, 9(134). 114 Falik, M., et al. (2006). 115 For a review of federal Health Center Program requirements (for Federally-Qualified Health Centers and health centers that fall under Section 330 of the Public Health Service Act for the Consolidated Health Centers Program) see: NACHC. (December, 2005). Background Paper: The Community Health Center Model. Prepared for the Health Centers and the Medically Underserved: Building a Research Agenda meeting. Retrieved from FINAL.pdf;HRSA, HHS. (July 2011). Program Requirements. Retrieved from Fiscella, K. & Williams, D.R. (December, 2004). Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Acad Med, 79(12): Chin, M.H. (2010). 118 Office of Management and Budget and Federal Agencies. Program. Retrieved from Kaiser Family Foundation. (2009). Population Distribution by Metropolitan Status, States ( ), U.S. State Facts. Retrieved from (this should not change the order of the references). 120 Gibbons & Willden, M.J. (February, 2009), Nevada Academy of Health Report Nevada Department of Health and Human Services, Packham, J. & Greater Basin Primary Care Association. (December, 2009). Access All Nevada: Preserve, Strengthen & Expand Community Health Centers. Retrieved from Packham & GBPCA, (December, 2009). 123 Packham & GBPCA, (December, 2009). 124 HRSA, HHS. (September, 2011). Find Shortage Areas: HPSA by State & County, Hardin County, Ohio. Retrieved from Robert Wood Johnson Foundation & University of Wisconsin Public Health Institute. (2011). Snapshot 2011: Hardin County, Ohio. County Health Rankings. Retrieved from Ohio Department of Health. (November 2010). Vital Statistics: Total Resident Deaths from Malignant Neoplasms per 100,000 population, age-adjusted, Data Warehouse. Retrieved from Public Health Surveillance Program Office, CDC, HHS. (November 2010). Behavioral Epidemiology. Behavioral Risk Factor Surveillance System. Retrieved from National Center for Immunization and Respiratory Diseases. (November, 2010). Estimated Vaccination Coverage with 4:3:1:3:3 by State and Local Areas. Retrieved from b26c_43133_race_iap&qtr=q1/2009-q4/ Ohio Department of Alcohol and Drug Addiction Services. Hardin County. State Epidemiological Outcomes Workgroup. Retrieved from Ohio Department of Job and Family Services & Health Policy Institute of Ohio. (2010) Ohio Medicaid Atlas. Retrieved from Hardin County Department of Job and Family Services. (2009). Organization Website. Retrieved from HRSA, HHS. (August, 2010). Health Partners New Access Point Application. Health Wanted: The State of Unmet Need for Primary Health Care in America 37

40 LOOK FOR THE 7200 Wisconsin Avenue, Suite 210 Bethesda, MD Tel: Fax: IN YOUR LOCAL COMMUNITY The National Association of Community Health Centers (NACHC) represents Community, Migrant, and Homeless Health Centers as well as Public Housing Health Centers and other Federally Qualified Health Centers. Founded in 1971, NACHC is a nonprofit organization providing advocacy, education, training, and technical assistance to health centers in support of their mission to provide quality health care to underserved populations. Our Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations. Health Wanted: The State of Unmet Need for Primary Health Care in America 38