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Health Center Federal Policy

One year ago the world as we knew it ground to a halt. It has been a year of staggering tragedies, with more than 540,000 deaths. We are not the same. Last March, Community Health Centers prepared to fight the unknown with essentially one hand behind their back, unaware of the heavy price the pandemic would exact on their patients, staff, board members, their families and friends. There were no COVID tests, limited supplies of protective gear and N95 masks, and looming funding cuts that threatened to shut their doors.

Today, we are hopeful. We are resilient. Health centers have not only survived a global crisis but stand as part of the solution to resolving it, ensuring equity in hard-to-reach communities. They are tasked with using their mission, their skills, their nimble adaptability, and their longstanding trust to bring COVID vaccines to underserved communities.

“We need to bring vaccines to people where they are, which is why Community Health Centers are so important,” explained Jeffrey Zients, the White House Coronavirus Coordinator recently on NBC’s Meet The Press. “They serve over 30 million Americans. Two-thirds of those that use community health centers live below the poverty line. Sixty percent come from communities of color. That’s why the president established a program to send vaccines directly to Community Health Centers.”

It’s working. A new analysis from the Kaiser Family Foundation shows that health centers are vaccinating those who disproportionately bore the worst of the pandemic.

https://www.kff.org/coronavirus-covid-19/issue-brief/are-health-centers-facilitating-equitable-access-to-covid-19-vaccinations/

More than half of those who received their first dose of a COVID-19 vaccine through a health center were people of color, an indication that health centers appear to be doing a better job of reaching people of color than are overall vaccination efforts. People of color accounted for 54 percent of those who received their first dose of the vaccine through a health center, including 26 percent who were Hispanic and 12 percent who were Black.

These health center vaccination efforts are now getting a boost in resources from Congress, which this week passed the $1.9 trillion COVID relief package, known as the American Rescue Plan. The legislation, which President Biden signed today, includes $7.6 billion in flexible emergency COVID-19 funding for Community Health Centers (see NACHC press release). The package will help spur more shots in the arms across the country, now that health centers are receiving direct allocations of the COVID vaccines.

In addition to the 250 health centers receiving direct access to the vaccines, the Health Resources and Services Administration and the Centers for Disease Control and Prevention have invited an additional 700 health centers to participate. These 700 health centers will have the opportunity to join the program over the next 6 weeks, increasing the total number of health center participants to 950. To learn more, please visit this link.

We still don’t know when this pandemic will officially end — but there is light at the end of the tunnel and maybe, just maybe, we’ll be writing about something else one year from now.

Photo courtesy of CCI Health & Wellness Services, Silver Spring, MD.

Sue Veer, CEO, Carolina Health Centers, Inc.

My name is Sue Veer and for the past 15 years I have served as CEO for Carolina Health Centers, Inc.  (CHC). We are a federally qualified health center (FQHC) – also known as a Community Health Center – that serves as the primary care medical home for over 28,000 patients across seven rural counties in South Carolina.  We operate 12 medical practices, a seasonal farmworker health program, and two community pharmacies that also deliver prescriptions to our patients in those outlying rural areas. 

Early in my tenure I realized the essential role prescription medication plays in improving health outcomes and the cost effectiveness of care.  By providing our patients with access to needed medication we help them effectively manage acute and chronic conditions.  By keeping our patients well we reduce hospital admissions and the use of costly settings like emergency rooms and urgent care centers.

The 340B program makes drugs affordable and supports other critical health care services

The 340B Drug Pricing Program, enacted by Congress in 1992, is what enables health centers like mine to provide access to affordable prescription medication.  This law requires manufacturers to sell prescription medication for outpatient use to safety-net providers – those serving the most vulnerable populations – at a discount, enabling not just affordability, but also providing savings that support the availability of more comprehensive health care services. 

There is much that is unknown, misunderstood, and even misconstrued about health center pharmacy programs and the 340B Drug Pricing Program. 

The problems with the Trump Administration’s Insulin Executive Order

Let’s talk about the cost of insulin for example.  Ostensibly to address the high cost of these medications, the Trump Administration issued an Executive Order requiring Community Health Centers to provide insulin to our patients at no more than our 340B cost.  The Final Rule for that EO was to be effective on January 22, 2021; however, President Biden has delayed the effective date by 60 days, igniting conjecture that the Biden Administration is “raising” the price of insulin.  Let’s examine the inaccuracies in that line of reasoning:

