Community Health Centers’ Role in Delivering Care to the Nation’s Underserved Populations During the Coronavirus Pandemic

Introduction

In the midst of the COVID-19 pandemic, almost 1,400 community health centers can serve as public health responders for medically underserved populations. Operating in nearly 13,000 community locations, community health centers cared for nearly 30 million patients in 2019, including many high-need populations such as people who are homeless, low-income elderly individuals, and those with complex medical, behavioral, and social needs. Because of their location, scope of care, and experience in serving at-risk populations, community health centers continue to serve these populations not only for ongoing health care but also for COVID-19-related care. In response to the COVID-19 pandemic, nearly all community health centers are providing diagnostic testing for the COVID-19 virus, despite facing significant losses in operational capacity. Early in the outbreak, health centers experienced a heavy loss of visits and revenue and a large number of site closures. By the week of December 4^th, health centers had made a significant recovery but still reported a 17% decline in visits compared to normal rates and closure of 1 in 20 sites.

In order to understand how community health centers have been able to serve their patients during the COVID-19 pandemic and the challenges they face in doing so, we interviewed respondents from 16 state and regional Primary Care Associations (PCAs) representing community health centers. In addition to the interviews, participating PCAs were asked to complete a supplemental questionnaire, with 14 out of 16 participating PCAs completing the questionnaire. Together, the 16 PCAs represent over 750 health centers (54 percent of all federally-funded health centers in operation during 2019, the latest year available) across 19 states and one U.S. territory. Community health centers in these states account for 63 percent of all health center patients served in 2019 and span inner-city and frontier areas. To maintain confidentiality of PCA discussants while providing some geographic context for the quotes, PCAs are identified as being located in one of four Census regions rather than identifying each by state. Additional detail on the methods underlying this analysis are in the Methods box at the end of the brief.

Key Findings

COVID-19 Testing, Contact Tracing, and Vaccine Distribution

Nearly all health centers are providing COVID-19 testing, focusing on vulnerable communities with limited testing resources. When the coronavirus pandemic hit, health centers quickly pivoted to providing COVID-19 testing in their communities. According to data from the Health Resources and Services Administration (HRSA), health centers provided over 335,000 tests in the week ending December 4^th. Testing capacity has increased since the early weeks of the pandemic in April 2020, from 80% to 98% of responding health centers as of December 4^th, 2020. PCA respondents described multiple efforts to increase capacity, including by setting up drive-thru testing sites in parking lots, creating temporary testing sites, some of which were in tents so that tests could be conducted outside, and deploying mobile testing units to target hard-to-reach populations, such as people who are homeless and migrant workers. Despite these efforts, several of responding PCAs said they were able to provide tests to all patients who need them, while a small share said they were uncertain if their members were able to meet all need (Appendix Table 1).

We have dozens of mobile units across the state and they have been mobilizing them just dramatically. It’s setting up the mobile pop-up test sites in random neighborhoods through the state or taking them to a homeless encampment to be able to make sure they’re also being taken care of for COVID reasons. Going out to migrant farms to be able to take care of those special populations that they kind of already had always done, but they kind of took it to the next level.

– PCA in the South

Barriers to meeting testing needs remain. Respondents cited several barriers to meeting the testing needs in their communities. Reflecting supply-chain issues reported across the country, the most common barriers reported were long waits for test results, shortages of PPE, and shortages of testing supplies and equipment (Appendix Table 2). In one case, a PCA respondent described two health centers that purchased their own testing equipment due to long wait times for results but, because of supply shortages on cartridges for the machine, the health centers were never able to activate the onsite testing equipment. In addition, several PCA respondents reported staff shortages as a concern for providing testing. Other barriers were a lack of clarity and/or communication on who should be tested, a lack of space to conduct testing, and an inability to cover all community locations, reflecting the diverse challenges reported by health centers to PCA respondents.

Health centers are coordinating with state and local public health agencies on COVID-19 response efforts. Since the beginning of the pandemic, respondents reported working closely with states and local health departments on a variety of issues from conducting COVID-19 testing and contact tracing to providing treatment for patients with COVID-19. For example, one PCA respondent described how the health care for the homeless project in their state helped to staff a temporary field hospital during the height of the crisis in the state. Additionally, some health centers have received funding to assist the state’s efforts to conduct contact tracing.

