Community Health Centers in a Time of Change: Results from an Annual Survey

With health centers playing an important role in the response to the coronavirus pandemic, findings from the KFF/Geiger Gibson 2019 Community Health Center Survey provide important information on health centers’ financial situation and their experiences in a changing policy environment. After years of growth following implementation of the Affordable Care Act (ACA), changes in Medicaid, public charge, and Title X family planning policies, among others, carry important implications for low-income patients as well as health center operations and revenue. While, overall, health center patient growth and revenue remain strong, some health centers had begun to feel the effects of these changes as they were being implemented across the nation. Federal legislation has directed additional resources to health centers in the wake of the current pandemic, but it is unclear what effect the current public health crisis will have on health centers. Findings from the survey include:

• Continuing trends following the ACA, most health centers reported patient coverage and patient care revenue remained stable or improved. One-third of health centers reported an increase in Medicaid patients, while 45% said the number had stayed the same in the past year. Similarly, three in ten health centers reported an increase in Medicaid revenue while nearly half reported no change.
• However, a growing share of health centers reported coverage and affordability challenges for their Medicaid and privately insured patients. One in five health centers (22%) reported that the number of Medicaid patients served has declined in the past year, and 44% saw an increase in the share of Medicaid/CHIP patients with a lapse in coverage. Nearly half (49%) reported an increase in the share of privately insured patients paying sliding scale fees in the past year in lieu of deductibles and other cost sharing required by their private plan, in effect forgoing use of their insurance. Mirroring the share of health centers reporting a decline in Medicaid patients, 23% reported a Medicaid revenue decrease in the past year, up from 15% in 2018.
• There is a great deal of confusion among health center staff about the status of Medicaid work requirement waivers—most of which are on hold pending legal challenges—and health centers perceive many barriers to work and to reporting work activity for their patients. One in five respondents in states with an approved or pending waiver incorrectly identified the status of the state’s waiver or indicated that they did not know if the state had or was considering a waiver. Perceived barriers to work for patients who are not currently working included caring for family members, lack of transportation, mental health or substance use conditions, and lack of skills and education, among others.
• Health centers reported limited capacity to expand family planning services as the Title X family planning program’s provider network constricts. Over three-quarters (77%) of health centers said they could increase the number of new family planning patients served by no more than 24%.
• The top three challenges facing health centers were workforce recruitment, increasing costs to operate the health center, and inadequate physical space. Health centers in non-expansion states also cited the high number of uninsured patients as a top challenge.

Introduction

Health centers are a significant source of care for low-income, medically underserved communities. They also serve as an essential part of the health care system’s response to public health emergencies and other disasters. They are playing an important role in responding to the current COVID-19 pandemic by providing COVID-19 testing as well as continuing to treat ongoing health needs of their patients. Federal legislation has provided emergency funding to support their response. Health centers experienced significant growth in service sites and patient care capacity following implementation of the ACA, which positions them well to respond to the current crisis; however, leading up to the current crisis, they had been facing more headwinds in their ability to serve patients because of recent federal policy changes.

As key providers of comprehensive primary care services in communities whose residents are more likely to experience poverty and its health effects, along with a shortage of accessible primary health care, health centers feel the effects of policies that limit benefits and services to low-income populations. As a result, changes to federal programs that provide health coverage and promote access to health care services for low-income populations can be expected to have a significant impact on health center patients and operations. Some of the policy changes that are having the biggest effects include: federal support for states interested in testing large-scale Medicaid eligibility and enrollment restrictions such as work requirements, premiums, and other policies; changes to “public charge” policies that expand the programs that can trigger public charge determinations for legal immigrants seeking to adjust to permanent legal status; and new constraints on providers that participate in the Title X family planning program.

This brief presents findings from the 2019 KFF/Geiger Gibson Community Health Center Survey on the experience of health centers in a changing policy environment. This survey was conducted before the current coronavirus crisis, and focused on changes in health center patient coverage and operations during the past year, as well as health centers’ experiences with Medicaid work requirements, and their responses to changes in the Title X program. Where appropriate, the brief also highlights differences in findings across health centers in Medicaid expansion and non-expansion states and those located in urban versus rural areas. The effects of the new public charge policy were described in an earlier brief.¹ While the findings do not relate specifically to the coronavirus pandemic, they provide important context for understanding the issues facing community health centers prior to the current crisis.