community health centers as primary providers of health care

COMMUNITY HEALTH CENTERS AS PRIMARY

PROVIDERS OF HEALTH CARE

SHELLY RAYMER DUNCAN AND CINTHIA L . DEYE

In their essay, Shelly Raymer Duncan and Cinthia L. Deye examine the experience of community health centers as primary providers of health care. These centers provide quality health care for their clientele and operate in an efficient manner. The authors argue that community health centers are a viable mechanism for the provision of comprehensive quality primary care for underserved persons. For some consumers, community health centers represent their only real choice for health care services, when their other options include no health care at all or severe financial duress.

Introduction

This essay addresses the role that Community Health Centers (CHCs) have played in the recent development of the American health care system. CHCs provide a "choice" for consumers whose other choices would be either no care or severe financial duress. Specific topics addressed in this chapter include: What is a community health center (CHC)? Who do community health centers serve? What services are provided? How many are there? Why are CHCs an important model of healthcare? What quality of care is provided at CHCs? Are CHCs reducing health disparities? Are CHCs cost effective? And, where is there room for improvement? In this essay we will show that CHCs have had significant success in improving access to health care services for many low-income Americans, but that important gaps still remain if the ultimate goal is widely available, high quality health care for all Americans.

I. What is a Communi ty Health Center?

Community Health Centers, along with public hospitals and other providers, form the backbone of the health care safety net in the United States (Felland, Kinner,

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and Hoadley 2003). A Community Health Center is a provider of comprehensive primary health care to underserved persons through a program created and sustained by Congress to meet health care needs of underserved communities. The federal community health centers program was created in 1965 as a pilot program of the Office of Economic Opportunity (OEO) and was initially called the Neighborhood Health Centers Program. The program was initiated after early efforts in the War on Poverty quickly uncovered major and untreated health problems, particularly among children. Many of the urban and rural communities targeted for aid under OEO programs were severely isolated from traditional sources of medical care and encountered serious financial, language, racial and cultural barriers to care among the few private physicians who were available. The program established several principles defining its concept of a multidimensional neighborhood center. First, the center must be located in an area with a high concentration of poverty. Second, it should integrate and coordinate its services with existing health and other community facilities. Third, it should provide personal, high quality health care (including medical care). Fourth, it should involve members of the community through their participation on boards of directors. Fifth, it should provide employment opportunities and training for community residents.

The program used public funds to establish and operate medical care practices in poor communities with serious health problems and insufficient access to healthcare. These practices would be governed by non-physicians who would have the power to set clinic policy and to hire and fire clinic staff. The health care services provided included not only traditional medical services, but also services essential to overall health: including special services, home improvements, and environmental health. So, there was a holistic approach to community health problems. Initially, eight centers were established in 1965. Formal statutory authority to operate health centers was added to the Economic Opportunity Act in 1966. However, in 1967, resistance to program expansion had begun. The Partnership for Health Amendments of 1967 placed constraints on who could receive free care, restricted centers to locations only in very poor neighborhoods, and limited their authority to spend funds on non-medical health services. In 1975, the program ultimately was authorized in essentially its current form (Rosenblatt et al. 1997).

CHCs are not free clinics. Community health centers are private, non-profit, community owned and operated centers that are governed by volunteer con- sumer boards, which are comprised of at least 51 percent users of the health center. These board members serve as the voice of the community and assure that the needs of their community are continually being met (Illinois Primary Health Care Association [IPHCA] 2004). CHCs are funded through the Bureau of Primary Health Care, part of the Health Resources Service Administration, a branch of the Department of Health and Human Services (DHHS/HRSA/BPHC) to provide primary care for the underserved, generally low income and uninsured. CHCs employ a sliding fee schedule based on patient income and seek direct and third-party reimbursement for services. Nationally, about 28 percent of CHCs' revenues are derived directly from the federal government through

156 Ageing International/Spring 2006

funds authorized under Section 330 of the Public Health Service Act plus other federal grants. Remaining funds come from Medicare (7 percent); Medicaid (34 percent); other third parties (8 percent); state, local, and private grants (17 percent); and direct patient fees (6 percent). The federal and other grant funds are used largely to support care for the uninsured who constitute 40 percent (3.2 million) of health center patients (Shi 2000). The dependence on revenue from state and local governments through direct assistance and public health insurance payments leaves CHCs highly exposed to changes in public spending and priorities (Felland, Kinner, and Hoadley 2003).

