If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Correspondence to: Sara Wilensky, JD, MPP, Assistant Research Professor, The George Washington University, School of Public Health and Health Services, Department of Health Policy, 2021 K Street, NW, Suite 800, Washington, DC 20006
Preconception care has been recognized as an important set of interventions necessary to improve pregnancy outcomes and the overall health of women of childbearing age. Traditionally underserved populations such as the low income, uninsured, racial and ethnic minorities, homeless, and migrant farmworkers have less access to a usual source of primary care and therefore are more at risk for adverse health outcomes. The national network of Community Health Centers was created to break down compounding barriers to care that leads to poor health. Health centers are a vital source of care for low-income women. Almost 60% of health center patients are women, about half of whom are women of childbearing age. In addition, health centers provide care for >17% of low-income births in the United States. Most health centers offer their patients preconception services, such as HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs, in addition to comprehensive primary care services. Three quarters of health centers provide mental health services and half provide substance abuse treatment services onsite; the rest provide these services in partnership with other providers. Health centers also participate in a number of community-based programs focused on improving women's health and providing preconception care services. As policymakers and public health planners consider options for enhancing the utilization of preconception care, they must also consider options for expanding access to health centers nationwide.
Preconception care has been recognized as an important set of interventions necessary to improve pregnancy outcomes and the overall health of women of childbearing age. It embodies primary and preventive services that all women need, regardless of whether or not they become pregnant. Despite its public health role, many preconception services are not widely used because of a lack of awareness among providers and patients, or lack of reimbursement by insurers (
). In addition, women in communities and populations that are marginalized from primary care owing to cost, language, cultural, geographic, and other barriers to care are particularly at risk for not receiving preconception care services. Traditionally, underserved populations such as the low income, uninsured, racial and ethnic minorities, homeless, and migrant farmworkers have less access to a usual source of primary care and therefore are more at risk for adverse health outcomes (
). With a health promotion mission for the entire community, health centers provide a comprehensive and diverse set of primary, preventive, and social services throughout the lifecycle and preconception care is integrated into these services. This article reviews the role of health centers in providing preconception care among vulnerable populations and discusses policy issues that challenge the ability to deliver these services and expand the Health Centers Program.
The Community Health Center Approach
Mission
The federal Health Centers Program has a 40-plus-year history of improving health status among traditionally at-risk populations. The earliest health centers recognized that improving community health starts by improving access to care and by addressing the social determinants of health, including poverty, low levels of education and health literacy, language and cultural barriers, and lack of health care resources. Today, the program includes Community Health Centers, Migrant Health Centers, Health Care for the Homeless Centers, Public Housing Health Centers, and even School-Based Health Centers. All health centers must meet 5 unique program requirements set in statute. Health centers must:
1
be located in a federally designated medically underserved area or serve a designated medically underserved population;
2
have nonprofit, public, or tax-exempt status;
3
provide comprehensive primary and preventive health care services throughout the lifecycle, and other services needed to facilitate access to care in a cultural competent manner;
4
be open to all community members, regardless of ability to pay or insurance status; and
5
be governed by a patient-majority board.
These core program requirements relate back to health centers' mission of serving those most in need and otherwise without health care. The governing board is a unique feature that ensures consumers directly manage their care and identify areas of remaining community need. Together, these programmatic prerequisites break down traditional and compounding barriers to care, broaden the definition and scope of health care, and make health centers an important intervention for patients of all ages and health care needs, including low-income women of childbearing age.
Program Size and Patients
More than 1,150 health center organizations currently serve >17 million patients through >6,300 service delivery locations across the country. Health centers are located in every state and territory, and are about evenly split between urban and rural communities (
). The National Association of Community Health Centers (NACHC) estimates that health centers will provide >68 million patient visits this year.
