Community health centers in the United States
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The community health center (CHC) in the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territori ...
is the dominant model for providing integrated primary care and public health services for the low-income and uninsured, and represents one use of federal grant funding as part of the country's health care
safety net A safety net is a net to protect people from injury after falling from heights by limiting the distance they fall, and deflecting to dissipate the impact energy. The term also refers to devices for arresting falling or flying objects for the ...
. The health care safety net can be defined as a group of health centers, hospitals, and providers willing to provide services to the nation's uninsured and underserved population, thus ensuring that comprehensive care is available to all, regardless of income or insurance status. According to the
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, 29 million people in the country (9.1% of the population) were uninsured in 2015. Many more Americans lack adequate coverage or access to health care. These groups are sometimes called "underinsured". CHCs represent one method of accessing or receiving health and medical care for both underinsured and uninsured communities. CHCs are organized as non-profit, clinical care providers that operate under comprehensive federal standards. The two types of
clinic A clinic (or outpatient clinic or ambulatory care clinic) is a health facility that is primarily focused on the care of outpatients. Clinics can be privately operated or publicly managed and funded. They typically cover the primary care needs ...
s that meet CHC requirements are those that receive federal funding under Section 330 of the Public Health Service Act and those that meet all requirements applicable to federally funded health centers and are supported through state and local grants. Both types of CHCs are designated as "
Federally Qualified Health Center A Federally Qualified Health Center (FQHC) is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. This designation is si ...
s" (FQHCs), which grants them special payment rates under Medicare,
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
, and the
Children's Health Insurance Program The Children's Health Insurance Program (CHIP) – formerly known as the State Children's Health Insurance Program (SCHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to ...
(CHIP). To receive Section 330 grant funds, CHCs must meet the following qualifications: :*Be located in a federally designated medically under-served area (MUA) or serve medically under-served populations (MUP) :*Provide comprehensive primary care :*Adjust charges for health services on a sliding fee schedule according to patient income :*Be governed by a community board of which a majority of members are patients at the CHC CHCs place great value in being patient-centered. Uniquely in
community health center A healthcare center, health center, or community health center is one of a network of clinics staffed by a group of general practitioners and nurses providing healthcare services to people in a certain area. Typical services covered are family pr ...
s, at least 51% of all governing board members must be patients of the clinic. This policy creates interesting implications in terms of how "participatory" CHCs are, as governing board members become directly invested in the quality of the clinic. A sliding fee scale based on income is implemented so that the cost of care is proportionate to the patient's ability to pay. The purpose of these stipulations is to ensure that CHCs are working alongside the community, instead of just serving the community, in order to improve access to care. Community health centers that receive federal funding through the
Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peop ...
, an agency of the U.S. Department of Health and Human Services, are also called "Federally Qualified Health Centers". There are now more than 1,250 federally supported FQHCs with more than 8,000 service delivery sites. They are community health centers, migrant health centers, health care for the homeless centers, and public housing primary care centers that deliver primary and preventive health care to more than 20 million people in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin.


