This chapter is dedicated to the life and memory of Senator Edward M. Kennedy (1932-2009), who was the legislative “father” of the community health center program in 1966 and its most steadfast and eloquent champion for the rest of his life.
In 2010, there were more than 1200 community health centers (CHCs) serving more than 20 million people at 8000 clinical sites all over the United States (National Association of Community Health Centers, 2010a). These programs provide medical, dental, mental health, and substance abuse services, nutrition counseling, outreach, transportation, and other social services to uninsured patients as well as those with Medicaid, Medicare, Children’s Health Insurance Program (CHIP), and even private health insurance. Community health centers also include programs serving migrant workers and the homeless.
CHCs are located in areas designated by the federal government as medically underserved and provide care without regard to insurance status or ability to pay. They are primarily funded by a mix of public insurance and federal grants. Patients served by CHCs are poorer, sicker, and much more likely to live in a rural area and to be persons of color than the general U.S. population (National Association of Community Health Centers, 2010a).
CHCs are unique health service institutions in several important ways. First, they are a community-oriented, culturally sensitive model of health care services integrated with social and educational services. Second, they are governed by consumer boards that by federal law must have a majority of members who are patients at the health center. Third, they are “safety net providers,” caring for people who do not have health insurance.
These health care institutions were first funded as “neighborhood health centers” as part of the War on Poverty in 1965, one aspect of President Lyndon B. Johnson’s Great Society program. They were created by activist physicians and federal government officials—“policy entrepreneurs”—who believed that disparities in health status were intimately linked to social, economic, and political inequalities. Health centers were to treat whole communities, not just individuals, and to provide jobs as well as health services. Although these programs were products of the policy environment of the 1960s, they survived the end of the War on Poverty and subsequent political challenges during the more conservative Nixon and Reagan Administrations. Not only did they overcome these challenges, but they became institutionalized as part of the federally funded health care system. In fact, health centers were the only domestic social program (other than abstinence-only health education) that was expanded during President George W. Bush’s tenure in office.
The policy history of the CHC program explains how a program providing care to communities with very few political resources and therefore little political influence was able to survive and grow in an era in which less and less attention was paid to problems such as poverty and inequality. This occurred because supporters within federal executive agencies and Congress nurtured the program during its first decade until an effective national advocacy organization was built. This national organization, its state partners, and local health centers then successfully created broad support for health centers that is bipartisan and exists across ideological boundaries. The story of the survival of the CHC program is a story about the creation of a “policy network” supportive of CHCs. The story of its expansion is a tale of skilled policy advocates who have been able to frame the argument for health center funding in a way that fits within a political environment vastly different from the one in which it was born.
The Creation of the Neighborhood Health Center Program
The first neighborhood health centers were funded in 1965 as demonstration programs by the Community Action Program established by the Economic Opportunity Act (EOA) of 1964. The goal of this legislation was to eliminate the causes of poverty in the United States. Health was not initially one of the areas in which programs were to be established, but early on it became clear that participants in the educational and training programs that were established (e.g., Head Start and the Jobs Corps) suffered from lack of access to health care. The very first health programs were created by two medical educators, Dr. H. Jack Geiger and Dr. Count Gibson, of Tufts University Medical School.
The model of the two centers that they established, one in a Boston housing project and one in a poor rural area of Mississippi, was based on a public health–social medicine approach. It combined comprehensive health services, community development, and the training and employment of community residents. Health center staff in Mississippi found that children in the community had recurring episodes of malnutrition and dysentery. In response they organized residents who decided to construct wells and establish a farm cooperative to feed themselves and their children. Other health centers funded under this program, which was authorized by an amendment to the EOA by Senator Edward Kennedy (D-MA), also provided community development and employment opportunities as well as health care services. For example, a neighborhood health center in Brooklyn, New York, gave preference in hiring to local residents, and health center staff facilitated the creation of a community organization to rehabilitate housing in the area.
By the end of 1971, 100 neighborhood health centers had been funded under Kennedy’s 1966 amendment. The original neighborhood health center model contained four elements: social medicine, community-based care, community economic development, and community participation. From the social medicine perspective, health status is shaped by the physical and social environment, and treatment includes intervention in that environment. Health care was to be community based by offering services to all of the residents of a specific geographic catchment area (rather than to those who fit within certain disease or health insurance categories) and by employing community residents to serve as a bridge between patients and professional staff. These workers, often called family health workers, made home visits and provided health education and advocacy services along with health care. The recruitment, training, and employment of these workers were also an example of the way in which neighborhood health centers were venues for community economic development.
Finally, “maximum feasible participation” of the poor was required of all programs funded under the EOA. The operationalization of this concept in the health center case included conflict between project administrators, many of whom were employed by hospitals, medical schools, and health departments, and health center consumers during the program’s early years. When health centers received a separate federal program authorization in 1975, community governance became a central component that defined the program (Sardell, 1988).