Health centers are preparing for a vaccine, but questions remain about their role in administering the vaccine within their communities. Most respondents indicated that health centers are involved in vaccine distribution planning with their states, but at the time of the interviews, they felt many questions remained unanswered. Several respondents noted they had been told health center staff would be vaccinated in the first phase of essential health care workers, though some were still unclear about how those vaccines would be administered. Although health centers are registered vaccine providers in their states, most respondents did not expect individual health centers to receive early doses of the Pfizer vaccine because of the cold storage requirements. While most anticipated receiving vaccines to administer to patients and community members in the coming months, one respondent noted the state was planning for large vaccination sites and was uncertain what role health centers might play in those events. Even as they prepare to administer the vaccine, respondents worried about the need to track multiple doses and multiple vaccines and the challenge of engaging in a large vaccination campaign at the same time staff are stretched thin responding to the current surge in COVID-19 cases.

Respondents also expressed the need for targeted messaging to encourage patients to get the COVID-19 vaccine. The Advisory Committee on Immunization Practices (ACIP) is now recommending people age 75 and older and frontline essential workers be vaccinated in phase 1b and adults ages 65-74, high-risk younger adults, and other essential workers be included in phase 1c. However, states will make the final decisions about vaccine prioritization and may vary from the ACIP. A recent report estimated that nearly half (47%) of health center patients would qualify for Phase 1b or 1c COVID-19 vaccination under the ACIP recommendations because they are adults of advanced age or with underlying health conditions that put them at higher risk of serious COVID-19 illness and many more are essential workers. PCA respondents noted that many of their patients may be more reluctant to get a vaccine due to mistrust of the health care system. Given health centers’ focus on underserved communities and their long-standing role in encouraging and providing immunizations, they can help garner trust among their patient communities, especially among communities of color who make up a disproportionate share of health center patients

Shift to Telehealth

A rapid shift to telehealth helped health centers continue serving patients while observing social distancing measures. PCA respondents reported that when lockdowns were first implemented, health centers quickly transitioned to providing patient visits via telehealth. Working closely with state Medicaid agencies, respondents noted they were able to get emergency authorization for telehealth approved, which was critical for the viability of telehealth at health centers given that the bulk of patients (48% as of 2019) are enrolled in Medicaid. As a result, health centers were much better equipped than in the past to continue seeing patients and providing non-COVID-19 related care. For example, most PCA respondents reported that, prior to the pandemic, less than 5% of total visits were conducted virtually (Appendix Table 3); in a separate survey of health centers conducted by HRSA, health centers reported that three in ten visits (30%) were conducted virtually for the week ending on December 4^th, 2020, down from as much as 54% in April. However, respondents noted that the shift to telehealth required new workflows and a shift in staff resources. While most respondents agreed that telehealth is “here to stay,” some expressed concern that shifting to telehealth will disengage health centers from their communities and their patients and could result in care that is less effective than face-to-face encounters.

The shift to telehealth presents challenges for medically underserved communities, such as technological and cultural barriers. Respondents noted that health centers faced a number of challenges in making the transition to telehealth. Technological issues, including internet access, particularly in rural areas, and smartphone data plan limits present barriers for some patients. Health centers have developed creative solutions to address these problems, including installing WIFI boosters in their parking lots and providing tablets to patients who participate in telehealth visits from their cars. They have also redeployed some staff to walk patients though the process of setting up for telehealth visits. Other concerns, though, are harder to address. Many patients do not feel comfortable using telehealth, and others living in crowded housing situations face privacy concerns. Several respondents also mentioned safety issues for patients at risk of or facing domestic violence.

Despite ongoing challenges, telehealth services have improved access for some hard-to-reach populations and for some services. Nearly all respondents noted that one benefit of telehealth has been improved access to care for some populations. One respondent reported that no-show rates had declined because patients did not have to deal with transportation, child care issues, or taking time off from work. The ability to provide visits over the phone has helped to engage certain groups, according to some respondents, including patients in early recovery from substance use disorder and Latino men. The phone visits allow these individuals to more easily fit appointments into their schedules. Across the board, respondents said access to mental health visits had increased because of telehealth.

