In 2003, Barbara Grace of Milwaukee, Wisconsin, found herself without health insurance when she lost her clerical job.
“I was terrified that I would be unable to pay for my insulin and would die,” says Grace, who has diabetes. “Fortunately, a friend suggested that I visit the Sixteenth Street Community Health Center in Milwaukee, which provides health care to all regardless of the ability to pay.”
In addition to insulin and blood testing supplies, Grace received nutritional counseling, eye check-ups, and other routine care to decrease the risk of serious, costly complications, such as blindness and heart disease.
“Best of all was the emotional support of the staff,” says Grace, sixty-eight, who is now retired and has Medicare coverage. “Although I could get health care elsewhere, I’m still a patient at the Sixteenth Street Center. Unlike my friends who must consult professionals all over the city, I get everything I need in one place.”
Grace is one of an estimated 27 million Americans who will receive their health care at the 1,400 community health centers across the nation in 2018.
“Community health centers provide the primary medical safety net for vulnerable Americans,” says Dan Hawkins, senior vice president of public policy and research at the National Association of Community Health Centers, an advocacy group in Bethesda, Maryland. Beneficiaries include 1.2 million homeless people, more than 300,000 veterans, and a significant number of patients who are uninsured or on Medicaid.
Hawkins notes that the civil rights movement was “the primary motivation for the establishment of the centers. Dr. H. Jack Geiger, a young New York physician, had observed how a pioneering health care model, which emphasized prevention and community involvement, had improved the lives of poor people in South Africa. He applied the model to areas of the United States where poor African Americans lacked medical care.”
The initial centers opened in Boston, Massachusetts, and Mound Bayou, Mississippi, in 1965. Today, community health centers provide care to more patients than any single primary care system, serving one in twelve Americans. Sixty-two percent of the patients are members of racial and ethnic minorities, the association’s June 2017 report found.
As governor of Texas, George W. Bush became a champion of community health centers because they kept health costs down. As President, he doubled the centers’ funding, enabling the creation or expansion of 1,297 clinics in medically underserved areas. The number of patients increased 60 percent. It was the largest expansion since the program was launched during President Lyndon B. Johnson’s War on Poverty.
Administering preventive care for chronic diseases—which affect nearly half of all Americans—is a top priority for the centers, making sure heart disease, hypertension, or diabetes don’t balloon into life-threatening, expensive conditions.
Although community health center patients have higher rates of diabetes than the national average, a Bureau of Primary Health Care study found that 70 percent of health center patients have their blood sugar under control, compared to 54 percent of all diabetics in the United States. Health center patients also have higher rates of controlled blood pressure than the national population.
Despite these accomplishments, funding remains a major concern of community health centers, which have been dependent on the federal government for the majority of their funds since the War on Poverty in the 1960s.
The centers are afraid they might come up short if Congress repeals the Affordable Care Act, President Barack Obama’s signature domestic legislation. The act created a special trust of $11 billion to expand the centers and their services. As a result, community center patient visits climbed from 77.1 million in 2010 to 97 million in 2015. Visits for dental care, eye care, and behavioral medicine also increased significantly during this time.
But the Supreme Court dealt the Affordable Care Act a severe blow when it made Medicaid expansion optional for states. As of this January, thirty-two states and the District of Columbia had expanded Medicaid, eighteen had not. In 2015, a year after the ACA took effect, about one in five health center patients in Medicaid expansion states remained uninsured, compared to one in three in the states that chose not to expand funding. Centers in those states saw a corresponding increase in uncompensated care.
Funding became a high-wire act when the Community Health Center Fund, which provides 70 percent of grant funding for the centers, expired on September 30. Fortunately, $3.8 billion for the current fiscal year and $4 billion in 2019, up from $3.6 billion in 2017, was included in the bipartisan budget passed by Congress February 9.
“The four-month standoff made it extremely difficult for centers to recruit staff and negotiate leases for clinics,” says Hawkins. “If the budget standoff had continued, 53 percent of the centers would have had to begin laying off staff and roughly a third of respondents said they would begin closing their doors or reducing their services.”
