Community Health Centers and Second-Class Health Care

Federally-funded community health centers (CHCs) are a significant part of the safety net. They provide care to low-income Americans, most of whom either have no health insurance or rely on Medicaid. The G.W. Bush Administration expanded CHCs dramatically, and the Affordable Care Act signed by President Obama does so even further, to the point they may serve as many as 30 million Americans a year in the near future. While seeing CHCs as laudable, many progressive health care policy analysts have fretted that the care provided in these centers is not at the same level of quality as that received by privately insured patients in other settings. A new study published in the American Journal of Preventive Medicine shows that this is indeed the case.

The research team examined over 30,000 ambulatory care visits to assess quality measures such as providing adequate medications for chronic illnesses, screening for high blood pressure, counselling patients about the need for exercise and the like. The quality of care provided in CHCs was compared to that provided by primary care doctors in private practice.

The difference in health care quality across the two settings was profound: CHCs provide much better primary care than do private practice doctors. Of the 18 quality measures examined, CHCs were superior on 11, equal on 6 and inferior on 1. When the researchers adjusted the findings for difference in patient characteristics, private sector care was not superior in any respect, and was on most indexes significantly worse.

Some people will find the prevalence of second-class health care in the private sector astounding, just as they are surprised to find out that VA medical centers frequently outperform their private sector counterparts in communities around the country. But there is simply nothing in the profit motive that guarantees quality health care. Indeed, it can just as easily drive needless and risky diagnostic procedures, overuse of specialists and a neglect of the fiscally low stakes but clinically important practices that are the bread and butter of high-quality primary care.

Improving the Quality of Addiction Treatment

To bring market forces to bear on health care improvement, one needs service consumers who (a) Can detect quality (b) Are aware of what they are paying and (c) Have choices between providers. These three things are rarely true of the people who receive services from public sector addiction treatment programmes.

One way to handle this problem is to create an artificial market within a public health care system, i.e., have experts measure quality of care and then pay a bonus to treatment providers who offer the highest quality services. The Veterans Health Administration has done this for years, with impressive effects. But, in a paper kindly flagged by Austin Frakt today, my colleagues and I found that this approach has been less successful at improving the outcomes of addiction treatment.