By law, 1 centers can be located in or serve only areas designated as medically underserved by the Secretary of Health and Human Services. Federal law also pro- vides extensive regulation of health centers, including requirements regarding the services that health centers must furnish, and community governance still remains a requirement and hallmark of the program. Centers must set charges in accordance with patient's ability to pay so that care for low income patients is virtually entirely underwritten with federal grant funds and other revenues. Health centers, and other safety net providers, derive some of their medical staff from physicians and mid- level providers who are fulfilling grant and scholarship service obligations under the National Health Service Corps. The total budget for health centers, including grants, third-party revenues and patient fees, exceeded $2 billion in 1994 (Rosenblatt et al. 1997: 104-107).

The 1989 Federally Qualified Health Center (FQHC) legislation, which required states to pay CHCs for Medicaid services on the basis of reasonable cost, significantly increased the amount and proportion of CHC revenues attributable to Medicaid and facilitated expansion of capacity. As a result, both Medicaid recipients receiving care from CHCs and total CHC service users, including the uninsured, increased as grant funds previously subsidizing Medicaid were freed up (Shi 2000). Federally Qualified Community Health Centers (FQHCs) are federally designated and defined non-profit entities whose explicit purposes are to provide primary care services to the medically underserved and to serve as the focus for wellness activities in their communities. FQHCs must also meet the same criteria for CHCs. In exchange for meeting these criteria, and providing comprehensive primary care to all without regard to ability to pay, FQHCs by statute are granted a reimbursement structure different from other providers and are eligible for specific federal grant funding. Federal statute requires that FQHCs receive "cost-based reimbursement" for Medicaid ambulatory visits, which is maintained even within the context of managed-Medicaid programs (Mazur et al. 2001). FQHCs receive reimbursement based on encounters rather than the traditional physician fee for service schedule.

Because of the complexity of the patient population they serve and the significant proportion of non-paying patients, patient visit revenue generally covers only a portion of the total cost of operating such a center. The remaining revenue typically is derived from other payer sources, governmental grants and private philanthropy.

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II. Who Do Community Health Centers Serve?

CHCs serve the poor, uninsured, and a large percentage of ethnic and racial minorities in medically underserved areas and populations. An increasing number of people are using CHCs. In Illinois, 65,030 were served in 2000-01 and 79,583 individuals were served in 2001-02 (IPHCA 2002). 2 In Illinois, there was a dispro- portionate increase in CHC patients who are racial or ethnic minorities: in 2000-01, 44,635 minority patients were served and in 2001-02, 64,795 minority patients were seen (ibid.). They operate 180 different primary care sites across the state of Illinois, which provide 600,000 patient visits annually (IPHCA 2004).

Community health centers provide care to the medically underserved who experience geographic, economic, cultural, or other barriers to accessing health care and preventive services. Health centers are America's premier primary health care providers serving the working poor, uninsured, low-income elderly, and medically underserved. Across the nation, there are more than 13 million individuals that rely on a community health center for care. They are: 1 of every 6 low-income children, 1 of every 10 uninsured, 1 of every 12 rural Americans (5.4 million people), and more than 7 million members of minority groups (ibid.).

However, CHCs do not solve the problem of the uninsured. In 1998, of the 44.3 million uninsured in the United States, only 3.6 million (or 8 percent) were served by CHCs. In 1999, 82 percent of patients seen at CHCs were uninsured (Bailey 2000).

Called by various names--neighborhood health centers, community health centers, family health centers, migrant health centers, and rural health initiatives--CHCs, whose ranks numbered 685 organizations in 1996, served an estimated 8 million people during that year, including 5.2 million whose income was below the poverty line and another 1.6 million whose income was between the poverty line and 200 percent above the poverty line. Data collected through the Bureau of Primary Health Care shows that their patients are primarily drawn from specific ethnic or racial minority groups: 28 percent black, 32 percent Hispanic, and 4 percent other minority groups (Shi 2000).

IH. What Services are Provided?

CHCs provide comprehensive primary health care that is culturally and linguisti- cally appropriate, oral health care, behavioral health care, case management, and a whole person approach to health. Community-based health care is focused on primary rather than institutional or acute care (National Library of Medicine 2004).

