Uninsured

REFORM: Sizing up Health Reform with Kristof

Allison Levy — Fri, 13 Nov 2009 20:49:00 -0500

It's no secret that people who lack health insurance have poorer health outcomes. In his column for the New York Times yesterday, Nicholas Kristof (who has been writing a lot about the need for health reform recently) tells the story of Sue, a 31 year old woman from Oregon:

Sue was a single mom who worked hard -- sometimes two jobs at once -- to ensure that her beloved daughter would enjoy a better life.

Sue's jobs never provided health insurance, and Sue felt she couldn't afford to splurge on herself to get gynecological checkups. For more than a dozen years, she never had a Pap smear, although one is recommended annually. Even when Sue began bleeding and suffering abdominal pain, she was reluctant to see a doctor because she didn't know how she would pay the bills.

Finally, Sue sought help from a hospital emergency room, and then from the low-cost public clinic where Dr. Harris works. Dr. Harris found that Sue had advanced cervical cancer. Three months later, she died. Her daughter was 13.

Cervical cancer can be detected early, and treated easily. Nobody has to die from it. Health reform would ensure that people like Sue would have timely access to appropriate screenings and treatment. And it would also prevent children, like Sue's daughter, from growing up without their mom.

"So," Kristoff questions, "where's the best place to spend $100 billion a year?"

If you're not convinced yet -- in an op-ed last week, Kristoff shared another heartbreaking story, sent by e-mail from one of his readers, Linda:

I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn't available to me. I read a comment from someone saying that they didn't want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn't get treatment and that I wasn't worth saving.

Now, Kristof declares, is the moment of truth. (And he was not referring to the apology he owed to Slovenia and its acting general consul, Ms. Melita Gabric, for positioning "the country as a seeming synonym for backwardness" in a few of his New York Times columns bemoaning the fact that on many health measures, the United States lags behind Slovenia.) It looks like Senate action might be delayed next week -- both Reid and the CBO are still working. You know what we think about this issue -- we're still optimistic and hopeful that a bill will be signed by Christmas. And we think Kristoff hopes so too.

QUALITY: More Getting Primary Care From Community Health Centers

Meredith Hughes — Tue, 29 Sep 2009 17:13:00 -0400

A growing number of Americans rely on federally qualified health centers for care, reports The Wall Street Journal. Last year, community health centers, as well as migrant and homeless health centers, served approximately 18 million people. That number is expected to hit 20 million this year, according to the WSJ and the National Association of Community Health Centers.

A disproportionate number of patients seen at the centers live in such low-income or underserved communities as inner cities and rural areas. According to the NACHC, 70 percent live at or below the poverty line. But with unemployment levels high, more middle class, college educated people are falling into the safety net of community heath centers, reports the WSJ. Loudoun County, VA Community Health Center operating chief Stephanie Kenyon told the WSJ the center's waiting list ballooned from 20 to 500 in just a few months.

Support for federally funded health centers (also known as Federally Qualified Health Centers or Community Health Centers) increased both during the Bush administration and more recently in the Obama administration through the American Recovery and Reinvestment Act (better known as the stimulus bill). By the end of the Bush administration, there were about 1,200 clinics nationwide, and this year's stimulus package provided $2 billion in funding to clinics. (That's $1.5 billion for infrastructure and another $500 million for operations -- and it represents a lot of money in the world of community health centers). Under the provisions in the pending House health reform bill, community heath centers could see an additional $38 billion over the next 10 years, although the specifics of the various congressional bills are still in flux.

Both Democrats and Republicans have seen the value of community health centers -- not just for the care they provide to millions who need it, but how they can help contain health costs by providing primary and preventive care in a community setting. According to the NACHC, the clinics save the U.S. health care system billions of dollars every year by providing preventative care that helps patients avoid costly trips to the emergency room. The centers are able to provide patients with comprehensive primary care services, including physical, dental and mental health. Patients pay for the visits based on a sliding scale, anywhere from $0 to $20 to $100 or more. According to the WSJ, the average cost of a visit to the health center in Loudoun County is $145 -- that's a lot cheaper than the national average for trips to the ER, which tend to run about $1,000 for a single visit.

