New report examines impact of health reform on community health centers and patients

A new report by the Geiger Gibson/RCHN Community Health Foundation Research Collaborative at the George Washington University School of Public Health and Health Services (SPHHS) examines the impact of health reform on community health centers (CHCs) and their patients. "Assessing the Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-by-State Analysis," estimates that more than 5 million health center patients would have gained coverage had all states participated in a sweeping Medicaid expansion. However, nearly half of all CHCs are located in states that have opted out of the expansion. As a result, more than a million uninsured CHC patients who would have been covered under a nationwide Medicaid expansion will be left without the protection of health insurance, the report says.

"Our analysis shows that if you are poor and live in one of the 25 opt-out states, you are likely to have been left out when it comes to health reform," says lead author Peter Shin, PhD, MPH, director of the Geiger Gibson Program in Community Health Policy and an associate professor of health policy at SPHHS. "Community health centers in the opt-out states will be faced with waiting rooms filled with uninsured patients, many with serious and costly health problems."

The nation's 1,128 CHCs form the core of the nation's safety net, providing comprehensive care in 8,000 medically underserved urban and rural communities. The new report uses survey data to estimate the number of CHC patients who would gain coverage under the Affordable Care Act (ACA) and a key part of the law--the adult Medicaid expansion. Last year's Supreme Court ruling upheld the ACA but allowed states to choose whether to participate in the Medicaid expansion. To date, 25 states, many of which are southern states, have rejected the Medicaid expansion. Of the health center patients denied expansion coverage, 72 percent live in a southern state.

Shin and his colleagues analyzed data from both the 2009 Health Center User Survey and the 2011 Uniform Data System to gauge the impact of the ACA on health center patients nationally and in all 50 states and the District of Columbia. Based on conservative assumptions, the analysis showed that over one million health center patients in the opt-out states who would have gained Medicaid coverage under an expansion will likely remain without insurance. These patients are very poor but do not qualify for the traditional Medicaid program and often cannot pay for health care - even at reduced fees, the study concludes. Ironically, these patients are also too poor to qualify for subsidies that would allow them to purchase health insurance at reduced rates on the new Health Insurance Exchanges.

The bottom line for the 518 health centers located in the opt-out states: the report says they'll forgo approximately $555 million they would have received had their states expanded Medicaid, yet by law, they will still be treating all community residents, including those who lack health insurance or the means to pay for care.

"Health centers in the opt-out states will face an ongoing struggle to meet the need for care in medically underserved communities as a result of the potential loss of hundreds of millions of dollars in revenues in 2014 alone," said Sara Rosenbaum, JD, the Harold and Jane Hirsh Professor of Health Law and Policy at SPHHS and a co-author of the report.

The report paints a very different picture for the 582 health centers in states that participate in the Medicaid expansion. Approximately 2.8 million patients at these health centers will gain coverage as a result of that decision. This added coverage will translate into a potential revenue increase of over $2 billion, which will support expanded staff and services.

States that have rejected the Medicaid expansion might reconsider and decide to expand coverage. Ohio's just-announced Medicaid expansion is estimated to translate to over 63,000 residents gaining coverage and an additional $29 million in revenue gains in 2014 across 33 health centers. But in the near term, the report warns that many poor people living in the 25 opt-out states will continue to lack coverage and might find long wait times at clinics, long distances to find care, and other barriers that could translate to delays in treatment or no care at all. CHCs in those states will be unable to add much-needed services such as mental health or dental care, or to expand into remote or other seriously underserved areas-places where people have to travel for hours just to find a doctor.

"Community health centers represent the backbone of the nation's safety net, providing high quality care to more than 20 million Americans who live in underserved neighborhoods," says Feygele Jacobs, president and CEO of the RCHN Community Health Foundation. "Without the Medicaid expansion, CHCs in opt-out states will fall behind and will have trouble providing the kind of care that keeps people and communities healthy."