Community Health Centers in a Time of Change: Results from an Annual Survey

Appendix A

Appendix Table 1: Health Center Responses to Specific Survey Questions by Medicaid Expansion Status and Urban/Rural Status
All Health Centers Medicaid expansion States Non-expansion States Urban Rural
Factors Accounting for Decrease in Medicaid Patients
Concerns from immigrant families about applying for or keeping Medicaid for themselves or their children 68% 73% 59% 77% 46%^
Enrollment and renewal process changes have made it more difficult for patients to enroll in Medicaid or renew Medicaid coverage 60% 58% 64% 60% 61%
Overall drop in health center patients 30% 28% 35% 23% 46%^
Patients are gaining jobs and losing Medicaid coverage due to increased income and/or employer-covered insurance 22% 30% 7%* 26% 11%
New Medicaid eligibility requirements (e.g., work requirements, premium and copayment requirements) make it harder for patients to maintain Medicaid coverage 20% 20% 21% 20% 23%
Significant changes in the demographic characteristics of the communities our health center serves 15% 14% 16% 13% 18%
Do not contract with some or all Medicaid managed care plans that operate in our health center’s service area 6% 3% 11% 6% 5%
Fewer Medicaid covered services being offered 6% 3% 11% 6% 6%
All Health Centers Medicaid expansion States Non-expansion States Urban Rural
Health Centers Providing Social and Support Services On-Site
Insurance Enrollment Assistance 96% 97% 92%* 97% 94%
Case Management Services 93% 93% 95% 93% 94%
Health Literacy 67% 67% 68% 68% 66%
Transportation 61% 59% 66% 65% 55%^
Healthy Foods 47% 49% 43% 51% 42%
Veterans Services 47% 43% 57%* 42% 54%^
SNAP, WIC, or Other Nutritional Assistance Services 40% 41% 39% 47% 31%^
Physical Activity and Exercise 40% 40% 39% 40% 41%
Education 39% 35% 49%* 35% 44%
Domestic Violence 31% 33% 27% 34% 28%
Agricultural Worker Support 18% 13% 29%* 11% 27%^
Housing (includes housing assistance and quality) 18% 18% 16% 20% 14%
Refugee Services 17% 17% 17% 23% 8%^
Criminal Justice/Recidivism 13% 12% 14% 13% 12%
Job Training 12% 12% 11% 11% 12%
Job Search and Placement 8% 7% 12% 7% 10%
Child Care/Head Start 5% 5% 8% 5% 6%
All Health Centers Medicaid expansion States Non-expansion States Urban Rural
Barriers to Working for Adult Health Center Medicaid Patients Who Are Not Currently Working
Caring for children or other family members 79% 83% 71%* 83% 73%^
Lack of transportation to jobs 78% 78% 80% 78% 79%
Substance use disorders 77% 80% 70%* 77% 77%
Acute or chronic mental health conditions 76% 79% 68%* 78% 72%
Skills and education do not meet requirements for available jobs 76% 79% 69%* 79% 71%^
Acute or chronic physical health conditions 71% 71% 70% 74% 67%
Concerns about losing health coverage if they earn too much money 56% 57% 53% 57% 54%
Lack of job training resources 53% 55% 51% 57% 49%
Lack of jobs in the community 45% 45% 46% 40% 53%^
Many jobs in our community are seasonal 20% 20% 18% 14% 28%^
All Health Centers Medicaid expansion States Non-expansion States Urban Rural
Top Three Challenges Facing Health Centers
Increasing costs to operate health center 52% 55% 46% 54% 49%
Workforce recruitment 52% 55% 43%* 45% 60%^
Inadequate physical space 31% 30% 34% 27% 36%^
Workforce retention 25% 27% 21% 27% 24%
High number of uninsured patients 24% 15% 45%* 28% 19%^
Insufficient insurance reimbursement 19% 21% 13% 18% 20%
Insufficient grant funding 18% 17% 20% 19% 17%
Competition from other providers 14% 13% 17% 15% 13%
Changes to Medicaid reimbursement 14% 14% 13% 13% 15%
Changes to Medicaid eligibility criteria, including work requirements 10% 9% 13% 9% 11%
Contracting with insurers 9% 8% 10% 9% 9%
Efforts to integrate care provided by your health center with healthcare provided by other providers 8% 8% 6% 8% 8%
Increased immigration enforcement and/or policy changes affecting immigrants 7% 7% 5% 8% 5%
Patient confusion regarding eligibility for insurance programs 6% 6% 4% 5% 6%
Efforts to integrate care with social services (e.g., housing, TANF, SNAP) 4% 5% 2% 5% 4%
Increased demand for family planning services 0% 1% 0% 0% 0%
NOTE: * Significantly different from Medicaid expansion at the <0.05 level; ^ Significantly different from Urban at p<0.05 level
SOURCE: KFF and Geiger Gibson/RCHN Community Health Foundation 2019 Survey of Community Health Centers
Appendix Table 2: Share of Health Centers Reporting Barriers to Reporting Work/Community Engagement Activities for their Patients
Potential Barriers to Reporting Work/Community Engagement Activities Barrier for many patients Barrier for some patients Not a barrier
Are unsure of how to request an exemption 76% 23% 1%
Are unsure of reporting deadlines and/or how often they need to report 70% 28% 2%
Have questions about how to report their activity 67% 32% 1%
Are confused about whether the rules apply to them 67% 32% 2%
Face more pressing needs 67% 31% 3%
Have limited understanding of what they need to report 66% 33% 2%
Do not have access to a computer 57% 41% 2%
Lack confidence to report on their own 49% 49% 2%
Do not have access to internet service 47% 51% 2%
Need translation services 32% 57% 11%
Need help because of a disability 15% 82% 3%
Do not have access to a phone 9% 66% 26%
NOTE: Question was asked of all health centers, so responses represent potential barriers. Don’t Know responses were excluded. Totals may not sum to 100% due to rounding.   Source: KFF and Geiger Gibson/RCHN Community Health Foundation 2019 Survey of Community Health Centers

