South Carolina
Rural Health
Research Center
Rural Health
Grand Rounds
The History, Evolution, Current Status and Issues of
Community Health Centers
Michael E. Samuels, Dr.P.H.
Distinguished Scholar and
Endowed Chair in Rural Health Policy
Center of Excellence in Rural Health
University of Kentucky College of Medicine
Department of Health Services Policy and Management
Arnold School of Public Health
University of South Carolina
McKissick Library
September 20, 2005
Columbia, SC
History
1854
John Snow, MD
(1813-1858)
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”
President Harry S. Truman
Importance of History
• Live in A-historical country.
• We think of it as not involved in our
daily life.
• It has to do with our self perception.
• We think of history as myth.
• We are bound by unproven assumptions.
Importance of History
• Our concepts (basic assumptions and
though patterns) come out of the past.
• History teaches inductive rather than
deductive reasoning.
• History is necessary for long-range planning.
• History is about balance between change
and continuity over time.
• Short term versus long term trends
CHC Traditions
Medical Care
(Individual)
Public Health
(Group)
The Greek Tradition
Hippocrates (470 - 377 B.C. )
“To maintain the correct balance, eat good food,
avoid red meat, drink pure water, get fresh air
and exercise and above all avoid quarrelsome
people for they cause stress and that is the most
injurious to your health.”
Oath of Hippocrates
“Whatever houses I may visit, I will come for the
benefit of the sick, remaining free of all
intentional injustice, of all mischief and in
particular of sexual relations with both female
and male persons, be they free or slaves.”
The Religious Tradition in Health
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
•
Thou shalt love the Lord thy God with all thy heart, and with
all thy soul, and with all thy mind. This is the first and great
commandment. And the second is like unto it: Thou shalt
love thy neighbor as thyself. On these two commandments
hang all the Law and the Prophets.
Matthew 22:37-40
US History of Health Care
• 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.
• 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 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 of the goodness of
the giver.
• The University of Pennsylvania School of Medicine - first medical school Fall,
1765
• Benjamin Rush “Father of US Medicine” – Farming, misfortune of others
• History of Physician Licensure
• Education – B.A., M.D.
• 1816 First Stethoscope
• 1869 –” Medicine, the most despised of the professions which liberally educated
men are expected to enter” (1925 3rd, 1933 1st)
• Technology – 1877 First telephone exchange, 1890’s “Buick, the Doctors Car”
US History of Health Care
• AMA founded 1851
• Hospitals – Either 1846, Antiseptic surgery 1867, Mayo Brothers abdominal
surgery 1889-1892 (45), 1900 (612), 1915 (2,157).
• Hospitals – 1873 <200, 1900 > 4,000, 1920 >6,000.
• Florence Nightingale Nursing, hospital architecture, health administration
• First x-ray 1895
• Medical Education Flexner Report 1910, Johns Hopkins Model, Licensure 1877,
Osteopathy 1891
• Group Practice 1918 Mayo Brothers
• Health Centers Dr. Herman Biggs, 1923, New York
• Baylor Hospital / Dallas Teachers Union “Birth of the Blues” 1929
• California Blue Shield, 1939
• Kaiser Permanente, 1942
Government
• 1798 “The Relief of Sick and Disabled Seaman”
• 1906 The Pure Food and Drug Act, Meat Inspection Act
• 1912 First White House Conference
urged creation of the Children's Bureau
• 1921 The Bureau of Indian Affairs Health Division
• 1930 The National Institutes of Health
• 1935 The Social Security Act
• 1938 Federal Food, Drug and Cosmetic Act
• 1939 Federal Security Agency
• 1946 Centers for Disease Control and Prevention.
• 1955 Department of Health, Education and Welfare
Government
• 1961 Indian Health Service transferred to HHS from DI
• 1964 The Migrant Health Act
• 1965 First Surgeon General's Report on Smoking and Health
• 1965 Medicare and Medicaid, the Older Americans Act, Head Start
• 1966 The Community Health Centers Act (Section 330, PHS Act)
• 1970 National Health Service Corps
• 1980 Health Care Financing Administration
• 1989 Passage of the McKinney Act to provide health care to the
homeless
• 1989 Agency for Healthcare Research and Quality
• 1993 Ryan White Comprehensive AIDS Resource Emergency
(CARE) Act
Government
• 1996 Personal Responsibility and Work Opportunity
Reconciliation Act
• 1996 The Health Centers Consolidation Act
• 1997 Health Insurance Portability and Accountability Act
(HIPAA).
• 1999 State Children's Health Insurance Program (SCHIP)
• 2002 Centers for Medicare & Medicaid
• 2002 Office of Public Health Emergency Preparedness
• 2003 Medicare Prescription Drug Improvement, and
Modernization Act
Community Health Centers
1965 - Present
Lyndon Baines Johnson Richard Milhous Nixon
1963–69
1969–74
Ronald Wilson Reagan
1981–89
George H. W. Bush
1989–93
Gerald Rudolph Ford
1974–77
Bill Clinton
1993–2001
Jimmy Carter
1977–81
George Walker Bush
2001–
Economic Opportunity Act of 1964.
"War on Poverty"
Executive Branch Initiatives
Work toward elimination of poverty or its causes
through developing: employment opportunities,
improving human performance, motivation, and
productivity.
Usually through community activity.
Health not an original OEO concern - Job
Corps/Headstart physicals.
Direct care - save money and effect basic way in
which health care is delivered.
Dr. H. Jack Geiger and Dr. Count Gibson
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 and
employ community residents, and involve them in community
development.