To secure long-term funding the community health centers plan to highlight their cost effectiveness, a potentially potent argument as Republicans plan to cut Medicaid.
“Ideally, we would like Congress to allocate funds for ten years, so that our patients would have the security of knowing that the centers will be there when they need them,” says Hawkins.
‘Ideally, we would like Congress to allocate funds for ten years, so that our patients would have the security of knowing that the centers will be there when they need them.’
Until then, community health centers across the country continue to be creative, focused, and forward-looking. Here’s a look at how three centers are positioning themselves to meet the needs of their clients.
Sixteenth Street Community Health Center — Milwaukee, Wisconsin
Occupying a tiny second-floor office in central Milwaukee when it was founded in 1969, the center now employs 300 people and has seven locations, three of them full-service medical centers. In 2016, it served more than 37,000 patients, including about 7,500 without insurance and nearly 19,000 on Medicaid.
“Access means more than having an insurance card and being able to get an appointment with a physician when you are not feeling well,” says Dr. Julie Schuller, the center’s chief executive officer. “Access means having a practitioner who understands your language and culture, so that you will receive sensitive care that will enable you to avoid complications that prevent you from working, attending school, and taking care of your family.”
About half the center’s patients are Hispanic. In recent years, immigrants from Iraq, Burma, and Somalia have moved into the area. In addition to staff members who speak Spanish, the center has added translation devices, which make it easier for patients to present symptoms and physicians to explain treatment plans.
“Community health centers like ours emphasize prenatal care and parenting classes because if you can get a child off to a good start, many health problems can be avoided,” Schuller says.
“Our zip code, 53204, has the highest number of infant and childhood deaths and injuries related to improper use of car seats in Wisconsin, so we offer a class in English and Spanish to educate parents,” Schuller says. “In addition to a six-week training course for parents who want to develop their skills in communication, disciplining and preparing their children to be successful in school, we also offer a testing and treatment program for children with attention deficit.”
The Sixteenth Street Community Health Center has tackled the problem of lead poisoning, which causes poor muscle coordination, developmental delays, and other problems in young children. Many of the homes in the areas it serves were built around 1900, using lead-based paint. The staff visit every home once a year to educate families about the risks and provide free testing to children under age six. The staff also teaches homeowners, tenants, and landlords how to identify lead paint and correct the problem.
As a result of this program, the prevalence of lead poisoning among children under six has declined from 32 percent in 1997 to 3.3 percent in 2018. Among the center’s patients, the rate is less than 2 percent.
Native Health — Phoenix, Arizona
Founded in 1978 as a small community nursing program, Native Health now includes more than two dozen health care professionals. The center provides dental care, behavioral medicine, and primary medical care to more than 17,000 individuals, 80 percent of them Native Americans.
“Native Americans who have moved to urban areas like Phoenix face numerous challenges,” says Walter Murillo, the center’s chief executive officer. “Unemployment, low wages, inadequate housing, and lack of transportation make it difficult for them to eat healthy and maintain their health.”
About two million residents of Arizona lack consistent access to adequate food each year, reports St. Mary’s Food Bank Alliance of Phoenix, which has partnered with Native Health on distributing food to the center’s patients since 2015.
“Initially, we provided food for families in the summer because the children were not receiving free lunches at school,” Murillo says. “But we soon discovered that food insecurity was a daily occurrence, so now the program operates year round. Once a week, families receive a backpack of ten pounds of nonperishable food.”
Native Health also educates Native Americans about healthy eating on a limited budget.
“Unfortunately, many individuals grab a soda and eat chips when they are short on time and money for meals,” he says. “Some people live in food deserts where there are few grocery stores where they can buy inexpensive fresh fruits and vegetables. so we have worked with local merchants to alleviate this problem.” The percentage of Native Americans with diabetes—33 percent—is higher than any other American ethnicity.
To stem the epidemic, Native Health targets young children because lifelong eating habits are often established in elementary school.
