Health Reform and Healthcare Homes:
The Role of Community Health Centers
[Published in the Harvard Health Policy Review, Vol. 8, No. 2, Fall 2007]
Daniel R. Hawkins, Jr., BA, Senior Vice-President for Policy and Programs, NACHC
Michelle P. Proser, MPP , Director of Research, NACHC
Roger Schwartz, JD , Director of State Affairs, NACHC
Author biographies:
Mr. Hawkins is Senior Vice-President for Policy and Programs NACHC.. A former health center director, he served as an aide to Health and Human Services Secretary Califano during the Carter
Administration. He teaches health policy at George Washington University and has lectured at
Harvard and Johns Hopkins Universities.
Ms. Proser is Director of Research at NACHC where she conducts research and analysis on health centers and the populations they serve, as well as remaining communities in need. She has authored and co-authored numerous publications, and coordinates activities promoting community-based participatory research as a tool for improving community health.
Mr. Schwartz is Director of State Affairs at NACHC. Prior to joining NACHC, he was a partner with the law firm of Feldesman, Tucker, Leifer and Fidell where he specialized in Medicaid reimbursement, services, and eligibility issues, particularly with regard to community health centers.
The US economic and political systems are increasingly falling behind in sustaining, much less improving, the accessibility, quality, and cost effectiveness of the nation’s healthcare system.
Despite a staggering $2 trillion, or 16% of the national economy, that the US spent on healthcare in 2005,
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the number of uninsured increased for the sixth straight year and stood at 47 million, or
15.8% of the population, in 2006. And while the country received some rare good news in health care more recently, when it was reported that the number of uninsured people fell by over 1 million in 2007 (the first time that the number of uninsured Americans has decreased since the late 1990s), the report also noted that virtually the entire decrease was due to expanded public coverage, especially Medicaid; moreover, nearly half of the decrease occurred in one state,
Massachusetts – the only state in America that is striving to achieve universal health insurance coverage. The simple fact is that, despite the recent decrease, the U.S. still has nearly 46 million uninsured people, and another 25 million are underinsured.
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Lack of insurance, however, is not the only noteworthy barrier to cost-effective primary and preventive healthcare. Our own recent research, carried out in conjunction with the Robert
Graham Center, found that 56 million people – nearly one in five – lack adequate access to primary care because of a shortage of such physicians in their communities.
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These “medically disenfranchised” live in every state, and many are actually insured. Still other barriers to care remain for those needing translation, transportation, and other specialized services to facilitate healthcare use. While only half of all Americans receive the care they require,
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the perseverance
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of access barriers and health disparities affecting the poor, uninsured, and racial/ethnic minorities indicate that policies targeting the medically disenfranchised may produce the greatest gains.
So what is the most viable solution to the tri-fold dilemma facing the US healthcare system? Greater access to primary and preventive healthcare, specifically through medical or healthcare homes, holds great promise for attacking the access-cost-quality problem while minimizing or even eliminating disparities within all three areas. Although lacking of insurance results in delayed care, fewer preventive services, poor health outcomes, and adverse financial consequences such as bankruptcy and costly hospital expenditures,
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the lack of primary care in general has a significant impact on healthcare outcomes, healthcare costs, and the national economy. Research indicates that while health insurance often facilitates access to care, it does not guarantee access to a usual source of primary care.
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In fact, people who have a usual source of care but no health insurance actually receive more primary and preventive care than those who have insurance but no usual source of care. Not surprisingly, those who have both fare best.
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If every American made appropriate use of primary care, the healthcare system would realize $67 billion in savings annually.
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These savings reflect not only those who currently lack access to primary care, but also those who rely extensively on costly specialists for most of their care, leading to inefficiencies in the system. As Congress, the White House, and Presidential candidates debate the best means for healthcare reform, several states have either enacted or are soon expected to enact policies directed at healthcare reform. In all such cases, the focus has been principally on making health insurance coverage more available and affordable, although some states have specifically aimed to improve access to coordinated, regular primary care.
The 43-year-old federal Community Health Centers program stands as confirmation that improving access to high-quality, continuous care to the medically disenfranchised – indeed, entire communities without access to other sources of care – improves health outcomes, narrows health disparities, and generates significant savings to the healthcare system and economic benefits to low income communities. This article will discuss the need for and benefits of medical homes, the role that health centers play in fulfilling this need to over 16 million people, and the means by which health centers serve as a critical platform for further improving access to care. Certain challenges, such as workforce shortages, capital needs, and payment structures that do not support primary care, stand in the way of improving broad access to primary care for all
Americans.
