FEBRUARY 2021 Issue Brief Holding On: How California's Health Centers Adapted Operations and Care for Patients During the Pandemic C alifornia's Federally Qualified Health Centers declined at California health centers by more than 4 mil- (FQHCs)1 are a critical part of the health care lion between April and December 2020, a reduction of safety net, providing care for communities of 20% compared to the same period in 2019.4 In the early color, people experiencing homelessness, and others days of the pandemic, health centers were forced to who do not have regular access to health care. It is vital make major operational changes that focused on meet- that health centers are financially and operationally sta- ing the most urgent community needs. ble so they can continue to effectively meet the needs of the patients who rely on them for primary care, behav- In the summer of 2020, Aurrera Health Group and ioral health, and dental services. Capital Link were commissioned by the California Health Care Foundation to release a series of three reports that At the start the COVID-19 pandemic, California's health will provide a comprehensive window into the financial centers were already facing financial challenges that had and operational impact of the pandemic on California's put them on uncertain ground, with significant reductions FQHCs. The first report, California Federally Qualified in operating margins between 2016 and 2019. Once Health Centers: Financial and Operational Performance the pandemic hit, face-to-face primary care visits and Analysis, 2016 – 2019, released in November 2020, ana- corresponding reimbursements dropped precipitously. lyzed the key financial and operating trends of the sector This paper identifies several key factors that enabled from 2013 through 2019, and identified several areas California's health centers to manage the financial strain of declining financial performance that preceded the exacerbated by the pandemic while continuing to serve pandemic.5 patients at a time when accessing health care involved new and unanticipated challenges. This paper, the second in the series, analyzes the finan- cial impact of the COVID-19 pandemic on California health centers from March through December 2020, Introduction based on a range of publicly available as well as propri- FQHCs have played a critical safety-net role in California etary data, as further described in the "Data Sources and since the 1960s. According to data submitted by health Methodology" section. It also identifies several key fac- centers to the federal Health Resources and Services tors that enabled California's health centers to manage Administration (HRSA), 5.6 million patients were served the financial strain caused by the pandemic, enabling at 1,963 sites across the state in 2019.2 Of the 5.6 mil- them to continue to serve patients at a time when access lion patients, 3.6 million were covered under Med-Cal, to health care was being curtailed due to stay-at-home the state's Medicaid program. The California Office of orders. These findings are informed by interviews con- Statewide Health Planning and Development's 2019 ducted in fall 2020 by Aurrera Health Group with FQHC Annual Utilization Report shows that 92% of patients executives and other health center experts. served in FQHCs are non-White, 67% have incomes at or below 200% of the federal poverty level, and 34% have a In addition to exploring short- and immediate-term primary language other than English.3 responses to the pandemic and the corresponding reductions in revenue, experts also shared thoughts The COVID-19 pandemic caused serious disruptions in about COVID-19-related implications for the future of care delivery throughout the country. In-person visits care delivery and reimbursement, and ways that health centers should anticipate and plan for future recessions. equaled almost $531 million. For the average California An exploration of these long-term considerations and FQHC, net losses between April and December 2020 opportunities will be presented in the third and final drained 27 days of cash from its balance sheet. The report in the series. majority of centers were left with very low levels of cash by year-end - with months of the pandemic still ahead in 2021. Existing Financial Environment and Vulnerability Assessment Table 1. N et Losses Due to COVID-19, California FQHCs At the start of the COVID-19 pandemic, California health April to December 2020 (9 months) centers were already facing financial challenges that put Lost Revenue $853,268,299 them on uncertain ground. The most recent financial and COVID-19-Related Costs $511,590,479 operational performance analysis by Capital Link found that California FQHCs experienced a significant decline Total Lost Revenue and Costs $1,364,858,778 in operating margins between 2016 and 2019 - from Federal Relief Funding $834,057,832 6.5% to 2.5% at the median.6 This decline was largely due to expenses growing more quickly than revenue. For Net Gains (Losses) ($530,800,946) example, personnel-related expenses grew from 70% of