History

According to historian John Duffy, the concept of community health centers in the United States can be traced to infant milk stations in New York City in 1901. In November, 1914, the city established the first district health center in New York at 206 Madison Avenue, serving 35,000 residents of Manhattan's lower east side. The staff consisted of one medical inspector and three nurses stationed permanently in the district who, through a house card system, developed a complete health record of each family. In 1915, the system expanded, adding four district centers in Queens. Wartime and political pressures ended this development in New York City, but privately funded clinics through the New York Association for Improving the Condition of the Poor were started in 1916 (Bowling Green Neighborhood Association), 1917 (Columbus Hill Health Center), 1918 (Mulberry Street Health Center) and 1921 (
Judson Health Center Judson Health Center, founded in 1921, was an early New York City Community Health Center inspired by the Rev. Alonzo Ray Petty of the Baptist Judson Memorial Church located at 55 Washington Square South. Petty appealed to fellow Baptist and p ...
). Founded by Eleanor A. Campbell in Greenwich Village, the Judson Health Center became the largest health center in the U.S. by 1924. The official establishment of community health centers was caused by the civil rights movement of the 1960s. The Office of Economic Opportunity (OEO) established what was initially called "neighborhood health centers" as a
War on Poverty The war on poverty is the unofficial name for legislation first introduced by United States President Lyndon B. Johnson during his State of the Union address on January 8, 1964. This legislation was proposed by Johnson in response to a national p ...
demonstration program. The aim of these clinics was to provide access points to health and social services to medically under-served and disenfranchised populations. The health centers were intended to serve as a mechanism for community empowerment. Accordingly, federal funds for the clinics went directly to nonprofit, community-level organizations. The health centers were designed and run with extensive community involvement to ensure that they remained responsive to community needs. Under the modern definition, the first community
health center A healthcare center, health center, or community health center is one of a network of clinics staffed by a group of general practitioners and nurses providing healthcare services to people in a certain area. Typical services covered are family pr ...
in the United States was the
Columbia Point Columbia Point is a high mountain summit of the Crestones in the Sangre de Cristo Range of the Rocky Mountains of North America. The thirteener is located east by south ( bearing 102°) of the Town of Crestone in Saguache County, Colorad ...
Health Center in
Dorchester, Massachusetts Dorchester (colloquially referred to as Dot) is a Boston neighborhood comprising more than in the City of Boston, Massachusetts, United States. Originally, Dorchester was a separate town, founded by Puritans who emigrated in 1630 from Dorchester ...
, which opened in December 1965. The center was founded by two medical doctors -
H. Jack Geiger Herman J. Geiger (November 11, 1925 – December 28, 2020), known as H. Jack Geiger, was an American physician and civil rights activist. He was a leader in the field of social medicine, the philosophy that doctors had a responsibility to treat ...
, who had been on the faculty of
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and later at
Tufts University Tufts University is a private research university on the border of Medford and Somerville, Massachusetts. It was founded in 1852 as Tufts College by Christian universalists who sought to provide a nonsectarian institution of higher learning. ...
, and
Count Gibson Count Dillon Gibson, Jr. (July 10, 1921 – July 23, 2002) was an American physician known for his advocacy in medical civil rights. As a young professor at the Medical College of Virginia, in 1955 he became the first person outside Tuskegee Syp ...
, also from Tufts University. Geiger had previously studied the first community health centers and the principles of community-oriented primary care with Sidney Kark and colleagues while serving as a medical student in rural
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,
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. The federal government's
Office of Economic Opportunity The Office of Economic Opportunity was the agency responsible for administering most of the War on Poverty programs created as part of United States President Lyndon B. Johnson's Great Society legislative agenda. It was established in 1964 as an i ...
(OEO) funded the Columbia Point Health Center, which served the poor community living in the Columbia Point Public Housing Projects located on an isolated peninsula far away from Boston City Hospital. On its twenty-fifth anniversary in 1990, the center was rededicated as the Geiger-Gibson Community Health Center and is still in operation. In 1967, Geiger and Gibson also established a rural community health center, the Tufts-Delta Health Center (now the Delta Health Center), in Mound Bayou,
Bolivar County, Mississippi Bolivar County ( ) is a county located on the western border of the U.S. state of Mississippi. As of the 2020 census, the population was 30,985. Its county seats are Rosedale and Cleveland. The county is named in honor of Simón Bolívar, earl ...
to serve the poverty-stricken Bolivar County. This center was also set up in conjunction with Tufts University with a grant from the OEO. While the Columbia Point Health Center was set in an urban community, the Delta Health Center represented a rural model, and included educational, legal, dietary, and environmental programs in addition to the health services carries out at the center and throughout the county by its public health nurses. The War on Poverty enlisted many idealistic men, such as Leon Kruger, the first Director of the CHC at Mound Bayou. As a result, many families such as his, were drafted in the War on Poverty, often at their own risk. In the early 1970s, the health centers program was transferred to the Department of Health, Education, and Welfare (HEW). The HEW has since become the U.S. Department of Health and Human Services (HHS). Within HHS, the
Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peop ...
(HRSA),
Bureau of Primary Health Care The Bureau of Primary Health Care (BPHC) is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA helps fund, staff and support a national network of health clinics fo ...
(BPHC) currently administers the program. Community health centers are primarily funded by
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
payments and federal grants set up by Section 330 of the Public Health Service Act. In 2010, the Community Health Center Fund was created by Congress to aid in the expansion of community health centers. Since the 2013 fiscal year, discretionary funding from Congress has flatlined at approximately $1.5 billion but increased to $1.6 billion in 2018 via the Consolidated Appropriations Act of 2018. Funding has increased for CHCs, allowing them to increase their reach, staffing, and the services they can provide. Between 2010 and 2017, the number of operating sites increased by over 4,000, and shares of centers providing mental health services increased by 22%. Since the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
's expansion of
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
, a challenge facing community health centers—and the health care safety net as a whole—is how to attract newly insured patients, who now have more options in terms of where to seek care, in order to remain financially viable. The evolution of the terminology used to describe what are now called "community health centers" is crucial to understanding their history and how they are contextualized in the United States social safety net. When they were titled "neighborhood health centers", heavy emphasis was placed on grassroots community involvement and empowerment. Since, the terms have shifted to "community health centers" and "Federally Qualified Health Centers", indicating how these clinics have transformed into government provisions, and are now subject to bureaucratization. While CHCs still retain their historical commitment to responding to community needs, through mechanisms such as requiring at least 51% of governing board members to be patients at the health center, their positioning as a government provision makes CHCs responsible for meeting federal requirements as well.