Managing Ongoing Health Needs

PCAs reported that following the initial shutdowns in March and April, visits for some services had rebounded to close to pre-pandemic levels by October while visits for other services remain low. In particular, most PCA respondents reported that preventive services for adults and dental visits showed the biggest drops at the time of the study compared to pre-pandemic levels (Appendix Table 4). Other services with the greatest declines according to respondents included well-child visits, child immunizations, and chronic conditions management. While health centers saw a large increase in telehealth utilization beginning in March, virtual visits were not enough to offset declines for most services, and respondents expressed concern that visits could drop again amid rising cases. Respondents attributed the decline in these visits to patients’ fear of infection when coming into the health centers for services; however, respondents noted the situation presents challenges to preventing and managing illness and could have long-term consequences for patients.

Health centers have increased telehealth availability, moved services outside the clinic, and made physical adaptations to ensure patient safety and to encourage patients to continue to seek regular care, but also fear a return to indoor services. At the time of the focus groups, respondents said health centers were focused on creating safe environments for the patients to return to in-person visits. Some health centers have reconfigured their space to have a “sick” clinic and a “well” clinic for both children and adults while others have designated age-specific locations – one site for pediatrics only and another for adults. Health centers that cannot set up separate spaces for sick and well patients have instead established time blocks for sick patients followed by an intensive decontamination before seeing well patients. Similar to drive-up COVID-19 testing, some health centers also have set up drive-up pharmacies to facilitate access to medications. Finally, some health centers are upgrading HVAC systems and building more walls to close off internal spaces. At the same time, while respondents noted that health centers remain focused on getting patients to return for in-person visits, PCA respondents from colder-climate states, in particular, were uniform in their concern about what would happen when the warm weather ended and they would no longer have the option of serving patients outdoors. All PCA directors were aware of the threat that fully returning indoors would carry for patients and staff alike, and the extent to which moving operations back inside could create barriers to accessing care for some patients.

Health centers are finding other creative solutions to help patients manage their ongoing health needs. Respondents described health centers’ use of mobile vans to provide certain services, such as flu vaccinations. Noting the limitations of telehealth visits for preventive and chronic disease management visits, respondents reported that some providers were teaching patients how to take their pulse or check their blood pressure or blood sugar so that maintenance visits could be conducted through telehealth rather than in person. They also discussed conducting home visits for certain populations, including high-risk elderly patients.

Targeting At-Risk Communities and Addressing Non-Medical Needs

Many health centers are taking services outside the clinic and into communities that are underserved and at elevated risk for contracting COVID-19. The threat of COVID-19 has made it even more difficult for some populations to access care out of fear of exposure to the virus and because of more limited capacity at health center sites, both for ongoing health needs as well as testing and treatment for COVID-19. Respondents described ways health centers are serving populations, including migrant farmworkers, American Indians, and people experiencing homelessness, outside of the clinic setting. According to respondents, given the longstanding relationships health centers have built with their communities, they are uniquely positioned to reach underserved populations. Using mobile vans, health center staff have gone into communities, sometimes outside of their service area, to provide COVID-19 testing and other services. Respondents noted that in addition to testing, health center staff are making sure these communities have masks, hand washing stations, and hand sanitizer so they can protect themselves against COVID-19. Some have also set up isolation camps or secured quarantine housing for migrant workers who test positive. One respondent noted that “taking health care to the community where it’s needed as opposed to a defined site” is something health centers see as a new opportunity to improve care and to offset the closing of some health center sites.

Health centers have expanded non-medical services that affect health, such as food distribution, in response to economic instability during the pandemic. The economic crisis caused by the coronavirus pandemic led to increased needs for food and other social services among health center patients, as well as the continued need for health centers to provide traditional enabling services such as outreach and enrollment assistance. Respondents reported that health centers partnered with food pantries and played a more active role in food distribution than before the pandemic. In Boston, health centers partnered with city officials to receive food deliveries that they then distributed in their communities. Health centers also stepped in to fill in gaps in providing food when schools closed. Beyond the pandemic, health centers in Minnesota were involved in distributing food after the civil unrest following the death of George Floyd. In addition, respondents also described adopting a trauma-informed care model to reassess the social needs of their patients, including needs for housing or other supports.

