WHAT KIND OF ROLE DO YOU THINK COMMUNITY HEALTH CENTERS PLAY IN PROVIDING HEALTH CARE TO LOW-INCOME COMMUNITIES OF COLOR?
I’d like to start with a little history for context, including why we were created and what their role is now.
During the height of the Civil Rights Movement in the 1960s, you had campaigns, like the Birmingham campaign, you had the march on Washington, you had the campaign in Selma and Bloody Sunday. Folks tend to think of those key moments of the 1960s and how divided we were as a nation on racial issues. What they often don’t remember is that there was also a campaign being waged in health care, as well. At that point in the 1960s African American students were denied admission to most medical schools, African American citizens were denied membership in most medical societies. Many African Americans were refused care at most hospitals in this country, especially in the south. Most Black births in the south were at home—and infant and maternal mortality rates were higher in Black and Brown cases.
In a place like Boston, segregation was more subtle. Privileges and practices in hospitals were dominated by White people, and White physicians were encouraged to send Black patients to other locations, either to county locations or historically Black institutions. Black patients felt like they were being treated as teaching material rather than being treated for their underlying conditions.
So, that context matters. Then there was the political landscape at the time, including the War on Poverty, Lyndon Johnson’s campaign in 1963 going into 1964, when Congress adopted that plan. And the creation of the Economic Opportunity Act in 1964. And that act created the Office of Economic Opportunity—the OEO, charged with administering the federal funds that were created under Lyndon Johnson’s legislation. There were 40 programs aimed at eliminating poverty, addressing the poor conditions in low-income neighborhoods, and helping people access equal opportunity. This was the next iteration of the New Deal.
And here’s why that all leads to health centers. Part of the OEO was the creation of these community entities. So, in 1965, the nation’s first community health center was launched as part of a demonstration project, funded by the legislative advancements under President Johnson—and it had its roots in civil rights. The architects of community health centers were also Civil Rights activists: Jack Geiger, Cal Gibson, Dr. John Hatch, Dr. Smith in Mississippi who is still seeing patients (I think he’s approaching his nineties now), Dr. Elsie Dorsey, Dr. Andrew James and others… They said, “Hey, we’re marching and we’re protesting, we’re showing up in Selma, but what about health care?” Jack Geiger and several others had experienced community health models in Africa and came back with this really disruptive concept of creating community health centers and used Lyndon Johnson’s legislation to really push for creating models of community health centers, one in Columbia Point in Dorchester, where some of my family grew up. Very poor neighborhood. Had been originally a veteran’s community for returning veterans. And then in the 1960s, it had become a Black and Latinx neighborhood. It was poor and there was a lot of food insecurity and had high morbidity rates. So, it made perfect sense that one of the locations for one of the first health centers would be in Columbia Point. The other was in the birthplace of Rep. Russell Holmes in Mound Bayou, Mississippi.
So, this is all leading up to where we are now. You had two different examples of poverty: urban poverty and rural poverty. Very different. There’s a great video called “Out in the Rural,” and it talks about the birth of health centers. Here is why I mention this for the context of where we are now.
I give speeches at health centers across the country and I say, “We were born for a moment such as this.” Jack Geiger and Count Gibson and others were such brilliant health leaders because they were preparing us for a moment such as this. They determined that half of the boards of health centers had to be consumers. As Congresswoman Ayanna Pressley has said, “Those closest to the pain need to be closest to the power.”
Health Centers were engrained with that philosophy when they were created. Those closest to the pain should be sitting at the board table discussing quality health care and access and affordability. Those closest to the pain should be at the table talking about enabling services and giving away food vouchers. Those closest to the pain should be empowering themselves by educating themselves about the terminology and federal, state and local funding mechanisms and getting acclimated and aware of that process. Those closest to the pain can transition from policy to being staff; they should be CEOs and CFOs and COOs. It is often not recognized how masterful the policy was was that they created. And if you watch “Out in the Rural,” they talk about Mt. Bayou and other places and what happened outside the buildings of these health centers as well. When you had bad irrigation systems and water supplies and how health centers became key to recognizing the addressing what we now consider to be the social determinants of health. They were created to encourage political power and economic power and voting power. And not partisan voting power, but power that gave people the agency and the confidence to represent their own interests.
