Community Health Centers Continued to Expand Patient and Service Capacity in 2017 Geiger Gibson / RCHN Community Health Foundation Research Collaborative Jessica Sharac, MSc, MPH Peter Shin, PhD, MPH Rachel Gunsalus, MPH Sara Rosenbaum, JD About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long- standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Newly released data from the United States Department of Health and Human Services Uniform Data System, an ongoing annual nationwide reporting system, show that in 2017, the nation’s community health centers provided outreach, comprehensive primary health care, patient support services, and care management to nearly 28 million patients. This dramatic growth in access to primary health care, a major health policy advance for low-income and medically underserved communities, is the result of a steady, bipartisan investment, begun by President George W. Bush, dramatically expanded under the Affordable Care Act (ACA), and continuing into the present. This policy brief provides an overview of the latest data.1 A Portrait of Steady Growth and a Changing Insurance Picture for Health Center Patients In 2017, 1,373 federally-funded community health centers, 44 percent of which were in rural communities, served 27.2 million patients across 11,000 sites.2 This figure represents a five percent growth over 2016 and a near-tripling in the number of patients served since 2000. An additional 56 Source: Bureau of Primary Health Care. (2018). 2017 Health Center Data: National “look-alike” health centers, which meet the requirements of Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ Section 330 of the Public Health Service Act (which datacenter.aspx?q=tall&year=2017&state=; Bureau of Primary Health Care. (2018). 2017 National Health Center Data: Health Center Program Look-Alike Data. Health authorizes the health centers program) but do not receive Resources and Services Administration. https://bphc.hrsa.gov/uds/lookalikes.aspx? federal grants, served 721,922 patients (Figure 1).3 state=national; GW analysis of 2017 Uniform Data System (UDS) data 1 The 28 million patients served includes look-alike health centers, but the rest of the brief presents data only on federally-funded community health centers. 2 Bureau of Primary Health Care. (2018). 2017 Health Center Data: National Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx? q=tall&year=2017&state= 3 Bureau of Primary Health Care. (2018). 2017 National Health Center Data: Health Center Program Look-Alike Data. Health Resources and Services Administration. https:// bphc.hrsa.gov/uds/lookalikes.aspx?state=national Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 Notes: Income distribution reflects 19.5 million patients with known income. Race/ethnicity distribution reflects 25.8 million patients with known race and/or ethnicity (excluding patients reported as non-Hispanic unreported race and patients with unreported race and ethnicity). Source: Bureau of Primary Health Care. (2018). 2017 Health Center Data: National Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2017&state= Together, these community health centers served 27.9 Since 2000, the number of patients served by health million patients in 2017—about one in twelve people across centers has grown dramatically. Figure 3 shows that in the United States —and approximately one in three of the 2000, 730 health centers served approximately 9.6 million 84 million people who reside in communities that have patients, of whom 3.2 million (one third) were covered by been designated as medically underserved by the federal Medicaid. By 2017, reflecting the Affordable Care Act’s major government as a result of elevated poverty and health risks Medicaid expansion as well as the establishment of a and a shortage of primary health care.4 special community health center growth fund, the number of health centers had grown substantially, and the number Nearly all community health center patients are low-income; of Medicaid patients served had increased to 13.3 million, a 69 percent have below-poverty income5 and 91 percent 314 percent growth. In 2017, Medicaid patients represented have incomes at or below 200 percent of the FPL (Figure 2). 49 percent of all health center patients served. The majority of patients are female (58%), non-elderly adults (60%), and people of color (63%). 4 Kaiser Family Foundation. (2018). Primary Care Professional Shortage Areas (HPSAs) as of December 31, 2017. https://www.kff.org/other/state-indicator/primary-care-health- professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 5 The federal poverty level in 2017 for a family of four was $24,600. https://aspe.hhs.gov/2017-poverty-guidelines Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 Despite the growth of insurance among health center and their patients. Health reform dramatically improved patients, large numbers remain uninsured. As health access to Medicaid for the poorest patients while also centers have grown, they have steadily expanded the establishing a pathway to subsidized private health number of uninsured patients served, from 3.9 million (40 insurance for low- and moderate-income patients. In 2013, percent of patients) in 2000 to 6.2 million in 2017. In 2017, people without health insurance represented 35 percent of 23 percent of all patients served by community health all health center patients; by 2017, this proportion had centers were uninsured. Community health centers serve declined by over one-third to 23 percent, while the actual approximately one in five uninsured people nationally.6 number of patients without health insurance dropped by 18 percent, from 7.6 million to 6.2 million. Although uninsured people remain a significant portion of those patients who depend on health centers, the ACA reforms have made a dramatic difference to health centers 6 Based on 2016 HRSA UDS and Kaiser Family Foundation estimates based on the Census Bureau's March Current Population Survey (CPS: Annual Social and Economic Supple- ments), 2014-2017. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc% 22%7D Notes: Patients with other public insurance not shown. Numbers (in millions) are shown for 2000, 2005, 2010, 2013, and 2017 Source: GW analysis of data reported in the UDS national reports 2000-2017 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 Health Center Patients by Age and Health Insurance Status Health centers serve patients across the lifespan (Figure 2). Table 1 shows that the majority of health center patients are non-elderly adults and children. At the same time, health centers experienced major growth in the number of elderly patients. Between 2010 and 2017, the number of elderly patients increased by 77 percent, from 1.3 million to 2.4 million, as health centers increased their capacity to manage patients with chronic and serious health conditions.7 Between 2010 and 2017, the number of patients covered by Medicaid grew by 78 percent, Medicare by 75 percent, and privately insured patients by 77 percent (Table 1). In 2017, health centers served roughly one in six Medicaid/ Children’s Health Insurance Program (CHIP) enrollees nationally, and more than one in four enrollees in nine states and the District of Columbia (Figure 4). Health Center Growth in Medicaid Expansion and Non-Expansion States Figure 5 shows the growth in the number of health center patients by state Medicaid expansion status. Between 2010 and 2017, health centers located in Medicaid expansion states reported a 43 percent increase in the number of patients served, compared to an increase of 33 percent among health centers located in non-expansion states. Differences in growth patterns likely reflect numerous Source: GW analysis of 2010 and 2017 UDS data. factors, including variations in overall Medicaid growth rates among the states and the resulting surge in operating revenue in expansion states that, in combination with grant funding, enabled health centers in expansion states to more dramatically grow their patient care capacity. 7 Markus, A., Sharac, J., Tolbert, J., Rosenbaum, S., & Zur, J. (2018). Community health centers’ experiences in a more mature ACA market. Kaiser Family Foundation. https:// www.kff.org/medicaid/issue-brief/community-health-centers-experiences-in-a-more-mature-aca-market/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Notes: US percentage does not include US territories. Source: GW analysis of 2017 UDS data (numerator) and CMS Medicaid/CHIP enrollment numbers for December 2017 (denominator); Kaiser State Health Facts. (2018). https://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/? currentTimeframe=5&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Notes: Medicaid expansion status as of 2017. Data do not include U.S. Territories. Source: GW analysis of 2010 and 2017 UDS data Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 Strengthened Services and a Growth in Services for the Most Seriously At-Risk Health Center Patients Health centers aim to meet the full range of primary care needs of those they serve. In 2017, total patient visits reached 110 million (Figure 6); 67 percent were for medical care. The remaining visits that year were distributed across mental health and substance use disorder services, dental and vision care, and enabling services that support access to health care. Figure 7 shows how health center services have changed over time. In 2017, over four in five health centers (81 percent) offered dental care, while 89 percent provided mental health services. As the magnitude of the opioid crisis has grown, so too have related health center services. In 2000 and 2010, one in five health centers provided substance use disorder services; by 2017, over one in three did so. In 2017, 64,597 patients received medication-assisted treatment for opioid use disorders, furnished by 2,973 health center clinical staff caring for patients under special waivers granted under the Source: Bureau of Primary Health Care. (2018). 2017 Health Center Data: National Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ Drug Addiction Treatment Act of 2000 (DATA). datacenter.aspx?q=tall&year=2017&state= • • Note: Data reflect health centers that reported any dental, mental health, or substance abuse services staff. This may underestimate the percentage of health centers providing substance abuse services (see Zur et al., 2018 [p. 3] https://www.kff.org/medicaid/issue-brief/the-role-of-community-health-centers-in-addressing-the-opioid-epidemic/) SOURCE: GW analysis of 2000, 2010, and 2017 UDS data Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 Note: “Other revenue” includes other public insurance revenue, other federal grants, non-federal grants and contracts, and other revenue. Percentages may not sum to 100% due to rounding. Source: GW analysis of 2010-2017 national UDS reports Figure 8 illustrates the correlation between state Medicaid The Importance of Medicaid and expansion status and Medicaid revenue. In non-expansion Grant Funding to Health Center states, Medicaid accounted for 29 percent of total revenue