As the figures below demonstrate, health center patients are overwhelmingly low income (Figure 1), uninsured or publicly insured (Figure 2), and racial/ethnic minorities (Figure 3) —demonstrating the ability of health center patients to reach populations customarily marginalized from care. Although 12.3% of the total U.S. population is low income, nearly all (92%) health center patients are low income, with most living below the federal poverty level (
). Although 15.8% and 12.9% U.S. residents nationally are uninsured and Medicaid insured, respectively, 40% of health center patients are uninsured and 35% have Medicaid (
). At the same time, roughly two thirds of health center patients are members of racial and ethnic minority groups, compared with roughly one third of the U.S. population (
). Health centers provide care for women who account for 17.2% of all low-socioeconomic births nationally, a proportion that increases for minority women (Shi, Stevens, Wulu, Politzer, & Xu, 2004). Health center patients range greatly in age (Figure 4), speaking to the ability of health centers to care for patients throughout the lifecycle. Large numbers of patients are also migrant farmworkers or homeless individuals.
Figure 1Health center patients by income level, 2006. Note. The Federal Poverty Level (FPL) for a family of 3 in 2006 was $17,170 (see http://www.aspe.hhs.gov/poverty/06poverty.shtml). Based on percent known. Percents may not total 100% owing to rounding. From the
Figure 2Health center patients by insurance status, 2006. Note. Other Public may include non-Medicaid SCHIP. Percents may not total 100% owing to rounding. From the
Female patients currently make up 59% of all patients, with women of childbearing age (ages 15–44) accounting for 29% of all patients and half (49%) of all female patients. One in 10 female patients of childbearing age is also a user of health center prenatal care services. The proportion of patients that are women of childbearing age is slightly higher in urban areas as compared to rural areas (51% vs. 46%). The same is true for the proportion of women of childbearing age that are prenatal care users (11% in urban areas vs. 8% in rural areas;
). Although these proportions have held fairly steady over time, the Health Centers Program has expanded dramatically in recent years, meaning that health centers have significantly expanded their reach to women of childbearing age. Between 2001 and 2006, both the total number of health center patients and the number of female patients ages 15–44 grew by 46% (
Speaking to their status as safety net providers, health centers rely on a diverse mix of grant funding, Medicaid, and third-party payments. At 37%, Medicaid is the largest single source of revenue for health centers. Federal health center grants are second, at 21%. State and local grants and contracts make up another 9% of total revenue, yet are a vital source of financing for health centers facing rising demand from new uninsured, underinsured, and chronically ill patients (
Although revenue from Medicaid is directly related to the proportion of patients with Medicaid, the same is not true for revenue from Medicare, other public insurance, and private insurance (Figure 5). Medicaid is the strongest payer because health centers are reimbursed for their Medicaid patients through a Prospective Payment System, which provides an average per-patient cost for each visit. On the other hand, although 15% of patients have private insurance, only 6.5% of revenue is related to private insurance, indicating that private insurance covers little of a health center's costs and that these patients are predominately underinsured (
). Additionally, federal grants have not kept up with the cost of patient care, covering only 50% of average costs for an uninsured patient, a steady decline since 2001 (
Health centers are associated with removing barriers to care and effectively reducing health disparities, while also generating savings to the health care system (
). For example, health center Medicaid, uninsured, Hispanic, and black female patients are more likely to have had a Pap test over 3 years than their counterparts nationally (
The Role of health centers in improving health care access, quality, and outcome for the nation's uninsured Testimony at Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A review of community health centers: issues and opportunities.” Washington, DC.
). Low socioeconomic status (SES) women seeking care at health centers experience lower rates of low birth weight (LBW) babies compared with all low-SES mothers (7.5% vs. 8.2%), a trend that holds for each racial/ethnic group. This is particularly noteworthy for African American women of low SES who are especially at higher risk for adverse pregnancy outcomes. If the LBW black–white disparity seen at health centers could be achieved nationally, there would be 17,100 fewer LBW black infants annually (
). Furthermore, patients who rely on health centers as their usual source care have lower total health care expenditures than those who receive most of their care elsewhere—saving the health care system between $9.9 billion and $17.6 billion annually (
Health centers both embody and go beyond the concept of a medical home. A medical home is a continuous and usual source of care that includes a personal relationship with a provider and a care management team of medical professionals that coordinates and integrates the patient's complete care, is committed to continuous quality improvement, is patient-centered and focused on the whole patient throughout her lifecycle, coaches the patient about changing behaviors, and helps the patient to understand her conditions (
American Academy of Family PhysiciansAmerican Academy of PediatricsAmerican College of PhysiciansAmerican Osteopathic Association Joint principles of a patient-centered medical home released by organizations representing more than 300,000 physicians.
