Community Health Centers Are Essential to a Safety Net

Steve FindlaySince we are in a political season, I’ll begin with one of the candidate’s positions on a facet of healthcare: Hillary wants to double funding for Community Health Centers (CHCs) over the next decade.

Is that a good or bad thing?  If you’re inclined to think that’s good, please read on; I’ll reinforce your views.  If your impulses are in the opposite direction….well, I hope you’ll still read on; I’ll hope to convince you.

By the way, I could find no mention by Trump of CHCs—no surprise there.

The role CHCs play in healthcare has gone largely unheralded for years, eclipsed by sexier health policy topics and debates.  But that role has expanded in recent years and become more important than you might think.  And not incidentally, CHCs have had broad bipartisan support for many years.

The National Institute for Health Care Management is out with a policy brief on CHCs, authored by Peter Shin.    Shin is an associate professor of health policy and management at George Washington University in Washington, D.C.  The brief, just a couple pages, presents results from a nationwide survey of CHCs Shin and his colleagues recently conducted.

Shin’s main argument is that CHC’s are not only a critical component of the nation’s healthcare safety net but also have become one main path by which millions of low-income people are gaining insurance coverage under the Affordable Care Act.

The CHC program was launched in the mid-1960s to provide care for the medically underserved and low-income populations, in both urban and rural communities.  Today, some 1,400 CHCs serve 24.3 million people nationwide.  In 2014, 92 percent of CHC patients had incomes below 200 percent of the federal poverty level and 28 percent were uninsured.  CHCs provide a comprehensive set of services, including dental, vision, prescription drugs, and mental health counseling.

Studies consistently show that CHCs improve the health status of communities and patients, and have been linked to reduced emergency room use and hospitalizations, enhanced preventive and chronic care management, and more use of less expensive providers.

Shin found that in 2013-14 about 80 percent of CHCs provided Medicaid application assistance and 90 percent helped people enroll in the ACA health exchanges.  And, he says, recent federal data indicate that CHCs have provided such assistance to some 17 million people since ACA enrollments began in 2013.

That means it’s feasible that a sizable number of people who have enrolled in Medicaid or an exchange under the ACA since 2014 did so with help at a CHC.

The Medicaid connection is especially strong since millions of Medicaid beneficiaries already get their primary care at CHCs.  Indeed, Shin found that in the first year of Medicaid expansion (in the states that did so) the share of all CHC patients with Medicaid coverage increased from 44 to 53 percent.  Not surprisingly, no increase occurred in the 19 states that didn’t expand Medicaid.

So what’s the problem?

It’s this:  CHCs don’t have stable or adequate funding, and some must scramble for money to meet the growing demand for their services.

By design, CHCs are not federally funded clinics.  They rely on a mix of revenue, including reimbursement from Medicare, Medicaid, and private insurers.  But federal grants do account for an important 22 percent of their revenue.

The ACA funded CHCs to the tune of $11 billion from 2011 to 2015, which paid for an increase in the capacity of existing CHCs and dozens of new ones.  In 2015, Congress extended funding, but only through 2017.
Shin says that the growth in the number of patients will require CHCs to recruit additional staff and expand their capacity significantly in the years ahead.  That’ll especially be the case if some or all of the 19 states that have not yet expanded Medicaid decide to do so in the next few years.

Shin says the CHCs in states that have expanded Medicaid are already feeling the pinch, largely because those were the states with less generous Medicaid coverage for childless adults to begin with.

In addition, the ACA requires private health plans sold in the exchanges to offer a contract to at least one CHC in every county where a CHC exists.  As exchange enrollment increases over time, CHC capacity will have to grow.

Despite bipartisan support for CHCs and the additional funding they got in 2015, funding beyond 2017 is no slam dunk, however.  And there’s no way to know now how the politics of that will go.  A Hillary Clinton White House is certain to support more funding for CHCs but if Congress remains in Republican hands, there’ll likely be a fight.  If Trump becomes president—as with almost every area of policy—all bets are off.

Bottom line: 29 million Americans remain uninsured.  CHCs are an essential component of the health care safety net that meets their medical needs, as well as the needs of millions of low-income insured people.   And CHCs are increasingly helping people gain coverage.

In 2017, Congress must not fail to adequately fund CHCs, and it should provide stable funding for at least five years.

Read the brief.  Here’s the link again.

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.

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15 replies »

  1. You missed my point, which means I could have communicated it better. FMGs are excellent physicians. Their training is often better than ours. Please don’t read prejudice where there isn’t any. I am frustrated by the system that places new physicians in a role for one year to three years and then starts fresh. The lack of continuity is hard for those with chronic conditions and the new physician. It hurts overall quality for all involved.

  2. You misunderstood my intent. I think foreign medical docs are excellent physicians. My point was that with j1 visa they only stay in small community for brief period. My dad has been in same town for 46 years. We still work together. Please read my comment again. You are correct my own father is a foreign medical graduate, why would I be prejudiced against that group or any other for that matter? It makes no sense.

  3. Defense of private small community docs is sorely absent. Funny you would mention prejudice profiling. What do you call paying $170 to providers at CHC and private MDs less than one quarter that amount? That is prejudiced profiling. There are docs cleaning up messes everywhere. All should be measured by the same yardstick. Please do not read prejudice where there is not any. See below for my clarification.

