The Role of Community Health Centers in Delivering Primary Care to the Underserved: Experiences of the Uninsured and Medicaid Insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.

[1]  Massey Jt,et al.  Design and estimation for the National Health Interview Survey 1985-94. , 1989 .

[2]  B. Starfield.  U.S. child health: what's amiss, and what should be done about it? , 2004, Health affairs.

[3]  A. Epstein,et al.  The role of public clinics in preventable hospitalizations among vulnerable populations. , 2001, Health services research.

[4]  R. Andersen.  Revisiting the behavioral model and access to medical care: does it matter? , 1995, Journal of health and social behavior.

[5]  Leiyu Shi,et al.  Primary care experience and racial disparities in self-reported health status. , 2004, The Journal of the American Board of Family Practice.

[6]  B. Carlson,et al.  Primary Care of Patients without Insurance by Community Health Centers , 2001, The Journal of ambulatory care management.

[7]  Leiyu Shi.  Primary Care, Specialty Care, and Life Chances , 1994, International journal of health services : planning, administration, evaluation.

[8]  Judith Smith,et al.  The effect of L-dopa on the potentiation of radiation damage to human melanoma cells. , 1990, British Journal of Cancer.

[9]  H. Picavet,et al.  National health surveys by mail or home interview: effects on response , 2001, Journal of epidemiology and community health.

[10]  G. Duncan,et al.  Effects of participation in the WIC program on birthweight: evidence from the National Longitudinal Survey of Youth. Special Supplemental Nutrition Program for Women, Infants, and Children. , 2002, American journal of public health.

[11]  C. Forrest,et al.  Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians' offices. , 2000, JAMA.

[12]  A Zuvekas,et al.  Community and migrant health centers: An overview , 1990, The Journal of ambulatory care management.

[13]  J. Wulu,et al.  America's Health Centers: reducing racial and ethnic disparities in perinatal care and birth outcomes. , 2004, Health services research.

[14]  R. Andersen,et al.  Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities , 2004, Inquiry : a journal of medical care organization, provision and financing.

[15]  B. Starfield,et al.  Primary Care Quality: Community Health Center and Health Maintenance Organization , 2003, Southern medical journal.

[16]  P. Gregory,et al.  Racial differences in birth outcomes and costs in relation to prenatal WIC participation. , 2003, New Jersey medicine : the journal of the Medical Society of New Jersey.

[17]  S. H. Murdock,et al.  Income, poverty, and health insurance coverage in the United States, 2008. , 2009 .

[18]  Gregory Pm,et al.  Racial differences in birth outcomes and costs in relation to prenatal WIC participation. , 2003 .

[19]  Rebecca L. Kinney,et al.  Health Status of a Low‐income Vulnerable Population in a Community Health Center , 2005, The Journal of ambulatory care management.

[20]  Bertrand Le Bourgeois,et al.  Racial and ethnic disparities in infant mortality: risk in social context. , 2001, Journal of public health management and practice : JPHMP.

[21]  J. Hadley,et al.  Availability of safety net providers and access to care of uninsured persons. , 2004, Health services research.

[22]  B. Starfield.  Perspectiv e U.S. Child Health: What's Amiss, And What Should Be Done About It? A strong primary care infrastructure is key to improving and reducing disparities in children's health. , 2004 .

[23]  C. Forrest,et al.  Consumer experiences and provider perceptions of the quality of primary care: implications for managed care. , 1998, The Journal of family practice.

[24]  James Macinko,et al.  The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. , 2003, Health services research.

[25]  V. Hunt.  Primary Care: America's Health in a New Era , 1997, The Journal of the American Board of Family Medicine.

[26]  B. Starfield,et al.  The effect of primary care physician supply and income inequality on mortality among blacks and whites in US metropolitan areas. , 2001, American journal of public health.

[27]  Christina H. Park,et al.  Continuity of primary care clinician in early childhood. , 2004, Pediatrics.

[28]  Leiyu Shi,et al.  Community Health Centers and Racial/Ethnic Disparities in Healthy Life , 2001, International journal of health services : planning, administration, evaluation.

[29]  William R. Fifer,et al.  At Risk in America: The Health and Health Care Needs of Vulnerable Populations in the United States , 1994 .

[30]  C. Forrest,et al.  Health center trends, 1994-2001: what do they portend for the federal growth initiative? , 2005, Health affairs.

[31]  M. Gaston,et al.  Cancer screening among community health center women: eliminating the gaps. , 1999, The Journal of ambulatory care management.

[32]  A. Zuvekas.  Health Centers and the Healthcare System , 2005, The Journal of ambulatory care management.

[33]  B. Stuart.  Access to Medical Care in the US: Who Has It, Who Doesn't , 1985 .

