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Bar Journal - Spring 2007





There is a need for the development of an economically sustainable system of comprehensive coordinated primary care for Manchester’s most vulnerable populations. The primary care delivery systems in this city are stressed, in large part from serving a growing population of persons who live in poverty, are uninsured, underinsured, or on Medicaid.  Both Manchester residents and providers face increasing economic barriers for getting or providing appropriate health care services.  Since no near-term relief from federal or state government sources is expected, the community has taken a proactive approach to health system reform and has established a community collaborative, the Manchester Sustainable Access Project (MSAP), to begin a planning process to evaluate and improve its current health delivery infrastructure.




The City of Manchester is the largest community in New Hampshire and in northern New England with a total population of 110,550 residents. Although Manchester is located in a predominantly rural and affluent state, it is an urban community with public health challenges and diverse demographics similar to those found in larger cities.  The number and proportion of Medicaid enrollees, underinsured, and uninsured populations (including refugee, immigrant, and homeless populations) living in the Manchester area have grown substantially over the past several years and the current health care system has become inadequate for meeting the needs of these local residents in a financially sustainable way. 


Manchester’s poverty rates are high and are growing as illustrated by the table below.  In 2005, over 14,000 Manchester residents, including 22 percent of Manchester’s children, lived below the federal poverty level.1  It is estimated that 28,000 residents – about 25 percent of Manchester’s population – currently have incomes below 200 percent of the federal poverty level.2


As the city’s poverty rates have increased, so has the number of residents who are enrolled in Medicaid, uninsured or underinsured.  Manchester is now home to a disproportionate share both of the state’s Medicaid recipients and uninsured.  While about 8 percent of the state’s population lives in Manchester, 15 percent of the state’s Medicaid enrollees and in 1999, 14.6 percent of the state’s uninsured, claimed Greater Manchester as their home. Subsequently, more Medicaid enrollees and uninsured residents are being seen by local providers as a proportion of their total patient population. For example, in 2000, 27 percent) of the patients cared for by the Manchester Community Health Center (MCHC) were uninsured compared to 56 percent in 2006.


The uncompensated costs of providing timely, comprehensive care to these more economically vulnerable populations is threatening the viability of the local provider organizations. Community providers incur financial losses every time they see a Medicaid patient (due to poor provider reimbursement) or a patient who is uninsured (due to increased uncompensated care losses).  For example, for fiscal years 2004-2006, Dartmouth-Hitchcock Manchester, The Mental Health Center of Greater Manchester, the Manchester Community Health Center and the city’s two local hospitals together contributed a total of $129,584,470 in uncompensated care to the community:  $95,520,423 in free care, $33,227,293 in costs above and beyond what they were compensated for by Medicaid, and $838,755 in costs for interpretation services to address language barriers.


To make matters worse, a large percentage (44 percent) of the cost of care for the uninsured is eventually paid for by people with health insurance through higher premiums. 4 And, as increases in insurance premiums continue to rise faster personal incomes, more people will be unable to afford  insurance coverage even when offered by their employers 5, 6.  (Health insurance premiums for New Hampshire families increased by 80 percent from 2000 to 2006 while median earnings of workers increased by only 18 percent 7.)


Additionally, those who are underinsured or uninsured often seek and obtain inefficient and costly services in emergency room settings, either long after the benefits of preventive health care can be realized, or in lieu of receiving care in a less costly primary care setting.  In many cases, these underserved populations do not ever access primary care due to: (a) a haphazard and difficult system to navigate, including limited clinic hours in relation to work schedules; (b) socio-cultural barriers, including language; (c) economic barriers, including the lack of health insurance, dental insurance, prescription drug coverage, childcare, telephone service, etc.; and (d) geographic barriers, including lack of adequate transportation.




The Manchester Sustainable Access Project (MSAP) was established in 2005 to address these economic barriers to access.  The aim of the project is to improve coordination of, and access to, financially sustainable safety-net health care services for vulnerable populations residing in Manchester.  The four major goals for MSAP are summarized below:


Project Goals

     Develop a leadership coalition in which all members agree to collaborate across local organizations to resolve the access issues for Manchester’s vulnerable populations.

     Use local and state data to summarize and continually evaluate the economic barriers to access in the Manchester community.

     Work to maximize federal, state, and local grant funding to reduce barriers to access, including work to expand funding through the Federally Qualified Health Center program.

     Design a long-term strategy to develop a community-wide, integrated health care delivery system in Manchester that is dynamic and enables the sharing of responsibility for caring for the city’s most vulnerable populations – now, and in the future.


