The community health center (CHC) in the United States is the dominant model for providing integrated primary care and public health services for the low-income and uninsured, and represents one use of federal grant funding as part of the safety net in the country's health care system. The health care safety net can be defined as a group of health centers, hospitals, and providers willing to provide services to the nation's uninsured and underserved population, thus ensuring that comprehensive care is available to all, regardless of income or insurance status. According to the U.S. Census Bureau, 29 million people in the country (9.1% of the population) were uninsured in 2015. Many more Americans lack adequate coverage or access to health care. These groups are sometimes called "underinsured". CHCs represent one method of accessing or receiving health and medical care for both underinsured and uninsured communities.
CHCs are organized as non-profit, clinical care providers that operate under comprehensive federal standards. The two types of clinics that meet CHC requirements are those that receive federal funding under Section 330 of the Public Health Service Act and those that meet all requirements applicable to federally funded health centers and are supported through state and local grants. Both types of CHCs are designated as "Federally Qualified Health Centers" (FQHCs), which grants them special payment rates under Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). To receive Section 330 grant funds, CHCs must meet the following qualifications:
Be located in a federally designated medically under-served area or serve medically under-served populations Provide comprehensive primary care Address many aspects of the patient health through different services (dental, mental health, substance abuses along with other social services) Adjust charges for health services on a sliding fee schedule according to patient income and provide the services to all of the patients regardless of their socioeconomic background and their ability to pay. Be governed by a community board of which a majority of members are patients at the CHC
CHCs place great value in being patient-centered. Uniquely in community health centers, at least 51% of all governing board members must be patients of the clinic. This policy creates interesting implications in terms of how "participatory" CHCs are, as governing board members become directly invested in the quality of the clinic. A sliding fee scale based on income is implemented so that the cost of care is proportionate to the patient's ability to pay. The purpose of these stipulations is to ensure that CHCs are working alongside the community, instead of just serving the community, in order to improve access to care.
Community health centers that receive federal funding through the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services, are also called "Federally Qualified Health Centers". There are now more than 1,250 federally supported FQHCs with more than 8,000 service delivery sites. They are community health centers, migrant health centers, health care for the homeless centers, and public housing primary care centers that deliver primary and preventive health care to more than 20 million people in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin.
History According to historian John Duffy, the concept of community health centers in the United States can be traced to infant milk stations in New York City in 1901. In November, 1914, the city established the first district health center in New York at 206 Madison Avenue, serving 35,000 residents of Manhattan's lower east side. The staff consisted of one medical inspector and three nurses stationed permanently in the district who, through a house card system, developed a complete health record of each family.Duffy, John. In 1915, the system expanded, adding four district centers in Queens. Wartime and political pressures ended this development in New York City, but privately funded clinics through the New York Association for Improving the Condition of the Poor were started in 1916 (Bowling Green Neighborhood Association), 1917 (Columbus Hill Health Center), 1918 (Mulberry Street Health Center) and 1921 (Judson Health Center). Founded by Eleanor A. Campbell in Greenwich Village, the Judson Health Center became the largest health center in the U.S. by 1924.
The official establishment of community health centers was caused by the civil rights movement of the 1960s. The Office of Economic Opportunity (OEO) established what was initially called "neighborhood health centers" as a War on Poverty demonstration program. The aim of these clinics was to provide access points to health and social services to medically under-served and disenfranchised populations. The health centers were intended to serve as a mechanism for community empowerment. Accordingly, federal funds for the clinics went directly to nonprofit, community-level organizations. The health centers were designed and run with extensive community involvement to ensure that they remained responsive to community needs.
Under the modern definition, the first community health center in the United States was the Columbia Point Health Center in Dorchester, Massachusetts, which opened in December 1965. The center was founded by two medical doctors - H. Jack Geiger, who had been on the faculty of Harvard University and later at Tufts University, and Count Gibson, also from Tufts University. Geiger had previously studied the first community health centers and the principles of community-oriented primary care with Sidney Kark and colleagues while serving as a medical student in rural Natal, South Africa. The federal government's Office of Economic Opportunity (OEO) funded the Columbia Point Health Center, which served the poor community living in the Columbia Point Public Housing Projects located on an isolated peninsula far away from Boston City Hospital. On its twenty-fifth anniversary in 1990, the center was rededicated as the Geiger-Gibson Community Health Center and is still in operation.
