Even as the coronavirus has exposed and deepened racial health disparities, it also has imperiled the health care providers that many minority and poor communities rely on for the medical care they receive.
Public hospitals and community health centers — the safety net providers that take all patients regardless of ability to pay — have sustained enormous financial losses during the COVID-19 crisis. Patients have stayed away from medical offices, deterred by government warnings, fears of infection and the canceling of dental care and elective surgeries.
Patient volumes and revenues have recovered somewhat since the early months of the pandemic, but they remain far below normal for safety net providers, which have slim operating margins.
Safety net providers and health policy experts warn that without additional federal support soon, those providers will be forced to cut services or even close — especially if a second COVID-19 wave materializes. Closures would make it even harder for vulnerable communities to get care, rendering racial health disparities even more pronounced.
“We treat those who no one else will treat,” said Allen Bennett, CEO of Park West Health System, a community health center in Baltimore, which saw patient volumes drop by half in March and April, contributing to revenue losses of more than half a million dollars through July.
While the center has received more than that in federal aid, it may have to pay back some of the money, which only can be used to meet payroll and for COVID-19 uses such as testing and personal protective equipment. It cannot be used to pay for medical supplies, rent, utilities and insurance. The financial strains have forced Park West to close one of its three branch sites, at least temporarily.
“We treat the marginal people, the working poor,” Bennett said. “If we go away, who’s going to take them?”
Mark Knight, chief financial officer of Jackson Memorial Health System, the safety net hospital system in Miami-Dade County, Florida, said he expects Jackson will have lost about $100 million by the end of the month as a result of COVID-19. Jackson has received that amount in federal aid, but the losses are mounting with no additional help in sight.
“We aren’t going to get federal support indefinitely, so how do we sustain ourselves going forward?” Knight said. “That’s our challenge.”
Dr. Bruce Siegel, president of America’s Essential Hospitals, which lobbies for safety net hospitals, said Jackson’s predicament is common. Some of his member hospitals have reported revenue drops between 20% and 30%, he said, much of it the result of suspended elective surgeries.
The losses may be even more severe for the 1,400 community health centers. According to a study published in August by George Washington University’s Milken Institute School of Public Health, the centers’ revenue was down nearly $2.2 billion between early April and mid-July. The losses, the study’s authors say, have resulted in the closure of one out of 10 branch community health center sites since the beginning of the pandemic. They have led to furloughs and layoffs as well.
Health centers have received $2.5 billion from the federal Paycheck Protection Program and have used other federal grant money to help ramp up telemedicine and COVID-19 testing. But Sara Rosenbaum, a professor of health law and policy at George Washington University and one of the co-authors of the study, said much of the money comes with restrictions. And it is running out fast.
“The dropping revenue is continuing and cannot be replaced fast enough,” she said. “The one-time money is going to run out. For a couple of months it may be that the new money offset the old, but now all that new money is gone and the old has not come back.”
Could Get Worse
As bad as those numbers are for the health centers, the situation could get considerably worse soon. A federal fund that community health centers have relied on since 2010 will expire in November without congressional action. That funding accounts for nearly 14% of the overall budgets of the nation’s community health centers. Without it, officials with some of those centers say they would have to sharply curtail services and close more sites.
Congress’ failure to act is part of a long pattern of temporarily extending money for the centers rather than coming up with a long-term solution. The current period of uncertainty already has had a negative impact, impairing recruitment, forcing centers to postpone purchasing needed equipment, and upending planning, including for capital projects.
Both political parties support community health centers, but the money has become entangled with surprise medical billing, drug prices and other controversial issues. If those issues don’t move through Congress, neither does funding for the health centers. That has left health centers in a perpetual state of uncertainty and frustration, never sure whether the funding will again be there as another extension comes to an end.
“It hampers and derails our planning,” said Sonya Bruton, CEO of CCI Health and Wellness Services, a community health center based in Silver Spring, Maryland. “We cannot look ahead in the way we need to look ahead.”
Vincent Keane, CEO of Unity Health Care in Washington D.C., said he lost out on two doctor recruits as a result of the funding uncertainties. “We had two doctors we hoped would come, but they were aware of the funding cliff we were facing and decided not to take the chance.”
He fears doctors and nurses on staff will decide the funding anxieties are no longer worth it. “Are providers going to want to keep working in this kind of environment?”
The unpredictable funding has forced Bruton to hold off on raises for staff members, many of whom think they are entitled to better pay in light of the risks they face in treating people with COVID-19. “That’s a worry,” she said, “that people feel they can’t lose more ground.”
About half of CCI’s patients are on Medicaid or its sister plan, the Children’s Health Insurance Program. Another 38% are uninsured, meaning that they pay little or nothing.
Providing Primary Care
Nationally, nearly 70% of patients seen by health centers have incomes below the federal poverty level, a population recognized as being in worse health than those with greater means. About 48% of health center patients are on Medicaid, and 23% are uninsured. More than 60% of their patients identify as belonging to a racial or ethnic minority. Altogether, the centers provide primary care to about 29 million Americans in both urban and rural areas.
“They are the single most important provider for primary care in medically underserved rural and urban communities,” said Rosenbaum of George Washington University. Not incidentally, the health clinics will be expected to play an outsize role in administering COVID-19 vaccines when they become available.
Even as health centers were losing revenue, the pandemic forced new expenses on them. They had to acquire personal protective equipment, often at vastly inflated prices as they competed with other desperate medical providers. Many centers have had to rely on handmade masks and gowns from patients, sometimes accompanied by home-cooked meals or treats. They had to retrofit offices with plexiglass and install air purifiers. Some brought infectious disease experts on board.
The federal money, including from the Paycheck Protection Program, helped, but that is quickly evaporating with no certainty that more will follow.
“What keeps me up at night is what happens when that [federal] funding is gone,” said Marcie Mir, CEO of El Centro de Corazón, a health center with four branches on Houston’s east side. “What happens in 2021?”
Many health centers saw patients virtually rather than through office visits after federal reimbursement policies on telemedicine were relaxed. But that didn’t work for some patients without computers or other electronic devices or in areas without reliable broadband. It also didn’t work for patients with chronic conditions such as hypertension or diabetes who couldn’t be monitored properly from afar.
Mir is trying to find money to give patients remote monitoring equipment.
Many health center officials say they worry about the patients who are staying away, going without needed vaccinations or allowing health conditions to fester and worsen.
Some have found workarounds. Health Partnership Clinic in the Kansas City area runs a drive-thru immunization service to make sure kids are getting their shots. It also is giving mammograms to patients one at a time in a van for women nervous about coming inside a clinic to get tested.
Many health centers have experienced infections among staff, which has resulted in quarantines and shortages of workers. Some centers report having lost staff members who are afraid of treating those with the virus. “We’ve had resignations,” said Bruton. “Some left for telemedicine-only practices.”
With health centers closing, Bruton said, patients would have to go farther from homes to find care, if it is even available. Many, she said, will end up doing without because of a lack of transportation or an inability to take time off from their low-wage jobs. “It would put up more obstacles to care, something that we were put in place to provide,” she said.
Any reduction in health centers, policy experts say, would only deepen health disparities. The same would result in diminished services from safety net hospitals. Many of those hospitals operate housing, food security, transportation and other social service programs under the theory that improvements in those areas contributes to the overall health of people.
Siegel, of America’s Essential Hospitals, said he fears that the pandemic’s financial burdens on safety net hospitals will force cuts to those programs. “It’s unfortunate, but when you’re trying to make payroll, you may have to decide those are things you’re going to have to do without.”