The Collapse of Health Care: The Effects of COVID-19 on U.S. Community Health Centers

Ashley Van Slyke

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According to the U.S. Centers for Disease Control and Prevention (CDC), community health centers are “community-based and patient-directed organizations that serve populations with limited access to healthcare.”1 Approximately 1,400 federally-funded community healthcare clinics serve roughly 28 million Americans, who are primarily low-income individuals (91%), people of color (63%), and uninsured individuals. They are located in areas with a high demand for accessible, affordable healthcare, and address a wide range of needs including primary care, chronic disease, behavioral health, and substance use treatment.2 Community health centers often provide access to housing and food-related support, services for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex and Asexuality (LGBTQIA+) patients and family members, and treatment for physical and mental illness. Many locations also provide physical, occupational, and speech therapy. Because of the populations they serve and the resources they provide, community health centers are considered safety net providers. 

These centers are primarily funded through state and federal Medicaid programs, among other federal means.1 In the wake of the COVID-19 pandemic, 1.98 billion federal dollars have been directed to community health centers through the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act. This additional funding was provided to increase COVID-19 testing, pay for personal protective equipment (PPE), and sustain facilities.2 Community health centers can also use these funds for employee or contractor payroll, employee health insurance, rent or mortgage payments, equipment lease payments, or electronic health record licensing.3 Thus, community health centers have played a pivotal role in our country’s response to the COVID-19 pandemic. Unfortunately, these establishments have had trouble sustaining all of their facilities and providing all of the services their communities need. Limitations on the use of federal funds, decreased capacity for in-person visits, and increasing state and federal debt prevent community health centers from adequately serving the vulnerable populations who need them most.4

Effects of COVID-19 on Community Health Centers
The pandemic has led community health centers to reduce the typical services offered before the outbreak and increase COVID-19 testing and telehealth visits. Because of stay-at-home orders, rising COVID-19 cases, social distancing, and increased cleanliness demands, clinics have largely ceased in-person appointments. Before the pandemic, in-person appointments accounted for 68% of the revenue at community health centers.1 Now, whenever possible, centers have switched to telehealth visits. Telehealth has presented community health workers with many complications in providing optimum care, including challenges related to insurance payments, telehealth training, technology availability, health literacy, and language barriers. Near the beginning of the pandemic, the U.S. government halted all elective procedures to ensure the maximum number of beds were available for COVID-19 patients. While elective procedures are now permitted, telehealth appointments are still preferred, and many centers remain unable to offer the same in-person services they formerly provided. In shifting to respond to COVID-19, community health centers have seen their revenue and stability slashed, and key programs and resources eliminated.4

The Public Health of Vulnerable Populations
The closure of community health centers removes a safety net program for Americans across the nation. Community health centers most often serve vulnerable populations, including people of color and other minorities, older adults, uninsured families, and individuals with disabilities. The COVID-19 pandemic has disproportionately affected the health of these populations along with their financial and social well-being.8 Black, Indigenous and People of Color (BIPOC) are more likely to suffer from chronic diseases, such as heart and lung diseases, and may use drug and alcohol treatment programs, housing support, and other services offered at community health centers.9 The closure of community health centers threatens to remove access to integral diagnosis, treatment, and care amidst a pandemic that heavily affects BIPOC people, further deteriorating BIPOC health.10 Many individuals and families within the LGBTQIA+ community utilize the healthcare and social support resources, which are integral to promoting their whole health. Without access to community health centers, the health of this disenfranchised population will suffer. For older adults and individuals with disabilities, local community health centers are often their long-term treatment providers. Transferring care to locations farther from their homes during the COVID-19 response interferes with their access to healthcare and exposes this population to unnecessary risk. Additionally, the COVID-19 response has left many people furloughed or unemployed and without health insurance, which is often tied to employment. Finding other avenues of health insurance while also seeking care places an unnecessary strain on both physical and mental health.11 The closure of community health centers disproportionately affects America’s most vulnerable populations and the country faces a steady decline in public health, complicating efforts to reopen society and the economy.

