The state’s FQHCs are responding to the non-medical needs of low-income patients with imagination and commitment.

J. Duncan Moore, Jr.

The COVID-19 pandemic has laid bare the inequities of the U.S. health system in an undeniable fashion. Blacks, Hispanics and other minorities were afflicted by the coronavirus at higher rates, with markedly higher death tolls, than white Americans. These imbalances were not caused by insufficient or inequitable medical care, though those cannot be completely ruled out, but rather by the conditions of life and employment that obtain in minority and working-class communities.

In other words, the underlying social determinants of health in these households and neighborhoods led to unfavorable outcomes for certain individuals. Their precarious health status, in the form of such conditions as asthma, hypertension, and diabetes, deprived them of the foundational strength to prevail against the onslaught of the virus. These higher morbidity and mortality rates became the visible expression of the social and economic injustices that are woven through American life.

The public’s fresh awareness of the COVID outcomes differentials, combined with the outrage over the George Floyd killing, has created an opening for the health system to step up and face the factors that cause these discrepancies. Community health clinics are poised to play a leading role in remediating these problems.

The evidence is stark, and difficult to unsee. A study published in the Annals of Epidemiology found that age-adjusted mortality rate ratios in California were 2.75 for Blacks and 4.18 for Hispanics, meaning Blacks were 2.75 times more likely to die of COVID than whites. Hispanics were four times more likely to die. The disparities were worse at younger ages. Early in the pandemic, Black residents of Chicago were dying at a rate nearly six times that of whites, the Chicago Tribune reported.

A study by the American Heart Association found that Black and Hispanic COVID patients had a disproportionate risk of landing in the hospital, and accounted for 53% of all COVID-19 deaths. Yet once members of these groups were admitted to the hospital, they did not die at a higher rate than white patients. Thus hospital care was not the problem; what happened before the patients entered the hospital was the determining factor.

"Our findings suggest that in order to address disparities in the burden of COVID-19 among vulnerable patient groups, we must focus on structural reasons for the higher rates of viral transmission and hospitalizations for Black and Hispanic patients," said Dr. Fatima Rodriguez, lead author of the AHA study.

The impact of COVID is giving the disparities in health status among minority and low-income groups new resonance among the public, said Dr. Olajide Williams, chief of staff of neurology at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City.

"While our battle is downstream in the trenches of medical care, the war can only be won upstream against social determinants of health,” he said in a comment about the AHA study. “This requires greater advocacy, greater community participation, and re-imagining healthcare through a more holistic lens."

A Brief History of SDOH

Most of the clinics profiled here were founded in...Read More

Vignette Spotlights

Salud Para La Gente

La Maestra Community Health Centers
(San Diego)

Northeast Valley Health
(San Fernando Valley)

Open Door Community Health Centers

Venice Family Clinic
(Santa Monica)

Community Medical Centers

La Clinica de La Raza

Tiburcio Vasquez Health Center

About the Author

J. Duncan Moore, Jr. is a journalist and communications consultant based in Chicago. He has written for a variety of publications, including the Los Angeles Times, San Francisco Chronicle, The Nation, Crain's Chicago Business, and Bloomberg News. Since 1992 he has specialized in the healthcare industry. He contributes blog posts to the California Health Care Foundation and has written about initiatives in quality of care for the Robert Wood Johnson Foundation.

Innovations by California’s FQHCs

California’s federally qualified health centers (FQHCs) have been in the forefront of this holistic movement for decades. A focus on social determinants has been in their DNA since they were founded. In many ways they are ideally positioned to lead other provider groups into an era in which social determinants are elevated to first-order considerations informing the direction and performance of the entire health system.

This report highlights innovations in social determinants of health developed by member clinics of the California Primary Care Association (CPCA). The association, based in Sacramento, is a convening organization for the interests and aspirations of the state’s more than 1,370 not-for-profit community health centers, most of them FQHCs.

CPCA identified eight clinics that have created strong programs supporting the social needs of their patients. Each has charted a unique pathway toward improved community engagement and better outcomes. The short vignettes that follow explain their innovations and how they have put them into operation.

To research the vignettes, we visited four of these sites during a lull in the COVID-19 pandemic in 2020, and interviewed providers, leadership, social outreach workers, and patients in person. Because of the winter surge in COVID cases and the state-mandated restrictions on travel, we interviewed participants at the remaining four sites by telephone and video call.