Community health centers can also become a vital component of care coordination and disease management. As we've written before, Denver Health in Colorado has been a model of bringing community health clinics into an integrated system. And they've been a pioneer in the use of health information technology. The network of community health clinics, a 911 ambulance and trauma system, school-based clinics, the local hospital, an HMO, and the county public health department all use health IT and electronic medical records so that doctors can communicate more easily -- with each other and with their patients. That helps them create efficient coordinated care plans, and help patients adhere to their treatments.

Colorado, where community health clinics have been ahead of much of the nation in adopting health IT, also has a program called Connected Care to expand telehealth resources for patients in remote, underserved rural areas. The program, a partnership between the state of Colorado, UnitedHealthcare, Centura Health and the Colorado Rural Health Center, aims to allow health centers and other providers to use timely and efficient electronic information so that clinicians can coordinate care, improve quality, and lower cost.

Community health clinics don't get a lot of attention in our national health care conversation. But with their focus on affordable primary care and chronic disease management, many of these clinics are at the forefront of the move to lower costs while improviding the quality of health care.

COVERAGE: The Uninsured. It Could Be Any of Us

Joanne Kenen — Wed, 23 Sep 2009 21:08:00 -0400

"Every day, 14,000 Americans lose their coverage," President Obama said in his speech to Congress this month, "It can happen to anyone."

An another era, another president might have said, "Ich bin ein uninsured."

A new analysis from the U.S. Treasury shows that it can, and does, happen to anyone.

In a recent 10-year span of relative economic prosperity and job creation (1997-2006) nearly half of all Americans under age 65 were uninsured at some point. More than one in three lacked coverage for at least a year. Looking ahead to another 10-year period including our current time of economic recession and job loss, the picture is even gloomier -- at least in the absence of comprehensive health reform.

The Treasury study found that during the decade:

48 percent are uninsured at some point
41 percent go without coverage for at least six months
36 percent go without coverage for at least one year
32 percent of people who are covered for all 12 months of a given year go without coverage at some point during the following nine years
57 percent of Americans under age 21 are insured at some point
53 percent of Americans in rural areas go without insurance
45 percent of Americans with household incomes between $50,000-$100,000 (ten-year average) go without insurance at some point.

Who are they? Just about anyone. U.S.-born and naturalized citizens. College educated and not. Men and women. Working and unemployed. USA Today took a look at the "five faces" of the uninsured. Here's a snapshot:

The self-employed

They can be like Patrick Bruce, 61, a success in corporate America who went out and started his own business. He went without insurance, briefly -- and had a heart attack and triple bypass surgery. The bills ruined him and he can't afford to spend the $20,000 it would cost to insure someone with his cardiac history. So he goes without insurance -- and without adequate medical care, just hoping he makes it through four more years until he can get Medicare.

"I'm not necessarily a big Obama fan," says Bruce, a self-described lifelong Republican until his heart attack. "But when he was talking (on Sept. 9 to Congress), it was like he was talking to me."

The Unemployed

Single mom Porchia Lewis had a full-time job testing sensors used in Fords, Cadillacs and other cars. She could support herself and her three kids. But the recession sent her hometown of Elkhart, Indiana, reeling. She is now unemployed, and uninsured -- and she's got plenty of company in a community where nearly one in five workers are jobless.

She's studying to retrain for a new career, and her kids got coverage through a state program. But she goes without. She isn't following the Washington debate in close detail but said, "I just want something to happen soon."

The Working Poor

Ratana Lim, a Vietnamese-born, California-raised, U.S. citizen with a degree from UC Berkeley and a full-time job at a company that recently dropped health benefits, earns too much to qualify for any government-run insurance program or clinic, but too little to get covered himself. Insurance would be expensive, as he has a preexisting condition, HIV.

"I don't know how my health is right now," says Lim, who is single and can't afford the drugs that can keep people with HIV healthy for many years. "I haven't even had my teeth cleaned in several years. There are basic needs I haven't met."

"There's a voice inside me that says I need to move to Canada," says Lim, a U.S. citizen. "I also have a sister in France, so I'm thinking about that."

Preexisting Condition

Cindy Shawcross is a 38-year old mother and thyroid cancer survivor. Without insurance, she can't afford the scans and monitoring to make sure the cancer has not returned -- or treat it if it has. She worries about a lump in her breast, but is postponing a mammogram until she finds a place that will give her one for free.