Average Days' Cash Drain 27 revenues in 2016 to 75% by 2019.7 At the same time, Source: Capital Link's analysis of sources cited in "Data Sources and cash reserves declined, totaling 77 days cash on hand for Methodology" section. the median California FQHC in 2019 - the lowest level achieved over the four years. Especially concerning, one- quarter of health centers had less than 28 days cash on Absent the federal relief funding discussed below, the hand at the end of fiscal year 2019. financial strain would likely have been untenable for most health centers. Even with the relief funding to date, it By mid-March 2020, California's FQHCs were begin- seems likely that most health centers will need several ning to feel the financial effects of the pandemic. Visits years of significant operating surpluses or additional had declined precipitously, resulting in $853 million in funding streams to fully recover from losses sustained estimated lost revenue between April and December during the pandemic. 2020 (see Table 1). At the same time, health centers were incurring additional costs related to the pandemic, including for the purchase of personal protective equip- FQHC Strategies to Mitigate Financial ment (PPE), equipment and licenses for a rapid transition Losses During the Pandemic to telehealth, and facility modifications to enable safer In response to the significant and necessary reduction execution of routine and pandemic-related care. in face-to-face visits during the first nine months of the COVID-19 pandemic, California FQHCs were able to Capital Link estimates that California FQHCs incurred pivot to meet patient needs. For patients who needed an a total of $512 million in COVID-19-related expenses in-person visit to address an acute care need, health cen- between April and December 2020.8 Together, lost rev- ters reconfigured physical space and workflows to ensure enue and COVID-19-related costs equaled an estimated patient and staff safety. Some programs were completely $1.36 billion through year-end 2020 - 19% of their restructured. For example, Hill Country Community entire 2019 budgets, which totaled just over $7 billion. Clinics moved wellness services "beyond the four walls" of the health center and provided virtual peer support, After taking into account $834 million in federal relief more outdoor activities, and care packages delivered funding received by the California FQHCs between April to people's homes, thereby supporting patients who and December 2020 (as detailed later in this paper), the needed contact and might otherwise be isolated during estimated net losses sustained by the health centers the pandemic. California Health Care Foundation www.chcf.org 2 A major takeaway from the expert interviews was that $ Use new and widely available technologies to reliance on the current prospective payment system (PPS) meet with patients virtually reimbursement structure created significant risks when $ Receive the same payments under Med-Cal responding to the COVID-19 pandemic. Under PPS, whether care was provided over the phone or reimbursement for primary care visits is contingent on through video the occurrence of an in-person visit. Alternative models of care delivery have historically not been reimbursable $ Provide telehealth to Medicare clients via phone nor incentivized. without the use of video technology and at any site - including the client's home California health centers employed a range of immedi- $ Use nurse practitioners to provide telehealth ate loss-mitigation strategies during the first months of services without the medical supervision of a the COVID-19 pandemic. The strategies varied in level physician of effort, but taken together, they sustained health cen- ters through 2020 as the pandemic continued. Strategies These policy modifications have broad and long-term included: applicability. All FQHC executives interviewed for this $ Embracing and investing in telehealth brief acknowledged that the ability to shift to telehealth so quickly came as a surprise but allowed them to con- $ Reassigning and furloughing staff tinue providing services. In the case of behavioral health $ Spending down reserves care, the accessibility of telehealth during the COVID-19 pandemic improved no-show rates. For Bay Area health $ Closing sites temporarily centers, one executive pointed out that telehealth as an $ Generating quick cash option for behavioral health services resulted in "a net plus . . . we went from about 25% no-show for behavioral $ Tapping into COVID-19-related federal support care to pretty close to zero." For patients who embrace $ Leveraging partnerships the opportunity to connect with providers virtually, con- venience is a key component of patient-centered care. Embracing and Investing in Telehealth Before the COVID-19 pandemic, discussions about a While the California budget has given indication that shift toward more consistent and extensive use of tele- telehealth will be compensated to some degree, the health were generally dismissed based on concerns details are still unclear. Health