Treating people for free or for very little money has been the role of community health centers across the U.S. for decades. In 2015, Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were .
The community clinics 鈥斅爊ow 鈥 have also expanded in recent years to serve people who gained insurance under the Affordable Care Act. In 2015, community health centers served 24.3 million people 鈥 up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities and they meet the criteria to be a . That means they can qualify for federal grants and a higher payment rate from Medicaid and Medicare.
The ACA was a game changer for these clinics 鈥斅爄t has enabled them to get reimbursement for much more of the care they provided, because more of their patients now had private insurance or were on Medicaid. Revenue at many clinics went up overall, and many of the health centers used federal funding available under the law to expand their physical facilities and add more services, such as dentistry, urgent care or mental health care.
With repeal of the ACA looming, clinic directors said聽they stay up at night wondering what鈥檚 next. We spoke with four, who all say their clinics are in a holding pattern as Congress debates the health law鈥檚 future.
Saban Community Clinic, Los Angeles
Julie Hudman, the CEO of in Los Angeles, Calif., said there鈥檚 a lot at stake for her patients.
鈥淎 lot of the folks that we see are single adults,鈥 she explained. 鈥淭hey鈥檙e maybe more transitional. They鈥檙e homeless patients. They have behavioral health challenges. They鈥檙e really, to be honest, some of the most vulnerable and poorest patients of all.鈥
Before the ACA went into effect, eligibility for Medi-Cal, as Medicaid is known in California, depended on a variety of factors, including income, household size, family status, disability and others. Under Obamacare, according to the California Department of Health Care Services, people can now qualify for Medi-Cal on the basis of income alone if their household makes less than 138 percent of the federal poverty level 鈥 that鈥檚 $16,395 for an individual and $33,534 for a family of four.
Prior the ACA, about half of the Saban clinic鈥檚 18,000 patients were uninsured, Hudman said. They paid little for treatment 鈥斅爉aybe a copay of $5 or $10. Almost all of those patients qualified for Medi-Cal after the health law expanded eligibility, she said, and that鈥檚 made a big difference for the clinic鈥檚 bottom line: Medi-Cal pays the clinic around $200 per patient visit.
These days, more than half of Saban鈥檚 revenue comes from health insurance. The possibility of losing some of that money, Hudman said, is forcing some hard decisions. She had been looking to lease or buy a fourth facility, she said, but now that plan is on hold; as are her hopes of expanding free help for the homeless.
鈥淚鈥檓 not willing to move forward and take some of those risks,鈥 she said. 鈥淚 need to make sure that we鈥檙e able to pay our bills and pay our staff.鈥
Before the last election, Hudman said, 鈥渨e had a lot of momentum moving forward. And now we鈥檝e just sort of stalled.鈥 鈥 , KPCC, Los Angeles
Jordan Health, Rochester, N.Y.
In the last few years, funding has been on the rise at , in Rochester, N.Y., and so has the extent of the clinic鈥檚 services.
The boost in funding has partly come from higher reimbursement rates the ACA authorizes, and from the increased number of patients at the clinic who have insurance. But Jordan Health, which has 10 locations in the area, has also benefited from the federal government鈥檚 pumping of into what are known as that enable expansion of services and facilities.
Janice Harbin, CEO of聽Jordan Health in Rochester, N.Y. says section 330 grants have allowed Jordan Health to hire more health practitioners. (Karen Shakerdge/WXXI)
The 330 grant money gives qualified clinics the option of offering services that aren鈥檛 billable to insurance plans. At Jordan Health, the funds enabled the hiring of some different types of health practitioners who were not previously part of the team 鈥 dietitians, behavioral health specialists and care coordinators. And that, in turn, said Janice Harbin, president and CEO of Jordan Health, means patients can increasingly get the different kinds of care they need in one place.
Almost 90 percent of Jordan鈥檚 patients are considered a racial or ethnic minority, and over 97 percent live at or below 200 percent of the federal poverty line, according to by the federal Health Resources & Services Administration.
鈥淲hen you鈥檙e dealing with a situation of concentrated poverty,鈥 Harbin said, 鈥測our patient needs more than just 鈥極K, let me give you a checkup, and pat you on the back and say now go out and do all these things I told you to do.鈥欌
Jordan Health received an increase of about $1 million since 2013,聽according to its grant coordinator, Deborah Tschappat.