For a larger discussion on medical homes and a review of literature, see National Association of Community Health Centers and the Robert Graham Center. Access denied: A look at America's medically disenfranchised. (2007, March). Available: www.nachc.com/research-reports.cfm.
Having a medical home is a greater predictor of receiving care than having insurance alone, and is associated with better utilization and outcomes, including needs recognition, earlier and more accurate diagnoses, reduced emergency room use, fewer hospitalizations, lower costs, better prevention, fewer unmet needs, and increased patient satisfaction (
). Low-income, minority, and uninsured populations especially benefit from having a medical home given that these groups run a greater risk of having adverse health outcomes, an inability to access primary care, and use of costly hospital-based care for avoidable conditions (
). The advantages of having a medical home are particularly pertinent regarding preconception care; having provider continuity, accessing consistent, quality care throughout the women's lifecycle, and receiving early intervention are all key factors in keeping women healthy.
As medical homes, health centers provide a comprehensive array of primary and preventive health care services, and many also provide dental, behavioral health, and pharmacy services. Health centers customize and tailor their services to meet the specific needs of their patients and communities, including language services. Within this mix are many interventions recognized by the CDC as essential to preconception care (
). As Table 1 denotes, most health centers offer on-site services that include HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs. Three-quarters of health centers provide mental health services and half provide substance abuse treatment services onsite, while the rest provide these services in partnership with other providers.
Table 1Select Interventions Important for Preconception Care Provided by Health Centers, 2006
Preconception Intervention
% of Health Centers Providing Onsite
% of Health Centers Providing Onsite and/or Through Formal Referral Relationship
HIV testing and counseling
91.6
99.8
Weight reduction program
77.3
95.1
Nutrition services
76.8
98.4
Smoking cessation program
57.9
96.0
Mental health treatment and counseling
76.3
99.4
Substance abuse treatment and counseling
50.9
98.7
Notes. These services are identified by the Centers for Disease Control and Prevention (CDC) as preconception interventions with proven health effects. See CDC, “Preconception Health and Care, 2006,” At A Glance, http://www.cdc.gov/ncbddd/preconception/documents/At-a-glance-4-11-06.pdf. “Onsite” includes services rendered by employees, contracted providers, volunteers and others who render services in the health center's name. Health centers may also provide services through formal and contractual referral arrangements. Includes health centers with federal health centers grants only, which make up roughly 90% of all health centers. Mental health treatment and counseling are not specifically identified by the CDC, but related interventions are (e.g., substance abuse, eating disorders).
From the 2006 Uniform Data System, Bureau of Primary Health Care, Health Resources and Services Administration, DHHS.
). Nearly every health center is now participating in a chronic care management initiative to improve health outcomes and minimize health disparities for patients with chronic illness. Known as the Health Disparities Collaboratives (HDCs), this continuous quality improvement initiative also incorporates patient self-management and decision support techniques, electronic information systems, and even community outreach. The diabetes HDCs, perhaps the most heavily evaluated HDC targeted condition, have been associated with improved patient outcomes and processes of care (
). The HDCs were designed to cover all chronic conditions and be “spread” to other health center services.
Additionally, to fully address the social determinants of health, health centers integrate education and social services into primary care delivery. One in 10 full-time employed health center staff are enabling services providers, including case managers, outreach workers, health educators, insurance enrollment workers, interpreters, child care providers, and social workers (
). Still other staff work through social services programs, commonly including Special Supplemental Food Program Women, Infants and Children, employment or educational counseling, and assistance in obtaining housing, with nearly all health centers providing these services onsite or through formal relationships or contracts with other organizations (
Maternal and Child Health BureauHealth Resources Services AdministrationU.S. Department of Health and Human Services A profile of healthy start: Findings from phase 1 of the evaluation.
One vital way to reach women in need of preconception care is through the use of promotoras or community health workers. These are lay workers who are members of the community or closely associated with the community served by health centers. They provide a vast array of services that may include culturally competent health education, translation, transportation, counseling and social support, advocacy, and some direct services such as blood pressure screenings (
Bureau of Primary Health CareHealth Resources Services AdministrationU.S. Department of Health and Human Services Border county health workforce profile: Texas.
