Women's Health Issues 22-2 (2012) e119–e121

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Commentary

Opportunities and Challenges for Community Health Centers in MeetingWomen’s Health Care Needs

Peter Shin, PhD, MPH *, Jessica Sharac, MSc, MPHGeorge Washington University, School of Public Health and Health Services, Washington, DC

Article history: Received 20 January 2012; Received in revised form 31 January 2012; Accepted 31 January 2012

1 Federal grantees are commonly referred to as federally qualified healthcenters (FQHCs), and non-grantees as FQHC-look-alikes. FQHC and look-alikestatus qualifies health centers to receive cost-based reimbursement fromMedicaid and Medicare (Centers for Medicare & Medicaid Services, 2011).

2 Health center estimate based on 5.4 million female patients age 15 to 44served by health centers and proportion (93%) of patients with incomes below200% of the Federal Poverty level in 2010.

3

Introduction

The Affordable Care Act (ACA) creates a number of provisionsthat will better secure healthier pregnancies and general well-being for low-income women (Kaiser Family Foundation, 2012).Namely, the ACA expands Medicaid eligibility to adults under133% of the Federal Poverty Level, allowing women to enroll inMedicaid before becoming pregnant, and increases the avail-ability and affordability of private health insurance for womenwho are low income, but are not eligible for Medicaid (Collins,Rustgi, & Doty, 2010). The ACA also ensures access to primarycare for women by mandating services that must be covered byExchange plans, such as annual well-women preventive carevisits (Institute ofMedicine, 2011). Additionally, the ACA providesan $11 billion investment to double community health center(CHC) capacity,whichwill help to address the complexhealth andsocial needs of low-income women at risk for acute and chronicconditions. Although CHCs present an effective option forincreasing access to primary care for women under the ACA, theyface significant challenges in expanding their capacity tomeet theprojected increase in demand for care.

CHCs Improve Access to Comprehensive Primary Care forLow-Income Women

Currently, over 1,100 CHCs serve nearly 20 million low-income individuals with incomes below 200% of the federalpoverty level across 8,100 sites nationwide (Bureau of PrimaryHealth Care [BPHC], 2011). As a result, CHCs serve a populationthat is disproportionally poor and uninsured compared withother primary care settings, and that includes those at greaterrisk for poor health (Hing, Hooker, & Ashman, 2011). Comparedwith other primary care settings, CHCs have a number of uniquefeatures that enable them to serve as “one-stop shops” fora variety of health issues across the lifespan. Specifically, CHCs

* Correspondence to: Peter Shin, RCHN Community Health Foundation, 1633Broadway, 18th Floor, New York, NY 10019. Phone: 202-994-4144.

E-mail address: pshin@gwu.edu (P. Shin).

1049-3867/$ - see front matter Copyright � 2012 by the Jacobs Institute of Women’doi:10.1016/j.whi.2012.01.005

must meet the following requirements to qualify for federalSection 330 funding1 from the Department of Health and HumanServices Health Resources and Services Administration: 1) Theymust be located in a federally designated medically underservedarea or serving amedically underserved population, 2) theymustprovide a comprehensive range of primary health care services,3) they must be governed by a patient-majority board, and4) they must provide care for all patients regardless of income.

CHCs serve as an important source of care to a majorityfemale patient population and their services are tailored to meetthe full spectrum of women’s health care needs. Between 2000and 2010, the number of women who received care at CHCsdoubled from 5.7 million to 11.4 million (BPHC, 2001, 2011).Three in five (59%) CHC patients are female and approximatelyhalf (48%) of female patients are of childbearing age; in 11 statesand the District of Columbia, CHCs serve at least one in threelow-income women of childbearing age. Today, CHCs providemedical care to approximately one in five low-income women ofchildbearing age nationwide.2

Nearly all CHCs provide either on-site or referral services thatare key to patients’ health and mental well-being (Wilensky &Proser, 2008; Wise, 2008). CHCs offer a number of preventiveservices that are required tobe provided under theACA, includingimmunizations (e.g., human papillomavirus), prenatal care, leadscreening, genetic screening and counseling, contraception, PAPtesting, tobacco counseling and cessation, sexually transmittedinfection and HIV screening, and depression screening.3 Some

Health center data do not provide a more detailed list of services CHCsprovide. The general categories of services include general primary care, dentalcare, enabling services, behavioral health, specialty care, and preventableservices related to cancer and diabetes, which nearly all CHCs provide on siteor by referral.

s Health. Published by Elsevier Inc.

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CHCs provide services beyond traditional primary care, such asoffering long-term care options and hosting other federalprograms, for example WIC and Head Start, to better promotehealthier pregnancies and families (BPHC, 2008). In effect, theACA strengthens and expands access to primary care for womenand provides significant opportunities for CHCs to further impactwomen’s health.