  • As of 2018 there were 26.8 million Americans diagnosed with diabetes[1].  Only 2,709,755[2] of those are patients of the nation’s 1,400 Community Health Centers.  The Trump Administration EO applied ONLY to Community Health Centers, meaning that it would only impact those patients with diabetes receiving their care – including having their prescription for insulin filled – at a health center.  The EO did ABSOLUTELY NOTHING to reduce the cost for the vast majority of people with diabetes in this country!
  • The EO was and is a completely unnecessary measure to solve a problem that doesn’t exist for the patient it impacts.  By both mission and mandate all services available at Community Health Centers – including prescription medications – are provided regardless of insurance status or ability to pay.  Each health center is required to offer an income-based sliding fee for those patients whose incomes fall at or below 200% of the poverty level[3].  Our sliding fee discount applies not just to the uninsured, but also to insured patients with high deductibles and copays — and if the patient can’t afford even the deeply discounted cost of their insulin, they are not turned away.  The cost is covered by other resources like patient assistance programs and at my health center, a Benevolence Fund that is supported by staff contributions. 
  • The implementation of this unnecessary EO will result in an unwieldy administrative burden that adds to the operating costs of nonprofit health centers, which already operate at thin margins.  In addition, it will eliminate the health center’s ability to retain any of the savings from participation in the 340B program – even those savings necessary to cover the cost of dispensing the drugs. 

Congress envisioned the 340B program as a way to give vulnerable populations access to affordable prescription medication, but their intention was so much more far-reaching and impactful.  Their intention was to support a strong and viable health care safety net that protected the most vulnerable of Americans.  Health centers have taken that vision and made it a reality, but recent developments including the Trump Administration EO regarding insulin and injectable epinephrine threaten the viability of our pharmacy programs so essential to the comprehensive primary care medical home model.

[1] American Diabetes Association https://www.diabetes.org

[2] 2018 UDS National Health Center Data www.data.HRSA.gov

[3] HRSA Health Center Program Expectations www.bphc.hrsa.gov/programrequirements

There’s good news for the jobless and uninsured struggling in the pandemic. Among the flurry of executive orders President Biden signed last week was one granting the Centers for Medicare & Medicaid Services (CMS) the ability to provide a Special Enrollment Period (SEP) for individuals and families to apply and enroll in the coverage they need, given the extraordinary circumstances of the COVID-19 pandemic. The SEP will be available to consumers in the 36 states served by health insurance Marketplaces that use the HealthCare.gov platform.  To get the word out, CMS  will conduct outreach activities to encourage eligible people to enroll in health coverage.

“The COVID-19 pandemic has underscored the need for Americans to have access to high-quality, affordable health care coverage,” said Tom Van Coverden, President and CEO of NACHC. “Health centers support opportunities and mechanisms to ensure that all Americans have the chance to sign up for health coverage – especially during a public health emergency.”

The effort kicks off February 15th  and continues through May 15, 2021. Marketplaces that use the HealthCare.gov platform will offer an SEP and will be open to all Marketplace-eligible consumers who are submitting a new application or updating an existing application. Consumers will be able to access the SEP through a variety of channels: through HealthCare.gov directly, the Marketplace call center, or direct enrollment channels. 

Additionally, consumers can work with a network of over 50,000 agents and brokers who are registered with the Marketplace, along with over 8,000 trained assisters, ready to assist consumers with their application for coverage. In 2019, health centers employed over 4,400 enrollment assisters who provided nearly 5 million assists to individuals seeking affordable health care coverage. CMS plans a host of activities to get the word out and ensure a broad and diverse range of consumers are aware this is happening.  Some consumers may already be eligible for other existing SEPs, Medicaid, or the Children’s Health Insurance Program (CHIP) – they can visit HealthCare.gov now to find out if they can enroll even before the new SEP.

For more information, visit: https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response-covid-19-emergency.

For more information about the Health Insurance Marketplace®, visit: https://www.healthcare.gov/quick-guide/getting-marketplace-health-insurance/.

On its first full day in office, the Biden-Harris administration released a comprehensive document laying out its widely anticipated plan to fight the COVID-19 pandemic. As we expected, the plan makes numerous references to the central role that Community Health Centers will play in this effort, given their status as trusted health care providers serving communities hard hit by the pandemic, testing more than 7,730,000 patients and diverting non-acute COVID cases from overwhelmed hospitals. The national strategy also includes a welcome discussion of the need for additional funding to enable health centers to expand their vaccination activities.

“We’re excited to see the Biden administration moving so quickly to initiate a coordinated national strategy to fight the pandemic and the significant role it envisions for Community Health Centers,” said Dr. Ron Yee, NACHC’s Chief Medical Officer. “Community Health Centers are up to the task, including helping to administer COVID vaccines. They just need vaccines, supplies, appropriate reimbursement, and a well-functioning vaccine reporting system to support them in meeting the ambitious goals set out in the White House plan.”

