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Four Concerns for Community Health Centers in a Post-Health Reform World

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I am a big fan of New York State's community health centers (technically termed federally qualified health centers, or FQHCs); I always call them the "jewels in the crown of our health system." These centers have been early adopters of an approach to primary care that addresses the needs of the most vulnerable New Yorkers. There are 57 organizations that run these centers all around New York, in both rural and urban areas, caring for nearly 1.6 million patients each year.

So, I have been following closely how the new expansion of health insurance encouraged by the Affordable Care Act might affect the operations and wellbeing of community health centers. The hope (and the original expectation) is that an expansion of the number of insured New Yorkers will be an unqualified good thing for centers that have always treated so many uninsured patients. But lately, I have had some concerns that expanded health care coverage among New Yorkers is not necessarily a good thing financially for FQHCs.

The key change that Obamacare will bring about is that more than 1 million New Yorkers will gain health care coverage. Most of those who are newly insured will be covered by the private insurance policies sold on the New York State of Health marketplace, the health insurance exchange that we have been reading so much about for the past couple of months.

So, how could this not be a great thing for community health centers? Won't it mean more revenue from newly-insured patients?

My first concern is that the private insurance companies are tough bargainers and may not offer community health centers very generous payment rates for the services they provide. Each insurance plan is supposed to have at least one FQHC in its network of providers and it is supposed to offer viable rates to at least one FQHC per county, but the details of what this means are not so clear. And, in the many counties with more than one FQHC, some of the centers could be offered rates that are much lower than what covers the actual cost of caring for needy patients.

My second concern is that some plans sold through the exchanges have high deductibles and other cost-sharing provisions. Health centers may have a difficult time collecting these payments from the relatively low-income individuals and families they serve. Particularly in the beginning of the year, when patients have not yet met their annual deductibles and will have to pay the entire cost of a health care visit out of pocket, health center patients may struggle to afford care. Historically, FQHCs have used sliding-scale fees that take into account patients' income and ability to pay, and have received support from charity care pools to make up the difference. But it is not clear whether health centers will be able to tap into charity care funds if they use sliding scale fees for insured patients who have not yet met their deductible.

Third, adding to this concern is the future of charity care pools across the board. Inevitably, the federal and State programs that have helped pay for services to the uninsured and underinsured in New York will be shrinking as the health reform law takes hold. The logic in shrinking those resources is that expanded numbers of insured patients should lead to less needed charity care, but it is likely that charity care will not decrease at the same rates for all types of providers. With an estimated 1.6 million New Yorkers remaining uninsured even after health reform is implemented fully, some health centers (and hospitals, too) will continue to see large shares of uninsured patients.

The final item on my list of concerns for community health centers is that some newly insured patients will not continue to use these centers as their primary source for health care. They will now have an insurance card and could choose instead to seek health care services with private physicians and in hospital-based ambulatory care centers. These types of primary care providers also often manage to negotiate good rates with private insurance companies, better than what community health centers can likely receive. Newly insured patients will be attractive new business for these providers, so community health centers will need to work even harder to establish themselves as the provider of choice for patients who have health insurance.

Of course, these concerns could be overcome, but it will take energy and vigilance.

Community health centers, with help from their professional associations (like CHCANYS, the Community Health Care Association of New York State), first need to be sure they are getting fair reimbursement rates from private insurers. Centers will also need to focus on delivering an excellent patient experience; having shorter wait times and extended hours will be important in a world of increased provider competition (and it will also be good for patients!). Community health centers also need to be sure charity pool dollars follow needy patients and can be used to partially support the care of the newly insured who end up in plans with high copayments and deductibles.

The Affordable Care Act's most promising aspects for community health centers, however, are the parts of the new law that encourage health system transformation and that put a bigger emphasis on expanded primary care and on closer integration of primary care with acute and specialty care. Community health centers have vibrant roles to play in the type of transformed health system that many people are working toward to improve the patient experience for all New Yorkers.