Patient demographics

Community health centers primarily provide health care to patients who are uninsured or covered by Medicaid. In 2007, almost 40% of all CHC patients lacked insurance, and 35% were Medicaid patients. In 2008, 1,080 CHCs provided comprehensive primary care to more than 17.1 million people. CHC patients typically have low family incomes, live in medically under-served communities, and have complicated health conditions. 70% of CHC patients in 2007 had family incomes of no more than 100% of the federal poverty level; more than 90% of patients had family incomes at or below twice the poverty level. Health center patients are also ethnically diverse. In 2007, half of all CHC patients were minorities, a third of which were Hispanic. All together, CHCs serve one in four low-income, minority residents. CHC patients are more likely to reside in rural areas relative to the rest of the population. They tend to be younger in age and are more likely to be female. In 2008, 36% of all CHC patients were children, and almost three in five patients were female. Many CHC patients suffer from chronic conditions such as diabetes, asthma, hypertension, or substance abuse. CHC patients are more likely to report these chronic conditions than adults from the national population. Characteristics linked to serious health problems, such as smoking and obesity rates, are also significantly higher in adult CHC patients compared to the general population. High rates of mental health conditions, including depression and anxiety, also contribute to the overall high rates of chronic illness in CHCs. Nonetheless, as of 2016, 91% of CHCs report having met at least one or more of Healthy People 2020 goals.


Immigrants and community health centers

Immigrants are some of the primary patients that community health centers serve due to the cultural and societal barriers the group experiences. From the 1970s up to the early 2000s, the effect on immigrant families has increased relative to families native to the U.S. due to factors such as parental education, parental employment, and racial/ethnic composition. However, immigrant families generally have a lower access to mental healthcare, leaving them at a greater risk to not treat their mental health issues. Part of this problem lays in the foundations of immigrant communities, as many non-Western cultures perceive a strong stigma towards mental health topics and lack a proper system of social support to address these issues. Even more common is the lack of understanding or awareness that these mental health help resources exist. Due to complexities in how insurance and healthcare works, which is compounded by language barriers, many immigrant families are unable to properly educate themselves on what services exist and how they may utilize these services. For those who are able to understand, lack of outreach may lead them to assume that they are ineligible, when, in fact, they are eligible to receive such services. The effects of this lack of understanding especially harms immigrant children, who rely on their parents' knowledge of mental healthcare, who may inadvertently deny their children of needed mental health services. One proposed solution to this problem is through community health centers (CHC), which are able to provide a unique service experience for the population it serves. For many of these CHCs, they must adapt to the geographical space it inhabits, in addition to cultural and linguistic variations in the surrounding demographics. As a result, they are equipped to address social stigmas present in their communities, an obstacle that hinders the use of available mental health resources. Additionally, CHCs also have the capability of overcoming local institutional barriers that may make it difficult or uncomfortable for immigrant groups to seek out healthcare. By providing translator services or linguistically appropriate health materials, for example, members of the local community are more empowered to educate themselves on mental health issues and solutions, as the information is provided in a form that is easily understood. Due to successes in some CHCs in impacting their communities, policies like the early 2000s Medicaid reform and the Bush Administration's health center initiative allowed for expansion of behavioral healthcare services in CHCs. Previously, there were large restrictions on reimbursement for these services, causing them to be very costly. However, the advent of such policies show a movement that trends towards further increases in healthcare accessibility.Wells, R., Morrissey, J. P., Lee, I., & Radford, A. (2010). Trends in behavioral health care service provision by community health centers, 1998–2007. ''Psychiatric Services, 61''(8), 759-764. Policies like the Affordable Care Act (ACA) and Chapter 58 have incrementally increased accessibility to healthcare, simultaneously setting a precedent for even further expansion.


