By Richard Kovar, MD - Community Clinic Physician
Editor's Note: According to the Washington Association of Community Health, community and migrant health centers in Washington serve more than 1,092,000 residents at over 300 clinic sites, offering primary, preventive and supportive health services. These clinics are directed by local consumers and respond to the needs of the community, serving all without regard to economic or insurance status.
As the US. continues to struggle with healthcare reform, it is vitally important to prioritize the central role of our nation’s community health centers (otherwise known as Federally Qualified Health Centers (FQHCs) and ensure they are not weakened in the process. As the African expression goes, “when elephants dance, the grass gets trampled." The debate regarding Medicare For All brings to the surface the simmering question of whether the FQHCs are a central part of the solution or a 50-year old finger in the dike. I believe it is strongly the former and there must be a win-win going forward.
FQHCs are community-based health centers that serve all people regardless of their zip code or insurance status. They are one of the few federally supported programs that have survived from President Johnson’s War on Poverty in the 1960s. From the original two demonstration projects in 1965, they now provide the medical home for some 28 million people in nearly 11,000 communities with 1400 organizations. Historically, most of these communities were ignored by traditional health care systems. They all have patient majority boards of directors. That comes to around 35,000 board members who along with their 160,000 health care professionals will need to be convinced that whatever reform we come up with is in their organization and community’s best interest.
FQHCs are by far the largest and most successful primary care system in the U.S., they are located in all 50 states and territories. They specialize in caring for the most vulnerable people in their communities and provide care to people challenged by housing and food insecurity, unemployment, chemical dependency, and language and transportation barriers. While emphasizing prevention, they usually care for sicker, more challenging patients and once connected to care, outcomes are as good or better than the private sector. They value and depend on public/ private partnerships and routinely measure their quality outcomes and cost effectiveness.
It is important to note that FQHCs are successful in large part due to the social or “wrap around” services they provide in the form of multidisciplinary teams. Most integrate medical care with behavioral health and dental care and collaborate closely between these services. There are so many examples that could be described but let’s take the case of diabetes, a disease on track to affect one out of three Americans in the next few decades if we don’t figure out how to change our lifestyles. A diabetic patient at a FQHC will receive medical management of their disease that is held to an accountable standard of national guidelines. They are also likely to see a diabetes educator, nutritionist, behavioral health specialist and perhaps a community health worker to try to address some of the socioeconomic disparities that worsen their disease. If they need help with transportation or interpretation in their primary language, that is available. Insurance eligibility and connection to housing support services are usually available. Dental care at the center is frequently the service that improves their diabetes control. Collaboration with local community social services is highly prioritized.
Or consider the example of obstetrical services. All pregnant women are immediately screened for modifiable risk factors, entered into prenatal care in the first trimester, seen by a nutritionist and nurse coordinator and when needed, provided assistance with transportation to appointments, translation, chemical dependency service, mental health support and evaluation and preventive dental care. The incidence of low birth weight babies is considerably lower in health centers than in other systems of care.
At my health center we have a program caring for around 500 people living with HIV disease. The providers who care for these folks are very good, but the case managers and specialized HIV nurses are even better. We are able to document extraordinary quality of care, address comorbidities as well as retain people in care and control the infection at much higher rates than national averages. Only two people have died of HIV disease in the last 13 years and both would not take their medications. Again, I credit our outcomes to the team-based care model.There are many other conditions treated by FQHC multidisciplinary teams and they are unique to the community needing those services. Whether it is caring for rural farmworkers, homeless individuals or families, prevention of HIV disease, mental illness, treatment of hepatitis C, or opiate use disorder (to name a few), these challenges often require multiple team members to address complex needs that come along with the health disparities of poverty.