Operational Challenges to Continuing Care

Health centers face ongoing shortages of testing supplies and PPE. As with many other health care providers, respondents reported that acquiring PPE and testing supplies has been a challenge for health centers since the pandemic began. With these items in high demand across the country, respondents reported having to compete with hospitals and large health systems for key protective gear. In addition, acquiring PPE in the different sizes that fit staff (for example, small gloves) has been a challenge. Many health centers have relied on consortia or PCAs for group buying power and for the ability to purchase supplies from the state or large health systems, although respondents indicated that health centers face continuing challenges acquiring testing supplies and PPE.

Although layoffs have been relatively limited, the pandemic’s impact on staff morale is a concern for the workforce and health care accessibility. According to respondents, health centers have managed to avoid large staff layoffs; most respondents reported either none or fewer than 10% of staff have been laid off or furloughed since March. Only one respondent estimated that more than 10% of clinical staff had been laid off at the health centers they represent, although no PCAs reported that more than 10% of administrative or enabling services staff had been laid off (Appendix Table 5). However, most respondents were concerned about how the uncertainty surrounding the pandemic was impacting staff morale and how the shift to telehealth had been more difficult for certain staff. For example, several PCAs reported that some providers, such as mental health and substance use disorder providers, have generally been able to transition from in-person visits to telehealth with few disruptions. However, other services have had greater difficulty transitioning to telehealth, such as dental or group nutrition classes. Another major concern among many PCAs was the staff with children who are balancing work demands along with virtual schooling at home. Some respondents reported staff leaving their jobs to support their children at home or reported increased risk of burnout among staff. Another concern raised by some respondents was that some providers who contracted COVID-19 and have since recovered are facing long-term conditions from the virus, such as fatigue, that have affected their ability to perform duties after returning to work. The range of staffing challenges related to the pandemic adds pressure on health centers that already faced challenges recruiting and retaining staff before the pandemic, and could affect health care accessibility even after the pandemic is over.

Financial Challenges

Health centers are facing a decline in revenue and increased operating costs, compared to finances before the pandemic. Due to social distancing measures and site closures, health centers have seen declines in visits, which has led to an estimated $4 billion in patient revenue losses since April, or roughly 13% of total 2019 revenue. When asked to estimate how current patient revenue had changed since before the pandemic, nearly all the PCAs estimated that revenues from patient visits were down either between 1% to 25% or down by roughly 26% to 50% (Appendix Tables 6). At the same time, however, health centers are facing increased operating costs during the pandemic related to increased costs for PPE, testing supplies, and implementing and operating telehealth programs (Appendix Table 7).

Federal financial relief has helped to limit revenue losses, but some health centers were ineligible for key federal funding programs or were concerned about meeting complex funding requirements. All federally-funded health centers received a total of nearly $2 billion in rapid response grants from HRSA to improve COVID-19 testing capacity, purchase PPE, and to maintain health center capacity generally. Health centers did not need to apply for these grants, and the award was determined by the size of the health center patient population and the number of uninsured patients reported in the Uniform Data System. In addition to the rapid response grants, health centers were also eligible for other federal funding made available through coronavirus recovery legislation, including the Paycheck Protection Program (PPP), the Provider Relief Fund, and the Uninsured Claims Fund. These funds had more restrictive application and awarding processes and had more limitations in how the funds could be spent. While respondents reported that smaller and rural health centers were generally able to access needed federal funding and loans, they were more concerned about larger health centers, generally located in urban areas, which also saw larger drops in patient visits compared to rural health centers due to more strict social distancing measures. They noted that some of these health centers could not apply for PPP loans because they exceeded the 500-employee limit for a non-profit to qualify. An estimated 93 health centers are ineligible for PPP loans because of their size; collectively, these health centers serve 28% of health center patients nationwide. PCAs also reported that some health centers expressed concerns with limitations on how some federal grants can be spent. In some cases, respondents reported that some health centers are not applying for more grants due to the complexity of spending restrictions.

