Community Health Centers on the Eve of the COVID-19 Pandemic: An Overview of Findings from the 2019 Uniform Data System Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Issue Brief #63 September 2020 Jessica Sharac, PhD, MSc, MPH Peter Shin, PhD, MPH Sara Rosenbaum, JD 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 Community Health Centers: A National In 2019, on the eve of the COVID-19 pandemic, federally-funded and look-alike community health Snapshot, 2019 centers served over 30 million medically underserved patients across thousands of rural and urban communities. In 6 states and the District of Columbia, 1,385 federal grantees community health centers cared for at least 3 in 10 operating in 12,785 sites Medicaid/CHIP beneficiaries. Since the start of the 58% of grantees in urban locations COVID-19 crisis, community health centers have 42% of grantees in rural locations played a vital role in making COVID-19 testing and care available in the poorest and most at-risk communities. They also have experienced financial losses estimated at nearly $2.9 billion to date as the pandemic has forced a major rollback in other 29.8 million patients served services, site closures, and staff layoffs. The Community Health Center Fund — accounting for over 70 percent of federal health center operating grant revenue — will expire at the end of November 2020, even as patient revenue remains far below levels needed to sustain services. Introduction 122.8 million clinic and virtual visits, Community health centers represent the nation’s including: single most important source of comprehensive 81.3 million medical visits primary health care in medically underserved rural 17.3 million dental visits and urban communities. Community health centers also play a vital role as health care first responders in 14.1 million behavioral health visits times of public health emergency; the most recent 6.4 million enabling services visits example of this role is the COVID-19 pandemic, whose worst impact has been experienced by the very 72 “look-alikes” operating 237 sites communities and populations that depend on health 595,030 patients centers for their care. 2.36 million visits Findings from the 2019 Uniform Data System SOURCE: Health Resources and Services Administration. (2020). 2019 Health The federal Uniform Data System (UDS) reports Center Data: National Data. https://data.hrsa.gov/tools/data-reporting/ program-data/national/table?tableName=Full&year=2019; Health annually on community health center patients, Resources and Services Administration. (2020). 2019 National Health Center services, staffing, and revenue, along with measures Data: Health Center Program Look-Alike Data. https://data.hrsa.gov/tools/ data-reporting/program-data/national-lookalikes/table? focused on the quality of their care. The latest data tableName=Full&year=2019; GW analysis of 2019 Uniform Data System from calendar year 2019 show that, on the eve of the (UDS) data, Health Resources and Services Administration. pandemic, community health centers were positioned to assume an integral role in the national coronavirus centers served more than 29.8 million patients across response. 12,785 sites,1 one in 11 residents nationwide.2 Another Community health centers serve one in 72 “look-alike” health centers, which meet federal eleven people in the U.S. grant funding requirements but receive base grant funding from other sources, served an additional In 2019, 1,385 federally-funded community health Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 Figure 1. A Profile of Community Health Center Patients, 2019 Income Race / Ethnicity 68 % Non-Hispanic Other, 3% Hispanic, Non-Hispanic 38 % All Races Asian, 4% 23 % Non-Hispanic 19 % 9% African American Non-Hispanic 37 % White <=100% FPL 101-200% >200% FPL FPL Sex Age 57 % Female 43 % Male 31 %, Age <18 60 %, Age 18-64 10 %, Age 65+ Notes: Percentages may not sum to 100% due to rounding. Income distribution reflects 21.4 million patients with known income. Race/ethnicity distribution re- flects 28 million patients with known race and/or ethnicity (excluding patients reported as non-Hispanic unreported race and patients with unreported race and ethnicity). Source: Health Resources and Services Administration. (2020). 2019 Health Center Data: National Data. https://data.hrsa.gov/tools/data-reporting/ program-data/national/table?tableName=Full&year=2019 595,030 patients across 237 sites.3 In all, both types of patients (63 percent) in 2019 were racial/ethnic community health centers served over 30.4 million minorities.5 patients and provided over 125 million patient visits. Community health center patients have Community health center patients are overwhelmingly increased steadily over time low-income and are disproportionately minority (Figure 1). In 2019, as in earlier years, 91 percent of all Between 2000 and 2010 – prior to passage of the patients had incomes at or below 200 percent of the Affordable Care Act – the community health centers federal poverty level ($42,660 for a family of three in program had more than doubled (Figure 2), rising 2019) and nearly 70 percent had below-poverty from 9.6 million to 19.5 million patients. The income (defined as family income for a family of three Affordable Care Act (ACA) led to significant further at or below $21,330 in 2019).4 About two in three growth, from 19.5 million to 29.8 million patients 1 Bureau of Primary Health Care. (2020). 