Since the start of the COVID-19 pandemic, the number of people enrolled in Medicaid has increased by nearly 20%, with close to 85 million people currently enrolled in Medicaid and CHIP. However, approximately 16 million people – including nearly 7 million children – are expected to lose coverage once the various coverage protections, established by Congress ultimately expire along with the federal public health emergency (PHE) designation. Known as the “continuous coverage” provision (enacted by the Families First Coronavirus Response Act), states are prohibited from disenrolling Medicaid beneficiaries during the PHE. Health and Human Services (HHS) Secretary Xavier Becerra recently renewed the PHE effective April 16, 2022 for another 90 days, and has said states will be given at least 60 days notice before its ultimate expiration, meaning the earliest the PHE would end is mid-July of this year. To learn more please visit the NACHC Blog.
NACHC Blog
Since the start of the COVID-19 pandemic, the number of people enrolled in Medicaid has increased by nearly 20%, with close to 85 million people currently enrolled in Medicaid and CHIP.
However, approximately 16 million people – including nearly 7 million children – are expected to lose coverage once the various coverage protections, established by Congress ultimately expire along with the federal public health emergency (PHE) designation.
In a new development, there is reason to believe that the PHE may be extended. In late 2021, the US Department of Health and Human Services stated it would provide states with 60 days’ notice prior to termination of the federal PHE. The 60-day window of notice passed earlier this week with indications that another extension is expected [see CNN interview with Biden Administration officials on continuing PHE]. Should HHS officially announce another extension, the PHE will have a new expected end date in mid-October 2022. The time period for states to process redeterminations remains the same. States are prohibited from disenrolling Medicaid beneficiaries during the PHE.
NACHC and the broader Medicaid community are closely monitoring and assessing ways to support patients. There is a lot at stake: nearly half of health center patients are enrolled in Medicaid, and as a result of the pandemic, continuous coverage, and other policy flexibilities, 90% of health centers have been able to treat more patients. States will have to redetermine eligibility for Medicaid, and it is critical that health centers be at the forefront of working with enrollees who are at risk of losing coverage.
To support states to prepare for the unwinding, the Centers for Medicare and Medicaid Services (CMS) issued new guidance last month that advises states they will ultimately have 14 months to complete their redetermination and renewal process from the time they choose to “unwind.” States can begin the redetermination process up to two months prior to the declared end of the PHE; however, they must maintain continuous coverage of all beneficiaries during the early start period. States are also required to develop “Unwinding Operational Plans” that outline strategies for the redetermination process.
Some state officials have expressed concerns about the timeline and the resulting “churn” of beneficiaries – people who will be disenrolled for a period of time before regaining coverage either through Medicaid, Affordable Care Act marketplace coverage or another pathway. Outreach is a major challenge because many beneficiaries have moved during the pandemic due to housing instability. Without updated contact information, state Medicaid departments face the difficulty of locating beneficiaries and sending notices to enrollees about their eligibility status. CMS also released a communications toolkit with strategies for enrollees and state agencies to engage in for more effective outreach.
Health centers play a vital role in assisting communities with Medicaid enrollment through their outreach and enrollment workers. In 2020, health centers employed almost 7,000 staff who provided 3.6 million enrollment education sessions to patients. For beneficiaries who are eligible for coverage through Affordable Care Act exchanges, health centers can begin working with patients to start the transition to coverage other than Medicaid. As states prepare for the termination of the PHE and resulting Medicaid redeterminations, it is imperative that health centers, PCAs, and HCCNs work closely with state Medicaid departments and other stakeholders to address the challenges. NACHC recommends that health centers develop campaigns to inform patients of the upcoming Medicaid “cliff” and work closely with their state’s Medicaid department and managed care organizations on their Unwinding Operational Plans.
NACHC recently hosted a briefing on the Medicaid “cliff” and state activities on March 28, 2022 and will continue to monitor the situation as it evolves. Please refer to the resources below for additional information:
- NACHC Memo on Unwinding CMS Guidance
- Medicaid Unwinding webpage
- CMS Slides for Health Plans
- Eligibility and Enrollment Planning Tool
- CMS State Renewal Report
- Perspectives on Guidance from CBPP
Mallika Yadwad is a Program Associate with NACHC’s Federal & State Policy team.
