The History, Evolution, Current Status and Issues of The History, Evolution, Current Status and Issues of Community Health CentersCommunity Health Centers

Michael E. Samuels, Dr.P.H.Michael E. Samuels, Dr.P.H.Distinguished Scholar and Distinguished Scholar and

Endowed Chair in Rural Health PolicyEndowed Chair in Rural Health PolicyCenter of Excellence in Rural HealthCenter of Excellence in Rural Health

University of Kentucky College of MedicineUniversity of Kentucky College of Medicine

Department of Health Services Policy and ManagementDepartment of Health Services Policy and ManagementArnold School of Public HealthArnold School of Public Health

University of South CarolinaUniversity of South Carolina

McKissick LibraryMcKissick LibrarySeptember 20, 2005September 20, 2005

Columbia, SCColumbia, SC

Rural HealthGrand RoundsRural Health

South

Research Center

Carolina

HistoryHistory

John Snow, MD(1813-1858)

1854

Medicare/Medicaid Signed Into Law

At the bill-signing ceremony President Johnson enrolled President Truman as the first Medicare beneficiary and presented him with the first Medicare card. This is President Truman's application for the optional Part B medical care coverage, which President Johnson signed as a witness. SSA History Archives.

““The only thing new is the history you haven’t read”The only thing new is the history you haven’t read”

President Harry S. TrumanPresident Harry S. Truman

Importance of HistoryImportance of History

• Live in A-historical country.Live in A-historical country.

• We think of it as not involved in our We think of it as not involved in our daily life. daily life.

• It has to do with our self perception. It has to do with our self perception.

• We think of history as myth.We think of history as myth.

• We are bound by unproven We are bound by unproven assumptions.assumptions.

Importance of HistoryImportance of History

• Our concepts (basic assumptions and Our concepts (basic assumptions and though patterns) come out of the past. though patterns) come out of the past.

• History teaches inductive rather than History teaches inductive rather than deductive reasoning.deductive reasoning.

• History is necessary for long-range planning.History is necessary for long-range planning.

• History is about balance between change History is about balance between change and continuity over time.and continuity over time.

• Short term versus long term trendsShort term versus long term trends

CHC TraditionsCHC Traditions

Medical Care(Individual)

Public Health (Group)

The Greek TraditionThe Greek TraditionHippocrates (470 - 377 B.C. ) Hippocrates (470 - 377 B.C. )

““To maintain the correct balance, eat good To maintain the correct balance, eat good food, avoid red meat, drink pure water, get food, avoid red meat, drink pure water, get fresh air and exercise and above all avoid fresh air and exercise and above all avoid quarrelsome people for they cause stress and quarrelsome people for they cause stress and that is the most injurious to your health.” that is the most injurious to your health.”

Oath of HippocratesOath of Hippocrates

““Whatever houses I may visit, I will come for Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all the benefit of the sick, remaining free of all intentional injustice, of all mischief and in intentional injustice, of all mischief and in particular of sexual relations with both particular of sexual relations with both female and male persons, be they free or female and male persons, be they free or slaves.” slaves.”

• Thou shalt love the Lord thy God with all thy heart, Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like first and great commandment. And the second is like unto it: Thou shalt love thy neighbor as thyself. On unto it: Thou shalt love thy neighbor as thyself. On these two commandments hang all the Law and the these two commandments hang all the Law and the Prophets. Prophets.

Matthew 22:37-40 Matthew 22:37-40

Before the Reformation, a religious duty for all Christians:

•feed the hungry •give drink to the thirsty •welcome the stranger •clothe the naked •visit the sick •visit the prisoner •bury the dead

The Religious Tradition in Health

US History of Health CareUS History of Health Care• Puritans could look at poverty as revealing a flaw in the poor person's Puritans could look at poverty as revealing a flaw in the poor person's

character; a sign that he or she was out of favor with the higher power.character; a sign that he or she was out of favor with the higher power.

• While acts of charity to help the needy were an important part of religious While acts of charity to help the needy were an important part of religious practice, there was not an expectation that such charitable acts would practice, there was not an expectation that such charitable acts would raise the underclass out of poverty. Charity was viewed as comfort to those raise the underclass out of poverty. Charity was viewed as comfort to those unfortunates doomed to suffer in this world, and the charitable act a sign unfortunates doomed to suffer in this world, and the charitable act a sign of the goodness of the giver.of the goodness of the giver.

