A Profile of Community Health Center Patients: Implications for Policy
The findings of this analysis point to two important sets of implications stemming from the ACA. The first has to do with the impact of health reform – primarily, the Medicaid expansion – on current health center patients and operations. The second concerns potential changes in the profile of the patients who seek care from health centers and potential resulting changes in health centers’ activities and role in the health care system.
Impact of coverage expansions on current health center patients and operations.The ACA is expected to significantly expand health coverage among current health center patients. A recent study estimates that approximately 4 million uninsured health center patients will gain coverage in 2014 through the Medicaid expansion and the new Marketplaces.1 In the 26 states (including DC) moving forward with the expansion, an estimated 2.8 million uninsured health center patients will gain coverage, of whom roughly 1.2 million will gain Medicaid. In the 25 states that, as of October 2013, were not moving forward with the expansion, about 1.2 million uninsured health center patients will gain coverage through the Marketplaces. However, over 1 million health center patients who could have gained Medicaid will remain uninsured.
State decisions on the Medicaid expansion have implications not only for health center patients but also for health center operations, because increased insurance coverage will generate new third-party revenues that health centers need to expand and improve care. The same study mentioned above estimates that health centers in the states expanding Medicaid will see $900 million more in patient revenues than they would have had they elected not to expand Medicaid. By the same token, health centers in the states not moving forward will miss out on an estimated $555 million in Medicaid revenues in 2014 – about half of the total $1.2 billion in new patient revenues that they could have generated if their states had opted in favor of the expansion.
An important positive implication of expanded coverage is that patients will join health plans that offer provider networks and formal referral arrangements that should improve their access to specialist care that is not furnished directly by health centers. Several factors currently contribute to health centers’ struggle to secure referrals.2 The first is their location in medically underserved communities, where the number of specialists is limited. A second factor is the slow development of formal affiliation agreements between health centers and specialty care practices and institutions.3 A third factor may be the fact that health centers must guarantee that all their patients, not only the insured ones, have access to specialty referrals; this requirement may reduce specialists’ willingness to enter referral arrangements if they seek to avoid a high volume of uncompensated cases. Even as health center patients gain insurance and plan membership under the ACA, travel time and distance to providers may continue to pose obstacles to access. In many communities, health centers are seeking to overcome travel and financial barriers through telemedicine arrangements with specialists. However, whether insurers will cover telemedicine consultations remains to be seen.
Health center patients are at higher risk for social and behavioral as well as health problems. To serve these patients effectively, the health care system, including health centers, must function at a higher level and on a broader set of fronts than the clinical health care front alone. A number of new demonstration programs and funding opportunities under the ACA are ushering in important system changes that have the potential to improve care for health center patients. In particular, increased funding for health centers provides support for expanded services, such as behavioral health care and dental care. Further, a new ACA demonstration program to test the patient-centered medical home (PCMH) model in health centers offers promise as a path to addressing patient needs more comprehensively. More than 500 health centers are participating in this program. Going forward, a key challenge will be to ensure that public and private insurers incorporate into their payment systems the financial support needed to sustain the PCMH model, which requires not only excellent clinical practice, but also greater patient engagement efforts, including the development of strong provider-patient relationships, investment in care management, ongoing communication, increased time, health education and patient supports, and the use of health information technology.
Health centers in the states not moving forward with the Medicaid expansion, and even in the states that do expand Medicaid, will continue to serve a large share of uninsured people and will need ongoing grant funding to treat these patients. They will also need grant support to cover the costs they absorb for insured patients who are unable to afford their cost-sharing amounts. In addition, they will have to bear the costs of non-covered services (e.g., adult dental care) and services for insured patients who hit their treatment limits (e.g., an annual maximum number of mental health visits). Further, despite the relative breadth of the essential health benefits, they are unlikely to include the array of health supports needed by low-income adult health center patients, such as health education and transportation, or social services, such as assistance with enrolling in and renewing their insurance. In Massachusetts, where health centers are in their sixth year of operating in a health reform environment, grant funding remains essential to program operations. Federal grant funding comprised approximately 18.3% of Massachusetts health center revenues in 2011, defraying the costs of serving both uninsured patients and uninsured clinical and health support services.4
ACA impact on the profile of patients that health centers will serve. The ACA will expand coverage not only among current health center patients, but also among the broader communities that health centers serve. As adults gain coverage, they can be expected to seek care, and in medically underserved communities (where uninsured adults disproportionately reside), the quest for care can be expected to further heighten the need for health center resources. An immediate after-effect of health reform in Massachusetts was a surge in the demand for primary care from health centers.5 Over the 2007-2011 time period, the number of patients served by health centers in Massachusetts grew by 6%, from 123,388 to 131,141. The growth was fueled by both insured and uninsured patients, as more insured people sought care and as more uninsured people turned to health centers as other sources of care for the uninsured shrank.
What will the new health center patients be like? Presumably, some will be similar to those who currently use health centers – very poor and confronting serious health risks and conditions. But many can be expected to be younger, healthier, and less impoverished men and women seeking primary health care that, for the first time, they can afford. Many health centers have established clinical sites on community college campuses and in other locations accessible to lower-income younger workers and their families. Given the possible shift in the demographic profile of the health center population under the ACA, current repositioning by health centers, to serve healthy individuals and families as well as patients with significant health needs, seems likely to continue, reshaping health centers’ role. In addition to increasing their capacity to manage chronic conditions, they may focus on building strong adult preventive services, including wellness programs, women’s preventive services, the full complement of adult immunization services, and other clinical services aimed at keeping adults healthy and active. This increased emphasis on prevention might also, in many communities, lead to partnerships between health centers and employers to offer worksite and community wellness activities that may reduce downstream health care costs and expand the role of health centers in advancing community health.
Additional support for this paper was provided by the RCHN Community Health Foundation.