Editor’s note: This story was updated on May 19th, 2022 to reflect new developments.
By Sheila Och, Chief Engagement & Equity Officer; Clare Gunther, Chief Advancement & Communications Officer. Lowell’s employee Equity Advisory Committee also reviewed this blog.
To mark our 50th anniversary two years ago, Lowell Community Health Center (Lowell CHC) installed a timeline in the lobby of our building, a renovated textile mill building in downtown Lowell, MA. The timeline’s start date: 1970, when Lowell CHC was established.
This June, we’ll be adding another panel to that timeline as we celebrate Juneteenth. The panel is titled “An Acknowledgement.” In it, we acknowledge that, without the labor of enslaved workers in the South, our historic mill building would not exist.
When it comes to working toward a more just and inclusive organization, Lowell CHC has learned that the first step is acknowledgement:
We must acknowledge the injustices that have played and do play out against people of color in this country.
Acknowledge that we, as a community health center born out of the Civil Rights movement, need to reconnect with and remain centered on that charge.
Acknowledge that we must constantly examine and adjust organizational practices to ensure they don’t perpetuate the same systemic barriers we pledged to dismantle.
Acknowledge that we must learn from and trust the voices in our community.
Since its inception, Lowell CHC has been at the forefront of providing culturally responsive and inclusive care and education. That commitment became heightened in 2009, when members of our Teen BLOCK youth program bravely led the way in giving voice to the first community-wide acknowledgement of racism in Lowell. In doing so, the youth held us accountable to our promise, our responsibility, and our purpose as a community health center. We recommitted to advancing equity, inclusion, justice, and more pointedly, anti-racism work. How could we not?
This acknowledgement has led to action. And we acknowledge it has not always been easy, or seamless. There have been some uncomfortable conversations and moments. Two years ago, the vast inequities laid bare by the pandemic, coupled with the murder of George Floyd, challenged us to again confront racism in our community, and our nation, head on. It was then that our Board of Directors adopted a resolution acknowledging that racism is a public health crisis, and committed to taking concrete actions to combat racism through:
- Data equity, transparency and accountability that expands our understanding of population health, inclusive of race, ethnicity, and language. We published COVID vaccine data equity reports to show the community where we stood in reaching those most impacted by the pandemic and to inform our strategy for advocacy and distribution.
- Cultural competency and anti-racism education and training, informed by our Equity Advisory Committee comprised of employees from across the organization, creating regular opportunities and safe spaces to learn, to listen, and to ask questions.
- Equitable and inclusive funding, fundraising, and purchasing decisions, such as more closely tracking efforts to work with businesses that have been historically racially underrepresented and positioning our patients from a standpoint of strength, not deficit.
- Diverse racial representation at all levels of governance, leadership, and workforce. This has included analyzing racial representation of our Board of Directors, leadership, and staff by refining the collection of race/ethnicity data, conducting an organizational pay equity audit, and assuring the broadest reach possible for recruitment, inclusive interviewing, and diverse search committees during that process. We also launched a Health and Wellness Series — learning spaces which featured BIPOC leaders in our community.
- Community and patient involvement in service and program design, including co-leading the region’s COVID-19 Equitable Vaccine Rollout Initiative, comprised of over 50 community and faith-based organizations working with and informing one another.
- Advocacy for policies that improve the health of racial and ethnic minorities at the local, state, and federal levels. We refuse to be silent.
Lowell CHC has also acknowledged that we needed to rename and rethink some of our holidays and celebrations as several are rooted in racism, trauma, and an erasure of true historical context. As examples of our commitment, rather than Columbus Day, we now celebrate Indigenous People’s Day. We also added Juneteenth to our list of holiday observances.
Soon, we will be adding another chapter to our timeline, acknowledging the displacement of indigenous peoples who first settled the region that became greater Lowell. That, too, is part of our history.
Just like understanding and acknowledging our history, the work of equity, inclusion, and anti-racism must be ongoing. This work is both reflective and aspirational. It must always work to ensure people are seen and heard, and that the work is transparent, culturally and linguistically rooted, and mindful of the trauma experienced by immigrants, refugees, and communities of color.