She was in a car accident in July, and lost her job -- and insurance -- soon after. She didn't chose to get sick, to leave her job, to lose coverage. "They (the choices) were made for me."

A Job -- With No More Benefits

As a legal secretary at big law firms, Alexandra Mitchell had a good salary and top-notch health insurance. Two years ago she left her job to take care of a family member, and couldn't afford to buy insurance herself. Nor could she manage to pay the rates available to her when she got a temp job at a small business. Healthy and in her 40s, she didn't worry too much about a temporary lapse. Then the recession hit, and when she returned to Dallas she could not get another good legal job. After months of looking and temping, she got a job -- and a salary cut and no health insurance.

"This isn't just happening to poor and/or uneducated people," she says. "It is happening to middle-income people by the millions.

The only thing they had in common -- they deserved better. With health reform, they can get it.

HEALTH CARE: The AARP Tries to Soothe Fears of Medi-Scared Seniors

Joanne Kenen — Fri, 04 Sep 2009 14:16:00 -0400

One of the great ironies of the health reform debate is that one of the groups that is most apprehensive about the drive to cover all Americans is the group that is already covered -- America's seniors. The AARP is gearing up its efforts to soothe their fears.

Another great irony is that the Republicans now casting themselves as the defenders of Medicare have for years pursued one version after another of radically changing the very nature of Medicare -- most recently, as Ron Brownstein in the National Journal pointed out, by voting for a House GOP budget this year that would have replaced Medicare's guarantees of coverage for the elderly and disabled with a voucher.

Here's the real story that the AARP wants to get out: All Americans age 65 and up are covered by Medicare, and that won't change under health reform.

The changes being put forward in current health reform proposals are trying to do things like help more seniors pay for their medications and provide them with more access, at more affordable rates, to preventive care and screenings. They're trying to get seniors better coordinated care and better primary care so they won't have to go from one specialist to another without anyone keeping track of the whole patient. They're focusing on follow-up care and discharge planning for seniors when they're are hospitalized, so they don't bounce right back into the hospital.

With reform, doctors and hospitals will have incentives to provide better quality care, not just better quantity care. And that will save the system money -- which is essential because without changes Medicare's hospital trust fund will run out of money in less than 10 years. Meaning it will be there for today's beneficiaries and tomorrow's -- including those 50-64 year olds who now pay an awful lot for their health coverage, if they can get it at all.

But that's not what many seniors heard in the shouting this summer. After all, the chairman of the Republican National Committee, Michael Steele, told them health reform means rationing and bureaucracy and "less power to control their own medical decisions." He twisted the goal of comparative effectiveness research -- to find out what drugs and treatments actually work best -- and turned into something that would morph into "government boards rationing treatments based on age." Throw in the "death panels" and it's no wonder that some seniors panicked.

So the AARP is going to try to set them straight. You may have heard that the organization had lost 60,000 members over health reform. USA Today reports that in that same period, the organization (which is more than 40 million strong) also signed up 400,000 new members. So maybe not all seniors are scared...

Steps the AARP is taking include:

A post-Labor Day direct-mail blast -- 8 million letters -- about health reform and Medicare.
The September AARP Bulletin has stories debunking health care myths.
Town hall forums and tele-town halls will address concerns and misunderstandings about health reform proposals from the White House and Congress.
National TV and Web ads. A multimillion-dollar ad campaign, which started in mid-August, will continue through Sept. 14, and plans are underway for a second set of ads to run this fall.

"There's clearly been an effort to scare people," USA Today quoted legislative director David Certner, referring to incorrect warnings issued by some Republicans, including former Alaska governor Sarah Palin, of "death panels" that would cut off care for the elderly. "We've been spending a lot of time trying to dispel the myths. I think it has derailed the debate."

Remember that the Republicans who now call themselves the defenders of Medicare initially opposed its creation. More recently, in the past 10-15 years, they have championed "withering away" of Medicare, privatization of Medicare, more managed care for Medicare, and far deeper spending cuts in shorter time spans than the Obama administration proposes. (Spending cuts, in this context, doesn't mean that we'd be spending less than we spend now. We will be spending more... but the increase will be more gradual, adding fiscal life to the program.)

