Months into the COVID-19 Pandemic, Community Health Centers Report Signs of Improvement, But Face Financial Uncertainty Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Issue Brief #64 October 2020 Jessica Sharac, PhD, MSc, MPH James Hernandez Feygele Jacobs, DrPH, MS, MPH Peter Shin, PhD, 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 / RCH N Community Health Foundation Research Collaborative 2 Executive Summary centers, to 14 percent as of the most current reporting period. This policy brief reports on the COVID-19 experience of the nation’s community health centers over a six-  In line with research that has found that minorities month period, utilizing data from the Health are disproportionally at risk for infection with the Resources and Services Administration’s (HRSA’s) COVID-19 virus, patients reported as racial and weekly Health Center COVID-19 Survey from April 3rd, ethnic minorities, particularly Hispanic/Latino 2020 to October 2nd, 2020. The data demonstrate patients, accounted disproportionately for patients that community health centers were immediately who tested positive. responsive to the public health crisis, initiating  Measures of operational capacity including diagnostic testing for the COVID-19 virus, and temporary site closures, staff unable to work, and adapting care such as telehealth to address patient declines in weekly visits have improved over the needs. However, with visits down overall and limited six months, but remain substantial and vary financial relief, the pandemic has taken an enormous greatly by state. financial toll on health centers. Cumulative patient revenue losses over six months are estimated at Introduction $3.364 billion, which amounts to nearly 11 percent of Community health centers are an essential source of total health center revenue reported nationally in care for low-income and racial and/or ethnic minority 2019. Other key findings include: patients, who are at high risk of COVID-19 infection  The share of health centers with the capacity to and poor health outcomes. In 2019, 1,385 federally- provide COVID-19 diagnostic testing grew from funded community health centers served nearly 30 80 percent in early April to nearly all (97 percent) million patients in the U.S.,1 or one in eleven residents six months later. nationally.2 That year, 91 percent of patients served by health centers were low-income and 63 percent were  Community health centers have tested a total of racial/ethnic minorities;3 health center patients more than four million patients for COVID-19 virus generally are at elevated risk of poor health, with both over six months. In the aggregate, a total of demographic characteristics and chronic conditions 456,682 health center patients and 14,562 staff that put them at greatest risk of poor outcomes from members have tested positive for the COVID-19 COVID-19.4 virus. With 7.3 million cases of coronavirus in the U.S. reported as of October 2nd, the number of Community health centers are required by statute to health center patients who have tested positive serve all patients regardless of their income or health accounted for 6.2 percent of cases nationally, or insurance status and to charge patients on a sliding one in 16 of all U.S. cases. fee scale based on their ability to pay. Before the pandemic, community health centers served one in  Average turn-around times for test results have three people living in poverty, 5 one in five uninsured improved from their lowest point in mid-July, individuals,6 and one in five Medicaid and Children’s when turn-around times of four or more days Health Insurance Program (CHIP) enrollees. 7 Their were reported by two thirds of responding health 1 Health Resources and Services Administration (HRSA). (2020). 2019 Health Center Data: National Data. https://data.hrsa.gov/tools/data- reporting/program-data/national/table?tableName=Full&year=2019 2 HRSA. (2020). HRSA Health Center Program. https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf 3 HRSA. (2020). National Health Center Data. https://data.hrsa.gov/tools/data-reporting/program-data/national 4 Sharac, J., S hin, P. & R osenbaum, S. (2020). Community Health Centers on the Eve of the C OVID -19 Pa ndemic: An Overview of Fi ndings from the 2019 Uniform Data System. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 63. https://www.rchnfoundation.org/?p=9180 5 HRSA. (2020). HRSA Health Center Program. https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf 6 National Association of C ommunity Health Centers. (2020). C ommunity Health Center Chartbook 2020. https://www.nachc.org/wp-content / uploads/2020/01/Chartbook-2020-Final.pdf 7 Sharac, J., S hin, P. & R osenbaum, S. (2020). Community Health Centers on the Eve of the C OVID -19 Pa ndemic: An Overview of Fi ndings from the 2019 Uniform Data System. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 63. https://www.rchnfoundation.org/?p=9180 Geiger Gibson / RCH N Community Health Foundation Research Collaborative 3 importance for low-income, uninsured, and Medicaid/ COVID-19 Survey to all health centers nationally since CHIP patients has only grown at a time when one in early April 2020.14 The survey captures data on health three U.S. adults has reported difficulty covering usual centers’ COVID-19 virus testing capacity, the number household expenses,8 an estimated 14.6 million and race/ethnicity of all patients tested and those who workers and their dependents have lost employer- tested positive for both the COVID-19 virus and sponsored insurance coverage following job losses, 9 antibodies, the effects of the pandemic on health and as new Medicaid and CHIP enrollments increased centers’ operational capacity, measured in site by over four million from February to June 2020. 10 In closures, weekly visit declines, and staff unable to addition to offering local access to both COVID-19 work, and the adequacy of personal protective testing and ongoing, comprehensive primary medical equipment (PPE) supplies. HRSA reports summary data care, community health centers offer services that for health centers nationally, by state, and for look- address the pandemic-related rise in mental health alike health centers, which meet all health center and substance use disorder problems. 11 Distancing program requirements but do not receive federal requirements and federal recommendations to avoid health center grants.15 Because the data are cross- “non-essential” care in the early months of the sectional, with different health centers reporting each pandemic led to drastic reductions in vaccinations, week, and the response rates vary by week, HRSA screenings, and dental services utilization among cautions against comparing data over the weeks; 16 Medicaid and CHIP child enrollees;12 health centers will notably, however, overall response rates have ranged likely face a surge in patient demand as social from 62 percent to 83 percent and have met or distancing requirements ease, and those who may exceeded 70 percent in 22 out of the 27 weeks of data. have avoided health care due to cost or coronavirus The Geiger Gibson/RCHN Community Health concerns return.13 Foundation Research Collaborative has produced a series of weekly updates based on HRSA’s survey HRSA’s Weekly Health Center COVID-19 data.17 This policy brief presents trend data for a full Survey six months (27 weeks) of HRSA’s survey data, from the first week of the survey, as of April 3rd, 2020, to the The Health Resources and Services Administration most recent week, as of October 2nd. We also present (HRSA) has been administering a weekly Health Center 8 Center on Budget and Policy Priorities. (October 2020). Tracking the COVID-19 Recession’s Effects on Food, Housing, and Employm ent Hard- ships. https://www.cbpp.org/sites/default/files/atoms/files/8-13-20pov.pdf 9 Fronstin, P. & Woodbury, S.A. (October 2020). H ow Many Americans Have Lost Jobs with Employer Health Coverage During the Pand emic? The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/oct/how-many-lost-jobs-employer-coverage- pandemic 10 CMS.gov. (September 30, 2020). CMS Releases Medicaid and CHIP Enrollment Trends Snapshot Showing C OVID -19 Impact on Enrollment. https://www.cms.gov/newsroom/press-releases/cms-releases-medicaid-and-chip-enrollment-trends-snapshot-showi ng-covid-19-impact- enrollment 11 Czeisler, M. É., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., ... & Czeisler, C. A. (2020). Mental hea lth, substance us e, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049. ; Pa nchal, N., Kamal, R., Orgera, K., C ox, C ., Garfield, R., Hamel, L., & C hidambaram, P. (2020). The implications of COVID -19 for mental health and substance use. https://www.kff.org/cor onavirus -covid-19/issue-brief/the -implications-of-covid-19-for -mental-health-and-substance-use/ 12 Center for Medicaid & CHIP Services (CMCS). (September 2020). Centers for Medicare & Medicaid Services. https://www.medicaid.gov/ resources-for-states/downl oads/medicaid-chip-beneficiaries-18-under-COVID -19-snapshot -data.pdf 13 Gonzalez, D., Zuckerman, S., Kenne y, G. M., & Karpman, M. (2020). Almost Half of Adults in Families Losing Work during the Pa ndemic Avoid- ed Health Care Because of Costs or COVID -19 Concerns. Washington, DC: Urban Institute. https://www.urban.org/sites/default/files/ publication/102548/almost-half-of-adults-in-families-losing-work-avoided-health-care-because-of-cost-or-covid-19-concer ns_2.pdf 14 HRSA. (2020). Health Center COVID-19 Survey. https://bphc.hrsa.gov/emergency-response/cor onavirus -health-center -data 15 The most recent survey data for l ook-alike health centers is available here: https://bphc.hrsa.gov/emergency-response/corona virus-health- center-data/look-alikes. This brief presents data only on federally-funded health centers and does not include data on look -alike health centers. 