It turns out that retail medical clinics may not serve the underserved after all, according to a study published in the Archives of Internal Medicine (see reports). Of the 930 retail clinics mapped by researchers, only 123 were located in areas defined by the federal government as medically underserved. Clinics were typically found in neighborhoods with lower percentages of black and Hispanic residents, lower rates of poverty, higher rates of home ownership and higher median incomes.

Proponents contend, however, that the poor and uninsured do make their way to retail clinics. “People go out of their neighborhoods to work and shop,” says Margaret Laws, director of the California Healthcare Foundation’s Innovations for the Underserved program. “I don’t think we should make the assumption that they won’t go out of neighborhoods to seek health care if it offers customer service, better hours and transparent prices.”

But what about those without a car or public transportation or childcare or safe, walkable sidewalks? Will people overcome these and other barriers for good “customer service, better hours and transparent prices”?

Of course, all this misses a bigger issue. Defining “access” is not only a matter of proximity. The real question is: access to what? Will the CVS walk-in clinic three neighborhoods away speak my language? Will it offer culturally sensitive care? Integrated medicine? Indigenous healers?

Consider what happened at Southcentral Foundation, a community health system serving Alaska Native and American Indian people living in Anchorage and 60 rural villages. In 1982, Southcentral was turned over from the government to the very communities it serves, as part of the Alaska Native Claims Settlement Act by Congress.

Now owned by the Alaska Native and American Indian communities, there has been a total system-wide transformation, dramatically increasing quality of care for heart disease, diabetes, and cancer, which is the number one killer of Alaska Native people.

But here’s the amazing part. Southcentral has reached deeper into the sources of health of illness within these communities – with programs for domestic violence, child abuse, alcohol and drug abuse, and suicide. They run the school Head Start program. And community health education covers the basics, plus traditional healing, tribal relations, and economic wellness.

Southcentral’s vision: A Native Community that enjoys physical, mental, emotional and spiritual wellness.

This is a community that has come together to change from within. Where everyone has a voice and a role. Where building community is a natural extension of living in the community. And as a result, community members have a sense of control, shared purpose and contribution.

So, what might a “care clinic” look like in Las Vegas or Houston or Benton Harbor, Michigan? Are we willing to turn over design and control to the people who live there? Can we see care as the highest expression of community?

I was reminded recently by a great teacher and CoH mentor that “shouting louder than the person across the table” rarely broadens perspective. And so I wonder whether President Obama, the administration, or anyone at all now debating the nation’s health care solution can hear an idea that doesn’t fit the prevailing health care frame.

In a 6,000-word interview by David Leonhardt (The New York Times Magazine, May 3), the president talks a lot about health care, but misses the opportunity to mention some fundamentals about health. Filling the gap were Letters linking education and health, and reminding us that most advances in the nation’s health have come from investment in population-based prevention, not individual care:

“…compared with college graduates, people who don’t finish high school are more than three times as likely in some states to have less than very good health. Their rates of diabetes and heart disease are five times higher than those of people whose health is very good or excellent… Improving education can improve America’s health, which in turn can help our nation lower health care costs, which in turn can help our economy. Education, health and the economy are all linked. Policy makers should develop a unified approach to addressing these issues.” – James S. Marks

“(Improving) the health of as many individuals as possible, minimizing the need and demand for critical care — have come about as a result of government involvement in what may be called indirect, nonclinical endeavors like healthful air, healthful water, healthful food, safe buildings, healthful waste disposal, large-scale epidemiology and basic scientific research. The extreme diversion of public funds to individual care shifts the public focus from public health to the financial benefit of the individual clinical practitioner, but it would be valuable for the government to consider ‘health care’ in the more general sense of public-health programs.” – David C. Garron

There are plenty of sound approaches, supported by evidence, that will dramatically improve health, and not just health care (some are posted here). Now, how do we crack the frame wide enough to get a new idea on the table?

Last Friday, a Harvard study revealed that those who lose their jobs (including the half-million people who joined the ranks of the unemployed in April) are at greater risk for high blood pressure, diabetes or heart disease. This is a particularly unsettling finding as the total number of people receiving jobless benefits climbed to 6.35 million, a 14th straight record week.

The study is an important reminder that the link between work and health, while intuitive, is also complex: the psychosocial aspects of relationships and meaning derived from work run at least as deep as the more tangible economic benefits a good job affords. See more from RWJF’s Commission to Build a Healthier America.

Dave Sweeney asks: Can an organization’s communications strategy improve the health of those who work there? There’s plenty of evidence to support this, and considering the emergence of the so-called “participatory class” – from politics to patients – it may be time to start paying attention.