All patients, regardless of income, insurance status, or race/ethnicity, require a patientcentered, culturally-appropriate and continuous source of care. Such places, usually referred to as medical homes, embody not just a physical place for primary and preventive care, but also an inter-personal relationship and a complete process of care. Medical homes are lead by teams of medical professionals committed to quality improvement that coordinate and integrate a patient’s care across multiple medical, behavioral, social, and other services, as well as help patients understand their conditions and coach them on how to improve their overall health.
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According to the American Academy of Family Physicians, the American Academy of
Pediatrics, the American College of Physicians, and the American Osteopathic Association, a medical home encompasses the following: 9

An ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.

A team of other individuals at the practice led by the personal physician to collectively take responsibility for the ongoing care of patients.
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An approach to care that covers the whole person , so that the personal physician is responsible for providing all of the patient’s healthcare needs or for arranging care with specialists as needed.
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Care is coordinated and/or integrated across the entire healthcare system, to ensure that patients receive the care they need when and where they need and want it.
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Quality and safety are key features to support optimal patient care, performance measurement, patient education, and enhanced communication.
Having a medical home offers improved health outcomes and lowers healthcare costs independent of other factors. For example, accessible primary care is associated with reduced heart disease and cancer mortality disparities related to socio-demographic measures and lifestyle factors whereas other medical services are not.
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When people have a regular source of healthcare, they better manage chronic illness, receive more cancer screenings, and even bring fewer lawsuits against emergency rooms.
11 In an extensive review of relevant literature,
Starfield and Shi found that having a medical home is a greater predictor of receiving care than having insurance alone, and that having a medical home is generally associated with better utilization and outcomes, including needs recognition, earlier and more accurate diagnoses, reduced emergency room use, fewer hospitalizations, lower costs, better prevention, fewer unmet needs, and increased patient satisfaction.
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Low income, minority, and uninsured populations especially would benefit from the expansion of medical homes because their health is more likely to be compromised and they run the greatest risk of using costly hospital-based care for avoidable conditions.
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Medical homes are therefore essential means for improved health outcomes, the prevention of costlier illnesses, and cost savings.
Despite these benefits, 56 million people living in the US do not have access to primary care, much less a medical home. Coming from all income levels and the ranks of the insured as well as the uninsured, they are America’s medically disenfranchised – those who live in communities with too few or no primary care physicians to treat them. In analyzing the U.S.
Medical Expenditure Panel Survey, which surveys Americans on whether or not they have a usual source of care (USC), we find that Of those without a USC, 32% are uninsured and 21% are low income.
This means that the majority of those without a USC are insured and not in poverty . Yet we find that the uninsured, low income, and members of racial and ethnic minority groups are disproportionately affected by the lack of USC. For instance, 52% of uninsured people under 65 years of age have no USC, compared to 17% of privately insured and 14% of publicly insured people. Nearly a quarter (24%) of poor or near-poor are without a USC, compared to 15% of higher income people. In addition, 32% of Hispanic or Latino Americans,
23% of Black, non-Hispanic Americans, and 21% of Asian/Pacific Islander Americans have no
USC, compared to 16% of White Americans. Moreover, several millions of those without a
USC report having fair or poor health.
14
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Unfortunately, shrinking numbers and rates of practicing primary care physicians will cause the number of medically disenfranchised to rise. In fact the number of primary care physicians per capita has been shrinking steadily, while the number of specialists continues to grow – accounting for more than three-quarters of the growth in per capita physicians from 1980 to 1999.
15 Adequate physician supply is fundamental for improving access, and essential to improving health outcomes and narrowing health disparities – even at the community level. For instance, increasing the number of primary care physicians is associated with diagnosing breast cancer at earlier stages,
16 cancer,
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lower incidence of and mortality from cervical cancer
fewer cases of infant mortality and low birth weight,
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and colorectal
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and reduced stroke and postneonatal mortality.
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Minorities living in poverty can make the most improvement through higher-quality primary care.
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People who live in states or counties where there is a higher concentration of primary care physicians are more likely to report being in good health than those living in areas with a low concentration of primary care providers.