If the official facts and figures don't convince you, maybe the voices of real people will. The AARP has maps and story banks. Click around. They speak for themselves:

Dorothy P, from Austin, Texas, wrote:

I AM A 52 YEAR OLD GRANDMA WHO WORKS BUT BARELY MAKE ENOUGH TO COVER MY BILLS FROM PAYDAY TO PAYDAY MUCH LESS CAN AFFORD MEDICAL INSURANCE. I HAVE COPD, 5 HERNEIATED DISKS, DDD, DJD, SEVERE ARTHRITIS AND A DEFORMED BACK BONE FROM BIRTH. YES, I COULD CERTAINLY USE HEALTH CARE NOW! I ALSO HAVING MISSING FRONT TEETH THAT PREVENT ME FROM GETTING A BETTER JOB BUT DENTALS COSTS ARE WAY OUT OF THE QUESTION!

Or Toni F, from Madisonville, Tennessee:

Both my husband and I are 60 years old. At age 53 I had one stint placed in my heart. He had pre-hypertension. We both were in extremely high stressed positions. We made a life choice to change everything about the way we lived. We moved from Louisiana to a small country setting in beautiful east Tennessee. We both have lost weight, grow our own chemical and pesticide free fruits, vegs., eggs and goat milk, work in very low stress positions. HOWEVER, most small companies in east TN don't provide healthcare insurance. Because of our earlier health issues, we both are classified as "uninsurable". We currently are on a 2 person group policy for as long as the small company I'm working for keeps their doors open. Our deductible is $10,000 and our premiums take 2/3 of our paychecks. The health clinics here are understaffed and what staff they do have, are poorly trained and unprofessional. Most critical of all, most don't have a RN on staff. We do not use food stamps, or any other government assistance (except unemployment when my husband can not find work (due to lack of work in the area and his age -- yes -- there is unrecognized discrimination) We have never been healthier or happier -- we just need affordable insurance so that we WON'T have to go onto government assistance. We want to take care of ourselves, and have need of affordable health insurance. We don't even have regualar checkups -- we can't afford it! Won't you please make this your first priority? Affordable healthcare for the elderly.

Or David P, from Myrtle Beach, South Carolina:

I am 53 years old disabled with cervical disk diesese and lukemia. I am not insured and not able to have any treatments. I cannot afford a health plan and my wifes employer does not offer health insurance. My Dr wants to start treatments but I cannot afford the hospital costs or medications. I worked all my life and provided health ins for my family, paid my taxes to the government and now I have no where to turn for help when I need it..It doesn't seem right!

So when you hear foes of reform telling you that it's going to hurt Americans who have worked hard their whole lives -- tell them, they are already hurting. They don't need politics and rhetoric. They need help.

COVERAGE: Russian Roulette in Rural America

Alex Mazerov — Tue, 16 Jun 2009 13:41:00 -0400

"If anything were to happen to my wife and I, the business is sunk," Larry Harbour, a small business owner in rural Nebraska, told NPR. "It's like playing Russian roulette. Every day, we wonder when it's going to happen — if something's going to happen, are we able to afford it?"

Like millions of other uninsured and underinsured Americans, many of whom live in rural areas and have difficulty obtaining affordable and reliable coverage, Harbour and his family are one serious illness, one accident, away from financial calamity.

In the Harbour family’s case, the only health insurance plans he and his wife could find had premiums ranging from $24,000 to $40,000, on top of a $2,000 deductible. The cost was simply too great.

He said the insurance he and his wife investigated was basic, to the point where the couple would have to pay more for the insurance than they would for the health care they'd receive.

"It's unaffordable for me, especially being a small business owner, because I don't have a certain amount of employees to be able to get a better rate," Harbour said.

The Harbours’ situation is not a unique one in rural America, where half of all jobs are provided by small businesses. Small employers are at a severe disadvantage when it comes to securing affordable rates from insurers, in part because risks can't be pooled in a large group. Workers at small businesses are twice as likely to be uninsured as other workers, according to Jon Bailey of the Center for Rural Affairs, based in Lyons, Nebraska.

In addition, farmers and ranchers, many of whom are self-employed, make up a sizable block of the rural population. One-third of farmers and ranchers are dependent on individual health insurance policies, four times the national average. Plans from the individual market often provide less coverage at a higher cost, according to Bailey, who co-authored a report released in April entitled, “The Causes and Consequences of the Rural Uninsured and Underinsured.”