16 “Data represents information provided by health centers from a single, specified reporting date. Summary information across r eport dates is not comparable due to differences in which health centers responded for a given report date.” https://bphc.hrsa.g ov/emergency-response/ coronavirus-health-center-data 17 The weekly updates can be accessed here: https://www.rchnfoundation.org/?page_id=8918 Geiger Gibson / RCH N Community Health Foundation Research Collaborative 4 updated estimates on the cumulative losses to date in funding provided to community health centers to patient revenue, both nationally and at the state level. respond to the COVID-19 pandemic, including an initial $100 million through the Coronavirus Testing Capacity and Average Turn-Around Preparedness and Response Supplemental Times for COVID-19 Viral Test Results Appropriations Act in early March 18 and $1.32 billion Six months after HRSA began reporting this data, in the Coronavirus Aid, Relief, and Economic Security nearly all (97 percent) responding health centers (CARES) Act.19 On May 7th, HRSA announced $600 report capacity for diagnostic testing for the novel million in additional grants to expand health center coronavirus, up from 80 percent as of the first testing capacity, funded through the Paycheck reporting period (Figure 1). Among health centers Protection Program and Health Care Enhancement Act with testing capacity, the share with drive-up/walk-up (PPPHCEA or “COVID-19 3.5” relief package), and testing capacity more than doubled, from 38 percent signed into law on April 24th. 20 to 80 percent. The increase in testing capacity reflects Figure 2 illustrates how average turn-around times Figure 1. Community Health Center COVID-19 Virus Testing Capacity, April-October 2020 18 HHS.gov. (March 24, 2020). HHS Awards $100 Million to Health Centers for COVID -19 Response. https://www.hhs.g ov/about/ news/2020/03/24/hhs-awards-100-million-t o-health-centers-for-covid-19-response.html 19 NACHC. (2020). Summary of Ke y CHC Provisions in the C oronavirus Aid, Relief, and Economic Security (C ARES) Act. https://wsd-nachc- sparkinfluence.s3.amazonaws.com/uploads/2020/03/C ARES-Act-S ummary-for-Health-Centers.pdf 20 HHS.gov. (May 7, 2020). HHS Awards More than Half Billion Dollars Across the Nation to Expand COVID -19 Testing. https://www.hhs .gov/ about/news/2020/05/07/hhs -awards-more-than-half-billion-acr oss-the-nation-t o-expand-covid19-testing.html Geiger Gibson / RCH N Community Health Foundation Research Collaborative 5 for COVID-19 viral test results have changed over the while this is a vast improvement, it still means that six months. In the first few months of testing, about one in seven test results is clinically useless in the four in five tests came back within an average of three effort to conduct contact tracing and to stop further days or less. However, with the spike in cases over the transmission. summer, associated increases in testing demands, and broader delays in lab capacity, average turn-around COVID-19 Diagnostic and Antibody Tests times worsened dramatically, reaching a peak in mid- Over 26 weeks of reported data,21 community health July, when two in three (66 percent) results were centers tested a total of 4,033,327 patients for the returned in four or more days, including 44 percent COVID-19 virus and a total 456,682 patients and returned in more than five days. As of the most 14,562 health center staff members had confirmed current reporting period of October 2nd, average turn cases. As of October 2nd, there were a reported -around times of four or more days were experienced 7,332,297 cases of coronavirus in the U.S., 22 meaning by just 14 percent of all reporting health centers; that the 456,682 health center patients with confirmed Figure 2. Community Health Center Average Turn-around Time to Obtain COVID-19 Virus Test Results for the Prior Week, April-October 2020 HRSA began reporting patient testing numbers for the second week of the sur vey (April 10, 2020). 21 Johns H opkins University Coronavirus Resour ce Center. (2020). C umulative Cases. https://cor onavirus.jhu.edu/data/cumulative-cases; https:// 22 www.statspost.com/world/country-covid-19-data/United_States Geiger Gibson / RCH N Community Health Foundation Research Collaborative 6 infection accounted for one in 16 (6.2 percent) of cases dropped by about half, from a high of 1,381 in April to nationally. 