This is why health centers today have the opportunity to do something that very few others will. We represent the community. We’re closest to the community. And we also have the ear of elected and appointed officials because they understand the cost savings that comes from health centers, the access that comes from health centers… And they understand how trusted we are, pre-pandemic or during a pandemic. So, you think about the 1960s and then you evolve to what we have today. Just in Massachusetts, we see over 1 million patients out of 52 health centers with over 300 practice sites. Health Centers have more than one practice site. Fifty-six percent of our health center patients identify as a racial or ethnic minority. Embedded in that are immigrant populations as well. So we think about all of these anti-immigrant policies, not just from the Trump administration but even before that.
A trusted home for many immigrant communities has been community health centers. You walk in and maybe you’re greeted by a Honduran or a Cape Verdean or Haitian Creole-speaking staff (member), or Russian… So, we reflect those populations. Jim Hunt, who was my predecessor used to say, “If you’ve seen one health center, you’ve seen one health center.” It is absolutely true. They were meant to be reflections of those communities. Eighty percent of patients at Massachusetts health centers have incomes below 200 percent of the federal poverty level. Closest to the pain. Twenty-three percent of our patients are children or adolescents. It’s why we’re the tip of the spear both on the front end of this pandemic, with reaching adults, but now on the other side of this pandemic with reaching youth. We’re being identified as a key access point to get these young people—12 to 17—who are eligible because we’re under 50 percent with reaching that population to get vaccines into their arms. We expect there to be hesitancy among that younger population, because their parents may be hesitant.
So, just as some background, health centers are very much publicly subsidized—80 percent publicly subsidized. That’s Medicaid, Medicare—the healthy safety net. Most of the patients we serve are on publicly subsidized health care. That says a lot: You can be publicly subsidized and you know that you’re reaching that population—that Medicare and Medicaid population—and we do it at relatively low cost.
Even the Secretary of Health and Human Services and the Governor and others recognize that we’re serving Medicare and Medicaid patients at a lower cost and that has an economic impact. I’ve had this conversation with Lee over the years and his predecessor at the Boston Foundation. When you think about economic engines, 52 health centers across the state. I’m sitting right now here in Brockton. Brockton Health Center is an economic engine for downtown Brockton. If you’ve ever gone to Main Street and walked Main Street, there are Mom and Pop shops and beauty salons and barber shops and convenience stores. But when you walk into the health center, you know that Brockton employs a large number of people in Brockton that represent the diversity of that neighborhood. And those workers walk out to the grocery stores. They get their hair done in the neighborhood. They have a real economic impact. That dollar figure for Massachusetts is $2.6 billion in economic impact across Massachusetts. Health Centers offer close to 18,500 jobs. That’s pretty significant.
Again, this goes back to Jack Geiger and Count Gibson. It was masterful what they created. They knew that they weren’t just providing access to medical care. They were always thinking about vision and dental and substance abuse. And they recognized that any one of those things creates disease and creates greater sickness and death in the communities they served. But then you bring us forward and understand that we still have that same responsibility, that same role to play. But, as they prescribed, we’re also creating jobs and transitioning people to the middle class, helping them buy homes and generating entrepreneurship. That’s the piece that people don’t often talk about.
You have to take the totality of what was created in the 1960s making us really prepared to meet this moment. So, for us right now, it’s about getting needles into arms and recovery. It’s also about what it means to families who have lost loved ones to recover from the trauma of having lost and suffered over the last 18 months. It’s also about jobs in communities that saw many layoffs and those struggling with foreclosure now and into the next few months.
All of those things are about how we serve patients when they walk in our doors and how we communicate with them through telehealth… The last year and a half really time-warped us forward. Now some of us can work remotely. We’re teaching remotely and we’re also providing care remotely with all of the challenges that come with that—the WIFI issues, the absenteeism from virtual classes… We’re pivoting from the administrative side across our school systems…
But also the telehealth issue is requiring us to develop new processes, new protocols, new privacy requirements or expectations. And then giving devices to our patients so that they can engage us. I think Jack Geiger is smiling somewhere in heaven seeing that what he created, quite frankly, was the tip of the spear in responding to this disease. He should be very proud. But for health centers, we would have lost a lot more lives.