It starts with acknowledgement.
Related Resources
Community Health Centers recently marked the one year milestone of vaccinating and protecting populations from COVID. With now 21 million vaccines administered, and a documented success of fewer deaths and infections in places where there is a health center, another challenge looms: financial uncertainty. With pandemic federal funding winding down, NACHC is tracking how health centers can continue to serve their mission by providing care to uninsured and underinsured Americans as additional COVID-19 variants emerge.
The Biden Administration requested $22.5 billion for COVID-19 services in a broader bill to fund the government. However, lawmakers in Congress were unable to agree on continuing the funding, and ultimately the COVID funds were stripped from the larger package. COVID-19 case numbers and hospitalizations have been in decline, but the White House warned in a recent fact sheet that “without funding, the United States will not have enough additional boosters or variant specific vaccines, if needed, for all Americans.” Also health centers were recently notified that starting on April 6th the federal COVID-19 Uninsured Program would stop accepting claims for vaccinating, testing, and treating COVID patients who do not have the means to pay their medical bills. The fund had been a lifeline during the worst upsurges of the virus, when health centers were exhaustively vaccinating, testing, and treating non-acute COVID cases and diverting them from overwhelmed hospitals.
In a recent letter to Congressional appropriators, NACHC called these developments “troubling” and noted that as “federally supported nonprofit, community-directed provider clinics, health centers operate on thin margins and cannot absorb pandemic-related costs without federal assistance… The announcement that the Uninsured Program will stop accepting claims due to a lack of funding has raised concerns for health centers across the country.”
Top federal health officials are also underscoring their concerns about stalled funding as a new highly transmissible Omicron subvariant is emerging. Health and Human Services Secretary Xavier Becerra warned that “continued execution requires continued support from Congress. And at this stage, our resources are depleted.”
NACHC is closely tracking these developments and will keep you posted.
With more than 61 million people living in areas of the United States designated as Dental Health Professional Shortage Areas (Dental HPSAs), it’s important to shine a light on an emerging dental care team provider that is helping community health centers expand access to dental care, the dental therapist. Oral Health in America (NIH 2021) provided a comprehensive review of the essential role oral health plays in overall health, the inequities in access to dental care, and the steps that can be taken to provide optimal oral health for all.
An increasing number of states and tribal communities have policies and regulations in place which allow health centers to employ dental therapists. We invite you to participate in our webinar on March 30th from 1:30 – 3:00 ET, where you can learn more about how health centers can include dental therapists on care teams to address health inequities.
Register for March 30th webinar
Q: What is a dental therapist?
A: Dental therapists are primary care dental providers. Some have compared the inclusion of a dental therapist to the dental care team as a parallel to the inclusion of nurse practitioners, physician assistants, and certified nurse midwives to the primary care team. In each instance, the new care team member provides high quality care within their scope of practice, expanding access to needed services. Dental therapists can provide services in health center dental clinics, as well as in community settings, such as schools or nursing homes.
Q: What are the benefits of adding dental therapists to your care team?
A: Dental therapists have been serving underserved at-risk communities and providing access to quality care in over 50 countries for years. In the United States, dental therapists are currently authorized to work in 13 states and tribal nations and working in AK, MN, OR, VT, and WA. Multiple studies demonstrated that within their scope of practice the care provided by dental therapists and dentists are of the same quality. Communities that have expanded care teams to include dental therapists report more access to preventive care services and fewer extractions than residents in areas with no dental therapists.
Q: How can dental therapists support health centers?
A: One of the goals of the people centered health home is to have everyone working at the top of their training and licensure. Dental therapists can provide routine services to more patients and help health centers provide more cost-effective care. Dentists can supervise dental therapists without being physically present, which gives dentists the flexibility and time to work on the more complex procedures. The addition of dental therapists can also help diversify the health center workforce.
To learn more about dental therapists and how health centers can expand access to dental care register for our upcoming orientation on March 30 from 1:30-3:00 p.m. ET.