Community health centers in California


Asian Health Services

One example of a community health center that serves immigrants is Asian Health Services (AHS) in
Oakland, CA Oakland is the largest city and the county seat of Alameda County, California, United States. A major West Coast port, Oakland is the largest city in the East Bay region of the San Francisco Bay Area, the third largest city overall in the Bay ...
. Asian Health Services aims to provide health, social, and advocacy services for the immigrant and refugee Asian community by entailing many of the strategies previously discussed. Additionally, they provide primary care services, including mental health, case management, nutrition, and dental care in English and 14 languages: Korean, ASL, Lao, Burmese, Mandarin, Cantonese, French, Mien, Karen, Mongolian, Karenni, Tagalog, Khmer, and Vietnamese. Their youth program provides services including health education, cultural awareness, job training, and college readiness to East Bay Asian American youth.


= Youth Program

= In addition to their main clinic they also have a youth program that attempts to address the stigma about mental and sexual health in Asian culture by recruiting local Asian American youth to get involved with advocacy and create educational resources/workshops surrounding these topics. Many Asian Americans, though a very diverse group, have historically felt discouraged from seeking help for mental health concerns due to stigma and pressure to focus on academic and professional success. Additionally, the “
model minority A model minority is a minority demographic (whether based on ethnicity, race or religion) whose members are perceived as achieving a higher degree of socioeconomic success than the population average, thus serving as a reference group to outgroup ...
” myth plays a role in Asian Americans not seeking support for mental health. Asian Health Services Youth Program (AHSYP) attempts to address these concerns using methods that Asian American immigrant youth claim would help. In a study on school-based mental health for Asian American immigrant youth, students suggested engaging students and parents, using peers to share their experiences to reduce stigma, and providing educational videos and materials. AHSYP also provides educational material through its social media outlets and workshops.


= Project: ''Revive Chinatown!''

= In the early 2000s, Asian Health Services envisioned a project called ''Revive Chinatown!'' that would create a safer pedestrian environment, while also transforming Oakland, California Chinatown's commercial district into a regional shopping destination. The key to securing the funding and support for this project was in re-defining the issue from one of public health into one of environmental justice. In doing so, Asian Health Services hoped to address the issue of pedestrian safety by simultaneously working on a long-term solution for increased quality of life. The ''Revive Chinatown!'' movement has gained traction and is cited as a success story of a CHC being able to successfully create a more public health-friendly environment, which bolsters their case and contributes to the trend towards further healthcare accessibility by means of CHCs.


Services

Integration of health care services is a major emphasis of community health centers, in addition to the provision of preventive and comprehensive care. Services provided can vary depending upon the site, but frequently include primary care, dental care, counseling services, women's health services, podiatry, mental and behavioral health services, substance abuse services, and physiotherapy. Often, CHCs are the only local source of dental, mental health, and substance abuse care available to low-income patients. Most recently, CHCs have played an increasing role in the
opioid epidemic The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse/abuse, and overdose deaths attributed either in part or in whole to the class of drugs opiates/opioids since the 1990s. It includes the sign ...
by facilitating access to treatment. CHCs have experienced an increase in the number of patients with
opioid use disorder Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Op ...
(OUD) from 2015 to 2018. As part of the substance use disorders (SUD) component of services provided by CHCs, services have been added and expanded relating to the prevention and treatment of opioid use disorder. The number of CHCs that provide services for SUD has increased from 20% in 2010, to 28% in 2018. There has been a 36% increase in the number of full-time staff at CHCs who are trained to provide SUD services. As of the federal budget for the 2019 fiscal year, over $5 billion has been requested for the Department of Health and Human Services to use over the upcoming five years towards addressing the opioid epidemic. Of that request, $350 million has already been available for grants to be awarded by the start of the 2019 fiscal year. Because patients can come from a diverse range of socioeconomic, educational, cultural, and linguistic backgrounds, CHCs offer additional public health services unrelated to direct care, such as health promotion and education, advocacy and intervention, translation and interpretation, and case management. CHCs emphasize empowerment, so they also have programs to help eligible patients apply to federally funded health coverage programs, such as Medicaid. Additionally, CHCs place great emphasis on meeting community needs. To meet this goal, administrative and health care personnel meet regularly to focus on the health care needs of the particular community that they are trying to serve. Individual CHCs will often provide specialized programs tailored to the populations they serve. These populations could include specific minority groups, the elderly, or the homeless. To determine what the community's needs may be, CHC staff may decide to engage in community-based participatory research. The success of community health centers depends on collaborative relationships with community members, industry, government, hospitals and other health care services and providers.