Policy innovation in the United States most often requires that one or more individuals “invest their resources—time, energy, reputation, and sometimes money” in advocating for a new policy idea. John Kingdon calls these advocates “policy entrepreneurs” (Kingdon, 1995). Policy advocacy is most successful when entrepreneurs in and outside of government work together to support a new policy or program. This is what happened in the case of the creation of the neighborhood health center program. Activist physicians and federal Office of Economic Opportunity (OEO) officials worked together to create a policy that would increase health care access to low-income populations and to provide services that were different from those offered by “mainstream” medical institutions. In addition, Senator Edward M. Kennedy (D-MA) acted as an advocate for the program within Congress, deflecting opposition to both antipoverty programs and to “socialized medicine.”
When President Nixon took office, the political environment changed; Nixon was not supportive of the social programs initiated by the Johnson Administration. Yet during the Nixon Administration, sympathetic federal agency officials protected the program until its advocates outside of government grew stronger (Sardell, 1988).
Program Survival and Institutionalization
Beginning in 1968, the public health service (PHS) within the Department of Health, Education and Welfare (DHEW) also provided funding for the establishment of about 50 comprehensive health centers in low-income areas. The involvement of the PHS in primary health services had been historically limited to the funding of categorical disease programs. However, the 1960s was a period in which socially concerned health professionals, administrators, and social scientists joined the agency as an alternative to serving in the military during the Vietnam War. Some of these individuals became policy entrepreneurs within the PHS for comprehensive health service programs for underserved populations. They were supported in their efforts by top DHEW officials appointed by President Johnson.
Although the Nixon Administration did not support the neighborhood health center program, there were civil servants in the PHS, as well as the OEO, who acted to protect it. As the OEO was phased out, decisions as to the timing of the transfers of individual programs to the PHS were made in ways that would protect more politically vulnerable programs, such as those in the south. In addition, agency officials awarded technical assistance grants to newly formed state health center associations and (in 1973) to the National Association of Neighborhood Health Centers, an organization created in 1970. Key congressional leaders such as Senator Kennedy and Congressman Paul Rogers (D-FL) also supported the health center program during the presidencies of Richard Nixon and Gerald Ford.
In 1972, the DHEW announced that it planned to phase out federal grants to health centers on the assumption that they would be funded through Medicaid. However in 1974 and 1975, in opposition to the Nixon and Ford Administrations, Congress enacted legislation that specifically described “community health centers” and authorized grant funding for them. The legislation was vetoed by both presidents, but in 1975 Congress overrode President Ford’s veto. The creation of the program took place within the wider context of intense conflict between presidents who aimed to reduce the role of the federal government in social policy and a liberal democratic Congress that wanted to preserve the social programs of the Great Society. This congressional action was a critical point in the history of the program because it now had its own legislative authority that defined its characteristics.
A CHC has to have a governing board with a consumer majority. This board establishes general policies for the center, has fiduciary responsibility, and appoints its executive director. A majority of board members have to be consumers who use its services. When enacted, this was the most rigorous community participation provision in any health service program up to that time. This legislative provision, reaffirmed many times (including the program’s last reauthorization in 2008), has meant that community-based primary care programs that don’t have such a governing board structure, such as those run by hospitals, cannot receive federal grants as CHCs. This provision has also enabled advocates to frame CHCs as embodying “local control,” an aspect of the program that has appealed to Republicans as well as Democrats.
The Ford Administration (1974 to 1977) attempted to reduce CHC program funding and to end categorical grant programs in health. Within that political environment, federal program officials initiated changes that helped to expand congressional support. New program monitoring systems were established that provided measurable performance criteria for the health centers so that congressional concern with efficiency was addressed. In addition, “rural health initiatives,” smaller-scale basic medical programs were funded. More centers could be funded because they required fewer resources than the large urban centers. Rural, white congressional districts could potentially become a part of the health center constituency. These changes were part of the “institutionalization” of the health center program (Sardell, 1988). Over time, the cost-effectiveness of CHCs has been one of the major arguments made for increasing support for this model of care. Further, since the 1980s, members of Congress from rural districts and states have been important health center champions.
At the same time that federal agency officials were making programmatic decisions that would ultimately strengthen congressional support for CHCs, the National Association of Community Health Centers (NACHC) began to focus on educating members of Congress about the value of CHCs. A policy analyst was hired, a weekly newsletter on policy events was published, and the association initiated an annual “policy and issues forum” in Washington, D.C. which brought together health center consumers and staff to learn about policy issues and the policy process. In 1976, a Department of Policy Analysis was created. During the following decades, membership in NACHC grew, as did the organizational infrastructure. Today this organization is one of the most effective advocacy organizations in Washington.