For nearly forty years, community health centers have provided a primary care safety net for the nation's poor and underserved in both inner-city and rural areas. Since their inception in the 1960s, community health centers have been reaching out to people with no regular source of health care, offering them accessible, affordable, and appropriate health care in communities where the medically underserved live and work (NACHC 2004). CHCs incorporate the concepts of comprehensive and coordinated health services along with continuity of care within a single institutional setting by providing integrated care, primary and preventive care services. Their


central mission is to increase access to community-based primary health care services and improve the health status of medically underserved populations (Shi 2000).

CHCs make a difference by improving access to care, and reducing barriers to quality primary healthcare. Health centers bring health care providers, services, and facilities to people and areas often not served by other providers (IPHCA 2004). Health center uninsured users tend to live in poverty-stricken areas, are poorly edu- cated, and are African American or Hispanic; yet, uninsured users had more regular contact with a physician and a usual source of care whereas the overall uninsured did not (Carlson et al. 2001). CHCs contribute to the strength and well-being of their communities by providing cost-effective care, and by keeping both children and workers healthy. They have evolved to a substantial business interest whose impact is most felt at the local level, in the communities they serve (IPHCA 2004).

With few exceptions, CHCs as a group meet or significantly exceed prevailing practice across other ambulatory health care settings. In a study published in 2001, of the thirty-one care elements assessed across the four conditions, CHCs significantly exceeded care norms in ambulatory care settings for seventeen elements and only fell below norms for five. These reality-based norms place CHC performance in context with performance in other settings, although positive CHC results do not necessarily imply that performance levels are optimal, either for CHCs or other settings. At the same time, as the complexity of performing an element increases--that is, the element requires more specialized testing or referral to an external resource---CHCs appear to have more difficulty exceeding the literature norms (Frick and Regan 2001).

Upon examining the socioeconomic status of adult community health center users and their use of screening services for secondary prevention, it was found that users of minority or lower socioeconomic status were not less likely to receive preventive screenings and the screenings conducted were most often at a health center. The study concludes that health centers are indeed providing preventive services to vulnerable populations that would otherwise not have access to certain services (Frick and Regan 2001).

IV. How Many CHCs are There?

Nationally, there are over 850 CHCs with more than 4,600 sites serving 11.3 million patients. Illinois has forty-three centers with 180 sites that serve 13.4 percent of the uninsured in that state. President Bush has made a commitment to double CHCs and people served by them in his President's Initiative on May 1, 2002 (President's Initiative to Expand Health Centers 2002). The goal is to create new and expanded health center access points to impact 1,200 communities by the end of fiscal year (FY) 2006 and to allow (BPHC) grantees to reach an additional six million people over the next five years. The goal of the initiative was to build on the existing foundation of the 750 Health Centers that were serving over 10 million people (Uniform Data System 2001) and lead to an eventual doubling of the total number of health center users (President's Initiative to Expand Health Centers 2002).

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V. Why CHCs are Important Models of Care: Quality and Cost Effectiveness

Health centers improve access to preventive services, health outcomes, and have been successful in reducing or eliminating health disparities (Politzer et al. 2001). In a review of Maryland Medicaid patient records, health centers consistently scored at or near the highest in twenty-one separate measures of quality assessment, even though their costs of care were among the lowest of the various provider types re- viewed. Patients in medium-cost community health centers had the lowest total costs, lowest cost per ambulatory visit, lowest incidence of hospital inpatient days, and lowest inpatient care costs, when compared with Medicaid patients of 106 private physicians and nineteen hospital outpatient departments (Starfield et al. 1994).

A. Quality of Care: Accreditation

Under the U.S. Public Health Service Act, health centers must meet strict, uniform, high national standards of accountability (IPHCA 2004). About 33 percent (279) of CHCs had achieved Joint Commission on Accreditation of Hospital Organi- zations (JCAHO) accreditation by March 2003. FQHC grant recipients are required to undergo periodic Primary Care Effectiveness Reviews (PCER), which may be combined with JCAHO reviews. The PCER explores compliance with FQHC program requirements around management, finance, governance, clinical operations, and mission. Additionally, FQHCs submit annual Uniform Data System (UDS) reports to the BPHC, which provide demographic information regarding patients served, the type of services provided and information about the staff providing services. As is the case with most grant programs, FQHCs submit annual renewal applications and undergo competitive renewals on a periodic basis.

B. Risk Management

FQHCs are eligible to be deemed under the Federal Tort Claims Act (FTCA). ~ae FTCA holds that for purposes of medical malpractice, FQHC providers are em- ployees of the federal government. Therefore, any medical malpractice suit brought against a provider at a FQHC is in fact brought against the federal government. This program was implemented to eliminate the ever-escalating medical malpractice premiums. F]'CA deeming is not automatic, rigorous credentialing and risk management practices must be in place at an FQHC in order for deeming status.