Individual insurance policies in rural areas are more expensive for a number of reasons.

The costs are higher because of the nature of individual insurance. There isn't a large group to spread risk. And the rural population trends older and sicker, according to studies quoted by Bailey. There is also less access to health care in rural places, he added. On top of that, farming and ranching are considered risky professions.

The high cost of insurance in rural America puts reliable health care coverage out of the reach of many families like the Harbours.

"We can put people on the moon," said Linus Solberg, an Iowa farmer. "We can go up and fix this Hubble satellite that we have up there. And we can't have health care for all these people. It's ridiculous."

COVERAGE: Uninsured Shift Costs onto Insured, Families USA Finds

Kyle Noonan — Thu, 28 May 2009 16:17:00 -0400

Families USA has released a report describing the costs to the insured that result from uninsured people who are unable to pay their bills. The report, entitled "Hidden Health Tax: Americans Pay a Premium," analyzes the cost-shift from the unpaid medical bills of the uninsured to those Americans with health insurance.

Key findings of the Families USA report:

The uninsured end up paying over a third of their medical bills out of pocket. Governments and charities pick up another quarter of the cost.
The remaining 37 percent of the cost of the medical bills for the uninsured, or a stunning $42 billion, went unpaid in 2007.
That unpaid portion is passed on by providers to private insurers, who pass the cost on to the insured.

Families USA estimates that the average American family pays over $1,000 a year in higher health insurance premiums due to this cost-shift. (For an individual purchasing in the individual market, it's about $368.)The Center for American Progress found similar figures in a report earlier this year.

This cost-shift has intensified in recent years, the report states, as more people lose their health insurance. Without comprehensive health reform, it's also expected to continue to worsen.

HEALTH REFORM: More Costs of Doing Nothing

Joanne Kenen — Thu, 21 May 2009 18:59:00 -0400

Nearly 66 million people, including many middle class families, could be uninsured a decade from now if we don't reform health care. That's the unhappy conclusion of a new report from the Robert Wood Johnson Foundation (RWJF) and the Urban Institute.

We at New America have done quite a bit of work on the cost of doing nothing. The new RWJF research paints a similarly worrisome picture of rising costs burdening families, taxpayers and businesses, more uncompensated care stressing the safety net, and more Americans lacking insurance.

The researchers used three economic scenarios. Even the best case (and we are not living in 'best case' times) showed serious strains.

"This report makes clear that as battered as our health system has been in recent years, unless we take action, the worst is far from over," RWJF president and CEO Risa Lavizzo-Mourey, M.D., M.B.A., said in a statement. "Without comprehensive health care reform, costs will continue to skyrocket, millions more will lose insurance, and the health of Americans will suffer. Congress must act quickly and decisively to make quality

Key findings:

Individuals and families would see health care costs dramatically increase, by 46 (best case) to 68 percent (worst case)
Businesses could see their health care costs double within 10 years, leading to a significant drop in the number of people getting health care insurance through their workplace.
Spending on government insurance programs such as Medicaid could double as enrollment surges.
Millions more people would be uninsured: 53 million in the best case (and some estimates are that we are already close to that) to 65.7 million in the worst case.
The amount of uncompensated care in the health system would increase—possibly doubling.

Hardest hit: people of moderate means. Too well off to qualify for public coverage, but not able to afford private alternatives.

So the cost of doing nothing continues to mount. Luckily there are strong signs that Congress has recognized the need to do not just something, but something big and bold.

COVERAGE: The Working (and Formerly-Working) Uninsured

Kyle Noonan — Thu, 07 May 2009 16:00:00 -0400

Fifty-two million—and rising? Is that the real count of the uninsured in the United States in this job-killing recession? It's the latest estimate from the North Carolina Institute of Medicine. And 52 million was the number for January, and unemployment rhas risen since then, hitting 8.5 percent in March. (April numbers are due out in a few days.)

The official US census figures are 46 million uninsured, but there's always a lag (it takes a long time to count 46 million people, even longer to count 52).

The North Carolina report was brought to our attention this week by the Center for American Progress, which looked at the uninsured in each state. As we know (even if there are wide misperceptions about this among the public) most uninsured people are not unemployed. They are the working poor or dependents of the working poor -- although nowadays of course more of them are losing their health coverage as they lose their job.