2019 National Health Center Data: National Data. Health Resources and Services Administration. https://data.hrsa.gov/tools/data-reporting/ program-data/national/table?tableName=Full&year=2019; GW analysis of 2019 Uniform Data System (UDS) data 2 HRSA. (2020). HRSA Health Center Program. https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf 3 Bureau of Primary Health Care. (2020). 2019 National Health Center Data: Health Resources and Services Administration. https://data.hrsa.gov/tools/data-reporting/program-data/ national-lookalikes/table?tableName=Full&year=2019; GW analysis of 2019 Uniform Data System (UDS) look-alike data. With the exception of this sentence, this brief’s findings are limited to federally-funded health centers. 4 The 2019 poverty guidelines was $12,490 for one person and $21,330 for a family of three. Office of the Assistant Secretary for Planning and Evaluation. (2019). 2019 Poverty Guide- lines. https://aspe.hhs.gov/2019-poverty-guidelines 5 HRSA. (2020). National Health Center Data. https://data.hrsa.gov/tools/data-reporting/program-data/national Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 served by federally-funded health centers, as a result number of Medicare patients served. of two policies: expansion of Medicaid; and Figure 2 also shows that the number of uninsured establishment of the Community Health Center Fund, health center patients has been growing; after falling the purpose of which was to ensure that health center to 5.9 million in 2015, the number then gradually capacity could grow in advance of full implementation increased to 6.8 million in 2019. Some of this growth of the ACA insurance reforms, when the demand for is likely attributable to overall patient growth, but it health care was expected to increase dramatically. As also mirrors a nationwide increase in the proportion expected, health centers achieved high overall growth of U.S. residents without health insurance, from 9.1 between 2010 and 2019, with particularly striking percent in 2017 to 9.5 percent in the first half of growth in Medicaid patients — 341 percent over the 2019.6 Growth in the number of uninsured patients entire 2000-2019 time period (Figure 2). The number may also reflect underlying Medicaid trends; national of privately-insured patients rose by 280 percent, data show a sizable decline in Medicaid-insured underscoring health centers’ role as a source of health residents over this time period,7 even as the care for patients insured through the ACA’s health proportion of poor workers with employer coverage insurance Marketplaces. Notably, while the elderly remained flat. This suggests a loss of coverage rather remain a relatively modest proportion of health center than movement from Medicaid into employer plans. patients (ten percent in 2019), the 2000-2019 time Factors that may contribute to declining Medicaid period also witnessed a 321 percent growth in the coverage include tighter eligibility rules and stricter Figure 2. Patient Volume, By Payer, 2000-2019: Federally-Funded Community Health Centers 6 Cohen, R.A., Terlizzi, E.P., Martinez, M.E., Cha, A..E. (2020). Health insurance coverage: early release of estimates from the National Health Interview Survey, January-June 2019. Washing- ton, DC: National Center for Health Statistics. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202005-508.pdf 7 Kaiser Family Foundation. (2019). Analysis of Recent Declines in Medicaid and CHIP Enrollment. https://www.kff.org/medicaid/fact-sheet/analysis-of-recent-declines-in-medicaid-and- chip-enrollment/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 requirements governing enrollment and renewal, as The impact of the ACA’s Medicaid expansion well as the Trump administration’s public charge rule, has been greatest in ACA Medicaid expansion which can result in denial of permanent legal states, but community health centers are residency status for immigrants who use Medicaid and other government benefits. This policy has had a major Medicaid providers in all states major, documented chilling effect on enrollment in The impact of the ACA’s Medicaid reforms can be programs that can trigger such a finding.8 seen clearly on health center patients, underscoring both the reach of the expansion into the low-income Continuing growth in the number of uninsured population and the importance of community health patients is also consistent with the results of an earlier centers, like other safety net providers, for insured survey of community health centers, carried out in patients living in