• The University of Pennsylvania School of Medicine - first medical school The University of Pennsylvania School of Medicine - first medical school Fall, 1765 Fall, 1765

• Benjamin Rush “Father of US Medicine” – Farming, misfortune of othersBenjamin Rush “Father of US Medicine” – Farming, misfortune of others

• History of Physician LicensureHistory of Physician Licensure

• Education – B.A., M.D.Education – B.A., M.D.

• 1816 First Stethoscope1816 First Stethoscope

• 1869 –” Medicine, the most despised of the professions which liberally 1869 –” Medicine, the most despised of the professions which liberally educated men are expected to enter” (1925 3educated men are expected to enter” (1925 3rdrd, 1933 1, 1933 1stst))

• Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Car”Car”

US History of Health CareUS History of Health Care• AMA founded 1851AMA founded 1851

• Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal surgery 1889-1892 (45), 1900 (612), 1915 (2,157).surgery 1889-1892 (45), 1900 (612), 1915 (2,157).

• Hospitals – 1873 <200, 1900 > 4,000, 1920 >6,000.Hospitals – 1873 <200, 1900 > 4,000, 1920 >6,000.

• Florence Nightingale Nursing, hospital architecture, health administrationFlorence Nightingale Nursing, hospital architecture, health administration

• First x-ray 1895First x-ray 1895

• Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure 1877, Osteopathy 18911877, Osteopathy 1891

• Group Practice 1918 Mayo BrothersGroup Practice 1918 Mayo Brothers

• Health Centers Dr. Herman Biggs, 1923, New YorkHealth Centers Dr. Herman Biggs, 1923, New York

• Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929

• California Blue Shield, 1939California Blue Shield, 1939

• Kaiser Permanente, 1942Kaiser Permanente, 1942

GovernmentGovernment• 1798 “The Relief of Sick and Disabled Seaman”1798 “The Relief of Sick and Disabled Seaman”

• 1906 The Pure Food and Drug Act, Meat Inspection Act1906 The Pure Food and Drug Act, Meat Inspection Act

• 1912 First White House Conference 1912 First White House Conference urged creation of the Children's Bureauurged creation of the Children's Bureau

• 1921 The Bureau of Indian Affairs Health Division1921 The Bureau of Indian Affairs Health Division • 1930 The National Institutes of Health 1930 The National Institutes of Health

• 1935 The Social Security Act 1935 The Social Security Act

• 1938 Federal Food, Drug and Cosmetic Act 1938 Federal Food, Drug and Cosmetic Act

• 1939 Federal Security Agency1939 Federal Security Agency

• 1946 Centers for Disease Control and Prevention. 1946 Centers for Disease Control and Prevention.

• 1955 Department of Health, Education and Welfare 1955 Department of Health, Education and Welfare

GovernmentGovernment• 1961 Indian Health Service transferred to HHS from DI1961 Indian Health Service transferred to HHS from DI

• 1964 The Migrant Health Act1964 The Migrant Health Act

• 1965 First Surgeon General's Report on Smoking and Health1965 First Surgeon General's Report on Smoking and Health

• 1965 Medicare and Medicaid, the Older Americans Act, Head Start 1965 Medicare and Medicaid, the Older Americans Act, Head Start

• 1966 The Community Health Centers Act (Section 330, PHS Act)1966 The Community Health Centers Act (Section 330, PHS Act)

• 1970 National Health Service Corps1970 National Health Service Corps

• 1980 Health Care Financing Administration1980 Health Care Financing Administration

• 1989 Passage of the McKinney Act to provide health care to the 1989 Passage of the McKinney Act to provide health care to the homelesshomeless

• 1989 Agency for Healthcare Research and Quality 1989 Agency for Healthcare Research and Quality

• 1993 Ryan White Comprehensive AIDS Resource Emergency 1993 Ryan White Comprehensive AIDS Resource Emergency (CARE) Act(CARE) Act

GovernmentGovernment• 1996 Personal Responsibility and Work Opportunity 1996 Personal Responsibility and Work Opportunity

Reconciliation ActReconciliation Act

• 1996 The Health Centers Consolidation Act1996 The Health Centers Consolidation Act

• 1997 Health Insurance Portability and Accountability Act 1997 Health Insurance Portability and Accountability Act (HIPAA). (HIPAA).