C. Quality of Care Studies

The Institute of Medicine (IOM) praised health centers for their "strong track record in chronic care management, electronic patient registries, and performance measurement... [that] contribute to providing care that is at least as good as, and in many cases superior to, the overall health system in terms of better quality and


lower costs" and recommended them as models for delivery of primary health care (Institute of Medicine 2002). Comparing selected ambulatory care sensitive health indicators, states with significant CHC penetration demonstrate: less disparity between black and white patients in infant mortality; less disparity between black and white patients in provision of prenatal care; and less disparity in overall mortality between black and white persons (Shin et al. 2004). They also show less disparity between Hispanic and white persons in early prenatal care, and less disparity between Hispanic and white persons in rates of tuberculosis (ibid.). In another study, medical records of patients in CHCs demonstrated higher rates on four of six process measures of quality of care (Porterfield and Kinsinger 2002). CHCs meet or exceed prevailing practices for otitis media, diabetes, asthma, and hypertension (Ulmer et al. 2000). Medicaid beneficiaries with access to FQHC preventative services are less likely to be taken to the ER or hospitalized than those without access to FQHCs (Falik et al. 2001). Uninsured CHC users had more regular contact with a physician and a usual source of care than the overall uninsured did (Carlson et al. 2001). In a review of Maryland Medicaid patient records, health centers scored highest among all providers for the proportion of their pediatric patients who had received preventive services, including immunizations (Stuart et al. 1995). Another study found that incorporating principles of Total Quality Management (TQM) is easy to do in a community health center setting and can enhance the effectiveness of health care delivery to a community and its members (St. Martin 1996).

However, rates of adherence to process measures of quality were relatively low among community health centers, compared with the targets established by the American Diabetes Association. Studies performed in diverse settings, including community health centers, consistently indicate that many physicians are not providing key processes of care to their patients with diabetes (Chin et al. 2000). The quality of care varied significantly across community health centers. Compara- tive benchmarking might help community health centers learn the best practices from other community health centers performing well for given quality measures (Chin et al. 2000).

VI. Are CHCs Reducing Health Disparities?

CHCs are part of the Bureau of Primary Health Care's Health Disparities Col- laborative started in 1998. The mission of the Health Disparities Collaborative is to achieve excellence in practice through the following goals: (1) to generate and document improved health outcomes for underserved populations; (2) to transform clinical practice through models of care, improvement and learning; (3) to develop infrastructure, expertise and multidisciplinary leadership to support and drive improved health status; and (4) to build strategic partnerships. Health centers have long been laboratories for reducing health disparities, including such areas as immunization rates, infant mortality and low birth-weight, diabetes and cancer screening. Overall, the low birth-weight rates for CHC patients are lower, but the disparities continue to exist, illustrating the need to continue to reduce this condition (Bailey 2000).

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A study by Shin and colleagues (2003) found that as the proportion of a state's low income population served by health centers grows, the black/white and His- panic/white health gaps narrow (i.e., declines) in such key areas as infant mortality, prenatal care, tuberculosis case rates, and age-adjusted death rates. The study also concluded that Medicaid alone has little direct impact on health disparities, but Medicaid coverage for low income patients is key to health centers' ability to serve more of the low income in states, and in so doing reduces health disparities. As evidence of this, Shin et al. found that health center penetration (defined as the proportion of state low income served by health centers) had its lowest impact in reducing disparities for heart disease and diabetes related death rates (ibid.). These diseases disproportionately affect older low income and working-age minority adults, who are the least likely to have Medicaid coverage. Hence, it is the combination of customized, supported health care with comprehensive health insurance that may most effectively reduce health disparities. Interviews with health centers showed that they actively pursue clinical initiatives aimed at reducing disparity, including interpretation and translation services, social services, and transportation (ibid.).

A study from John Hopkins School of Hygiene and Public Health examined the contribution of health centers in reducing and eliminating disparities in access to care and showed that access to a regular and usual source of care alone can mitigate health status disparities. The safety net health center network has reduced racial/ethnic, income, and insurance status disparities in access to primary care and important preventive screening procedures. In addition, the network has reduced low birth weight disparities for African American infants. Evidence suggests that health centers are successful in reducing and eliminating health access disparities by establishing themselves as their patients' usual and regular source of care. This relationship portends well for reducing and eliminating health status disparities (Politzer et al. 2001).