MSAP has been generously funded for the past year by the New Hampshire Endowment for Health; the Norwin S. and Elizabeth N. Bean Foundation; and by the local community providers of Catholic Medical Center, Dartmouth-Hitchcock, and Elliot Health Systems.  MSAP is an official project of the Healthy Manchester Leadership Council.  The project’s work and activities are coordinated by the Director of the City of Manchester’s Public Health Department and supported by key community organizations and state leaders.




Key informant interviews of Manchester’s health care leaders (2006) provided a clearer description of the issues and potential solutions for decreasing the economic barriers to access to primary care.  Several of the leaders interviewed felt that efforts to improve access and financial viability of health care service delivery would fail if they were focused at issue-specific or organizational-specific levels.  Ultimately, provider organizations must take a systems approach and work together to address the issues that are threatening the economic sustainability of their organizations and the subsequent health of the community.  




The national Institute of Medicine has promoted organizational collaboration as an approach to health system reform and improvement for some time 8, 9.  In addition, the National Citizens’ Health Care Working Group recently recommended to the President and to Congress 10 that they support the development of integrated community health networks similar to the vision being developed through the work of the MSAP.


 Manchester is a city in need.  It is also a city at the tipping point of great change.  The question today for Manchester leaders is not whether they will work together to improve their local health system infrastructure - rather, the question is how community leaders will maximize the cumulative resources of local providers to create a delivery system that is appropriately utilized and fiscally sustainable… a system that works for all area residents, community organizations and health care providers. 



1.   U.S. Census Bureau. American Community Survey.

2.   U.S. Census Bureau. United States Census 2000.

3.   U.S. Census Bureau. United States Census 1990.

4.   Families USA. The Added Cost of Care for the Uninsured in New Hampshire. Washington, DC: Families USA; 2005.

5.   Families USA. Who’s Uninsured in New Hampshire and Why? Washington, DC: Families USA; 2003.

6.   Glimer T, Kronick R. It’s the Premiums, Stupid:  Projections of the Uninsured Through 2013. Health Affairs. 2005;24(1):W5143 - W5145 5151.

7.   Families USA. Premiums Versus Paychecks:  A Growing Burden for New Hampshire’s Workers. Washington, DC 2006.

8.   Institute of Medicine. Improving Health in the Community:  A Role for Performance Monitoring. Washington, DC: National Academy Press; 1997.

9.   Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press; 2003.

10.  Citizens Health Care Working Group. Health Care the Works for All Americans. Bethesda: Agency for Healthcare Research and Quality; 2006.


Around the country, State Public Health Systems (SPHS) are set up with varying degrees of infrastructures, yet many share the same common mission: to assure and protect the health and safety of its residents. All SPHS have a central state run office or division within the government to carryout its mission. Many SPHS break down the state in regions and have some type of governmental county or district health departments. Some states then have city health departments within those counties or districts.


In New Hampshire, there is a central governmental state office within the Department of Health and Human Services called the Division of Public Health Services (NH DPHS). The NH DPHS mission is to “assure the health and well being of communities and populations in NH by protecting and promoting the physical, mental and environmental health of its citizens and by preventing disease, injury and disability”. Since the beginning of the century, NH State RSA 128, indicates that each town shall have a health officer appointed to enforce public health laws and regulations and investigate sanitary public health threats. Two cities, Nashua and Manchester, have built upon this statute and created governmental city health departments.


The City of Manchester Department of Health (MHD) has a congruent mission to the NH DPHS: to improve the health of individuals, families, and the community through disease prevention, health promotion and protection from environmental threats. The vision of the MHD is “to be a healthy community where the public can enjoy a high quality of health in a clean environment, enjoy protection from public health threats and can access high quality of health care”. Since the Department’s formation in 1885, MHD has diligently worked to adhere to its mission and has met the changing public health needs of its population with great vigor. The MHD is served by a 5 member Board of Health. The Board provides professional advice to the Department, acts as a hearing body for regulatory matters pertaining to permits and licenses, and represents the public interest in Department policy matters. The composition of the board includes a physician, a dentist, a nurse, and representatives of labor and the public at large.


The Manchester Health Department has a history of commitment towards the community health improvement process. Community health improvement efforts are based on a commitment of shared responsibility and an ethic of shared accountability. This ensures that health improvement efforts are strategic, coordinated, unduplicated and employ an effective use of community assets and resources. In Manchester, the community health improvement process is carried out through the Healthy Manchester Leadership Council (HMLC). HMLC is a partnership of key health and social services organizations with the MHD providing local health data analysis, guidance on evidence-based public health interventions and best practices and as needed, acting as a fiscal agent on HMLC grant initiatives. Over the last decade, HMLC has initiated many health improvement efforts, of which, two of the most notable achievements include the implementation of comprehensive school education in Manchester city schools and the passing of the referendum for community water fluoridation.





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