Neighborhood Health
Center Model
Vehicle to community development and a challenge to
mainstream medicine, dignified, accessible,
comprehensive, and community based.
Elements:
Community health services
- Public health model, deal with social and
physical environment
- Health care team
- Decentralize health care
outreach/communications
family health care workers
health education
social advocacy (housing, welfare).
Neighborhood Health
Center Model (Cont.)
-Community economic development
-Community participation.
-Re-integrate public health and personal
health care services, including
prevention, environmental, and
outreach.
-Ignoring the previously negotiated
boundaries between private
medicine/public health.
-Salaried physicians.
-Health teams.
-Consumer participation.
A New System
"The hospital as we know it is an obsolete and
ineffective institution for ambulatory care, ...
hospitals for the future should be vastly
different - in effect, intensive care units for
patients with critical and complex illness ... The
hub of the medical care universe would be a
network of comprehensive community health
centers"
1968 Dr. Jack Geiger.
Alternative to hospital based care for the entire
community. A system for the entire US.
population.
More History
• Initially grants to hospitals/medical schools
• 1966 Kennedy amendments (OEO Act) - planning and operation
of comprehensive health service programs in urban/rural areas,
low income requiring adequate health services. (100 centers by
1971).
• 1967 “When they reach 25 centers, there will be no private
practice” “Another step to socialism” “Dispensary abuse – 1890s”
"Limited to the poor:, limited to 20% self pay.
-local opposition
-involvement of organized medicine
-means test
• 1966-1970 Most grants to medical schools
and hospitals – quick success/legitimacy
More History
• 1966-1970 Most grants to medical schools
and hospitals – quick success/legitimacy
• Community participation vague at first
• 1968-69 PHS “Yellow Berets”, 314e (24 centers)
• 1975
55
314e centers
• 1970 - 1974 Nixon transfer all OEO NHCs
to PHS
More History
• 1972-1974 Family Health Center CHCs
• established
• 1975-1977 Rural Health Initiative CHCs established
• 1977 - 3rd Party billing required
• 1981 - First Reagan budget cuts program in half
• 1983 - All funds restored
• 2001 – 2006 President Bush Initiative doubling the
number of patients served by Community Health
Centers
Organizing
• 1970 - New York Association of Neighborhood Health Centers
• 1971 – The Massachusetts League of Neighborhood Health
Centers
• 1970 - National Association of Neighborhood Health Centers
now National Association of Community Health Centers
• 1975 – National Rural Primary Care Association now
National Rural Health Association
CHCs 2004
.
914 Grantees (51% Rural)
5,502 Service Delivery Sites
13,127,811 Patients
HC
HC
*
HC
Source: 2003 UDS data.
Health Center Patients By
Income Level, 2004
Over 200% FPL
8.9%
151-200% FPL
6.3%
101-150% FPL
14.3%
100% FPL
and Below
70.5%
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
By Insurance Status, 2004
Private
14.7%
Other Public
2.1%
Medicare
7.5%
Uninsured
40.1%
1
Medicaid/
SCHIP
35.7%
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
Race/Ethnicity, 2004
African
American
23.4%
White
36.5%
American Indian/
Alaska Native
1.1%
Hispanic/
Latino
35.6%
Asian/Pacific
Islander
3.3%
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,
2004
Ages 65+
7.1%
Ages 45-64
19.4%
Under 5
12.2%
Ages 5-12
13.2%
Ages 13-19
11.7%
Ages 25-44
28.0%
Ages 20-24
8.4%
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
547.8
760,986
2,548.0
2,732,571
1,633.7
8,575.0
50,541.0
N/A
3,842,581
N/A
83,688.2
52,323,834
Dental Hygienists
Mental Health & Substance Abuse
Specialists
Pharmacy
Total Enabling Services#
Other Staff
Total†
* 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%
Percent of Health Centers Providing Select Services Onsite (cont.)*
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.
Patient Visits and Patients by Selected
Primary Diagnoses and Services
Patient
Visits
Medical Conditions
Asthma
773,763
Diabetes mellitus
2,476,613
Hypertension
3,006,082
Heart disease (selected)
556,625
Mental health & substance abuse 3,494,668
Preventive Services
Health supervision ages 0-11*
Selected immunizations#
Pap smear
Mammogram
HIV test
Oral Dental Exams
2,994,513
2,364,496
1,509,973
256,811
425,266
813,324
Patients
418,256
778,628
1,257,930
230,596
N/A
1,764,835
1,610,822
1,333,253
234,083
376,358
631,739
* Well child visits.
# Includes DPT, MMR, oral polio vaccine, influenza, hepatitis B, HIB.
The Future of CHCs
RWHC Eye On Health
Inside
Medicaid
CHCs?
Pay them less.
They grow their
own vegetables.
Health Center Patient Insurance Status and
Revenue By Source, 2004
Grants/Contracts/Other
40.1%
2.1%
43.3%
14.7%
6.2%
6.3%
7.5%
5.7%
Uninsured/Self-Pay
Private
2.2%
Other Public Insurance
Medicare
35.7%
36.4%
Patient Insurance
Status
Health Center Revenue
Medicaid
Percent of Health Center Charges Collected
from Third Party Payers, 1999-2004
100%
91.2%
90%
88.1%
80%
75.0%
70% 73.6%
60%
61.7%
74.9%
Medicaid
89.0%
88.9%
88.9%
73.0%
73.4%
76.5%
87.0%
Other Public
69.6%
72.3%
74.4%
67.5%
Medicare
69.5%
57.7%
Private
57.1%
2003
2004
72.1%
60.7%
60.3%
60.7%
2000
2001
2002
50%
1999
Suggested Reading
Thank You
Questions ?