VII. Cost-Effective Care

CHCs provide cost-effective, high quality health care. In fact, studies show that total health care costs for CHC patients are on average 30 percent lower than other providers serving the same population. Every grant dollar invested in a health center saves $7 for Medicare, Medicaid, and private insurance ($6 through lower use of specialty and inpatient care, and $1 from reduced use of costly hospital emergency rooms). According to the Kaiser Commission on Medicaid and the Uninsured, community health centers in Illinois saved the state $34.8 million annually in state Medicaid expenditures alone (Illinois Primary Health Care Association 2004). CHCs also save 26-40 percent on prescription drugs, 35 percent on diabetic care, and 20 percent on asthmatic care (Center for Health Policy Studies 1994). Another study found that states could save money by increasing their investment in health centers because they reduce high-cost specialty and hospital care (Hawkins and Schwartz 2003).

Preventable hospitalizations in communities served by health centers are lower than in other medically underserved communities not serviced by health centers.


Patients in underserved areas served by these centers had 5.8 fewer preventable hospitalizations per 1,000 people over three years than those in underserved areas not served by a health center (Epstein 2001). A study of Medicaid beneficiaries in five states in 2001 found that Medicaid beneficiaries who receive care at health centers were significantly less likely to be hospitalized or to visit hospital emergency rooms for ambulatory care sensitive conditions (ACSCs) than beneficiaries who receive care from other providers (Falik 2001). Health center patients have hospitalization rates that are equal to patients who saw private physicians and lower than patients who attended hospital clinics (Falik 1998). The per capita cost of care at all U.S. health centers in 1988 was $183, compared to $238 for all Americans below 200 percent of poverty (Zuvekas 1990).

In addition to being cost-effective, CHCs create jobs and improve the economy. Health centers challenge communities to take ownership in developing innovative programs to meet special community health needs. In Illinois, they have created more than 4,600 jobs and have a direct economic impact of over $212 million per year (IPHCA 2004).

VIII. Where is There Room for Improvement?

The elimination of health status gaps among minority and low income populations is part of the mission of community health centers. CHCs are frequently the only ambulatory care providers available to the underserved, low-income, and minority populations (Regan et al. 1999). However, according to the recent HHS health disparities report, there are still very significant disparities between U.S. populations (National Health Disparities Report 2003). So, there are still many barriers to care that remain unsolved by the CHC system.

The number of CHCs remained stable from 1996 to 1998, at a little over 600 grantees. In 1998, centers on average served more patients and provided care at a greater number of locations than they did in 1996. Nevertheless, The Center for Medicare and Medicaid Services (CMS) estimates that about half of the CHCs have some operational or financial problems and about 10 percent are struggling to maintain operations. While approximately 2 percent lost federal grant funding each of the last three years, about the same number of grantees entered the program. A high--and increasing--proportion of the centers' patient population is uninsured and a significant proportion is enrolled in Medicaid. In addition to primary care, CHCs provide ancillary services, such as transportation, but at times have had to curtail these services because of declining revenues. While federal grant funding for the CHC program increased significantly in recent years, from about $825 million in fiscal year 1998 to about $1.02 billion for fiscal year 2000, the program's major source of funding since the 1980s has been Medicaid payments (GAO 2000).

According to the 2000 GAO report, legislative and programmatic changes, including the growing use of managed care by Medicaid, can affect the number of

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Medicaid beneficiaries that CHCs treat and, in some cases, reduce centers' Medicaid revenues. In implementing mandatory Medicaid managed care programs, some states discontinued cost-based reimbursement for CHCs and some health centers in these states experienced declines in Medicaid reimbursements. The Balanced Budget Act of 1997 (BBA) allowed all states to gradually reduce reimbursement levels. BBA also required states to make supplemental payments to centers participating in Med- icaid managed care to cover differences between the managed care organizations' payments and the minimum reimbursement level established by BBA. However, some states had been slow in giving centers these required payments, resulting in reduced Medicaid reimbursements at some centers (IPHCA 2004).

In 2000, the GAO found that CHCs had adapted to recent changes in Medicaid and the overall health care environment, and that CHCs that had formed partnerships and networks and are participating in managed care are more likely to be successful. Attracting patients with diverse payment sources and pursuing other revenue sources--such as foundation grants--had also contributed to better CHC financial performance. CHCs that had not adjusted to the changes in Medicaid and the health care market and whose management and board had not paid sufficient attention to their financial operations were more likely to have problems (ibid.).

