August 2018 | Issue Brief Community Health Centers’ Experiences in a More Mature ACA Market Anne Markus, Jessica Sharac, Jennifer Tolbert, Sara Rosenbaum, Julia Zur Executive Summary Community health centers provide comprehensive primary care services in some of the most underserved communities in the nation. Four years following implementation of the ACA’s coverage expansions, health centers continue to play a central role in connecting consumers to expanded Medicaid and marketplace coverage even as they faced challenges during the 2018 marketplace open enrollment period because of the administration’s decision to shorten the enrollment period to six weeks, reduce advertising funding, and reduce federal Navigator funding. In addition, in response to improved financing from having more insured patients as well enhanced federal grant support under the ACA, health centers have also experienced significant growth in their service capacity. This brief summarizes findings from the Kaiser Family Foundation/Geiger Gibson Program in Community Health Policy 2018 Health Center Survey to provide a snapshot of health centers’ outreach and enrollment activities as well as changes in service capacity, and overall financial condition since implementation of the ACA. Key findings include:  Most health centers took steps to prepare for the shorter open enrollment period in effect in most states. Nearly four in five health centers took some action, including contacting consumers ahead of November 1st to inform them of the shortened enrollment period and increasing outreach activities.  The majority of health centers employed the same level of outreach and enrollment staff as last year and served about the same number or more people seeking enrollment assistance. Two- thirds of health centers indicated that the number of full time equivalent (FTE) paid enrollment assistance staff had stayed about the same since the last open enrollment period, but 21% said staffing had decreased. Despite arguments from policymakers that the need for in-person assistance would diminish, over seven in ten health centers reported serving the same number or more people seeking enrollment assistance during the most recent open enrollment period.  Many health centers received state or federal navigator funding and some experienced reductions in that funding. Funding for outreach and enrollment activities is included in the federal Section 330 grants health centers receive. In addition, about four in ten health centers reported receiving state or federal navigator funding in 2018. Of those, 34% said their funding had been cut compared to the previous year. In response to these funding cuts, nearly a third said they reduced staff and 27% reduced the number of outreach activities.  Health centers’ support for patients applying for Medicaid remained strong, while assistance with marketplace applications stayed about the same or decreased. Over four in ten health centers said they provided assistance for more new Medicaid applications in calendar year 2017 compared to 2016, and 34% said they helped with more Medicaid renewals. In contrast, less than a quarter of health centers said they helped with more new marketplace applications during the 2018 open enrollment period compared to the 2017 enrollment period, and only 26% said they assisted with more marketplace renewals.  Health centers are continuing to expand their services and staffing. The most commonly reported increases for services and staffing in the past year were for mental health services and staff, substance use disorder treatment services and staff, chronic care management services, and dental services and staff.  Most health centers experienced stable or improved financing from key revenue sources in the past year. Nearly half of health centers reported increases in their Medicaid revenue in the past year and an additional 38% reported that their Medicaid revenue did not change. Following the delay in reauthorizing the Community Health Center Fund in 2017, most health centers reported an increase or no change in their federal grant funding in the past year. Importantly, though, about 20% of health centers experienced a decrease in their federal grant funding.  Health centers reported increasing financial pressure on privately insured patients and lapses in coverage for Medicaid and privately insured patients. More than half of health centers reported increases in insured patients who are unable to afford their cost-sharing payments and deductibles. Roughly a third of health centers reported that the percentage of privately insured and Medicaid/CHIP patients with lapses in coverage also increased compared to last year.  