Access to primary health care services is a significant issue for many communities seeking to improve the health of their populations. This single case study describes the 12-year journey of 2 adjoining rural counties in 2 states towards meeting the primary and specialty care needs of the uninsured and underinsured population. Data were triangulated using historical documents, first-person interviews, and health utilization data. The community leadership moved through various models including a free clinic and a university-sponsored health center before finally establishing a federally qualified health center, which now serves 40,000 citizens in these counties. The site is now hosting new programs funded by research grants in alliance with area universities. Success is contributed to an unwavering desire to provide a medical home for the underinsured and underinsured, a shared vision, recognition that continued success was dependent on a funding source, recognition that practices and processes must be in place to assist with navigation for those in need of services to seek care at the appropriate venue, and a belief that the infrastructure built to provide care was sustainable. All participants recognized the importance of funding for sustainability. Positive social change has occurred from the emergence of a multidisciplinary center to serve the community's uninsured and underinsured, thus improving access to care, management of chronic conditions, and access to behavioral health professionals. Findings from this study may inform other communities faced with similar problems and can inform legislators of the importance of federally qualified health centers in the provision of health care to vulnerable populations.

Contemporary health care systems in the United States are not equitable. Indeed, as the literature indicates, there are substantial differences in the variety and scope of service delivery based on age, income, and other socio-economic indicators. The recent passage of health care reform in the United States illustrates that Americans are seeking to bring balance and equity to health care. However, as learned in this study, county governments across the country have been working in their communities to ensure some balance and equity, by making a safety net available for those citizens who are unable to access health care. Perhaps this is because health care quickly becomes a local government problem. In this current economic climate, county governments are being pinched between declining revenues and rising demands for services (Eaton, 2009; Phaup, 2009). The Orange County Primary Care Access Network is one example studied here that provides clear evidence of how organizations can work together to develop and maintain a sustainable health care safety net for the underinsured and uninsured. This study is the first of its kind to examine county government influences, environmental pressures, and community resources in the context of health care network performance. The methodological research question for this study is what determinants (exogenous constructs) contribute to a health care network and its performance (endogenous construct) within the framework of county government participation? Further, is the model supported by the data and can prediction, direction, and strength of relationships among the variables be identified? The simple answer is yes. For this study, the responses from 123 counties were analyzed with a variety of statistical techniques, culminating in structural equation modeling. The outcome of these analyses provided a reasonable explanation for the variation among the variables leading to network performance improvement in meeting the health care needs of uninsured and underinsured people. These quantitative data were also supported in their results with the inclusion of a case study analysis of a particular health care safety-net, the Orange County Primary Care Access Network in Orange County, Florida. Ultimately, this study learned three valuable lessons that can be used by county government decision-makers and health care providers alike. First, county involvement in community based health care networks results in a benefit that reverberates during economic stress- the leveraging of resources. Second, public-private initiatives are fundamental to reducing disparities in health care access. Third, health care networks improve access to health care for uninsured and underinsured people. Ultimately, county government participation is the largest predictor of network performance in this study.

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