685 as of October 2nd. Figure 3 shows the number of patients tested for Based on the reported numbers of patients tested for COVID-19 virus (PCR, antigen), the number of patients COVID-19 virus and those who tested positive each and health center staff members who tested positive, week, the percentage testing positive over six months and the percentage of health center patients who was at its peak in early May, at 28.3 percent, and as of tested positive for COVID-19 at approximately monthly October 2nd stood at 8.1 percent. However, given the intervals since April 2020. At its highest point, the week widespread delays in test results over the summer of August 14th, community health centers nationally months, these percentages may not reflect the true conducted over a quarter of a million COVID-19 virus positive rates over time due to the lag in results tests (251,246). The number of tests conducted per reporting. HRSA notes that “the reported number of week then decreased by nearly 108,000, to 143,377 as patients tested do not represent the same patients of the most recent reporting period. Patients who included in the reported number of patients tested tested positive decreased from a peak of 36,155 in positive due to a lag between the date the specimen is early May to 11,568 as of the current reporting period, collected and the availability of test results.”23 Over the and the number of staff members who tested positive six months, the percentage of positive testing results Figure 3. Community Health Center Patients Tested for COVID-19 Infection and Patients and Staff Who Tested Positive, April-October 2020 23 https://bphc.hrsa.gov/emergency-response/cor onavirus -health-center -data Geiger Gibson / RCH N Community Health Foundation Research Collaborative 7 reported by community health centers has fairly a wide body of research has found that members of consistently been above the national positive case racial and/or ethnic minority groups are rate across public health, clinical and commercial labs disproportionally more likely to be infected with the reported to the Centers for Disease Control and novel coronavirus and to have serious illness, to be Prevention (CDC). Results for the most recent week hospitalized, and to die from COVID-19.26 are consistent with this experience; the 8.1 percent Findings from HRSA’s survey are consistent with positive case rate at health centers as of October 2nd evidence of racial/ethnic disparities in COVID-19 was much higher than the 4.9 percent reported infection. Figure 4 shows that for each week of nationally to the CDC as of the week ending October reported data, the share of patients who tested 3rd.24 positive for COVID-19 virus who are racial/ethnic Antibody tests, also known as serological tests, minorities exceeded the share of tested patients who indicate if a person was previously infected with the are racial/ethnic minorities. COVID-19 virus. HRSA began reporting the number of Figure 5 provides more detail on the race and health center patients tested for COVID-19 antibodies ethnicity of tested patients and patients who tested in June 2020. Over 18 weeks of reported data, a total positive for COVID-19 infection from the most recent of 251,628 health center patients were tested for week of reporting. While White, Hispanic/Latino antibodies and 41,008 tested positive. Over the half- patients accounted for 19 percent of health center year of all testing data, community health centers patients tested for COVID-19 infection in this have tested a total of 4,284,955 patients with a COVID reporting period, they represented 27 percent of all -19 test of any type and a total of 497,7690 patients positive cases. Similarly, Hispanic/Latino patients with have tested positive for either COVID-19 virus or no reported race accounted for six percent of those antibodies. tested for infection, but nine percent of positive cases Race and Ethnicity of Health Center Patients for infection. HRSA reports that over all the weeks of Testing Positive for COVID-19 Virus reported race and ethnicity patient testing data from April to October, Hispanic patients accounted for 30 Community health centers, which by mission and percent of patients tested with a COVID-19 test of any federal mandate are located in underserved type but 45 percent of patients who tested positive communities, are a vital resource in many minority for either COVID-19 virus or antibodies.27 communities. The Department of Health and Human Services (HHS) counts community health center Losses of Operational Capacity: Sites, testing capacity among their initiatives to make Staffing, and Visits testing more accessible and to reduce COVID-19 While adding testing and adapting their services, racial/ethnic disparities.25 As the pandemic continues, health centers have been operating at reduced 24 CDC. (Oct ober 9, 2020). COVIDVIE W: Key Updates for Week 40, ending Oct ober 3, 2020. https://www.cdc.g ov/cor onavirus/2019-ncov/covid- data/covidview/index.html 