New England Journal of Medicine: “The new CHCs have arrived.”

Eli Y. Adashi, M.D., H. Jack Geiger, M.D., and Michael D. Fine, M.D.

During the debate over U.S. health care reform, relatively little attention was paid to the long-established network of community health centers (CHCs) in the United States. And yet this unique national asset constitutes a critical element of any reform intent on expanding access to health care through a primary care portal. With an eye toward meeting the primary care needs of an estimated 32 million newly insured Americans, the recently passed Patient Protection and Affordable Care Act underwrites the CHCs and enables them to serve nearly 20 million new patients while adding an estimated 15,000 providers to their staffs by2015. The “new” CHCs have arrived.

Launched in 1965 by the Office of Economic Opportunity as a component of President Lyndon Johnson’s War on Poverty, the very first CHCs — in urban Columbia Point (Boston) and rural Mound Bayou (Mississippi) — were designed to reduce or eliminate health disparities that affected racial and ethnic minority groups, the poor, and the uninsured. The CHCs were to constitute a key component of the national public safety net, focused simultaneously on the care of individual patients and on the health status of their overall target populations. With their host communities involved in their governance, the centers were to be “of the people, by the people, for the people.”

Now operating at more than 8000 sites, both urban and rural, in every state and territory (see Figure 1), run by about 1200 CHC grantees, the centers are the medical home to 20 million Americans, 5% of the current U.S. population (see Figure 2). Federally funded under the authority of the Public Health Service Act, the nonprofit CHCs are administered by the U.S. Health Resources and Services Administration. Support from federal (and frequently state, county, and city) grants notwithstanding, CHCs must meet budget requirements through fees for services rendered to insured patients and “pay-as-you-can” (sliding-scale) collections from the uninsured (who account for 40% of patients served). No one is turned away, regardless of ability to pay. The CHCs are dedicated to the delivery of primary medical, dental, behavioral, and social services to medically underserved populations in medically underserved areas. Marked by a substantial representation of young women and children, the characteristic patient mix includes geographically isolated, migrant, and urban (includinghomeless) constituencies that are often estranged by linguistic and cultural barriers. Seven of 10 CHC patients live in poverty, and well over half are members of minority groups; the CHC is often the sole health care provider available to these patients.