key: cord-0906011-ki7n69zd
authors: Wright, Brad; Fraher, Erin; Holder, Marni Gwyther; Akiyama, Jill; Toomey, Brian
title: Will Community Health Centers Survive COVID‐19?
date: 2020-05-16
journal: J Rural Health
DOI: 10.1111/jrh.12473
sha: 8d321fece828825dce95ff817c03225daffbd8f0
doc_id: 906011
cord_uid: ki7n69zd

nan

2 behavioral health) to all regardless of ability to pay. CHCs also provide other health and social care services including pharmacy, nutrition, care management, health education, transportation, eligibility assistance, interpretation, and community outreach.

CHCs are critical to our nation's ability to respond to COVID-19 in rural and underserved communities, which are experiencing a rapid increase in cases. As of , there are 85,748 cases and 3,298 deaths from COVID-19 in non-metropolitan counties in the US, representing 6.4% of cases and 4.2% of deaths nationwide. 3 Rural residents are at increased risk of poor outcomes due to age and health status, and there are substantially fewer health care resources available in rural areas, meaning that once the virus becomes more widespread in these communities, the results could be disastrous. 4 Throughout their 55-year history, CHCs have survived social and political challenges despite limited resources. Once sustained almost entirely by grant funding, they now rely heavily on revenue from third-party payers, and most CHCs constantly struggle to meet the overwhelming demands of their mission while operating with razor-thin margins. The reality is even more grim in non-expansion states where there has been no influx of Medicaid dollars to offset previously uncompensated care.

Unfortunately, the current COVID-19 pandemic has exacerbated the financial vulnerability CHCs face. As shown in Table 1 , survey data collected by the Health Resources and Services Administration (HRSA) indicate that most-but not all-CHCs can provide COVID-19 testing, but nearly 15% of delivery sites are closed and over 10% of staff cannot work. Patient visits have declined by more than half compared to pre-COVID-19 levels, and more than half of remaining visits are being conducted virtually. 5

Data from the National Association of Community Health Centers (NACHC) suggest many CHCs are experiencing dramatic decreases in net revenue-between 70% and 80%-as patients stop coming to CHCs because of stay-at-home orders and fears of COVID-19 exposure. The CHC workforce is also being reduced because of COVID-19 exposure/infection and the use of CHC staff as relief for hospital staff stretched thin.

Meanwhile, CHCs' COVID-19-related expenses have increased for personal protective equipment (PPE), medical tents, testing supplies, and increased sanitation efforts. Amidst declining revenues and increasing costs, CHCs are closing delivery sites and/or furloughing staff. 6 NACHC projects that over the next 6 months, CHCs will lose $7.6 billion in revenue and be forced to eliminate over 100,000 jobs. 7 COVID-19 is also accelerating CHCs' adoption of telehealth, as payers revise policies to classify CHCs as distant site providers and increase telehealth reimbursement during the crisis. This may improve health care access in rural areas, but it also strains CHCs' already precarious financial solvency as they invest significant resources in infrastructure. 8 Simultaneously, many rural residents lack high-speed Internet connections, and many lower income and older adults may lack web cameras, technological know-how, or a monthly Internet subscription. Most of these challenges can be overcome using telephonic visits, but-notwithstanding a new rule from the Centers for Medicare & Medicaid Services (CMS) that increases reimbursement for these visits 9 -many insurers refuse to pay for them, meaning CHCs often lose money each time they pick up the phone to care for a patient. 10

The federal government has taken action to help CHCs at this critical time. Other CARES Act funding may also help CHCs, 13 which offers potentially forgivable loans to help small businesses meet payroll and avoid layoffs. Based on language in the CARES Act, CHCs should be given priority for PPP loans because they are located in "underserved and rural markets" and their patient majority governing boards mean they are "owned and controlled by socially and economically disadvantaged individuals." 15 Ironically, some of the nation's largest and most successful CHCs may be hardest hit, because they have more than 500 employees and are ineligible for the PPP. While just 6.5% of CHCs fall into this category, they employ 31% of CHC staff and treat 28% of CHC patients nationally. 13 HRSA and CMS have used their regulatory capacity to relax policies in ways that will help CHCs function more effectively during the crisis. HRSA is allowing CHCs to temporarily suspend services at delivery sites, change the scope of services provided, offer COVID-19 screening and triage at off-site locations, and alter operating hours without seeking formal approval. 16 Similarly, using Section 1135 Waiver authority, CMS is relaxing CHC staffing requirements to increase flexibility, recognizing that CHCs may experience staffing shortages due to Following COVID-19, CHCs Will Be Needed More Than Ever Before

The pandemic's effects will be felt long into the future, both as new cases are detected and as health outcomes deteriorate for patients who have delayed care for urgent and chronic conditions. We are just beginning to see the significant effects that the crisis is having and will continue to have on behavioral health, with a marked rise in depression and anxiety. 18, 19 By providing integrated primary care and behavioral health services, CHCs will continue to serve an invaluable role in addressing these health care needs, reducing emergency department visits and potentially avoidable admissions, thereby easing the burden on already strained hospital systems.

The debate over what our "new normal" will look like is far from settled, but one thing is certain: we will need a robust primary care safety net just as much as, if not more than, we always have. Public health efforts to combat COVID-19, while effective, have also drastically reduced economic activity. The prospect of a serious recession or depression is very real. We have already witnessed a record number of individuals filing for unemployment benefits, and the economy may or may not quickly recover once social distancing policies are loosened. People will lose their health insurance coverage along with their jobs. In some cases, people will newly qualify for Medicaid or Marketplace coverage; in others, people will simply become uninsured. Either way, demand for CHC services will increase. 8 To bolster the program, NACHC is petitioning Congress for $77.3 billion in CHC funding. This includes $7.6 billion to offset revenue lost due to COVID-19, $7.8 billion over Rural communities will benefit greatly from the rapid expansion of telehealth capacity at CHCs in response to COVID-19 if payers sustain the increase in telehealth reimbursement post-pandemic. Still, there remains a crucial need for skilled providers-physicians, nurse practitioners, physician assistants, dentists, behavioral health providers, pharmacists, nurses-to serve America's rural populations. CHCs are well positioned to provide that care, but their future is now threatened by the COVID-19 pandemic. We must invest in CHCs now or risk many of them closing. Allowing the COVID-19 pandemic to lead to a reduction in primary care, dental, and behavioral health capacity in rural areas with an already limited supply of providers would prove catastrophic. 

Department of Health and Human Services. HHS awards $100 million to health centers for COVID-19 response

Rural Data Brief No. 2020-2. Iowa City, IA: RUPRI Center for Rural Health Policy Analysis

It really is the perfect storm': Coronavirus comes for rural America

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Letter from the National Association of Community Health Centers to Mr. Alex Azar, Secretary of the U.S. Department of Health and Human Services

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