At 198 pages, the White House plan is detailed. It includes the following specific goals where health centers are identified as having a key role:

  • Create as many venues as needed for people to be vaccinated.
  • Drive equity throughout the vaccination campaign and broader pandemic response.
  • Expand access to high-quality health care.

Of particular note is the plan’s description of a new federal partnership with health centers to accomplish the administration’s goal of creating vaccination venues that people trust:

“Launch new partnership with Federally Qualified Health Centers nationwide. Federally Qualified Health Centers (FQHCs) serve more than 30 million patients each year—one in 11 people nationwide. Many are people of color and individuals struggling to make ends meet. Given the critical role that these providers play in their communities, the federal government, through HRSA and CDC, will launch a new program to ensure that FQHCs can directly access vaccine supply where needed. At the same time, the Administration will encourage jurisdictions to engage health centers closely in their overall jurisdictional plans. And to ensure that health centers have the resources they need to successfully launch vaccination programs, HRSA will launch a new program to provide guidance, technical assistance and other resources to prepare and engage these providers nationwide.”

Read the full plan.

With 2020 in the rearview mirror, Community Health Centers confront new challenges and a year that will hopefully look a lot different than the last. With passage of the stimulus package in the closing days of the year, health centers have some resources. President Trump signed into law on December 27, 2020, a massive spending bill that includes $1.4 trillion in government funding through the remainder of FY 2021 and $900+ billion in emergency COVID-19 relief. The funding package also includes Surprise Billing legislation. The bill passed Congress by a vote of 359-53 in the House and 91-7 in the Senate.

Congress approves mandatory funding for Community Health Centers

The bill includes the following funding provisions for Community Health Centers:

Three years of Mandatory Funding from FY2021 to FY2023 at $4 billion per year, $1.7 billion in Discretionary Funding (appropriations) for FY2021 and three-year mandatory funding extensions for Teaching Health Center Graduate Medical Education Program (THCGME), and the National Health Service Corps (NHSC).

The law also grants all health care providers (including health centers) the flexibility to calculate lost revenues under the Provider Relief Fund. There are also resources and support as health centers join with federal, state, and local partners to carry out a massive vaccination strategy and help bring about an end to the pandemic.

COVID-19 vaccination begins

The vaccination effort at health centers is already underway. NACHC is tracking reports of health centers getting their first doses of the vaccine and starting the process of vaccinating both staff and patients, depending on the doses available. A few highlights we know about so far:

Waianae Comprehensive Health Center in Hawaii has nearly finished vaccinating their 650 employees with the Pfizer COVID vaccine. The center mastered the complex transportation, storage, and vaccination clinics with impressive precision and has begun the process of educating the public about the safety of the COVID vaccine with a town hall that you can watch here.

CompleteCare Health Network in Bridgeton, New Jersey, has vaccinated about 130 staff members and health care volunteers with the Moderna vaccine and will continue vaccinating staff later this week. They are making plans to expand vaccination to a larger group, such as first responders, later in January, according to Kimberly Tweed, Director of Marketing & Development at the center.

Also in New Jersey, Henry J. Austin Health Center held a Facebook Live event in December to answer questions about vaccine safety, featuring CEO, Dr. Kemi Alli, CMO, Dr. Rachael Evans, and New Jersey Primary Care Association’s President and CEO, Selina Haq, Ph.D.

In rural southwest Georgia, Albany Area Primary Health Care (AAPHC), a COVID hot zone a few months ago, is preparing to vaccinate community members starting next week with their latest shipment of the Moderna vaccine.

“Phase 1A has been expanded to include adults aged 65 and older, law enforcement officers, firefighters, and first responders to the current group of individuals eligible to receive COVID-19 vaccination,” says Ronda Arline, Director of Nursing for AAPHC, in a press release issued by the health center.

Promoting equitable vaccine distribution

Vaccine equity also remains a special focus. Health centers are working to ensure all community residents who want a COVID vaccine can get one, especially in medically underserved communities of color who have been disproportionately affected by the virus, suffering higher rates of infections and hospitalizations.

Andrea Skolkin, CEO of OneWorld Community Health Centers Inc. in South Omaha, NE, underscored to the local Omaha World-Herald in a recent interview that minority populations “especially devastated” by the virus should be prioritized because they work jobs that expose them to greater risk.

Health centers serve millions of essential workers, millions of America’s essential workers – those who harvest our food in the field, clean public spaces, and work in our factories. Health centers also serve 14.5 million people in poverty,  2.9 million people 65 and older, 19 million people who are of minority background, 1.5 million homeless people, and 20 million people with chronic conditions. View our recent infographic to learn more about the work health centers are doing to help communities affected by COVID.

