Fiscal Fitness: How States Cope

Community health centers are a cost-effective resource for the nation’s poor, underinsured

While considerable attention routinely is focused on the number of people who don’t have health insurance coverage, another important statistic is the number of people — often including those who have insurance — who don’t have access to basic medical care, generally because they live in communities with an acute shortage of health care providers.

The National Association of Community Health Centers (NACHC) reports there are at least 36 million Americans in this situation, with 13 states accounting for nearly two-thirds of those who are unable to access a regular health provider.

In A Nation’s Health at Risk, a new NACHC report, the organization describes who and where those without a regular source of health care are, why having a regular primary care provider is important, and how the national initiative to expand community health centers has helped meet the need.

NACHC’s analysis finds:

  1. The growth of community health centers during FY 2002 and 2003 reduced the number of Americans without a regular source of care by more than 2.4 million people over the period.
  2. The number of Americans without a regular source of care would have been reduced by nearly 4 million more people (an additional 11%) had all qualified applications for new health center cities been funded.
  3. Health centers serve as the regular source of care for one-fifth of the nation’s low-income uninsured population.

More support would help

NACHC vice president for federal, state, and public affairs Dan Hawkins tells State Health Watch the problem has been that while Congress has made expansion of community health centers a priority, there has not been enough money appropriated for all the communities that want to open a center.

"There were more than 400 grant applications approved," Mr. Hawkins says, "but almost 1,300 submitted for either new centers or existing centers to expand into new communities. "We’re grateful that we’ve been the beneficiaries of a lot of new money over the years with strong bipartisan support in Congress," he continues. "We’d just like to be able to do even more. We know there are other worthy groups vying for money. The point of our report is not to criticize Congress, but to say there is a significant unmet need out there."

According to the NACHC report, the medically unserved live in inner-city neighborhoods and isolated rural communities that have been designated by the federal government as having severe shortages of providers, especially primary care providers. They live in every state and in all but 417 of the 3,140 U.S. counties. The highest concentration of unserved people is in metropolitan areas with populations of less than 1 million. But one-fifth of all rural resident adults receive care through a health center or community clinic, a rate nearly twice that of urban residents throughout the country.

The map below shows the 2003 percent of state populations medically unserved. In each of 13 states — Alabama, California, Florida, Georgia, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, Tennessee, and Texas — the medically unserved population exceeds 1 million people. Thus, these states together account for 63% of all Americans who lack a regular health care provider.

In Louisiana and Mississippi, the unserved account for one of every three state residents, and in 10 other states — Alabama, Arkansas, Georgia, Idaho, Kentucky, Nebraska, Nevada, North Carolina, Tennessee, and Wyoming — at least 20% of residents have no regular provider of care.

Many studies, the report says, have concluded that having a regular doctor improves access to primary care and health outcomes more effectively than having health insurance or even the ability to pay fully for one’s health care alone. When people have a regular source of health care, they use it more often, and thus are better able to prevent a costlier illness later on. Primary care is seen as essential for those with chronic diseases such as diabetes or hypertension and for those needing screenings such as cancer screenings.

"In fact," the report says, "a regular source of care is related to better management of chronic diseases, increasing cancer screenings for women by one-third, and even fewer lawsuits against emergency rooms."

Studies also have shown that not having a regular health care provider is a greater predictor of delay in seeking care than insurance status, and that mortality is related to a lack of primary care physicians. What works best in improving overall health for the entire population, the studies show, is the combination of health insurance coverage and a regular source of care.

NACHC says the number of medically unserved would have been 50 million people were it not for the community health centers that were family doctor and health care home for more than 14 million people who would otherwise face barriers in gaining access to health care, including a lack of available health care providers.

The health centers program operates as a public-private partnership, with federal resources going to community organizations for development and operation of local health systems. Under program rules, a majority of the membership of all health centers’ policy boards must receive their care at the centers and thus represent the communities being served.

In its efforts to demonstrate the need and then increase funding for health centers to meet the need, NACHC also points to the economic stimulus health centers have become in their communities. They employ more than 70,000 people nationwide — including many local community residents — bolster local businesses, and stabilize neighborhoods by stimulating community development and economic growth.

"America’s health centers are unique among primary care providers because they remove common barriers to care by serving communities who otherwise confront geographic, language, cultural, and other barriers," the report maintains. "They are located in high-need areas identified by the federal government as having elevated poverty, higher-than-average infant mortality, and fewer practicing physicians. They are also open to all residents, regardless of insurance status, and provide free or reduced cost care based on ability to pay. Health centers tailor their services to fit the special needs and priorities of their communities and provide services in a linguistically and culturally appropriate setting, which helps avoid underuse of preventive services and substantial treatment disparities. In fact, nearly a third of all patients are best served in languages other than English. Moreover, health centers offer services that help their patients access health care, such as transportation, translation, case management, health education, and home visitation."

Studies, NACHC says, have shown that health centers save the Medicaid program at least 30% in annual spending for health center Medicaid beneficiaries due to reduced specialty care referrals and fewer hospital admissions. Based on those reports, the organization estimates that health centers already have saved almost $3 billion annually in combined federal and state Medicaid expenditures, nearly twice the current total of all congressionally approved funding provided to health centers this year.

Other studies have shown a reduction in expensive emergency department (ED) use associated with health centers along with improved health outcomes and lower incidence of chronic disease and disability.

Mr. Hawkins tells SHW he has no doubt that health centers could meet the need of 50% or more of the 36 million who currently are unserved. He points out that some hospital EDs have been asking neighboring health centers to participate in joint ventures as a way of easing the overloading of EDs with nonurgent patients. In some instances, he says, hospitals even have been willing to put up money to help organize a system that works through a health center.

Hospitals face a problem, he says, because the managed care revolution of the late 1990s has eliminated much of the cost-shifting that had provided funds to hospitals to subsidize care for the uninsured. With the cost-shifting all but gone, he says, other providers are significantly less able to provide care. Thus, they are trying to work with health centers.

"A key message for policy-makers at the federal and state levels," Mr. Hawkins writes, "is that dramatic improvements in health care can be achieved from system change. But any health care organization that is working for quality improvement has a need for infrastructure and the development of capacity. Policy-makers should recognize that health centers are making these changes and generating significant savings for the system, even as they improve the well-being of their patients and communities. By sharing the savings that they produce with the centers themselves, policy-makers will be enabling the centers to cover more medicines for their patients, ensure better access to specialists, and support innovation like group visits and outreach."

[Contact Mr. Hawkins at (301) 347-0400. Download the report from]