“Kids who eat fruits and vegetables encourage their parents to do so too, which helps decrease the risk of kidney failure, blindness, and other complications among adults who are battling the metabolic disease,” says Murillo.
Wellness Warriors, a program for seven- to twelve-year-olds and their parents, includes activities like a healthy dinner with Santa and a bike rodeo. The children participate in soccer, hikes, and other activities, which help prevent obesity, a major cause of Type 2 diabetes later in life. There is also a summer camp where members of the Wellness Warriors play sports and receive daily education in nutrition. Native Health has partnered with the Phoenix Public Library to offer a monthly “Read It and Eat It” class. The families read a food-themed book, prepare a healthy recipe like watermelon sundaes, and receive a bag of fresh produce to take home.
“Our programs emphasize Native American culture,” Murillo says. “Individuals and families grow indigenous plants in our community gardens and use them to prepare dishes their ancestors ate.”
The Indian Health Service found that, on average, the life expectancy of Native Americans was 4.4 years younger than for all ethnic and racial groups. Although they were less likely to die of lung cancer, Alzheimer’s disease, and cervical cancer than other groups, they had high rates of death caused by accidents, intentional self-harm, and chronic liver disorders.
“Many of these deaths are associated with alcoholism,” says Murillo. “Poor people face a lot of stress in their lives, which often leads them to self-medicate with alcohol.”
In addition to individual, group, and family counseling for depression, marital problems, grief, and other mental health issues, there are recovery programs for alcoholics and drug abusers.
Native Health has pioneered several programs to help victims of domestic violence and sexual abuse, problems often exacerbated by addiction.
These include Creative Confidence, a ten-week course for thirteen- to eighteen-year-old girls to help them develop self-esteem and confidence. Native STAND (Students Together Against Negative Decisions) is a twelve-week program to help teens aged fourteen to eighteen avoid HIV, sexually transmitted disease, and domestic violence.
Rutgers Community Health Center — Newark, New Jersey
The Rutgers Community Health Center serves residents of four public housing projects in Newark.
“Our patients are a vulnerable population,” says Susan VonNessen-Scanlin, associate dean for clinical affairs at Rutgers University. “In addition to the lowest incomes in the state, they face many barriers in navigating the health care system. Some residents do not speak English, others are immigrants from countries with very different health care systems.”
To overcome the problem, the community board, which is comprised of residents of the public housing projects and other parts of the neighborhood, recommended that the center initiate a community health care worker program to assist the health professionals in meeting these challenges.
The center is staffed by faculty and students from the School of Nursing, New Jersey Medical School, and the School of Public Health, all part of the School of Health Professions of Rutgers, the State University of New Jersey.
“Because board members live, work, and interact with our patients 24/7, the board helps us look at the big picture,” VonNessen-Scanlin says. “They can identify needs like transportation, which make a difference in whether a person gets into the heath care system.”
Victoria Lane applied for the twelve-week training course because she “wanted to give back to the community.” Applicants must be high school graduates who live in the projects.
“In addition to learning about conditions like heart disease that take a toll on our community and how to conduct home visits, we learned how to relate to the whole person and not be judgmental,” she says. “Every patient needs someone to listen to their concerns and help them get the care they need.”
“We build trust so that the patients will turn to us for whatever they need to stay well and adhere to their treatment plans,” Lane explains. “If a woman can’t pick up her prescription from the pharmacy, we get it. If an elderly man falls during the middle of the night, we accompany him to the emergency room.”
Health education is an important part of the community health worker’s role. If a patient with hypertension is having difficulty using the blood pressure monitor, she will show them how to use it and provide encouragement while they master the procedure. She will also suggest foods they may eat to reduce their consumption of salt.
“The ongoing support of the community health workers is often the springboard that enables our patients to turn their lives around,” saysVonNessen-Scanlin. “They begin to believe in themselves and take small steps that lead to major changes for themselves and their families.”
Sharon Johnson is a freelance reporter in New York City.