Federally qualified health centers (FQHCs) provide essential healthcare to people who are uninsured or underinsured. Increasingly, FQHCs are answering the call to bolster what have traditionally been public health and social services, and the question of how we support and enhance these resources is becoming more pressing. In this podcast, Abt's Ann Loeffler speaks to Lathran Woodard—the Chief Executive Officer of the South Carolina Primary Health Care Association—about the history of the health center movement, the mission that sets it apart, and the need to support and grow FQHCs and their workforce.
Read the Transcript
Eric Tischler: Community health centers provide essential healthcare to people who are uninsured or underinsured. Increasingly, these health centers are offering additional critical services like dental and mental healthcare, and the question of how we support and enhance these resources is becoming more pressing. In this podcast, Abt's Ann Loeffler speaks to Lathran Woodard—the Chief Executive Officer of the South Carolina Primary Health Care Association—about the health center movement, how centers can address the social determinants of health, and what the future might hold for these vital resources.
Ann Loeffler: I am so excited to have a conversation with someone that I've admired for many years in the health center movement. Lathran Johnson Woodard is the Chief Executive Officer of the South Carolina Primary Health Care Association. She has been with the organization for more than 35 years. Ms. Woodard is a member of several state and national organizations. She most recently held the position of chair of the National Association of Community Health Centers, and currently serves as the immediate past chair. With that, I would love to get started, Lathran, with our first question: Lathran, tell us, what was the health center movement like when you started?
Lathran Woodard: Well, first, Ann, I want to thank you for inviting me today. I'm very excited to talk about the community health center movement. I started in 1987 when I started working with the Primary Care Association, but really got to know health centers in terms of from an outside perspective when I was with the public health department, which was in the '70s and '80s. I actually worked with health centers and contracted around maternal health, which was the area I worked in. I worked with two health centers, so I had a feel for “this is what health centers do.” They had these doctors, because our health department was a nurse-run clinic. For our high-risk maternity patients, we contracted with two of our health centers who had OBs, so I thought I knew health centers from that perspective. In December 1987, when I joined the Primary Care Association, is when I had the rude awakening of, "You really knew nothing about the health center movement."
I started, as I said, in '87 with the Primary Care Association which, just to make sure people know, that is the membership organization for health centers. In each state we have Primary Care Associations. I started finding out more about the health centers. Being the person I am, I really wanted to understand the origin, because I'm really into how things got started, how did this model get started and the term, community health center movement. The word movement really made me want to know more because when I hear that word it evokes the civil rights movement, which I'm a child of civil rights. I thought, "Okay, you're using this word. Let me look back." I actually pulled the original grant application, which was on microfilm, which some of our new generation don't know what that is.
Ann: I know what that is.
Lathran: That's how I had to find it. When I was reading about the health center in the first application, it was touching my heart. It was touching and showing, "This is what I'm interested in," because basically to summarize it without taking up so much time—because I really do get excited talking about health centers—it started the same way, really, as the Civil Rights Act. People who saw injustices said, "We need to do something about it." It wasn't about color or anything, race or anything. It was about injustices, social injustices and health inequities. We had people who were very instrumental in saying, "This isn't right, not in this day and time." The health center movement, the model itself came out of South Africa.
Learning all of this and seeing how this is now in the '80s, it's something that started back in the '50s really, is when Dr. Clark and Dr. Geiger were working in South Africa with the Zulu population, and this is the model that was used. It was about people teaching people how to take care of themselves. I have to stress this, and I'll probably stress it a couple of times. Health centers aren't about medical care, they're about healthcare, which is very important. Because when I started back in the '80s, I saw not just the physicians, I saw all these other services.
What comes to mind to me is Beaufort Jasper Health Center. They actually had an environmental health section, which they had a backhoe. "What are you doing with this? You're a health center." The providers would say, "We are not taking care of what's really wrong and causing the problems they're having, and giving them a pill is not going to change that they have unclean water, poor sanitation." The health center actually was going and digging wells for people, and actually sewer systems and stuff. That was a part of it. That's why I say “more than just medical.”
