Washington Gov. Jay Inslee had originally planned to visit a community health center in Seattle this week to promote Cascade Care, the first statewide public insurance option in the United States. The health center, International Community Health Services, offers care in multiple languages and is treating more uninsured people than usual, thanks in part to the Trump administration’s attacks on immigrants and refugees. Cascade Care will provide more Washington residents with health coverage and allow the clinic to recoup revenue.
However, an outbreak of COVID-19, the disease caused by the novel coronavirus that has created a global panic, changed the governor’s plans to visit the clinic. Inslee declared a statewide emergency over the weekend. At least 39 confirmed cases of COVID-19 and 10 deaths from the disease have been reported in the Seattle area and other parts of the state.
On Tuesday, Inslee met privately with state health officials and International Community Health Services staff to discuss the public health response to COVID-19. Publicly, he congratulated the federally funded clinic for ramping up efforts to contain COVID-19 infections — on top of providing health care to 31,000 people who may otherwise struggle to access it. Beyond Seattle, the National Association of Community Health Centers (NACHC) is coordinating with the Centers for Disease Control’s Coronavirus Response Task Force to provide the latest information needed by local providers.
“With any public health challenge, whether it be the novel coronavirus or H1N1 or even Ebola a few years ago, community health centers are uniquely positioned because they have the existing relationships with community stakeholders and a framework to communicate important information to the community at large,” said NACHC spokeswoman Amy Simmons Farber in an interview.
Although community health centers are among the nation’s first responders during an outbreak of disease, clinics nationwide are currently staring over a fiscal cliff. On May 22, a stopgap measure temporarily extending federal funding for community health centers expires. If lawmakers do not act before this deadline, crucial public health services could disappear during an outbreak of a potentially deadly disease.
In 2010, legislation added to the Affordable Care Act (ACA) by Sen. Bernie Sanders established a fund that provides about 72 percent of funding for thousands of community health centers nationwide, and lawmakers have since voted to renew and expand the fund twice. While community health centers open their doors to everyone regardless of health coverage, they have a long history of serving patients covered by Medicaid, the government insurance program for lower-income people that was expanded under the ACA.
In the first seven years after the ACA became law, the number of health centers increased by 59 percent nationally, bringing much-needed services to rural and lower-income areas as an opioid overdose epidemic swept the country. During that time, the share of health centers offering mental health services grew by 22 percent and the number offering substance abuse treatment grew by 75 percent, according to the Kaiser Family Foundation.
Unless Congress votes to extend the community health center fund once more, community health centers across the country could collectively lose billions of dollars in federal support, forcing clinics to scale down services, lay off staff and even close their doors. In 2018, lawmakers extended funding for two years. In December, lawmakers signed off on a last-minute, five-month temporary extension that left health care providers anxious well before coronavirus began making alarming international headlines.
“We are especially concerned that at a time of escalating health care costs and decreasing access to primary care for millions of Americans, Congress failed to prioritize the funding of programs that have a proven track record of success in expanding access to primary care,” wrote John Cullen, chair of the American Academy of Family Physicians, in a letter to congressional leaders last month. “Because of this record of success, Congress has relied on each of these programs to tackle the tough public health issues of our time — opioid addiction, HIV/AIDs, maternal mortality, care for rural and underserved populations, caring for veterans and natural disasters.”
Fiscal uncertainty has long been a problem for community health clinics. Unstable funding makes it difficult for clinics to recruit providers, plan services and expand capacity when a robust public health response is needed to address challenges like the current outbreak of coronavirus, according to NACHC. Last year, a survey found that more than half of community health clinics were considering a hiring freeze due to funding uncertainty, and one-third were considering reducing their hours of operation.
This time, advocates are asking Congress to extend the community health center fund for at least five years and expand funding to pay for enhanced medical training programs and public health services. Along with other members of Congress, Sanders and Sen. Elizabeth Warren have pushed legislation that would do just that.
Community health centers are also known as Federally Qualified Health Centers, because they must meet certain standards to qualify for federal funds. For example, at least 51 percent of the membership of a federally qualified clinic’s governing board must be patients and local stakeholders. Community health clinics are often designed to serve lower-income patients and located in rural or urban areas with a dearth of quality providers, filling critical gaps in the nation’s health care system.
“Community health centers have a longstanding history of being trusted community providers,” Simmons Farber said.
This localized system has been expanding for decades, and today federally qualified community health centers serve 29 million patients at 11,000 locations across the country. Each clinic is individually tailored to the community it serves. For example, International Community Health Services staffs providers who speak Mandarin, Cantonese, and other languages spoken in Seattle’s Asian and immigrant communities. Your faithful reporter receives his primary care at a community health clinic in New Orleans founded by a pro-LGBTQ organization combating high rates of HIV.
“No two communities look alike, and community health centers are all different,” Simmons Farber said. “They reflect the community that they serve because they are built from the bottom up and are run by governing-boards with a 51 percent patient majority.”
Coronavirus is not the only public health challenge addressed by community health clinics. For the past decade, rates of liver disease have been on the rise despite new treatments for hepatitis C, according to Robert G. Gish, a liver expert who founded a liver care program at a community health center in San Diego. The opioid crisis caused an uptick in new hepatitis C infections, and heavy alcohol use among young people is also a factor. However, nonalcoholic fatty liver disease and a related condition called nonalcoholic steatohepatitis or NASH remain the most widespread liver health challenge.
“NASH and fatty liver disease [are] expanding rapidly due to the obesity epidemic and the population getting older,” Gish said in an interview.
Community health centers are designed for medically underserved populations, and about half of their adult patients seek treatment for diabetes, hypertension, obesity, and other chronic conditions linked to liver disease. Gish said community health centers screen all patients for liver issues, and those at risk of liver disease are tested regularly. The community health system is also expanding use of FibroScan, an ultrasound machine that quickly identifies liver damage.
By catching liver problems early, patients can start treatments and make lifestyle changes that will improve both their quality of life and lifespan, Gish said. This reduces the chance that patients will suffer from chronic diseases like cancer later in life.
“It’s an incredible motivational force for the patients to realize that they are in control of their lives, they are in control of their quality of life, they are in control of their life span,” Gish said.
Screening for health problems early is known as “preventative” health care, which lower-income and marginalized patients often go without when care is not accessible. Making health care accessible saves lives — and a whole lot of money. By signing patients up for Medicaid and providing a range of culturally and linguistically accessible health services under one roof, community health centers prevent traditionally underserved patients from filling hospitals and emergency rooms. In 2016, a landmark study found that care provided by community health centers reduced spending on Medicaid patients by 24 percent.
These savings are one reason lawmakers in both parties have supported community health centers in the past. Keeping the clinics in their home districts open and expanding their services is also a concrete deliverable to constituents, particularly for lawmakers representing rural and lower-income communities.
However, the Trump administration and congressional Republicans have consistently worked to destroy the ACA, push people off their Medicaid coverage and reduce the community health program’s funding. Most recently, President Trump proposed slashing federal health spending by $1 trillion over the next decade. Allowing funding for community health clinics to expire during a coronavirus outbreak would be political suicide for Congress, but whether lawmakers in the Republican-controlled Senate will commit to extending and expanding funding for clinics on the front lines of public health remains an open question as the May 22 deadline approaches.