  4. Dr. Al-Agba, I believe you worked with a foreign graduate, your own father from Baghdad, for many years……

  5. I fix plenty of messes made at private docs and top rated hospitals. Quit your prejudiced profiling.

  6. I have spent most of my career at FQHCs and I am the Medical Director of one. True, I went to medical school in my native Sweden, five and a half years of it, at the second oldest university on the planet, home of Linnaeus, Celsius, Berzelius, Ångström and others. I don’t know what you base your prejudiced views on. There are good doctors and bad doctors everywhere but you are not helping the profession by throwing mud around. FYI, the other MDs at my FQHC were born in this country and trained at Yale, Tufts and Rush.

  7. “I don’t regret putting the debate over CHC funding in a political context”

    That debate has to be contemplated in unison by both sides of the isle. It seems you prefer to light fires rather than have that debate.

    Trump will not be the one discussing this topic. He will have his experts doing so. No one man or woman knows enough to manage the intricate details of all the things a President has to concern himself with. That Trump has said nothing on to the topic might mean his is open to different opinions.

  8. Steven, why are we fund/supporting CHC’s to provide substandard care, then having non-contracted Medicaid patients pay me and other PCP’s in cash to fix the messes made at those places? Why not pay a board certified physician with years of experience and excellent outcomes $170 for the office visit and save money by having a single point of care instead of multiple different variables at play? DataDriven is correct that more primary care physicians would be available if we could make a living doing the work for which we were properly trained. You either missed the important point we were all making below or maybe there is no answer at the moment?

  9. Thanks for the comments. “DataDrivenFP” is correct that CHCs and federally qualified health centers get paid more for certain services by both Medicare and Medicaid…than Medicaid pays primary care docs. That is a build-in way to fund/support them, and a critical part of CHC budgets. Perry raises a good question about quality of care at CHCs. I don’t know how MACRA treats them….but I’d say they certainly should not be exempt from performance/quality assessment since I’m quite sure quality varies from CHC to CHC.

    CMS does not oversee CHCs; another federal agency does. They are heavily regulated.

    I don’t regret putting the debate over CHC funding in a political context — some commenters objected to that. Reason: They WILL be an issue in 2017 even as efforts to fix parts of the ACA get underway, and Congress must extend their funding. I viewed CHCs as yet another example of a healthcare issue where Hillary has been very specific (whether you agree with her or not) and Trump has been completely nonspecific.

  10. Curiously, in all this there’s little mention of how much Medicaid pays FQHCs vs. primary care docs (PCDs.) In California, MediCal pays PCDs $25-35 for an office visit, while they pay $300 for an ED visit and $170 for a FQHC visit. Despite this, FQHCs seem financially stressed and unable to provide timely care. I wouldn’t be surprised that the Medicaid FQHC billing snipe hunt is so complicated it chews up a substantial portion of that $170, but that’s another matter.

    If Medicaid paid PCDs $170 for a visit, most of us would participate in MCD, and there’s be more primary care docs available. But bureaucracy wins. I dropped MCD 20+ years ago in NY, when they wouldn’t even pay me the $19.50 they ‘allowed’ for a visit-they ‘pended’ all my visits for 2 years, then just decided not to pay. After that they went to the ED instead.

    The answer is not more bureaucratic FQHCs. It’s more primary care. But you can’t get what you don’t pay for.

  11. You and I both know CMS is going to prop up CHC everywhere selling them as the answer to underserved areas. They should be graded just as we are going to be. The problem is health policy experts (read NOT MD’s) are extolling on the virtues of poor quality care for the poor. They are selling snake oil as an acceptable alternative form of care, but will never partake in it themselves. Sadly, MACRA is just going to be another nail in the primary care coffin.

  12. If CHCs are graded with the same requirements as other safety net facilities, they may not be around that long either, having the same problems with “quality” measures for those who have emotional, social or financial problems with care and medication compliance.
    Already we are seeing that the geniuses that thought up ACOs haven’t accounted for the fact that they don’t want to set up in “high risk” areas:

    And now we have MACRA? Lovely.

  13. I agree political statements were an unecessary part of the post. I highly doubt Mr. Findlay has ever received care at a CHC, otherwise he would understand medical segregation: remember separate but equal? (except in reality it’s anything but.) Desperate Medicaid patients pay cash just to obtain a modicum of care from a physicians locally. There is no mention about CHCs being staffed with non-physician providers exclusively and foreign med graduates on J1 visas doing their time. Why bother with facts when you can sell the concept of poor care for the poor. At least it’s something, right? No. It’s disgraceful.

  14. “ If your impulses are in the opposite direction….well, I hope you’ll still read on; I’ll hope to convince you.

    By the way, I could find no mention by Trump of CHCs—no surprise there.”

    I would be more likely to read on with an open mind if you gratuitously didn’t make your political comments.

    I don’t know about your statistics supporting CHC’s nor how they were obtained, but no matter. What is the end objective of CHC’s? I might find them reasonable in certain patient populations. Is the objective to grow the CHC or to look in a broader sense and mandate that the CHC is temporary and will by mandate disappear? Look at what has happened with Medicaid. That is supposed to be emergency relief, but it no longer is to the detriment of the population it care’s for.