underserved communities. partnership with the Kaiser Family Foundation. This 2019 survey found that nearly half (44 percent) of Between 2010 and 2019, Medicaid-insured patients health center respondents reported an increase in grew by 9 percentage points (from 39 percent to 48 coverage lapses for Medicaid or Children’s Health percent) while uninsured patients dropped by 15 Insurance Program (CHIP) patients in the past year, percentage points (from 38 percent to 23 percent) and that 32 percent reported an increase in coverage (Figure 3). This coupling of rising Medicaid and lapses for privately-insured patients.9 The survey also declining uninsured health center patients is an found that 22 percent of responding health centers indicator of the extent to which, for the poorest reported a decrease in Medicaid patients, with Americans, the Medicaid reforms have provided a contributing factors being concerns among immigrant source of health insurance. families about applying for or keeping Medicaid for However, as Figure 4 shows, growth in Medicaid themselves or their children, new procedural patients has been concentrated in ACA Medicaid restrictions on enrollment and renewal, and new expansion states. In 2010, 41 percent of the patients Medicaid eligibility requirements, such as the use of served by community health centers in the 33 states premiums and work requirements. The impact of the and District of Columbia that adopted the ACA public charge rule has been especially important; a Medicaid expansion by 201911 were insured through separate analysis of the survey data found that nearly Medicaid; by 2019, the proportion of Medicaid- half (47 percent) of health centers reported that some insured patients in these jurisdictions had grown to 53 or many immigrant patients were refusing to enroll in percent. By contrast, in 2010, the proportion of Medicaid, while 38 percent reported that some or Medicaid patients in non-expansion states stood at 31 many children in immigrant families were refusing to percent (a lower pre-ACA baseline compared to states enroll.10 Similarly, 32 percent of health centers that ultimately adopted the ACA expansion, since reported that some or many immigrant patients were non-expansion states historically have tended to elect dropping or refusing to renew their Medicaid narrower Medicaid coverage).12 By 2019, the coverage and 28 percent reported that some or many proportion stood at 32 percent — a three percent children in immigrant families were dropping or not increase from 2010 levels and virtually unchanged renewing Medicaid. from 2013 (32 percent).13 8 Bernstein, H., Gonzalez, D., Karpman, M., & Zuckerman, S. (2020). Amid Confusion over the Public Charge Rule, Immigrant Families Continued Avoiding Public Benefits in 2019. Urban Institute. https://www.urban.org/research/publication/amid-confusion-over-public-charge-rule-immigrant-families-continued-avoiding-public-benefits-2019 9 Sharac, J., Markus, A., Tolbert, J., & Rosenbaum, S. (2020). Community Health Centers in a Time of Change: Results from an Annual Survey. Kaiser Family Foundation. https:// www.kff.org/medicaid/issue-brief/community-health-centers-in-a-time-of-change-results-from-an-annual-survey/ 10 Tolbert, J., Artiga, S., & Pham, O. (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/ 11 Expansion status as of 2019. Note that five states that either implemented or acted to implement Medicaid expansions in 2020 (ID, MO, NE, OK, and UT) were categorized as non- expansion in this analysis. See Kaiser State Health Facts. (2020). Status of State Action on the Medicaid Expansion Decision. https://www.kff.org/health-reform/state-indicator/state- activity-around-expanding-medicaid-under-the-affordable-care-act 12 Heberlein, M., Brooks, T., Artiga, S., & Stephens, J. (2013). Getting into gear for 2014: shifting new Medicaid eligibility and enrollment policies into drive. Kaiser Family Foundation. https://www.kff.org/medicaid/report/getting-into-gear-for-2014-shifting-new-medicaid-eligibility-and-enrollment-policies-into-drive/ 13 GW analysis of 2013 UDS data. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Figure 3. Health Insurance Coverage, Community Health Center Patients, 2010-2019 Figure 4. Health Insurance Coverage, Community Health Center Patients by State Medicaid Expansion Status, 2010 and 2019 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 Whether serving communities located in ACA Medicaid enabling services such as transportation and expansion or non-expansion states, health centers play translation that make care accessible (Figure 6). In a major role in Medicaid patient care, serving 1 in 5 2019, health centers employed 252,868 full-time Medicaid patients nationally.13 In 2019, health centers equivalent (FTE) staff members (Figure 7), 34 percent in six states and the District of Columbia (DC) served at of whom were medical providers. Their larger least 3 in 10 Medicaid/CHIP patients (Figure 5). proportion of insured patients means that community