Workforce recruitment, inadequate physical space, and insufficient grant funding are top challenges for health centers. Workforce recruitment is a consistent challenge for health centers and was ranked as a top-three challenge by nearly six in ten health centers. Other commonly-reported top- three challenges were inadequate physical space (36%) and insufficient grant funding (32%) and, among health centers in non-expansion states, high numbers of uninsured patients (42%). Introduction Community health centers provide comprehensive primary care services in some of the most underserved communities in the nation. In 2017, 1,373 health centers operated in over 11,000 sites and served nearly 27.2 million patients.1 Four years following implementation of the ACA’s coverage expansions, health centers continue to play a central role in connecting consumers to expanded Medicaid and marketplace coverage and have experienced significant growth in their service capacity. Assisting community members enroll in health insurance programs for which they may be eligible has long been a core feature of the health centers program. Building on this commitment, health centers have been actively engaged in the outreach and enrollment efforts under the ACA. In addition, growing revenue associated with improved insurance coverage of health center patients combined with increased grant funding under the ACA, bolstered health centers’ overall financial capacity, enabling them to expand much needed services.2 At the same time, health centers face serious challenges that reflect the poverty Community Health Centers’ Experiences in a More Mature ACA Market 2 and health risks that characterize their patients, challenges related to recruiting sufficient clinical and administrative staff into seriously medically underserved urban and rural communities, and reliance on two key revenue sources – federal grant funding and Medicaid – that remain vulnerable to political and policy uncertainties. Health centers faced particular challenges during the most recent open enrollment period. The open enrollment period was shortened in most states3 (ending on December 15, 2017 instead of January 31, 2018), although nine states that run their own marketplaces extended the open enrollment period beyond December 15, 2017.4 In addition, the administration cut the federal government’s advertising budget by 90%, halted Department of Health and Human Services (HHS) staff’s participation in local enrollment events, and reduced navigator grant funding by about 40% below FY 2017 levels.5 Despite these changes, marketplace enrollment fell only slightly to 11.8 million for the 2018 open enrollment period from 12.2 million in 2017.6 At the same time, the Administration’s reduced ACA enrollment efforts increased the importance of health centers’ longstanding’ outreach and enrollment activities that predated the ACA. This issue brief presents findings from the Kaiser Family Foundation and Geiger Gibson Program in Community Health Policy 2018 Health Center Survey to describe health centers’ experiences under the ACA. It provides a snapshot of health centers’ outreach and enrollment activities for the 2018 open enrollment period, describes strategies that health centers implemented to respond to the shortened open enrollment period, and compares the experiences of health centers in Medicaid expansion and non- expansion states. This brief also describes findings on overall operational and financial capacity as well as ongoing challenges. Findings Health Center Experiences with Outreach and Enrollment Most health centers took steps to Figure 1 prepare for the shorter open Share of Health Centers Taking Actions to Prepare enrollment period in effect in most for the Shortened 2018 Open Enrollment Period states. Nearly eight in ten health centers reported taking some action to help them Contacted patients ahead of November 1 to inform them of shortened OE period 45% serve the same number of clients as in Increased outreach events ahead of OE 42% past years in half as much time. The Increased hours for enrollment assistance during OE 32% most common actions were contacting Developed educational and marketing materials to send to patients 30% patients ahead of November 1st to inform Scheduled pre-enrollment appointments prior to November 1 29% them of the shortened open enrollment Increased number of enrollment assistance 27% period (45%) and increasing outreach appointments during OE Added assisters, outreach, and/or enrollment staff 15% events ahead of open enrollment (42%) (Figure 1). Other actions included No changes 22% increasing hours during open enrollment Note: Responses from states with the same enrollment period as last year’s open enrollment period were excluded. Source: GW/KFF 2018 Health Center Survey (32%) and developing educational Community Health Centers’ Experiences in a More Mature ACA Market 3 materials to send to patients (30%). However, over 20% of health centers reported taking no actions in response to the shortened open enrollment period, and these health centers were located both in states that extended the open enrollment Figure 2 deadline beyond December 15th and in Changes