Community health centers face changes, challenges under health reform

An influx of newly-insured Americans are inundating community health centers, which have traditionally served poor and uninsured populations. As journalist Lauren Whaley explained in a recent article, “That pent-up demand, which is predicted to grow again after Covered California opens its second enrollment period,” is most obvious at the state’s community clinics and health centers.

These centers are actively enrolling as many people as possible in private insurance or Medicaid and trying to position themselves as providers of choice, rather than providers of last resort. But even with more insured patients under the Affordable Care Act (ACA), financial challenges still loom, including lower-income patients with high-deductible health coverage who struggle with high out-of-pocket costs.

The Affordable Care Act Blog caught up with Dan Hawkins, the senior vice president for policy and research at the National Association of Community Health Centers, to hear more about the changes and challenges facing these centers following health reform. Below are his responses, edited for clarity and space.

Q: Please describe how the ACA has changed the role of community health centers.

A: The ACA has not changed the mission of health centers, but what the law did do was invest in the expansion of health centers and provide a base of support to meet the growing demand for primary care among the newly insured and people who remain uninsured or underinsured.

Health centers have expanded to meet the growing demand for comprehensive primary care among the newly insured. They now serve more than 23 million people, or one in 15 people living in the United States. Health centers have also had a nearly 30 percent increase in patients since 2008, and the demand continues to grow. We estimate that there are 62 million people who struggle without access to a primary care provider, and many of them do have health insurance, just no place to go for care.

Health centers are also helping to educate and enroll people into insurance coverage, whether it is through Medicaid or the Health Insurance Marketplace. To date, health centers have helped more than 7 million people enroll either under Medicaid or exchange coverage. 

Q: How has your role been different in distinct regions of the country?

A: Roughly half of all states have opted not to expand their Medicaid programs, often leaving the poorest adults in those states—those with incomes below 100 percent of the Federal Poverty Level—without any option for coverage. In those states, these poor and uninsured populations will require care, and health centers provide care to anyone who needs it. However, caring for large numbers of poor and uninsured does pose a financial strain. Also, it’s worth noting the Congressional Budget Office projects that the ACA will reduce the number of people without health insurance by about 25 million, yet 31 million will remain uninsured. Health centers will be a critical source of care for patients who don’t have insurance for any number of reasons, including unaffordability of local coverage options, choosing to decline coverage, homelessness and mental illness.

Q: How has the financial solvency of these centers changed with health reform?

A: Our main concern at the moment is the primary care funding cliff. Millions of patients could be shut out of care if lawmakers do not act to fix it. If more states do not expand Medicaid, the number of patients cared for by health centers could fall more than 25 percent—or 7 million patients—by 2020. We detailed this in a press release over the summer. There is an encouraging move toward a solution among a bipartisan group of lawmakers in the House and Senate to address the problem, but no definite proposal has been agreed to by all sides yet.

Q: This article in Modern Healthcare describes the strain of high-deductible plans on community health centers. Is that a common experience nationwide?

A: Yes, published reports indicate that of the more than seven million people who bought coverage on the federal and state exchanges, about 20 percent chose the bronze plans that include deductibles as high as $5,000 per person. Health centers are essentially subsidizing the bronze plans because these underinsured are counting on health centers for discounted care. (Another worrisome problem is that people may be delaying or forgoing care because of costs). Compounding financial strain for health centers is the fact that private insurance only reimburses them an average of about 56 cents on the dollar (compared to 81 cents on the dollar for Medicaid patients). As an unintended consequence of the Affordable Care Act, this costly trend has thrown the spotlight on the need for continued funding for health centers as they open their doors to a growing influx of underinsured and insured alike.  

Q: How do you become a provider of choice vs. provider of last resort?

A: Health centers are doing that all over the country.  We have found that even after people gain access to an insurance card, they generally stay with the health center because they like the quality of care they are getting.  At a health center, patients encounter a team approach that addresses their whole health, such as diet, exercise, housing and joblessness. This is what patient-centered care is about and why 57 percent of health centers have achieved recognition as patient centered medical homes (PCMH). More than 80 percent of health center patients rated their quality of care as high. Health centers not only focus on illness prevention but also the factors that may cause illness, the social determinants of health. Also, in terms of talking about quality of care, researchers at Stanford University also found that the quality of care at health centers is as good or better than what one would find with private practice providers. 

Q: What health outcomes are improving the most at health centers?

A: In terms of specific health related outcomes, I would point to their success in lowering infant mortality rates and low birth weights among children. You can find excellent summaries of peer-reviewed studies of health center quality of care here.

Q: Which specific communities have been the hardest for health centers to reach?

A: Rural communities generally face the biggest challenges in access to care.

Q: How are you able to staff centers in less desirable or remote regions of the country?

A: Recruitment is always a challenge for health centers, especially in rural areas. The National Health Service Corps and Teaching Health Centers are significant sources of workforce for health centers, but they also face looming funding cliffs.

Q: Are there any specific health delivery models that have been funded/supported through the ACA’s innovation grants that are noteworthy?

A: CMS [Centers for Medicare and Medicaid Services] has launched numerous programs and models to help health providers achieve large-scale transformations. Some of those grant awardees have included health centers, notably Denver Health, for creating an ambulatory care model for low-income children and adults, and Mary’s Center in Washington, D.C. to reduce emergency room dependence among the chronically ill.

Q: What are some of the untold stories about community health centers? What are reporters missing?

A: I would say that the work in innovation and the multiple ways that health centers go beyond the walls of traditional medicine are stories that deserve more attention.  There are health centers addressing the social determinants of health by, for instance, sponsoring or hosting farmer’s markets or community gardens to ensure better nutrition; cooking classes to teach patients how to avoid diabetes; or even legal services or job training to empower people.   Also, health centers are doing incredible outreach and enrollment to the uninsured in their communities so they can connect them with insurance options – hosting coffee talks, offering expanded hours to meet with enrollment assisters and hosting enrollment events.