Book Review: Out in the Rural, A Walk Back in Time

Few may realize the remarkable history behind the Civil Rights Movement and its role in launching Community Health Centers.  The narrative of how this happened is eloquently told in a new book, Out in the Rural: A Mississippi Health Center and its War on Poverty (the title is borrowed from a short film of the same name produced in 1969).  Author and history professor Thomas J. Ward vividly deconstructs how a small group of medical students and young physicians from far-flung parts of the country organized to provide health and triage care to activists who descended onto rural Mississippi during Freedom Summer. The group, among them H. Jack Geiger, MD, called themselves the Medical Committee for Human Rights (MCHR). It was their small but fierce coalition that launched what one activist called “the medical arm of the Civil Rights Movement.”

Though initially immersed in fighting voter suppression during Freedom Summer, Ward describes MCHR’s shift from engaging in civil rights activities to improving the shocking conditions of African Americans living in Bolivar County, MS. Ward writes, “They became convinced of the inability to truly bring about racial equality without dramatic improvements in the health care of the state’s black population.” Scores of people went without medical care and struggled under poor living conditions —   living in dilapidated homes without toilet facilities or plumbing, and suffering from malnutrition. The infant mortality rate for African American children was 54.4 deaths per 1,000 live births, more than twice the rate for white children. Bob Smith, MD, a physician with MCHR, recalled:

“I understood for the first time what it truly meant to be black in Mississippi and underprivileged, and poor and without medical care, and saw people by the hundreds, and really by the thousands, go without medical care… Saw what I call a Third World Country…People had been denied benefits under Social Security… Thirty to 40 percent of children had intestinal parasites…The maternal mortality rate was out of this world.”

Image courtesy of Dan Bernstein, Southern Historical Collection, University of North Carolina at Chapel Hill.”

The story of how Geiger joined with other pioneering activists, including John W. Hatch, L.C. Dorsey, and Andrew B. James, to start a Community Health Center and address the health needs of the medically underserved in Bolivar County is well established. We know the health center in Mound Bayou, now known as the Delta Health Center, was one of the nation’s first two Community Health Centers, along with urban Tufts-Columbia Point Health Center in the Dorchester neighborhood of Boston. Lesser known are the struggles, large and small, that took place on the ground, including no small amount of skepticism from the white and African American residents as these dedicated activists attempted to launch a program that reached beyond addressing basic health needs and become, as Dr. Geiger put it, “an instrument of social change.” This was the boldest effort yet to not only treat illness but to directly intervene against the root causes of it – poverty, lack of food and jobs, and poor drinking water.

“To treat symptoms, and then to send patients back, unchanged in knowledge, attitude, or behavior, to the same physical and social environment – also unchanged—that overwhelmingly helped produce their illness and do so again, is to provide antibiotics for cholera and then send patients back to drink again from the Broad Street pump.”

Programs began to take shape in Mound Bayou to target the environmental conditions affecting the community. An agricultural co-op was established to fight food scarcity, and Dr. Geiger regularly prescribed groceries from the health center’s pharmacy for malnourished families, explaining, “The last time I looked in my textbook, the specific therapy for malnutrition is food.”

Geiger and the team at the Tufts-Delta Health Center also labored to resolve the problem of unclean drinking water and sewage disposal, the hallmarks of poverty and disenfranchisement that, until that time in history, had been the status quo.  Ward offers up a rich narrative that is instructive in demonstrating how entrenched local communities and public officials can be when it comes to resisting progress.  Bureaucracies needed to be unraveled and stubborn civic leaders needed to be coaxed. History writ large can often fool us into thinking that change is immediate when people mobilize, yet this is hardly the case.  Ward provides the context, the small skirmishes, the obstructionism, and the exhaustive effort required to empower people used to being forgotten.

More than 50 years later, original mission of MCHR and  Tufts-Delta Health Center to address the social determinants of health continues to this day in the Community Health Center Movement. There are nearly 1,400 health centers across the country in rural and urban areas providing not just excellent care, but local solutions that improve population health, create jobs, and empower communities.  “That is what we do: make a road out,” explained Dr. Geiger. “We work with people to build a road out of their circumstances, out of the inequity, out of poverty.”

New Studies On Quality of Care at Health Centers

New research published today in Health Affairs underscores the value of Community Health Centers and their longstanding partnership with Medicaid. Two studies focused on states that opted to expand the public insurance program under the Affordable Care Act and  provide clear links between the Affordable Care Act’s expansion of Medicaid and improved care quality at health centers.