SPEAK A LITTLE MORE ABOUT SEIZING THIS MOMENT GOING FORWARD. ARE THERE THINGS THAT WE’VE LEARNED FROM IT? IS THIS A MOVEMENT?
Oftentimes, health centers are in a position where we’re not allowed as voices in the world. We’re small, nonprofit organizations… Here in the city of Boston or across the Commonwealth or across the country, we’re not big systems. Most are small. The largest you might see is the health center in East Boston. But they tend to be small nonprofit organizations that operate on the margins. They have low cash on hand and thin operating margins. They’re scrambling to get a fair reimbursement. They’re responding to every crisis without the resources to do it. So, if there are high rates of flu in a season, public health departments are turning to health centers and saying, “We need you to do more. And we need you to do more for people who aren’t your patients. So, we need you to do flu clinics.” And we responded to that. When there was the earthquake in Haiti, public health departments said, “We’re going to relocate patients to Boston and to Brockton and to Dorchester. And we need health centers to be the landing place to give them care. Or, when there’s an ice storm in Western Massachusetts that has an impact on the community and they need an emergency preparedness response…”
We are often called upon in the moment to step up and meet those needs, but we do it with very few resources. The opioid crisis. Homelessness. Way before this pandemic. And I think all of those things prepared us for responding to a crisis.
The problem is that there are underlying issues. We are operating with resources that mean we can’t pay as much as other institutions. So, we’re often losing some of our providers to those other institutions. We have to create a pipeline of people who drank the primary care/social justice Kool-Aid and want to stay in communities and serve communities and be part of the solution. So, we created residency programs so that people can be exposed to the populations that are in need. So, many of them stay, but it takes money to invest in that work because that’s not being reimbursed in a significant way.
SO YOU’RE BEING ASKED BY THE PUBLIC HEALTH SYSTEM TO INCREASE THE WORK THAT YOU’RE DOING, BUT YOU’RE NOT BEING GIVEN THE RESOURCES.
Exactly, and that’s historically true both here and across the country. And part of that work requires you to be nimble enough to respond to the needs of the community. Someone said to me when I came over to work at the League, representing health centers—and I came from a health plan—the former speaker of the house said, “Good, you’re going to do God’s work.” And it wasn’t until I took a seat in the job that I realized how true that was. Because health centers are serving communities with duct tape and giving out food vouchers and giving away clothes. And, of course, because their mission is broad to address the inequities in those communities.
I’m on a national Public Health Task Force that I just got named to a few weeks ago. And part of the challenge there is that our local public health departments are under-resourced. They’re understaffed. They’re underfunded. So, what happens in a crisis is: Everyone turns to the local health center and says, “Hey, we need you to do the testing, the contact tracing, the vaccinations. And then health centers, with their local public health colleagues and partners, lean in and do that work.
But to the question of whether this is a moment or a movement and where we are now—and going into the future, what I realize is that the pandemic and all of the negatives we can talk about really shined a light on the role of community health centers in a way I’ve never seen. People understood that you just couldn’t just say, “Come get tested.” That you needed a community health worker to tell communities why it was important to get tested, that this is a disease that could impact their lives, and where the locations were, and that the government wasn’t going to be engaged in anti-immigrant activities if they got tested or contact traced. We had to be trusted sources on the ground to do that work.
But for health centers and other community organizations, people wouldn’t have responded in the same way, so we’re very fortunate that—whether it’s Governor Baker or Secretary Sudders, Mayors, Public Managers, Public Health Departments, the philanthropic community, the business community, everyone was calling. I’ve never experienced a moment like that. And then, put on top of that, the social justice moment after the murder of George Floyd, and people are now connecting the dots to the two issues. It’s not just about disparate health outcomes, it was also about racial justice and the fact that, but for systemic racism, the numbers of Black and Brown people who were close to the disease would not have taken place. So, they’re calling and saying, “Mike, we want to do something around racial justice and health care and we want to respond to this disease. What do we need to do? And I was very fortunate when the Boston Foundation called—Elizabeth Pauley and Orlando Watkins—and that team—and they said, “Hey, we want to be partners. What do you need?” Then Jim Canales of the Barr Foundation called and said, “What do you need. We can help organize it for you.” When Blue Cross Blue Shield called and Secretary Sudders and I spoke at 7 a.m. in the morning and they’re saying, “What do you need? What are you hearing? What can we do? When the Governor’s staff, including Tony Richardson, was text messaging me almost every other day to give me updates and asked me what I was seeing.
