Alaska Health Policy Review

Community Health Centers (CHCs) are sponsored and operated by not-for-profit organizations, local governments, and tribal organizations. In Alaska, a network of 26 CHCs serve patients at 124 sites, providing services to more than 80,000 people through 360,000 patient visits. The growth of CHCs in Alaska has been both recent and rapid.

Anchorage Neighborhood Health Center, funded in 1974, was the pioneering CHC in Alaska. In 1995, Interior Community Health Center in Fairbanks became the second CHC in the state. Since 1995, the number of CHCs has expanded to 26 organizations, which reach across the state to serve Alaska's most vulnerable residents.

One unique aspect of the Community Health Center organization is its governance. Each CHC has a governing body, composed of volunteers from within the community. At least 51% of the board must be consumers of CHC services. This helps ensure that each CHC provides the appropriate, needed services for its particular community without wasting resources for unnecessary services. The board works closely with the medical staff and the administration of the health center. Community Health Centers remove common obstacles to care, which distinguishes them from most private, office-based practices.

CHCs serve communities that otherwise confront financial, geographic, language/cultural and other barriers. CHCs are located in high-need areas-areas identified by federal and state government as having elevated poverty, higher than average infant mortality, and fewer practicing providers. CHCs are open to all residents, regardless of insurance status, and provide reduced cost care based on ability to pay through a sliding fee scale. Here are a few additional facts about Alaska CHCs:

More than 50% of patients are at or below the Federal Poverty Level (FPL)
42.2% of patients served by CHCs are uninsured
30% or 34,000 of Alaska's 114,000 uninsured are served by CHCs
22% of patients served have Title XIX or Denali KidCare coverage
14% or 18,000 of Alaska's 128,000 Medicaid enrollees are served by CHCs
7.5% of patients served have Medicare coverage
33% of patients are under age 21; 60% are age 21 to 64; 7% are age 65 or older
More than 35% of patients served are Alaska Native/American Indian

(above information supplied by Alaska Primary Care Association)

Recently, the National Academy for State Health Policy (NASHP) released a report, Community Health Centers and Health Reform: Highlights from a National Academy for State Health Policy Forum, which details findings from a spring 2008 meeting on health care reform. The NASHP is "an independent academy of state health policy makers working together to identify emerging issues, develop policy solutions, and improve state health policy and practice." In May of 2008, NASHP convened a one-day meeting with 40 participants, including representatives from organizations in Alaska. Their dialog generated the ideas that formed the report, which focuses on the role of federally qualified health centers (FQHCs) in helping policy makers meet their goals for health care reform. Community Health Centers are one form of FQHC.

This article is a summary of the NASHP report, which gives current examples of promising efforts to increase access to health care in the U.S. and improve the quality of care. Emphasis is placed on the ability of FQHCs to improve health care access and coverage to those who need it most. The state examples include actions that Alaska has taken, including the use of lay community health workers to fill service gaps in underserved areas.

The use of technology is discussed as well. Technology can be used in the application of more efficient state service program enrollment procedures, and as a tool for recruiting and retaining providers. The report focuses on both health care providers and system capacity to tackle chronic health conditions. It also addresses the issue of meeting workforce demands should universal coverage be implemented.

Federally Qualified Health Centers

FQHCs are required by federal mandate to provide services to medically underserved populations, or to be located in medically underserved areas. Three types of health care facilities are considered FQHCs: Community Health Centers (CHCs), which are public and private nonprofit clinics that receive federal grant funds and meet specific Medicare and Medicaid standards; Look-Alike Health Centers, which are similar to CHCs except that they do not receive federal grant funding; and Tribal or Urban Indian FQHCs, which are outpatient health programs or facilities operated by Tribal or Indian organizations.

In Alaska, FQHCs are most commonly referred to as Community Health Centers, and the Alaska Primary Care Association (APCA) is a group dedicated to increasing funding for, capacity, and availability of CHCs. According to the APCA, CHCs help to reduce the barriers to care by providing services in communities that face financial, geographic, language/cultural and other barriers. The Alaska Primary Care Association describes Community Health Centers as:

Located in high-need areas identified by the federal and state government as having elevated poverty, higher than average infant mortality, and where fewer providers agree to practice
Open to all residents, regardless of insurance status, and provide reduced cost care based on ability to pay
Tailoring services to fit the special needs and priorities of local communities, and provide services based on the advice of local residents, businesses, churches, and other organizations
Offering services that help patients access health care, such as transportation, translation, case management, health education, and chronic disease management

The health care crisis is not only a result of high numbers of the under-insured and uninsured. It is partially the result of a lack of effective health care delivery systems that enable the regular use of primary care and comprehensive services. There are many ways that Community Health Centers can help states increase health care access and improve the quality of care. They can identify and enroll individuals in care, establish a regular source of ongoing health care, and provide comprehensive and coordinated (and ultimately, more effective) health care.

Increasing Enrollment for Eligible Individuals

Recently, Pennsylvania and Delaware implemented more aggressive programs to increase enrollment and retain eligible individuals for medical assistance. In response to survey results showing high numbers of the uninsured and low numbers of FQHCs, the state of Pennsylvania funded 2.9 million dollars toward FQHCs, nurse manager centers, and mobile wellness vans.