• 1999 State Children's Health Insurance Program (SCHIP) 1999 State Children's Health Insurance Program (SCHIP)

• 2002 Centers for Medicare & Medicaid 2002 Centers for Medicare & Medicaid

• 2002 Office of Public Health Emergency Preparedness 2002 Office of Public Health Emergency Preparedness

• 2003 Medicare Prescription Drug Improvement, and 2003 Medicare Prescription Drug Improvement, and Modernization ActModernization Act

Community Health Centers Community Health Centers 1965 - Present1965 - Present

Lyndon Baines Johnson Lyndon Baines Johnson

1963–691963–69

Ronald Wilson Reagan Ronald Wilson Reagan 1981–891981–89

Richard Milhous Nixon Richard Milhous Nixon

1969–741969–74Gerald Rudolph Ford Gerald Rudolph Ford

1974–771974–77Jimmy Carter Jimmy Carter

1977–811977–81

George H. W. Bush George H. W. Bush 1989–931989–93

Bill Clinton Bill Clinton 1993–20011993–2001

George Walker Bush George Walker Bush

2001–2001–

Economic Opportunity Act of 1964. Economic Opportunity Act of 1964. "War on Poverty""War on Poverty"  

Executive Branch InitiativesExecutive Branch Initiatives  Work toward elimination of poverty or its Work toward elimination of poverty or its causes through developing: employment causes through developing: employment opportunities, improving human performance, opportunities, improving human performance, motivation, and productivity.motivation, and productivity.  Usually through community activity.Usually through community activity.  Health not an original OEO concern - Job Health not an original OEO concern - Job Corps/Headstart physicals.Corps/Headstart physicals.  Direct care - save money and effect basic way Direct care - save money and effect basic way in which health care is delivered.in which health care is delivered.

Dr. H. Jack Geiger and Dr. Count Dr. H. Jack Geiger and Dr. Count GibsonGibson

Concept of Neighborhood Health Center Developed by Tufts Medical School professors Count Gibson/Jack Geiger Original request from Tufts went to PHS June, 1965 Tufts Medical School receives funding for Columbia Point and Mound Bayou Neighborhood Health Centers Model comprehensive health center development, train andemploy community residents, and involve them in community development.

Neighborhood Neighborhood Health Center ModelHealth Center Model

Vehicle to community development and a challenge to Vehicle to community development and a challenge to mainstream medicine, dignified, accessible, mainstream medicine, dignified, accessible, comprehensive, and community based.comprehensive, and community based.

Elements: Elements: Community health services Community health services

- Public health model, deal with social and - Public health model, deal with social and physical environmentphysical environment

- Health care team- Health care team- Decentralize health care - Decentralize health care outreach/communicationsoutreach/communications

family health care workers family health care workers health educationhealth educationsocial advocacy (housing, welfare).social advocacy (housing, welfare).

Neighborhood Health Neighborhood Health Center Model (Cont.)Center Model (Cont.)

--Community economic developmentCommunity economic development-Community participation.-Community participation.-Re-integrate public health and personal -Re-integrate public health and personal health care services, including health care services, including

prevention, environmental, and prevention, environmental, and outreach.outreach.-Ignoring the previously negotiated -Ignoring the previously negotiated

boundaries between private boundaries between private medicine/public health.medicine/public health.

-Salaried physicians.-Salaried physicians.-Health teams.-Health teams.-Consumer participation.-Consumer participation.

A New SystemA New System

"The hospital as we know it is an obsolete and "The hospital as we know it is an obsolete and ineffective institution for ambulatory care, ... ineffective institution for ambulatory care, ... hospitals for the future should be vastly different hospitals for the future should be vastly different - in effect, intensive care units for patients with - in effect, intensive care units for patients with critical and complex illness ... The hub of the critical and complex illness ... The hub of the medical care universe would be a network of medical care universe would be a network of comprehensive community health centers" comprehensive community health centers" 1968 Dr. Jack Geiger.1968 Dr. Jack Geiger.

Alternative to hospital based care for the entire Alternative to hospital based care for the entire community. A system for the entire US. community. A system for the entire US. population.population.

  

More HistoryMore History• Initially grants to hospitals/medical schoolsInitially grants to hospitals/medical schools

• 1966 Kennedy amendments (OEO Act) - planning and operation of comprehensive 1966 Kennedy amendments (OEO Act) - planning and operation of comprehensive health service programs in urban/rural areas, low income requiring adequate health service programs in urban/rural areas, low income requiring adequate health services. (100 centers by 1971). health services. (100 centers by 1971). 