When I saw that, I realized, "This is for me." It's about how one person or a few people can make a difference, and the fact that it is truly community focused, community controlled, community governed.
Ann: That's great, Lathran. I can relate to that too. I think many of us at Abt Associates can. A lot of us joined Abt because we have people who are deep experts in housing, deep experts in climate, deep experts in Social Security, Department of Labor, and we can draw from all of those experts to do the work that we came there to do in health. For me, I think health centers were doing social determinants of health before it was cool. Now we talk about vital conditions, and these vital conditions are the types of things that health centers keep at the forefront because they look at the whole person, and not just the whole person, they look at the whole family and how the family is within the community, and all of the systems that come into play to serve them in their health.
I think that's one thing about the movement that I love, is that we have a lot of leaders who make a pilgrimage to South Africa to learn more about the model and to get more in touch with the roots. I think that's a beautiful thing. Over the years that you've been in the movement, what do you think have been the most important changes, good and bad?
Lathran: Before I do that, you just brought something up. I do want to stress that when you go back and look at the health center original model and look at the application, it's one sentence in that application that says, "Health centers are about addressing the social and environmental factors that impact health," which now we are calling social determinants or social drivers of health. Health centers were doing this a long time ago.
That is one thing I feel, that in going into your next question, the changes I've seen, I think some of that is we are getting back to basics. We may be calling it different things, but we are realizing that it takes more than a provider laying hands on for a person to have a better quality of life. It takes all these other pieces, other pieces meaning not just in the healthcare arena in terms of nutrition and things like that, but also food security, also the environmental issues.
Changes I've seen is getting back to basics and bringing in more of the services at that one-stop shop for our patients, and recognizing that there's evidence-based services that we know we need to be providing. Because when we started, it was almost volunteering. How do we get to piecing things together? Now it's more of a system, and we are about serving more than just the underinsured and the uninsured. We're about serving the community, and how do we make the community healthy. Each community needs different things because they have different resources, and that's what make health centers unique, in that they look and do a needs assessment of what's needed in this community.
I do need to give this example, because I came from maternal health. When I started working with the Primary Care Association, there was one center in South Carolina that wasn't providing OB services, wasn't doing prenatal care. I was like, "Why? This is one of the worst areas. You need to be providing it." They said, "Well, we didn't need to be providing it, because we had OBs in the area who were seeing the patients." I said, "Okay, those OBs retired, left or died." There was no OBs in the area, which is why our health centers are required to do needs assessments, to see what has changed in the area. I think that's a big one in terms of it has come down from on high, of keep up with what's going on in your area.
A positive is the comprehensive services that we are providing. Positive is that we have—people say bipartisan, I say non-partisan—support in Congress, that people realize healthcare should not be politicized, that that's not what healthcare is about. How we've done that, but the other positive is how we've taught—and this is the analogy I use—we've taught community people how to fish instead of fishing for them, meaning we've taught them and we are teaching them how to take care of themselves in terms of better health practices, as opposed to just providing it and saying, "Out the door."
Ann: Yeah. I think the heart of the health center program is the fact that the majority of the board of directors needs to be the patients. I think that's a really important differentiator, or it's a difference in how those health centers operate. Thinking about the needs assessment, the requirement that they do a needs assessment and how beautifully it's done by health centers. Not just looking at what the data and the numbers say, but talking to people in the community who are living that every day I think is a really, really great way that they do that.
Thinking back to the roots in Mound Bayou in Mississippi and how they had a lot of patients, especially children, who were malnourished, and so they set up a farm next door. In this day and age, maybe you're not going to have a health center establish a farm next door, but what you might have is a community or a network of places where patients can go get access to food or access to places that deliver food to them. Looking at the systems level is a level of sophistication that it's been fun to see health centers move toward.
Lathran: We talk about the food. One other thing that is very innovative is some health centers—and in South Carolina I know a couple of centers—have contacted farmers markets, and the farmers market people have actually come and set up in health centers' parking lots so people can have access to food. There is so much that health centers are doing. We would not have enough time to talk about that, so many things, in terms of our goal is improving not just health outcomes but improving the quality of life for our patients and their families.
