Clinical repression

Sip Mouden, CEO of Community Health Centers of Arkansas, says FQHCs are the best kept secret that shouldn't be a secret.

When WORLD intern Kira Clark asked 37 charitably minded Americans what they thought about FQHCs, she found that not one had heard of them.

FQHCs are Federally Qualified Health Centers. They receive cash from Washington-start-up funding of up to $650,000, and millions afterward - plus free malpractice coverage under the Federal Tort Claims Act. They must be governed by a board of directors, a majority of whom must be active, registered FQHC patients.

Legislators and officials originally created FQHCs to reduce the patient load on hospital emergency rooms, but their function has expanded to serve potentially all poor or uninsured Americans and immigrants. Some 1,100 FQHCs now provide services regardless of ability to pay.

What's not to like? Just this: FQHCs may be a healthcare blessing to some poor Americans, but if historical precedent holds, they will also become a curse. The precedent: American poverty-fighting until the 1930s was Christian - and community - based. The Depression intensified the challenge, but the New Deal, instead of bulwarking private programs, marginalized them. A generation later the War on Poverty warred on the remaining Christian programs.

The result: Soulless welfare offices replaced charities that offered challenging, personal, and spiritual help. In many households, provision from the government replaced provision from a husband and father - and devalued men slunk away. Washington enabled more people to disable themselves by using drugs or alcohol. The same dollar flow went to a mother who cared for her children and one who selfishly ignored them.

American churches and charities before the 1930s, within the material opportunities of their eras, did a good but incomplete job of poverty-fighting. Today, America's charity clinics do a good but incomplete job of providing medical help to the poor and the uninsured. Sure, gaps exist and more resources would be great, but does that mean that the Affordable Care Act ("Obamacare") should wave a magic wand, with dollars stuck to it, and turn many of them into FQHCs?

A recent Kaiser Permanente Institute for Health Policy (KP) study offered an imperative for federal policymakers: "First, do no harm. … Policymakers should consider the impact of reform measures on the financial viability and operational stability of these programs." The KP study noted that "current financial support for charity care programs may diminish amid health reform implementation. For example, donors may perceive a reduced need for funding, given the extensive coverage expansions."

Our experience with welfare suggests that this will happen. It will happen sometimes by choice, as donors feel they're paying taxes to fix the problem, so why should they contribute more? It will happen sometimes by necessity, as taxes rise and those who supported charity clinics have fewer discretionary dollars and (as they struggle to maintain their standard of living) less discretionary time.

We should be giving charity clinics more support and flexibility by voucherizing healthcare expenditures: Then individuals rather than officials could decide which programs will live and which will die. Instead, the KP study suggests that many Christian and other charity clinics within the new health order will become "subcontractors for health plans and Medicaid as the organizations serve a newly insured population. Charity care programs could screen and enroll members, or advise plans and Medicaid on outreach and health management."

Whoop-de-do: Charity clinics will become, to use biblical terminology, hewers of wood and drawers of water for Washington. That's not the case now: Right now, Christian FQHCs are doing great work, serving the poor in an explicitly Christian way - but the history of welfare suggests that the golden age will become silver, then bronze, then mud. The Obama administration's demand for mandatory contraception coverage already shows how religious liberty can slip away.

Some Christian proponents of Washington-dominated poverty-fighting in the 1930s and the 1960s were as optimistic as Obamacare backers now are, but the results have not been pretty, as the welfare reform movement of the 1990s attested. Please read our special section on charity healthcare and learn about the remarkable body of programs that Christians and others have built. Let's help them, not pave them over.

Email molasky@worldmag.com