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

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The History, Evolution, Current Status and Issues
of Community Health CentersMichael E.
Samuels, Dr.P.H.Distinguished Scholar and
Endowed Chair in Rural Health PolicyCenter of
Excellence in Rural HealthUniversity of Kentucky
College of MedicineDepartment of Health
Services Policy and ManagementArnold School of
Public HealthUniversity of South
CarolinaMcKissick LibrarySeptember 20,
2005Columbia, SC
Rural Health Grand Rounds
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History
1854
John Snow, MD (1813-1858)
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Medicare/Medicaid Signed Into Law
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The only thing new is the history you havent
read President Harry S. Truman
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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.

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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

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CHC Traditions
Medical Care (Individual)
Public Health (Group)
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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.

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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 2237-40

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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,
  1890s Buick, the Doctors Car

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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 lt200, 1900 gt 4,000, 1920 gt6,000.
• 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

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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

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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

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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

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Community Health Centers 1965 - Present
Lyndon Baines Johnson 196369
Richard Milhous Nixon 196974
Gerald Rudolph Ford 197477
Jimmy Carter 197781
George Walker Bush 2001
Ronald Wilson Reagan 198189
George H. W. Bush 198993
Bill Clinton 19932001
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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.
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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.
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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 famil
y health care workers health
education social advocacy (housing,
welfare).
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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.

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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.
•  

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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
• 1968 - PHS 314e (Phil Lee) Yellow berets

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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

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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

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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

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CHCs 2004
914 Grantees (51 Rural) 5,502 Service Delivery
Sites 13,127,811 Patients
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HC
HC
HC

Source 2003 UDS data.
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Health Center Patients By Income Level, 2004
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
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Health Center Patients By Insurance Status, 2004
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
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Health Center Patients By Race/Ethnicity, 2004
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
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Health Center Patients By Age, 2004
Note Percents may not total 100 due to
rounding. Source Bureau of Primary Health
Care, HRSA, DHHS, 2004 Uniform Data System
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United States, 2004 Health Center Staff and
Related Patient Visits
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Percent of Health Centers Providing Select
Services Onsite
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Percent of Health Centers Providing Select
Services Onsite (cont.)
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Patient Visits and Patients by Selected Primary
Diagnoses and Services

• Patient Patients
• Visits
• Medical Conditions
• Asthma 773,763 418,256
• Diabetes mellitus 2,476,613
  778,628
• Hypertension 3,006,082
  1,257,930
• Heart disease (selected) 556,625 230,596
• Mental health substance abuse 3,494,668
  N/A
• Preventive Services
• Health supervision ages 0-11 2,994,513
  1,764,835
• Selected immunizations 2,364,496
  1,610,822
• Pap smear 1,509,973
  1,333,253
• Mammogram 256,811
  234,083
• HIV test 425,266
  376,358
• Oral Dental Exams 813,324 631,739
• Well child visits.

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The Future of CHCs
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Health Center Patient Insurance Status and
Revenue By Source, 2004
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Percent of Health Center Charges Collected from
Third Party Payers, 1999-2004
Medicaid
Other Public
Medicare
Private
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Suggested Reading
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Thank YouQuestions ?