25 HHS. (2020). HHS Initiatives to Address the Disparate Impact of COVID -19 on African Americans and Other Racial and Ethnic Minorities. https://www.hhs.g ov/sites/default/files/hhs-fact -sheet-addressing-disparities-in-covid-19-impact-on- minorities.pdf 26 CDC.gov. (2020). COVID -19 H ospitalization and Death by Race/Ethnicity. https://www.cdc.gov/coronavirus/2019 -ncov/covid-data/ investigations-discovery/hospitalization-death-by-race-ethnicity.html; Kim et al. (2020). H ospitalization rates and characteristics of children aged< 18 years hospitalized with laboratory-confirmed COVID-19—COVID -NET, 14 States, March 1–Jul y 25, 2020. Morbidity and Mortality Weekly Report, 69(32), 1081.; M oore et al. (2020). Disparities in Incidence of COVID -19 Among Underrepresented Racial/Ethnic Groups in Coun- ties Identified as Hotspots During June 5–18, 2020—22 States, February–June 2020. Morbidity and Mortality Weekly Report, 69(33), 1122.; Stokes et al. (2020). C orona virus disease 2019 case surveillance —United States, January 22–May 30, 2020. Morbidity and Mortality Weekly Re- port, 69(24), 759.; Wortham et al. (2020). C haracteristics of persons who died with COVID -19—United States, February 12–May 18, 2020. MMWR. M orbidity and Mortality Weekly Report, 69. 27 HRSA. (2020). Health Center COVID-19 Testing: Explore COVID-19 Testing by Race/Ethnicity. https://data.hrsa.gov/topics/health-centers/ covid-testing Geiger Gibson / RCH N Community Health Foundation Research Collaborative 8 Figure 4. Share of Community Health Center Patients Tested for COVID-19 Virus and Patients Who Tested Positive Who are Racial/Ethnic Minorities, April-October 2020 Figure 5. Health Center Patients Tested for COVID-19 Virus and Patients Who Tested Positive, by Race/Ethnicity, as of October 2nd Geiger Gibson / RCH N Community Health Foundation Research Collaborative 9 capacity since the pandemic began. As Figure 6 centers running.28 Similarly, the 17 percent reduction illustrates, health center activity has been recovering; in weekly visits amounts to approximately 400,000 the decline in weekly visits compared to average fewer weekly health center visits nationally, 29 for weekly visits before the pandemic has greatly services which may include routine check-ups, improved, from a peak decline of 53 percent as of vaccinations, and other preventive care services. April 10th to 17 percent currently. Similarly, the share Furthermore, while losses in operational capacity may of temporarily closed sites improved over that same have improved nationally over time, they vary greatly time period, from 16 percent to six percent, while the by state.30 As shown in Figure 7, as of October 2nd, share of health center staff members unable to work nearly seven months into the public health due to COVID-19, for reasons that included site emergency, ten states were reporting declines in closures, family/home obligations, lack of personal weekly visits of at least 25 percent (with the greatest protective equipment, and exposure to coronavirus, decline of 36 percent reported by New Jersey health fell from 16 percent in the first week of the survey to centers),31 and in an additional seven states, visits four percent in the most recent week. were down by at least 20 percent. Still, these losses continue to reflect the toll that Financial Uncertainty and Revenue Losses COVID-19 is having on health center capacity, staffing, The loss in patient visits has translated into ongoing and operations. A four percent reduction in health and substantial revenue losses, estimated at $3.364 center employees translates to about 10,000 fewer billion nationwide over the six months, an amount working full-time equivalent (FTE) staff members who that represents 10.7 percent of total revenue reported are essential to serve patients and to keep health nationally in 2019 (Figure 8). Cumulative patient Figure 6. COVID-19 Impact on Community Health Centers, April-October 2020 28 Based on 252,867.67 FTE staff members reported in the 2019 UDS. HRSA. (2020). National Data. Table 5: Staffing and Utilization. https:// data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=5&year=2019 29 Based on 122.8 million visits reported in 2019, divided by 52. HRSA. (2020). National Data. Table 5: Staffing and Utilization . https:// data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=5&year=2019 Geiger Gibson / RCH N Community Health Foundation Research Collaborative 10 Figure 7. Decline in Community Health Center Weekly Visits Compared to Pre-COVID- 19 Average Weekly Visits, By State, as of October 2nd Figure 8. National Community Health Center Estimated Weekly and Cumulative Patient Revenue Losses over Six Months, April-October 2020 Geiger Gibson / RCH N Community Health Foundation Research Collaborative 11 revenue losses over this time