center leaders emphasized about how challenging the change would be for provid- that while they are encouraged by this, it is important ers, patients, and payers alike. However, the sudden and that reimbursement and subsequent policy changes sup- unexpected nationwide shutdown caused by COVID-19 port equitable access to telehealth. resulted in a widespread, necessary, and immediate shift to the use of telehealth across the country. Between April Shifting to telehealth and video visits on a long-term and December 2020, 53% - 8.4 million out of 15.9 mil- basis will take some effort. Experts cited the need to lion - of all health care visits were conducted virtually reconsider workflows, staff responsibilities, and physical (including video- and telephone-enabled telehealth) at space to facilitate providing care remotely. Most noted California FQHCs. One CEO pointed out that over two that the use of telehealth did not improve efficiency weeks, they "flipped from a model that was about 8% and in fact, required more time for staff to determine telehealth to 80% telehealth." appropriate care in advance of the visit. Additionally, interviewees noted that some patients do not have the Due to federal flexibilities9 and the emergency order of digital literacy skills needed for successful video visits. the California Department of Health Care Services allow- Health center leaders in rural areas where high-speed ing telehealth visits to be reimbursed through the PPS internet is limited have been particularly challenged by system during the pandemic, FQHCs were able to: the transition to telehealth. However, one expert pointed Holding On: How California's Health Centers Adapted Operations and Care for Patients During the Pandemic www.chcf.org 3 out that telehealth has allowed health centers to reach offered remotely. Rather than furloughing these staff, La people they have not before, creating long-term poten- Clínica de la Raza reassigned staff to conduct COVID- tial for improving access to care, ultimately facilitating 19 testing. Support staff became patient screeners. Hill the goal of reducing health disparities. Country Community Clinic reassigned dental staff to backfill medical staff who were not able to come in physi- More than ever, California health centers are ready to cally to the clinic. Peach Tree Health transitioned some make changes to facilitate more flexible and patient- of their behavioral health staff to be outreach and social centered models of care, which may include the ongoing workers, providing follow-up and check-in care to clients promotion of telehealth and video visits in certain cir- that providers believed may be isolated or neglected cumstances, even after the pandemic ends. Payers and during the pandemic. While the time spent was not policymakers would also need to acknowledge the always reimbursable, the new assignments meant keep- validity of this model to ensure financial sustainability. In ing staff on payroll. the words of one expert, health centers long for more predictability about revenue, and desire to get off the As part of its pre-COVID-19 strategy to redesign care "hamster wheel" where only face-to-face encounters delivery, San Mateo County clinics restructured the medi- with a licensed provider are reimbursable. cal assistant and front-desk staff roles. Instead of rooming patients and taking vitals as part of a patient visit, medical Reassigning and Furloughing Staff assistants now focus on prevention and population health COVID-19-related guidelines limiting physical contact management. They conduct outreach to patients about severely impacted delivery of services that require face- well-child visits, mammograms, and other screening to-face visits, leaving FQHCs in the difficult position of reminders. Front-desk staff now have care coordination determining how to keep staff on payrolls. Given the dif- responsibilities. These redefined roles helped San Mateo ficulty in recruiting and retaining staff during even the clinics respond quickly to a new care model during the best of times, letting staff go because of the pandemic COVID-19 pandemic. By quickly reassigning staff, health is particularly problematic in the long term. It is likely centers were able to avoid extensive furloughs and layoffs that patients will have care needs that were neglected by redirecting resources to address the more immediate during COVID-19, which could cause an increase in needs of clients, while at the same time reducing the demand for primary care. There are already signs that impact of service disruptions on revenue. people are delaying important care. As of June 30, 2020, an estimated 41% of US adults reported having Spending Down Reserves delayed or avoided medical care during the pandemic Though FQHCs quickly pivoted to provide remote because of concerns about COVID-19, including 12% patient care through telehealth, the significant reduction who reported having avoided urgent or emergency in patient visits forced them to tap into financial reserves. care.10 Simultaneously, Medi-Cal enrollment is