[34]  S. Kendig.  Primary Care Safety , 2006 .

[35]  J. Ware,et al.  Linking primary care performance to outcomes of care. , 1998, The Journal of family practice.

[36]  N. Moss,et al.  The effect of WIC and Medicaid on infant mortality in the United States. , 1998, American journal of public health.

[37]  Alan M. Zaslavsky,et al.  Using Telephone Interviews to Reduce Nonresponse Bias to Mail Surveys of Health Plan Members , 2002, Medical care.

[38]  F. J. Fowler,et al.  Comparing telephone and mail responses to the CAHPS survey instrument. Consumer Assessment of Health Plans Study. , 1999, Medical care.

[39]  F. Hellinger.  The Impact of Financial Incentives on Physician Behavior in Managed Care Plans: A Review of the Evidence , 1996, Medical care research and review : MCRR.

[40]  Anne Dievier,et al.  Community Health Centers: Promise and Performance , 1998, Medical care research and review : MCRR.

[41]  R. Andersen,et al.  Access to medical care in the U.S. : who has it, who doesn't , 1985, American Political Science Review.

[42]  B. Starfield,et al.  Primary care, infant mortality, and low birth weight in the states of the USA , 2004, Journal of Epidemiology and Community Health.

[43]  N. Powe,et al.  Costs vs quality in different types of primary care settings. , 1994, JAMA.

[44]  D Braddock,et al.  Using Medicaid fee-for-service data to develop community health center policy. , 1995, Managed care quarterly.

[45]  J. Needleman,et al.  Ambulatory Care Sensitive Hospitalizations and Emergency Visits:: Experiences of Medicaid Patients Using Federally Qualified Health Centers , 2001, Medical care.

[46]  S. Kendig.  Primary Care Safety , 2006 .

[47]  H. Freeman,et al.  Community health centers: an initiative of enduring utility. , 1982, The Milbank Memorial Fund quarterly. Health and society.

[48]  K. Fiscella,et al.  Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. , 1998, The Journal of family practice.

[49]  V. Chande,et al.  Role of the primary care provider in expediting care of children with acute appendicitis. , 1996, Archives of pediatrics & adolescent medicine.

[50]  B. Starfield,et al.  Primary Care, Income Inequality, and Stroke Mortality in the United States: A Longitudinal Analysis, 1985–1995 , 2003, Stroke.

[51]  J. Emilio Carrillo,et al.  Cross-cultural Primary Care: A Patient-Based Approach , 1999 .

[52]  Laura Petersen,et al.  Does Pay-for-Performance Improve the Quality of Health Care? , 2006, Annals of Internal Medicine.

[53]  L. Shi.  Type of health insurance and the quality of primary care experience. , 2000, American journal of public health.

[54]  J. Wulu,et al.  Immunization Coverage of Vulnerable Children: A Comparison of Health Center and National Rates , 2003, Medical care research and review : MCRR.

[55]  A. Shields,et al.  Process of Care for Medicaid-Enrolled Children With Asthma: Served by Community Health Centers and Other Providers , 2002, Medical care.

[56]  R. Andersen,et al.  Equity of Access to Medical Care: A Conceptual and Empirical Overview , 1981, Medical care.

[57]  F. Mullan,et al.  Primary care physician supply and the medically underserved. A status report and recommendations. , 1991, JAMA.

[58]  J. Cantor,et al.  Accessibility of primary care services in safety net clinics in New York City. , 2001, American journal of public health.

[59]  R. Deprez,et al.  The substitutability of outpatient primary care in rural community health centers for inpatient hospital care. , 1987, Health services research.

[60]  A. Green,et al.  Cross-Cultural Primary Care: A Patient-Based Approach , 1999, Annals of Internal Medicine.

[61]  Michelle Proser.  Deserving the Spotlight: Health Centers Provide High‐Quality and Cost‐Effective Care , 2005, The Journal of ambulatory care management.

[62]  B. Armour,et al.  The effect of explicit financial incentives on physician behavior. , 2001, Archives of internal medicine.

[63]  Barbara Starfield,et al.  The Future Role of Health Centers in Improving National Health , 2003, Journal of public health policy.

[64]  M. E. Stuart,et al.  Patient-Mix Differences Among Ambulatory Providers and Their Effects on Utilization and Payments for Maryland Medicaid Users , 1993, Medical care.

[65]  R. Politzer,et al.  The role of federally funded health centers in serving the rural population. , 2003, The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association.

[66]  B. Lefkowitz,et al.  An overview: health centers at the crossroads. , 1999, The Journal of ambulatory care management.

[67]  R. Hughes,et al.  Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care , 2001, Medical care research and review : MCRR.

[68]  Gregory D. Stevens,et al.  Vulnerable Populations in the United States , 2004 .