Community Health Centers in the U.S. Territories and the Freely Associated States

The U.S territories — American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and US Virgin Islands — and the Freely Associated States (FAS) — the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau — have faced an array of longstanding fiscal and health challenges, made worse by recent natural disasters and the coronavirus pandemic. Community health centers are an important part of health care system in the territories and FAS, providing access to a range of primary care services to low-income and vulnerable individuals. Based on findings from a survey of health centers, data from the Uniform Data System (UDS), and interviews with Primary Care Associations in those regions, this brief examines the roles of health centers in U.S. territories and FAS during the COVID-19 pandemic.

Key Findings

Health center patients in the territories and FAS face significant health concerns and social issues. Health centers reported heart disease, diabetes, and obesity as the most prevalent health conditions among patients and the economic effects of COVID-19 and endemic poverty as the most prevalent social issues. Most patients served by health centers in the territories and FAS are poor and most patients in the territories are covered by Medicaid. Citizens of the FAS are not eligible for Medicaid if they reside in the FAS and therefore 81% of health center patients are uninsured.

Overall, health centers in the territories and FAS saw a decline in the number of patients and visits during the pandemic, but use of telehealth services increased significantly. Despite fewer visits overall, health centers reported an increase in the number of patients seeking mental health and substance use disorder services and an increasing need for social and supportive services. In 2020, health centers in the territories and FAS provided nearly 380,000 telehealth visits, up from almost no telehealth visits in 2019. However, health centers face numerous challenges to providing telehealth services including lack of internet access, inadequate reimbursement, and lack of comfort using telehealth among providers and patients.

Health centers provided COVID-19 testing and vaccinations to patients in the territories and FAS. Since January 2021, health centers in the territories have administered 7% of all vaccine doses while health centers in the FAS have administered 35% of all vaccine doses. Health centers are administering the COVID-19 vaccination at fixed health center sites, community sites, via mobile vans, and in workplaces.

An increase in federal COVID-19 related funding and an increase in Medicaid funds led to an overall increase in health center funding in 2020 compared to 2019. Federal grants and Medicaid make up the majority of revenues for health centers in these regions. Medicaid made up close to 50% of health center funding and federal Section 330 grants made up a quarter of funding in the territories and FAS in 2020 (compared to 39% and 14% respectively in the U.S. states). Health centers in the territories and FAS received over $28 million in COVID-19 related funding in 2020, while the territories received an overall increase of 22% in Medicaid funding through additional federal funding appropriated by Congress. These enhanced funds helped offset revenue losses from reduced patient utilization.

Health centers in the territories and FAS face ongoing operational challenges, including ongoing healthcare provider shortages. As COVID-19 relief funding expires, the Build Back Better Act proposes enhanced Medicaid funding and enhanced federal matching rates. Stable grant and Medicaid funding would allow health centers to continue to offset revenue losses due to decreased utilization.

Issue Brief

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