Continuing Policy Advocacy
During the next two decades, under both Republican and Democratic Presidents, the health center community strengthened its advocacy efforts and Congress continued to increase funding for the program. While Jimmy Carter was President (1977-1981), the rural health initiative concept of smaller centers was extended to urban areas and the focus on management efficiency continued. President Ronald Reagan’s attempt to end the community health center program as a separate federal grant program was rejected by Congress in 1981. An important shift in health center funding occurred as a result of legislation initiated by the staff of Senator John Chafee (R-RI) and NACHC to deal with the problem of low Medicaid and Medicare reimbursement rates for services delivered at CHCs. Under the Federally Qualified Health Center (FQHC) program, which became part of Medicaid in 1989 and Medicare in 1990, CHCs and “look-alikes” (clinics that did not get federal grant monies under the CHC program but had the characteristics of CHCs) would have special Medicaid and Medicare reimbursement rates that were closer to actual costs than regular per-visit rates paid by Medicaid in many states. As a result, health centers were able to collect higher reimbursements for Medicaid and Medicare patients, and Medicaid replaced federal grants as the major source of revenue for health centers. From 1990 to 1998, the proportion of health center revenues from federal grants substantially decreased from 41% to 26%.
The Expansion of CHCs Under a Conservative President
Republican George W. Bush was elected president in 2000 as a conservative who would look to outside government for the solutions to social problems. Yet he embraced CHCs, a program created by liberal Democratic President Lyndon Johnson in the 1960s. In 2001, in his first year in office, President Bush proposed a 5-year initiative to expand health center sites to serve 6.1 million new patients. Congress supported funding for this initiative, and throughout his two terms in office President Bush acted to fulfill his promise to expand the community health center program. Each time that Congress did not approve his full request for health center funding, the president would add the missing funds to his request for the following year (Hawkins, 2009). While the Bush Administration was promoting the expansion of health centers, it was slashing spending for a wide variety of domestic programs including food stamps, home energy assistance, training grants for health professions, veterans’ benefits, and Medicaid (Pear, 2005). The CHC program was only one of two domestic public health programs that grew during the Bush Administration, but the money budgeted for the other program (abstinence-only sex education) was far less than the amount appropriated for the health center program.
In addition, during the effort to reauthorize the CHC program during 2007 and 2008, the Bush Administration was “quietly supportive.” It helped to get the votes of some Republican members of Congress, in spite of conservative opposition to expansions of federal funding for social programs. Along with the president, a bipartisan coalition of members of Congress was supportive of the program’s expansion and, for the first time, the CHC authorization contained “hard numbers,” that is, explicit amounts were targeted for the program, rather than leaving funding amounts to the appropriations process as previously (Hawkins 2009). The Health Care Safety Net Act of 2008 (PL 110-355) authorized a total of $13 billion for 5 years, increasing each year: $2.2 billion in fiscal year (FY) 2008 and $ 3.3 billion in FY 2012. Although this includes funding for the National Health Service Corps, most of the money goes to expand the health center program (BNA, 2008). What explains the support that CHCs (programs serving ethnic minorities and the poor) had from President George W. Bush, a Republican conservative?
First are the data-based policy arguments that show that health centers provide access to high-quality health care for underserved populations in a cost-effective way. For example, studies comparing uninsured patients who receive care at CHCs with uninsured patients who do not receive care have found that CHC patients are more likely to report having a usual source of care and receiving preventive health counseling, and are less likely to wait to see providers. Low-income minority women who are uninsured or have Medicaid are more likely to have had cancer screening tests if they are patients at health centers than similar women who are not health center patients (Proser, 2005). Health centers are also central in efforts to reduce ethnic and racial disparities in health status. One way in which this occurs is through the provision of enabling services such as health and nutrition education, central to the management of chronic diseases, and outreach services, such as translation and transportation.
Second is the expansion of the policy network to include conservative members of Congress, so the network now includes an ideologically diverse set of policymakers. Beginning as early as the 1980s, policy staff at NACHC worked with moderate and conservative Republicans as well as Democrats on issues of concern to health centers. This process of building relationships on a bipartisan basis became critical when the Republicans gained control of Congress in 1994 and then in 2000 when Bush was elected president. In addition to the liberal Democrats and moderate Republicans who were program supporters in its formative years, health center champions in Congress during Bush’s first term in office included powerful Republican conservatives such as Senators Orin Hatch of Utah (R), Christopher “Kit” Bond of Missouri (R), and Representative Henry Bonilla (R) of Texas. In fact, Senator Bond and Congressman Bonilla educated George W. Bush on the value of the health center model during his first campaign for the presidency (Hawkins, 2005).
