Community health centers were supposed to be one of the key vehicles to get low-income patients care under the Affordable Care Act. So why are North Carolina’s health center leaders worried as the law moves forward?
By Rose Hoban
Brian Toomey is worried.
Toomey runs Piedmont Health Services, a network of community health clinics serving eight counties in the center of the state. More than half of the patients who visit Piedmont’s six clinics lack any form of health insurance, including Medicaid.
So you might think that Toomey would be sleeping better now that it’s clear that, in the wake of President Obama’s reelection, the Affordable Care Act will proceed. Once the law goes into effect, many of Toomey’s patients could either gain Medicaid or some form of insurance coverage, making it easier for Piedmont to cover its costs.
But Toomey said his relief at knowing the law will go forward is tempered by a multitude of questions still remaining about the implementation of health reform in North Carolina.
“Now there will be other forks in the road,” said Toomey, who’s wary of upcoming budget battles in Washington and Raleigh.
Funding for community health clinics had gained bipartisan support in the past decade – the largest expansion of the clinics took place during George W. Bush’s administration – and politicians on both sides of the aisle in Congress have championed them.
But when Democrats included the clinics as an integral part of expanding access to care under the Affordable Care Act, the clinics’ Republican allies in Congress were no longer answering phone calls from people like Toomey, who is also the board chairman for the North Carolina Community Health Center Association.
“We can take care of a person for an entire year for less than half the cost of one emergency room visit,” said Toomey. “For 45 years, community health clinics have been the most cost-effective way to deliver care to millions. … Why don’t you believe us now that we can make a difference?”
In 2011, Congress cut $600 million per year for community health clinics from the federal budget. To make up for the loss, federal health officials shifted dollars from a trust fund that had been established to build new community health clinics needed for the huge influx of newly insured patients once the Affordable Care Act is fully implemented in 2014.
Community health centers were thereby spared pain in the short run, but removing that trust fund money means fewer dollars to build new community health clinics in time for full implementation. And that trust fund money will run out in 2015, removing whatever other cushion exists (see www.kff.org/uninsured/upload/8098-02.pdf).
“It was one of the ways that folks who didn’t like the ACA could chip at it,” said Ben Money, executive director of the North Carolina Community Health Center Association. “Taking away base funding and taking from the trust fund limits growth.”
Growth slower than hoped
Even if the Affordable Care Act is fully implemented, there will still be uninsured North Carolinians.
Right now, there are at least 1.5 million uninsured in North Carolina, according to estimates by the N.C. Institute of Medicine. In 2014, the first year of implementation, up to 800,000 of those people could end up with coverage through subsidized health insurance from the health benefits exchange and from Medicaid, should the state decide to expand it.
But lawmakers have been mostly quiet about whether they plan to expand Medicaid.
“If the state elects not to participate in the Medicaid expansion, there’s a huge gap,” said Money. “Childless adults that would have coverage under Medicaid through the expansion would not be eligible. And they won’t be able to buy into subsidized insurance in the health benefit exchange.”
Even if lawmakers do expand Medicaid, that still leaves several hundred thousand people in North Carolina lacking insurance. And many of those people will end up in community health centers looking for care.
“The understanding was that the community health center expansion was designed to create greater accessibly for primary care for these individuals,” said Money.
North Carolina has a lower rate of low-income and uninsured served by community health centers than in many other states, such as West Virginia, Maine and Montana, but Money and others want that to change. The state received $11.4 million in federal grants this past spring to start expanding community health center capacity around the state. Of that, $2.2 million went to repairs and upgrades on existing clinics and $9.2 million for new centers.
Southside United Health and Wellness Center in Winston-Salem recently received status as a federally qualified health center (FQHC), allowing it to tap into some of those federal dollars and get slightly better Medicaid reimbursement to cover the cost of uninsured patients.
“Prior to Southside getting status, the Triad was the largest metropolitan statistical area in the country without a [FQHC-designated] community health clinic,” said Toomey. Now Greensboro is the largest metropolitan area in the country without one.
Before Congress cut funding for community health centers in 2011, North Carolina submitted 30 applications to create new clinics or convert others to the federally qualified status.
One of those applicants, Triad Adult and Pediatric Medicine – a group of six clinics in Guilford County – was turned down by federal officials for FQHC status.
“It would be wonderful to get FQHC designation,” said Brian Ellerby, head of Triad. “It’s not so much about getting the $650,000 base grant [that comes with FQHC status], it’s about the other federal funding that we could apply for if we got the FQHC.”
Ellerby’s organization had more than 90,000 visits last year, a third of which were by people who had no insurance. He said that those patients came to his clinics when they needed care instead of going to local emergency departments. That saved the local health-care system tens of millions of dollars, he said, at a cost of about $5.4 million to Triad.
“I’m frustrated because I know that there’s so much more that we could do if we had the funding,” Ellerby said. “But now we’re caught up in the financial affairs that are affecting the rest of the country; the fed is now looking at cutting funding. We don’t know how much funding is going to be set aside for new access points like ours.”
Other community health centers are being planned in rural areas, including near Boone and Bakersville, and in the more densely populated areas of Concord, Rocky Mount and Gastonia.
But that’s probably not enough to cover the need.
Pump up the volume
Kim Schwartz, executive director of the Roanoke Chowan Community Health Center in Ahoskie, spent the week before Christmas moving her clinic from its old digs into a new building.
“For us, the biggest thing is that we received from the Affordable Care Act $2 million for capitol improvements,” said Schwartz, whose clinic used to have three sites, including a drafty old trailer that had two exam rooms to accommodate one part-time nurse practitioner.
“Now we can house a full-time and two part-time nurse practitioners in five exam rooms,” Schwartz said, “and we could have more just at that site, it’s so busy.” The clinic had more than 46,000 patient encounters last year.
The ACA money allowed Schwartz to pay for the new building and will pay for upgrades on her old main clinic, more than 45 years old.
“I can roll that $90,000 a year I was paying in leases back into the program. For a community health center this size and for what we’re doing, that’s a big deal,” she said.
Roanoke Chowan sees 80 percent of the patients in the four-county area around Ahoskie. But Schwartz said her volume will grow more with implementation of the health reform law.
“When you realize that almost everyone should have some kind of coverage under the law, the challenge is going to be about helping people accessing their coverage,” she said.
Schwartz is worried that even with everybody having some form of insurance, there still will be holes in their coverage, such as dental and mental health. Her clinic has a telehealth program that monitors remotely about 100 patients with diabetes and high blood pressure.
“I still don’t have a funding stream for that,” she said, “and I don’t see that changing. But we have to do these kinds of things to manage the volume of people who are coming on board.”
Schwartz said she’s been working with private foundation funders to help them understand that the need for grants won’t go away with the new law.
“We have a 1 percent margin, and no reserves.” Schwartz said. “And we’re small. That’s what most community health centers look like; we don’t have a lot in reserve to fall back on.”
She said that funders believe community health centers won’t need as much funding five years from now, but that that’s not true.
I’ll still need to find grant funding to cover things like dental and mental health and telehealth,” she said.