projected As indicated in Table 1 above, Capital Link estimates that to grow.11 Given the significant role that health centers California's FQHCs sustained operating losses totaling play in providing care to Medi-Cal enrollees and this almost $531 million between April and December 2020, potential increase in primary care demand, maintaining even after accounting for federal relief funding. health center capacity should be a priority for the state. Without staff to see these patients, access to care could Covering this level of loss greatly impacted cash reserves, be impeded. requiring the average health center to drain their reserves by 27 days. Given that the median California FQHC had While dozens of health centers resorted to staff 77 days cash on hand and the bottom 25th percentile furloughs,12 many interviewees noted that they went to had 28 days of cash at fiscal year-end 2019, a cash drain great lengths to keep their staff intact, redeploying them of 27 days means that many health centers are entering to other critical tasks during the pandemic. Dental assis- 2021 and the next phase of the pandemic with danger- tants and staff at school-based health centers were most ously low levels of cash on hand. Given that visit levels are impacted by shutdowns, as their services could not be likely to be depressed going forward and health centers California Health Care Foundation www.chcf.org 4 will continue to incur COVID-19-related costs until the Several health centers pursued a short-term strategy that, pandemic recedes, these minimal reserves will continue while not a permanent solution, demonstrated the seri- to constrain their operations in 2021 and could lead to ousness of COVID-19-related circumstances. California deeper furloughs or other loss of capacity for the system. allows for converting existing licensed primary care clin- ics to "intermittent clinics" - sites owned by the main In the words of one executive, "We decided we would clinic organization but operated at a separate location. use our reserves to ride it out . . . even though there was This conversion allows FQHCs to bill at the higher reim- a lot of financial heartburn - for people on the front lines bursement rate of the primary site. While rules regarding and the staff, they didn't have to feel like we were los- the intermittent site must be followed (not operating ing ground. We were losing ground, but we had already more than 40 hours per week, for example), leveraging committed that whatever happened, we would ride it this flexibility has been a relatively simple strategy with out." immediate financial benefits. Closing Sites Temporarily Tapping into COVID-19-Related According to weekly data analyzed by Capital Link, Federal Support California FQHCs closed an average of 242 sites per As estimated by Capital Link, Table 2 summarizes the week between April and December 2020, representing major sources of federal support that health centers 13% of sites in the state. Without patients, it was unrea- in California were able to access between April and sonable for both financial and safety reasons to keep December 2020, totaling $834 million. Four major sources clinics staffed at full capacity. However, site closures did contributed to this support: (1) HRSA, through three grant not eliminate financial losses since most site costs are still allocations administered by the Bureau of Primary Health fixed in the short term. Not only is this a short-term fix Care; (2) US Department of Health and Human Services' with minimal financial benefit, closing clinics, even if only Provider Relief Fund, including a "General Distribution" temporarily, can have a significant negative impact on and a "Rural Distribution;" (3) telehealth grants awarded patients. Representatives of San Mateo clinics observed by the FCC (Federal Communication Commission); and that limiting access to ambulatory care resulted in seri- (4) loans through the Small Business Administration's ous implications for the county's hospital emergency Paycheck Protection Program, eligible for forgiveness department. They noted that they had never seen as subject to certain conditions that most health centers many people in diabetic ketoacidosis as they had seen in should be able to meet.13 the last few months and were astounded by what people had deferred during this period. While clinics were hastily Table 2. F ederal Relief Funding Available to California Health transitioning to telehealth, people invariably fell through Centers, April to December 2020 (9 months) the cracks, and even with telehealth access, there are still $ HRSA patients who for a variety of reasons need to be seen in $ H8C14 $13,842,902 person. The impact of COVID-19 is likely to have signifi- $ H8D15 $193,072,106 cant health effects for Californians with low incomes for some time to come. $ H8E16 $102,794,295 $ US Dept. of Health and Human Services, Provider Relief Fund Generating Quick Cash $ General Distribution17 $94,890,209 In the first months after COVID-19 hit, many health cen- ters focused on improving immediate cash