period varied by state, Uninsured Claims Fund.32 However, it is unclear when ranging from three million in Wyoming to $686 – or how much – additional COVID-19 relief aid will be million in California. (Table 1). forthcoming, with the delays adding to the financial burden. Health centers are also facing financial In addition to the funding directly allocated to uncertainty because the Community Health Center community health centers through the Coronavirus Fund (CHCF), which accounted for over 70 percent of Preparedness and Response Supplemental Appropriations Act, the CARES Act, and the PPPHCEA, federal health center grant funding in FY2019, 33 has been extended only to December 11th, 2020. The community health centers have also received some financial support through the Paycheck Protection continued financial uncertainty about both any additional COVID-19 relief funding and the extension Program, the HHS Provider Relief Fund, and HRSA of the CHCF, and the sheer magnitude of estimated Table 1: Cumulative losses in health center patient revenue, by state, April to October 2020 State Cumulative losses State Cumulative losses (in millions) (in millions) AK -$22 MT -$16 AL -$19 NC -$52 AR -$20 ND -$5 AZ -$56 NE -$10 CA -$686 NH -$8 CO -$57 NJ -$42 CT -$42 NM -$25 DC -$34 NV -$5 DE -$4 NY -$283 FL -$141 OH -$69 GA -$44 OK -$24 HI -$23 OR -$69 IA -$24 PA -$83 ID -$29 PR -$38 IL -$113 RI -$22 IN -$62 SC -$59 KS -$20 SD -$5 KY -$70 TN -$30 LA -$45 TX -$160 MA -$79 UT -$15 MD -$54 VA -$29 ME -$29 VT -$20 MI -$67 WA -$180 MN -$22 WI -$48 MO -$76 WV -$59 MS -$29 WY -$3 Note: Weekly patient revenue l osses estimated based on the decline in weekly visits compared to pre -COVID-19 a verage weekly visits reported each week from the Health Center COVID-19 Survey and weekly patient revenue (total patient revenue reported for 2019 in the 2019 Uniform Data System, divided by 52). Data for DC and LA health centers were not reported the week of September 4th, so the visit decl ines for that week were imputed by taking the average of the weekly declines the week before and after. Cumulative losses reflect the sum of est imated losses based on 27 weeks of survey data. Sources: HRSA. (2020). Health Center COVID -19 Surve y; HRSA. (2020). 2019 Uniform Data System data. Geiger Gibson / RCH N Community Health Foundation Research Collaborative 12 patient revenue losses to date, could prevent health than half (43 percent) of community health centers centers from fully restoring services and reopening reported using telemedicine to provide remote clinical sites, and could also force health centers to cut back care services34 and virtual visits accounted for only 0.4 and lay off staff members, resulting in further job percent of the 122.8 million health center visits that losses and economic distress in the communities that year.35 At its peak, as of April 24th, 54 percent of visits health centers serve. on average were conducted virtually; this percentage had fallen by half, to 27 percent, as of October 2nd, Virtual Visits but virtual visits still accounted for over a quarter of As a way to continue to provide care to their patients visits that week (Figure 9). Recent policy changes may and to earn patient revenue, community health have helped to increase health centers’ use of centers rapidly pivoted to telehealth. In 2019, less telehealth services during the pandemic, yet many still Figure 9. Average Percentage of Community Health Center Visits Conducted Virtually, April-October 2020 30 HRSA has created maps that show state variation in the percentages of site closures and staff unable to work, available here: HRSA. (2020). COVID-19 Health Center Survey Maps. https://bphc.hrsa.g ov/emergency-response/coronavirus-health-ce nter-data/survey-maps 31 HRSA. New Jersey Health Center COVID-19 S urvey S ummary Report. Latest data from October 2, 2020. https://bphc.hrsa.gov/emergency- response/coronavirus-health-center-data/nj 32 Shin, P., Sharac, J., Morris, R., Jacobs, F., & Rosenbaum, S. (2020). As C OVID -19 Surges, C ommunity Health Centers Face Near-Te rm and Long- Term Funding Instability. Geiger Gibson/RCHN Community Health Foundation Research Collaborative Data Note. https:// www.rchnfoundation.org/?p=9075 Note that the estimated losses published in this brief differ from those reported in Figure 8 because they were based on 2018 patient revenue data while later estimates of losses were updated with 2019 patient revenue data once it w as available. 33 NACHC. Federal Grant Funding. https://www.nachc.org/focus-areas/policy-matters/health-center-funding/federal-grant-funding/ 34 Health Resources and Services Administration (HRSA). (2020). 