In the absence of a national health system, community health centers (CHCs) are critical infrastructure for the delivery of preventative health services in the United States (Starfield et al. 2005; Pacia et al. 2024). CHCs are the nation’s largest primary care network, providing prenatal care, vaccination, health education, screenings, chronic disease management, and disease prevention to over 32 million patients nationwide (NACHC 2024). With roots in racial justice movements in the U.S. and South Africa, the CHC movement was born out of a moral commitment to ensuring access to and quality of basic health care and prevention for all people, regardless of ability to pay. Historically, community health has not been a focus of bioethics scholarship, either in public health ethics or clinical ethics (Berlinger 2022).

In this presentation, we use results from the Moral Uncertainty in Community Health (MUCH) Study to examine ethical challenges facing CHCs, and how they respond. We conducted hour-long, one-on-one qualitative interviews with 24 clinician-leaders at federally funded community health centers in 12 states asking, “what keeps you up at night?” Our interviewees repeatedly described a daily struggle between maximizing patient access and ensuring quality of care. Centers strive to see as many patients as possible, both to keep health centers financially viable and to ensure that all patients access needed care. Maximizing encounters is how centers address population health issues such as disease prevention and tracking. Simultaneously, CHCs are a safety net serving low-income medically underserved patients with complex medical and social needs that are difficult, if not impossible, to address in a typical 15-minute appointment window. We describe how this tension between population health needs and the needs of individuals manifests in everyday ethical decision-making regarding scheduling, referrals, and patient follow-up. In doing so, we highlight the role of ethics in the ordinary work done by community health providers in the delivery of primary care (Sideman and Razon 2024) and the importance of federal funding for a variety of programs, including Medicaid, the Health Center Program, and National Health Service Corps, that ensure both access and quality of care for medically underserved populations.