In terms of challenges, when you mentioned the governing board, I love that it is required that a health center's board has to be majority patients receiving care, and there's a reason for that. It's basically what you're alluding to, is who best to know what I need than me, for me to tell you the challenges? I think everybody in healthcare now, the cost, but also from a health center perspective of what I call— and this is Lathran talking with my 30-plus years, really 40 years experience in healthcare, public health specifically—we have what I call counterfeiters who are trying to get in and call themselves health centers. They've got that name and imply that they're doing the same thing health centers are doing, but they're not. I always say, "Look at how our model is different," which is one reason I think we started using, instead of Community Health Centers ... which I love, that's who we are ... we use the term now FQHCs, which is Federally Qualified Health Centers, to try to distinguish us. We do do that, so that people don't get confused when they see other organizations saying they're community health centers.
Ann: Yeah. There are a lot of things that health centers need to do to demonstrate that they deserve that trust from the public and from the government which funds them, that they are approaching their work with the integrity and rigor that's required. It also creates a lot of work for them, for health centers.
Lathran: Yeah. At least we have checks and balances that I don't think any other system has.
Ann: In terms of the data reporting requirement, you can go online and look up any health center's performance data, anything related to their clinical outcomes, their financing, how many people they have. That's something that health centers are required to report on each year. In fact, I think their latest report from 2022 was due this week. It's a lot of effort, and it's a lot of work to demonstrate the difference that you're making in the community. I think that's the kind of data that helps the community understand that these health centers deserve their confidence, and it's great that it's readily available at any health center in this country. Then it's also available at a national level, so you can look at the program nationally.
Lathran: Yes. Go in and look at not just the numbers in terms of the dollars, but look at costs. Look at outcome as well, clinical outcomes.
Ann: Yeah. I love that about health centers. When you look at the demographic data of those health centers, it's not necessarily those who have the most privilege. It's those who have the least privilege. It's people who are disenfranchised from the healthcare system as it is today, and yet you still see these clinical outcomes that are very impressive, and I feel so proud that we can say that.
Lathran: As well as we see it's required by law that our health centers are located in medically underserved areas as determined by the federal government, are seeing medically underserved populations, yes, that's how we started. I think it's very important to say we provide quality healthcare for everyone in the community. Even if you have insurance, even if you're above 200% of poverty, it doesn't matter. We are there for the community. For those patients who are having problems with little to no resources, we have what is called a sliding scale.
We will help you get the care, because the reality is sick people or communities who have a lot of people who have health issues, it impacts everybody. It hits everybody's pocketbook. It hits whether businesses come into the area, because if you're sick, you can't work. It impacts education. If you're sick, you can't learn. That is something that we look at in terms of community care and leaving no one behind, regardless of whether you have insurance coverage or not.
Ann: Yeah. We have a lot of folks who joined the health center movement as it was beginning, and we have a lot of folks like you who've been around for 30-plus years, and we're getting a new crop of leaders these days from different sectors. I'm curious, for those who weren't in the movement from the beginning, what do you think is most critical for these newer leaders to understand? As someone I consider to be an icon in the health center movement, what is that wisdom that you feel like, "Oh, they need to know this"?
Lathran: Lathran's take on this, which isn't always popular, it's first, "Is this really the right position? Is this the right career for you?" It can't be a job. As new leaders, I say to them, "Understand the origin and the roots of what the health center, this model, is about. Understand from whence you came, this model." Yes, we can't continue to operate as we've done in the past. New leadership is bringing business acumen. They're bringing all this new understanding of the technology and stuff that has happened that we need to have in our centers, because we want our patients to have the best.
I say to them, "Don't forget the heart of the movement. Don't forget this is a health center that has a history—or a core, if you will, a value—of addressing social justice and health equity. That's how we started, and everything you do should be around that. Be champions for the model that exists in providing healthcare. Be a champion in terms of looking at how do we get the best care for the patient population we serve. How do we listen to the community? Because this is more than just an economic engine, a business. This is about the people and teaching people." That's where I start them with.
