Community health centers: health care as it could be.

• Author: Lesnik, Juniper

INTRODUCTION I. COMMUNITY HEALTH CENTERS II. COMMUNITY HEALTH CENTERS AND NATIONAL HEALTH GOALS III. GRADUATE MEDICAL EDUCATION: TRAINING DOCTORS TO FILL NATIONAL HEALTH CARE NEEDS IV. CONCLUSION INTRODUCTION

This Article explores the potential of community health centers (CHCs) to become a central component providing health care in America. It focuses on health centers as a proposed solution to the dual national problems of access to care and the shortage of primary care doctoring. It argues that CHCs have the capacity to address the problem of access to health services and to provide a vibrant model for the revival of primary care. Part I deals with the history, structure, current scope, and funding of CHCs. Part II looks at national health care goals and how CHCs are uniquely poised to actualize those goals. The demonstrated successes and potential growth of the CHC model are viewed against the backdrop of national health care priorities established through the Healthy People 2010 report. Part III looks at physician workforce issues, Graduate Medical Education (GME), and efforts to extend residency programs to ambulatory settings, including CHCs. State initiatives to reform GME so that it will produce a physician workforce better adapted to meet local health care needs are discussed, and the needs for federal action are identified. The role of the GME funding structure is examined as a key component in shaping potential reforms. Finally, the conclusion summarizes the benefits delivered by CHCs and notes the need for systemic shifts to help facilitate the growth of this successful health care model. The broader policy questions of how CHC expansion fits into health care policy reform as a whole will be left to another Article.

Nonetheless, a brief overview of the current state of the U.S. health care crisis helps place the expanded need for CHC services in perspective. In August 2000, a groundbreaking World Health Organization (WHO) survey evaluating national health systems worldwide ranked the United States 37th in overall health system performance--sandwiched between Costa Rica and Slovenia. (2) This dismal showing occurred despite the fact that the United States spends more on health care than any other of the 191 WHO nations. (3) In 2004, U.S. health spending rose to a whopping 15 percent of the gross domestic product, a higher percentage than any other nation, including those that provide universal coverage to all residents and those with much more modest Gross Domestic Products ("GDP"). (4) WHO Director-General Dr. Gro Harlem Brundtland says: "The main message from this report is that the health and well-being of people around the world depend critically on the performance of the health systems that serve them." (5) Though the methodology of the WHO study has been criticized, it illuminates the areas in which the U.S. health system clearly falls short. (6) The factor that had the greatest negative impact on the U.S. ranking was access to care.

The most basic requirement of a successful health care system is that people have access to care when they need it. Health care is not a luxury good, reserved for the rich. It is a fundamental need, a precondition to being able to do virtually anything else--work, play, love, serve. In fact, the majority of Americans view health care as a "right and not a privilege." (7) This view reflects the American commitment to equality of opportunity, which logically leads to a social obligation to meet health care needs. (8) For a nation that prides itself on "equal opportunity for all," the United States is failing to provide the necessary baseline to enable all citizens to operate on a level playing field. If the disruptions of disease and injury are not met with the appropriate medical responses, these events can derail even the most determined of citizens. As the U.S. health care system stands today, tens of millions of Americans are living without a doctor to call if they are in pain or a medical office to accept them if they show up sick.

Why does the United States lag behind the rest of the industrialized world in health care, despite our wealth and technological prowess? Central to this failure is the consistent political failure in the U.S. to provide basic health care access to all Americans. This lack of commitment is spurred on by rising costs. To contain spiraling health care expenses, access is restricted in blatant and subtle ways. (9) Limiting medical care to those who can pay for it (in one way or another) backfires both on an economic and on a human level. According to the U.S. Census Bureau, a staggering 45 million Americans--or 15.6 percent of the population--permanently live without any form of health insurance. (10) This creates serious barriers to care, which lead to unnecessary illness and death. It is increasingly clear that, for individuals and their families, the financial burden of medical expenses is unmanageable without insurance. If anyone doubts, pause on this fact: medical debt is now the leading cause of personal bankruptcy in this country. (11) The position of the uninsured leads to dire national consequences as well. According to a 2004 Institute of Medicine (IOM) report, Insuring America's Health, 18,000 deaths occur each year because of lack of health insurance, and the U.S. loses around $65 to $130 billion annually as a result of the poor health and early deaths of uninsured adults. (12)

Lack of health insurance, however, is not the only significant factor affecting individuals' access to health care. Race and geography count, too. The system currently does very little to ensure that medical resources are evenly distributed according to health care needs or official national health priorities. Hidden doors keep some patients out. Health disparities based on race stubbornly persist in the U.S., creating significant access problems for people of color. There are proven racial and ethnic disparities in health status and levels of care among the general population even alter controlling for socio-demographic factors. (13) Additionally, there is a geographic maldistribution of health care workers, limiting access for those in rural and poor communities.

The access problem has not sparked adequate changes in the way young doctors are trained. Graduate Medical Education (GME) continues to produce an oversupply of specialists and a glaring undersupply of primary care and family doctors. This places ambulatory settings under strain when it comes to recruiting top medical school graduates. Despite the fact that a significant percentage of medical students enter medical school with the intention of going into general practice, many are ultimately lured into specialties by higher incomes and institutional pressures. The days of the family doctor who knows all of her patients by their first names are quickly disappearing. Well over 40 million Americans do not have a particular doctor's office, clinic, health center, or other place where they regularly seek health care or advice. (14) This indicates an erosion of the doctor-patient relationship on an unprecedented scale. Unfortunately, access is largely determined by what serves the medical business model instead of by doctors serving patients.

There is little reason to believe that the forces currently in control of our health care system will independently act to address these inequities. Like so much else in American life, medicine has gone "big business" and the delivery of health care has relied on the market model, a blunt instrument notoriously unaccountable to equity concerns. (15) It appears the system is steered more by profit motives than by health outcomes, by managing costs and not by care. (16) At the same time, costs continue to spiral out of control. As fiscal pressures mount, it is increasingly difficult to sell reform measures that carry big pricetags, though everyone may agree that reform is needed. To make things more difficult, the health care system involves multiple disjointed sectors that rarely work in a coordinated effort to meet the nation's health care needs. Surely, the system we now have does not reflect healthcare as we want it to be. Too many Americans are shut out, health care is too expensive, and the system is too disjointed. Better than asking how we got here is asking: what can we do about it?

Amidst these shocking failures, there is one underreported success: the Community Health Center. A federally-funded program begun in the mid-1960s, community health centers (CHCs) "provide family-oriented primary and preventive health care services for people living in rural and urban medically underserved communities regardless of their ability to pay. Health centers overcome economic, geographic, and cultural barriers to primary health care, and they tailor services to the needs of the community." (17) As far as existing health care delivery institutions go, CHCs are the nation's best shot at putting a deliberate step forward to improving the unsatisfactory patchwork system that marks U.S. health care. They are one of the few places where the uninsured have access to non-emergency and preventive care; they virtually eliminate racial disparities in care; and they provide a setting for the practice of quality, cost-effective primary care.

1. COMMUNITY HEALTH CENTERS

   Community health centers present a model of health care that is an anomaly in the U.S. system. (18) They acknowledge that health involves more than medical diagnosis and procedures. At a time when public health and related services were being institutionally segregated from specialized medical care, CHCs bucked this trend of bifurcated services in favor of a more holistic approach to improving the health of individuals. (19) This approach presents a model of unified medicine that counteracts the increasing fragmentation found in the modern landscape of U.S. medical care. The unique delivery...