in Staffing for Enrollment Assistance those that did not. During the 2018 Open Enrollment Period Compared to the last open enrollment period, how has the number of FTE paid staff at your Health centers in Medicaid non- at your health center changed? expansion states were significantly more likely to reach out to consumers in Decreased advance of the open enrollment period 21% to schedule pre-enrollment Increased Stayed about appointments (36% vs. 24%) and to 12% the same 66% contact patients to inform them of the shortened open enrollment period (52% Average number of staff employed during 2018 vs. 40%). They were also more likely to open enrollment add additional outreach and enrollment period – 4.5 FTE staff (20% vs. 11%), Source: GW/KFF 2018 Health Center Survey The majority of health centers were able to employ the same level of outreach and enrollment staff as last year. Two-thirds (66%) of health centers reported the number of full-time equivalent (FTE) paid enrollment assistance staff has stayed about the same since the last open enrollment period (Figure 2). On average, health centers employed 4.5 FTE enrollment assistance staff during the open enrollment period and 4.3 FTE staff throughout the year. Health centers in Medicaid expansion states employed more staff both during open enrollment and throughout the year than health centers in non-expansion states (5.0 FTE vs. 3.4 FTE during open enrollment and 4.9 vs. 3.1 FTE throughout the year). Compared to the previous open enrollment period, health centers served about the same number or more people seeking enrollment Figure 3 assistance. While some policymakers Changes in the Number of People Seeking Enrollment argued that the need for in-person Assistance, by State Medicaid Expansion Status assistance would diminish during the Compared to the last open enrollment period, has the number of people seeking assistance during the most recent open enrollment period increased, decreased, or stayed about the same? most recent open enrollment period as Increased Stayed the same Decreased people became more familiar with how to apply for and enroll in coverage, a 23% 29% 40%* majority of health centers reported that the number of people seeking 39% 36% assistance was about the same as, or 31%* more than, last year. Thirty-five percent 35% 38% said the number of people needing help 29%* increased while 29% said the number All respondents Health Centers in Medicaid Health Centers in Medicaid Expansion States Non-expansion States had decreased (Figure 3). The Note: “Don’t know” and “open enrollment in my state has not ended” responses were excluded. experience differed in Medicaid * Significantly different from health centers in Medicaid expansion states at p<0.01. Source: GW/KFF 2018 Health Center Survey Community Health Centers’ Experiences in a More Mature ACA Market 4 expansion and non-expansion states. Over three-quarters (77%) of health centers in Medicaid expansion states said the number of people seeking assistance had increased or stayed the same compared to only 60% of health centers in non-expansion states. Most health centers continued to Figure 4 participate in off-site outreach Additional Services Provided by Enrollment Staff during activities. Over nine in ten (93%) health the 2018 Open Enrollment Period centers indicated that they participated All respondents in off-site outreach activities. Among Provide counseling on how to use insurance 72% these health centers, nearly half (47%) Provide health insurance literacy counseling 66% Assist consumers with appeals of eligibility reported similar participation in off-site determinations 63% outreach events this enrollment period Provide interpretation services 63% Assist with post-enrollment problems, such as billing 62% compared to last year’s enrollment issues or denied claims Provide case management for difficult cases 59% period, while 25% reported participating Assist with resolving data match inconsistencies 49% in more off-site activities than last year. Assist consumers with obtaining exemptions from 34% the individual mandate Participating in off-site outreach events Provide financial literacy counseling 26% enables health center staff to reach None of these activities 4% consumers in the community who are not patients of the health center. Source: GW/KFF 2018 Health Center Survey In addition to eligibility assistance, health centers’ outreach and enrollment staff provided a range of services to support consumers seeking health insurance. Nearly three-quarters (72%) of health centers reported counseling consumers on how to use insurance while over six in ten said they provided health insurance literacy counseling, assisted consumers with appeals of eligibility determinations, provided interpretation services, and assisted consumers with post-enrollment problems regarding billing or denied claims (Figure 4). These services are critical to ensuring consumers can understand