22 A higher primary care physician-to-population ratio is also associated with lower mortality rates overall, while higher rates of specialty care providers are associated with higher mortality rates. This finding is especially pronounced in the case of family physicians, the only primary care specialty consistently associated with lower mortality and the one most likely to distribute evenly across the population.
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Several states, aware of this information, are now focusing on medical homes as a key component to state health reform. In dealing with the aftermath of Hurricane Katrina, the state of Louisiana has initiated an overhaul of its hospital-based system of care to focus more on community-based ambulatory medical homes. The Louisiana Health Care Redesign
Collaborative aims to “improve healthcare by providing every [resident] with a medical home that is prevention centered, neighborhood located and electronically connected.” 24
Missouri
Governor Matt Blunt, in his recent State of the State Address, called for an “entirely new system” for poor residents, revamping Medicaid while also establishing “health care home coordinators” and increasing financial support for health centers in the state.
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In addition, at least twelve states (including California, Connecticut, Florida, Idaho, Iowa, Louisiana, Maryland,
Mississippi, Rhode Island, Texas, Washington, and West Virginia) have enacted legislation to create or encourage the creation of medical homes specifically for children.
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Notably, in response to a questionnaire sent out by the National Association of Community Health Centers, a substantial number of state primary care associations—such as those in Connecticut, Missouri,
Oregon, Tennessee, Texas, and West Virginia—maintained that health centers and other safety net providers were viewed by decision-makers in their state as critical players in establishing access to medical homes as part of the state’s overall move toward healthcare reform.
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Clearly, medical homes play an important role in the balancing of healthcare cost, access, and quality. Improving access to primary care can in fact make health insurance more affordable to those who are insured by lowering the overall costs of care. While attention must be paid to the growing numbers of uninsured and underinsured, policymakers will want to pay close attention to where those individuals, and the millions who will remain uninsured, are able to turn for affordable, accessible primary healthcare.
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The 7000-plus Community Health Center (CHC) delivery sites across the country provide comprehensive medical, dental, social, behavioral, and in many instances pharmaceutical services to well over 18 million traditionally underserved patients. Sites are spread over every state and territory, and nearly evenly split between urban and rural areas. Each health center is firmly grounded in its local community, with a long history of serving the entire community through extensive needs assessments, outreach, and quality improvement initiatives. Unique among all healthcare providers, health centers are directed by patient-majority governing boards, as mandated under federal law, thus ensuring a voice for consumers and community members in the direction of their care.
Ninety two percent of CHC patients are low income individuals, with most living below the federal poverty level (Figure 1), compared to 12.3% of the total US population.
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While roughly a third of the US population are members of racial and ethnic minority groups,
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nearly two-thirds of CHC patients are members of minority groups, as demonstrated in Figure 2.
Nearly 40% of patients are uninsured and 35% have Medicaid (Figure 3), compared to national rates of 15.8% and 12.9% respectively.
30 While 15% of patients are privately insured, the fact that private insurance covers so little of their costs implies that they are predominately underinsured.
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Finally, CHC’s also serve nearly 900,000 migrant and seasonal farmworkers, and another nearly 900,000 homeless individuals.
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[INSERT FIGURES 1, 2, AND 3 APPROXIMATELY HERE]
Health centers fulfill the previously-noted five-point definition of medical homes.
Nationally, 84% of health center patients report being able to identify a particular health center physician as their own compared to 38% of adults and 36% of children nationally.
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Health centers care for patients throughout their lives, and deliver care in team-based settings. Health center providers include physicians, nurse practitioners, physician assistants, nurses, dentists, dental hygienists, behavioral healthcare providers, case managers, health educators, and others.
In this way they coordinate and integrate social services to mitigate the effects of poverty.
Health centers have a proven record of reducing health disparities, improving birth outcomes, and effectively managing chronic diseases. They have been credited with reducing infant mortality and low birth weight rates.
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Moreover, fully 99% of patients are satisfied or very satisfied with the quality of care they receive at health centers, compared to satisfaction rates of
67% to 87% reported in other national surveys of physician visits.
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In addition, health centers expand on the medical home concept in several ways, and thus are more suitably described as “health care homes.” For example, they provide healthcare services not normally seen in primary care settings , such as dental care, behavioral healthcare, and pharmacy services. Health centers are open to all residents and their services are not contingent on ability to pay , and they are located in high-need areas identified by the federal government as having elevated poverty and infant mortality rates, too few physicians in practice, and social and financial barriers to the existing healthcare infrastructure. They also customize and tailor their services to meet the specific needs of their patients and communities. While nearly one-third of their patients are best served in languages other than English, 95% of patients
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report that their doctor speaks the same language as they do.