Quality of care

Quality of care at CHCs can be assessed through many measurements and indices, including the availability of preventative services, treatment and management of chronic diseases, other health outcomes, cost effectiveness, and patient satisfaction. According to several studies, the quality of care at community health centers is comparable to the quality of care provided by private physicians. However, one major challenge that community health centers face is that the population that they serve is usually dealing with many other factors that can also detrimentally affect their health. As CHCs primarily treat the low-income and uninsured, many of their patients do not regularly see a
primary care physician A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The term ...
, which can lead to poorer health outcomes. Additionally, there is research to indicate that many CHC patients delay seeking health care because they hold a negative view of the health care safety net and expect discrimination from CHCs. It is crucial for CHCs to evaluate the quality of care they provide in order to meet federal requirements and to fulfill their mission of eliminating health disparities based on socio-economic and insurance status. Only recently has an evaluation program been instituted for CHCs. Such a program did exist briefly from 2002 to 2004; the
Agency for Healthcare Research and Quality The Agency for Healthcare Research and Quality (AHRQ; pronounced "ark" by initiates and often "A-H-R-Q" by the public) is one of twelve agencies within the United States Department of Health and Human Services (HHS). The agency is headquartered i ...
(AHRQ) and
HRSA The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peopl ...
jointly monitored CHC providers. As of 2016, the
HRSA The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peopl ...
utilizes th
Uniform Data System
to gather performance data from all health center grantees ( FQHCs) and their look-alikes, which would include CHCs as well. Reporting instructions for the annual UDS report include information on patient demographics, clinical processes and outcomes, services, costs, and more. UDS data has been used to provide a health center adjusted quartile, which ranks the clinical performance of a health center in comparison to other health centers with similar characteristics such as minorities served, etc. In addition, external organizations such a
The Center for Health DesignKaiser Permanente
and th
CDC
also offer evaluation tools for CHCs.


Continuity of care

Community health center patients are less likely to seek medical care consistently, as many of these patients tend to be from vulnerable populations in terms of socioeconomic background and insurance status. Nevertheless, those who use community health centers as a regular source of care are likely to have a positive patient experience and receive high-quality preventative services. Medicaid's shift to managed care has helped create more
medical home The medical home, also known as the patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal heal ...
s for patients, allowing for greater continuity of care within CHCs.


Preventive services

Studies have indicated that CHCs provide preventive services at similar rates to private physicians. Preventative services studied included cancer screenings, diet and exercise counseling, and immunizations. CHCs performing higher than private providers in terms of immunization rates, but lower in terms of diet and exercise counseling.


Specialty care

Although CHCs are able to provide comprehensive primary care, they are limited in their ability to provide specialty care due to a lack of providers. The people affected most by this scarcity in services are the uninsured and Medicaid patients. In areas with a high uninsurance rate, which tend to be the medically underserved areas where CHCs operate, there is often a lack of availability of specialty care.


Chronic disease management

Compared with patients who receive care from private providers, CHC patients are almost three times more likely to seek care for serious and chronic conditions. However, with the exception of those with private insurance, CHC patients are also more likely to meet referral obstacles than comparable patients treated by private physicians. In one study investigated management of diabetes in CHCs, a majority of patients exhibited signs or symptoms of diabetes, but relatively few received comprehensive monitoring and management. Moreover, adherence to treatment protocols was low in CHCs, speaking both to the effectiveness of CHCs and to the social determinants of health that make CHC patients so vulnerable.


