Nonprofit health-care providers served more low-income and vulnerable patients during the pandemic. Now they may have to cut staff and scale back services.

April 12, 2023

US community health centers for low-income and vulnerable people are bracing for a major hit to their resources that could force many to reduce staffing and scale back services as the federal government’s Covid-19 public health emergency ends in May.

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US community health centers for low-income and vulnerable people are bracing for a major hit to their resources that could force many to reduce staffing and scale back services as the federal government’s Covid-19 public health emergency ends in May.

These nonprofit health-care providers served more patients than ever during the pandemic partly because of more coverage under Medicaid — government health insurance for low-income people — after the US declared a public health emergency in 2020.

But starting this spring, and as early as this month, between 5.3 million and 14.2 million Medicaid enrollees overall could eventually lose coverage if they are no longer eligible or face barriers re-enrolling, according to estimates from Kaiser Family Foundation. The anticipated “cliff” of the uninsured “is pretty significant. We’ve never been in this position before,” said Jennifer Tolbert, director of state health reform at KFF.

The drop-off would affect some of the most vulnerable people and further burden community providers that serve them. “These changes come as health centers are still reeling from the pandemic, a shortage of health-care workers and high rates of medical inflation,” warned the National Association of Community Health Centers (NACHC) last week in a new report.

International Community Health Services held pop-up clinics at the Seattle Betsuin Buddhist Temple to serve people who faced language or tech barriers in accessing Covid vaccines. Credit: International Community Health Services

NACHC found that 85% of community health centers surveyed will face financial and operational strain due to the unwinding of increased Medicaid coverage. Over half of centers expect to reduce staffing and scale back some services, according to the new survey, which included responses from 420 community health centers in 50 states polled between Jan. 24 and Feb. 17, 2023.

In 2021, 59% of community health center patients were insured by government programs like Medicaid or Medicare, and 20% were uninsured. That year, 1,400 centers across the US served over 30 million patients — up from about 28 million in 2018.

In California’s Bay Area, Asian Health Services serves 50,000 low-income and underserved patients in Alameda County. “The projected loss of 1 million Asian community members across our nation who may lose Medicaid coverage, and the implications locally, weighs heavy on our minds,” said Julia Liou, chief executive officer of AHS.

Across the US, Medicaid is expected to end for 4.8 million Latinos, 3.2 million African Americans, and 1 million Asian Americans and Pacific Islanders, according to a report from advocacy groups Unidos US, Families First and First Focus.

At the East Boston Neighborhood Health Center in Massachusetts, more than one-third of patients are covered by Medicaid. “The impact of potential interruptions to Medicaid coverage could be significant for the immigrant and Hispanic communities that EBNHC serves,” said a spokesperson.

Nationwide, community health centers are scrambling to reach out to patients and re-enroll them in Medicaid or other health insurance programs — a task that requires considerable resources.

In January 2020, the US federal government declared the Covid-19 pandemic a public health emergency, which led to more flexible health care policies and increased coverage under Medicaid. States were soon allowed to offer continuous enrollment in Medicaid. People could forego renewing coverage each year and avoid a bureaucratic process that can require extensive documentation.

Enrollment in Medicaid and the Children’s Health Insurance Program grew by 23.3 million to a record high of nearly 95 million from February 2020 through March 2023, KFF estimated.

This February, the US Health and Human Services department announced the Covid-19 public health emergency would finally end on May 11. In eight states, continuous Medicaid enrollment will stop as early as this month; then 15 states in May; and 28 states in June, according to KFF. 

The impact will vary from state to state, depending on regulations, communication efforts and staffing to help patients with applications. But outreach often falls to community health centers, which operate on thin margins.

Barriers might include Medicaid enrollees not receiving notices after moving, not understanding policy changes after three years of continuous enrollment or lacking documentation such as income statements during the pandemic.

An estimated 45% of people who will likely become disenrolled would still be eligible for Medicaid or other programs such as CHIP, said Tricia Brooks, research professor at Georgetown University’s Center for Children and Families. They might also be eligible for insurance through new employers or the health insurance marketplace under the Affordable Care Act.

In the NACHC survey, 28% of respondents estimated that at least 15% of their patients enrolled in Medicaid will lose coverage in coming months. Half said at least 10% of patients will lose coverage.

Disruptions in care could result in more severe disease that requires costlier treatments, visits to emergency rooms or hospital stays, said NACHC.

Community health centers would not turn away uninsured people, but serving them without funding from Medicaid or other sources would create more financial and operational strain.

Nationwide, the centers serve 1 in 11 people, including agricultural and migrant workers, public housing residents, seniors and people experiencing homelessness and low-income families in urban and rural areas. Some 65% of patients were racial and ethnic minorities and 90% had incomes below 200% of federal poverty level.

In NACHC’s survey, 75% of community health centers said increased funding for outreach would smooth Medicaid enrollment or transition to other coverage. Health centers are ramping up communication to patients with mailings, videos, social media virtual, in-person sessions and more, but resources are spread thin.

“Our teams have activated in-person outreach and texting while utilizing ethnic and social media platforms in-language such as WeChat,” said Liou of Asian Health Services.

In a tight national labor market, the health-care industry in particular is struggling with labor shortages and burnout. “Retention and recruitment is a challenge,” said Joe Dunn, senior vice president for public policy at NACHC. “There is a strain on the community health center system right now.”

Threats to Progress

During the pandemic, some community health centers made strides in serving marginalized communities through more Medicaid coverage as well as funding from Covid-19 relief programs. Now the outlook for hard-won gains is uncertain.

In the Seattle region, International Community Health Services reached more people through innovative means such as mobile vans and pop-up clinics. ICHS has been serving low-income people since 1973 when it launched to help neglected patients such as elderly Filipino and Chinese people with limited English. Today it serves nearly 30,000 people who need affordable health care, especially immigrants and refugees. 

ICHS has 11 clinics, but during the pandemic, it also set up vaccination sites in the community, at houses of worship, schools and ethnic supermarkets. Staff worked with grocery store owners to get employees vaccinated, in addition to customers. In 2021, ICHS administered some 36,000 Covid vaccinations, nearly 5,400 of them at pop-up clinics, said Sharissa Tjok, ICHS community access manager.

The health-care provider is trying to maintain inroads made during the pandemic, but with fewer resources, the outlook is unclear.

The nonprofit also reached new underserved communities during the pandemic. For instance, Muslim leaders asked ICHS to offer Covid-19 vaccination sites at mosques that serve Ethiopians in Redmond and Bothell, two Seattle suburbs. Staff implemented culturally appropriate approaches such as female staff wearing headscarves while vaccinating women separately from men. They also scheduled clinics around prayer times and addressed concerns about vaccinations during Ramadan fasting.

ICHS also connected with the hard-to-reach Pacific Islander community in Federal Way, outside Seattle. Staff held pop-up clinics in the parking lot of a local high school to answer questions, provide Covid-19 testing and vaccinations. “If you don’t go there, then people don’t feel comfortable. They need to trust you,” said Tjok.

During the pandemic, ICHS also vaccinated residents at a Buddhist temple across from a Japanese-American low-income senior housing building. But by last year, funding for that mobile team ended. Many seniors who wanted another booster were left waiting, said Tjok. 

“If we don’t have outreach, I don’t think they can get vaccinated,” said Tjok of vulnerable people. “Seniors don’t have internet. People don’t know how to use computers. There are still so many barriers.”

https://www.bloomberg.com/news/articles/2023-04-12/as-millions-face-loss-of-medicaid-community-health-centers-strained