Also I love to say, "Understand the history. If you don't have a heart for people and concern for people, maybe this isn't the right job for you," because we need people who are here and have the passion as those who did during the health center movement start, during civil rights, because it's about not the money, because health centers are all nonprofits. You probably can be making more money somewhere else, but if you care about people and want to see a change, then this is the place for you.
Ann: That's great. What do you think new leaders should be keeping in mind as the payment landscape evolves toward more value-based care and payment?
Lathran: I think some centers are going to do really great with value-based. We're far down the road with several centers, in terms of we were doing it before and now it's all over the healthcare industry, of looking at how I can improve the health outcomes, which then our reimbursements will go with it. Except the negative I feel that can happen with value-based care—and I'm not the expert on it—is when we look at how we are reimbursing centers, we can't compare them with a private-practice office, because, improving patients’ healthcare, our model is we are looking at total health. We are looking at transportation. We are looking at housing. We have to look at all that, because we can't provide it all. We are partnering with others, but we have to consider those things, the outreach for patients.
You don't have reimbursement for me—and I was an administrator at one time of a center—to send my outreach workers out to see, "Okay, what's happening to this patient who had uncontrolled diabetes and blood pressure? They didn't come back." We don't get paid for sending someone out there to do that, but if we want to improve outcomes of this patient who's on our system, we need to do that.
Ann: Yeah. The promise of value-based care and payment is that you get paid to keep someone healthy, like you were saying. I think the communities that are served by health centers require more investment.
Lathran: I am concerned about the viability of some centers in terms of this new arena, but it's here. As a Primary Care Association, one of the things I'm tasked with is looking at those centers who may not be quite ready and how do I get them ready, and working with them on it.
Ann: Lathran, we know that a lot of staff from federal agencies listen to this podcast, and I'm curious if there are specific things that you feel should be on their radars as we move forward in the health center movement.
Lathran: Well, I would say yes, but I would first have to say the Bureau of Primary Health Care, HRSA, since I've been working with health centers, I've never seen such a good partnership. We've had some downs, but right now it is, "Let's talk." They sit and talk with us, specifically about the base grant. I feel they understand it's not equitable. Okay, it is a problem. We haven't had a base grant adjustment. Cost of living is steady going up, but we don't have a base grant adjustment. When we get additional dollars, it's earmarked, and they have nothing to do with that, HRSA doesn't. That's Congress, who say, "When you get the money, this is what it's for."
They, meaning the Bureau, have changed a lot in terms of, lately, actually coming out and sending staff out to see what's going on in the centers and doing listening sessions. The HRSA administrator actually did some listening sessions as well, and said, "Tell us." That's the best thing you can do, hear from the field, because you can make policies that sound great on paper and then you try to implement them, and you're like, "This isn't going to work."
Ann: One thing I appreciate about the leadership at the Bureau of Primary Health Care is that they've been involved in the health center movement for so long and they've seen lots of health centers on the ground, and so when they make decisions about policies, it really does come from a place not only of technical knowledge about what happens on the ground but also this commitment—decades-long commitment—to the work. I remember, I think Tonya Bowers did my first new access point grant review training back in like 1999, and so to see her now as the deputy administrator, it's comfort for me to see that the leadership has such longevity in the Bureau of Primary Health Care.
Lathran: I have to go back and say something, because it's been on my mind. When you talk about challenge, I think everyone would get me, listening to this, if they're in the health center movement, if I did not mention workforce.
Ann: I was going to ask you. Great.
Lathran: I think I may have deliberately wanted to have amnesia when it comes to this. We are really having problems with workforce, and not just the clinical ones. Not just providers or clinicians, but I'm seeing all levels in terms of even CFOs, Chief Finance Officers, billing staff. We get them, and even at Primary Care Associations. I was really acting out one day and said, "I'm tired of getting people, training them, and someone else is taking them," because we can't offer the salaries that some of these big other healthcare institutions or payers can offer. They're letting us train them and they're taking them, and that's hurting us, as well as COVID.