That’s what Jack Geiger built! So I just think it was fascinating. Then, all of a sudden, there was a conversation about increasing our reimbursement rates—after years at the table saying, “Hey, please reimburse us for the care we are providing, allow us to give more benefits to staff and build the pipeline for development and making sure that our buildings are respectful to the patients we serve. Hazard pay and all of the other issues that we weren’t able to respond to because of our finances, there was now an appetite for repositioning (that’s the best word) health centers statewide. And that’s why we reached a new agreement with the state several months ago to increase our reimbursement rates significantly, starting in 2022. And it rippled across the country.
So, we are optimistic going into the future that, although we’ve had historic deficits, at least we could start anew at the beginning of 2022, knowing that reimbursements will be increased. And then we can pursue targeted funding to do the homeless work, connecting people to child tax credits… I was talking with former Congressman Kennedy just this morning, and he said, “Mike, health centers are in a unique position to educate people that they can get a check and reposition their own households and families, at least in the short term.” And that’s the kind of work that can be done when you have staff and have the resources to do it. I think we’re headed in that direction.
YOU’VE SPOKEN ABOUT PHILANTHROPY’S ROLE AND BUSINESSES’ ROLE, BUT IS ADVOCACY GOING TO BE AN IMPORTANT TOOL GOING FORWARD? LOOKING FOR REAL CHANGE ON A SYSTEMIC BASIS?
So, there is a movement afoot and Lee Pelton and the Boston Foundation are part of it, along with Juan Lopera at BI Lahey, leaders at Mass General Brigham, Manny Lopes at East Boston Health Center, Stephanie Brown and others at Blue Cross Blue Shield—a whole group of us who are in key positions in health care and are related to those who are supporting health care, like Lee. We’re having conversations about meeting the moment of health equity and that’s the challenge. We now have a legislative report from the Health Equity Task Force that I co-chaired with Dr. Sayah of Cambridge Health Alliance that includes groundbreaking material on how to deal with health equity issues that result in higher rates of infection, hospitalization and death and how we address that going forward.
The City of Boston put out a health equity analysis, which was started under Mayor Walsh and now is being finished under Mayor Janey. Monica Bharel at the Department of Public Health organized a health equity support group that I worked on. That report is out and also mirrors what is in those other reports. Mayors and town managers are all saying the same thing. We have to prioritize equity. We need to hold ourselves accountable to equity. We need to have equity dashboards that can measure and hold us accountable. And we need to deal with the social determinants of health: housing, education, access to affordable health care, food, a healthy environment… Eighty percent of the health status of the folks that we are targeting and trying to reach are impacted by their social conditions. The first is just access to care. That puts a lot of pressure on us to focus on those issues that exist outside of our health centers.
So, yes, health equity is campaign number one. There’s a movement afoot of a bunch of us who are in key positions that are prioritizing DEI work. Many companies now have DEI leaders that are not only trying to change the internal cultures of their for-profit or nonprofit organization, but they’re also reaching out and asking how they, as an organization, can contribute to the work that’s going on in health equity.
What we’ve been proposing to Juan Lopera and state representative Jeffrey Sanchez is a health reform bill. Now, in Massachusetts, we had Chapter 58 in 2006, which was near-universal health coverage. It was groundbreaking. Then the Affordable Care Act of the Obama Administration. We’ve had several iterations of it since that dealt with payment reform. We’re asking that the next train to leave the station—and it may be the next train or two, because there’s talk of having a behavioral health bill, which I think is very important as well. But one of the trains leaving the station needs to be a health equity bill. An omnibus proposal that takes into consideration all those things that were raised in the Health Equity Task Force final report. And we’re hoping that can get done within the next year.
Jim Hunt, who I love, of the many pieces of sage advice he gave me, always says, “If you’re not at the table, you’re on the table or you’re on the menu. And it’s sage advice for anyone who wants to understand public policy. One of my examples of that is when the state was meeting to determine who got a ventilator. There was a shortage. And they wanted not to give them to people who had co-morbidities. And of course, that would have played out racially. But we didn’t have a seat at the table, so we were ultimately going to be on the table or on the menu. So, it requires that, wherever possible, we have people voicing an interest in communities at the table.