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Health centers are committed to community health improvement and patient involvement in healthcare delivery . Community boards remain a key aspect of the health center model, ensuring that health center care prioritizes the particular needs of the community being served. Moreover, they offer enhanced access to care, actively engaging their communities through outreach to publicize their services and often providing transportation to and from their sites. They also make use of “open access scheduling” so that patients can make same day appointments, and are often open evenings and weekends.
Over half (54%) of health center patients report seeing their doctor within 15 minutes of arrival.
In addition, only 24% indicate that their wait to see a provider was too long, compared to other settings where 53% of Medicaid and privately insured patients felt their wait was too long.
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These features common to all health centers help overcome barriers to care and make the care provided much more effective.
Health centers are high performers of care despite their at-risk patient mix. Research shows the quality of their care has been found to be as good as or better than other providers,
38 and they meet or exceed quality performance results in the private sector.
39 Health centers meet or exceed nationally accepted practice standards for treatment of chronic conditions,
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and their chronic disease management programs have improved both the processes of care and patient outcomes.
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Health centers also reduce racial and ethnic health disparities at the state level.
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In fact, disparities in health status do not exist among health center patients, even after controlling for socio-demographic factors. The absence of disparities may be related to health centers’ culturally-sensitive practices and community involvement – features that other primary care settings often lack.
43 Shi and colleagues found that health center prenatal care patients have lower rates of low birth weight (LBW) than women nationally, regardless of race/ethnicity and despite the fact that health center patients are low income. If the LBW black-white disparity seen at health centers could be achieved nationally, there would be 17,100 fewer LBW black infants annually.
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Both the Institute of Medicine and the General Accountability Office have recognized health centers as effective models for reducing health disparities and for screening, diagnosing, and managing chronic conditions such as diabetes, cardiovascular disease, asthma, depression, cancer, and HIV.
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Through their efforts, health centers are generating substantial savings to the entire healthcare system while bringing much-needed economic benefits to the low income communities they serve. In a recent national study done in collaboration with the Robert
Graham Center and Capital Link, we found that people who use health centers as their usual source of care have 41% lower total healthcare expenditures than people who get most of their care elsewhere. As a result, NACHC calculates that health centers saved the healthcare system up to $18 billion last year alone. At the same time, health centers produced more than $12.6 billion in economic benefits and helped to sustain more than 140,000 jobs, in turn helping to attract or retain other local businesses (including other healthcare providers), sustaining a sense of “community,” giving residents a feeling of pride, and fostering community revitalization.
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These savings extend to federal and state Medicaid spending. Health center Medicaid patients are significantly less likely to use the emergency department or be hospitalized for ambulatory care-sensitive (i.e., avoidable) conditions and are therefore less expensive to treat than Medicaid patients treated elsewhere.
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While there is broad agreement among the American people, regardless of their political affiliation, that improved access to affordable insurance coverage must be a top priority, progress is stymied by political disagreements over the best means for achieving this goal. Meanwhile, more and more people and decision-makers understand that, in addition to affordable coverage, every American also needs a regular source of primary – a home. As Washington and the states continue to debate coverage, other steps can be taken to ensure that the healthcare system more effectively reaches more people, and in doing so providing higher quality care. Among those steps are the following:
1. Making a primary health care home for every American an explicit goal of reform.
As demonstrated above, primary care is cost-effective. At the same time, achieving a primary care system that functions well takes as much planning and policy development as retooling any other aspect of healthcare. Simply reducing expenditures for inpatient care will not yield advances in primary care. Therefore, it is important that the goal of assuring a primary healthcare home for everyone be made explicit and that it receive the same careful attention as other health system reforms.
Since 2001, President Bush and Congress have collaborated to significantly expand the
Health Centers program. Yet, as already noted, there remains much unmet need in communities across the country – need that will only grow worse until and unless it is effectively confronted by policymakers. In this context, health centers stand ready to do their part: as others have noted, expanding health center capacity would further reduce unmet need, narrow health disparities, increase the percent of uninsured with a usual source of care, and make the overall system more efficient with reduced hospitalizations and emergency room use.