How the ACA and CHCs Present Opportunities for ImprovingWomen’s Health

By 2014, approximately 10 million women will gain coverageunder Medicaid and 8 million will gain coverage throughsubsidized (7 million) and unsubsidized (1 million) privateExchange plans (Commonwealth Fund, 2011). However, if theindividual mandate provision of the ACA is struck down by theU.S. Supreme Court, fewer individuals than expected will enrollin health insurance (Sonfield, 2011). Although a small proportionof CHC patients are expected to be covered through exchangeplans, most are likely to be eligible for and enroll in Medicaid.Furthermore, the ACA requires exchange plans to cover preven-tive services such as immunizations (including human papillo-mavirus vaccines), prenatal care, interpersonal and domesticviolence screening and counseling, tobacco counseling andcessation interventions, alcohol screening and counseling,gestational diabetes screenings, folic acid supplements, sexuallytransmitted infection and HIV screening and counseling,contraception and depression screening, and well-women visitswithout cost sharing (Kaiser Family Foundation, 2011; U.S.Department of Health and Human Services, 2011). BecauseCHCs already provide comprehensive primary care, the ACAsignificantly enhances their ability to fully address the healthcare needs of newly insured women.

To meet the increased demand for primary care, the ACAinvests $11 billion for CHCs’ expansion and also provides $1.5billion over 5 years for the National Health Service Corps. Suchinvestments in primary health care infrastructure and healthworkforce capacity, particularly in medically underserved areas,are key to improving women’s health in the United States(Chavkin & Rosenbaum, 2008). However, CHCs face significantchallenges in meeting the projected increase in demand forservices.

Challenges for Expanding CHC Impact

Workforce shortages remain a critical barrier for CHCs todoubling their capacity. In general, CHCs already operate at orabove peak capacity given current resources, reporting over 3.1million clinical visits to 932 full-time equivalent obstetrician/gynecologists with an additional 1.3million visits to 520 certifiednurse midwives and over 264,000 deliveries in 2010 (BPHC,2011). In 2004, the CHC vacancy rate for obstetricians was 21%compared with 13% for family physicians (Rosenblatt, Andrilla,Curtin, & Hart, 2006); in a more recent study, the vacancy ratefor obstetricians was 18% for New York CHCs alone (McGinnis,Martiniano, & Moore, 2011). The workforce shortage problem isexacerbated in rural areas, because the mean full-time equiva-lent number of family physicians, internists, pediatricians, andobstetricians/gynecologists is significantly lower in rural healthcenters than in urban health centers (Rosenblatt et al., 2006).However, it is unclear how states that have relatively moresevere shortages can dramatically increase their provider supply(Ku, Jones, Shin, Bruen, & Hayes, 2011). Unless states can better

leverage available resources, CHCs may not be able to retainenough providers and increase capacity to meet the increase indemand.

Compounding general workforce issues are the ongoingthreats to CHC funding. In fiscal 2011, CHCs saw their basefunding reduced by $600million, which effectively reduced theirability to serve approximately 5 million patients, more than halfof whom are likely to be women. The $1.5 billion made availableseparately to the National Health Service Corps under healthreform to increase the medical, nursing, dental, and mentalhealth workforce in underserved communities was also reducedby $117 million. No doubt these losses translate to limited abilityto serve newly insured residents in medically underservedcommunities.

Even as CHCsmove toward addressing the primary care needsof newly insured patients and an increased patient volume, CHCsremain an important source of care for the uninsured. A study ofthe Massachusetts universal health insurance program foundthat while the proportion of uninsured patients at CHCs droppedfrom 36% to 20% post-reform, the total number of CHC patientsincreased by 31%, and CHCs currently serve over one in threeuninsured residents in Massachusetts (Ku, Jones, Shin, Byrne, &Long, 2011b).

In conclusion, the ACA substantially expands the definition ofprimary care for women across the lifespan and increases thechance that womenwill get the care they need. Given the successof CHCs in providing comprehensive primary care, CHCs are theideal sites in which to expand health care access to low-incomewomen. However, continuing funding threats and health work-force problems will likely hinder CHCs’ ability to build enoughcapacity to meet the needs of the large number of newly insuredpatients whilemaintaining their role as amajor source of care forthe remaining uninsured population.

Acknowledgments

This project was supported by the Geiger Gibson/RCHNCommunity Health Foundation Research Collaborative at GeorgeWashington University. The authors thank D. Richard Mauery,MS, MPH, for his provision of thoughtful reviews and commentsduring the preparation of this commentary.

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Author Descriptions

Peter Shin, PhD, MPH, Associate Professor of Health Policy at George WashingtonUniversity, focuses on the financing, organization, and delivery of quality healthcare to medically vulnerable populations.

Jessica Sharac, MSc, MPH, is a Senior Research Associate in the Department ofHealth Policy, George Washington University, where she conducts research for theGeiger Gibson/RCHN Community Health Foundation Research Collaborative oncommunity health centers, women’s health, and behavioral health.