). Community health workers can provide services that directly impact specific preconception care management issues highlighted by the CDC, such as diabetes management, immunizations, and HIV/AIDS and sexually transmitted disease screening and testing. For example, the Gateway Community Health Center in Laredo, Texas, uses promotoras as key components of their diabetes self-management program. The promotoras run a 10-week diabetes self-management course, a 10-week support group, and provide weekly phone call follow-ups to reinforce what patients have learned and to help with morale (
). La Clinica de Familia in Las Cruces, New Mexico also uses promotoras to provide educational services on issues such as substance abuse and tobacco cessation, prenatal care and parenting classes, breast and cervical cancer education and screening, environmental home assessments, and diabetes management (
Examples of Health Center Programs That Address Preconception Care
From the board of directors, which is made up of mostly patients, to the specific programs and services they offer, health centers are responsive to the needs of their community. Although all health centers have similar missions and general approaches to providing health services to their community, each health center is also unique because it responds to the particular needs of their patients. The programs described below are just a few examples of the types of programs and services all health centers provide to improve preconception health. The common thread among all of these programs is the connection with the greater community and the creative approach health centers take to ensure the health of their patients.
Arizona Rural Frontier Women's Health Coordinating Center (RFCC)
In 2004, the Arizona Association of Community Health Centers, which represents health centers and their patients, was awarded a contract by the U.S. Department of Health and Human Services to create the RFCC. The RFCC was established to “coordinate and leverage a network of existing resources to provide a full range of services to women and their families living in rural/frontier communities of Arizona” (
). Women who reside in rural areas must overcome a number of hurdles to leading a healthy lifestyle such as high rates of uninsurance, underinsurance, and poverty, geographic isolation, and lack of accessible providers (
). The RFCC helps health centers to provide care tailored to the specific needs of rural women throughout their lifecycle through clinical care, outreach, education, and leadership skills. The RFCC's wide range of services include extensive clinical services geared toward women, research and clinical trials, a newsletter that shares information about women's health and well-being, and the creation of the Arizona Women's Health Initiative Council that is tasked with “analyz[ing], evaluat[ing], and think[ing] innovatively about rural women's health in Arizona” (
The U.S. Department of Health and Human Services' National Community Centers of Excellence in Women's Health (CCOE) program is designed to integrate, coordinate, and strengthen linkages between existing community programs and activities to enhance services available to women, and to reduce fragmentation in women's health services. The program provides recognition and resources to community-based programs to develop and integrate 6 components: health services delivery, particularly preventive services; training for health care professionals including allied health professionals and others; community-based research; public education and outreach; leadership development for women; and technical assistance to other communities to replicate the CCOE model (
). Several health centers across the country are currently participating in this program, and have integrated CCOE programs into their primary care programs. Two examples include the Mariposa Community Health Center and the Kokua Kalihi Valley Health center.
The Mariposa Community Health Center, located on the border of southern Arizona and Sonora, Mexico, provides women with women-focused clinical care, health education for women and the communities they live in, leadership training, and educational opportunities. Mariposa health center offers a wide array of clinical services that assist women with preconception care such as education about HIV/AIDS, diabetes, tobacco cessation, cancer prevention, and nutrition (
Kokua Kalihi Valley Health in Honolulu, Hawaii, serves a population that primarily consists of low-income, Asian-American and Pacific Islander women. This population has historically had high rates of diabetes mellitus and overweight/obesity and associated conditions (
). The health center uses its Center of Excellence funding to bolster its education and outreach programs through women's health workshops, women's health maintenance groups that offer a wide variety of dance and exercise classes, community-based health promotion and screening activities, and monthly outreach activities to isolated parts of the community (
). These programs are all intended to prevent chronic diseases and use physical activity and dietary changes to improve the health of at-risk and high-risk women.