Health centers are relying heavily on telehealth to supplement lost revenue, but uncertainty remains over whether states will roll back temporary telehealth payment policies. Respondents reported that many state Medicaid agencies temporarily increased payments for many services conducted via telehealth to be comparable to in-person visits, which they felt was critical to keeping health centers solvent as well as making telehealth more widely available. However, state Medicaid agencies have not authorized the telehealth reimbursements permanently, and most respondents identified the uncertainty of future telehealth reimbursement as a concern for health centers’ finances. They were especially concerned that state Medicaid agencies could eliminate or reduce the temporary telehealth reimbursement rates if states seek budget cuts to make up for lost revenues during the pandemic.

Respondents also expressed concerns about the eventual end of the temporary Medicaid continuity of coverage provisions and the potential loss of coverage for Medicaid patients that could result when states resume Medicaid redeterminations. As part of the Families First Coronavirus Response Act, states are eligible to receive an increase in the federal match rate for certain Medicaid spending if they meet maintenance of eligibility (MOE) requirements that include ensuring continuous coverage for current enrollees. The MOE requirements are tied to the end of the public health emergency (PHE), at which point state Medicaid agencies cannot be penalized for removing Medicaid enrollees who are no longer eligible due to changes in circumstances that are identified or reported during redeterminations. Several respondents raised concerns that patients currently covered by Medicaid could lose coverage when the MOE requirements end. They also noted that confusion over how states will handle redeterminations may result in otherwise eligible individuals losing coverage if they have trouble completing redetermination processes or providing verification. The potential for a decline in Medicaid enrollment and an increase in uninsured individuals seeking care could impact health center finances, and it would come as health centers attempt to recover from revenue losses during the pandemic.

Congress recently voted to reauthorize continued federal funding for the Health Center Program and, if signed into law, could add stability to health center finances through FY 2023, though it is unlikely to be a panacea for health center finances during the pandemic. In total, Congress voted to appropriate $5.7 billion to the Health Center Program for FY 2021, most of which ($4 billion) comes from the Community Health Center Fund (CHCF) that provides an additional $4 billion per fiscal year until FY 2023. PCA respondents described the CHCF as an ongoing source of stability for health centers, especially as health centers manage a number of other financial uncertainties during the pandemic. While the three-year funding of the CHCF will help to stabilize health center finances, they will likely face more financial challenges going forward as their role in vaccine distribution ramps up, as well as when they reconfigure their services, staffing, and clinics back to normal operations following the resolution of the pandemic.

Conclusion

Community health centers play a key role in addressing COVID-19 outbreaks, particularly in communities with high poverty and high health care needs. They have quickly adapted to the emergency situation with new models of care, responded to both medical and nonmedical needs, and moved care into new locations and configurations. Health centers’ history of reaching medically underserved communities and populations has made them core members of many states’ coronavirus response.

Health centers are expected to be involved in administering the COVID-19 vaccine in the coming months. As states finalize their vaccine distribution plans, health center staff and many of their patients will be among the priority groups to receive early doses of the vaccine. Although health centers have experience providing vaccines for other diseases, they will face unique challenges with the COVID-19 vaccine, including cold storage requirements and the need to track multiple doses from multiple vaccines. At the same time, they can serve as a trusted source of information to overcome concerns about getting the vaccine among at-risk and other vulnerable patients.

As health centers seek to continue serving their patients, numerous difficulties remain. Although the shift to telehealth has helped to restore access to primary care, there are still barriers to managing ongoing health needs and addressing the increased need for social services and supports among health center patients. At the same time, health centers face cumulative revenue shortfalls and uncertainty surrounding various revenue streams. Failure to address these challenges may undermine their ability to provide care to vulnerable and historically underserved communities.

The health center experience also shows a need to focus on the pandemic aftermath. Reviving effective preventive and primary care services that were set aside in order to mount the pandemic response will be a challenge. In addition to restoring services, providers will also need to re-establish the trust relationship that has enabled community health centers to succeed in ensuring that hard-to-serve populations have access to culturally competent care. If the nation is to fully move back to normal, designing and implementing long-term recovery policies will be as important as the initial response.