health centers in Medicaid expansion states are able to Community health centers provide provide significantly higher average staff-to-patient comprehensive care and are major ratios, see significantly more patients on average, and community employers average significantly more visits (Table 1). Of note, in Community health centers’ care spans preventive and 2019, nearly all (99.6 percent) visits were conducted primary medical, dental health, vision care, and mental face-to-face in clinical settings rather than virtually (0.4 health and substance use disorder services, along with percent). Figure 5. Proportion of Medicaid and CHIP Enrollees Receiving Care at Community Health Centers, by State, 2019 13 HRSA. (2020). HRSA Health Center Program. https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 Figure 6. Community Health Center Patient Visits, by Type of Service, 2019 Figure 7. Community Health Center Personnel, by Service Category, 2019 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 Table 1. Community Health Center Sites, Patients, Visits, and Staffing, by State Medicaid Expansion Status, 2019 In 2019, certain trends regarding the nature of visits compared to 50 percent).15 Similarly, based on an were notable, as shown in Figure 8, when mental analysis of 2019 UDS data, health centers in expansion health services were the dominant type of virtual visits states were more likely to report having any clinical (52 percent) and physical health conditions staff, either on-site or contracted, with the special dominated (66 percent) in-office clinical visits. As certification (DATA waiver) required to furnish MAT Figure 9 shows, by 2019, 60 percent of all community services (75 percent versus 52 percent for health health centers employed substance use disorder centers in non-expansion states), even though several services staff – triple the share offering such services of the non-expansion states rank among those with in both 2000 and 2010.14 In 2019, nearly 7,100 the highest opioid overdose death rates.16 community health center physicians and advanced Medicaid and federal health center grants practice clinicians were certified to provide medication-assisted treatment (MAT) for opioid use are the financial base on which community disorder (OUD) and furnished care to 142,919 health center operations rest patients. Our recent nationwide survey of health Health centers reported $31.4 billion in total revenue centers found that, consistent with other services, for 2019. As Figure 10 shows, Medicaid was the community health centers in Medicaid expansion largest source of health center revenue (43 percent) states were significantly more likely than those in non- followed by federal grant funding under Section 330 expansion states to provide on-site MAT (70 percent 14 This method was used to make a comparison with 2000 and 2010 data. HRSA reported that “in 2019, 93 percent of health centers provided mental health counseling and treatment and 70 percent of health centers provided substance use disorder services”; these percentages were calculated by taking the number of health centers reporting these services in the scope of their project and dividing by the total number of active health centers (personal communication, BPHC). https://bphc.hrsa.gov/sites/default/files/bphc/about/ healthcenterfactsheet.pdf 15 Corallo, B., Tolbert, J., Sharac, J., Markus, A., & Rosenbaum, S. (2020). Community Health Centers and Medication-Assisted Treatment for Opioid Use Disorder. Kaiser Family Founda- tion. https://www.kff.org/uninsured/issue-brief/community-health-centers-and-medication-assisted-treatment-for-opioid-use-disorder/ 16 Kaiser Family Foundation. (2019). Medicaid’s Role in Addressing the Opioid Epidemic. https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 Figure 8. Community Health Center Clinic, Virtual, and Total Visits, by Type of Service, 2019 Figure 9. Community Health Centers Providing Dental and Behavioral Health Services in 2000, 2010, and 2019 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11 Figure 10. Community Health Center Revenue, by Source, 2019 Figure 11. Community Health Center Revenue, by State Medicaid Expansion Status, 2010 and 2019 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 12 of the Public Health Service Act (16 percent). However, Medicaid, Medicare, and private insurance steadily these nationwide financing percentages vary rising, and the percentage of revenue from self-pay significantly when Medicaid expansion is taken into patients or other sources falling. Despite the growing account; in expansion states, Medicaid revenue importance of Medicare and private health insurance accounted for 48 percent of total revenue in 2019, to health center operations, Medicaid and federal compared to 28 percent in health centers in non- grants remain the principal drivers of community expansion states that year (Figure 11). In both cases, health center operations and revenue. Medicaid’s special cost-related payment rules for services furnished by “federally qualified health How is the pandemic impacting centers” (as community health centers are known for community health centers? Medicaid funding purposes) ensured that the By virtue of their location and mission, community proportion of revenue mirrored the proportion of health centers are at the epicenter of the COVID-19 Medicaid patients, but the Medicaid revenue pandemic. The health profile of health center patients differences between expansion and non-expansion on the eve of the pandemic (updated since our March states are striking. 