CAP's state by state data shows that in every state, the majority of uninsured adults are employed. In several states, including Maine, Montana, and Kansas, more than two-thirds are employed.

CAP reminds us that the status quo isn't working. The employer-sponsored insurance system still covers millions of people at big businesses, but those who are self employed, who work in service industries, and in small businesses are less and less likely to get health insurance on the job—or to be able to afford their share of the costs if it is offered. Without reform, the strains will keep growing in a time of deep recession and rapidly escalating health care costs.

In a separate report mapping uninsurance rates in the states, CAP found an overall 13-percent jump since 2007,the largest two-year leap since the last effort at national health reform in 1994. As the CAP report says:

What's more, these numbers are undoubtedly worse today due to deteriorated economic conditions and rising national and state unemployment rates since January.

It's important to point out that the national average increase obscures the unprecedented increase that some states have seen over the last two years, including a 22-percent increase in North Carolina, and Indiana, and a 21-percent increase in Nevada. Approximately 890,000 more people are uninsured in California, 551,000 more people are uninsured in Texas, and 506,000 more people are uninsured in Florida than in 2007.

Kaiser Family Foundation calculates that every one percent increase in unemployment leads to an additional 1.1 million uninsured and another 1 million added to the Medicaid and SCHIP ranks (assuming eligibility doesn't change). The recession cuts deeper than that, though, because many businesses that offer insurance to employees are cutting back or eliminating the benefit. As CAP reports, the percentage of Americans who receive their insurance through an employer has declined from 67 to 63 percent in a decade. Employers will probably continue to cut insurance benefits (and retirement contributions) as the recession wears on. We may not have even seen the worst yet; most employers have year-long contracts with health plans, and we may see more of them letting coverage lapse as they try to protect what they can of their bottom line.

IN THE STATES: Colorado Expands Coverage and Hospital Care

Joanne Kenen — Thu, 23 Apr 2009 20:41:00 -0400

In what's been hailed as the most significant health legislation in Colorado in some 40 years, Colorado has a new law that will help cover up to 100,000 uninsured people and reduce some of the uncompensated care and cost-shifting that hurts the state's health care system and raises costs for people who are insured. It's an impressive achievement in a time of great economic pressure—one that we hope the folks here in Washington notice.

"At no increased cost to taxpayers, the Colorado Healthcare Affordability Act will allow us to provide critical health services to people who need those services the most," Gov. Bill Ritter said in a statement when he signed it into law earlier this week.

The law needs to get final approval from federal Medicaid officials. The goal is to implement it next spring. Ritter said that the law will provide coverage to about 100,000 and improve access to hospital care for the other 700,000 uninsured. (Colorado had an estimated 800,000 uninsured in 2007, that figure may be rising because of the job losses of the recession.)

The new law will devote $1.2 billion—an estimated $600 million each from hospital provider fees and federal Medicaid matching funds—to support health care for low income people on Medicaid and the state's children's health insurance program. Hospitals will get better reimbursements for treating patients on Medicaid and the Colorado Indigent Care Program (CICP).

Denver's Channel 7 reported that the law garnered bipartisan support during months of negotiations, in part because it will keep health care costs down. When the uninsured get coverage, they get better access to doctors, keeping them out of emergency rooms.

"The most expensive place to treat someone is in the emergency room," Steven Summer, President and CEO of the Colorado Hospital Association, told the station. "What happens is (uninsured patients) go there because they don't have a physician."

QUALITY: Community Health Centers Fill Unmet Needs -- Better Than You Might Think

Joanne Kenen — Fri, 06 Mar 2009 18:37:00 -0500

Community health centers (Federally Qualified Health Centers) are an aspect of the recently enacted fiscal stimulus package that hasn't gotten much attention. Perhaps that's because they mostly serve a population we often overlook. Perhaps that's because they are misunderstood—and underestimated.

President Obama earlier this month described his vision for their growth:

These health centers will expand access to care by helping people in need, many with no health insurance, obtain access to comprehensive primary and preventive healthcare services...That helps relieve the burden on emergency rooms across the country, which have become primary care clinics for too many who lack coverage, often at taxpayer expense.