Appendix B

2019 Survey of Community Health Centers
(Questions 1-7 request survey respondent contact information; questions 18–26 and 28 were released separately)


Q8. Several states have received approval from the federal government to implement work/community engagement requirements in Medicaid and several others are considering such requirements. Is your health center in a state that has an approved or pending waiver or is considering developing a waiver request to require that Medicaid enrollees engage in work/community engagement activities as a condition of enrollment?

Yes, my state has an approved or pending waiver.
Yes, my state is considering developing a waiver request.
No
Don’t know


Q9. Have state Medicaid officials provided or offered to provide training to health center employees about the new Medicaid work/community engagement requirements?

Yes, state officials have provided the training.
Yes, state officials have offered to provide training.
No, state officials have not provided nor offered to provide training.
Don’t know.


Q10. Has your health center or PCA provided, or does it provide, additional training to health center employees about the Medicaid work/community engagement requirements?

Yes, our health center or PCA has provided training.
Yes, out health center or PCA plans to provide training.
No, our health center would like to provide training but does not have the resources.
No, our health center has not provided training and does not plan to provide training.
Don’t know.


Q11. Is your health center assisting or does it plan to assist patients with meeting reporting requirements related to the Medicaid work/community engagement requirements, including explaining the requirements, creating online accounts, reporting monthly work/community engagement activity, or seeking and reporting exemptions?

Yes, we are currently assisting patients.
Yes, we plan to assist patients.
No, we would like to assist patients but do not have the resources.
No, we are not assisting patients and do not plan to assist patients.
Don’t know.


Q12. People deemed “medically frail” are excluded from Medicaid work/community engagement requirements. Has your state explained the process for designating patients with physical health conditions or mental health conditions/substance use disorders as medically frail?

Yes, state officials have explained the process.
No, state officials have not explained the process.
Don’t know.


Q13. Does your health center have the resources to complete the clinician evaluation that is required as part of the medical frailty determination for patients with physical health conditions or mental health conditions/substance use disorders?

Yes
No
Don’t know


Q14. If Medicaid enrollees were required to report work/community engagement activity online or by phone, please indicate whether the following factors would be a barrier for many patients, some patients, or not a barrier to meeting these reporting requirements among your Medicaid patients.

Do not have access to a computer
Do not have access to internet service
Do not have access to a phone
Have limited understanding of what they need to report
Have questions about how to report their activity
Are unsure of reporting deadlines and/or how often they need to report
Are unsure of how to request an exemption
Need translation services
Need help because of a disability
Lack confidence to report on their own
Are confused about whether the rules apply to them
Face more pressing needs
Have other barrier to reporting (specify)


Q15. Among your health center’s adult Medicaid patients who are non-elderly and non-disabled and who are not currently working, what would you identify as the barriers, if any, that prevent them from working? (Check all that apply).

No barriers (if so, please do not select other options)
Acute or chronic physical health conditions
Acute or chronic mental health conditions
Substance use disorders
Lack of jobs in the community
Lack of job training resources
Skills and education do not meet requirements for available jobs
Lack of transportation to jobs
Caring for children or other family members
Concerns about losing health coverage if they earn too much money
Many jobs in our community are seasonal
Don’t know


Q16. Over the past year, has your health center noticed any of the following among your immigrant patients and their family members? Please indicate whether the following have been seen among many patients, some patients, a few patients, or no patients. Mark not applicable if these scenarios do not apply to your health center or don’t know if you are unsure.