The other thing that I often bring up—and I was on a call with the pharmaceutical industry yesterday as they were talking about clinical trials— how do we have community advisory boards who help to direct clinical research going forward?
My favorite cry out on the streets after the murder of George Floyd was, “Nothing about us without us.” I loved that phrase because that’s health centers, that’s immigrant communities, that’s poor people, that’s Black and Brown folks. We don’t need you to provide some road map for addressing our issues. We need to be at the table to help address those issues. The work that the Boston Foundation has done, along with its colleagues in philanthropy, is really to empower communities to have a seat at the table, to have a voice in the conversation, and to be aspirational about eliminating racial health inequity in the Commonwealth in a way that we’ve never seen before.
I am very optimistic that if you fund it, if you track it, if you hold somebody accountable for it, it will change. So, I think that’s where we’re headed.
IT’S ALMOST AS IF YOU’RE SAYING IT IS A MOVEMENT.
I believe it could be. If it walks like a duck and talks like a duck… But, we have to wait and see. When it comes to racial justice, I think we have ADHD. We will focus on it. We will talk about it. Rodney King and Simpson, Ferguson, Chicago and Baltimore…
We have these really forced conversations… And I’ll say a last piece on that. I use this analogy when I speak on racism from 1690 to today.
Speaking up comes with great risk. Now you’re the militant, the rabble rouser, the party pooper… You become the person who is souring the mood. You become the person who is raising an issue which we don’t have the time or the capacity to do anything about. And as a result, it’s just so much easier for Blacks, Whites and others to just cover their heads and not see it.
And I think that’s where we are, this reckoning that we’ve been in over the last year and a half (it overlapped with the pandemic and the post-George Floyd moment) is: Do we finally embrace the challenge and the risk that comes with eliminating racial injustice in this country—and I am hoping and praying that we’re ready to do that.
DO YOU SEE PEOPLE FROM DIFFERENT SECTORS GETTING TOGETHER ON THE SAME PAGE?
We have these really forced conversations. I do these presentations where I do this two-hour walk-through of time and one of the analogies I use is the little boy from the movie “The Sixth Sense.” And the classic line from that film is, “I see dead people.” And I use that example on this issue of racism. The little boy didn’t want to see dead people. People were asking him to cross over, to say goodbye to a loved one. And he wanted to ignore them, because seeing them came with risk. People would question you and question your motivations and, quite frankly, it’s so much easier to cover your head up and pretend that you didn’t see it.
And I think the same is true for racism. We, like that little boy, see it. It’s everywhere, right? The poverty rates, the mortality and morbidity rates, those who are incarcerated and who’s not. Who gets convicted of drug crimes and who doesn’t. The difference between the crack cocaine and the opioid crisis. Who is foreclosed on? Who’s evicted? The data is right there. We see George Floyd and Tamir Rice as prime examples. However, as I tell people when I speak and make presentations, speaking up comes with great risk.
And, as a result, it’s so much easier for Americans—Black, White, Asian, Latinx, others to just cover their heads up and pretend they don’t see it. And I think that’s where we are with this reckoning we’re in. The pandemic and the post-George Floyd moment is: Do we finally embrace the challenge and the risk that comes with eliminating racial injustice in this country? And I am hopeful and praying that we are ready to do that.
I tell people that when I was getting taught about disparities in health care, there was a group of physicians that had us in a room at Health Care for All. And they asked, “Have you ever heard of the weathering effect? And none of us had ever heard of it. And they said, “Well, we want to give you an example. If you go into a Black community and you ask parents to rate their kids’ asthma from one to ten…. And parents in that study rated their kid’s asthma as a four or five or six. And then the doctor would evaluate those kids and they were eights, nines and tens. That’s the weathering effect, because you can be so used to being sick, so used to taking Flovent two or three times a day. You’re so used to having to take a pill at a certain time or being in the Emergency Room at Boston City Hospital, like we were, it becomes normal to be sick. You don’t even think of it as sickness anymore. It becomes part of life.