Also in 2000, a study found that CHCs involved in managed care have more diversified sources of revenue and depend less on grant funding than other CHCs, and they serve a significantly smaller proportion of uninsured and homeless patients. Involvement in managed care was also associated with greater financial vulnerability, reflected in higher costs and net revenue deficits. CHCs had become involved in managed care largely in response to external market pressures, such as the prospect of reduced federal grant funding. Other significant factors included center size, loca- tion, and the percentage of users who are Medicaid patients (Shi et al. 2000).

In 2000, the rapid increase of managed care participation among CHCs was no accident. Concerned that they may lose Medicaid patients, who accounted for one- third of their funding, an increasing number of CHCs were participating in Medicaid managed care arrangements. Since the onset of Medicaid managed care, four major models of CHC participation have emerged:

1. CHCs contract directly with the state within the context of primary care case management (PCCM). Centers receive cost-based reimbursement as well as a case management fee.

2. CHCs subcontract with health maintenance organizations (HMOs) as a primary care provider, usually beating some risk associated with primary care delivery.

3. CHCs form networks with other providers for the purpose of group contracting with an HMO.

4. CHCs form their own managed care plans and contract directly with the state for full risk (Shi et al. 2000).


IX. Conclusion and Parting Thoughts

CHCs are a viable mechanism for the provision of comprehensive quality primary care for underserved persons, so long as they are supported. CHCs do not provide specialty care; the fragility of the safety net is increasingly evidenced as CHCs seek to link to other needed services. Through CHCs, low-income and uninsured people's access to primary health services has improved, but serious gaps in care still exist. Many of the uninsured and people covered by Medicaid or the State Children's Health Insurance Program have significant problems obtaining specialty, mental health, and dental services. This is due to declining physician and dentist involvement, changes in funding and more people in need (Felland et al. 2004).

CHCs have been shown to furnish high quality health care and operate in an efficient fashion, but they have been criticized over the years for their failure to re- spond more decisively to the health problems of rural residents and for their failure to use more of the grant funds allocated to them to undertake additional expansions (Rosenblatt et al. 1997: 104-107). From 1990 to 2000, however, the number of CHCs has increased from 545 to nearly 700 and the number of delivery sites has increased from 1,400 to 3,000. There has also been a doubling of the number of people served nationwide, from 5.1 million in 1990 to nearly 9 million in 1999 (Bailey 2000). Expansion of CHCs, along with insurance coverage expansions, is a sure way to increase access to care for uninsured people (Cunningham and Hadley 2004). However, safety net organizations need to have a number of characteristics and strengths--that many do not have--to apply for and obtain federal CHC and CAP grants. Therefore, while CHCs have been a success for many communities, they are not a panacea for bridging significant gaps in safety net infrastructure or filling some of the largest holes in services for low-income people (Hoadley et al. 2004).

CHCs provide a "choice" for consumers whose other choices would be either no care or severe financial duress. Consumers who have private health insurance do not usually "choose" to utilize CHCs, perhaps because the services available there are limited and the lines are long, or because they do not have access to a CHC. In 2003, only 14.8 percent of CHC patients had private insurance (NACHC 2004).

Biographical Notes

Shelly Raymer Duncan, M.H.A., M.B.A. is vice president of Community Health Services at the Illinois Primary Health Care Association in Chicago, Illinois. She directs the association's efforts for implementation of technical services and related activities involving key association staff, association members, and agencies of local, state, and federal government. Prior to her current position, she served as director of plan development and compliance for Community Health Choice in Chicago, an HMO contracted with the State of Illinois.

Cinthla L. Deye, B.A. is a graduate student in the Medical Scholars Program at the University of Illinois at Champaign-Urbana. She is working on both an M.D. degree at the U of I College of Medicine and a Ph.D. in the Department of Community Health with a focus in health policy. Her research is on the impact of the State Children's Health Insurance Program on health disparities among low-income children in Illinois. She recently co-authored the article, "The

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State Children's Health Insurance Program: an Administrative Experiment in Federalism;' published in the U. of lllinois Law Review.

Notes

1. 2.

42 U.S.C.A. § 254c(b)(1). 2002 UDS, from graphs created by Kathleen Burton, Data Analyst, IPHCA. Increase in Health Center Patients < or = 200 percent of FPL and Racial/Ethnic Minorities (% known) Illinois 330 Grantees.

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