Death Watch for Health Clinics

The Mary Howard Health Center sits on the first floor of a ten-story, low-rise office building a few blocks from the heart of downtown Philadelphia. The center serves the city's homeless residents, providing everything from wound care to mental-health services. Like all community health centers, Mary Howard provides health care without regard for income or insurance status.

"They're doing a good job, giving me all the attention I need," says James Brown ("like the soul singer"), a 71-year-old Mary Howard patient with a painful abscess on his back the size of a fist. "It's just like a regular hospital."

The center saw 1,760 patients last year, a capacity increased by funding from the American Recovery and Reinvestment Act's (ARRA) $2 billion earmark for community health centers. Most of the $636,000 ARRA grant Mary Howard received went to expanding the center's capacity from four to ten patient rooms.

Without Mary Howard, Brown says, "I would have just gone to emergency care ... but I trust [the health center] just as much as emergency care."

The nation's 8,000 community health centers -- nonprofit organizations that provide primary care to medically underserved areas and populations -- serve more than 20 million patients a year, about half in rural areas. They do this at under half the cost of emergency rooms (where the uninsured might otherwise receive treatment), which is why they were a key component of the Obama administration's health-care reform law.

In addition to receiving a boost from the economic stimulus, the Affordable Care Act included $11.5 billion over five years for expanding community health centers nationwide, largely for the reasons highlighted by Brown's case: When they are run well, health centers provide comprehensive medical coverage to those who wouldn't otherwise receive it, at a cost savings of $24 billion per year. Advocates and policy-makers argue that an expanded health-center network could accommodate the needs of the tens of millions of newly insured Americans, including Americans newly eligible for Medicaid under the health-care law.

"There are actually more people -- about 60 million -- who live in federally classified underserved areas of the country than there are uninsured," says David Reynolds, senior health policy adviser to Senator Bernie Sanders, an independent from Vermont, who made community health centers a priority during the legislative wrangling over health-care reform. "[Insurance] coverage alone is not sufficient. If we are to expand coverage to 32 million people, we should expand access [to health care] to the same degree."

Although their origins lie in Lyndon Johnson's Great Society programs, community health centers have received the blessing of both political parties. George W. Bush was a big booster, and in 2008, the Health Care Safety Net Act, which provided funding for health centers, passed both houses unanimously. But the Tea Party-dominated 112th Congress, which swept into power on the heels of dissatisfaction with the ACA, mangled the $2.2 billion in appropriations allocated annually to health centers, slicing $600 million from their budget. This August, the Department of Health and Human Services dispensed a round of ACA grants to fund 67 new health centers, to serve 286,000 patients. The original proposal, before the slash-happy budget deal, was supposed to fund at least 350 new health centers this year, to serve 5 million patients. At existing health centers, money originally intended for expansion has gone into keeping the centers afloat.

"We have enjoyed, and I believe we still enjoy, broad bipartisan support," says Dan Hawkins, policy director for the National Association of Community Health Centers. "Because the GOP is ardently opposed to the Affordable Care Act, they saw the action of cutting back funding on health centers as a way of cutting back on the expansions [from Obama's health-care reform]."

"It was an anti-health-reform action rather than an anti-health-center action," he added. "Whatever the motivation, the effect is the same: five million people won't get care."

The future of existing health centers looks uncertain in this austerity-prone environment. "If there is no mandatory fund and you reduce the appropriations," Reynolds explains, "you have effectively killed community health centers."

Some centers would be hurt worse than others. The Public Health Management Corporation (PHMC), which runs Mary Howard, relies primarily on reimbursements from Medicaid. But community centers in many Southern states, which historically have weak Medicaid programs, rely on federal appropriations to pay the bills. If those appropriations aren't there, they may not be, either.

But PHMC officials are hopeful about the future. The center was one of the lucky 67 applicants that received an August ACA grant. The $162,500 will go toward a new health center in a largely Hispanic area of north Philadelphia, to be developed in partnership with the Latino advocacy organization Congreso de Latinos Unidos.

"One of the reasons we exist is because we can do things with such flexibility and speed and low administrative cost, in ways government alone can't do," says Dina Wolfman Baker, vice president of communications for PHMC. "We really don't have a fear that the need for that partnership will go away."

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