The United States health care system is plagued with at least three serious problems: rising costs, deterioration of the health care safety net, and inadequate public and private health insurance. With 47 million people uninsured, comparative health statistics that rank the U.S. below other industrialized nations, and wide performance variations within the country, it is clear that bold strategies—requiring public and private resources from national, state, and local levels—are essential.
Community health initiatives—locally crafted responses to health care access problems—have been steadfast in their efforts to connect uninsured and medically indigent people to health care services and health insurance. Typically, they unite community leaders, providers, and other key stakeholders, building on good-faith relationships to reduce uncompensated care and support the local safety net.
Recognizing that merely referring people with complex medical and social needs to care is often insufficient, these initiatives assist in outreach, coordinate and integrate care, and help clients use limited resources efficiently. Previous research has catalogued and described individual community efforts, evaluated the results of specific funding programs, explored how local efforts can substitute for national or state programs, and examined the role of local efforts in changing national policy. This study offers new insights about community initiatives and the successes and challenges they face. Findings fall into the following three areas: 1) the critical importance of state context; 2) the need for community health initiatives and, paradoxically, the difficulty of sustaining them; and 3) the challenges of replication.
The research team developed case studies of five community health initiatives that seek to improve access and coverage for those most likely to be uninsured: low-income, nonelderly adults.
Highlights from the five case studies include:
- Community Health Works in Forsyth, Ga., has served nearly 4,000 uninsured residents with incomes at or below 200 percent of the federal poverty level since 2001. The program emphasizes appropriate use of services and a rigorous case management element across the continuum of care, and enrolls only residents with any of four specific chronic diseases: hypertension, diabetes, heart disease, or depression. Community Health Works estimates that its clients use 40 percent less hospital care and 15 percent less emergency room care than a national control group.
- The General Assistance Medical Program (GAMP) in Milwaukee, Wis., served approximately 26,000 county residents in 2004 with incomes less than $902 per month. The program makes services available at 17 clinics (including federally qualified health centers) in 23 sites and 10 local hospitals. It leverages millions of national, state, and local dollars to serve the county's uninsured.
- Choice Regional Health Network in Olympia, Wash., helps people enroll in Medicaid, the State Children's Health Insurance Program (SCHIP), and the Washington Basic Health Program. The program has enrolled as many as 17,000 local residents since 1996. Ninety-eight percent of its applications result in enrollment (compared with 4% of individuals who enroll on their own) and 96 percent remain enrolled three years later (compared with 40% who enroll on their own).
- Community HealthLink's Health Care Access Program in Ratcliff, Ark., is a network health insurance plan currently serving 120 working uninsured residents with incomes below 300 percent of the poverty level. Employers and employees support two-thirds of the cost of coverage, and HealthLink has developed a subsidy fund to cover the final third.
- Project Access in Wichita, Kan., serves uninsured residents with incomes below 200 percent of the poverty level. The program enrolls eligible residents when they seek care for a health problem and links them to a "medical home" for ongoing primary care. The program covers primary care for three months and specialty care for six months.
Success Factors and Barriers
Context matters. Across the five case studies, it is apparent that state political, economic, and social context matters. Local programs can support or complement state public and private insurance programs, but are unlikely to thrive independently. Community initiatives that do not capitalize on state policies and resources struggle against greater barriers.
Sustainable leadership, funding, and evaluation. Despite their value to both individuals and the community as a whole, local initiatives are difficult to sustain. Community leaders identified several organizational attributes as necessary for sustainability: strong, dedicated leadership; funding sources, including provider volunteerism, Medicaid partnerships, and federal grants; and data to evaluate and demonstrates initiatives' success.
Challenges of replicating local initiatives. Diffusion of innovation among community health initiatives is more likely when there is extensive face-to-face communication between individuals in the original and replication sites, and when there are contextual and organizational factors that are common to both sites. This research indicates that important contextual factors include strong local leadership, high levels of knowledge among interconnected parties, and a state environment with opinion leaders and change agents who value local innovation.
Organizing local resources to contribute to health care access and health status improvement is a critical and often neglected component of the health care system. Local initiatives provide bridges to public and private coverage, create steps to care for those who are not covered, and serve as a vehicle for investment.
Because all community health initiatives are, in effect, created by national and state policy, it follows that changes in policy would cause the initiatives to adapt and change. Policy change in the current environment, however, would not eliminate their purpose: to serve low-income residents at the edges of both public programs and private coverage. Some proposals at the national level—in particular, block grants to finance Medicaid—could greatly increase the need for community initiatives if states were forced to respond by narrowing program eligibility. Without greater resources for community initiatives, however, the volunteerism they rely on would be strained and could fray.
Other national proposals—in particular, those that offer new opportunities for financing coverage—might be used to provide much-needed support to these programs, if care were taken to define qualified coverage to include that offered through community initiatives. In turn, the initiatives could leverage and amplify the value of those funds. For example, refundable tax credits could be used to buy the coverage offered through these networks and their providers. Community initiatives also might be allowed to qualify as "association health plans" that could enroll any small group that includes a threshold proportion of low-wage workers. Small employers might offer these programs as an option available to low-wage workers or to their entire group. Certainly such proposals would warrant careful review by state insurance regulators, but they may be quite feasible with narrow and strategic changes in regulation and oversight and highly beneficial to workers who otherwise could not afford coverage.