By NACHC Data Analysis Team, Dr. John W. Hatch Center for Science
Community Health Centers (CHCs) are central to the health care safety net, providing care to 52 million patients nationwide. They are especially vital in states that have not expanded Medicaid, where affordable coverage options are scarce. An increasing percentage of CHC patients are privately insured. Continued affordable coverage for these patients depends upon swift congressional action to extend expiring enhanced premium tax credits.
Rapid growth in privately insured patients
The coverage expansions that began in 2014 quickly reshaped the CHC patient mix. Previously, patients who were privately insured were a modest percentage of overall CHC patients. Between 2015 and 2016, however, CHCs added more than 1 million patients with private insurance, accounting for about one-quarter of all new privately insured patients by 2016. Over the longer-term, privately insured CHC patients grew steadily, from 2.1 million in 2005 to 7.1 million in 2024. (Figure 1)
Coverage gains through the Affordable Care Act (ACA) Marketplace coverage likely drove much of the increase.
Today, at least 2 million CHC patients are enrolled through the ACA Marketplace. While the exact share of all privately insured CHC patients covered through the ACA Marketplace is not known, the data show these plans have been a major factor in expanding private coverage at CHCs.
This coverage growth has helped reduce reliance on uncompensated care funding and enabled CHCs to expand services in behavioral health, oral health, and chronic disease management. Particularly in non-expansion states, where commercial plans play a larger role, looming threats to affordable Marketplace coverage pose a significant threat to these critical services.
CHC patient coverage patterns in expansion and non-expansion states
Coverage patterns differ significantly between expansion and non-expansion states. (Figure 2) In expansion states, 52% of CHC patients have Medicaid, 20% have private insurance, and 15% are uninsured. In non-expansion states, 32% have Medicaid, 28% have private insurance, and 28% are uninsured. With reduced Marketplace coverage in these states, the number of uninsured CHC patients will likely rise substantially, straining finances and limiting service capacity.
Looming coverage losses and sustainability challenges
To make Marketplace coverage more affordable for those who might otherwise be uninsured, temporary federal subsidies – or enhanced premium tax credits – were instituted as part of the American Rescue Plan Act in 2021 and extended through the Inflation Reduction Act in 2022. These tax credits have made Marketplace coverage more affordable for over 24 million Americans. However, these subsidies expired at the end of December 2025. Last week, the House of Representatives passed a bill that would extend the premium tax credit enhancements for three years. For these changes to take effect, however, the Senate also must pass the bill.
Unless Congress extends marketplace support beyond 2025, premiums are expected to rise sharply, and over 4 million people nationwide could lose marketplace coverage, with some analyses projecting up to 5.4 million.This comes on top of 8 million projected to lose Medicaid coverage. Those most likely to rely on Marketplace coverage include low-income adults above Medicaid thresholds, working adults with variable income, people with disabilities who do not meet Medicaid eligibility criteria, rural residents, and young adults without employer-sponsored insurance.
In addition to the catastrophic impact on patients, loss of coverage would put CHCs under severe strain, forcing them to care for far greater numbers of uninsured patients while operating with limited resources. CHCs report operation margins below -2% on average, and almost half have less than 90 days of cash on hand, leaving them financially vulnerable.
Additionally, one-quarter of CHCs have margins below -5% (based on unpublished analysis of 2024 CHC audits). The situation is further compounded by the expiration of federal CHC funding on January 30th. As a result, CHCs may be forced to reduce costs by shrinking the workforce, leaving vacancies unfilled, or scaling back service lines, leading to longer appointment wait times and delays in preventive and chronic care visits and directly limiting care availability.
If CHCs are forced to close sites, patient mortality and poor outcomes are likely to rise. These risks are not limited to the loss of premium tax credits. Additional Marketplace restrictions, including additional verification requirements and shorter enrollment periods, further limit access and add to CHCs’ uncompensated care burden.
Consequences for local economies
The consequences extend beyond health. CHCs also anchor local economies. Staff reductions or slower hiring could affect over 650,000 jobs linked to CHC operations, including over 200,000 jobs in rural communities, while decreased patient volume reduces spending on the local economy. Together, these dynamics can undermine both health outcomes and economic stability in the communities CHCs serve.
Protecting coverage and care
CHCs are essential to care for millions of patients, particularly in underserved and non-expansion states. ACA Marketplace coverage has helped CHCs manage uncompensated care and expand critical services, but declining coverage would strain already fragile margins, limit service availability, and threaten both patient and community health and economic stability. Swift congressional action is needed to preserve affordable ACA Marketplace coverage and critical health services for millions of Americans.