Community health clinics under managed competition: navigating uncharted waters.

In this article, we consider how major changes in the health care system, both real and proposed, may affect the future of community health clinics (CHCs) in the United States and their ability to continue to provide comprehensive care to underserved populations. We discuss the constraints and opportunities that CHCs face in a health care system that is rapidly moving away from fee-for-service medical care toward a model of managed competition. We describe the role that the National Association of Community Health Centers has played in advocating for CHCs in Congress and the role state primary care associations are playing in spear-heading the development of statewide CHC-sponsored health maintenance organizations. We also analyze CHC reactions to the changes in federal policies that were proposed in the major health care reform bills of the 103d Congress, as well as the prospects for CHCs under Medicaid managed care as it sweeps rapidly across the nation. As a case study, we examine California's policies that mandate that Medicaid recipients enroll in either a private managed care plan or a newly created public plan, which compete against each other within each county. CHCs are vulnerable during the transition to managed care and managed competition, and they have neither the resources nor the ability to integrate or compete successfully with private health maintenance organizations without safeguards, new sources of funding, technical assistance, improved infrastructure, and vigorous monitoring and oversight from federal and state governments, as well as the continued education, training, and policy advocacy provided by the National Association of Community Health Centers and state primary care associations.