Women's Health Services in Community Health Centers
In addition to specially funded programs such as RFCC or CCOE, many health centers incorporate women's health programs into their standard set of primary care services. For example, the Joseph M. Smith Community Health Center in Allston and Waltham, Massachusetts, provides women-focused health care throughout the lifecycle. They hire providers who focuses on the needs of adolescents; offer a full array of prenatal and pregnancy related services, including a “centering pregnancy” program that focuses on healthy living for the whole family; have a gynecology specialist on site to address any complex needs; run a nutrition program with a special emphasis on women with weight-related issues; use a mobile mammography van at their sites to reach women who cannot visit local hospitals for screening; and provide eligible women with breast and cervical cancer screening through their Women's Health Network (
). The David Powell Clinic in Austin, Texas, specializes in treatment of patients with HIV and AIDS. This health center runs a “fully-integrated HIV-specific women's health clinic staffed entirely by women, including physician services provided by a Board Certified Family Practitioner” (
) The women's health clinic offers HIV-specific early gynecologic assessment and treatment services and reassesses women every 6 months.
Policy Discussion
Health centers play a vital role in providing preconception care services to women who might otherwise not have access to care. Unfortunately, health centers face many threats to their survival. It is essential that policy changes are made to increase the primary care workforce in health centers, broaden access to insurance, improve insurance coverage and reimbursement, and increase federal and state funding to health centers.
Overcoming Remaining Barriers to Care
Health centers provide an effective model for the delivery of preconception care and have the infrastructure and experience to deliver preconception care, especially to those women most likely to lack access to such care, or primary care in general. Although lack of insurance is a common barrier to accessing primary care, being insured does not guarantee access to a usual source of care. Compounding this, a looming primary care workforce shortage and the fact that too few providers locate in underserved areas could mean that fewer women have access to the preventive services they require, regardless of insurance status (
The crisis in the primary care physician workforce Testimony before the Senate Health, Education, Labor and Pensions Committee on behalf of University of California, San Francisco and Center for California Health Workforce Studies.
Primary care professionals: Recent supply trends, projections, and valuation of services Testimony before the U.S. Senate Committee on Health, Education, Labor, and Pensions on behalf of the U.S. Government Accountability Office.
). In fact, NACHC and the Robert Graham Center recently found 56 million insured and uninsured people already do not have access to a primary care physician—much less a medical home—because of a shortage of such physicians in their local communities (
). However, focusing on the sheer numbers of health professionals for the underserved is not enough. Providers must be culturally competent, speaking the same language and understanding the customs and beliefs of the patients they serve.
Health centers have launched an aggressive growth plan to ensure that the medically disenfranchised and others facing additional barriers have access to a usual source of care. The ACCESS for All America plan envisions reaching 30 million patients by the 2015. Assuming that women of childbearing age would make up the same proportion of all patients as they do currently, this would mean that 8.7 million such women would have access to comprehensive and regular care through a health center. But to reach this goal, a substantial investment in health center infrastructure and the clinical workforce to staff the expansion is needed.
Insurance and Reimbursement Challenges
Delivering high-quality, culturally competent care to vulnerable populations in medically underserved areas is not an easy task given the fiscal realities of the health care system. At a time when health care costs are rising each year and health centers have slim operating margins, health centers and their patients cannot afford reductions in their funding sources. To the contrary, they will need additional resources to meet increasing demand and this need is exacerbated in down economic cycles. Policies that increase both federal and state funding for health centers are essential to their continued success.
Financial pressures come from treating both uninsured and insured patients. As noted, 40% of health center patients are uninsured, yet federal and state grants do not cover the full cost of caring for the uninsured. As a result, health centers often need to shift revenue from other sources to meet the needs of the uninsured. Even if patients have insurance, policies may not cover essential preconception care services or billing codes may not exist for particular services (
). Yet, many low-income women remain uninsured during the preconception period because they do not become eligible for Medicaid until they are pregnant, making it difficult for them to access preconception services.
On the federal level, the passage of the Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA;
) have changed the way health centers are reimbursed under Medicaid and allowed new restrictions to Medicaid coverage. BIPA created a new Prospective Payment System for health center Medicaid reimbursements that replaced the prior cost-based reimbursement system. Because health centers receive a PPS rate for Medicaid services, they are not harmed in the same way other safety net providers are when states reduce Medicaid cost-based reimbursement rates. Whether or not PPS reimbursement rates are adequate depends on how states implement the statute. Those states that allow for frequent rate recalculation to account for changes in health care costs and scope of services provided by health centers are more likely to provide adequate reimbursement levels (
Government Accountability Office (GAO) Health centers and rural clinics: State and federal implementation issues for Medicaid's new payment system (GAO-05-452), 17-22.
