kaiser I commission on S S U medicaid and the E uninsured August 2010 P A Community Health Centers: Opportunities and Challenges of Health Reform P E R Introduction The enactment of comprehensive health reform1 will bring about important changes to the health insurance and health care delivery systems. Community health centers2 will play a role in implementing many health reform provisions and in providing access to care for millions of Americans who will gain health insurance coverage under the law. To meet this new demand for services, particularly in underserved areas, the health reform law makes a significant investment in the expansion of health centers and also introduces important changes in health care delivery while strengthening efforts to improve community and population health. Health reform brings major shifts in the health insurance status of health center patients. Increasing access to affordable insurance, coupled with the law’s emphasis on greater clinical integration and health care innovation lays the groundwork for far-reaching changes over time in how health centers deliver care and develop affiliations with other providers as well as with community-wide prevention efforts. The transformation has already started. Most health centers once operated independently, but the advent of Medicaid managed care (which depends on networked providers) coupled with the growth of information technology has led to the formation of at least 83 health center networks.3 These networks allow multiple health center grantees to integrate financial and in some cases clinical services as well as develop their service capacity on a regional basis.4 Similarly, the growing proportion of patients with significant physical and mental health conditions, as well as the aging of the population, has led health centers to deepen the range of services they furnish and enter into increasingly comprehensive service delivery arrangements. Despite coverage expansions and improvements to the health system, health reform will leave an estimated 23 million persons without access to affordable coverage, so health centers will likely continue to play a central—and perhaps increasingly critical—role in caring for the uninsured. The experience of health centers in Massachusetts following implementation of that state’s landmark health reform law has demonstrated that as coverage has expanded, health centers have served an increasing proportion of the state’s uninsured residents.5 This policy brief reviews the opportunities and challenges facing community health centers as a result of health reform. Following an overview, we describe how reform affects the growth trajectory of the health center program and the evolving role of health centers in a health care system poised to undergo significant transformation. 1330 G STREET NW, WASHINGTON, DC 20005 P HONE: 202-347-5270, F AX: 202-347-5274 W EBSITE: WWW. KFF. ORG Overview Community Health Centers: Fast Facts Initially established in 1965 by the Office of Economic Opportunity Patient population 17.1 million (OEO) as a War on Poverty Health center grantees 1,080 demonstration program with roots Service sites 7,500 in the civil rights movement,6 today’s federally funded health Total patient visits 66.9 million centers reflect a national investment Medical visits 49.9 million of considerable proportions targeted Dental visits 7.3 million to increase access to care among underserved and medically Mental health/substance abuse visits 4.0 million Enabling and other professional disenfranchised populations. In 5.8 million 2008, 1,080 health centers operating service visits in more 7,500 sites provided Source: GWU analysis of 2008 UDS primary and comprehensive health care to more than 17.1 million people.7 An additional 100 “look-alike” health centers meeting all federal health center requirements but not receiving a federal grant under §330 of the Public Health Service Act served an estimated one million additional patients. Organized as non-profit clinical care providers and operated in accordance with comprehensive federal standards, health centers are defined by four key characteristics:8 Serve medically underserved populations; Provide a comprehensive range of “primary” health care services; Adjust charges for care based on patient income; and Governed by a community board, the majority of whose members are health center patients. Health centers are a key clinical presence in their communities. In 2008, health centers employed 51,187 medical, dental and mental health/substance abuse staff. The National Health Service Corps (NHSC), which provides scholarship and loan repayment support in exchange for service in urban and rural communities identified as experiencing a shortage of primary health