“The first year of Medicaid expansion was associated with increases in insurance coverage and improvements in asthma treatment, BMI screening, pap testing and blood pressure control,” wrote the authors of the study from Brown University [see Becker’s Health Care article].

The study looked at comparative data between states that expanded Medicaid and those which did not and found higher rates of insurance among patients in expansion states by just over 11 percent.  The impact on quality care for patients was also affected.  More patients came to health centers for care in expansion states and were substantially more likely to contribute to their health centers’ revenue (due to having insurance) and more likely able to purchase medications and access specialty care.

Another study in Health Affairs by the Center for Health Policy Research at George Washington University [See Kaiser Health News article] also uses data to examine Medicaid. In this case, researchers looked at data from 2012 to 2015 to track visits to Community Health Centers.  Again, in states that opted for expansion, health centers experienced more patient visits, lower rates of uninsured patients, and an increase in patients seeking mental health care.

With so much uncertainty about what the future holds for health care, these studies provide solid data showing the value of having both access to health care and coverage.

Both studies are available to Health Affairs subscribers here.

Innovation and Partnerships Bloom in Rural America

What happens when two adversaries meet in health care? In Hazen and Beulah, North Dakota, where a Community Health Center and Critical Access hospital were vying for market share and staff, something extraordinary took place.  They decided to work together.   The two organizations, Sakakawea Medical Center and Coal County Community Health Center, realized that cooperation was better for the bottom line than competition.  So the two started talking.  That was six years ago.  Today, the two entities are a success story as one of the few hospital health center combinations in the country that share leadership and have integrated governance and staff — and they are gaining notice.  They won the 2015 Outstanding Rural Health Organization award from the National Rural Health Association (watch video about the award).

“When individuals or organizations work together towards a common goal there are no disadvantages,” says Darrold Bertsch, who serves as Chief Executive Officer of both Coal County Community Health Center and Sakakawea Medical Center.  “We are seeing improved patient care, improved patient outcomes, and in a rural area like ours people should not have to settle for less.”

How this unusual model came about is a story about vision.  Competing for the same market share, services and staff produced a lot of duplication, as well as an adversarial relationship.  When the prior CEO of the health center and the health center governing board chose to end their employment relationship, with the encouragement of the health center Medical Director, the boards of both organizations saw an opportunity for shared CEO relationship, and indeed a shared vision.  Now, the hospital and health center boards are working together, sharing resources and training, and even providers back and forth as needed.

“The collaboration between the two organizations has provided a host of benefits for health care delivery in our area,” explains Bertsch.  “There is now a community framework in place to conduct a collaborative community health needs assessment for the services areas so we can develop a strategic plan and a community health improvement plan  around the health needs of the entire community — the local nursing home, ambulance service and public health agency.   Steadily, we are reducing the fragmentation and waste of resources that all too often drive up costs and reduce the quality of patient outcomes in health care delivery.  So much good can come of working together and forming a shared mission.  That is how health care is supposed to work.”



NACHC Year Ender Round Up

The year 2016 started with NACHC’s efforts to reach out across multimedia channels and share the compelling success of Community Health Centers.  We began our podcast series to showcase how health centers innovate, save health care costs, attract bipartisan support and confront the emerging public health crises of our times.  The podcasts help listeners gain insight from the frontline perspective about how health centers solve problems in their community — problems that so often are linked to preventable illnesses and chronic disease.  We featured a health center mobile van that is fighting an epidemic of tooth decay among children in Nevada, AIDS/HIV prevention in rural Iowa, and dealing with opioid addiction in West Virginia. These are our stories.

Health centers were also widely featured in the news media on various fronts.  Here is a breakdown of the year’s highlights:

An overwhelmingly bipartisan coalition of House and Senate lawmakers called on key subcommittee chairs  “to recognize health centers as providers of high quality, cost-effective primary care” and to ensure continued funding for a model of care that offers a “bipartisan solution to the primary care access problems” facing the U.S.   In an otherwise politically contentious election season, health centers drew a rare consensus on Capitol Hill as a successful health care solution [see NACHC release].  The media paid attention.

“I doubt there is any program that has delivered more in terms of saving both lives and taxpayer dollars over the course of over the last half century.”

