Clin­ics brace for more unin­sured

Modern Healthcare - - NEWS - By Steven Ross John­son

The na­tion’s 1,200 fed­er­ally qual­i­fied com­mu­nity health cen­ters would be hit hard by a pos­si­ble U.S. Supreme Court rul­ing this month elim­i­nat­ing pre­mium sub­si­dies for fed­eral ex­change-plan en­rollees.

Such a rul­ing would have a ma­jor ef­fect on the clin­ics, which are re­quired by law to serve all pa­tients for free or on a slid­ing-scale ba­sis. They would then have to pro­vide far more un­com­pen­sated care, clinic lead­ers say. Given the short­age of pri­mary-care physi­cians, com­mu­nity health cen­ters have been key pri­mary-care providers for Amer­i­cans who have re­ceived ex­panded pri­vate and Med­i­caid cov­er­age un­der the Af­ford­able Care Act.

“The vast pre­pon­der­ance of peo­ple with ex­change cov­er­age who are get­ting care at health cen­ters are be­low 200% of the poverty level,” said Dan Hawkins, pol­icy direc­tor for the Na­tional As­so­ci­a­tion of Com­mu­nity Health Cen­ters. “If they lose that sub­sidy, they lose the abil­ity to af­ford their cov­er­age.”

If the court strikes down the sub­si­dies in King v. Bur­well, it’s es­ti­mated that 6.4 mil­lion Amer­i­cans would lose sub­si­dies and that many would drop cov­er­age be­cause it would be­come un­af­ford­able. Hawkins es­ti­mated that com­mu­nity health cen­ters na­tion­ally are serv­ing nearly 1 mil­lion pa­tients cov­ered by plans pur­chased through the fed­eral ex­changes.

The clin­ics’ loss of rev­enue from pri­vately in­sured pa­tients would come on top of a decline in state fund­ing for the cen­ters over the past few years.

With the sub­si­dies gone, the cen­ters “could draw a line and say they sim­ply don’t have the re­sources to serve any more peo­ple,” Hawkins said. “But if th­ese are cur­rent pa­tients who have sim­ply lost their cov­er­age, the cen­ter is go­ing to have to fig­ure out a way to serve them.”

A sud­den spike in unin­sured pa­tients could force many clin­ics to cut back or de­lay health­care ser­vices. “From a fi­nan­cial stand­point it could be dev­as­tat­ing to us,” said Kay Crane, CEO of Pied­mont Ac­cess to Health Ser­vices, a com­mu­nity health cen­ter in south cen­tral Vir­ginia.

Founded in 2001, Pied­mont has grown with the help of fed­eral grants, ex­pand­ing into den­tal and be­hav­ioral health­care. Un­like many other cen­ters, Pied­mont sees a sub­stan­tial share of pri­vately in­sured pa­tients, who ac­count for nearly a third of its pa­tient-care rev­enue.

Crane said a large por­tion of those pri­vately in­sured pa­tients re­ceive ACA pre­mium sub­si­dies, and that a court rul­ing end­ing those sub­si­dies could cut over­all rev­enue by up to 30%. The ef­fect would be ex­ac­er­bated by the fact that Vir­ginia is one of 21 states that has not ex­panded Med­i­caid for low­in­come adults. The re­sult­ing rev­enue loss would crimp her clinic’s plans to ex­pand ser­vices, she said.

More broadly, a rul­ing strik­ing down the sub­si­dies would set back many years of ef­forts by pres­i­dents and con­gres­sional lead­ers of both par­ties to ex­pand health­care ac­cess to low­in­come Amer­i­cans through the cen­ters. For ex­am­ple, Sen. Roy Blunt (R-Mo.), an ar­dent Oba­macare foe, re­cently vis­ited a St. Louis com­mu­nity health cen­ter that has ex­panded through ACA fund­ing. “I think (CHCs) are a great ex­am­ple of how you meet the needs of a com­mu­nity that oth­er­wise would not have their needs met nearly as ef­fec­tively,” Blunt told St. Louis Public Ra­dio.

The num­ber of cen­ters has grown from 730 in 2000 to about 1,300, op­er­at­ing more than 9,000 sites. That sharp growth was made pos­si­ble by fed­eral grants un­der the ACA. The cen­ters served more than 21 mil­lion pa­tients in 2013, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. Of those pa­tients, 14% were cov­ered by pri­vate in­sur­ance, 41% by Med­i­caid and 35% were unin­sured.

The rise in pri­vately in­sured pa­tients at the cen­ters as a re­sult of Oba­macare has given the clin­ics greater fi­nan­cial ca­pac­ity to serve the unin­sured, said Judy Solomon, vice pres­i­dent for health pol­icy at the left-lean­ing Cen­ter on Bud­get and Pol­icy Pri­or­i­ties.

Dr. Stephen McKer­nan, CEO of Lone Star Fam­ily Health Cen­ter in Con­roe, Texas, said his cen­ter is used to serv­ing a high per­cent­age of unin­sured peo­ple and would con­tinue to do so, re­gard­less of the loss of sub­si­dized cov­er­age.

On the other hand, his pa­tients would suf­fer. “This law­suit would pun­ish the peo­ple who are buy­ing in­sur­ance with a sub­sidy who have very lit­tle means to get health­care in­sur­ance oth­er­wise,” he said.

Dr. Stephen McKer­nan says his pa­tients at Lone Star Fam­ily Health Cen­ter in Con­roe,

Texas, will suf­fer if they lose in­sur­ance sub­si­dies.

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