in 2017. By contrast, Medicaid accounted for 48 percent of Capacity and Growth: Expansion and total revenue for health centers in expansion states, reflecting both an increase in CHC service capacity and Non-Expansion States their importance to state Medicaid agencies in an era of Table 2 shows that in 2017, Medicaid accounted for 44 major eligibility expansion. Federal health center grants percent of operating revenue. Between 2010 and 2017, represented the second largest source of revenue in both Medicaid as a percentage of health center operating expansion and non-expansion states, but grant funding revenue grew from 38 percent to 44 percent, with virtually plays a distinctly different role. In non-expansion states, all of this growth occurring after 2013, when the ACA these grants accounted for 26 percent of operating Medicaid reforms took effect. revenue; in non-expansion states, the grants accounted for 15 percent of operating revenue. Federal health center grant funds, which cover the cost of uninsured patients and services critical to improving access The relative importance of Medicaid in expansion and non- and health outcomes, represented 18 percent of revenue in expansion states is reflected in differences in patients’ 2017. This figure has remained relatively constant as a insurance status. As Figure 9 shows, in non-expansion percentage of health center operating revenue as grant states, 33 percent of health center patients were insured by funding has increased over time to keep pace with the Medicaid in 2017 compared to 55 percent in Medicaid growth in health center capacity, thereby ensuring that, expansion states. Similarly, a far higher proportion of even as the proportion of insured patients grows, health patients remained uninsured in non-expansion states (36 centers do not lose their capacity to treat the uninsured. percent) than in Medicaid expansion states (18 percent). This capacity is especially important in non-expansion states, where Medicaid enrollment rates remain relatively low. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 Note: Medicaid expansion status as of 2017. Data do not include U.S. Territories. Percentages may not sum to 100% due to rounding. “Other grants and revenue” includes other public insurance revenue, other federal grants, non-federal grants and contracts, and other revenue. Source: GW analysis of 2017 UDS data. Note: Data do not include US territories. Source: GW analysis of 2017 UDS data. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 transportation, outreach and patient support, and case The Role of Subsidized Private management. Health center patient care capacity has Health Insurance Available Through grown across all ages and in all regions, with the most significant overall growth occurring in Medicaid expansion Marketplace Health Plans states. With this growth has come major service expansion, including health care for adults with serious and chronic Since community health centers serve millions of near-poor health conditions and major new service capacity with patients, the subsidized health insurance market respect to mental health and substance use treatment.8 established by the ACA also has played an important role for health centers and their patients. In 2010, 14 percent of Despite this substantial growth, health centers today serve health center patients had private health insurance. By only a third of all people classified by the federal 2017, this figure had risen to 18 percent, an increase of 27 government as medically underserved. Yet major percent in the share of patients with private health challenges remain to future growth. Health centers’ ability insurance, but a 77 percent increase in the actual number to grow will depend on sustained investment in the form of of privately insured patients (Table 1). Health centers play a public and private insurance coverage for low-income key role in the Marketplace, providing ongoing enrollment populations and a continuing commitment to grant assistance across all forms of health insurance, and funding. Growth will also turn on health centers’ ability to participating in qualified health plan provider networks. attract and retain health care professionals, underscoring the importance of continued investment in the National Implications Health Service Corps, the nation’s most important program for training and deploying clinical professionals to serve in The latest federal data shows the continued growth of health professions shortage areas, and the Teaching Health community health centers, a phenomenon that reflects a Centers (THCs) program, established under the ACA, which dramatic change in the insurance prospects of health now funds primary care physician residency training for center patients across both the Medicaid and subsidized more than 700 residents at more than 60 THCs, most private insurance markets, with the latter assuming outsize located at community health centers. importance in non-Medicaid-expansion states. The growth of health insurance has been coupled with the sustained investment in health center grant funding that covers the cost of uninsured patients and key services whose costs remain uncovered, such as adult dental care, 8 Markus, A., Sharac, J., Tolbert, J., Rosenbaum, S., & Zur, J. (2018). Community health centers’ experiences in a more mature ACA market. Kaiser Family Foundation. https:// www.kff.org/medicaid/issue-brief/community-health-centers-experiences-in-a-more-mature-aca-market/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11