care services, is an important source of clinical staffing for health centers. From 2003 through 2008, health centers employed approximately 5,350 full-time equivalent (FTE) clinicians supported by the NHSC, and health centers represent the single largest NHSC placement site.9 Given their location in the nation’s most medically underserved urban and rural communities, health centers are also a source of jobs and community enrichment, with a high rate of return into local health economies.10 2 00 Health Center Patients Figure 1 Anchoring the safety net in many Health Centers Serve Disproportionately Poor, Uninsured, and Publicly Insured Patients, 2008 communities, health centers play an 92% important role serving low-income, Health Center Patients U.S. Population uninsured, and publicly insured 70% patients. Compared to the U.S. population, health center patients are nearly six times as likely to be poor, 38% 36% two-and-a-half times as likely to be 31% uninsured, and nearly three times as 15% likely to be enrolled in Medicaid. 13% 12% Uninsured patients represent 38 percent of all health center patients. Together, Uninsured Medicaid At or below 100% of Under 200% of uninsured and Medicaid patients Poverty Poverty account for almost 75 percent Source: GW Department of Health Policy Analysis of 2008 UDS data and 2008 Current Population Survey of health center caseloads (Figure 1). Figure 2 Health center patients are Health Center Patients by Race/Ethnicity, 2008 disproportionately members of racial Total Patients Reporting Total Patients of Hispanic/Latino and ethnic minority groups. In 2008, of Race: 13.2 million Ethnicity: 5.7 million the patients for whom data on race was More than one race available 40 percent were racial White 6.2% 60.2% Hispanic minorities. Further, one-third of all 33% Asian All patients, many of whom reported their 0.9% Others* Black 67% race as White, were of Hispanic/Latino 27.7% ethnicity (Figure 2). Health center Amer. Indian, Native patients are also more likely to live in Hawaiian, rural areas (44 percent of health center Pacific Race Hispanic/Latino patients, compared with 21 percent of Islander 1.8% Identity NOTE: Race percentages are among patients who reported their race; 22.8 percent of total patients are missing race data. ‘White’ may include individuals of Hispanic/Latino descent. The 2008 UDS does not allow for estimates of White, non-Hispanic patients, but from 1996 - the population) and to be younger and 2006, one-third of patients identified as White and not of Hispanic/Latino ethnicity. *Ethnicity data are reported in two categories: Hispanic or Latino, and all others; All Others includes patients who did not report ethnicity. female; in 2008, children comprised 36 SOURCE: GW Department of Health Policy analysis of 2008 UDS data percent of all health center patients Figure 3 while nearly three in five patients were Health Center Patients and Visits are Chronic Illness- female.11 Related, Compared With Office-Based Physicians Percent of Patients with Serious 11% and Chronic Conditions 25% Compared with patients receiving care Percent of Health Centers Primary Care Offices from private physicians, health center Patient Visits 9% Involving Serious patients are nearly three times more and Chronic 7% likely to seek care for serious and Conditions 5% chronic conditions (Figure 3). At the 4% same time, health center patients, with 9% 3% 3% the exception of health center patients with private insurance, are more likely 1% to experience referral difficulties Health Centers Private Physician Offices Mental Diabetes Asthma Hypertension compared to similar patients treated in Disorders Notes: Estimates based on comparable diagnoses of diabetes, hypertension, asthma, heart disease and mental illness as a proportion of total medical visits. Source: Burt CW, McCaig LF, Rechtsteiner EA. Ambulatory Medical Care Utilization Source: Private Physicians from 2006 NAMCS (CDC National Center for Estimates for 2005. Advance data from vital and health statistics; no 388. Health Statistics, 2008). UDS, 2006. Hyattsville, MD: NCHS 2007. Health center data from 2007 UDS, HRSA. 00 3 private physicians’ offices (Figure 4). Key factors that explain these barriers may include the greater referral difficulties in the case of uninsured and Medicaid-insured patients generally coupled with the far higher volume of health center patients who require Figure 4 referral. Patients Experiencing Referral Difficulties, by Coverage Source: Health Centers and Physician Practices, 2006 Health Centers’ Patient Care Role Community health center Physician office 72% Health centers play an important role in reducing health disparities and 54% promoting population health by 39% 40% providing high quality care.12 Of particular