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To answer the call, America’s health centers have developed a strategy to reduce unmet need and thin the ranks of America’s medically disenfranchised. The “Affordable
Comprehensive Care, Expanded to Strengthen Service (ACCESS) for All America” plan charts future health center growth so that, over the next eight years, health centers can become healthcare homes for an estimated 30 million Americans, nearly twice the number of patients currently served. Once health centers reach 30 million patients by 2015, the cost savings they are predicted to generate for the entire healthcare system will grow to between $22.6 billion and
$40 billion annually, while bringing $40.7 billion annual economic benefits and supporting
460,000 jobs in their local communities.
49 The ACCESS for All America plan is envisioned to eventually reach 51 million Americans, with health centers serving as the model and innovation leader for what primary care practice could become.
The federal and state funds that flow to health centers today help to anchor them in communities that otherwise could not afford to maintain a healthcare infrastructure – and yet they constitute less than 1% of healthcare spending today
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, and would remain below 1% even if funding were increased to triple the number of people they serve over the next fifteen years.
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2. Investing in the development of a primary care workforce.
Investment in funding to support the education and training of a primary healthcare workforce covering medicine, nursing, dentistry, mental health, and other primary and community service specialties is essential. Training and education programs also need to be linked to primary care sites in order to foster the growth of skills in primary care settings, particularly in urban and rural shortage areas.
To accomplish this goal, federal and state workforce programs and funding for this purpose should be clearly targeted at meeting three key workforce goals: first, reversing the decline in primary healthcare training and its workforce; second, significantly expanding the diversity of the healthcare workforce, and developing culturally proficient providers; and third, linking federal support for healthcare education and training to a clear expectation of training conducted in community-based settings, along with a mandate to practice in underserved areas.
We recently reported that that expansion to 30 million patients will require health centers to locate and recruit almost 16,000 more health professionals. Clearly, this goal cannot and will not be achieved without major changes in healthcare workforce policy at the federal and state levels. Currently, far too few new medical graduates are choosing a career in primary care, and too few of them are choosing to practice in underserved areas. Policy makers should heed the alarms over the collapse of primary care as indicators of an increasingly unstable health care system nationally – one that will cause serious problems for everyone, and especially for communities that are underserved.
3. Stemming the erosion in primary care through payment reforms that reward results and quality of care improvements.
As with other services, the accessibility and quality of primary healthcare is sensitive to payment incentives. The evidence strongly suggests that current Medicaid policy significantly limits primary care investment in both safety net and private practice settings.
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A system of payment incentives is needed that is expressly grounded in primary care improvement, reflects the achievement of milestones in health system management reforms, health information technology adoption, and health quality outcomes.
In a healthcare safety net context, Medicaid and Medicare are the principal sources of revenue to examine. At the same time, there is very little evidence regarding the adequacy of primary care provider payment rates among private insurers and health plans. As part of any health reforms, significantly greater focus should be placed on the extent to which private insurers and plans emphasize payments for quality and in the most cost-effective settings.
Current reimbursement practices reward specialty care and more services through a feefor-service system, while primary care providers are predominately restricted to payments that do not cover the full range of services a patient needs, such as coordinating a patient’s full range of care, ensuring continuity of care, offering multiple means of communication with patients, and providing translation and interpretation services. These services are both time consuming and
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least likely to be reimbursed, yet play a central role in improved health outcomes.
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Reforms to the reimbursement system must narrow the gaps between primary care and specialty providers, thereby encouraging more students to enter primary care fields.
4. Stimulating capital investment in primary care facilities, equipment, health information technology, and performance improvement.
Augmented payment levels alone cannot ensure transition to a higher performing primary healthcare system. Carefully planned capital investments are required in the development of new facilities where needed, the acquisition of equipment to help modernize primary care, and of course, health information technology adoption. While much attention has been given to technology adoption in hospital settings, it will be most important in primary care, where the bulk of healthcare is delivered. A deliberate investment strategy — one that includes capital investment and technical assistance — is particularly essential for health centers and other safety net providers. Furthermore, the lessons learned in these practice settings yield important information that over time can be transferred to primary care practice settings generally.
A growing body of evidence converges on a single critical conclusion: that expanding access to primary care will significantly improve healthcare outcomes, lower healthcare costs, and benefit the national economy. Community Health Centers are an important part of the solution to America’s healthcare problems because they cost-effectively improve the health of those they serve. They do this by providing effective, regular primary and preventive care that translates into reduced hospitalizations, lower use of emergency rooms, and fewer referrals to costly specialists. Expanding the health centers program will further improve outcomes, reduce disparities, and bring additional economic benefits to their local, low income communities – all while saving taxpayer money.
