Take Care is pleased to present a series of posts offering thoughts on how Congress might address key issues in the healthcare system.
By Sara Rosenbaum | Professor of Health Law and Policy | GW Law School
In thinking about pressing health reform priorities in the upcoming Congress, typically what comes to mind is making private insurance more affordable, extending Medicare to the near-elderly, and bringing down the cost of health care. Also on tap is how to incentivize the remaining hold-out states, predominantly but not exclusively located in the South, to expand Medicaid.
But an additional top-tier challenge, one of increasing urgency, must be ensuring that nearly 1,400 community health centers don’t go “over the cliff”—that is, ensuring they do not lose 71 percent of their grant funding. Over five decades, operating grants have made it possible for health centers to serve as primary care anchors in communities and for populations designated by law as medically underserved. This designation results from elevated poverty and health risks, as well a shortage of primary care professionals. Without government grants, community health centers would lack the main source of stable, reliable financing that allows them to hire staff, expand their services, add service sites, serve the uninsured, and provide the patient support and health-promotion care that remains uncovered by health insurance.
Quick Background on Community Health Centers
In 2017 health centers served more than 27 million residents in 11,000 communities across the country and provided services across the lifespan: pregnancy and newborn care; comprehensive care for children and adolescents; primary care management for adults with physical and mental health conditions that can be well-managed in primary care settings; women’s preventive health services; and, increasingly, community-based long-term services and support for people living with disabilities and for the elderly.
Nearly 1 in 3 health center patients is a child. Working-age adults make up 60 percent of all patients, and 1 in 10 is elderly. Virtually all health center patients have family incomes twice below the poverty line; 70 percent of patients live in families with below-poverty incomes ($20,780 for a family of 3). Almost two-thirds of health center patients are members of racial and ethnic minority populations.
Because of where they are located, what they offer, and whom they serve, health centers have become an integral part of the American health care system. They are also a basic building block of the national response to population health priorities and public health crises. As the biggest single source of primary care for the low-income population, health centers have become indispensable partners to state Medicaid programs as they expand their investment in the managed care systems that today serve 70 percent of the nation’s 70 million Medicaid beneficiaries.
In addition, community health centers represent one of the country’s most important providers of comprehensive family planning services for low-income and at-risk populations, serving more than 6 million women of reproductive health age. Today two-thirds of all health centers offer the most effective forms of contraception onsite. Their scope of care in this regard has only grown as other crucial sources of publicly-funded family planning services have come under attack.
In the poorest communities, health centers occupy a central role as first responders in public health crises, both naturally occurring and man-made. Registering over 1.5 million visits for 352,000 patients in 2016, health centers have been essential to Puerto Rico’s recovery effort following total hurricane devastation. Health centers also serve on the front lines of the opioid crisis; over the past three years, nearly 7 in 10 have reported growth in the number of patients with opioid use disorders and today half provide onsite medication-assisted treatment.
A History of Bipartisan Support—and an Emerging Threat
Since they were first established in 1965 by the Office of Economic Opportunity as a response to poverty and health care inequality, community health centers have been embraced by Republicans and Democrats alike. Part of their bipartisan support comes from the inherently appealing nature of the health center model. By law, health centers are situated in underserved communities, must be available to all community residents, must prospectively adjust their charges based on ability to pay, must provide comprehensive primary care across all ages, and must be governed by community boards (a majority of whose members are active, registered patients). A related source of their bipartisan appeal has been their repeatedly documented success, with relatively modest investment, in achieving improved health care access and better health outcome results in a cost-effective manner. That includes more efficient management of health conditions in non-emergency care settings. Yes another part of their bipartisan support lies in their positive community-level impact and the jobs they generate.
Why, then, should this program be threatened, even when its penetration into medically underserved communities continues to fall short of national need?
Ironically, the problem can be traced to a critical and vitally important decision by Congress in the ACA. There, Congress decided to invest in health center growth, which was deemed essential to ensuring access to care as millions of disproportionately low-income people gained insurance coverage. This investment actually began with a one-time, $2 billion investment in supplemental grant funding as part of the economic stimulus package in 2009—a.k.a. the American Recovery and Reinvestment Act (ARRA). Building on the ARRA, the ACA established a $12.5 billion, five-year investment fund for health centers and the National Health Service Corps, whose scholarship and loan repayment support help ensure the clinical workforce that make community health centers possible. This fund was extended for 2 years in 2015 and again for two years in 2018. As a result, health center grant funding more than trebled over the 2002- 2018 time period, fueling major growth and deeper penetration into the nation’s highest-need areas.
Medicaid represents the largest single source of health center revenue. But grant funding—constituting just under 20 percent of ongoing health center operations in 2018—is the foundation on which the program rests. It is the means by which operations remain stable, new staff can be hired, new sites can be opened, new services (such as opioid treatment) can be added, and services essential to health but not covered through insurance can be maintained. (These services include care management, nutritional support, outreach, patient health education, translation, and transportation.) Most important, perhaps, grants are the means by which community health centers served 6.2 million uninsured patients in 2017, nearly 1 in 4 patients nationally, and a far greater percentage in Medicaid non-expansion states.
Congress has made relatively short-term investments in health centers. The ACA Fund covered five years, but its 2015 and 2018 extensions have been far shorter: only 2 years in 2018. If the fund is permitted to lapse, a system of care responsible for 1 in 3 low-income Americans is in serious jeopardy, since some 70 percent of all grant funding now comes through this dedicated source.
A Strategy for the Future
What is needed at this point is a longer-term strategy, one that acknowledges health centers for what they have become – an indispensable part of the American health care landscape.
A solution could come as part of a package of long-term investments in health care affordability that, like the ACA itself, recognizes health centers as the means by which low-income communities effectively are linked to the health care system. It could also come as a piece of basic infrastructure investment, given the economic impact of health centers in their communities.
In 2018, Congress established a 10-year funding window for the Children’s Health Insurance Program (CHIP) as part of the Bipartisan Budget Act. This same funding window is needed for health centers. The same time horizon is necessary for health centers. For Fiscal Year 2020 and beyond, this means coming up with a strategy that can accommodate about $4 billion annually, adjusted over time for new investments (such as special opioid treatment investments made in 2018) and growing medical care costs.
In light of health centers’ vital role and their judicious use of the resources entrusted to them, to say that this investment should be doable is the understatement of the century.
 Eli Adashi, Jack Geiger, and Michael Fine, Health Reform and Primary Care – The Growing Importance of the Community Health Center, 362 New Eng. Jour. Med. 22 (June 3, 2010)