2019 Health Center Data: National Data. Table ODE: Other Data El ements. https://data.hrsa.gov/t ools/data-reporting/program-data/national/table?tableName=ODE&year=2019 35 Sharac, J., S hin, P. & R osenbaum, S. (2020). Community Health Centers on the Eve of the C OVID -19 Pa ndemic: An Overview of Findings from the 2019 Uniform Data System. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington Univer sity. Policy Research Brief No. 63. https://www.rchnfoundation.org/?p=9180 36 Morris, R., Hernandez, J., Rosenbaum, S., Jacobs, F., Shin, P., & Sharac, J. (2020). What Can We Learn fr om Telehealth Experi ence of Community Health Centers During the COVID-19 Pa ndemic? Geiger Gibson/RCHN Community Health Foundation Research Collaborative Dat a Note. https://www.rchnfoundation.org/?p=8744 Geiger Gibson / RCH N Community Health Foundation Research Collaborative 13 Figure 10. Community Health Center Availability of Adequate PPE Supply, By Type and Duration, as of October 2nd Figure 11. Community Health Centers with an Adequate Supply of Personal Protective Equipment (PPE) for the Next Week, April-August 2020 37 HRSA. (September 4, 2020). COVID -19 Data Collection Surve y Tool Questions. https://bphc.hrsa.gov/emergency-response/covi d-19-surve y- tools-questions 38 https://web.archive.org/web/20200412205141/https:/bphc.hrsa.gov/emergency-response/cor onavirus-health-center-data Geiger Gibson / RCH N Community Health Foundation Research Collaborative 14 face barriers to adopting or expanding telehealth.36 Furthermore, the essential role of community health centers in serving Latino, Black, and other minority Supply of Personal Protective Equipment and low-income communities, those known to be the HRSA has queried health centers about their supply of most affected by COVID-19 and other public health personal protective equipment (PPE) over six months. crises, underscores the need for long-term, stable The question on PPE supply was amended in federal investment to sustain and expand access to September37 so that data are not comparable over the care. six months, but for the most recent reporting period Finally, while the data indicate a trend of (Figure 10), nearly all health centers reported that improvement over time, it remains to be seen if they either do not need some types of PPE or have community health centers can continue to provide adequate supplies of all five types of PPE supplies for COVID-19 diagnostic testing and to remain open and the next week or more. The question did not assess operational to provide other health care services, at a the extent to which health centers are prepared to time of historic job losses and increased uninsured secure an adequate supply of PPE should COVID-19 rates. In the face of deep financial losses, continued infections surge during this flu season. Earlier data financial uncertainty, and as the nation faces the based on the original PPE question, illustrated in threat of both flu season and increased coronavirus Figure 11, show that the share of responding health cases in the fall and winter, the future of our nation’s centers reporting adequate supplies of PPE ranged by health centers should be a cause for both deep type from 67 percent to 89 percent in the first week38 concern and renewed support. and that in April and May, a substantial percentage of health centers were unable to access a sufficient supply of gowns, a core PPE item. Additionally, the weekly survey shows that adequacy of the PPE supply can vary significantly from state to state.39 Conclusion Six months of reported data from HRSA’s Health Center COVID-19 Survey indicate that community health centers have risen to meet the challenges of the COVID-19 pandemic, with nearly all offering COVID-19 testing and over four million COVID-19 diagnostic tests conducted by health centers nationally over six months. Operational capacity has also improved over this time period, but site closures and declines in weekly visits remain substantial, resulting in an estimated total of $3.364 billion in cumulative losses of patient revenue over six months. These steep revenue losses, as well as the known widespread racial/ethnic and income disparities in the risk of serious illness from COVID-19, and the high proportion of low-income health center patients at greater risk for infection, suggest a continued need for the expansion of health center testing resources. 39E.g., Sharac, J., Hernandez, J, Velasquez, M, S hin, P, & Jacobs, F. (2020). Key Updates from the Health Center COVID -19 Surve y (Week #18): Average Turn-around Times for COVID-19 Viral Test Results Reported by Community Health Centers Improved this Week, but More than Half Still Experienced Long Waits. Geiger Gibson/RCHN Community Health Foundation Research Collaborative Data Note https:// www.rchnfoundation.org/wp -content/uploads/2020/08/Week-18-HRSA-C OVID-19-Update-FINAL-8.11.20.pdf Geiger Gibson / RCH N Community Health Foundation Research Collaborative 15