The stimulus package provides $2 billion to the clinics—$1.5 billion for infrastructure and another $500 million for operations. That's a whole lot of money in the world of community clinics. They currently serve 16–18 million people (depending on which authoritative source you ask), in medically underserved inner cities and rural areas, and that will now grow. Other stimulus legislation provisions, involving primary care workforce development, Medicaid and health IT funds, as well as the recent expansion of the State Children's Health Insurance Program, will also expand resources available to the clinics. The money is particularly welcome, advocates say, because the clinics are trying to meet rising demand as more people become uninsured during the recession.

Governed by community boards that include patients, the clinics provide primary care, as well as education and related support services. Dental and behavioral health care are in high demand. The clinics take all comers, with sliding payment scales. In 2007, about one-in-three patients were children and teens. About 40 percent of the patients were uninsured in recent years; that's rising. Blacks and Hispanics were disproportionately represented. The clinics are also a key source of care for the homeless and for migrant workers.

Those facts and figures might be expected. What could be more surprising for anyone who doesn't know much about CHCs is that they can teach the rest of the country a thing or two about how to provide cost-effective primary care, according to presentations at a recent briefing sponsored by the Alliance for Health Reform, United Health Foundation and the National Association of Community Health Centers.

The best of the community health centers (and nobody would argue that they are all "the best", just as not all of the clinics and practices serving affluent and better-insured Americans are "the best") are already providing the kind of patient-centered primary care that the rest of the country is talking about moving toward.

Paloma Hernandez, the CEO of Urban Health Plans, an organization serving the South Bronx and New York City, says her clinics are more than a "medical home." They are a "health home." She told the Alliance briefing:

Urban Health Plan has been in existence since 1974. It was founded by a physician who happens to be my father who started out as a private practitioner on one corner, worked there as a solo practitioner before Medicaid and Medicare was enacted, moved over into a group practice, and in 1974, we became Urban Health Plan. ...He grew up in the community, has been a part of the community for 70 years. So we have 35 years of service to the South Bronx community.

We have currently four primary care sites. We have built our latest, which was built about eight years ago, it is a 40,000-square foot facility that no one ever thought we would fill. In eight years that we've been opened, we've had 110-percent growth in our visits.

We are currently expanding into another borough in Queens. We have five school health programs, four sites at homeless shelters, adult day treatment programs, and in dental clinic and in a boys and girls club. We also have a large support services site that houses our WIC program, community health worker program and that sort of program.

We have a health literacy site... the attempt is really to reduce health disparities by increasing health literacy. We predominantly serve a Latino population and we provide a broad array of services from primary specialty care, diagnostic services, and support services. We have been fully implemented with our electronic health record since September of 2006. What this has done for us is it actually has increased productivity. It has increased our ability to document properly and it's increased our efficiency overall.

Lastly, we are an economic engine in our community. We employ over 400 people, many of whom come, get trained and move on to other jobs and that's great. We understand that that's part of the mission that we also provide. ...These are some of the components that make up a medical home and health centers really believe that they're not necessarily a medical home but more so a health care home because of the type of services that we provide. We provide not only primary care but dental care, behavioral health services.

So when you look at us, it's a place where people come and get a continuum of services that address not only their primary health care needs but deal with the person as a whole.

Sara Rosenbaum and health care research colleagues at George Washinton University have found that CHCs by several measures outperform other settings in providing preventive health care for medically vulnerable and high risk populations. The private sector is taking note. According to Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group, commercial insurers would be wise to bring more health centers into their networks. "In our United Health Care business, we are doing that. We're trying to make sure that every [nearby] community health center ... is enrolled in the network there. Also because we know that community health centers provide such good quality care and especially for certain patients, it's the ideal place to be because of the expertise that they have in managing some of the more comprehensive and complex problems where disease is comingled with socioeconomic challenges."

Community health centers can help build the primary care workforce. Young physicians who rotate through community clinics during their training often choose to become primary care doctors, Tuckson said, a trend that can be built upon with the right loan forgiveness and training opportunities. As the NACHC's Dan Hawkins said, the bottom line of solving the workforce problem "is going to be to 'grow our own.'"

BTW, Obama's appointment of Mary Wakefield as the next administrator of Health Resources Services Administration has been warmly welcomed, both because as a nurse-policymaker she understands care from the inside-out and because of her insights and experience in rural healthcare.