The locations range from the mist-enshrouded redwood forests near the Oregon border to the dry and dusty homeless encampments in urban San Diego. The patient communities served by these clinics include undocumented immigrants, substance abusers, multi-generational families, recently released offenders, as well as service workers dwelling in the midst of the bejeweled entertainment industry who can’t afford to feed their families.

These clinics, by and large, tend not to be situated near the postcard vistas of California that most Americans carry in their heads. Rather they are built where the service personnel, farm laborers, and immigrants live -- the truly essential workers who make everything else possible.

Value-Based Payment is the Catalyst

The business case for investing in social determinants of health is, in essence, an ounce of prevention is worth a pound of cure. To the extent that we can prevent costly medical interventions for complex illnesses such as heart disease, cancer, or diabetes, it makes sense to support upstream investments. However, devoting public or private resources toward social determinants of health can be expensive, and the payoff may take decades; the returns do not necessary accrue to the organizations that put the money in. In some cases, organizations may discover their own economic outcomes are worsened by improving population health.

The movement toward value-based care is gradually altering the economic equation. Reimbursement schemes to hospitals, health systems, and large medical practices increasingly incentivize them to keep patients healthy rather than collect fees for specific episodes of sick-care.  “The CMS has said they want to get to a goal of 100% value-based care,” Fichtenberg said. “The writing is on the wall. We are not going back from that.”

As in any transition period, it’s not always smooth sailing. But habits of mind are changing. Some mission-driven legacy institutions, such as large academic medical centers and UCSF itself, are now thinking about ways to invest their reserves in community health, Fichtenberg explained. They want to use their leverage as major employers and purchasers of goods to contribute to the economic security of their communities, a philosophy known as anchor mission. ProMedica, a large health system in Ohio, has launched a National Social Determinants of Health Institute.

Venerable integrated provider organizations such as Kaiser Permanente are also pivoting toward social determinants. In February the massive HMO announced it would appoint two veteran executives to advance its community health programs. “At this point in our pandemic response, it is critical that we accelerate our efforts to integrate how we address our members’ social health with our broader care delivery system,” said Dr. David Grossman, newly appointed co-leader of the company’s Office of Community Health. Kaiser is making it an explicit goal to foster health and equity by addressing the root causes of health, “such as economic opportunity, affordable housing, health and wellness in schools, and a healthy environment.”

FQHCs “have the most historical alignment with this upstream agenda, yet don’t have the revenue stream,” Manchanda said. Even though the great promise offered by value-based payments is flexibility, the standard prospective-payment reimbursement structure of FQHCs means “they don’t have flexibility to invest in services to provide this upstream care. They have to beg and borrow.”

The blessing of flexibility, Ducas observed, is that “it frees up your ability to say, ‘You know what? We are going to use those payments to hire a social worker. Or we are going to invest in supportive housing in the community,’ You can be very creative when your dollars are not attached to specific services to the patient.”

Manchanda continued: “We need to start providing opportunities for FQHCs in California to explore alternative payment models that can provide more opportunities for stable outcomes-based payments, so they can align and pay for resources to address the very things that they as a clinic were designed to do, which is address social needs.” The unique governance structures of FQHCs – their boards of directors are required to have a majority of community members – make them ideally attuned to this mission, he added.

COVID-19 as ‘Moment of Opportunity’

Creativity will be the watchword as the health delivery system adapts to post-COVID realities. FQHCs have already jumped in to fulfill new needs during the pandemic. The community health centers are not just a crucial part of primary care for low-income populations, but they have it in their culture and their history to think holistically about people. “We are seeing huge numbers of organizations that are helping provide access to non-healthcare resources,” Fichtenberg said. “They are at the vanguard of what whole-person care is.”

Community health centers are optimally positioned to operationalize the novel approaches that the public is demanding in the post-pandemic era. They have a long history of redressing healthcare inequities, and they are sensitized to the effects of racism on health. They have the committed staff, the professional savvy, and the mission-driven organizational heft to make a difference in the lives of millions of Californians, and to create a model that the rest of the country can emulate.

“I really do think it is plausible,” Fichtenberg said. “This is a moment of opportunity to not go back to how we were doing things before, but to really think about how do we transform our healthcare system. How do healthcare organizations and systems partner and support transformation of other systems, whether housing affordability, economic development, assuring access to affordable food, or addressing systemic racism, and so forth?

“Our awareness of the impacts of differential access to resources has been staring us in the face for the past year. It’s creating urgency for action.”