• 1967 “When they reach 25 centers, there will be no private practice” “Another 1967 “When they reach 25 centers, there will be no private practice” “Another step to socialism” “Dispensary abuse – 1890s”step to socialism” “Dispensary abuse – 1890s”

"Limited to the poor:, limited to 20% self pay."Limited to the poor:, limited to 20% self pay.-local opposition-local opposition-involvement of organized medicine -involvement of organized medicine -means test -means test 

• 1966-1970 Most grants to medical schools 1966-1970 Most grants to medical schools and hospitals – quick success/legitimacyand hospitals – quick success/legitimacy

• 1968 - PHS 314e (Phil Lee) Yellow berets1968 - PHS 314e (Phil Lee) Yellow berets

More HistoryMore History

• 1966-1970 Most grants to medical schools 1966-1970 Most grants to medical schools and hospitals – quick success/legitimacyand hospitals – quick success/legitimacy

• Community participation vague at firstCommunity participation vague at first

• 1968-69 PHS “Yellow Berets”, 314e (24 centers)1968-69 PHS “Yellow Berets”, 314e (24 centers)

• 1975 1975 5555 314e centers 314e centers

• 1970 - 1974 Nixon transfer all OEO NHCs 1970 - 1974 Nixon transfer all OEO NHCs to PHSto PHS

More HistoryMore History• 1972-1974 Family Health Center CHCs 1972-1974 Family Health Center CHCs • establishedestablished

• 1975-1977 Rural Health Initiative CHCs 1975-1977 Rural Health Initiative CHCs establishedestablished

• 1977 - 3rd Party billing required1977 - 3rd Party billing required

• 1981 - First Reagan budget cuts program in 1981 - First Reagan budget cuts program in halfhalf

• 1983 - All funds restored1983 - All funds restored

• 2001 – 2006 President Bush Initiative 2001 – 2006 President Bush Initiative doubling the number of patients served by doubling the number of patients served by Community Health CentersCommunity Health Centers

OrganizingOrganizing

• 1970 - New York Association of Neighborhood Health Centers1970 - New York Association of Neighborhood Health Centers

• 1971 – The Massachusetts League of Neighborhood Health 1971 – The Massachusetts League of Neighborhood Health CentersCenters

• 1970 - National Association of Neighborhood Health Centers 1970 - National Association of Neighborhood Health Centers nownow National Association of Community Health CentersNational Association of Community Health Centers

• 1975 – 1975 – National Rural Primary Care Association nowNational Rural Primary Care Association now

National Rural Health AssociationNational Rural Health Association

CHCs 2004CHCs 2004.

                                                                         

          

914 Grantees (51% Rural)

5,502 Service Delivery Sites

13,127,811 Patients

* Source: 2003 UDS data.

HC

HC

HC

Health Center Patients By Health Center Patients By Income Level, 2004Income Level, 2004

100% FPL and Below

70.5%101-150% FPL

14.3%

151-200% FPL 6.3%

Over 200% FPL 8.9%

Note: Federal Poverty Level (FPL) for a family of three in 2004 was $15,670. (See http://aspe.hhs.gov/poverty/03poverty.htm.) Based on percent known. Percents may not total 100% due to rounding.

Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

Health Center Patients Health Center Patients By Insurance Status, 2004By Insurance Status, 2004

Medicaid/SCHIP35.7%

Private14.7%

Uninsured40.1%Medicare

7.5%

Other Public2.1%

1

Note: Other Public may include non-Medicaid SCHIP. Percents may not total 100% due to rounding.Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

Health Center Patients By Health Center Patients By Race/Ethnicity, 2004Race/Ethnicity, 2004

Asian/Pacific Islander

3.3%

White36.5%

Hispanic/Latino35.6%

African American

23.4%

American Indian/Alaska Native

1.1%

Note: Based on percent known. Percents may not total 100% due to rounding.Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

Health Center Patients By Age, Health Center Patients By Age, 20042004

Ages 45-6419.4%

Ages 13-1911.7%

Ages 65+7.1%

Under 512.2%

Ages 25-4428.0% Ages 20-24

8.4%

Ages 5-1213.2%

Note: Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2004 Uniform Data System