and use their insurance to access the care they need. About half (52%) of health centers that reported offering these additional services said they spent Figure 5 about the same amount of time engaging Share of Health Centers Experiencing Reductions in in these activities compared to the last Navigator Funding and Actions Taken in Response open enrollment period, and 34% Share of Health Centers Actions Taken by Health Centers in reported spending more time. Experiencing Cuts to their Response to Navigator Funding Cuts Navigator Funding Reduced staff 32% While funding for outreach and Reduced the number of 27% outreach activities enrollment activities has been Reduced the number of enrollment assistance 10% incorporated into health centers’ appointments Limited assistance to federal grants, many health centers 39% consumers who are not patients 10% 34% received additional state or federal Limited time assisting with 8% 20%* complex cases navigator grant funding and some Reduced service area 8% experienced reductions in those All Health Health Centers Health Centers in Centers in Medicaid Non-expansion grants. Because enrollment assistance Expansion States States Did not make any changes 45% is a requirement of all health centers, Note: * Significantly different from health centers in Medicaid expansion states (p=0.014). Source: GW/KFF 2018 Health Center Survey Community Health Centers’ Experiences in a More Mature ACA Market 5 grants under Section 330 of the Public Health Service Act (which establishes the program) include modest funding for outreach and enrollment. In addition, about four in ten (38%) health centers also reported receiving navigator funding, either as a grantee or as a sub-grantee, to provide outreach and enrollment services (Figure 5). Of those that reported receiving this funding, over a third (34%) said that their funds were cut in the 2017-2018 funding year, with health centers in Medicaid expansion states twice as likely to report funding cuts as those in non-expansion states (39% versus 20%). Among health centers whose funding was cut, nearly half (45%) said they did not make any changes in response to the funding cuts. However, about a third (32%) said they reduced staff and 27% reduced the number of outreach activities and events. Changes in New Applications and Coverage Renewals Health centers’ support for patients applying for Medicaid remained strong and grew in both expansion and non-expansion states. Over four in ten (41%) health centers said they provided assistance for more new Medicaid applications in calendar year 2017 compared to calendar year 2016, and just over a third (34%) said they helped with more Medicaid renewals (Figure 6). In contrast, only 20% reported providing assistance for fewer new Medicaid applications and 14% said they helped with fewer Medicaid renewals in 2017. Health centers in Medicaid expansion states were more likely to report seeing increases in new Medicaid applications and renewals; however, health centers in non-expansion states also reported growth in the Figure 6 number of Medicaid applications. Changes in New Applications and Renewals for Almost half of health centers in Medicaid and Marketplace Coverage Medicaid expansion states (44%) More About the same Fewer reported an increase in new Medicaid Medicaid Coverage applications in 2017, while in non- New Medicaid applications 41% 39% 20% expansion states, slightly over one-third Medicaid renewals 34% 52% 14% (35%) of health centers reported an increase in Medicaid applications Marketplace Coverage (Table 1). Additionally, over a third of health centers in Medicaid expansion New Marketplace applications 24% 38% 38% states reported more renewals for Marketplace renewals 26% 49% 25% Medicaid coverage in 2017 compared Note: The comparison period for Medicaid new applications and renewals was calendar year 2017 to calendar year 2016 while the comparison to about a quarter of health centers in period for Marketplace new applications and renewals was the 2018 open enrollment period compared to the 2017 open enrollment period. The “not applicable” responses for Medicaid questions and the “open enrollment in my state has not ended” responses for Marketplace questions were excluded from this analysis. non-expansion states. Source: GW/KFF 2018 Health Center Survey In contrast, assistance with marketplace applications and renewals stayed about the same or decreased during the most recent open enrollment period. Fewer than one in four health centers (24%) reported that they assisted with more new marketplace applications compared to the last open enrollment period, and just 26% said that marketplace renewals had increased (Figure 6). In contrast, 38% indicated they assisted with fewer new marketplace applications since last open enrollment. The drop-off was more significant in non-expansion states. A higher percentage of health centers in non- expansion states (45%) reported