Health Care Reform To Do List
By Jennifer Ginn, CSG Associate Editor
When Jan. 1, 2014, rolls around, one of the most significant parts of the Affordable Care Acts takes effect. That’s when all U.S. citizens and legal residents are required to have health insurance coverage.
While tens of millions of Americans will join the rolls of the insured, one thing is not so clear: Where will those millions of people get their primary care?
Many of the newly insured probably will find themselves at a federally qualified community health center. These centers, created in 1965, are designed to ensure everyone has access to basic primary care and preventive services regardless of insurance coverage or ability to pay.
“They provide basic primary health care services … and also provide oral and mental health services,” said Dan Hawkins, senior vice president of public policy and research at the National Association of Community Health Centers.
Health centers must meet several standards to be considered federally qualified, which allows them to receive federal grants that help subsidize care for the uninsured and underserved. The centers must:
Be located in a medically underserved area or serve a high-need population;
Be governed by a community board whose majority is made up of patients;
Provide comprehensive primary care;
Provide services to all regardless of a patient’s ability to pay; and
Meet certain performance and accountability measures.
More than 22 million Americans get their primary care from one of 8,500 health centers across the country.
Hawkins said the Affordable Care Act provided $11 billion over five years to expand health centers to increase patient capacity up to 40 million people. Due to the federal fight over the budget, only about $22 million of that $11 billion has been appropriated and distributed to community health centers. The sequester—which cut $120 million in health center funding—hasn’t helped, Hawkins said.
Health centers are being stretched thin due to increased demands for their services during the Great Recession, and Hawkins is worried about their ability to take on new patients Jan. 1, especially in the area of primary care.
“We have such a shortage of primary care, nurse practitioners and physician assistants,” he said. “Every one of them is worked to the nub. … I think, in the broader health care community, it’s really questionable where we can expand to accommodate the new folks who gain coverage.”
Here’s how various health centers across the country have been affected by the Great Recession and how prepared they think they are for the health insurance expansion in 2014.
Covering Dental Needs for Low-Income Families
Name: Family Health Center of Marshfield Inc.
Location: 26 sites across northern Wisconsin
Number of Patients: 92,063
Poverty: 90 percent of patients have incomes less than 200 percent of the federal poverty level.
2012 Total Patient Contacts: 516,290 visits
2012 Budget: $160 million
Funding Sources: 61 percent Medicaid; 13 percent private insurance; 9 percent Medicare; 9 percent private support/grants; 3 percent self-pay; 3 percent federal grants; 1 percent state funding; and 1 percent investment/other income
In 2006, only 21 percent of children in low-income families in Wisconsin received any kind of dental care. That was a real problem, said Greg Nycz, executive director of the Family Health Center of Marshfield Inc. Only Florida had fewer low-income children visiting a dentist at the time.
“It’s because our state has many underpaid private dentists and they feel they just can’t serve that population,” Nycz said. “Many of them (low-income children) have that benefit, but they just don’t have anywhere to go to get that realized.”
So in late 2006, the secretary of the state Department of Health Services called Nycz and asked for help from Wisconsin health centers. Nycz devised a 10-year plan to increase low-income children’s access to dental services.
“Collectively, our state community health centers have gone from serving about 24,000 largely low-income people for dental in 2003,” said Nycz, “and right now we’re serving over 124,000. That’s in 2011. … We have eight dental centers now with 45 dentists. Our ninth dental center is being built in collaboration with the Ho-Chunk Nation.”
When states started feeling the bite of the Great Recession in 2008, Nycz said his health centers began seeing a lot more people coming through its doors. When more people become insured Jan. 1, Nycz said it will be a mixed bag on whether patients can get the care they need.
“Where we are in our service area now, the single biggest need used to be dental,” he said. “We’re kind of meeting that need now. The single-biggest need now … is in the behavioral health area. This is an area of growing concern for us. When we meet with tribal folks up north, they tell us they’re going to lose a generation of children because they don’t have access to child psychologists.”
Photo by Wendy Moore
Recruiting Doctors to Fill the Need
Name: Yakima Neighborhood Health Services
Location: Five sites spread over 40 miles in central Washington
Number of Patients: 18,700
Poverty: 90 percent of patients have incomes less than 200 percent of the federal poverty level.
2012 Total Patient Contacts: 65,000 visits, plus 5,000 housing/outreach encounters
2012 Budget: $14 million
Funding Sources: 70 percent Medicaid; 10 percent federal government grants; 6 percent Medicare; 5 percent state funding; 5 percent private/self-pay; and 4 percent private insurance
The five sites of the Yakima Neighborhood Health Services in Washington state see a high number of patients who are migrant workers or uninsured. When the Great Recession hit, it saw a rapid increase in the uninsured, according to CEO Anita Monoian.
Yakima received a federal grant to expand to a new location in the Sunnyside community.