1 Catlin A, et al. “National Health Spending in 2005: The Slowdown Continues.” January 2007 Health Affairs
26(1):142-153. http://content.healthaffairs.org/cgi/content/abstract/26/1/142 .
2 Schoen C, et al. “ , How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007 , June 2008,
Commonwealth Fund .
3 National Association of Community Health Centers and The Robert Graham Center. Access Denied: A Look at
America’s Medically Disenfranchised . March 2007. www.nachc.com/research .
4 McGlynn EA, et al. “The Quality of Health Care Delivered to Adults in the United States.” June 2003 New
England Journal of Medicine 348(26): 2635-2645.
5 Institute of Medicine (IOM). Coverage Matters: Insurance and Health Care . National Academy of Sciences Press,
2001. Hadley J. Sicker and Poorer: The Consequences of Being Uninsured . Prepared for the Kaiser Commission on
Medicaid and the Uninsured, May 2002.
6 Starfield B and Shi L. “The Medical Home, Access to Care, and Insurance: A Review of Evidence.” May 2004
Pediatrics 113(5): 1493-1498. Williams C. “From Coverage to Care: Exploring Links Between Health Insurance, a
Usual Source of Care, and Access.” September 2002. Robert Wood Johnson Foundation. Policy Brief No. 1. http://www.rwjf.org/publications/synthesis/reports_and_briefs/pdf/no1_policybrief.pdf
. Institute of Medicine
(IOM). Coverage Matters: Insurance and Health Care . National Academy of Sciences Press, 2001.
7 Phillips RL, et al. “The Importance of Having Health Insurance and a Usual Source of Care.” Robert Graham
Center One-Pager #29, September 2004. http://www.graham-center.org/onepager29.xml
. See also DeVoe JE, 2003.
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8 Spann SJ. “Task Force 6: Report on Financing the New Model of Family Medicine.” December 2004 Annals of
Family Medicine 2(2 Suppl 3):S1-21. doi: 10.1370/afm.237.
9 American Academy of Family Physicians Press Release, “Joint Principles of a Patient-Centered Medical Home
Released by Organizations Representing More Than 300,000 Physicians.” March 5, 2007. http://www.aafp.org/online/en/home/press/aafpnewsreleases/20070301releases/20070305pressrelease0.html
10 Shi L. “The Relation Between Primary Care and Life Changes.” 1992 J Health Care Poor Underserved 3:321-
35. Shi L. “Primary Care, Specialty Care, and Life Chances.” 1994
Int J Health Serv 24(3):431-58. Shi L.
“Balancing Primary Versus Specialty Care.” 1995 J R Soc Med 88(8):428-32. For a review of these articles, see
Shi L, et al. “The Relationship Between Primary Care, Income Inequality, and Mortality in U.S. States, 1980-1995.”
Sept-Oct 2003 J Am Board Fam Pract 16(5):412-22. Ferrer RL, Hambidge SJ, and Maly RC. “The Essential Role of Generalists in Health Care Systems.” 19 April 2005 Annals of Internal Medicine 142(8):691-699.
11 Lambrew J. et al “The Effects of Having a Regular Doctor on Access to Primary Care.” February 1996 Medical
Care 34(2):138-151.
12 Starfield and Shi, 2004.
13 Politzer RM, et al. “The Future Role of Health Centers in Improving National Health.” 2003 Journal of Public
Health Policy 24(3/4):296-306.
14 National Association of Community Health Centers and The Robert Graham Center. Access Denied: A Look at
America’s Medically Disenfranchised . March 2007. www.nachc.com/research . Extrapolation based on US
Medical Expenditure Panel Survey (MEPS), 2004. See www.meps.ahrq.gov/mepsweb . Because MEPS data are based on self-reports on access to a usual source of care, they represent a broader set of factors creating access barriers, such as cost, insurance, and language, than our 56 million estimate, which represents only those without access to a primary care due to physician shortages.
15 The Robert Graham Center. “The US Primary Care Physician Workforce: Minimal Growth, 1980-1999.” One-
Pager Number 22, October 2003. www.graham-center.org/x467.xml
16 Ferrante JM, et al. “Effects of Physician Supply on Early Detection of Breast Cancer.” Nov-Dec 2000 J Am
Board Fam Pract 13(6):408-14.