Ricardo Guzman, NACHC Board Chair, The Hill newspaper, November 4, 2016

“Health centers treat patients for a fraction of the cost of one emergency room visit.  Health centers not only focus on illness prevention, they reach beyond the walls of the exam room to address the factors that actually cause poor health, such as homelessness, lack of nutrition, stress or unemployment. They are innovators in treating chronic conditions that are typically ignored until they become a costly illness.”

NACHC CEO and President Tom Van Coverden, The Pulse, a blog published by the Community Clinic Association of Los Angeles County, August 3, 2016

It was easy to make the case for supporting health centers because of their longstanding record of cost-savings, as evidenced by the published release of a landmark report on Medicaid savings at health centers (“Health Centers Save Medicaid 24 Percent, Health Leaders Media“).

The critical role that health centers play in addressing emerging public health threats, such as Zika, opioid addiction, and contaminated water in Flint, MI,  was also under the spotlight, as was their role in caring for growing numbers of veterans (see NACHC release).  In fact, new data showed that the number of health center patients who are veterans grew by 43 percent in less than a decade (from 2008 to 2015) to 305,000 from 214,000. Nearly 9 in 10 health centers serve veterans, who are able to access a wide range of services in addition to primary care.

Health center challenges in recruiting and retaining the workforce needed to meet the demand for care was also widely featured in the media:

“CHCs also innovate to recruit and retain staff members, especially family physicians. In an examination of recruitment needs at CHCs across the country, the NACHC report showed that family physicians are in greatest demand. Nearly 70 percent of CHCs had an open position for a family physician and 51 percent said their highest priority vacancy was for a family physician. Salary was ranked as the largest obstacle to recruitment and retention.”

AAFP News Now, March 23, 2016

Health centers also continued to prove they are innovators in health care. From embracing health information technology to integrating behavioral health care in order to provide patient centered care, health centers stood out. 

“This week, let us thank the dedicated professionals in our Community Health Centers who provide quality care at affordable prices. Let us build on their efforts to improve the well-being of our people and together continue working to bring about a stronger, healthier Nation for all.”-President Barack Obama,  National Health Center Week 2016 White House Proclamation.

We look forward to sharing the successes of 2017 in this blog. Stay tuned!


Fighting Opioid Addiction: An Update

It’s been a while since we updated you on the activities related to fighting opioid addiction — a task Community Health Centers are taking on with vigor and innovation. First, with $500 million in hand to fight the opioid epidemic, White House officials are moving quickly to get that money flowing to the hardest-hit states—and pushing local officials to spend the new dollars on treatment above other addiction-related initiatives. Earlier this week the President signed into law “The 21st Century Cures Act,” sweeping legislation that packages together various health policy provisions related to cancer research and the Federal Drug Administration (FDA) approval process for medications (including several provisions that are helpful to health centers that you can read about in more detail in this press release). But the law also funds mental health services and efforts to fight substance abuse.

The focus on this public health crisis could not come at a more urgent time.  As we noted in a previous blog post, the U.S. Surgeon General’s office reports that one in seven people in the United States is expected to develop a substance use disorder at some point, but only 1 in 10 will receive treatment.  Meanwhile, nearly 80 Americans die every day from an opioid overdose.   In West Virginia, also known as “ground zero” for the epidemic, the numbers are far more startling.   Louise Reese, CEO of the West Virginia Primary Care Association, recently described it this way in an op-ed published in the Charleston Gazette-Mail:

“A high unemployment rate, a disproportionate share of manual labor jobs with high injury rates — in addition to aggressive marketing by pharmaceutical companies — all have contributed to our state’s vulnerability. We have paid dearly. West Virginia claims 32 overdose deaths per 100,000 people, nearly triple the national average in 2015.”

Reese goes on to describe efforts the state’s health centers are launching in collaboration with local partners to address every aspect of the crisis, including its direct impact on families and children.

“Health centers are forging partnerships with state and local organizations, schools, churches, the mental health community, pharmacies and law enforcement because we recognize we can all be more effective when we work together. We are developing approaches aimed at helping families and children affected by addiction. A case in point is Handle with Care, a program implemented by the West Virginia Center for Children’s Justice, to support children in school who have experienced a traumatic event. West Virginia health centers operate 143 school-based health centers and are in a position to support this program with additional behavioral health services. Health center providers will be participating in an interactive web-based system called Project Echo to receive consultation from specialists on evidence-based treatments for chronic pain management and opioid addiction.”

You can also listen to our podcast on opioid addiction, featuring Reese and journalist/author Sam Quinones by visiting this link.