flow, including $ Rural Distribution18 $18,379,034 locking cash flow (postponing plans and eliminating new $ FCC Telehealth Grants19 $7,559,979 spending) in hopes of ensuring financial viability. The $ Paycheck Protection Program Loans 20 $403,519,307 need to infuse cash into the system prompted Peach Tree Health to pursue reconciliation of past accounts Total Relief Funding $834,057,832 receivable with the state, an exercise often postponed Note: Calculation assumptions for estimated funding sources are described in during normal times. the "Data Sources and Methodology" section. Holding On: How California's Health Centers Adapted Operations and Care for Patients During the Pandemic www.chcf.org 5 All interviewees articulated that they took advantage of receive additional funds. Other Medi-Cal health plans these grant opportunities to mitigate the impact of the have accelerated claims payments to health centers to pandemic on patients and revenues. In addition to the help mitigate cash flow challenges. federal relief funding, some health centers have been able to tap into funding and/or PPE through various Several experts cited the importance of existing partner- charitable sources, local and national relief organiza- ships during the pandemic. Community Medical Centers tions, and counties. For example, Community Medical worked quickly to launch (and pivot to telehealth) a new Centers, based in Stockton, took advantage of all federal partnership that was already being planned before the opportunities to avoid furloughing staff, but in doing so pandemic. In partnership with the local community col- needed to hire a grant manager to keep track of the mul- lege, which has over 2,700 students who live at or below tiple funding streams available during the pandemic. 200% of the federal poverty line, Community Medical Centers opened a student health center on campus. Some organizations, such as the California Primary Care Since the community college is not holding classes in Association (CPCA), also made short-term emergency person, before opening the health center, they began loans available, in collaboration with several partners. seeing students virtually and have also offered in-person The CPCA COVID-19 Response Loan Fund awarded COVID-19 testing and flu shots. They plan to open the eight low-interest loans totaling $5.65 million and eight physical space in early 2021. technical assistance companion grants totaling $240,000 to FQHCs. Interviewees noted that the CPCA funds are being used for renovations to existing facilities to deal Looking to the Future with COVID-19 requirements, including plexiglass, auto- Despite entering 2020 already facing financial chal- mated doors, and touchless faucets, in addition to other lenges, health centers have been nimble and creative in changes to allow for better social distancing. In some the face of the pandemic, delivering care in new ways to cases, funds are going toward maintaining key staff and meet patient needs during an extraordinary time. avoiding layoffs due to lost revenues during the pan- demic. While loans are an important mechanism for With the ongoing pressure the pandemic is placing on short-term cash flow relief, borrowers are expected to the state's health care delivery systems and the corre- repay them. For this reason, they do not play the same sponding financial challenges faced by FQHCs, health role as grants in mitigating the financial consequences of centers will need to continue to be creative. COVID-19 the pandemic. has presented an opportunity to further explore oppor- tunities to strengthen operations and garner long-term Leveraging Partnerships support from multiple stakeholders to continue health FQHCs found value in their relationships with health centers' essential community health care role. plans when attempting to minimize losses due to the pandemic. L.A. Care has between 335,000 and 350,000 A more detailed, nuanced analysis by type of health Medi-Cal members who have a primary care home in Los center (region, size, rural vs. urban) is currently being Angeles community health centers. These health centers conducted to better understand each group's unique are paid on a capitated basis, which means they were opportunities and challenges in the current environment. paid during the pandemic even when patient census was down. In order to improve health center cash flow, L.A. In addition, policy actions can speed health centers' abil- Care prepaid its 2020 pay-for-performance (P4P) pay- ity to recover from the financial shocks of the pandemic ments in April 2020, based on what they had paid out in and ensure they can continue to provide essential access 2019, and determined they would then reconcile these to care. As the state considers how to prioritize health payments at the end of the year. FQHCs that earned equity, California's health centers have a vital role to play. less in P4P than they received in advance will be able to The experiences of health centers during 2020 high- keep the funds, and those that earned more in P4P will lighted in this brief point to those policy solutions. These California Health Care Foundation www.chcf.org 6 include extending reimbursement for telehealth beyond A Small Business Administration (SBA) Paycheck the pandemic and reforming the PPS system to allow Protection Program (PPP) loan amounts for each health centers to provide more flexible care beyond just eligible California FQHC: in-person visits. $ Based on surveys of health centers in several states conducted by Capital Link and the National A deeper exploration of these operational changes and Association of Community Health Centers policy considerations will be provided in a final report to (NACHC) between April 13, 2020, and June 9, be published in spring 2021. 