17 Campbell RJ, et al. “Cervical Cancer Rates and the Supply of Primary Care Physicians in Florida.” Jan 2003 Fam
Med 35(1):60-4.
18 Roetzheim RG, et al. “Primary Care Physician Supply and Colorectal Cancer.” December 2001 Journal of
Family Pratice 50(12):1027-31.
19 Shi L, et al. “Primary Care, Infant Mortality, and Low Birth Weight in the States of the USA.” May 2004 J
Epidemiology Community Health 58(5):374-80.
20 Shi L, et al. “Income Inequality, Primary Care, and Health Indicators.” April 1999 Journal of Family Practice
48(4):275-84.
21 Shi L, et al. “Primary Care, Race, and Mortality in U.S. States.” Jul 2005 Soc Sci Med 61(1):65-75. Epub 2005
Jan 22. Shi, Green, and Kazakova, 2004.
22 Shi L and Starfield B. “Primary Care, Income Inequality, and Self-Rated Health in the United States: A Mixed-
Level Analysis.” 2000 International Journal of Health Services 30(3):541-55.
23 Green LA et al. “The Physician Workforce of the United States: A Family Medicine Perspective.” The Robert
Graham Center.
2004. Shi et al, 2003.
24 Louisiana Health Care Redesign Collaborative. Department of Health and Human Services. http://www.dhhs.gov/louisianahealth/
25 Medical News Today. “Missouri Medicaid Changes Proposed By Governor's Staff.” December 13, 2006. http://www.medicalnewstoday.com/medicalnews.php?newsid=58721 . Southeast Missourian. “Blunt Promises
Improved Healthcare.” January 25, 2007. http://www.semissourian.com/story/1186753.html
26 National Conference of State Legislatures, email communication, February 2007.
27 NACHC, Reform on the Horizon: A Compilation of Primary Care Association Reports on the Status of Health
Care Reform in the States, State Policy Report #16 , July 2007. www.nachc.com
.
28 DeNavas-Walt, C, Proctor, BD and Smith, J. U.S. Census Bureau, Current Population Reports, P60-233, Income,
Poverty, and Health Insurance Coverage in the United States: 2006, U.S. Government Printing Office, Washington,
DC, 2007.
29 Kaiser State Facts Online, “ Population Distribution by Race/Ethnicity, states (2004-2005), U.S. (2005).
” From
Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau''s
March 2005 and 2006 Current Population Survey (CPS: Annual Social and Economic Supplements).
www.statefactsonline.kff.org
.
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30 DeNavas-Walt, Proctor, and Smith, 2007.
31 NACHC, Safety Net on the Edge , August 2005, www.nachc.com/research .
32 NACHC estimate, based on 2006 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS and extrapolated to include all patients currently served in federally-funded and non-federally funded health centers.
33 Roby D, et al. Exploring Healthcare Quality and Effectiveness at Federally-Funded Community Health Centers:
Results from the Patient Experience Evaluation Report System (1993-2001) . National Association of Community
Health Centers. http://www.nachc.com/research/Files/PEERSreportfinal0226.pdf
.
34 For a review of literature, see Proser M. “Deserving the Spotlight: Health Centers Provide High-Quality and Cost-
Effective Care.” Journal Ambulatory Care Management.
28(4): 321-330. October-December 2005.
35 Roby D, et al. Exploring Healthcare Quality and Effectiveness at Federally-Funded Community Health Centers:
Results from the Patient Experience Evaluation Report System (1993-2001). National Association of Community
Health Centers, March 2003. http://www.nachc.com/research/Files/PEERSreportfinal0226.pdf
. Based on
NACHC’s 2001 Patient Experience Evaluation Report System (PEERS) and And other national surveys., including
Leatherman, Sheila, and McCarthy, Douglas, Quality of Health Care in the United States: A Chartbook. The
Commonwealth Fund, New York, NY, April 2002; National Survey of Americans as Health Care Consumers: An
Update on the Role of Quality Information, Kaiser Family Foundation, Menlo Park, CA, 2000; and Summary Report for the Robert Wood Johnson Foundation on the National Strategic Indicators Survey Project, Foundation for
Accountability, Portland, OR, 2000.
36 Roby, et al, 2003.
37 Ibid.
38 Starfield, B., et al. (1994). Costs vs. quality in different types of primary care settings. Journal of the American
Medical Association , 272 (24), 1903-1908.