Photo: Karla Pope, Registered Nurse, CompleteCare Health Network, Bridgeton, NJ, prepares the COVID vaccine.

Ron Yee, MD, CMO, NACHC
Ron Yee, MD, is the Chief Medical Officer of NACHC

News that an effective COVID-19 vaccine may be available within months or even weeks is a hopeful sign that an eventual end to the pandemic is on the horizon. But there is much logistical planning ahead to ensure an effective and equitable vaccine delivery system.

Pfizer and its German partner BioNTech have asked the Food and Drug Administration (FDA) to authorize its COVID-19 vaccine for emergency use after clinical trial results showed it was safe and 95 percent effective. Pfizer hopes to produce up to 50 million doses in 2020 and up to 1.3 billion doses in 2021. Each person needs two doses. Another frontrunner, Moderna, is also expected to apply for emergency authorization. While it may be months before the vaccine is widely available for the general public, Community Health Centers stand ready to play a role in a national vaccination strategy.

To prepare, NACHC is collaborating with key partners, such as the Centers for Disease Control and Prevention (CDC) and the Association of Immunization Managers (AIM). NACHC is also coordinating the allocation of 3,697,470 doses of influenza vaccine free to health centers to prevent a potential “twindemic” of both influenza and COVID-19. The goal is to alleviate the potential burden of high rates of flu-related hospitalizations amid a dangerous surge of the virus now happening across the nation.

The Flu Vaccine Is a Dress Rehearsal for COVID-19

In a recent letter to the field, NACHC underscored to health centers and Primary Care Association partners that the flu vaccination campaign is the dress rehearsal for COVID-19 vaccine distribution when it becomes available to health centers. Administering flu vaccines can be used to check and test policies, procedures and workflows.

The CDC’s guidance for a COVID-19 Vaccination Program identifies health centers as one of the entities expected to administer the vaccine. This designation for health centers is based on the fact that their patient populations are at increased risk for the virus. Consequently, NACHC is urging centers to work with local and state health departments to be pre-screened, invited, credentialed, trained, and accepted into the COVID-19 Provider Enrollment and Ordering Management System. The CDC has also published a vaccine planning guidance for providers.

COVID-19 Vaccine Challenges Facing Community Health Centers

Our goal is to ensure efforts to fight the spread of the virus are aligned and coordinated and that health centers are sufficiently resourced for the long battle ahead. However, the COVID-19 vaccine is uncharted territory for all providers. There are many logistical hurdles that NACHC is tracking. For instance:

Staffing: Health centers have more than 50,000 nurses, medical assistants and outreach staff on the ground ready to organize once a safe and approved vaccine becomes available. At this point, we estimate that to vaccinate all current health center patients and staff, as many as 60 million doses of COVID-19 vaccine would be necessary. More doses would likely be needed to vaccinate additional community residents. Protecting health center workers on the frontlines is also a vital concern as more than 12,000 health center workers have been infected by COVID-19.

Vaccine Hesitancy: Immunizations are a very important part of primary care prevention, and health centers have a solid history of optimizing immunization coverage in at-risk populations as a trusted health care source. But we also know that many members of our patient populations have skepticism about government vaccination programs — and, certainly, a COVID-19 vaccine will be no exception. We need to prepare now and develop culturally responsible messaging for patients, providers and care teams around the following key issues for the COVID-19 vaccine that address: safety, access, quality, cost, and timeliness. The other challenge is that the COVID-19 vaccine will require two doses to be effective and require in-person visits at a time when many patients have been staying at home and avoiding preventive care services.

Storage & Logistics: There is a lot we don’t know but once the COVID-19 vaccine is ready for distribution the focus will be on storage and cold chain technology management. Human resource needs for the release of vaccines to health center sites will also be a consideration, as well as the management of supply needs (syringes, needles, documentation tools such as tablets, and protective gear for workers). NACHC is also communicating with the Bureau of Primary Health Care regarding FTCA coverage on COVID-related activities for health centers, including administering vaccines.

Community Health Centers Will Rise to the Challenge

The past few difficult months have shown that health centers are always adapting workflow models to meet the challenges of the pandemic and better meet the ongoing needs of their patients. Indeed, in a matter of weeks, they radically changed how they practice medicine in response to COVID-19.

To prepare for the COVID-19 vaccine, NACHC will work hard to ensure health centers are informed and equipped with the tools they need to stop the spread of COVID-19 in medically underserved communities.

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