By Jerin Philip and Ryan Smith, NACHC staff
Recently the CMS Innovation Center (CMMI) invited NACHC to speak on recruiting health centers in value-based care (VBC) models. After announcing a new initiative to advance health equity, CMMI kicked off the expert panel with NACHC’s SVP of Public Health Priorities, Ben Money, who described the unique responsibilities health centers share:
“Health centers and other safety-net providers are located in areas of greatest need, have a common mission to assure that no one lacks health care, regardless of their ability to pay, and thereby assume inherent downside risk,” said Money. “CMMI should craft APMs specific to safety-net providers that focus on health outcomes, not downside risk.”
Under[AS1] strict financial constraints for decades, health centers now have a once-in-a-generation chance to be funded in ways that recognize the hidden value they deliver and compensate them for the hidden costs they incur.
Yet, VBC has traditionally been associated with complicated contracts, disjointed reporting burdens, and insufficient data for misaligned quality improvement demands. So the question is can VBC be re-imagined to work better for the safety net and its most marginalized hardest-to-reach patients at health centers?
Make Equity a Less Risky Business
All health care providers, from large hospitals to small family practices, urban and rural, wrestle with reducing financial risk. With system-wide shocks like the pandemic, protection against financial losses remains top of mind.
However, the severity of this challenge sets safety-net providers like health centers apart from all other health care organizations, both nonprofit and for-profit. Most health centers operate on slim financial margins, limited cash reserves, and struggle to remain viable, particularly during the COVID-fueled “great resignation” amid inflationary pressures. Hiring qualified providers and paying allied health professionals like community health workers had been hard enough before the pandemic. With historically static, volume-oriented payments that do not factor in the full cost of care and support for their complex patients, it’s harder now more than ever for health centers to fulfill their mission and mandate to serve all patients who come through the door—regardless of their ability to pay.
Health centers have known for years the inherent financial risk of welcoming patients who fall into special categories (e.g., people with unstable housing, disabilities, language barriers, low-wage jobs). Safety-net providers are critical to ensure Medicaid, Medicare, and uninsured patients receive the medical care and social services necessary for their well-being. For many patients, there is simply nowhere else to turn for comprehensive care.
Account for the Full Value of a Health Center’s Impact
Understanding this reality, NACHC strongly recommends that CMMI develop alternative payment models specific to safety-net providers and address and risk adjusts for social drivers of health while integrating behavioral health. Health centers should be paid for all the work they already do to keep people healthy and out of hospital or institutional care. As other health care organizations have reaped the benefits from the older fee-for-service emphasis on episodic, downstream treatment of chronic illness, NACHC emphasizes the cost-saving innovations that safety-net providers have achieved under enormous challenges. NACHC encourages CMMI to design alternative payment models that “price in” the assumed risks of safety-net providers and spillover economic benefits they generate. With sufficient upfront federal and state infrastructure investments, innovative providers can reorganize and expand their care teams to deliver the wraparound services that drive quality health outcomes for the populations at greatest risk. After decades of doing “more with less,” the safety net stands ready to do even more with more.
Higher Standards for Greater Access
Participating in the federal health center program requires accountability standards, quality oversight, competitive applications/re-applications, and technical assistance that HRSA’s Bureau of Primary Health Care (BPHC) delivers. BPHC requires substantial levels of public accountability for patient outcomes and in caring for the uninsured and underinsured. The accountability and mandatory requirements for health centers are steeper and more exhaustive than what other health care organizations confront. They now need flexibility in VBC models that allow them to tailor their approaches to best meet the needs of their patients and communities.
As health centers consider ways to align their infrastructure to succeed in a more value-driven payment landscape, they need accurate and timely PPS reimbursements that account for the current costs of care and set a solid foundation to build towards value-based payment.
Value starts with primary care and prevention. It gains momentum with useful, timely data that informs clinical practice improvements and more effective care coordination. And it multiplies with greater ties between safety net health care providers and community-based social service organizations.
NACHC will continue to engage all federal agencies, including CMMI and HRSA, who share this vision.
Jerin Philip is NACHC’s Deputy Director of Federal and State Policy. Along with helping coordinate Medicaid policy responses, Jerin advises health centers on VBC policy and helps formulate policy positions with federal partners and national coalitions.
Ryan Smith, Specialist, PCA and Network Relations, has been convening internal and external collaboration with NACHC, and PCAs, and health centers to inform NACHC’s VBC policy positions.