Third, it is the long experience and high levels of skill of the officials and staff of the CHC advocacy community that has successfully wedded policy arguments with grassroots political activity. In 2010, NACHC’s Department of Policy Analysis and Research has 17 full-time and two part-time staff members. Primary care associations at the state and regional levels, together with the NACHC, have successfully met a series of policy challenges to the program’s continued existence and growth and have helped to create the very broad support enjoyed by the CHC program 45 years after its creation.
Community Health Centers in the Obama Era
The election of a liberal Democratic president who began his professional life as a community organizer (and who was famously endorsed during the Democratic presidential primary by Senator Edward M. Kennedy, long-time champion of community health centers) suggested that the CHC program would continue to enjoy presidential support.
The American Recovery and Reinvestment Act (ARRA), signed into law in February 2009, included an almost $2 billion investment in community health centers for both new sites and the expansion of existing sites. Three quarters of the funding ($1.5 billion) was allocated for CHC construction, renovation, and equipment, while the rest was to help fund the operation of the centers (Bureau of Primary Health Care, 2010). The CHC program was the only direct health services program to receive money under the ARRA.
When Congress was beginning to consider this legislation, two CHC “champions”—Congressman David Obey (D-WI), Chair of the House Appropriations Committee, and Senator Tom Harkin (D-IA), Chair of the Senate Appropriations Subcommittee for Labor-HHS programs—included funding for CHCs in the House and Senate bills. Health centers presented data to members of Congress about the many newly unemployed workers seeking care at CHCs, the cost savings achieved when disparities in access to care were reduced and chronic disease was effectively managed, and the fact that health centers were engines of job creation and community economic development.
The $2 billion authorized for community health centers in the ARRA was more than that recommended by either the House ($1.5 billion) or the Senate ($1.87 billion). Usually, when the Senate and House negotiate on final legislation, the amount of funding for a program is a compromise. But in the case of funding for community health center expansion in the Recovery Act, those negotiating the final bill—Democratic party leaders from both Houses, representatives from the Obama Administration, one conservative Democrat (Ben Nelson of Nebraska), and a small group of Republicans supporting the stimulus package (Susan Collins and Olympia Snowe of Maine and Arlen Spector of Pennsylvania, then a Republican)—agreed to actually raise the amount (Hawkins, 2009). Clearly, support for CHCs comes from both parties and from members of Congress across the liberal/conservative ideological spectrum—from socialist Bernie Sanders to conservative Orin Hatch.
Community health center advocates were very active in the process of formulating health care reform legislation during 2009, arguing that expanding health insurance alone is not sufficient to create access to high-quality preventive and primary health care. Senator Bernard Sanders (I-VT) and the House Majority Whip James Clyburn (D-SC) were key congressional champions for including funding for health centers in the health reform bills (Hawkins, 2009).
The health reform legislation enacted in March 2010 (The Reconciliation Act of 2010 and HR 3590, the Patient Protection and Affordable Care Act) emphasizes public health initiatives and preventive and primary health services as means to improve health outcomes, reduce health care disparities, and save money. The legislation continues federal support for expansion of the numbers of community health centers and the services that they provide. Eleven billion dollars in new funding is authorized for the CHC program over a period of 5 years, beginning in FY 2011, both to serve an additional 20 million patients and to increase medical, dental, and mental health services. While most of the funds will be spent on providing services, $1.5 billion of the authorization is for new construction and renovation of existing facilities.
Other provisions of the new health reform legislation also affect the operations of health centers. Federal eligibility for Medicaid is expanded (to all those with an annual income less than 133% of the federal poverty level), and this will provide health insurance coverage to 16 million more people, some of whom were previously treated as “self-pay” patients at CHCs, and some of whom probably did not seek primary care. The legislation also seeks to protect the financial viability of health centers within the new health insurance system. Additionally, $1.5 billion is authorized for the National Health Service Corps (NHSC) which provides educational scholarships and loans to primary care providers who agree to serve in provider shortage areas. In addition, new grant programs are established for the development of teaching and residency programs at community health center sites (National Association of Community Health Centers, 2010b).
1. First is the crucial importance of understanding the general political environment and framing policy solutions in ways that fit that environment. Socially concerned health professionals and others created neighborhood health centers as part of the War on Poverty, and health center advocates today frame their policy arguments in terms of current health policy concerns such as reducing health care disparities and cost-effectiveness.
2. Second is that program survival and institutionalization during the 1970s was the result of the actions of federal officials who were ideologically and personally committed to health center programs and helped to create a nongovernmental advocacy organization to represent them. The resulting health center policy community or policy network consisted of federal agency officials, members of Congress, and the NACHC.
3. Third, the expansion of health centers as a central plank of Bush Administration health policy was the result of the development of long-term relationships between health center advocates and members of Congress from across the political and ideological spectrum and policy arguments made in terms of access, reduction of health disparities, and cost-effectiveness of the program.