Financing

Community health centers rely on a combination of
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
payments, grant revenues, and other private and public funding sources to fund their operations. The sources of funding for health centers have changed significantly over time. Public Health Service Act grants under Section 330 were once a prominent source of funding for CHCs. Although 330 grants remain important to the financial viability of health centers, federal reimbursement policy under Medicaid has become their largest source of revenue. In 2008, Public Health Service Act grants comprised 18.3% of all CHC revenues. The expansion of CHCs has instead been largely funded by the growth in Medicaid resulting from eligibility expansions, coverage reforms, and modified payment rules. In 1985, Medicaid patients made up 28% of all CHC patients but only 15% of CHC revenues. By 2007, the share of Medicaid patients matched their share of revenues. In the same time period, grants for the uninsured decreased from 51% to 21%. In 2008, Medicaid payments had grown to account for 37% of all CHC revenues. In 1989, Congress created the
Federally Qualified Health Center A Federally Qualified Health Center (FQHC) is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. This designation is si ...
(FQHC) program, which established a preferential payment policy for health centers by requiring "cost-based" reimbursement for both Medicaid and Medicare. The policy designated FQHC services as a mandatory Medicaid service that all states must cover and reimburse on a cost-related basis, using the Medicaid prospective payment system. The aim of these payment changes was to prevent health centers from using Section 330 and other grants (intended for the uninsured) to subsidize low Medicaid payment rates. The resulting payment structure reimbursed health centers on the basis of their actual costs for providing care, not by a rate negotiated with the state Medicaid agency or set by Medicare. Medicaid's shift to a managed care delivery system in the 1990s required CHCs to again modify their financial structure. The implementation of managed care in Medicaid was intended to curb costs while providing patients with greater freedom to choose where they access care. However, the shift had adverse financial implications on safety net providers. Health centers largely lost money in their early experiences of contracting and assuming risk for Medicaid managed care patients. Uncertainty about financial viability also lead to concerns about the ability of CHCs to continue serving the uninsured. In 1997, to protect health centers under managed care, Congress mandated that state Medicaid agencies make a "wrap-around" payment to FQHCs to cover the difference between their costs for providing care and the rates they were receiving from
managed care organization The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("ma ...
s (MCOs). Since the initial shift to managed care, Medicaid has helped a wider group of patients access consistent medical care. The economic recession in the United States continues to pose significant challenges for community health centers. In 2002, President Bush launched the Health Center Expansion Initiative, to significantly increase access to primary health care services in 1,200 communities through new or expanded health center sites. However, these funds furthered disparity between CHCs, as they primarily benefitted larger, financially stable CHCs, rather than expanding and improving care in smaller clinics. In 2008, the Health Care Safety Net Act reauthorized the health centers program for four years with the expectation of expanding the program by 50% over the time period. In 2009, the American Recovery and Reinvestment Act (ARRA) appropriated $2 billion for investment in health center expansion. By 2010, assisted by funding received through the ARRA, health centers had expanded to serve more than 18 million people. The health center program's annual federal funding grew from $1.16 billion in the 2001 fiscal year to $2.6 billion in the 2011 fiscal year. Health centers served 24,295,946 patients in 2015. After the September 30, 2017 expiration of the Community Health Center Fund (CHCF), 2018 funding finally passed in the House of Representatives and on November 6, 2017 was referred to the Senate Finance Committee as th
CHIMES act
The CHCF accounts for approximately 70% of available grant funding for CHCs, and represents approximately 20% of revenue. In anticipation of the delay in funding for the 2018 fiscal year, CHCs froze hirings, laid off staff, reduced hours of operations, and took other actions while facing funding uncertainty. On February 9, 2018, the Bipartisan Budget Act authorized $3.8 billion for 2018, and $4 billion in 2019 for CHC funding. In addition, to address

in CHCs, the act also increased funding for HRSA's Teaching Health Centers Graduate Medical Education (THC-GME) programs, which provides residency training in community-based primary care settings, rather than hospitals. Additionally, on August 15, 2018, HRSA announced that it awarded $125 million in grants via its Quality Improvement grant program to 1,352 CHCs.


See also

*
Clinic A clinic (or outpatient clinic or ambulatory care clinic) is a health facility that is primarily focused on the care of outpatients. Clinics can be privately operated or publicly managed and funded. They typically cover the primary care needs ...
*
Community Health Community health refers to simple health services that are delivered by laymen outside hospitals and clinics. Community health is also the subset of public health that is taught to and practiced by clinicians. Community health volunteers and communi ...
* Eula Hall, Founder of the Mud Creek Clinic *
Federally Qualified Health Center A Federally Qualified Health Center (FQHC) is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. This designation is si ...
*
Free clinic A free clinic or walk in clinic is a health care facility in the United States offering services to economically disadvantaged individuals for free or at a nominal cost. The need for such a clinic arises in societies where there is no universal ...
* West Side Community Health Services


References

{{Reflist, 33em


See also

*
Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peop ...
*
United States Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is ...


External links


Health Center Program

National Association of Community Health Centers

Community Health Centers of Central Florida

Community Health Centers of the Central Coast
(California)
Community Health Center Association of Connecticut

Community Health Center, Inc.
(Middletown, Connecticut) Clinics in the United States Healthcare in the United States ca:Centre d'Atenció Primària de:Medizinisches Versorgungszentrum es:Centro de salud pt:Posto de saúde