“So, when can I actually see you again, doc?” Silence fills the space of our televisit, save for the occasional crackle of static. Do we tell our patients the truth — that we don’t know whether we’ll ever see them again?
As residents, we were already terrified by the threat that Covid-19 poses to the lives of our patients. Now we’ve come to fear for another victim: community health centers (CHCs).
We serve part-time at Upham’s Corner Health Center in Boston, one of roughly 1400 federally qualified CHCs. These clinics provide comprehensive medical care to nearly 30 million Americans regardless of their insurance or immigration status; 70% of their patients have household incomes below the federal poverty level, more than half are members of racial or ethnic minority groups, and one in five residents of rural areas receives care from a CHC.
At our clinic, Covid has led to widespread staffing furloughs, reduced hours, and decreased services. Upham’s is not alone. A sharp decrease in clinic visits cost CHCs billions of dollars in a matter of months. According to the Kaiser Family Foundation, more than 15% of CHC sites had temporarily closed as of May 8, 2020.1
CHCs are financially vulnerable. They depend on federal subsidies for nearly 20% of their revenue, most of which comes through the Community Health Center Fund (CHCF) established under the Affordable Care Act. But this support has been tenuous. In 2017, Congress allowed the CHCF to lapse for several months before renewing it for just 2 years. Since then, it has been renewed for only months at a time, and it’s now set to expire in November 2020.
Although Covid has decimated budgets throughout the health system, CHCs lack any buffer: more than 40% of these centers had negative operating margins in 2018.2 Unless Congress acts immediately, we may lose CHCs as we know them.
CHCs have been critical to the U.S. response to Covid. They were already caring for the black and brown communities that have been most affected by the pandemic. Now, more than 90% of them are also Covid testing sites, more than half the people they test are people of color, and the test-positive ratio in CHCs is more than double the national average.1 Given the disastrous delays in testing and tracing in the United States, CHCs are providing life-saving surveillance and mitigating the profound inequalities of our Covid response.
Our clinic has the privilege of caring for working-class people of color. Many are essential employees working in nursing homes and grocery stores; others lack housing or stable incomes. Our patients often live in multigenerational households and cannot socially distance. In short, they are vulnerable.
Upham’s, like so many CHCs throughout the country, has risen to the challenge of protecting people at risk by relying on the heroic efforts of clinicians and staff. Even as nearly a quarter of staff members remain at least partially furloughed and supplies of personal protective equipment remain limited (10% of CHCs have less than a week’s supply of N95 masks and gowns), our colleagues have worked overtime to arrange for Covid testing and to counsel families in Spanish, Vietnamese, and Cape Verdean Creole.3
They’ve also managed to transition to telehealth despite lacking funding for robust information technology services. Less than half of CHCs had adopted telehealth as of 2018, citing lack of financing and training as major barriers.4 Our mentors have scrambled to build clinical systems to engage our predominantly non–English-speaking population, many of whom lack stable phone access, but it has been a challenge. As we prepare for a Covid resurgence, we need to ensure that all CHCs have the resources, technology, and personnel to do right by patients.
CHCs are key to treating other medical problems as well. Evidence suggests that they are able to perform as well as or better than private clinics with respect to common quality metrics and that they can reduce costs by preventing emergency visits.5 As many as 30 million Americans will lose their jobs and thus their private health care coverage during this pandemic. Given their mandate to accept all patients, CHCs can help serve the newly uninsured — but cannot meet demand if they lack the capacity.
CHCs also train the next generation of health care workers in the art of healing. As new physicians, we often reflexively focus on studies, procedures, and medications. At Upham’s, we’ve learned that our prescriptions can’t heal all. We have absorbed the greatest lessons from the moments when a recent immigrant describes her depression after a wave of xenophobic public policy moves or when a man questions his purpose on his release after two decades in prison. We’ve come to see that the most therapeutic intervention is often not to “do more,” but simply to “be with.”
This philosophy is part of a moral framework underpinning CHCs that can help us reimagine health care in the United States. The centers were founded during the “War on Poverty,” building on the radical recognition that power shapes pathology; staff at one of the first centers famously wrote malnourished patients prescriptions for food and dug wells to increase access to clean water. Today, in addition to caring for all comers, CHCs are governed by the people they serve: by statute, patients must make up more than 50% of each CHC board.
CHCs’ embrace of universal primary care, human dignity, and accountability place them in stark contrast to our mostly private health care system in which millions of people lack access, trust, and ownership. Yet the very existence of CHCs proves that we can center our care on the needs of poor Americans. As our nation grapples with racism in the wake of Covid and police brutality, we would argue that CHCs can be the foundation of an antiracist health system. We believe health care and public health professionals should call on Congress to rescue our health centers and lay the foundation for a health system that works for everyone.
First, Congress should adequately fund CHCs. We cannot rely on our private health system to care for Americans in crisis. Though the $1.3 billion provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act was a start, it amounts to less than 10% of CHCs’ normal annual revenue. The Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, now under consideration, would provide $7.6 billion in emergency funding to CHCs to help clinics make up for revenue losses. Congress should also provide CHCs with $77 billion over 5 years, as requested by Senators Elizabeth Warren (D-MA) and Bernie Sanders (I-VT) and Representative Ayanna Pressley (D-MA), reauthorizing the CHCF for this period, funding infrastructure for scaling up telehealth, and supporting critical workforce programs such as the National Health Service Corps and the Teaching Health Center Graduate Medical Education program.
Second, we believe it’s critical to provide universal coverage to the millions of Americans set to lose employer-sponsored coverage. The Medicare Crisis Program Act, sponsored by Representatives Pramila Jayapal (D-WA) and Joe Kennedy III (D-MA), would guarantee coverage and limit out-of-pocket expenses in the short term. Moving forward, CHCs could be integrated within a unified system under a Medicare for All plan and we could transition toward a global payment model that guarantees sustainability.
Finally, we could extend the reach of our CHCs by investing in a New Deal–like program that would hire hundreds of thousands of unemployed Americans, as proposed in a bill sponsored by Senators Kirsten Gillibrand (D-NY) and Michael Bennet (D-CO). This new corps could focus on Covid contact tracing in the short term and chronic disease management in the long term.
A pandemic reveals a truth that is often easy to ignore: as a society, we are only as well off as our most vulnerable members. Out of the darkness of Covid-19, we have an opportunity to rebuild a more humane and just America. We believe CHCs should be not just the foundation of a new system, but our moral North Star.