This special issue of the Journal of Ambulatory Care Management (JACM) is devoted to community health centers-their history and origins, their evolution and achievements, their relationship to broader developments in healthcare financing and organization, and their place and future in the American healthcare system. The issue brings together some of the nation's most important thinkers about health centers and healthcare for the poor and underserved; these thinkers collectively have produced a series of essays designed to give readers a solid grounding in health centers' achievements and challenges.
The deepest roots of health centers are found in more than a century of activism by community and public health leaders who, as Paul Starr reminds us in The Social Transformation of American Medicine, battled immense odds to bring basic healthcare to the nation's most disenfranchised populations: the immigrants who built America's great cities; the rural poor-including millions of migrant and seasonal farmworkers-on whose shoulders the modern US agricultural industrial behemoth rests; and the millions of individuals who, by virtue of age, disability, extreme poverty, homelessness, and incapacity, historically have lived at society's edges.
The modern health centers program celebrates its 40th anniversary in 2005. Its origins can be found in a healthcare experiment launched by a small group of young visionaries, with the help of an equally small and visionary group of federal officials from the Office of Economic Opportunity-the action arm of the War on Poverty. The experiment unfolded in inner city and rural communities across the country and it had an elegantly simple notion at its core: the belief that an innovative, broadened model of healthcare could transform the health of a population.
Two basic purposes undergirded the original demonstrations. The first purpose was to improve population health by anchoring sources of affordable, comprehensive, and high-quality healthcare in communities whose social and cultural isolation, economic circumstances, population health measures, and lack of healthcare resources combined to create enormous health risks and extraordinary levels of medical underservice. The population health conditions that surrounded the initiation of health centers seem almost inconceivable today. The first health centers opened their doors at a time when the US nonwhite infant mortality exceeded 40 deaths per 1000 live births, and nonwhite mothers routinely went without prenatal care. Life expectancy rates among disadvantaged populations were severely diminished and, in the poorest communities, diseases and conditions now associated with the Third World were common.
Health centers were intended to improve health by transforming healthcare in these communities. In their structure and operation, health centers introduced a specific, public health-oriented approach to healthcare, unbounded by either the cramped definition of medicine driven by the power and dominance of physicians and the strictures on medical practices imposed by medical customs and traditions, or the medically-driven definitional limits of healthcare that are the hallmark of conventional health insurance. Health centers also led the way in developing a generation of health professionals trained to practice in a style that we now label "culturally competent" and that, at its heart, incorporates into healthcare the characteristics and strengths of patients themselves.
The second purpose-and one that was explicit among the program's early leaders-was to translate the aspirations and goals of the civil rights movement into healthcare. This translational effort extended well beyond the fundamental act of anchoring healthcare in communities whose residents were disproportionately members of racial and ethnic minority groups. It included the nurturing and development of a new generation of minority health professionals, some of whom were health center patients or their children.
Most strikingly perhaps, health centers captured their civil rights roots-and their true community orientation-through the concept of community board governance. This concept remains at the heart of the program today and continues to be the feature that distinguishes health centers from all other forms of comprehensive primary healthcare for the poor and underserved. Community governance is not merely a legal requirement on which grants to health centers are conditioned. It reflects a basic belief that in order to function properly, a healthcare system must be grounded in an extraordinary level of accountability on the part of a "sovereign profession" unaccustomed to such externalities.
In a world of "consumer-driven" healthcare, health centers remain singular in their formal dedication to the role of healthcare consumers in determining the direction of their health system. For this reason, the sponsoring organizations that have led the establishment of health centers in communities throughout the nation-from mighty urban health departments such as Denver Health and Hospitals, to religious and faith-based sponsoring organizations and not-for-profit civic groups-have remained true to the concept of community board governance as the characteristic that sets health centers apart from all other models of accessible healthcare.
Collectively, these articles illustrate the relevance of health centers to the great challenges of the modern era. Regardless of whether the focus is on broadening access to care, controlling the cost of care, elevating healthcare quality and consumer orientation, or improving community and population health, the articles in this collection underscore the continued freshness of the health center approach to primary healthcare. The articles also remind us about what health centers need in order to grow and thrive for another 40 years.
First and foremost, health centers depend on Medicaid's continued presence and, indeed, its sustained expansion into the low-income, uninsured population. Medicaid is by far the largest source of health insurance for health center patients; it is also the single largest revenue source of health centers. At both the individual patient and the institutional level, Medicaid is the financial fulcrum on which health centers rest. As Karen Davis and Cathy Schoen wrote in their landmark study, Health and the War on Poverty, the importance of the marriage between Medicaid and health centers was understood from the two programs' earliest days. Aspirational goals for health centers' continued growth and achievement-along with health centers themselves-will fall by the wayside if Medicaid's strengths are diminished rather than enhanced.
Beyond a strong Medicaid program, health centers need other investments as well: public commitment to the capital financing necessary to be able to establish health centers in all low-income communities; ongoing grant support to enable subsidized healthcare for uninsured patients and provision of essential health support services not covered by health insurance; and a health workforce of clinical professionals, educators, and administrators who are not only well trained but who also are committed to the program's goals.
This special issue of JACM brings together some of the nation's best writers on the subject of health centers. Collectively, these authors explore the program and its accomplishments, as well as the long-term implications, for both health centers and their communities, of modern trends in the areas of healthcare costs, population health and health quality, and public and private financing of healthcare. The senior guest editors for this special issue, Ann Zuvekas and Bonnie Lefkowitz, are highly respected scholars who are themselves among the program's pioneers and seminal thinkers. The junior guest editors, Sara Wilensky and Michelle Proser, represent the new generation of young analysts whose writings and research in the coming years will help shape policy makers' understanding of health centers. Dan Hawkins, Vice President for Federal and State Policy at the National Association of Community Health Centers, who is an enormously respected voice in health center policy, has lent his talents to both the writing and the editorial shaping of this special issue. Finally, we extend our great thanks to Dr Norbert Goldfield, JACM editor, for his unflagging interest in health center research over the years, and for his support.
This special issue is an undertaking of the Geiger Gibson Program in Community Health Policy. Supported through gifts and grants from individuals, private funders, and health centers and their communities, the Geiger Gibson program is named after Drs Jack Geiger and Count Gibson, pioneers of the modern health center movement and untiring advocates for health and human rights.
Established at the George Washington University School of Public Health and Health Services in 2004, the program is a celebration of health centers and the communities they serve. Above all, the Geiger Gibson Program operates in the belief that any healthcare system ultimately is a window into the soul of the society that organizes and sustains it. Its broader purpose is to develop a new generation of health policy scholars and community health leaders, whose focus is on the nation's poorest communities, the challenges that arise in removing barriers to health and healthcare in these settings, and the implications of broader health trends and policy directions for the poor and medically underserved.
Sara Rosenbaum JD
Hirsh Professor and Chair, Department of Health Policy, The George Washington University, School of Public Health and Health Services, Washington, DC