assisting with fewer new applications for marketplace coverage Community Health Centers’ Experiences in a More Mature ACA Market 6 compared to health centers in Medicaid expansion states (33%). Nearly half of health centers (49%) indicated the number of marketplace renewals remained relatively stable while a quarter said they assisted with fewer marketplace renewals. Table 1. Changes in New Medicaid and Marketplace Applications and Renewals by State Medicaid Expansion Status Health Centers in Health Centers in Medicaid Coverage1 Medicaid Expansion Medicaid Non-expansion States States New Medicaid Coverage Applications* More than last calendar year 44% 35% Fewer than last calendar year 22% 15% About the same as last calendar year 34% 49% Medicaid Coverage Renewals* More than last calendar year 37% 26% Fewer than last calendar year 15% 14% About the same as last calendar year 48% 61% Health Centers in Health Centers in Marketplace Coverage2 Medicaid Expansion Medicaid Non-expansion States States New Marketplace Coverage Applications* More than last year’s open enrollment period 25% 24% Fewer than last year’s open enrollment period 33% 45% About the same as last year’s open enrollment period 42% 31% Marketplace Coverage Renewals More than last year’s open enrollment period 25% 27% Fewer than last year’s open enrollment period 24% 26% About the same as last year’s open enrollment period 51% 47% * Distribution of responses for health centers in non-expansion states is significantly different from health centers in Medicaid expansion states at p<.05. 1 “Not applicable” responses were excluded. 2 “Open enrollment in my state has not ended” responses were excluded. General Health Center Capacity and Access Fueled by the additional revenue flowing from patients’ improved insurance coverage coupled with growing grant funding under the ACA, health centers are continuing to expand their service capacity. A majority of health centers reported increased capacity for services they provided in the past year. Health centers were most likely to report expanding mental health and substance use disorder treatment services (70% and 69%, respectively) as well as mental health staff (67%) and substance use disorder treatment staff (60%) in the past year (Figure 7). Over half of health centers also reported expanding chronic care management services, dental services, and dental staff. Health centers in Medicaid expansion states were significantly more likely to report increased substance use disorder treatment services (74% versus 59%) in the past year, while health centers in non-expansion states were significantly more likely to report increased family planning staff (25% vs. 14%). Community Health Centers’ Experiences in a More Mature ACA Market 7 Health centers have taken additional Figure 7 steps to expand access to services, Share of Health Centers Reporting Increased including increasing hours of Services and Staffing in the Past Calendar Year operation, particularly in Medicaid Services expansion states, but some struggle Mental health services 70% Substance use disorder treatment services 69% to meet the increased demand for Chronic care management services 58% Dental services 56% care. Almost four in ten health centers Enabling services 49% Telemedicine services 48% reported increasing the number of sites Pharmacy services 47% (39%) and hours of operation (36%) Social services (e.g., housing, TANF, SNAP) 35% Family planning services 23% (Table 2). Health centers in Medicaid Staffing expansion states were significantly Mental health staff 67% Substance use disorder treatment staff 60% more likely to report increased hours of Dental staff 53% operation (41% versus 29 %) in the Family planning staff 18% past year compared to health centers in Note: “Not applicable” responses were excluded. non-expansion states. At the same Source: GW/KFF 2018 Health Center Survey time, health centers also reported increased pressure on access to care for their patients. Just under a third reported increased wait times for new patient appointments (32%) and increased wait times for follow-up appointments (27%), while nearly one in five (19%) reported longer waits in the waiting room for patients with appointments. Table 2. Share of Health Centers Reporting Efforts to Expand Access and Pressure on Access Increased in the Past Calendar Year by State Medicaid Expansion Status, 2018 Health Centers in Health Centers in All Health Medicaid Medicaid Non- Centers Expansion States expansion States Expanded access Increased number of sites 39% 39% 39% Increased hours of operation 36% 41% 29%* Increased pressure on access Increased waits for new patient appointments 32% 30% 35% Increased waits for follow-up appointments 27% 25% 32% Increased waits in the waiting room 19% 18% 20% * Significantly different from health centers in Medicaid expansion states at p<.05 NOTE: Statistical significance is based the percentage reporting increased vs. decreased or no change. “Not applicable” responses were excluded from this analysis. Health Center Financing As a result of growing insurance coverage among their patients, most health centers experienced stable or improved financing from key revenue sources in the past year. Medicaid and Federal Section 330 grants are the most important revenue sources for most health centers, comprising over 60% of total revenues in 2017.7 As Medicaid coverage grew, nearly half (47%) of health centers reported Community Health Centers’ Experiences in a More Mature ACA Market 8 increases in their Medicaid revenue in the past year and an additional 38% reported that their Medicaid revenue did not change (Figure 8). Following the Congressional delay in reauthorizing the Community Health Center Fund in 2017, most health centers reported an increase or no change in their federal grant funding in the past year. Importantly, though, about 20% of health centers experienced a decrease in their federal grant funding. For health centers that are particularly reliant on these grants to finance care to the uninsured, any reductions in funding can affect operations, and the uncertainties created by the delay in reauthorizing grant funds added to the pressures created by grant reliance. These findings were similar for health centers in expansion and non-expansion states. Revenue from private insurance also remained relatively stable. Approximately a third (35%) of health centers reported an increase in Figure 8 their private insurance revenues since Changes in Health Center Revenues in the Past last year, while 50% reported no Calendar Year change. Since implementation of the Increased No change Decreased marketplaces in 2014 and as more low- Medicaid revenue 47% 38% 15% income people have gained private coverage, all health centers, and Private insurance revenue 35% 50% 14% particularly those in non-expansion Federal grants 29% 49% 21% states, have seen an increase in State and local grants 15% 46% 38% revenues from private insurance. Health centers in non-expansion states were Funding for community benefit 13% 55% 32% activities from hospitals/health plans significantly more likely to report Access to private capital 11% 69% 20% increased private insurance revenue (44% versus 30%) in the past year Family planning funding 9% 77% 14% compared to health centers in Medicaid Note: “Not applicable” responses were excluded. Source: GW/KFF 2018 Health Center Survey expansion states. Some health centers saw reductions in state and local funding. State and local grants represented about 7% of total revenues in 2017.8 Nearly four in ten (38%) health centers reported decreased revenue from state and local grants in the past year and nearly a third (32%) reported a drop in funding for community benefit activities from local hospitals and health plans (Figure 8). For some of these health centers, these losses may have been made up for by increases in other revenue sources. Health Center Challenges Health centers reported increasing financial pressure on privately insured patients. As a sign of the heightened vulnerability of low-income patients to rising out-of-pocket health care costs, more than half of health centers (58%) reported that the share of their insured patients who were unable to pay their deductibles and cost-sharing payments had increased in the past year. Additionally, half of health centers reported increases in privately insured patients who pay sliding scale fees, presumably for care that is subject to their insurance plans’ deductible or high cost-sharing (Figure 9). These trends have financial implications for health centers by increasing the need to rely on federal grant funding to finance these Community Health Centers’ Experiences in a More Mature ACA Market 9 unreimbursed costs. About a third of Figure 9 health centers reported that the Changes in the Percentage of Health Center Patients percentage of Medicaid/CHIP and Experiencing Affordability Challenges and Coverage privately insured patients with lapses in Lapses in the Past Calendar Year Increased No change Decreased coverage also increased compared to Percentage of insured patients who are last year. unable to pay their deductibles and 58% 38% 4% cost-sharing payments Workforce recruitment and Percentage of privately insured patients who pay sliding scale fees 50% 46% 4% insufficient grant funding continue to Percentage of Medicaid/CHIP patients be top challenges for health centers. who have a lapse or break in insurance 38% 59% 3% coverage Staffing has been a perennial challenge for health centers because of the Percentage of private insurance patients who have a lapse or break in 32% 66% 2% inherent difficulties in recruiting sufficient insurance coverage staff to high-poverty communities. Note: “Not applicable” responses were excluded. Nearly six in ten health centers (58%) Source: GW/KFF 2018 Health Center Survey said workforce recruitment was one of their top three challenges (Table 3). Given their location in rural and underserved communities, recruiting staff, especially as health centers seek to expand their services, remains a perennial problem. In 2016, workforce recruitment was also the most commonly reported top- three challenge.9 Other challenges facing health centers included inadequate physical space (36%), insufficient grant funding (32%), and high numbers of uninsured patients (26%). Health centers in non- expansion states were significantly more likely than health centers in Medicaid expansion states to rank as their top challenges high numbers of uninsured patients (42% versus 17%) and insufficient grant funding (38% versus 29%). Perhaps reflecting concern over efforts by a number of states to impose new work, premium, and other requirements on Medicaid enrollees, particularly expansion enrollees, health centers in Medicaid expansion states were significantly more likely to report changes to Medicaid eligibility criteria as one of the top three challenges facing their health center (15% versus 5%). Table 3. Share of Health Centers Ranking Selected Factors Among Their Top Three Challenges, by State Medicaid Expansion Status, 2018 Health Centers in Health Centers in All Health Challenges Medicaid Medicaid Non- Centers Expansion States expansion States Workforce recruitment 58% 59% 57% Inadequate physical space 36% 37% 34% Insufficient grant funding 32% 29% 38%* Workforce retention 28% 29% 25% High numbers of uninsured patients 26% 17% 42%* Changes to Medicaid reimbursement 23% 24% 21% Insufficient insurance reimbursement 20% 21% 18% Changes to Medicaid eligibility criteria 11% 15% 5%* * Significantly different from health centers in Medicaid expansion states at p<.05 Source: GW/KFF 2018 Health Center Survey Community Health Centers’ Experiences in a More Mature ACA Market 10 Discussion Now four years out from the major expansions in Medicaid and marketplace coverage, health centers are continuing to expand their operational capacity amid a relatively stable financial situation. At the same time, health centers remain financially vulnerable because of reliance on funding sources that may be susceptible to policy and political uncertainties, as reflected in the delay in extending ACA grant funds. Consistent with their mission, health centers also report a strong presence in outreach and enrollment activities. Increased insurance coverage for health centers patients, along with enhanced federal grant funding through the ACA have contributed to a significantly improved financial picture for health centers. Health centers report that they are continuing to grow their capacity in terms of staffing, services, number of sites, and hours of operation. However, as they seek to expand capacity, health centers continue to face workforce recruitment challenges. Furthermore, while many health centers have experienced increased federal grant funding over the past four years (and 29% reported an increase in the past year), for some, particularly those in non-expansion states, the amount they receive is still insufficient to meet rising health care costs overall as well as the ongoing costs of caring for the uninsured. Together, these challenges create additional pressures and constraints on health centers’ ability to maintain their increased capacity to provide services, including their ability to provide outreach and enrollment support. Health centers also continue to play an important role in outreach and enrollment assistance for low- income consumers. With funding for enrollment activities included in their federal grants, health centers have been able to maintain staffing and eligibility assistance at levels they had previously reported. As a result, health center staff were able to take steps to prepare their patients and community members for the shorter enrollment periods in effect in most states. They also continued to provide essential services beyond enrollment assistance, including counseling on health insurance literacy and how to use insurance, to ensure their clients are able to use their coverage to access needed health care services. Looking ahead, health centers will remain critical sources of comprehensive primary care services as well as outreach and enrollment assistance in their communities. With the Community Health Center Fund reauthorized, and the ACA coverage expansions still in place, the financial situation of health centers will likely remain stable in the immediate term. However, the uncertainty over future funding remains; any delays in securing funding could cause disruptions to health center operations. Additionally, if the threat to repeal and replace the ACA resurfaces and the ACA were to be repealed, it would jeopardize future health center growth. Finally, 1115 Medicaid waiver proposals in several states to impose work requirements, premiums and cost-sharing, and time limits on benefits, will restrict Medicaid enrollment, which could lead to coverage losses among health center patients, and further add to the financial uncertainty facing community health centers. Additional funding support for this brief was provided to the George Washington University by the RCHN Community Health Foundation. Community Health Centers’ Experiences in a More Mature ACA Market 11 Methods The 2018 Survey of Community Health Centers’ Experiences and Activities under the Affordable Care Act was conducted by the Geiger Gibson Program in Community Health Policy at the George Washington University (GW) and the Kaiser Family Foundation Program on Medicaid and the Uninsured, with input from the National Association of Community Health Centers (NACHC). The purpose of this survey was to assess the experiences of community health centers in a more mature ACA market. The survey focused on three key issues: (i) health centers’ role in health insurance outreach and enrollment; (ii) how health centers are evolving under the ACA and the financial, professional, and patient care-related challenges they face; and (iii) how health centers are approaching the opioid crisis and the treatment options that are available. A report presenting findings on the role health centers play in addressing the opioid epidemic was published separately. The online survey was emailed to all CEOs of federally funded community health centers (n=1,337) in the 50 states and the District of Columbia (DC) identified in the 2016 Uniform Data System (UDS), to which all health centers must report annually. The survey was fielded from early January to late February 2018. There were a total of 489 survey responses from 49 states and DC, resulting in a response rate of 37%. Survey respondents and non-respondents were compared on the basis of 2016 UDS variables. Comparisons of 2016 UDS data found no significant differences between survey respondents and non-respondents for location in rural or urban locations, location in Medicaid expansion states, the number of patients served and clinic visits, the percentage of patients who are low-income, the percentage of patients by insurance type, or average total revenue. However, there were significant differences by the percentage of patients who are racial/ethnic minorities, the ratio of total staff FTEs to 10,000 patients, and the total revenue per patient. The survey data was weighted using 2016 UDS variables for total health center patients, the percentage of their patients reported as racial/ethnic minorities, and total revenue per patient. Bivariate analyses (t-tests and X2 tests) were conducted to test for significant differences by Medicaid expansion status. Findings are presented for all respondents and by location in states that expanded Medicaid and in non-expansion states. Community Health Centers’ Experiences in a More Mature ACA Market 12 Endnotes 1 Bureau of Primary Health Care. (2018). 2017 Health Center Data: National Data. Rockville, MD: Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2017&state=; number of sites based on a GW analysis of 2017 UDS data 2 Rosenbaum, S., Tolbert, J., Sharac, J., Shin, P., Gunsalus, R., & Zur. (2018). Community Health Centers: Growing Importance in a Changing Health Care System. Kaiser Family Foundation. https://www.kff.org/medicaid/issue- brief/community-health-centers-growing-importance-in-a-changing-health-care-system/ 3 Nine states with state-run marketplaces extended the open enrollment period beyond December 15, 2017. 4 These states are CA (January 31, 2018), CO (January 12, 2018), CT (December 22, 2017), MA (January 23, 2018), MN (January 14, 2018), NY (January 31, 2018), RI (December 31, 2017), WA (January 15, 2018) and DC (January 31, 2018). 5 Pollitz, K., Tolbert, J., & Diaz, M. Data Note: Changes in 2017 Federal Navigator Funding. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/data-note-changes-in-2017-federal-navigator-funding/ 6 Kaiser Family Foundation: State Health Facts. Changes in Marketplace Enrollment, 2017-2018. Data source: Marketplace Open Enrollment Period Public Use Files for February 2017 Effectuated Enrollment Snapshot and February 2018 Effectuated Enrollment Snapshot. Available at https://www.kff.org/health-reform/state- indicator/change-in-marketplace-enrollment-2017- 2018/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 7 GW analysis of data reported in the 2017 UDS National report. Bureau of Primary Health Care. (2018). 2017 Health Center Data: National Data. Rockville, MD: Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2017&state= 8 Ibid. 9 Rosenbaum, S., Paradise, J., Markus, A. R., Sharac, J., Tran, C., Reynolds, D., & Shin, P. (2017). Community health centers: Recent growth and the role of the ACA. Kaiser Family Foundation. http://kff.org/medicaid/issue- brief/community-health-centers-recent-growth-and-the-role-of-the-aca/ Community Health Centers’ Experiences in a More Mature ACA Market 13