(This story previously appeared in The Hill Extra)
A little-discussed side effect of the ObamaCare repeal effort could be losing gains that community health centers — a lifeline for the nation’s most vulnerable — have made.
Republicans’ vow to gut President Obama’s signature domestic achievement has thrust all facets of the health system into uncertainty — and community health centers are no different. Nearly 25 million people receive care through the nonprofit groups, and in interviews, nearly a dozen state community health associations expressed concerns over whether advances under the law would be reversed.
“Talking points are wonderful, but we live in a reality here that talking points don't help,” Alan Pruhs, executive director of the Association for Utah Community Health, told The Hill Extra. “So we're really going to be vigilant and watching what the replacement strategies look like and how that's going to affect the populations that we’re focused on serving.”
As the nation’s largest source of comprehensive primary care for medically underserved populations, the centers are closely eyeing three major items: changes to Medicaid, a Sept. 30 fiscal cliff and the possibility of absorbing patients from Planned Parenthood
Providers at the nearly 1,400 clinics can’t, under federal law, turn patients away — even those who are uninsured — and they often provide a wide array of services, from mental health and substance use disorder treatment to dental care.
The Affordable Care Act helped these centers grow in brick-and-mortar locations and in their ability to provide services, according to the Kaiser Family Foundation, because more patients with Medicaid and private health insurance increased revenues. The health law also infused more federal funds into the programs, dollars which were extended in 2015.
Expansion of coverage and increased funding under the law helped the centers’ revenues grow from $15.9 billion in 2013 to $21 billion in 2015, according to Kaiser.
“The problem that we’re having right now, the 50,000-foot view, is the instability in the funding environment,” Jose Camacho, executive director of the Texas Association of Community Health Centers, told The Hill Extra. “You’ve got a lot of money that goes to health centers that’s on the table, and unless we're able to resolve those issues, then I think we’re going to have some problems.”
Medicaid changes are coming.
The health centers are in better fiscal shape in part because an increasing number of health center patients are insured largely due to the expansion of the federal-state program for the poor and disabled.
But it’s unclear how Medicaid expansion will fare when Republicans repeal and replace ObamaCare.
“For us, the biggest concern that we have is Medicaid,” Deb Polun, government affairs and media relations director for the Community Health Center Association of Connecticut, told The Hill Extra. “This is a huge part of how federally qualified health centers are funded and represent a huge chunk of our patients.”
At the very least, a GOP health law likely means changes to how Medicaid is financed. Republicans have been pushing two main proposals — locking states into a preset level of funds (known as a block grant) or reimbursing a state per beneficiary (called a per capita cap).
The Congressional Budget Office has estimated that recent Republican block grant proposals are likely to cut spending, according to Kaiser. Critics of the proposals say that’s sure to lead to cuts in benefits.
The proposals are hard to analyze because no legislative decisions have been made, Jonathan Watson, of the Minnesota Association of Community Health Centers, said. So he interprets the concept as less money for states, in either scenario.
“When states have less money to operate their medical assistance programs, to me, that only means cutting benefits, cutting eligibility, cutting payments to providers or asking patients for additional cost-sharing,” Watson, associate director and director of public policy, told The Hill Extra.
It might not be easy for states to make up for funding losses. Take Nebraska, for example: The state is facing a nearly $900 million shortfall over the next two years.
“So there isn’t room in our state budget right now to cover some of those needs in a Medicaid program were the federal dollars to be reduced — so it’s really kind of a double impact for us,” Amy Behnke, CEO of Health Center Association of Nebraska, told The Hill Extra.
A fiscal cliff looms.
Community health centers benefited from the Affordable Care Act in several ways, including a new trust fund for the program.
More than 70 percent of federal grant funding for health centers comes from this pot of money.
Congress extended the fund in 2015, authorizing $7.2 billion for two years, and it will hit a fiscal cliff on Sept. 30. State associations are hyper-focused on what will happen to these funds.
“That would cripple our health centers,” Jane Hayward, president and CEO of Rhode Island Health Center Association, told The Hill Extra.
And it would have a “devastating” effect on Utah, Pruhs said, adding it could lead to close to half of the state’s health centers shuttering their doors and potentially upwards of 35,000 patients losing access to care.
“I think if there's support for anything, there's probably support for continuing health centers,” Sara Rosenbaum, a George Washington University professor of law and policy, told The Hill Extra. “But there's no guarantee that they're going to have their funding continued.”
Federally qualified health centers “play a vital role” in the country’s health, the likely new head of the Department of Health and Human Services said.
“I think it’s imperative that we retain them or improve the delivery of care in that area,” Rep. Tom Price (R-Ga.) said at a Senate Finance Committee hearing on his nomination to head HHS.
The Planned Parenthood factor.
There’s another potential wrinkle — House Speaker Paul RyanPaul RyanCotton: House 'moved a bit too fast' on healthcare Budget chief: 'Powers that be in Washington' won healthcare fight Schumer: Dems 'willing' to work with GOP if they stop 'undermining' ObamaCare MORE (R-Wis.) has said cuts to federal dollars for Planned Parenthood should go to community health centers instead.
“We think it's better to send these dollars to those clinics that do a very good job of giving women the services they need, the preventive services, without all the controversy surrounding Planned Parenthood,” he said recently.
But, at least in the short term, it’s not realistic that they would be able to care for the millions of patients that Planned Parenthood serves.
“There are a lot of services that are provided by Planned Parenthood that are not really that controversial,” Polun, of Connecticut, said, “and health centers do provide many of those same services, but it would be extremely difficult to take on all of those patients in one fell swoop.”
Some community health centers are no stranger to this debate.
Utah’s Republican governor, Gary Herbert, attempted to defund Planned Parenthood, raising a similar issue among centers.
At the time, the Association for Utah Community Health discussed the matter, and Pruhs said absorbing some of Planned Parenthood's patients would have taken time, Pruhs said. He added that Planned Parenthood is a referral partner and part of the healthcare safety net.
Ultimately, a federal appeals court halted the Utah governor’s effort.
Pause button on hiring, expansion.
When strategic planning came up at a recent Minnesota community health center board meeting, there were too many unknowns to make decisions.
The uncertain future is “putting, let’s say, a pause button on any significant strategic planning, capital expansions or really further integration of some services of the community health centers,” Watson said. “It’s creating a lot of angst amongst patients — patients are coming into providers saying, ‘Are you guys going to be here in a year?’”
In New York, there are about 28 job openings at Finger Lakes Community Health, which Mary Zelazny runs.
“I’m desperately trying to find people to take those jobs, and it’s hard,” Zelazny, who is also the board chair of the Community Health Care Association of New York State, told The Hill Extra. “Do I go ahead and fill those positions? Because I don’t really know if I’m going to have the funding that I have right now.”
Others echoed that sentiment.
“I think you're going to hear repetition from anybody in our world that there's a lot of concern,” Andrew Behrman, Florida Association of Community Health Centers president and CEO, told The Hill Extra, “and I think a lot of the concern is the unknown.”
See more exclusive content on policy and regulatory news on our subscription-only service here.