Patients who refuse to enroll in Medicaid for themselves
Patients who refuse to enroll in Medicaid for their children
Patients who disenroll or refuse to renew their own Medicaid coverage
Patients who disenroll or refuse to renew Medicaid coverage for their children
A reduction in the number of adult patients seeking care from the health center
A reduction in the number of patients seeking care for their children from the health center


Q17. If your health center has noticed immigrant patients and their family members choosing not to enroll in Medicaid, disenrolling from or not renewing Medicaid, or not seeking care, do you think the following federal policies or actions are a factor?

Recent proposed changes that would permit officials to consider use of Medicaid, SNAP, or other non-cash programs in public charge determinations
Enhanced immigration enforcement activity
Changing federal policy limiting immigration pathways (e.g., elimination of protected status for some groups, limiting entry from certain countries, etc.)
Other factor (please specify)


Q27. Please indicate whether your health center has experienced changes to the following financial factors in the past year. (Mark no change, increased, decreased, or not applicable for each option).
Access to private capital

Federal grants
State and local grants
Medicaid revenue
Private insurance revenue
Title X family planning grants
Percentage of Medicaid/CHIP patients who have a lapse or break in insurance coverage
Percentage of private insurance patients who have a lapse or break in insurance coverage
Percentage of insured patients who are unable to pay their deductibles and cost-sharing payments
Percentage of privately insured patients who pay sliding scale fees
Funding for community benefit activities from local hospitals and/or health plans


Q29. Over the past year, would you say the number of patients enrolled in Medicaid at your health center has increased, decreased, or stayed about the same? (If you answer increased or stayed the same, please skip to question 31).

The number of Medicaid patients has increased
The number of Medicaid patients has stayed about the same
The number of Medicaid patients has decreased


Q30. What would you say are the factors that likely account for the decrease in Medicaid patients at your health center? (Check all that apply).

Overall drop in health center patients
Do not contract with some or all Medicaid managed care plans that operate in our health center’s service area
Significant changes in the demographic characteristics of the communities our health center serves
Patients are gaining jobs and losing Medicaid coverage due to increased income and/or employer-covered insurance
Concerns from immigrant families about applying for or keeping Medicaid for themselves or their children
Enrollment and renewal process changes have made it more difficult for patients to enroll in Medicaid or renew Medicaid coverage
New Medicaid eligibility requirements (e.g., work requirements, premium and copayment requirements) make it harder for patients to maintain Medicaid coverage
Fewer Medicaid covered services being offered


Q31. Does your health center currently receive funding from the Title X Family Planning Program?

Yes
No
Don’t know


Q32. In the next year, what it the estimated percentage increase in new family planning patients your health center could accept with current staffing and clinic space?

Not applicable, we do not currently have any family planning patients
None
Less than 10%
10-24%
25-49%
50-74%
75-99%
100% or more


Q33. How do patients at your health center receive prescription medications? (Check all that apply).

Dispensed by provider
Through an on-site pharmacy (either in-house or contract pharmacy)
Through an off-site contract pharmacy
Through an off-site, non-contract pharmacy
Don’t know


Q34. Which of the following types of social or support services does your health center provide on-site and/or through referrals to local organizations (Mark provide on-site, provide through referral, provide both on-site and through referral, or do not provide)?

Agricultural worker support
Child care/Head start
Criminal justice/recidivism
Domestic violence
Education
Job training
Job search and placement
Healthy foods
SNAP, WIC, or other nutritional assistance services
Housing (includes housing assistance and quality)
Health literacy
Insurance enrollment assistance
Physical activity and exercise
Refugee services
Transportation
Veterans services
Case management services


Q35. Please identify the top 3 challenges facing your health center.

Patient confusion regarding eligibility for insurance programs
Changes to Medicaid reimbursement
Changes to Medicaid eligibility criteria, including work requirements
Insufficient grant funding
Insufficient insurance reimbursement
Contracting with insurers
Workforce recruitment
Workforce retention
High number of uninsured patients
Competition from other providers
Efforts to integrate care provided by your health center with healthcare provided by other providers
Efforts to integrate care with social services (e.g., housing, TANF, SNAP)
Increased immigration enforcement and/or policy changes affecting immigrants
Increased demand for family planning services
Inadequate physical space
Increasing costs to operate health center
Other challenge (please specify)

Key Findings