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Forty-three million Americans are without adequate health care, according to estimates by the Bureau of Primary Health Care at the Department of Health and Human Services.

The bureau should know. Its job is to make sure underserved and uninsured Americans receive proper medical treatment. The BPHC also works to eliminate what are known as "health status disparities," or health problems particularly endemic to a single group. "Our mission is to provide 100 percent access to health care and eliminate health status disparities," says Dennis Wagner, special adviser to the BPHC's director.

Wagner points out that an African-American male living in Washington, D.C., has an average life expectancy of 54 years, whereas an Asian-American woman living in New Jersey has an average life expectancy of more than 90 years. That disparity concerns the BPHC.

Contributing factors to health status disparities include poverty, culture, health care access, genetics and lifestyle. Life expectancy is one figure that health professionals can use to target specific health status disparities because it synthesizes so many disparate pieces of information. For example, part of the reason for the lower life expectancy for African-American men is that they have cancer rates that are two and three times the rate of the general population. Such statistics help the BPHC target funding and community assistance.

In 1999, the bureau came to a turning point. The BPHC discovered it was only reaching 25 percent of the 43 million Americans it was created to serve. The bureau manages the National Health Service Corps and a large network of community health centers in addition to issuing grants to health care organizations.

But because the bureau is not expecting a fourfold increase in budget and staff, says Regan Crump, director of the Division of Programs for Special Populations, it had to find a way to reach nearly 33 million people.

"If we continue doing what we've always done, we will continue to accomplish only 25 percent of our mission," Wagner says.

So the bureau created a new plan to guide the actions of every BPHC office: the 100 Percent Access, Zero Health Disparities Campaign. The campaign seeks to guarantee that all Americans get the treatment they need by coordinating efforts at the federal, state and local levels.

"Now our objective is to systematically eliminate health status disparities community by community," Wagner says.

The bureau isn't pouring money into every community however-it doesn't have the funding for that. Rather, it identifies communities that have had success in eliminating health status disparities and guaranteeing health care to underserved populations. The BPHC then attempts to match those successful communities with others in hopes that the best practices can be replicated. BPHC officials are careful about how they pair communities, though, because they know the effort will fail without strong community leadership.

"This is a whole new way of thinking about acquisition," says James Macrae, director of the BPHC's Office of State and National Partnerships. "If you just have a model and don't have a champion, you can have as many models as may want but none of them will ever take off. We really work with communities to lead the effort to change-to help communities down the path to owning their own health and health care delivery system." That is where the BPHC adds its support. The bureau engages in what it calls "performance partnerships." It helps find community leaders who can push successful practices originating in other areas. Once the BPHC has found a community leader, it may help him or her with a grant or marketing and public relations support.

To date, the BPHC has set up six performance partnerships. These partnerships receive from $50,000 to $150,000 in grants from the BPHC. This money is often used to help leverage even more funding from sources within the communities. Also, the agency is working with 115 communities to help them locate income sources. Such efforts have helped the communities snare a total of about $5 million in funding, a number the BPHC hopes will grow to $115 million over the next three years.

But the BPHC really sees its role as a liaison between the communities and as part of a movement that is helping generate a groundswell of support for guaranteeing every American adequate health care.

"We are sharing the success of certain communities with others so they can adapt others' best practices and approach 100 percent access and zero health disparities in ways that fit their community," says Crump. "It takes time. What it really is is social marketing-we are marketing the movement. I like to say this is all about human rights-the right to health care. It's also a social justice issue. We, in our society, have divided people by class and ethnicity and have allowed differences in health status among them."

The campaign already has success stories. One of them is Buncombe County, N.C., in which the city of Asheville is located.

Community leaders in Asheville were attempting to create a system for parceling out free medical service to the uninsured. Some doctors already had a quota of patients they saw for free, but many others had very good reasons for not wanting to see uninsured patients. If, for example, they prescribed a medicine to a patient, that patient could not get the drugs for free. Similar scenarios followed for those doctors sending the patient to a specialist or surgeons on a referral basis. In all likelihood, the surgeon or specialist would not see the patient for free.

But some would. The leaders figured that if they could create a system of doctors that committed to seeing a certain number of patients for free and coordinated efforts among primary care physicians, pharmacies, specialists and surgeons to provide those free services, the doctors were more likely to see the uninsured.

Primary care physicians told the local medical society they would be more likely to see uninsured patients if free prescription drugs were available. The society brought this to the attention of the county government, which decided to spend $300,000 on purchasing prescription drugs for the uninsured. This led to more primary care physicians agreeing to see the uninsured.

The medical society also took rain checks from surgeons who agreed to see patients for free if a hospital provided the necessary operating room, associated staff and materials. The county government then went to area hospitals and convinced them that if they donated rooms, staff and materials, fewer uninsured patients would end up in the hospitals' emergency rooms as a result of untreated illnesses.

"They went to the hospitals and told them that if the uninsured have good primary care they won't show up in the emergency room and they could help this by donating surgery units," Wagner says.

The medical society connected primary care sites and free clinics to an infrastructure that enabled them to arrange visits to specialists through an organized system of referrals, Wagner says. "Primary care physicians now are no longer dealing with unresolved specialty needs," he says.

Now free clinics, primary care providers, specialists, surgeons, hospitals and pharmacists are linked together, with the medical society taking leadership and the county providing funding. Buncombe County offers free services to 12,264 people who are either at or below the poverty line and may be uninsured.

With the new system in place, the county's free medical capacity for primary care has increased by 50 percent.

"The only way to do this is to mobilize others to do it with us," Crump says. "There are assets out there but they are not currently aligned properly."

BPHC has now arranged for representatives from Buncombe County to work with leaders in Wichita, Kan., to replicate the county's success. BPHC is helping to fund and coordinate the replication efforts, but it doesn't cover all the costs of the venture. The agency's partners "do far more than what we pay them for," says Crump. "The performance partnership is a leveraging mechanism."

Tampa, Fla., also has a successful program that the BPHC is working to replicate. The agency also has begun to work with national and state organizations to spread the word about performance partnerships. "It's possible to get 100 percent access [to health care]," Wagner says.

BPHC is now creating a database that tracks successful communities. "We are developing a system for replicating success in other communities," Wagner says.

To help manage the nationwide effort, BPHC has created the Center for Communities in Action to match communities, award performance partnerships, agree on project goals and monitor community results. "The campaign has crystallized what the goal is we are shooting for," Macrae says. "Our method is the performance partnership. When we work together with communities, we agree on the results, then we agree on how we are going to do it."