Community Health Centers' Experiences in a More Mature ACA Market

Community health centers provide comprehensive primary care services in some of the most underserved communities in the nation. Four years following implementation of the ACA’s coverage expansions, health centers continue to play a central role in connecting consumers to expanded Medicaid and marketplace coverage even as they faced challenges during the 2018 marketplace open enrollment period because of the administration’s decision to shorten the enrollment period to six weeks, reduce advertising funding, and reduce federal Navigator funding. In addition, in response to improved financing from having more insured patients as well enhanced federal grant support under the ACA, health centers have also experienced significant growth in their service capacity. This brief summarizes findings from the Kaiser Family Foundation/Geiger Gibson Program in Community Health Policy 2018 Health Center Survey to provide a snapshot of health centers’ outreach and enrollment activities as well as changes in service capacity, and overall financial condition since implementation of the ACA. Key findings include:

• Most health centers took steps to prepare for the shorter open enrollment period in effect in most states. Nearly four in five health centers took some action, including contacting consumers ahead of November 1^st to inform them of the shortened enrollment period and increasing outreach activities.
• The majority of health centers employed the same level of outreach and enrollment staff as last year and served about the same number or more people seeking enrollment assistance. Two-thirds of health centers indicated that the number of full time equivalent (FTE) paid enrollment assistance staff had stayed about the same since the last open enrollment period, but 21% said staffing had decreased. Despite arguments from policymakers that the need for in-person assistance would diminish, over seven in ten health centers reported serving the same number or more people seeking enrollment assistance during the most recent open enrollment period.
• Many health centers received state or federal navigator funding and some experienced reductions in that funding. Funding for outreach and enrollment activities is included in the federal Section 330 grants health centers receive. In addition, about four in ten health centers reported receiving state or federal navigator funding in 2018. Of those, 34% said their funding had been cut compared to the previous year. In response to these funding cuts, nearly a third said they reduced staff and 27% reduced the number of outreach activities.
• Health centers’ support for patients applying for Medicaid remained strong, while assistance with marketplace applications stayed about the same or decreased. Over four in ten health centers said they provided assistance for more new Medicaid applications in calendar year 2017 compared to 2016, and 34% said they helped with more Medicaid renewals. In contrast, less than a quarter of health centers said they helped with more new marketplace applications during the 2018 open enrollment period compared to the 2017 enrollment period, and only 26% said they assisted with more marketplace renewals.
• Health centers are continuing to expand their services and staffing. The most commonly reported increases for services and staffing in the past year were for mental health services and staff, substance use disorder treatment services and staff, chronic care management services, and dental services and staff.
• Most health centers experienced stable or improved financing from key revenue sources in the past year. Nearly half of health centers reported increases in their Medicaid revenue in the past year and an additional 38% reported that their Medicaid revenue did not change. Following the delay in reauthorizing the Community Health Center Fund in 2017, most health centers reported an increase or no change in their federal grant funding in the past year. Importantly, though, about 20% of health centers experienced a decrease in their federal grant funding.
• Health centers reported increasing financial pressure on privately insured patients and lapses in coverage for Medicaid and privately insured patients. More than half of health centers reported increases in insured patients who are unable to afford their cost-sharing payments and deductibles. Roughly a third of health centers reported that the percentage of privately insured and Medicaid/CHIP patients with lapses in coverage also increased compared to last year.
• Workforce recruitment, inadequate physical space, and insufficient grant funding are top challenges for health centers. Workforce recruitment is a consistent challenge for health centers and was ranked as a top-three challenge by nearly six in ten health centers. Other commonly-reported top-three challenges were inadequate physical space (36%) and insufficient grant funding (32%) and, among health centers in non-expansion states, high numbers of uninsured patients (42%).