How Are CHCs Faring?
To better understand the experience of CHCs in this post-ACA environment, my colleagues and I conducted a nationwide survey of CHCs and analyzed program data submitted by all CHCs.9 Our results underscore the critical role CHCs are playing in helping the uninsured apply for and get coverage: more than 80 percent of CHCs said they provided Medicaid application assistance during the first open enrollment period, and 90 percent reported providing application assistance for health plans in the exchanges. Recent data from HRSA confirm that CHCs have continued their outreach and enrollment efforts, providing assistance to over 17 million people since ACA enrollments began.10We also found substantial benefits to CHCs from the ACA Medicaid expansion. In the first year of the coverage expansions, for example, the share of CHC patients with Medicaid coverage increased from 44 to 53 percent for CHCs in Medicaid expansion states while remaining almost unchanged for CHCs in non-expansion states (Figure 1). Importantly, these latter clinics were already at a disadvantage due to their states having less generous Medicaid coverage for childless adults, and the gap has grown significantly wider as the expansion states have further improved their coverage of this population. Additionally, reflecting the benefits of new revenue from insured patients, we found that CHCs in Medicaid expansion states were significantly more likely than clinics in non-expansion states to report improved capacity to provide dental and mental health care.
CHCs in expansion states also experienced a commensurate drop in the share of patients without insurance. Despite the gains in coverage, however, the CHC patient population still looks very different from the nation overall. Namely, CHCs continue to serve a significantly disproportionate share of uninsured and Medicaid patients and a much smaller share of patients with private coverage.
Propelled forward by the Affordable Care Act, CHCs are making a major difference in expanding coverage and access to comprehensive primary care in many of the nation’s poorest communities. However, these providers continue to face major challenges in serving a patient population that is not only much more likely to be uninsured but also at higher risk for more complex health and social problems than seen in other primary practice settings. Sustained and even enhanced support is needed to help them fulfill their mission.
Currently, federal grants cover only about a fifth of CHCs’ operating costs, and several of the major federal funding streams are promised only through 2017. These funds are a critical supplement to the reimbursements received from third-party payers and the modest fees paid by patients, allowing CHCs to serve uninsured patients, provide the enhanced services important to low-income patients, and perform needed outreach and enrollment. The funding also helps CHCs to reduce the cost-sharing burden faced by privately insured patients who cannot afford their out-of-pocket costs for covered services—a contribution that will be even more important if the Administration loses its appeal of the House of Representatives v. Burwell decision determining that funds for the ACA cost-sharing subsidies were not properly appropriated. As a new Administration and Congress make budgeting and appropriation decisions in the coming year, it will be important to consider the evidence showing the many ways CHCs are serving the most needy patients among us.
Future state decisions about Medicaid expansion will also weigh heavily on CHCs. The much larger coverage gains we documented for CHCs in Medicaid expansion states, combined with the improvements in their capacity to provide mental health and dental care, highlight the importance of motivating the 19 non-expansion states to reconsider that choice. Millions of low-income, non-elderly people have fallen into a “coverage gap” in these states. CHCs and other safety net health care providers are crucial for these patients but will continue to struggle to meet their needs without Medicaid expansion. One can only hope that future decisions about state Medicaid programs will be motivated less by politics and more by objective assessments of the benefits to population and community health, which our findings show are substantial through CHCs.