Community health centers across the country are anxiously watching the budget impasse in Congress. Some 1,400 clinics depend on federal funds to serve the most vulnerable patients, and any interruptions in their funding will only add to the financial pressures they already face.
These federally-qualified health centers, or FQHCs, are often located in low-income or rural communities. They deliver care on a sliding-fee scale and are mandated to serve everyone regardless of a patient's ability to pay. For millions of Americans, these clinics are the only way they can access primary care.
At a Pittsburgh FQHC, North Side Christian Health Center, federal grants comprise approximately a quarter of the clinic's budget, says clinic CEO Bethany Blackburn.
Without it, she warns, North Side Christian might have to cut hours or services, such as dental and behavioral health care.
This would be a blow to North Side Christian's patients, including those who receive care at a satellite clinic located in Northview Heights, a majority-Black neighborhood.
Northview Heights doesn't have a grocery store, a post office, or a library — but it does have this clinic, which makes health care, at least, accessible.
The clinic sits on the ground floor of a mid-rise apartment building that provides subsidized housing. Late afternoons are busy as parents hustle kids to pediatrician appointments before the office closes at 5:00 pm.
Lenee Hayward has brought her preschool-age son; she suspects he has asthma like some of his older siblings. Hayward watches closely as Dr. Dallas Malzi listens to the boy's lungs.
"He does have some wheezing," says Malzi, who prescribes an inhaler and recommends a follow-up appointment to make sure his breathing doesn't get worse this winter.
Providing more than just primary care
Down the hall from Malzi, case manager Leslie Hawthorne is researching emergency services for a patient who has recently become homeless and is living in a broken RV.
Hawthorne has spent all afternoon on the case, researching food assistance and mental health treatment for the patient: "It is a really complex case because she also has high-risk medical diagnoses, and that's the kind of patient we see a lot of here," Hawthorne says.
This kind of care coordination is common at FQHCs. Many patients' health conditions are complicated by housing instability or poverty, so in addition to medical care, clinics often provide food assistance or transportation to get people to and from appointments.
FQHCs get funding from several sources, though their second-largest revenue stream are federal grants, which are now in jeopardy. (Their largest source of support comes in the form of reimbursement from Medicaid, a public insurance program jointly funded by the federal and state governments.)
The longest federal government shutdown in recent U.S. history ended in January 2019, and lasted 34 full days. FQHCs anticipate that if another shutdown occurs, their grant funding will be restored, eventually.
But even a short interruption is disruptive, and during previous funding crises, safety-net clinics had to make tough choices, according to Melinda K. Abrams, the executive vice president for programs at the Commonwealth Fund.
To navigate the uncertainty, FQHCs might have to institute hiring freezes, delay signing leases or vendor contracts, reduce hours of operation or lay off staff, Abrams says.
Even before the current threat of a government shutdown, FQHCs have been struggling. High inflation means they're paying more for medical supplies, and they've had trouble retaining staff in a competitive labor market.
These problems have affected another multi-site FQHC in southwestern Pennsylvania, Centerville Clinics, which serve some 40,000 patients in rural areas.
Until Congress fixes the budget impasse, Centerville will have to watch its discretionary spending, including employee salaries and benefits, according to Executive Director Barry Niccolai.
"You always have to worry because you can never predict the future and what may happen," he says.
A 'financial one-two punch' for safety-net clinics
Recent changes to the Medicaid program have only added to the financial tumult: For the first time since the start of the COVID pandemic, Medicaid is requiring its low-income beneficiaries tosubmit paperwork and prove eligibility before re-enrolling.
This enormous bureaucratic task is being handled at the state level, but clinics who serve Medicaid patients are finding that large proportions of their patients are losing coverage temporarily, or even permanently. Until their eligibility is restored, or they obtain different insurance, the clinics must treat them for free.
"It's kind of a financial one-two punch," says Abrams.
In 2021, Medicaid enrollees comprised nearly half of the 30 million patients treated by FQHCs across the country.
To cope, federally funded clinics are scrambling to help people navigate the process needed to re-enroll in Medicaid coverage.
Several groups of patients will need the extra help, predicts Bradley Corallo, a Medicaid analyst with the nonpartisan health-policy think tank KFF. Those include patients in rural communities, those with limited-English proficiency and people who struggle with housing instability.
"People don't know they lost their Medicaid until they show up at a doctor's office, or to go fill a prescription, and a lot of times, that's going to be at a health center," says Corallo.
Helping so many patients navigate Medicaid enrollment is a labor-intensive project, and inevitably some patients will slip through the cracks, even if they are eligible, says Susan Friedberg Kalson, the CEO of Squirrel Hill Health Center, another FQHC in Pittsburgh.
"We will just have to absorb those people, those costs on the thin air that we live on. And somehow, we will make it happen, because we always have," says Kalson. "But I really do worry that we're going to have to scale back what we do."
The extent of these fiscal woes varies from clinic to clinic, and Congress could still alleviate some of the pain by passing a temporary funding bill.
At the North Side Christian Health Center, Lenee Hayward contemplates the possibility that her medical home could suffer setbacks from the looming budget impasse. She recalls how it was before she started bringing her family here: they had to take two buses, just to see the pediatrician.
"Don't take it away," Hayward says. "We need it."
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