United States, 2004 Health Center Staff and Related Patient Visits

FTE Patient Visits

Primary Care Physicians 6,487.6 25,325,866

NPs/PAs/CNMs 3,693.1 10,414,386

Nurses 8,075.5 3,091,731

Dentists 1,586.5 4,365,671

Dental Hygienists 547.8 760,986

Mental Health & Substance Abuse Specialists

2,548.0 2,732,571

PharmacyTotal Enabling Services#

Other Staff

1,633.78,575.0

50,541.0

N/A3,842,581

N/A

Total† 83,688.2 52,323,834* Includes psychiatrists and other specialist physicians.# Includes health educators, case managers, translators, transportation, eligibility workers, etc. Does not include workers for other social services, such as WIC, Head Start, housing assistance, food banks, and employment counselors. † Not all staff types are included in this table. Hence, total FTE and total patient visits are greater than the sum of all types listed above.

Percent of Health Centers Providing Select Services Onsite*

Professional Services

General Primary Medical Care 99%

Prenatal Care 72%

Preventive Dental Care 71%

Mental Health Treatment/Counseling 72%

Substance Abuse Treatment/Counseling 48%

Hearing Screening 87%

Vision Screening 93%

Pharmacy 35%

Preventive Services

Pap Smear 97%

Smoking Cessation Program 57%

HIV testing and counseling 93%

Glycosylated hemoglobin measurement, diabetes

83%

Blood pressure monitoring 99%

Blood cholesterol screening 89%

Weight reduction program 76%

Enabling Services

Outreach 91%

Case Management 91%

Eligibility Assistance 88%

Health Education 98%

Interpretation/Translation Services 88%

Transportation 55%

Outstationed Eligibility Workers 42%

* “Onsite” includes services rendered by salaried employees, contracted providers, National Health Service Corps Staff, volunteers and others such as out-stationed eligibility workers who render services in the health center's name. Health centers may also provide services through formal referral arrangements.

Percent of Health Centers Providing Select Services Onsite (cont.)*

Patient Visits and Patients by Patient Visits and Patients by Selected Primary Diagnoses and Selected Primary Diagnoses and

ServicesServicesPatient Patient PatientsPatientsVisitsVisits

Medical ConditionsMedical Conditions AsthmaAsthma 773,763773,763 418,256 418,256 Diabetes mellitusDiabetes mellitus 2,476,613 2,476,613 778,628 778,628 HypertensionHypertension 3,006,082 1,257,930 3,006,082 1,257,930 Heart disease (selected)Heart disease (selected) 556,625 556,625 230,596 230,596 Mental health & substance abuse 3,494,668Mental health & substance abuse 3,494,668 N/A N/A

Preventive ServicesPreventive ServicesHealth supervision ages 0-11* 2,994,513 1,764,835 Health supervision ages 0-11* 2,994,513 1,764,835 Selected immunizations#Selected immunizations# 2,364,496 1,610,822 2,364,496 1,610,822 Pap smearPap smear 1,509,973 1,333,253 1,509,973 1,333,253 MammogramMammogram 256,811 234,083 256,811 234,083 HIV testHIV test 425,266 376,358 425,266 376,358Oral Dental ExamsOral Dental Exams 813,324 813,324 631,739 631,739

* Well child visits.* Well child visits. # Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB.# Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB.

The Future of CHCsThe Future of CHCs

RWHC Eye On Health

CHCs?Pay them less.

They grow their own vegetables.

InsideMedicaid

Health Center Patient Insurance Health Center Patient Insurance Status and Revenue By Source, 2004Status and Revenue By Source, 2004

7.5% 5.7%

14.7%

40.1% 43.3%

36.4%35.7%

2.2%2.1% 6.3%6.2%

Patient InsuranceStatus

Health Center Revenue

Grants/Contracts/Other

Uninsured/Self-Pay

Private

Other Public Insurance

Medicare

Medicaid

88.1%91.2%

89.0% 88.9% 88.9%87.0%

72.3%74.4%

72.1%

67.5%

74.9% 76.5%73.0% 73.4%

61.7% 60.7% 60.3% 60.7%57.7% 57.1%

69.6%75.0%

69.5%

73.6%

50%

60%

70%

80%

90%

100%

1999 2000 2001 2002 2003 2004

Percent of Health Center Charges Collected from Third Party Payers, 1999-2004

Medicaid

Medicare

Other Public

Private

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