Community Health: Is a Public Good at Risk from For-Profit Competition?
Community health centers are a public good. They embody our belief that healthcare is a human right and essential to our well-being as a nation. The first health centers were born in Massachusetts and Mississippi in the 1970s, the offspring of our nation’s commitment, through Medicare and Medicaid, to care for the elderly, the poor, and those with disabilities.
Today, America’s community health centers are at a disadvantage against emerging, privately-funded, for-profit competitors. These new provider organizations, backed by venture capital and private equity, find community-based primary care newly attractive. When Google has begun to back community care, can Amazon, with its growing network of Amazon Care health centers, be far behind? Financiers, retail, and tech companies see the potential to disrupt and dominate care in local and regional markets.
Why should anyone care who is not a patient at a community health center? The answer is that health centers are an essential part of the Commonwealth’s safety net. Since their establishment in the 1970s, Federally Qualified Health Centers (FQHCs) have treated the most under-resourced members of society in all fifty states, primarily serving patients and families who have low incomes, many of whom cannot access services and/or distrust the medical system.
One in 12 patients is cared for at an FQHC, which deliver higher rates of quality care than the general U.S. healthcare system; those with diabetes or hypertension achieve higher rates of chronic disease control at FQHCs than the national average. Health centers are also more cost-effective than other types of primary care and provide higher satisfaction to their patients. National studies show total cost of health care associated with health centers is 24% lower than other types of primary care, without any reduction in quality. In addition, health centers provide more accessible and satisfying care, with 96% of low-income patients satisfied with FQHC hours vs. 37% nationally, and 98% of low-income patients satisfied with FQHC care vs. 87% nationally.
In a private market, high-value organizations like health centers would raise money from investors to attract talent, innovate, and grow. But health centers are designed to provide public service and community benefit, not to make a profit margin. Health centers are not-for-profits and, by law, have Boards on which the majority of directors are patients of the health center.
Furthermore, because health centers serve a disproportionate share of people of color and people of all races who have public insurance or no insurance at all, health centers are undercapitalized, lacking the financial clout of for-profit providers and healthcare systems, which are designed to serve whiter, more affluent patients. When health centers do provide care for commercially insured patients, they receive payment far below what health systems receive for the same services.
Why are health centers undercapitalized? We believe health insurers choose to under-compensate FQHCs because they can get away with it. Whether intending to or not, by underpaying health centers, private insurance companies perpetrate and sustain institutionalized racism and the stigma held against people who have low-incomes and/or behavioral health conditions.
As a result, philanthropy, non-profits, and the public sector have led the way in investing in health centers. In Massachusetts, a recent Medicaid reform enabled the creation of accountable care organizations (ACOs) like C3 that are rewarded for providing high-quality care to those who can least afford it. In our first year of operation, we beat our $533.6M total cost of care budget projections, saving Massachusetts more than $12 million. C3 earned a $8.1 million shared savings payment as well as $1.3 million due to a 100% quality score from MassHealth. These funds were largely invested back into health centers for improvements in care.
More is needed. Health centers need the investments that will ensure they retain and attract the best providers and continue to innovate in virtual care, in-home care, and the range of medical, behavioral health, dental and, especially, pharmacy services that patients need. This critical investment will allow health centers to continue to ensure their high quality, mission-driven care is accessible to all.
With investment, health centers can continue to serve as crucial partners in state and federal public health emergencies. A similar commitment cannot be guaranteed under the for-profit, primary-care model, in which investors and corporate boards drive providers to meet “performance measures’’ prioritizing the bottom-line over authentic care goals.
The endgame of the big-tech and big-consumer-retail backed primary care movement is to monetize and take over community-based primary care. If FQHCs are to remain strong and provide their measurable, valuable benefits, we need public investment and infrastructure support that allow continued access to care for underserved communities and continued growth of quality care offerings. Then, new competition will not spell the end of the value that health centers provide to our communities, especially to Massachusetts’s most vulnerable people.