39 Shin P, Markus A, and Rosenbaum S. Measuring Health Centers against Standard Indicators of High Quality
Performance: Early Results from a Multi-Site Demonstration Project. Interim Report . Prepared for the United
Health Foundation, August 2006. www.gwumc.edu/sphhs/healthpolicy/chsrp/downloads/United_Health_Foundation_report_082106.pdf
.
40 Ulmer, C., et al. “Assessing Primary Care Content: Four Conditions Common in Community Health Center
Practice.” 2000 Journal of Ambulatory Care Management 23(1): 23-38.
41 Chin, M. H., et al. “Barriers to Providing Diabetes Care in Community Health Centers.” 2001 Diabetes Care
24(2): 268-274. Huang E, et al. “The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified
Community Health Centers.” June 2007
Journal of General Internal Medicine, 21(4) supp: 139.
42 Shin P, Jones K, and Rosenbaum S. Reducing Racial and Ethnic Health Disparities: Estimating the Impact of
High Health Center Penetration in Low-Income Communities . Prepared for the National Association of Community
Health Centers, September 2003. www.gwumc.edu/sphhs/healthpolicy/chsrp/downloads/GWU_Disparities_Report.pdf.
43 Shi, L., et al. “Community Health Centers and Racial/Ethnic Disparities in Healthy Life.” 2001 International
Journal of Health Services 31(3): 567-582.
44 Shi, L., et al. “America’s Health Centers: Reducing Racial and Ethnic Disparities in Perinatal Care and Birth
Outcomes.” 2004 Health Services Research 39(6): Part I, 1881-1901.
45 General Accountability Office, Health Care: Approaches to Address Racial and Ethnic Disparities . GAO-03-
862R. 2003. Institute of Medicine. Fostering Rapid Advances in Health Care: Learning from System
Demonstrations . 2002 Washington, DC: National Academy Press. Institute of Medicine. Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care . 2003. Washington, DC: National Academy Press.
46 NACHC, the Robert Graham Center, and Capital Link. Access Granted: The Primary Care Payoff . August 2007. www.nachc.com/research .
47 McRae T. and Stampfly R. “An Evaluation of the Cost Effectiveness of Federally Qualified Health Centers
(FQHCs) Operating in Michigan.” October 2006 Institute for Health Care Studies at Michigan State University. www.mpca.net
. Falik M, Needleman J, Herbert R, et al. “Comparative Effectiveness of Health Centers as Regular
Source of Care.” January - March 2006 Journal of Ambulatory Care Management 29(1):24-35. Falik M, et al.
“Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using
Federally Qualified Health Centers.” 2001
Medical Care 39(6):551-56. Starfield, et al, 1994. Duggar BC, et al.
Utilization and Costs to Medicaid of AFDC Recipients in New York Served and Not Served by Community Health
Centers . Center for Health Policy Studies, 1994. Duggar BC, et al. Health Services Utilization and Costs to
Medicaid of AFDC Recipients in California Served and Not Served by Community Health Centers . Center for Health
Policy Studies, 1994.
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48 O’Malley AS, et al. “Health Center Trends, 1994-2001: What Do They Portend for the Federal Growth
Initiative?” March/April 2005 Health Affairs 24(2):465-472. Hadley J and Cunningham P. “Availability of Safety
Net Providers and Access to Care of Uninsured Persons.” October 2004 Health Services Research 39(5):1527-1546.
49 NACHC, the Robert Graham Center, and Capital Link, 2007.
50 Health centers’ total budgets for CY 2006 were $8.1 billion, while total U.S. health care spending reached $2.0 trillion in 2005, and was projected at $2.1 trillion for 2006; see http://bphc.hrsa.gov/uds/2006data/National/NationalExhibitArevenue.htm
, and http://www.cms.hhs.gov/NationalHealthExpendData/
51 See for example Cunningham, PJ, and May, JH, Medicaid Patients Increasingly Concentrated Among
Physicians, Center for Studying Health System Change, August 2006 ( Tracking Report No. 16); downloaded
October 14, 2007 at http://www.hschange.com/CONTENT/866/?topic=topic02 .
52 Starfield B and Shi L. “The Medical Home, Access to Care, and Insurance: A Review of Evidence.” May 2004
Pediatrics 113(5): 1493-1498.
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