Delaware's Public Policy Institute, a nonprofit research organization, released a report in 2008 recommending a two-pronged method of reaching the uninsured, targeting both those eligible for assistance but not enrolled, and low- to moderate-income uninsured workers and their families. Delaware's efforts used an existing program, the Community Healthcare Access Program (CHAP), the Robert Wood Johnson Foundation's "Covering All Kids and Families Program", as well as a public media campaign to help achieve their goals.

Increasing Regular Use of Primary Care Services

The term "medical home" is now mentioned more frequently in health care reform discussion as a means for improving the quality and consistency of care. The NASHP report highlights recent findings that FQHCs are better able to meet the requirements of a medical home than health maintenance organizations. A medical home fulfills four principles:

1) provides a personal physician for first-contact care
2) delivers ongoing care over time
3) has the capacity to deliver comprehensive care
4) coordinates care across an individual's conditions, providers, and settings.

Improving health care involves not only increasing the number of the insured, but attending to the factors that impede the regular use of primary and preventive care. Health care reform requires finding ways to remove barriers to continued care such as transportation, communication, and cultural barriers. Delaware uses care coordinators to assist individuals in finding a physician, as well as provide assistance with transportation and translation.

Another option discussed in the NASHP report is changing health care systems to better meet the needs of the consumer rather than the provider. One such change would be extending hours of operation. Many Community Health Centers already do this, and have seen a surge of clients that might otherwise seek care in an emergency room. Extended hours along with the coordinated services of local transportation, case workers, and interpreters, might serve to increase continuity of care.

Health Information Technology (HIT)

Health information technology is a key component in health care reform, given its potential for multiple uses across the health care delivery spectrum. Methods discussed at the NASHP forum include using more advanced computer programs to assist in enrollment processes (which can take up to one hour and often deter eligible individuals), and using HIT as a means for recruiting and retaining qualified health professionals.

HIT might also play a vital role in coordinating care, where health care is tracked consistently and follows the patient from visit to visit and between providers. HIT could decrease medical errors and increase patients' ability to navigate the health care system. HIT might facilitate monitoring patients' health and keeping track of records across multiple types of services.

In Washington D.C., recent efforts use HIT to track trends in health, manage billing and scheduling, and educating clients about their own health histories and potential health risks through patient software programs. With high national rates of chronic conditions, especially among the underserved, HIT will be required to contain costs and improve quality of care for complex conditions. Other uses for HIT include referral services to specialists for Medicaid enrollees, as well as linking providers that offer special rates and services to clients in need.

Common barriers to successful implementation and use of HIT include a lack of infrastructure. One suggestion for HIT goals was the presence of Medicaid as a health information technology hub that serves as a web portal.

The objective of this action is for Medicaid-only management of data for the state, which could allow states better manage population health and design local health care systems based on the available data. Implementation of this infrastructure would use Community Health Centers as training arenas for community-based providers and staff. For success in this area, it will be crucial that Medicaid systems have a solid foundation and strong management.

Comprehensive Services and Care Coordination

Community Health Centers are required by law to provide a range of services, including primary care, diagnostic laboratory services, prenatal and perinatal services, cancer and disease screening, emergency medical and dental services, and pharmaceutical services. In an environment of increasing chronic illness, comprehensive services are necessary to meet the needs of the chronically ill. Chronic disease care is often first in state health care reform plans, primarily as a measure of reducing health care costs.

CHCs are capable of delivering comprehensive service for chronic disease due to their success with Health Disparities Collaboratives (HDCs). These collaboratives are a part of a national effort of to bridge gaps in care that result in higher disease rates among minorities and the poor. Currently, there are almost 800 health centers participating in HDCs, working together with state primary care associations' staff and others to improve health center capabilities to better serve patients with chronic conditions.

Other efforts of Community Health Centers to improve comprehensive services capabilities include coordinating common services used by clients (such as behavioral health care and acute care, or WIC health services with food stamps). Co-location of these services can help reduce barriers to care, and has the potential to improve continuity of primary care. In Alaska, Community Health Centers have emerged from mental health clinics, and one CHC, Peninsula Community Health Center, has merged its facilities with a community mental health center, Central Peninsula Counseling Services.

Workforce Challenges

Continuity of care requires the availability of regular services. Our current health care system faces workforce shortages that could increase substantially in the event of increased health care coverage. At the state level, examination of this issue has shown that even after controlling for income, states with more primary care physicians have reduced mortality rates and greater life expectancies. Selected state actions include adding an accelerated track for students who commit to stay in the area (Michigan), and the use of residency programs as a method to fill service gaps (Arizona).

Increasingly common methods used to retain health care professionals include loan reimbursement and repayment programs. These methods were discussed at length in the 2008 Alaska legislative session and will most likely reappear in January when the legislature reconvenes. Legislation passed in the 2008 legislative session involved expanding access to care through laws that assist licensure for health care professionals. In rural areas especially, the licensure of mid-level and lay practitioners is crucial to ensuring health care access for all Alaskan residents. Alaskan efforts were highlighted in the NASHP report:

Alaska has no formal workforce commission, but it does have a collaborative that includes the state primary care and nursing associations and a university to address recruitment issues. The state has been progressive in addressing scope-of-practice issues, using mid-level practitioners significantly more than other states. The state also licenses and certifies lay alternative providers through the community health aide program within the tribal system.

Conclusions

Community Health Centers have tremendous potential to meet policy makers' goals in health care reform. The offer high quality care to meet the medical needs of the under-insured and uninsured. Community Health Centers can help identify and enroll individuals into care, establish a regular source of ongoing health care, and provide comprehensive and coordinated services at lower cost than many alternatives.

Back to top