2020, and $ For non-survey respondents, the SBA PPP loan Data Sources and Methodology amount was calculated for eligible health cen- The data analysis contained in this report is based on ters (those with 2019 UDS FTEs less than 450), information from the following sources: from FY 2019 Audited Financials: Salaries & Related Expenses, divided by 12 and multiplied A Audited financial statements of FQHCs (both Section by 2.5. 330s and Look-Alikes) as reported by fiscal year. $ If a health center's FY 2019 audit was not avail- A Uniform Data System (UDS) reports as submitted able, the loan amount was calculated as follows: annually by FQHCs by calendar year to the Health Total Revenues (from 2019 UDS) multiplied Resources and Services Administration (HRSA). by the California FY19 median for Personnel- A HRSA's Data Warehouse for the number of California Related Expense as Percentage of Operating FQHC sites and the size of COVID-19 grants issued Revenue, as calculated from the FY19 audits. to each California FQHC. The result was then divided by 12 and multi- plied by 2.5. A HRSA's Health Center COVID-19 Survey, including weekly responses from health centers from April 4, A COVID-19-related expenses include costs of pur- 2020, through January 1, 2021. chasing PPE, telehealth implementation, and facility modifications related to COVID-19. They were esti- A US Department of Health and Human Services (HHS) mated on a per-patient per-month basis, based on Data Warehouse for the amount of Provider Relief data collected from health centers in multiple states Fund (PRF) General Distribution issued to each by NACHC and Capital Link between March and California FQHC health center: October 2020. $ General Distribution estimated at 2% of 2019 Net Patient Service Revenue. Financial audits were collected directly by Capital Link to create the data set for California health centers. The A HHS Data Warehouse for the amount of each PRF comparative national health center data set was devel- Rural Distribution issued to each rural California oped from Capital Link's proprietary database of health FQHC health center: center audited financial statements. $ Rural Distribution based on FQHC site addresses mapped by RUCA (rural-urban commuting area) codes 4 to 10, with a fixed amount of $103,253 per rural site. A FCC telehealth grants as published by the FCC on July 8, 2020. Holding On: How California's Health Centers Adapted Operations and Care for Patients During the Pandemic www.chcf.org 7 Health center financial health and performance were About the Authors calculated for all California FQHC Section 330 and Carol Backstrom, MHA, is the vice president for Medicaid Look-Alikes (including public entity FQHCs) for which Policy & Programs at Aurrera Health Group, a mission- financial audits were provided to Capital Link. The num- driven national health policy and communications firm ber of audits included in the data set varies each year, based in Sacramento. Allison Coleman, MBA, is the as Capital Link continues to add audits to its database chief executive officer of Capital Link, a national non- as they become accessible. The health center data set profit organization focused on strengthening FQHCs examined for the current analysis is outlined as follows: - financially and operationally - in a rapidly changing marketplace. Capital Link helps health centers plan for Table 3. N umber of Audits, California FQHCs sustainability and growth, access capital, improve and 2013–19 (fiscal year) optimize operations and financial management, and FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 articulate their value. 134 145 155 163 164 167 157 About the Foundation The California Health Care Foundation is dedicated to Table 4. N umber of UDS Reports, California FQHCs 2013–19 (calendar year) advancing meaningful, measurable improvements in the way the health care delivery system provides care to the 2013 2014 2015 2016 2017 2018 2019 people of California, particularly those with low incomes 164 182 198 200 197 200 202 and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 8 Endnotes 1.FQHCs are outpatient clinics that qualify for specific 15.Through the CARES Act passed into law on March 27, 2020, reimbursement systems under Medicare and Medicaid. They HRSA made "H8D" grants totaling $1.32 billion to Section 330– include federally funded health centers known as "Section 330 funded health centers nationally. The grants were made via a grantees" and those that meet certain federal requirements, but formula to cover the costs of responding to COVID-19 and for do not receive federal grant funding, known as "Look-Alikes." maintaining or increasing grantee capacity. Awards were made This document includes FQHC public health system clinics and on or around April 7 and 8, 2020, to cover costs incurred within refers to all types as "health centers." one year of award, unless otherwise extended. 