COVID really had an impact that I think is still being measured in terms of how many of our workforce, how much of our staff, after being out, decided, "I don't want to come back," for whatever reason, of, "I didn't know I was under that much stress, so I'm not going back," or, "I'm really interested in doing something else, because I've been out and tried something else," so they're doing entrepreneur work, and then it is, "I'm not going back because of my safety."
Ann: What I'm seeing now—and I'm curious if you're seeing this, too—is just we had a lot of the leadership of health centers get their health center through that really difficult time and experience their own burnout and experience their own challenges. Now that people are talking about the pandemic being over or behind us, it is different. I'm seeing a lot of senior leadership in health centers say, "Okay, now I can retire or now I can leave," because in the middle of it, they just didn't feel like that was an option. Now I feel like there's this second wave of senior leadership in health centers also leaving. Have you been seeing that in South Carolina?
Lathran: I've been seeing the more seasoned of us leaving and retiring, but for different reasons. I think, yes, there was some commitment of, "We don't want to jump ship," but there is also the issue of we are seeing our colleagues we work with who are passing away. It's just a reality check of, "My season should be going into my retirement, my next season," but we cannot do that without preparing, and that's succession planning and getting someone else ready.
I have to talk about the grow-your-own piece. I find that if we train people who are from a rural area that's home, they will come back and stay. We also need to look at the pipeline for primary care providers. As opposed to people going to medical school and specializing because they need to get more money to pay off this high debt they have from medical school, we need to promote the National Health Service Corps. How many people know about the National Health Service Corps? I have a granddaughter who's talking about going to medical school, and she was looking at financing and stuff. I'm like, "Have you heard about… ?" and I'm working with this! We can't assume people know. We've got to do more with how do we encourage people to go into medical school and be diverse, have diversity in terms of in medical school.
Ann: When you look at the Bureau of Health Workforce's data ... and they have a lot of it, they've got some pretty amazing dashboards ... they do have a high retention rate. If you can place someone somewhere, they tend to stay. That's the beauty of it, because once you've fall into the movement, it's the type of community that if you're connected in, it's your people.
Lathran: That comes with the selection. We can't fill a position just because we need a warm body. Is it a right fit? We need to do the recruiting not just for skill set.
Ann: Yeah, that's a great point. Lathran, I know we have to wrap up, but if people take away only one thing, what would you like that to be?
Lathran: One of my mantras that, after reading the history of the health centers, just came to me, it was a quote from Franklin Delano Roosevelt, and it was, "The test of our progress is not that we give to those who have much, it is how much do we give to those who have little." That's what the health centers are about. That's when we know as a country that we are progressing. Are we bringing up, in terms of quality of healthcare? Are we providing it to those who have little, instead of just keep putting more on those who have? Bringing that floor up is what the community health centers are doing for healthcare.
I can go on and on, but I think just to stress that we as community health centers, we are about more than just the medical care. Remember, we were established based on social justice and health inequities, and it's sad to say that's over 50 years ago we were established for that, and what are we dealing with right now? The same thing. We know what works. Why aren't we doing it? If it's policy, we just need to have that think tank of saying, "Come on guys, we can handle this, we can figure this out." Don't be afraid, health centers, to speak up when you see social injustice, because violence is a public health issue.
Thank you. I enjoyed it, and I hope that your listeners have gotten enough that they want to dig deeper to find out more about the history of health centers and find that this is their calling, this is what they're really interested in.
Ann: I could listen to you talk all day long, and I feel like whenever you speak to health centers and health center leaders, we're all on the edge of our seats because you're so inspiring. I also know that a lot of folks in the health center movement look up to you as a mentor, and you do take that one-on-one time to mentor folks. We're all really grateful for your wisdom and your commitment to this work that we all are very passionate about. Thank you for taking time with us today, and thank you so much for just being in this world and being so great.
Lathran: Thank you for having me, and I appreciate you doing this to get the word out, get the message out. Thank you.