“Health Care Reform and Primary Care – The Growing Importance of the Community Health Center”

1. “Health Care Reform and Primary Care – The Growing Importance of the Community Health Center” Alexis Ponder Noon Ambulatory Conference July 21, 2010

2. INTRODUCTION “After nearly a century of failed attempts, comprehensive health care reform was enacted on March 23, 2010, when President Barak Obama signed the Patient Protection and Affordable Care Act in an attempt to modernize and improve a large part of the health care system.”

3. AFFORDABLE CARE ACT (ACA) • Requires most U.S citizens and legal residents to have insurance • Expands Medicaid to 133% of the federal poverty level ($18,310 in 2009) • Creates state-based American Health Benefit Exchange for which individuals can purchase coverage: • Income between 133-400% of federal poverty level

4. AFFORDABLE CARE ACT (ACA) • Creates separate Exchanges through which small businesses can purchase coverage • Imposes new regulations on health plans in the Exchanges, individual and small group markets

5. BACKGROUND During the debate over U.S. health care reform, relatively little attention was paid to the long-established network of community health centers (CHC), a critical element to reform as its intent is to expand health care through the primary care pathway

6. COMMUNITY HEALTH CENTERS(CHC) • Launched in 1965 by the Office of Economic Opportunity • Colombia Point (Boston) • Mound Bayou (Mississippi) • Designed to reduce or eliminate health disparities that affected racial and ethnic minority groups, the poor, and the uninsured

7. COMMUNITY HEALTH CENTERS • Medical home to 20 million Americans, 5% of the current US population • Federally funded under the authority of the Public Health Service Act • Must meet budget requirements through • fee for services rendered to insured patients • 35% of CHC patients have Medicaid • 25% of CHC patients have Medicare • “pay-as-you-can” (sliding-scale) from uninsured patients

8. Nationwide Distribution of Community Health Center Sites, 2008 Data from the 2008 Uniform Data System, prepared by the Robert Graham Center, Apr 2010.

9. Percentage of the Population of Each State Served by Community Health Centers, 2008 Data on total numbers of CHC patients in each state are from the National Association of Community Health Centers

10. COMMUNITY HEALTH CENTERS • As recently as 2009, the Government Accountability Office reported that 43% of medically underserved areas continue to lack a CHC site • 2008: Congress doubled the annual appropriation to $2.1 billion • 2009: American Recovery and Reinvestment Act (AARA) directed and additional one-time appropriation of $2 billion

11. CHC & PRIMARY CARE • Deliver affordable, comprehensive, coordinated, patient-centered care to those who need it: • Translation and interpretation services • Transportation • Financial Assistance • Multi-disciplinary teams: PCP, behavioral health specialists, dentists, pharmacists, health and nutrition educators, social workers

12. IMPACT OF HEALTH CARE REFORM ON CHC • The Affordable Care Act, with a focus of meeting the primary care needs of an estimated 32 million Americans, enables the CHC to serve ~12 million new patients while adding 15,000providers to their staffs by 2015

13. CHALLENGES FACING CHCs • Increase in uninsured due to economic downturn • Reimbursement policies that undervalue primary care services • Difficulty of securing specialty referrals due to: • Geographic isolation • Increase in specialty providers who choose not to care for the uninsured / Medicaid- or Medicare-sponsored health plans

14. CHALLENGES FACING CHCs Nakela L. Cook, LeRoi S. Hicks, A. James O’Malley, Thomas Keegan, Edward Guadagnoli, and Bruce E. Landon, Access To Specialty Care And Medical Services In Community Health Centers, Health Affairs, Vol 26, Issue 5, 1459-1468

15. CHALLENGES FACING CHCs • Recruiting and retaining providers Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists Bodenheimer, Thomas. “ Primary Care – Will It Survive?” N Engl J Med 355:861-864; Aug 31, 2006 Perspective

16. OPTIMIZING PRIMARY CARE • ACA seeks to address challenges by: • Offering capital for the renewal and expansion of the CHC infrastructure • National Health Service Corps (NHSC) – recruits and places health care professionals in “health professional shortage areas” • Title III grant program ($230 million - 5 yrs) – community based teaching programs • Title VII grant program – development of primary care residency training programs in CHCs • Enhancing the compensation of the PCP • Facilitating the adoption of information technology

17. OPTIMIZING PRIMARY CARE • Incorporating the CHC model into development of patient-centered medical homes (PCMH) • Whole-person orientation • Accessibility • Affordability • High quality care • Accountability

18. REFERENCES • Adashi EY, Geiger HJ, Fine MD. “Health Care Reform and Primary Care- The Growing Importance of the Community Health Center”. N Engl J Med 362:2047, June 3, 2010 Perspective • Bodenheimer, Thomas. “ Primary Care – Will It Survive?” N Engl J Med 355:861-864; Aug 31, 2006 Perspective • “Focus on Health Care Reform”. Kaiser Family Foundation. • Nakela L. Cook, LeRoi S. Hicks, A. James ;Malley, Thomas Keegan, Edward Guadagnoli, and Bruce E. Landon. “ Access To Specialty Care And Medical Services In Community Health Centers”. Health Affairs, Vol 26, Issue 5, 1459-1468 • Orszag Peter R., Emmanuel Ezekial J. “Health Care Reform and Cost Control”. N Engl J Med. www.nejm.org on June 16, 2010 (10.1056/NEJMp1006571). Perspective