2019 UDS Resources, Health Resources & Services 2. 16.Through the Paycheck Protection Program and Health Care Administration (HRSA), n.d. Enhancement Act (PPPHCEA) passed into law on April 24, 2020, HRSA made "H8E" grants totaling $600 million to Section 330– 2019 Pivot Table - Primary Care Clinic Utilization Data, California 3. funded health centers and Look-Alikes nationally. The grants Health and Human Services Open Data Portal, accessed were made via a formula to cover costs to purchase, administer, December 2020. and expand capacity for testing to monitor and suppress COVID- 4.Capital Link estimate based on weekly data submitted by health 19. Awards were made on or around May 7, 2020, to cover costs centers to HRSA beginning in April 2020. See Table 1 for a incurred within one year of award, unless otherwise extended. summary of the financial and operational impacts of COVID-19 17.The Provider Relief Fund, administered by Health and on California FQHCs from March through December 2020. Human Services, was originally funded in the CARES Act California Federally Qualified Health Centers: Financial and 5. ($100 billion), expanded in PPPHCEA ($75 billion), and further Operational Performance Analysis, 2016–2019 (PDF), expanded by the Consolidated Appropriations Act, 2021 ($3 Capital Link, 2020. billion). Beginning in April 2020, it reimburses eligible health care providers for health care–related expenses or lost revenues that 6. California FQHCs, Capital Link. are attributable to coronavirus through July 31, 2021. Through 7.This finding was also bolstered by interview responses from December 2020, health centers have received several rounds of health center leaders who cited workforce competition and "General Distributions" totaling approximately 2% of 2018 net increasing labor costs as their biggest concern before the patient revenue. pandemic. 18.A portion of the PRF was distributed to certain providers 8.See "Methodology" section herein for a description of sources in rural areas beginning in May 2020. Funds were distributed to and methods used to develop estimates for this analysis. eligible sites, totaling approximately $103,253 per site. "Policy Changes During COVID-19," US Dept. of Health and 9. 19.Funded through the CARES Act ($200 million nationally), Human Services, n.d. the FCC made 30 awards between April and July 2020 to California FQHCs for devices and services related to telehealth. 10.Mark É. Czeisler et al., "Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns - United States, 20.Administered by the Small Business Administration, June 2020," Morbidity and Mortality Weekly Report 69, no. 36 Paycheck Protection Program Loans were made available to (Sept. 11, 2020): 1250–57, doi:10.15585/mmwr.mm6936a4. businesses with fewer than 500 employees beginning in April 2020 through the CARES Act (many large FQHCs were not 11.Shannon McConville, "Predicting the COVID-19 Medi-Cal eligible). The program was extended and expanded through Enrollment Surge," Public Policy Institute of California Blog, the PPPHCEA. The loans, which are forgivable if borrowers June 5, 2020. meet certain criteria, were meant to incentivize small businesses 12."California Health Center COVID-19 Survey Summary (including nonprofits) to retain staff on their payrolls. Additional Report," latest data from January 29, 2021, HRSA, n.d., funding and requirements related to this program were added accessed February 10, 2021. through the Consolidated Appropriations Act of 2021, but it is unlikely that health centers will be eligible for this round of 13.Some centers may have also received funding through funding. HRSA's Uninsured Claims Program, funded through the Families First and PPHCE Acts, which covers testing and treatment for uninsured patients. Because of overlapping eligibility criteria with other sources of federal funding, and difficulty in accessing these data in a systematic way, the authors have not separately accounted for funding from this source. 14.Through COVID Supplemental Appropriations passed into law on March 4, 2020, HRSA made "H8C" grants totaling $100 million to Section 330–funded health centers nationally. The grants were made via a formula to cover the costs of responding to COVID-19 and for maintaining or increasing grantee capacity. Awards were made on or around March 27, 2020, to cover costs incurred within one year of award, unless otherwise extended. Holding On: How California's Health Centers Adapted Operations and Care for Patients During the Pandemic www.chcf.org 9