In 1967, Geiger and Gibson also established a rural community health center, the Tufts-Delta Health Center (now the Delta Health Center), in Mound Bayou, Bolivar County, Mississippi to serve the poverty-stricken Bolivar County. This center was also set up in conjunction with Tufts University with a grant from the OEO. While the Columbia Point Health Center was set in an urban community, the Delta Health Center represented a rural model, and included educational, legal, dietary, and environmental programs in addition to the health services carries out at the center and throughout the county by its public health nurses.Thomas J. Ward Jr., Out in the Rural: A Mississippi Health Center and Its War on Poverty (Oxford University Press, 2017) The war on poverty enlisted many idealistic men, such as Leon Kruger, the first Director of the CHC at Mound Bayou. As a result, many families such as his, were drafted in the war on poverty, often at their own risk.
As the war on poverty expanded, the federal government began to recognize the need for a more organized and sustainable approach to healthcare in underserved areas. With increasing federal involvement and funding from programs like the OEO, the model of community health centers began to take shape, providing critical care to low-income populations. In the early 1970s, the health centers program was transferred to the Department of Health, Education, and Welfare (HEW). The HEW has since become the U.S. Department of Health and Human Services (HHS). Within HHS, the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC) currently administers the program. However, despite the federal backing, funding cuts in the 1970s and 1980s, low reimbursement rates, and political opposition hindered the expansion of CHCs.
By the early 2000s, community health centers (CHCs) were supported by policies from the Centers for Medicare and Medicaid Services, HRSA and the Affordable Care Act. These shifts highlighted the ongoing struggle of community health centers to provide comprehensive care despite funding challenges. In response, community health centers began relying more heavily on Medicaid payments and federal grants set up by Section 330 of the Public Health Service Act. In 2010, the Community Health Center Fund was created by Congress to aid in the expansion of community health centers. Since the 2013 fiscal year, discretionary funding from Congress has flatlined at approximately $1.5 billion but increased to $1.6 billion in 2018 via the Consolidated Appropriations Act of 2018. Funding has increased for CHCs, allowing them to increase their reach, staffing, and the services they can provide. Between 2010 and 2017, the number of operating sites increased by over 4,000, and shares of centers providing mental health services increased by 22%.
Since the Affordable Care Act's expansion of Medicaid, community health centers—and the health care safety net as a whole—have sought to attract newly insured patients facing increased care options in order to remain financially viable.
The evolution of the terminology used to describe what are now called "community health centers" is crucial to understanding their history and how they are contextualized in the United States social safety net. To qualify as FQHC, CHCs receive cost-related reimbursement rates from Medicare or Medicaid, operate as a non-profit, and require a patient-majority community board. CHCs retain their historical commitment to responding to community needs, through mechanisms such as requiring at least 51% of governing board members to be patients at the health center.
Patient demographics Community health centers primarily provide health care to patients who are uninsured or covered by Medicaid. In 2007, almost 40% of all CHC patients lacked insurance, and 35% were Medicaid patients. In 2008, 1,080 CHCs provided comprehensive primary care to more than 17.1 million people. CHC patients typically have low family incomes, live in medically under-served communities, and have complicated health conditions. 70% of CHC patients in 2007 had family incomes of no more than 100% of the federal poverty level; more than 90% of patients had family incomes at or below twice the poverty level. Health center patients are also ethnically diverse. In 2007, half of all CHC patients were minorities, a third of which were Hispanic. All together, CHCs serve one in four low-income, minority residents. CHC patients are more likely to reside in rural areas relative to the rest of the population. They tend to be younger in age and are more likely to be female. In 2008, 36% of all CHC patients were children, and almost three in five patients were female.
Many CHC patients suffer from chronic conditions such as diabetes, asthma, hypertension, or substance abuse. CHC patients are more likely to report these chronic conditions than adults from the national population. Characteristics linked to serious health problems, such as smoking and obesity rates, are also significantly higher in adult CHC patients compared to the general population. High rates of mental health conditions, including depression and anxiety, also contribute to the overall high rates of chronic illness in CHCs. Nonetheless, as of 2016, 91% of CHCs report having met at least one or more of Healthy People 2020 goals.
Immigrants and community health centers