By TOMMY BEVERIDGE
Thought experiment. What if the United States had a vast network of primary care-oriented non-profit health clinics? Imagine if there were, say, 17,000 locations in the most needed corners of our country? What if these clinics had to see everyone, had to offer a sliding fee scale for their services, and be run by boards comprised of a patient majority? Just for fun, what if they also provided dental and behavioral health services, worked with local social programs, and helped coordinate with specialists and hospitals? Couldn’t that be a solid cornerstone for primary care-centric health reform?
Stop dreaming, say the skeptics. Stick to reality. It is real. Sometimes called Federally Qualified Health Centers, America’s Community Health Center (CHC) program is the usual source of care for 34 million people, or around 9% of the country. That’s a lot of people, and yet they have a fairly low public profile outside healthcare circles. One reason is that most people who go to a CHC don’t know it’s a CHC. It’s just the local clinic. It’s just their doctor. It’s not another government program to complain about. If you have a problem, you talk to the management, who are also your neighbors.
Of course, it’s also a government program. The federal government gives CHCs annual operating grants, prospective payments for Medicare and Medicaid, subsidized malpractice insurance, physician incentives, and host of other benefits in exchange for following strict program requirements. While the program operates under the standard writhing mass of legislation, regulation, guidance, and program oversight, the patient’s perspective is simply affordable, local health care with minimal complexity.
Where did all this come from? The Community Health Center Program originated with little fanfare around the same time as Medicare and Medicaid. It fit in neatly and discretely with President Johnson’s War on Poverty; little more than a demonstration project alongside the era’s far more massive reforms. From the beginning, program leadership understood the moral and political imperatives to serve all underserved communities, no matter the demographic. The first two CHCs opened in 1966 in the Mississippi Delta and in a low-income part of Boston. With a sample size of two, they were already urban and rural, black and white, north and south.
By 1980, CHCs served around 1 million people a year. By the end of the Reagan era, they served 5 million. By the end of George W. Bush’s second term, it was 18 million. During the struggles over the Affordable Care Act and COVID, CHCs continued their expansion with funding reauthorizations, even when other programs were cut. At 34 million patients, the program costs the federal government around $6 billion a year, not including reimbursements from insurance plans. There are many more CHC locations than there are McDonald’s.
The CHC program is also a movement. This dual status is the program’s secret to growing despite shifting political winds. CHCs have a deep bench of community advocates. A well-organized network of interested citizens is trained to interact with their state and federal representatives, demonstrating that they are a viable voting bloc not to be trifled with. Today, CHCs have affiliate state associations, more than one independent advocacy group, and an army of concerned citizens ready to show up at the Capitol and statehouses across the land.
In the vulgar terms of realpolitik, CHCs and their advocates have something for every politician. For the cynical, they are cheaper than expanding coverage, but still make for a great photo op at a local ribbon cutting. For the idealist, they are an exemplar of public spending and community involvement. For the libertarian, they are self-governing enterprises that keep the government at arms-length. For all politicians, they are simply unavoidable in much the same way that defense contractors spread their industrial base across as many states and congressional districts as possible. The difference is that they have a mission to actually be there, whether it’s Appalachia, Alaska, or Atlanta.
[Brief aside: How many aircraft carriers can you buy for the money that helps 34 million people access high-quality, comprehensive primary care? (answer: about one half)]
Maybe they’re ubiquitous, but how good are CHCs? A substantial body of peer-reviewed literature demonstrates that CHCs have real, measurable impacts on cost and quality. Comprehensive econometric analyses published in the Journal of Ambulatory Care shows that patients who rely on CHCs for the majority of their ambulatory care generate 24% lower overall annual medical expenditures compared to non-users, largely due to effective primary care management. Longitudinal county-level studies captured in Academic Emergency Medicine show that increasing geographic access to CHCs leads to a 26% to 35% reduction in emergency department visits among uninsured adults by diverting non-emergent care away from expensive hospital settings. Broader health services research published in Health Affairs highlights that the high-quality preventive care, chronic disease management, and integrated support services provided by CHCs lower ambulatory care-sensitive hospitalizations, consistently reducing total federal and state spending. Apparently, comprehensive primary care does matter.
If you’ve never been to a CHC, you may be surprised by how clean and modern many of the facilities are. They receive dedicated capital funding for upkeep and expansion of their offerings, and they take pride in appearances. Ninety percent of health center patients have household incomes below 200% of the Federal Poverty Level, and over 40% are Medicaid beneficiaries, but unlike so many other programs for lower-income families, CHCs offer a dignified care experience, where nothing is second-rate. They simply don’t feel like a poverty program, and, despite serving a plurality of poor people, they really aren’t.
Experts often note that underinvestment in primary care is one of the big differences between U.S., and international health outcomes. Here’s a program that is ready to support change. Most of us want a health system that maximizes personal and local decisionmaking, reduces the perverse incentives of profit maximizing, and better coordinates the various specialists and ancillary services that go into keeping us healthy. Here is a program that uses the best of the private sector in service of public health, but can’t be bought out by private equity.
For me and many others, it’s also personal. I lost a friend who was uninsured and didn’t know he had options. Today, whenever someone asks me where to seek care when they’re broke and uninsured, CHCs are first places I suggest. They’re everywhere, and they will see you, regardless of your circumstances.
Looking ahead at possible future reforms, the CHC model offers something beyond the financial overhaul that gets all the attention. With the right payment and tax incentives, reformers could foster a new class of CHC-like medical homes with broader operating latitude, some maybe even for-profit, but with legal requirements to take all comers, maintain local governance, provide a set of required services, and play well with others in their region’s health and social sectors. Or community health plans with the legal leverage to operate like public utilities. That’s far from impossible, far from costly, and it all comes with decades of dividends from controlled hypertension and lower A1Cs.
America’s experience with COVID and the ACA are leading indicators that comprehensive reform will be a cage match of feral cats. You can’t walk into that with technocratically sound policy solutions and a winning smile. It will take an army. The politics of healthcare are eternally contentious. Something else that’s eternal is the hoovering away of local dollars and decisions by the leviathans of industry. Combined Annual Growth Rates for Evermore is its own form of tyranny.
As we try to move past this helpless era, there’s something to learn from the Health Center Program’s success. Movements matter. Local ownership matters. These principles should be front-and-center in the fight for reform, and not just in the health sector.
TommyBeveridge is a longtime health care policy wonk who has worked in the .org, .mil, .com, .edu, and .gov worlds. Due to present employment constraints, Tommy is sticking to a nom de plume. The pic is Asclepius, the Greek god of medicine. Because why not?
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