). PPS rates should be regularly and adequately adjusted to reflect the true cost of providing services to health center patients so that health centers may expand the preconception care and other preventive services they offer. In addition, the DRA imposed strict citizenship verification requirements that create barriers to proving one's eligibility, resulting in many eligible individuals not remaining on Medicaid owing to lack of documentation. Given health centers' limited profit margins and inadequate reimbursement for providing care to the uninsured, replacing Medicaid patients with uninsured patients would place significant financial strain on health centers.
Unlike the federal government, states are required to balance their budgets every year. This means that when the economy weakens, states lose revenue and are likely to cut public funding for programs. For example, a one percentage point increase in unemployment is estimated to result in an increase of 1 million Medicaid and SCHIP beneficiaries at a cost of $1.4 billion in additional state spending. At the same time, state general revenues would be expected to fall 3%–4%, reducing the resources states have available to pay for health care or other programs (
). States have historically restricted Medicaid and SCHIP programs during downturns in the economy and 13 states are already anticipating cuts in 2008 owing to the current economic situation (
). Although the DRA protects health center services as a mandatory benefit, other safety net providers could be harmed by Medicaid benefit reductions. As noted, health centers will be negatively affected by state decisions to restrict Medicaid eligibility that results in health centers serving more uninsured patients and fewer Medicaid patients.
Finally, it is essential that federal and state governments continue and expand funding to health centers. Federal funding takes the form of grants to cover uninsured patients and program areas (e.g., dental services), insurance reimbursement, and funding for special programs such as the CCOE. In fact, health center directors report stretched resources for the HDCs as a major challenge to their sustainability (
). Health centers regularly conduct quality improvement assessments as part of an on-going effort to improve the service they provide. Additional funds from the federal or state governments to assess how health centers collaborate with other programs that promote preventive care for women may help to increase access to preconception services. Health centers also may receive state support to cover general operations, construction, funds for improving health information technology, care for the uninsured, and emergency preparedness resources. In fiscal 2008, 36 states provided >$600 million to health centers, funding that is essential to the ability of health centers to provide a full array of services to their patients (
Health centers are part of the fabric of their communities and the opportunities to reach out to other community organizations and patient populations are essential in ensuring the success of programs that assist women with preconception care needs. As policymakers and public health planners consider options for improving the utilization of preconception care, enhancing health centers is one important way to increase access to preconception care and women's health services to low-income and uninsured women. Their comprehensive, prevention- and community-oriented approach is the ideal setting for the delivery of preconception care to traditionally at-risk women. In addition, health centers augment the effectiveness of care that patients receive by integrating social and enabling services into primary care delivery. Investment in health centers that allows them to maintain their current capacity and expand into new service areas will increase their reach to more underserved women in need of preconception care as well as general preventive services.
Acknowledgments
The authors thank Shira Gitomer, a Research and Data Specialist at the National Association of Community Health Centers, for her valuable assistance with this article.
References
American Academy of Family Physicians
American Academy of Pediatrics
American College of Physicians
American Osteopathic Association
Joint principles of a patient-centered medical home released by organizations representing more than 300,000 physicians.
Sara Wilensky, JD, MPP, is a Special Services Faculty for Undergraduate Education at The George Washington University School of Public Health and Health Services. She is the Director of Undergraduate Programs in Public Health and her research focuses on access to care for medically underserved populations.
Michelle Proser, MPP, is the Director of Research at the National Association of Community Health Centers where she conducts extensive research and writing on health centers, access to care, health disparities, quality improvement, and other health care issues related to medically underserved populations.
Article info
Publication history
Published online: October 24, 2008
Accepted:
June 30,
2008
Received in revised form:
June 26,
2008
Received:
May 19,
2008
Footnotes
The authors have no direct financial interest that might pose a conflict of interest in connection with the submitted article.
00093-5&id=gr1.jpg){kind=link}
00093-5&id=gr2.jpg){kind=link}
00093-5&id=gr3.jpg){kind=link}
00093-5&id=gr4.jpg){kind=link}
00093-5&id=gr5.jpg){kind=link}