2020 report17) shows a patient population that In the years following enactment of the ACA, as Table experiences the range of socioeconomic, 18 2 shows, the health center revenue picture changed in demographic,19 and health factors20 — alone or in important ways, with Section 330 grant funding rising combination — that place them at highest risk for somewhat as a percentage of total operations and grave illness and death from COVID-19: 10 percent then falling back to 2010 levels, revenue from are elderly; 91 percent are low-income; over one-third Table 2. Community Health Center Revenue, by Source, 2010-2019 17 Sharac, J., Shin, P., Velasquez, M., & Rosenbaum, S. (2020). In the COVID-19 Pandemic, Community Health Centers Are the Front Line for High-Risk, Medically Underserved Communi- ties. GW Health Policy & Management Matters blog. http://gwhpmmatters.com/covid-19-pandemic-community-health-centers-are-front-line-high-risk-medically-underserved 18 Koma, W., Artiga, S., & Neuman, T. (2020). Low-income and communities of color at higher risk of serious illness if infected with coronavirus: Kaiser Family Foundation. https:// www.kff.org/coronavirus-covid-19/issue-brief/low-income-and-communities-of-color-at-higher-risk-of-serious-illness-if-infected-with-coronavirus/ 19 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html; https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/ hospitalization-death-by-race-ethnicity.html 20 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html Geiger Gibson / RCHN Community Health Foundation Research Collaborative 13 (37 percent) are Latino and 22 percent Black;21 28 provided important insight into the challenges health percent of adults are diagnosed with hypertension; 15 centers are facing in the COVID-19 response. percent of adults with diabetes; five percent of The August 21st weekly update shows that 97 percent patients with asthma, one percent with HIV;22 and five of community health centers have testing capacity, percent experience homelessness (Figure 12).23 but 32 percent continued to experience average test Weekly data collected by the federal Health Resources turn-around times of four or more days, seriously and Services Administration (HRSA) since early April reducing the value of the tests. The loss of other 2020 has tracked community health centers’ response primary health care capacity because of the need to to the pandemic. The HRSA survey measures focus on ramp up for COVID-19 has been striking. As of August health centers’ COVID-19 testing capacity, the 21st, 953 community health center sites were closed - number and race/ethnicity of patients tested for - 1 in 14 sites nationwide. One in 20 health center COVID-19 virus or antibodies, average turn-around staff members was unable to work, and weekly patient times for test results, the adequacy of the supply of visits were down by 20 percent compared to before personal protective equipment (PPE), and measures of the pandemic.24 We estimate that by August 2020, operational capacity. These weekly snapshots have cumulative revenue losses over 21 weeks reached Figure 12. Community Health Center Patients at High Risk of Infection and Poor Outcomes for COVID-19, 2019 21 HRSA’s reported percentage of Black/African American patients includes both Hispanic and Non-Hispanic patients. 22 HRSA. (2020). National Health Center Data. https://data.hrsa.gov/tools/data-reporting/program-data/national 23 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/homelessness.html 24 Sharac, J., Hernandez, J., Velasquez, M., Shin, P., & Jacobs, F. (September 2, 2020). Key Updates from the Health Center COVID-19 Survey (Week #21): Geiger Community Health Cen- ters Reported Improved Turn-Around Times for COVID-19 Viral Test Results as They Conducted Nearly 218,000 Tests. Geiger Gibson/RCHN Community Health Foundation Research Collaborative Data Note. http://gwhpmmatters.com/key-updates-health-center-covid-19-survey-week-21-community-health-centers-reported-improved-turn Geiger Gibson / RCHN Community Health Foundation Research Collaborative 14 Figure 13. National Community Health Center Estimated Weekly and Cumulative Patient Revenue Losses over 21 Weeks, April-August 2020 nearly $2.9 billion (Figure 13), or nine percent of total Near-term and long-term challenges revenue reported in 2019, up from an earlier estimate of $2.2 billion in losses based on 16 weeks of survey Lawmakers have