So if you’re in communities across the state—particularly those communities that are disparately impacted—in Springfield, Worcester, Mattapan and Chelsea, you become weathered about being stopped by the police for no reason. You become weathered to being followed around in parks or when you go to Faneuil Hall. You get weathered to seeing your aunts and uncles and cousins dying of heart disease and diabetes and hypertension and cancer, because it wasn’t diagnosed soon enough. You get used to having family members with no insurance and, as a result, no primary care provider. You’re used to uncles and aunts being incarcerated. Often for non-violent drug offenses. You become weathered to community violence, where shots in your neighborhood don’t even phase you anymore. The potential for a bullet to come through your door or your window and hit your child while he’s studying… You don’t even think about it, but it’s sitting on you. That’s the weathering effect. And I’d say part of the challenge in the Commonwealth—and we have the potential here to ‘un-weather’ ourselves and lead a movement across the country where none of that is normal! It’s unacceptable. When you think about low-birthweight babies and you think about the challenges that the Boston Foundation has been trying to invest in—to dismantle these structural and systemic issues—it’s also related to the decisions of individuals. Some people are in positions of power and their decisions are hurting us. Their indecision and indifference are hurting us. So, part of that is investing in awareness that our lives matter. And how does the fact that our lives matter manifest in terms of policy? That means that mothers who are giving birth in a country where too many Black and Brown parents have low-birthweight babies and high infant mortality rates; investing in those families to make sure they have the nutrition and the mental health supports they need. That is critical work. Frankly, that’s as urgent as getting knees off our necks. I would even argue that it’s more urgent because many more people are dying of those diseases and inequities.
I’m remembering that the money the Boston Foundation put into health centers is helping to develop a curriculum that talks about these exact issues. Going into communities and talking about COVID vaccines and dispelling myths that they make you infertile and whether there are some long-term effects from the vaccines that we don’t know about and whether that is preventing people from taking vaccines that can save their lives and prevent the spread and prevent future mutations of this virus. That money that the Boston Foundation invested is already on the street, on the ground, resourcing community health workers to be our eyes and ears and navigate through this crisis. I think that’s the critical work the Foundation has invested in.
People say, “Put your money where your mouth is.” One of the things I’ve appreciated about the Boston Foundation—and I would also put Eastern Bank in the same category—often putting their money where their mouths are and asking folks on the ground, “How can we support you?” And those grants—the money—went to 52 community health centers for new hires and purchasing technology and equipment to ramp up their capacity to give out vaccines. That’s groundbreaking stuff. That’s life-saving stuff. Health Centers used those dollars to purchase refrigerators to store their vaccines in their pharmacy and launched dedicated call centers and new phone systems so that people could reach them and they wouldn’t be on hold. HVAC systems to make sure we keep the health care workers safe. All of that is the Boston Foundation’s impact.
YOU STARTED BY SPEAKING ABOUT THE ‘60S AND ALL OF THE VARIOUS FORCES THAT CAME TOGETHER THEN. AND WE’RE IN ANOTHER MOMENT LIKE THAT.
Yes. Lee speaks about seizing the moment.
It’s unfortunate that it took a public health crisis to force us to work together. When I think about the front end of this pandemic, it forced the pharmaceutical companies to forgo their own interests and come together around a vaccine. It forced government to work collaboratively with research to fast track what was already in development to counter the spread of this disease. How do you get government, nonprofits, for-profits all rolling in the same direction? An example of that was the testing early in the epidemic; how East Boston was working with community organizers and other health centers across the Commonwealth who were working with their local schools and local businesses to do testing and contact tracing with the state department. That wasn’t heard of. There was no template for doing that. We were doing that on the fly.
YES, MANY PEOPLE I’VE SPOKEN WITH PRAISE THE PARTNERSHIPS THAT HAVE OCCURRED AND THAT THEY WANT THEM TO CONTINUE.
Yes, I think of Boston Medical Center and its partnership with Mattapan Community Health Center and our Baptist church. They got national attention for opening up the church to give vaccines. I went there to get my shot. I thought that maybe a church wasn’t the right place to do clinical care or provide treatment. But I changed my mind immediately. The comfort that people had. People felt comfortable seeing their Bishop standing there. They felt comfortable seeing the other members of their congregation sitting in chairs, the music, the greetings, the smiling faces… And then I started sending people there on a regular basis. That’s some powerful stuff. And then there were all of these organizations—grassroots organizations and Latinx organizations—who very few people had heard of before. Now they have the resources to do this work on the ground. That’s real partnership.