Tschappat said she expects Jordan will get about the same annual award in 2017, assuming federal funding for the 330 program stays about the same. If federal funding is cut significantly, they would potentially lose some services.
For now, Jordan Health plans to 鈥渆xpand services judiciously, while increasing efficiency and productivity,鈥 Tschappat said.
In the coming months Harbin and her colleagues lawmakers in Albany and Washington, D.C., to renew Jordan鈥檚 funding 鈥 including the 330 grant, which is set to end in September.
鈥淲e鈥檙e used to doing a lot with a little, but we increasingly know that we do need to have financial support,鈥 Harban said. 鈥淎nd that鈥檚 keeping us up at night.鈥 鈥 , WXXI, Rochester
Adelante Healthcare, Phoenix
has been part of the health safety net in Phoenix for nearly four decades 鈥 when its doctors began helping farm workers in the city鈥檚 surrounding fields. But the Affordable Care Act enabled Adelante to expand like a brand new business.
鈥淎delante has grown by 35 percent in the last 12 months,鈥 said Dr. Robert Babyar, Adelante鈥檚 assistant chief medical officer. 鈥淲e鈥檝e increased our provider staffing 鈥 almost doubled our providers. And the number of services we provide has doubled.鈥
Adelante operates nine clinics throughout the Phoenix metro area. The one where Babyar met with me includes play areas for children and a dental office.
Most of their 70,000 patients are low-income and about half are covered by either Medicaid or KidsCare 鈥 Arizona鈥檚 version of the Children Health Insurance Program. In 2014, Arizona became one of the Republican-led states that expanded Medicaid under the ACA. That brought more than 400,000 people onto the state鈥檚 Medicaid rolls and created big demand for Adelante. Low-income patients who did not have insurance before the expansion had relied on Adelante鈥檚 sliding fee schedule. Much of that population now has health coverage, either through the ACA marketplace or the state.
鈥淭hat opened up more options for our patients, more specialists they could see, procedures they could have done,鈥 Babyar said.
As Congress moves to repeal and replace the health care law, Adelante is in a holding pattern. It has delayed the groundbreaking of a new site until later this year because of the uncertainty. A full repeal of the ACA 鈥斅爓ithout a replacement that keeps its patients covered 鈥斅爓ould limit any future growth, and strain the new staff and resources it has added. It wouldn鈥檛 be the first time Adelante had to scale back its services because of changes to Medicaid. In 2010 and 2011, Arizona lawmakers froze enrollment for its CHIP program and for childless adults in聽Medicaid. Then, in 2012, Adelante lost more than a million dollars.
Babyar said it has taken several years to get their new patients into the system and working with doctors consistently to manage their conditions.
鈥淎ll the progress we made with those patients to stay and be healthy 鈥 that can fall apart really quick,鈥 said Babyar. 鈥 , KJZZ, Phoenix
Denver Health, Denver
顿别苍惫别谤鈥檚 is part of 鈥 the safety-net system that takes care of low-income people.
鈥淒efinitely this clinic has benefited from Obamacare,鈥 said聽, who practices family medicine for Denver Health and helps lead the clinic. 鈥淎nd this population has benefited from Obamacare by the expansion of Medicaid.鈥
That鈥檚 what helped make the economics work as Denver Health put a new $26 million clinic in a high poverty neighborhood in 2016, said聽, Denver Health鈥檚 CEO of Community Health Services. With the ACA in place, he said, the health system was able to count on the new clinic having a population of paying patients with insurance that could help support it.
Hambidge predicted the hospital will weather the storm if Obamacare is repealed and there are to safety-net programs, like Medicaid and Medicare, as some Republicans have suggested. But it will probably be harder to open new clinics in other high-need neighborhoods, he conceded.
鈥淲e鈥檒l survive,鈥 Hambidge said. 鈥淲e may not be able to be as expansive, because we would be back to less secure times.鈥 鈥 , Colorado Public Radio
This story is part of NPR鈥檚 reporting partnership with local member stations and Kaiser Health News.