recommended that the next COVID- data and 2018 UDS data.25 19 relief bill include $77.3 billion in funding for community health centers, including at least $7.6 Congress has appropriated approximately $2 billion in billion in emergency supplemental funding and a five- dedicated funding for COVID-19 testing and for year extension of the Community Health Center Fund, maintaining health center staffing and operations,26 sufficient to maintain existing programs and services and health centers also have been able to benefit while addressing the extraordinary financial demands from the Paycheck Protection Program.27 They also of the COVID-19 pandemic.29 These financial demands have received limited help from the Provider Relief include acquisition of PPE, modification of service Fund and the Uninsured Claims Fund established by delivery sites to ensure patient and staff protection, the Trump administration with the $175 billion and other reforms aimed at adapting health centers appropriated under the CARES Act. But all community to the needs of patients for both diagnostic testing health centers depend for basic operations on the and treatment. Ultimately these costs also include Community Health Center Fund, which accounts for routine testing that increasingly may be required for over 70 percent of total Section 330 grant funding.28 essential workers, who are disproportionately low- Without further action, the CHC Fund will expire at income. the end of November 2020, triggering a catastrophic revenue loss if not renewed. Beyond the services and costs attributable to the direct pandemic response lies the challenge of being Geiger Gibson / RCHN Community Health Foundation Research Collaborative 15 able to adapt health care practices designed for the poorest Americans to a world in which the traditional high-touch, high-contact way of doing things may no longer be possible. It also means being able to bring back urgently needed forms of health care that demand physical contact such as dental care, laboratory testing, medical procedures, and other health interventions for which virtual visits are a weak substitute at best. Also essential is upgrading virtual visit capacity in order to be able to maintain participating provider status for insurance billing and payment purposes.30 In the early weeks of the pandemic, special restrictions on virtual visits were waived in order to allow patient services that do not meet normal HIPAA privacy and security rules. As health centers transition to a more permanent virtual service capability, these early procedures will need to be upgraded. Most challenging of all may be how to make the virtual visit model work for patients who overwhelmingly lack the technology to be able to take maximum advantage of virtual visits and other technology advances such as in-home patient monitoring as a substitute for frequent office visits. All of this is playing out against a backdrop of historic community-wide unemployment, skyrocketing social risks, and elevated threats from poverty and its consequences, along with signs of insurance erosion.31 These trends are in evidence in ACA Medicaid expansion states and non-expansion states alike. The deeper question becomes, how do health centers maintain the community resilience for which they are so well known? 25 Shin, P., Sharac, J., Morris, R., Rosenbaum, S., & Jacobs, F. (August 3, 2020). As COVID-19 Surges, Community Health Centers Face Near-Term and Long-Term Funding Instability. Gei- ger Gibson/RCHN Community Health Foundation Research Collaborative Data Note. https://www.rchnfoundation.org/?p=9075 26 https://bphc.hrsa.gov/program-opportunities/coronavirus-disease-2019; https://bphc.hrsa.gov/program-opportunities/cares-supplemental-funding; https://bphc.hrsa.gov/program- opportunities/expanding-capacity-coronavirus-testing-supplemental-funding 27 https://www.nachc.org/wp-content/uploads/2020/07/Health-Centers-and-PPP-Loans-Final.pdf 28 http://www.nachc.org/focus-areas/policy-matters/health-center-funding/federal-grant-funding/ 29 https://www.warren.senate.gov/imo/media/doc/CHC%20letter.pdf 30 Morris, R., Hernandez, J., Rosenbaum, S., Jacobs, F., Shin, P., & Sharac, J. (2020). What Can We Learn from Telehealth Experience of Community Health Centers During the COVID-19 Pandemic? GW Health Policy & Management Matters Data Note. http://gwhpmmatters.com/what-can-we-learn-telehealth-experience-community-health-centers-during-covid-19- pandemic 31 National Center for Health Statistics and the U.S. Census Bureau. (2020). Health Insurance Coverage: Household Pulse Survey. https://www.cdc.gov/nchs/covid19/pulse/health- insurance-coverage.htm; Dorn, S. (2020). The COVID-19 pandemic and resulting economic crash have caused the greatest health insurance losses in American history. Families USA. https://familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economic-crash-have-caused-the-greatest-health-insurance-losses-in-american-history/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 16