Community health centers: health care as it could be

INTRODUCTION I. COMMUNITY HEALTH CENTERS II. COMMUNITY HEALTH CENTERS AND NATIONAL HEALTH GOALS III. GRADUATE MEDICAL EDUCATION: TRAINING DOCTORS TO FILL NATIONAL HEALTH CARE NEEDS IV. CONCLUSION INTRODUCTION This Article explores the potential of community health centers (CHCs) to become a central component providing health care in America. It focuses on health centers as a proposed solution to the dual national problems of access to care and the shortage of primary care doctoring. It argues that CHCs have the capacity to address the problem of access to health services and to provide a vibrant model for the revival of primary care. Part I deals with the history, structure, current scope, and funding of CHCs. Part II looks at national health care goals and how CHCs are uniquely poised to actualize those goals. The demonstrated successes and potential growth of the CHC model are viewed against the backdrop of national health care priorities established through the Healthy People 2010 report. Part III looks at physician workforce issues, Graduate Medical Education (GME), and efforts to extend residency programs to ambulatory settings, including CHCs. State initiatives to reform GME so that it will produce a physician workforce better adapted to meet local health care needs are discussed, and the needs for federal action are identified. The role of the GME funding structure is examined as a key component in shaping potential reforms. Finally, the conclusion summarizes the benefits delivered by CHCs and notes the need for systemic shifts to help facilitate the growth of this successful health care model. The broader policy questions of how CHC expansion fits into health care policy reform as a whole will be left to another Article. Nonetheless, a brief overview of the current state of the U.S. health care crisis helps place the expanded need for CHC services in perspective. In August 2000, a groundbreaking World Health Organization (WHO) survey evaluating national health systems worldwide ranked the United States 37th in overall health system performance--sandwiched between Costa Rica and Slovenia. (2) This dismal showing occurred despite the fact that the United States spends more on health care than any other of the 191 WHO nations. (3) In 2004, U.S. health spending rose to a whopping 15 percent of the gross domestic product, a higher percentage than any other nation, including those that provide universal coverage to all residents and those with much more modest Gross Domestic Products ("GDP"). (4) WHO Director-General Dr. Gro Harlem Brundtland says: "The main message from this report is that the health and well-being of people around the world depend critically on the performance of the health systems that serve them." (5) Though the methodology of the WHO study has been criticized, it illuminates the areas in which the U.S. health system clearly falls short. (6) The factor that had the greatest negative impact on the U.S. ranking was access to care. The most basic requirement of a successful health care system is that people have access to care when they need it. Health care is not a luxury good, reserved for the rich. It is a fundamental need, a precondition to being able to do virtually anything else--work, play, love, serve. In fact, the majority of Americans view health care as a "right and not a privilege." (7) This view reflects the American commitment to equality of opportunity, which logically leads to a social obligation to meet health care needs. (8) For a nation that prides itself on "equal opportunity for all," the United States is failing to provide the necessary baseline to enable all citizens to operate on a level playing field. If the disruptions of disease and injury are not met with the appropriate medical responses, these events can derail even the most determined of citizens. As the U.S. health care system stands today, tens of millions of Americans are living without a doctor to call if they are in pain or a medical office to accept them if they show up sick. …