“That’s going to be a dramatic expansion, which of course we’re doing to get ready for Medicaid expansion. … We want to be sure our facilities are ready,” Monoian said.
One of the biggest challenges she faces is finding enough doctors to serve the new patients they expect to see. Monoian said 300,000 people are expected to gain insurance coverage just in Washington with the Medicaid expansion.
“It won’t surprise you to know that we’ve been recruiting for this for several months now, knowing it was coming,” she said. “There’s a huge need in this country and a shortage of primary care physicians. We have for years had a very nice mix of physicians to nurse practitioners to physician’s assistants that, of course, has really helped us expand our services.
“It (recruiting) is the biggest challenge. There’s no getting around it.”
Photo by Chad Bremerman
Growing, Again, to Care for More People
Name: East Boston Neighborhood Health Center
Location: One main campus located in East Boston
Number of Patients: 60,000
Poverty: 69 percent of patients have incomes less than 200 percent of the federal poverty level.
2012 Total Patient Contacts: More than 300,000
2012 Budget: $96.4 million
Funding Sources: 37.4 percent Medicaid and other state low-income insurance programs; 25.4 percent nonfederal grants/contracts; 21.2 percent federal government grants; 13.6 percent private insurance/other; and 2.4 percent self-pay
The East Boston Neighborhood Center is one of the limited groups of professionals in the country that can say, “been there, done that” regarding Medicaid expansion. Massachusetts enacted its own law in 2006 requiring most state residents to get health insurance.
“We saw an increase in demand soon after the law was passed,” said CEO Manny Lopes. “We increased our hours, we brought on as many (employees) as we could afford and had space for. … All of our buildings, we had taken up just about every corner closet … to see patients.”
Lopes thinks the center will once again see more patients after the Affordable Care Act is implemented because it “changes people’s mindset once they feel like they have less concern about going to the doctor, less concern about how to pay for that.”
To prepare, the East Boston Neighborhood Center has been expanding. It received $12 million from the American Recovery and Reinvestment Act, which helped it build a new 50,000 square foot building.
Lopes said state policymakers should pay close attention to an often-overlooked piece of health insurance reform—patient navigators.
“Massachusetts made the investment and helped pay for folks who worked at the health centers and helped the patients understand what options they had,” he said. “At least for us, that was a very important piece, making sure people who were signing up were signing up for a program that met their needs.”
Lopes said policymakers also need to remember to bring health centers, not just the big insurance companies, to the table when discussing health care reform.
“We have a consumer board that really gives us direction,” Lopes said. “ We have ears on the street to know what’s going on. We’re really in tune with the community that we’re serving and we can really help.
“Understand us, understand what we do and bring us to the table. I think you’ll find we’ll be good partners.”
Photo by Steven Snyder
Providing Local Solutions to Local Problems
Name: Teche Action Board Inc.
Location: Eight clinics located in rural southern Louisiana
Number of Patients: 18,000
Poverty: 78 percent of patients have incomes less than 200 percent of the federal poverty level.
2012 Total Patient Contacts: 65,000
2012 Budget: $11 million
Funding Sources: 40 percent Medicaid; 33 percent federal government grants; 20 percent Medicare; 6 percent private insurance; and 1 percent state funding
Dr. Gary Wiltz, CEO of the Teche Action Board Inc. and chair-elect of the National Association of Community Health Centers, said the board’s Gulf Coast health centers have seen tremendous growth in recent years.
“We had a double whammy,” Wiltz said. “We had both natural and man-made disasters hitting us. I had 19 relatives come live with us in Franklin after Katrina. We saw a great influx of community health center patients come out of New Orleans.
“Then as the recession hit, people became unemployed. Between 2005 and 2012, … we went from having two sites to eight sites. We had a tremendous increase in access.”
Wiltz said the board secured federal funding to build three new clinic sites. There now are six doctors and 10 nurse practitioners spread over those eight sites. Wiltz credits President Obama with being systematic in how the Affordable Care Act has rolled out, but he is concerned about the federal budget cuts that already have hit and what the future may hold.
“I think we’ve positioned ourselves well,” he said. “I’m saying that community health centers, if we got adequate funding, we could increase to capacity and serve those folks.
“There just aren’t enough of us. We have plans to expand to six days a week, 12 hours a day to keep it convenient and keep people from going to the emergency room. This country has go to get away from that cost of care. We’ve got to invest in primary preventive care.”
Wiltz said health centers have learned to be nimble out of necessity. Local uninsured women, for example, needed mammograms and a local hospital didn’t have enough mammogram patients to keep its certification. Wiltz said he helped put together a plan benefitting both sides where patients only had to pay half of the cost of the test and the hospital got enough patients to keep its certification.
“That’s the great thing about community health centers,” he said. “Fifty-one percent of the board are users of the clinic. I always make the comment: It’s local problems with local solutions by local people using state or federal money. When people talk about states’ rights, you can’t get any more local than community health centers.”
Photo by Alfreida Edwards