Health centers grow, but gaps remain (Gannet News)

By Larry Wheeler
Gannett News Service

Americans are used to hearing bad news about their health care system -- that millions of people lack health insurance and medical costs are spinning out of control.

But amid those trends is evidence that a vital and often overlooked health care safety net is performing effectively and efficiently.

That national network of 952 federally approved community health centers -- including six in Vermont -- serves more than 14 million poor and uninsured patients who otherwise might go without prenatal care, cancer screenings, diabetes treatment and a long list of other services.

"I have no idea where else I would go for health care," said Shirley Dorsey, 51, a patient at Baltimore Medical System's health center. "It's important to have some place where poor people who don't have insurance can come and not be afraid of being turned away."

Since 2000, the Bush administration and Congress have nearly doubled annual spending on community health centers, to almost $2 billion. That's the largest increase in the history of the public health program, born during the 1960s War on Poverty.

Over the same period, the number of centers has increased by more than 200 and the number of patients they treat has risen by 4.5 million, or 53 percent.

The centers, located in areas deemed medically underserved, rely heavily on Medicaid payments and federal grants and must meet a number of requirements to qualify for federal funding. Most of their patients are minorities, with Hispanics far outpacing other racial and ethnic groups in growth.

Since 2000, the number of Hispanic patients has surged to 4.8 million, a 52 percent increase. How many of those patients are in the country illegally isn't known. Community health centers are required to treat everyone, regardless of ability to pay or immigration status.

Taxpayer-subsidized services for illegal immigrants is a focus of contentious debate nationwide. Community health centers appear to have escaped the controversy, perhaps because much of their care is delivered to pregnant women and newborns.

By fall, an additional 120 health centers in high-poverty counties will get federal startup grants.

"We've been able to make health centers available to a lot more people in places that have never had health centers," said Elizabeth Duke, administrator of the Health Resources and Services Administration. "In the very best sense, (this) is what's right about America."

Studies show community health centers are more cost-effective than other treatment options. But rising demand for their services underscores their limitations.

The number of people treated at community health centers represents less than a third of those who need such services, according to the National Association of Community Health Centers.

Demand far exceeds the number of available doctors.

"We're looking for clinicians to work in our centers and we can't find them," said Alvin Jackson, director of the Ohio Department of Health and former medical director of Community Health Services in Fremont, Ohio. "It's a tragedy."

The centers focus on preventive care and don't offer surgery or specialty care for heart disease, cancer or other serious problems.

"We oftentimes have clinicians who, frankly, beg specialists to take on patients," said internist and pediatrician Kyu Rhee, chief medical officer for Baltimore Medical System.

Help wanted

About 56 million people, including many with health insurance, live in places where there are acute shortages of primary care physicians and little prospect for improvement, according to the National Association of Community Health Centers.

Without a community health center, they lack clear options for treating problems -- such as an infected tooth or high blood pressure -- that can develop into more serious conditions.

"The toll of unmet health care needs among these health care have-nots is incalculable, and the tragic outcomes they experience are appalling," Joseph Feaster, a board member of the Whittier Street Community Health Center in Boston said at a congressional briefing this spring.

Family practitioners, pediatricians and obstetrician-gynecologists are in short supply, especially in urban neighborhoods and rural towns where the centers are located.

There are more than 2,500 clinical vacancies at community health centers across the country, according to the National Health Service Corps. It offers grants, scholarships and student loan repayments to those who agree to work in medically underserved settings.

The number of doctors, dentists and other medical professionals employed at community health centers through the corps has increased by 74 percent since 2002, but that hasn't been enough.

Some of the reasons have to do with money.

Funding for the National Health Service Corps, a vital source of medical professionals for community health centers, has not kept pace with the growing need.

Because community health centers depend so heavily on federal, state and local government money -- and to a lesser extent on grants from hospitals and charities -- doctors at the centers make less than they would in private practice.

And fewer medical school graduates are choosing to go into primary care, one of the lowest-paying disciplines.

Those who choose to work at a health center say they're motivated by a sense of public service.

"During residency, I realized I didn't necessarily like taking care of the worried well," said Jessica Osborn, medical director of the school-based health program at Baltimore Medical System. "You see where there's need and I don't know that you can actually turn your back."

Focus on efficiency

Despite their problems finding doctors, community health centers deliver better continuity of care than private physicians or hospital outpatient facilities, according to a 2000 study published in the Journal of the American Medical Association.

Other studies show community health centers can outperform private physicians, hospitals and emergency rooms in price, quality of care and efficiency.

The centers give expectant mothers greater access to prenatal care, increase childhood vaccinations, lower infant mortality rates and improve the prognosis of patients living with chronic conditions such as diabetes and high blood pressure.

Health centers also reduce the disease gap between whites and minority populations.

African-American women who receive care at community health centers, for example, deliver significantly fewer low-birth-weight babies than the national average, according to a 2004 analysis published in the Journal of Public Health Policy.

Patients at community health centers also are less likely to use a hospital emergency room for nonemergency treatment, saving money for hospitals and patients.

A 2001 study of 50,000 Medicaid beneficiaries concluded that patients who got most of their care at community health centers were significantly less likely than other patients to be hospitalized or seek emergency room care.

"Emergency rooms all over the country are providing too much primary care," said David Sjoberg, vice president of strategic services for the Baptist Health Care hospital system in Pensacola, Fla. "You have people coming in sick because they have not taken their insulin, people with the flu. Instead of going to a $40 primary care visit at a health care center, they're spending $1,500 to $3,000 to get treated in an emergency room."

Contact Larry Wheeler at

THE CLIENTELE About 40 percent of people who seek treatment at community health centers have no health insurance. Two-thirds are racial and ethnic minorities. Health center patients are predominantly female, relatively young, and about 70 percent have family incomes below the federal poverty level of $20,650 for a family of four. About the same number of patients are treated at health centers in rural communities and urban neighborhoods, according to the National Association of Community Health Centers. ON THE WEB National Association of Community Health Centers Inc.: National Health Service Corps: Baltimore Medical System: Health Resources and Services Administration: