Community Health Centers Ten Years After the Affordable Care Act: A Decade of Progress and the Challenges Ahead Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Issue Brief #61 March 2020 Sara Rosenbaum, JD Jessica Sharac, MSc, MPH Peter Shin, PhD, MPH Maria Velasquez, MPH About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long-standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Executive Summary By insuring the poorest Americans and creating a Community Health Center Fund to directly support expansion, the Affordable Care Act (ACA) enabled community health centers to reach millions of new patients. Between 2010 and 2018, the number of patients served by health centers grew by 8.9 million, from 19.5 million to 28.4 million. As the ACA reaches its tenth anniversary, the enormous growth of community health centers represents one of its greatest achievements. Community health centers located in Medicaid expansion states have experienced the most robust transformation in size and capacity, but in all states, community health centers have added locations, expanded the range of services they offer, and are treating more complex patients, including those with HIV/AIDS and substance use disorders. Several key factors will determine the continued strength of community health centers: the survival of the Affordable Care Act; stable Medicaid policies and a rejection of eligibility restrictions; adoption of the ACA Medicaid expansion by all states; sustaining and stabilizing the CHC Fund; and a workforce that is able to grow to meet the need. From Health Experiment to Health Care How the Affordable Care Act Expanded Anchor in Medically Underserved and Strengthened Community Health Communities Centers With roots in pioneering work in South Africa’s The ACA contained a series of policy reforms that homelands1, community health centers were launched dramatically expanded and strengthened community in 1965 as a small experiment with a large aim: to health centers. improve the health of populations and communities Expanding coverage for the poor. First and foremost, experiencing deep poverty, elevated health risks, and by expanding Medicaid and establishing a new a severe shortage of comprehensive primary care.2 pathway to coverage through subsidized Marketplace Guided by the needs of the populations they served, plans, the ACA provided health coverage to millions community health centers sought to bridge public of community health center patients. Because of the health and health care, combining comprehensive concentrated nature of U.S. poverty,4 those assisted primary care with a broader effort to improve the disproportionately resided in urban and rural underlying social and health conditions affecting their communities designated as medically underserved patients and the residents of their service areas. Early and more likely to be served by community health evaluations documented their positive impact on centers.5 access to care and on key health outcomes such as infant mortality.3 Permanent authorization of health centers program and establishment of the Community Health Center In 1975, community health centers were formally Fund. Second, the ACA permanently authorized the established in law as part of the Public Health Service community health centers program and created a Act, and their growth became a key element of health long-term funding system to propel health center policy for successive Presidential administrations. By growth.6 By permanently authorizing the program, 2010, more than 1,100 community health centers Congress eliminated the need for periodic operating in nearly 7,000 locations served nearly 19.5 reauthorization and underscored the essential nature million patients. 1 Thomas J. Ward, 2017. Out in the Rural: A Mississippi Health Center and its War on Poverty (Oxford University Press); see also, Adele Oltman. (May 3, 2017). For Health and Freedom. Jacob Magazine. https://www.jacobinmag.com/2017/05/good-doctors-out-in-the-rural-review-freedom-summer 2 Eli Adashi, Jack Geiger, and Michael Fine, 2010. Health Care Reform and Primary Care — The Growing Importance of the Community Health Center. New Engl. Jour. Med. 362:2047 (June 3, 2010). 3 Karen Davis and Cathy Schoen, 1977. Health and the War on Poverty (Brookings Press). 4 Elizabeth Kneebone and Natalie Holmes, 2016. U.S. concentrated poverty in the wake of the Great Recession (Brookings Institution), https:// www.brookings.edu/research/u-s-concentrated-poverty-in-the-wake-of-the-great-recession/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 of health centers as a permanent and key feature of Because of the major expansion of insurance coverage the U.S. health care landscape. Furthermore, by and the infusion of revenue it produced for medically establishing the Community Health Center (CHC) Fund underserved communities, the ACA had an enormous – and providing the first five years of funding – impact on community health center growth and Congress sought to ensure that, ahead of full patient care capacity. By ensuring payment for covered implementation of the ACA in January 2014, services, insurance expansions, together with the CHC communities could jump-start health center expansion Fund investment in new sites and operations, have in order to be ready for an expected surge in new enabled community health center grantees to grow in patients. Following creation of the CHC Fund, Section number. The revenue produced by the ACA’s insurance 330 health center funding more than doubled, from expansions, along with increased direct investment $2.2 billion in FY 2010 to $5.6 billion in FY 2019.7 under the CHC Fund, also allowed existing grantees to increase capacity by adding new service sites, and to Together, these two coverage reforms were designed expand the scope of services they are able to offer, to aid all low-income Americans. However, in the case particularly for patients with long-term, serious health of the Medicaid expansion, decisions by some states to problems encompassing both physical and behavioral reject the expansion after the United States Supreme conditions, including opioid addiction. Court’s 2012 ruling that effectively made expansion optional initially left over 5 million, including many Health center patients have gained insurance health center patients, without coverage.8 Today, the coverage. Even as they have maintained their leading number of Medicaid-eligible residents of non- role in health care for the uninsured, community expansion states stands at 2.3 million – down from its health centers serve as a major source of care for height, but considerable nonetheless.9 Over 90 percent uninsured patients. Their expanded role for insured of those affected live in the South, and half live in just patients likely is the result of several factors: the two states – Texas and Florida.10 primary care shortage areas in which health centers operate; their accessible locations and flexible hours; In addition to the CHC Fund, the ACA created special their accessibility to uninsured family members as well funding for the National Health Service Corps – a as their affordability for patients who periodically may major source of health center clinical staffing – as well experience periods without health insurance coverage; as the Teaching Health Centers Graduate Medical their expansive scope and range of services; and the Education (THCGME) program, whose purpose was to availability of patient support services such as strengthen the ties between health centers and health translation, transportation, onsite enrollment into professions and medical residency training programs. health insurance and other health, social, and nutrition Together, these additional reforms were aimed at programs for which patients may be eligible. expanding near-term clinical workforce capacity, while creating a longer-term clinical staffing recruitment Insurance gains have been dramatic. In 2010, 38 strategy. percent of health center patients were uninsured, 39 percent had Medicaid, and 14 percent were covered How has the ACA affected community by private insurance (Figure 1). By 2018, the health centers and the patients and proportion with Medicaid had grown to 48 percent, communities they serve? the proportion with private insurance had risen to 18 5 Sara Rosenbaum et al., 2009. National Health Reform: How Will Medically Underserved Communities Fare? (Geiger Gibson Program in Community Health Policy, Research Brief #10), https://www.rchnfoundation.org/wp-content/uploads/2013/02/medically-underserved-reform-FINAL.pdf 6 Pub. L. 111-148, § 5602; see Elayne Heisler, 2017. Federal Health Centers: An Overview (Congressional Research Service), https://fas.org/sgp/crs/misc/ R43937.pdf 7 Community Health Center Financing: The Role of Medicaid and Section 330 Grant Funding Explained. https://www.kff.org/report-section/community-health- center-financing-the-role-of-medicaid-and-section-330-grant-funding-explained-issue-brief/ 8 Galewitz, P. (October 16, 2013). Report: 5.2 Million Adults Will Fall Into ACA Coverage Gap Next Year, Kaiser Health News. https://khn.org/news/report-5-2- million-adults-will-fall-into-aca-coverage-gap-next-year/ 9 Rachel Garfield et al., The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Kaiser Family Foundation, 2020), https://www.kff.org/ medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ 10 Id. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 Figure 1. Health Coverage of Health Center Patients, 2010 and 2018 Note: Percentages may not add to 100% due to rounding. In line with the UDS, CHIP Medicaid is included with Medicaid, while non- Medicaid CHIP enrollees are counted under “Other Public Insurance.” Source: George Washington University analysis of data reported in the UDS national reports for 2010 and 2018 UDS data percent, and the proportion without insurance had from 42 percent to 55 percent while growth in the declined to 23 percent. Given the documented privately insured share was more modest. These key relationship between insurance coverage and access differences in Medicaid and Marketplace coverage to more advanced treatments and specialty care when rates are likely the result of two factors: first, the appropriate,11 expanded insurance coverage has led absence of a Medicaid coverage pathway in non- to measurable improvements in both how health expansion states for working-age adults not eligible centers perform for patients with serious health under traditional coverage categories; and second, conditions and the accessibility of specialty services. the fact that in non-expansion states, the threshold Improvements have been especially notable in ACA for subsidized marketplace coverage drops to 100 Medicaid expansion states.12 percent of the federal poverty level compared to 138 percent of poverty in Medicaid expansion states. After the Medicaid expansion effectively became Despite their patients’ greater access to marketplace optional, health insurance coverage patterns among coverage, however, health centers in non-expansion health center patients began to diverge depending on states continued to treat a far greater share of whether health centers operated in expansion or non- uninsured patients by 2018 — virtually double the expansion states. In 2018, in non-expansion states, percentage (35 percent vs. 18 percent). the percentage of Medicaid-enrolled patients was virtually identical to the 2010 rate, while the Community health centers play a critical role in percentage of privately insured had increased serving Medicaid and uninsured patients. Overall, significantly (Figure 2). By contrast, in expansion health centers serve nearly one in five (19%) Medicaid states, the percentage insured through Medicaid rose and CHIP enrollees, and in ten states and the District 11 Mabel Ezeonwu, 2018. Specialty-care access for community health clinic patients: processes and barriers, JMultidiscip Healthc 11:109-119, https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5826087/ 12 Megan B. Cole et al., 2017. At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care, Health Affairs 36:1 pp. 40- 48. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 Figure 2. Health Coverage of Health Center Patients, by State Medicaid Expansion Status, 2010 and 2018 Note: Percentages may not add to 100% due to rounding. Medicaid expansion status as of 2018. Data does not include health centers in U.S. territories. Source: George Washington University analysis of 2010 and 2018 UDS data of Columbia, health centers serve one in four or number of patients served by federally funded health more.13 For the uninsured population, health centers centers increased by 46 percent, while patient visits continue to play a central role, furnishing care to an rose to 116 million visits, an increase of 50 percent estimated 22 percent of uninsured people in 2018.14 from 77 million visits in 2010. Health centers have grown in size, service sites, Such a dramatic expansion of care has been possible staffing, and patient capacity. In 2018 (the most because the number of health center staff surged. recent year for which data from the Department of Between 2010 and 2018, the number of full-time Health and Human Services Uniform Data System equivalent (FTE) physicians grew by 40 percent, [UDS] are available), the number of community health behavioral health staff increased 165 percent, FTE center grantees reached 1,362, a 21 percent increase nurses grew 62 percent, and dental staff nearly in grantees from 2010, and the total number of doubled (Table 2). grantee service sites grew by 69 percent from 6,949 to Given their larger percentage of uninsured patients, 11,744 (Table 1). Table 1 also shows that federally health centers in non-expansion states have funded community health centers served 28.4 million experienced more modest growth. They remain patients in 2018; an additional 84 “look-alike” health somewhat smaller, maintain fewer operating sites, centers (community health centers whose operating have fewer staff, and generate lower overall operating grants come from state and local funds) served nearly revenue, with a greater dependence on grant funds. In 900,000 more patients.15 Between 2010 and 2018 the 13 Sharac, J., Shin, P., Rosenbaum, S., & Handarov, T. (2019). Community Health Centers Continue Steady Growth, But Challenges Loom. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 60. https://www.rchnfoundation.org/?p=8436 14 National Association of Community Health Centers. (2018). Community Health Center Chartbook 2020. Figure 2-8. http://www.nachc.org/wp-content/ uploads/2020/01/Chartbook-2020-Final.pdf 15 Bureau of Primary Health Care. (2019). 2018 National Health Center Data: Health Center Program Look-Alike Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/lookalikes.aspx?q=tall&year=2018&state= Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Table 1. Health Center Grantees, Sites, Patients, and Visits, 2010-2018 Percentage change 2010 2018 2010-2018 Health center grantees 1,124 1,362 21% Health center grantee sites 6,949 11,744 69% Total visits 77,069,234 115,816,238 50% Total patients 19,469,467 28,379,680 46% Source: George Washington University analysis of 2010 and 2018 UDS data Table 2. Health Center Staff FTEs, 2010-2018 Percentage change Staff Category 2010 (FTEs) 2018 (FTEs) 2010-2018 Physicians 9,592 13,394 40% Nurses 11,365 18,445 62% Dental staff 9,452 18,715 98% Behavioral health staff 5,095 13,518 165% Source: George Washington University analysis of 2010 and 2018 UDS data Table 3. Average Number of Health Center Sites and Patients, by Medicaid Expansion Status, 2010-2018 Medicaid Medicaid Non-expansion Non-expansion Averages expansion expansion 2010 2018 2010 2018 Number of sites 5.8 8.1 7.3 9.1 Total patients 14,815 17,767 18,743 22,599 Source: George Washington University analysis of 2010 and 2018 UDS data. Medicaid expansion status as of 2018. expansion states, health centers report, on average, In Medicaid expansion states, total patients and total 22,600 patients and operate in over 9 locations; by visits increased by 50 percent and 56 percent, contrast, each non-expansion state community health respectively, while non-expansion state health centers center serves slightly fewer than 17,800 patients and experienced 39 percent growth in patients and patient maintains slightly more than 8 sites, on average (Table visits between 2010 and 2018 (Table 4). Most striking, 3). perhaps, between 2010 and 2018, community health Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 Table 4. Health Center Visits, Total Patients, and Patients by Insurance Type, by State Medicaid Expansion Status, 2010-2018 Non- Medicaid Non- Non- expansion Medicaid Medicaid Visit/Coverage expansion expansion expansion percentage expansion expansion Category percentage change change 2010 2018 2010 2018 2010-2018 2010-2018 Total visits 20,942,224 29,021,697 39% 54,260,002 84,876,080 56% Total patients 5,777,758 8,048,406 39% 13,251,091 19,841,735 50% Uninsured 2,629,896 2,817,139 7% 4,549,649 3,506,377 -23% Medicaid 1,777,335 2,584,435 45% 5,508,918 10,874,303 97% Private insurance 783,818 1,731,239 121% 1,856,535 3,416,994 84% Medicare 477,062 821,317 72% 950,528 1,873,470 97% Other public 109,647 94,276 -14% 385,461 170,591 -56% insurance Source: George Washington University analysis of 2010 and 2018 UDS data. Medicaid expansion status as of 2018. centers in non-expansion states actually experienced a were using telehealth for specialist provider 7 percent growth in the number of uninsured patients consultation, 54 percent for patient interaction, and while the number of uninsured patients fell by 23 over 400 health centers were using telehealth to percent in expansion states. expand behavioral health capacity.17 In 2018, 44 percent of all health centers offered four or more Health centers have expanded the range of services services onsite in addition to medical care, such as they offer. With the additional revenue and in the face case management, dental care, behavioral health, of growing patient needs, health centers have vision, and pharmacy services. broadened the range of services they offer, especially in Medicaid expansion states. By 2018, 95 percent of As the ACA has expanded coverage and increased all health centers offered some level of behavioral operating revenue, the patients served by health health care onsite, and 57 percent of all health centers centers have become more complex. Historically, had onsite staff authorized to provide medication- community health center patients have experienced assisted treatment for opioid use disorder.16 That year, higher health risks than the low-income population 77 percent of all health centers had achieved generally, a not-unexpected pattern given the fact that recognition as patient centered medical homes with sicker people generally are more likely to seek health the capacity to provide integrated, continuous care for care, particularly at health centers, where their open both physical and behavioral health conditions. Sixty access policies remove considerable barriers to care. percent of all health centers with telehealth services As the ACA has enabled more people to seek medical 16 National Association of Community Health Centers. (2018). Community Health Center Chartbook 2020. http://www.nachc.org/wp-content/uploads/2020/01/ Chartbook-2020-Final.pdf 17 Bureau of Primary Health Care. (2019). 2018 Health Center Data: National Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ datacenter.aspx?q=tall&year=2018&state= Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 Table 5. Health Center Patients and Patients with Selected Diagnoses, 2013-2018 Patients with Patients with Patients with alcohol-related Patients with Patients with depression, other Year Total patients overweight and and other HIV diabetes mood, or anxiety obesity substance use disorders disorders 2013 21,726,965 115,421 1,882,608 2,228,089 506,279 2,740,638 2014 22,873,243 134,540 2,005,338 2,822,118 566,634 3,020,562 2015 24,295,946 154,994 2,118,178 3,396,723 666,503 3,381,315 2016 25,860,296 158,323 2,283,360 4,472,815 713,829 3,805,893 2017 27,174,372 165,745 2,441,686 5,491,407 803,510 4,311,722 2018 28,379,680 191,717 2,566,358 6,520,928 908,984 4,724,691 Increase 31% 66% 36% 193% 80% 72% 2013 –18 Source: George Washington University analysis of 2013-2018 UDS national reports care, and as health centers have increased the range greater insurance coverage, and growing health risks of services they offer, their patients have grown more means that over the past half-decade, health centers complex and high-need. The growth in capacity to have come to play a growing role in caring for people serve high need patients also has coincided with the with serious health problems and an aging patient rise of significant community health risks such as population. Between 2013 and 2018, the total number those created by the opioid epidemic and its of health center patients increased by 31 percent, consequences for both physical and mental health. while the number of CHC patients with complex Compared to the low-income population generally, medical diagnoses involving physical and behavioral health center patients are more likely to have health problems exhibited greater increases. Overall, diabetes, asthma, or hypertension and are far more UDS data show that between 2013 and 2018, the likely to exhibit health risks such as smoking and number with HIV increased by 66 percent, the number obesity.18 Health center patients are substantially with alcohol and other substance use disorders by 80 more likely to experience two or more health percent, and the number with depression, other conditions over their lifetimes and are more than mood, and anxiety disorders by 72 percent (Table 5). twice as likely to report being in fair to poor health.19 The number of patients with diabetes rose by 36 percent, while the number of overweight/obese The confluence of Medicaid expansion financing, 18 Shin, P., Alvarez, C., Sharac, J., Rosenbaum, S., Van Vleet, A., Paradise, J., Garfield, R. (2013). A profile of community health center patients: implications for policy. Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation and the RCHN Community Health Foundation. http://kff.org/medicaid/issue-brief/a -profile-of-community-health-center-patients-implications-for-policy/ 19 National Association of Community Health Centers. (2018). Community Health Center Chartbook 2020. Figure 1-10. http://www.nachc.org/wp-content/ uploads/2020/01/Chartbook-2020-Final.pdf Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 patients – a health condition that leads to major 2021 term beginning October 2020) a lower court complications – grew by 193 percent. decision that opens the door to a complete repeal of the law. Should the ACA be repealed, this would end The Challenges Ahead the insurance expansions that have proven pivotal for Health centers, their patients, and the broader health center patients, along with the CHC Fund itself. communities they serve have made extraordinary Such a result would be existential to the future of gains under the ACA. They also face major challenges community health centers themselves, since the Fund in the coming decade. Their response to the HIV and accounts for 70 percent of all health center grant opioid epidemics, as well as their history of response funding and the insurance reforms have led to a major to public health disasters such as hurricanes and expansion of health center capacity nationwide. flooding, underscore their nimbleness in the face of Even should the ACA survive this constitutional community health threats. In the face of the new challenge, challenges loom. After years of growth, threat from coronavirus, community health centers Medicaid enrollment among both adults and children can expect to be tested again, as critical providers in began to decline in 2017.21 According to experts, the the nation’s most underserved rural and urban rate of decline appears to be too large to be solely communities. attributable to an improving economy and higher How to sustain a far larger program with wages; indeed, unemployment rates have not larger revenue and workforce needs changed appreciably over the time period in which the enrollment decline has been occurring.22 Especially Medicaid and Marketplace coverage. With health worrisome, this decline is coming at a time when the center growth has come the challenge of sustaining a nation faces a major public health threat from the program robust enough to serve as health care coronavirus, which adds new urgency to rapid access providers for one in twelve Americans, one in five to testing and treatment. Medicaid/CHIP beneficiaries, and one in five A number of factors have emerged as potentially uninsured individuals. Sustainability requires special significant contributors to declining enrollment: the attention on the two most important sources of health chilling effect from the public charge rule, issued by center financing – Medicaid, which in 2018 accounted the Trump administration’s Department of Homeland for 44 percent of total CHC revenue nationally; and Security, that penalizes certain legal immigrants for federal grant funding under Section 330 of the Public using Medicaid benefits and that has caused extensive Health Service Act, which represented 17 percent of uncertainty and confusion within communities and total revenue that year.20 among health center patients;23 tightened eligibility Where Medicaid policy is concerned, the problems verification procedures that are beginning to reverse faced by health centers operating in non-expansion the effects of the ACA’s enrollment and renewal states persist, of course. But recent developments streamlining for Medicaid beneficiaries;24 and the present cause for concern on a broader scale. First, is potential effects of §1115 eligibility restriction the survival of the ACA itself. The United States experiments, such as those imposing work Supreme Court has agreed to review (likely during its requirements as a condition of coverage, that may be 20 Sharac, J., Shin, P., Rosenbaum, S., & Handarov, T. (2019). Community Health Centers Continue Steady Growth, But Challenges Loom. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 60. https://www.rchnfoundation.org/?p=8436; see, also, General Accounting Office, 2019. Health Centers: Trends in Revenue and Grants Supported by the Community Health Center Fund (GAO-19-496), https://www.gao.gov/products/gao-19-496 21 Berchick, E. R., Barnett, J.C., & Upton, R.D. (2019). Current Population Reports, P60-267, Health Insurance Coverage in the United States: 2018. U.S. Government Printing Office, Washington, DC. https://census.gov/content/dam/Census/library/publications/2019/demo/p60-267.pdf 22 Matt Broaddus, 2019. Research Note: Medicaid Enrollment Decline Among Adults and Children Too Large to Be Explained by Falling Unemployment (Center on Budget and Policy Priorities), https://www.cbpp.org/research/health/medicaid-enrollment-decline-among-adults-and-children-too-large-to-be-explained-by 23 Jennifer Tolbert et al., 2019. Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients (Kaiser Family Foundation), https://www.kff.org/medicaid/issue-brief/impact-of-shifting-immigration-policy-on-medicaid-enrollment-and-utilization-of-care-among-health- center-patients/ 24 Research Note: Medicaid Enrollment Decline Among Adults and Children Too Large to Be Explained by Falling Unemployment, op. cit. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 perceived as being in effect even when they are not, planning counseling, maternity care and support, thereby leading to widespread confusion over nutrition, and other public health professionals who Medicaid’s availability. furnish care. Care teams have received a good deal of attention over the years; community health centers The impact on community health centers of broader depend on them. Medicaid enrollment trends is reflected in the results of a 2019 community health center survey. This survey Health centers supported a staffing complement of found that between 2018 and 2019, one in five health more than 236,000 FTEs in 2018,27 including more centers (22 percent) experienced a decline in Medicaid than 81,000 medical personnel, nearly 19,000 dental patients and more than two in five (44 percent) staff, and over 13,500 mental health and substance experienced an increase in the share of Medicaid/ use disorder services providers. But CHCs face gaps in CHIP patients with a coverage lapse.25 essential clinical staffing. The National Association of Community Health Centers estimated in 2016 that Declining Medicaid enrollment may be compounded were all clinical vacancies filled, health center service by the adoption of policies that reduce access to capacity would grow by two million patients.28 The heavily-subsidized Marketplace coverage. Among National Health Service Corps provides a vital source reforms being considered by the Trump of clinical staffing; more than half of all Corps administration in its annual 2021 Proposed Payment professionals fulfill their service at health centers.29 But Notice is ending the Obama administration’s policy of clinical vacancies extend far beyond what the Corps automatically renewing enrollment for people with can fulfill. Thus, while health centers need a fully- incomes low enough to qualify for zero-premium funded Corps, they also need an expanded Teaching health plans.26 The administration cites as the basis for Health Centers program, a training program that such a policy a desire to encourage greater shopping serves as a powerful pipeline and recruitment tool. for lower-priced deals, but consumers may interpret According to a NACHC survey, 58 percent of all this strategy as the loss of eligibility for premium respondents reported that the health professions staff subsidies altogether, and their coverage could lapse. It that they had hired in the previous two years had is too early to know if this policy will be adopted, but actually trained at their health center; another 30 it is an important development to monitor, particularly percent reported that new hires had trained at since virtually all community health centers play a another health center. critical role as enrollment assisters in order to maximize access to coverage and avert unnecessary Stabilizing and Extending the CHC Fund coverage losses. Such assistance will grow in The CHC Fund was initially financed for 5 years. The importance if automatic marketplace renewal Fund subsequently has been extended twice (in 2015 practices cease and streamlined Medicaid renewal and 2017) each time for two years. The agreement policies are threatened. reached by the Trump administration and Congress at Recruiting and retaining the necessary workforce. A the end of 2019 provided only a brief funding community health center is only as strong as its staff – extension for community health centers, the National from the outreach worker and insurance enrollment Health Service Corps, and the Teaching Health Centers assister who is multi-lingual and trained in effective program. This brief extension lapses once again on communication across multiple cultures, to its chief May 22, 2020. information and financial officers who keep the health What is essential is stabilizing and extending the CHC center operating effectively and efficiently, to the chief Fund, given the fact that this Fund now accounts for medical officer and the medical, nursing, dental, social approximately 70 percent of all health center grant work, mental health and addiction counseling, family funding.30 In Medicaid non-expansion states, the 25 Jessica Sharac et al., (Forthcoming, 2020). Community Health Centers in a Time of Change: Results from an Annual Survey. Kaiser Family Foundation 26 Katie Keith, 2020. The 2021 Proposed Payment Notice, Part 2: Exchange Provisions (Health Affairs Blog), https://www.healthaffairs.org/do/10.1377/ hblog20200201.566219/full/ 27 Bureau of Primary Health Care. (2019). 2018 Health Center Data: National Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ datacenter.aspx?q=tall&year=2018&state= Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11 Figure 3. Federal Section 330 Grants as a Share of Total Health Center Revenue, by State, 2018 Note: U.S. percentage does not include U.S. territories Source: George Washington University analysis of 2018 UDS data Fund, in combination with the annual health center health centers, as well as the National Health Service appropriation, accounts for a considerably greater Corps and Teaching Health Centers program are, by share; in eight states, Section 330 grant funding definition, unable to bear the financial or health risks represents 30 percent or more of total health center associated with periodic lapses in, or concerns over, revenue (Figure 3). health center grant funding. Indeed, if anything, the importance of the Fund has grown. Over the past Even if health center patients increasingly are insured, decade, Congress has fundamentally altered what the need for the CHC Fund will remain. Community began as a fund to incubate program expansion, with health centers have long been recognized for their annual appropriations supplying ongoing operational efficiency, in addition to the quality of their care. But support. Today the CHC Fund is the principal source the law obligates them to serve patients regardless of of ongoing operational funding and is not merely the their insured status and to provide a comprehensive means of jump-starting new operations.31 range of primary care services. Even the most efficient health center requires a steady source of grant The Fund may merit a different financing approach. funding to meet the cost of uninsured patients, The immediate challenge is passage of a multi-year uninsured clinical services, and of patient supports renewal of the CHC Fund in order to avert reduction in such as translation, transportation, care management, services, staffing, and patient supports. But a longer- and assistance in obtaining health, educational, and term challenge is to develop a strategy for the CHC social services. Fund that parallels the program’s status as a permanently authorized part of the health care Health centers also need a steady and reliable revenue system. In the case of the Children’s Health Insurance flow to recruit staff, to secure space, equipment and Program (CHIP), Congress adopted a longer-term supplies, and to maintain operational stability. funding strategy in 2018. Indeed, given the fact that Rural and urban communities served by community 28 NACHC, 2016. STAFFING THE SAFETY NET: Building the Primary Care Workforce at America’s Health Centers (Washington D.C.), http://www.nachc.org/wp- content/uploads/2015/10/NACHC_Workforce_Report_2016.pdf 29 NACHC, 2016. STAFFING THE SAFETY NET: Building the Primary Care Workforce at America’s Health Centers (Washington D.C.), http://www.nachc.org/wp- content/uploads/2015/10/NACHC_Workforce_Report_2016.pdf Geiger Gibson / RCHN Community Health Foundation Research Collaborative 12 community health centers are now permanently their Medicaid agencies. This type of activity could be authorized, this may warrant an approach similar to even more strongly encouraged through incentivizing Medicaid’s “disproportionate share hospital (DSH)” supports to Medicaid programs and partnering health payment program, which is a basic and permanent center associations and networks to jointly develop feature of law. and undertake alternative payment models, as permitted under existing federal law.34 Addressing the needs of an increasingly complex patient population through delivery Concluding Thoughts and payment reform The Affordable Care Act has had a remarkable impact, As the U.S. adult population experiences heightened both direct and indirect, on community health centers risk of serious illness, disability, and premature death and the communities and populations they serve. and disability from public health risk factors, this Insuring health center patients has proven increasing risk tends to be concentrated in transformational, not only for the patients themselves communities served by health centers. This is true in but for the health system through which they receive the case of substance use disorders, such as opioid comprehensive primary care. Coupled with the use disorder. HIV infection rates also loom in these insurance expansion, the CHC Fund has helped propel communities, and today community health centers and sustain further growth. Now the challenge is to serve 22 percent of all people living with HIV who are sustain and build on this growth, not only to reach the receiving HIV-related care.32 Even as funding estimated 78 million residents living in primary care prospects grow more uncertain, the need for health health professional shortage areas,35 but also to centers to strengthen their services intensifies as maintain the successes that have been achieved for multiply-burdened patients increase in number. nearly 30 million patients. For community health centers confronting rising numbers of high-need patients, well-designed delivery and payment reform strategies are becoming especially important. Recent research shows that increasingly, community health centers are active participants in Medicaid initiatives to test new payment and delivery reform efforts designed to achieve greater patient satisfaction, to promote greater participation in integrated care delivery models, to increase delivery efficiency, and to integrate health care and social services.33 Indeed, in some states, health centers have taken on a leading role in designing and implementing complex delivery and payment reform innovations in partnership with 30 General Accounting Office, 2019. Health Centers: Trends in Revenue and Grants Supported by the Community Health Center Fund (GAO-19-496), https:// www.gao.gov/products/gao-19-496 31 GAO, Trends in Revenue and Grants, op. cit. 32 Sara Rosenbaum et al., 2019. Community Health Centers and the President’s HIV Initiative: Issues and Challenges Facing Health Centers in High-Burden States and Communities (Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Milken Institute School of Public Health, Issue Brief #56), http:// gwhpmmatters.com/sites/default/files/2019-03/Community%20Health%20Centers%20and%20the%20President%E2%80%99s%20HIV%20Initiative%20% 28Rosenbaum%2C%20Sharac%2C%20Shin%2C%20Gunsalus%29%202-26-19.pdf 33 Corinne Lewis et al., 2019. Changes at Community Health Centers, and How Patients Are Benefiting: Results from the Commonwealth Fund National Survey of Federally Qualified Health Centers, 2013–2018 (Commonwealth Fund), https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/changes-at- community-health-centers-how-patients-are-benefiting 34 Sara Rosenbaum et al., 2019. Community Health Centers and Medicaid Delivery and Payment Reform: A Closer Look at Massachusetts and New York (Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Milken Institute School of Public Health, Issue Brief #57) 35 Kaiser State Health Facts. (2019). Primary Care Health Professional Shortage Areas (HPSAs). https://www.kff.org/other/state-indicator/primary-care-health- professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Geiger Gibson / RCHN Community Health Foundation Research Collaborative 13