Community Health Center Closures Across the U.S.
Throughout the United States, community health centers have converted to mainly COVID-19 testing sites. Despite this shift, many still lack the funds to sustain themselves. An article in U.S. News cited several different centers experiencing difficulties. Centers in New York City, Pittsburgh, Los Angeles, and many other cities have shifted their focus away from general health care and instead focus primarily on COVID-19 testing and telehealth visits. A community health center in Illinois has lost $181 million due to a lack of drop-in visits.4 In Indiana, the Community Health Network has closed an outpatient rehabilitation clinic and a specialty hospital, laying off approximately 121 people, despite receiving $218 million in federal stimulus aid. Patients of the network have been left confused and without readily available care. Children with disabilities often used the specialty hospital and are currently without treatment. Many are forced to seek care from hospitals that are more expensive and farther from their community.3 In Minnesota, one of the largest nonprofits in the state, HealthPartners, has closed seven community health centers and a drug and alcohol treatment program, citing a lack of patient visits, a ban on elective procedures, and insufficient funding. They are replacing their in-person services with a video and telehealth approach. Most community health centers face a similar outcome: reduce and replace in-person capacity with telehealth, virtual visits, and drive-up testing.5 

ACR Health, located in Central New York, provides physical and behavioral health care, substance use treatment, syringe exchanges, insurance enrollment, housing support, and resources for LGBTQIA+ individuals and families, among many other services. The center serves approximately 16,000-20,000 individuals.6 ACR Health has also been affected by the COVID-19 pandemic, and with facilities closing across Upstate New York, many will be left without access to important care.7

Recommendations for Policy and/or Practice
Without increased financial support from state and federal government entities, many more community health centers will face budget cuts and closures, dismantling the safety net of the nation’s healthcare system. If the physical and mental health of the country’s most vulnerable individuals continue to go untreated, the U.S. will enter a secondary public health crisis. Funds distributed to community health centers must not only increase, but expand in purpose, allowing centers to use the money to maintain staff and services beyond COVID-19 relief efforts.12 Reallocating funds within city budgets to uplift community organizations, like these health centers, will improve public health and prevent further health issues in the wake of COVID-19. Local, state, and federal governments must come to understand the effects of limited access to healthcare on the everyday lives of their citizens as well as the nation’s ability to remain afloat throughout the COVID-19 pandemic.13

References

  1. Centers for Disease Control and Prevention. (2018, March 21). Community Health Center Strengthening. Retrieved July 15, 2020, from https://www.cdc.gov/nchhstp/preventionthroughhealthcare/healthdepartments/commhealthcenters.htm
  2. Corallo, B., & Tolbert, J. (2020, May 20). Impacts of coronavirus on community health centers. Kasier Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/
  3. Kenney, K. (2020, July 1). Questions surround hospital, clinic closures despite influx of federal stimulus money. RTV6Indianapolis. Retrieved July 15 2020 from, https://www.theindychannel.com/news/call-6-investigators/questions-surround-hospital-clinic-closures-despite-influx-of-federal-stimulus-money
  4. Galvin, G. (2020, April 3). Can community health centers survive the coronavirus fight? U.S. News and World Report. Retrieved from https://www.usnews.com/news/healthiest-communities/articles/2020-04-03/can-community-health-centers-survive-the-coronavirus-fight
  5.  Snowbeck, C. (2020, July 2). HealthPartners closing 7 clinics with COVID-19 changes. StarTribune. Retrieved July 15, 2020, from https://www.startribune.com/healthpartners-closing-7-clinics-with-covid-19-changes/571587412/?refresh=true
  6. News. (2020). ACR Health. Retrieved July 15, 2020, from http://acrhealth.org/news/serviceandoperations
  7. Moriarty, R. (2020, July 1). ACR Health to lay off 70 workers, close 3 offices. Syracuse.com. Retrieved July 15, 2020, from https://www.syracuse.com/business/2020/07/acr-health-to-lay-off-70-workers-close-3-offices.html
  8. Centers for Disease Control and Prevention. (2020, July 21). Other people who need extra precautions. Retrieved July 22, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/other-at-risk-populations.html
  9. Brewer, L. C., & Cooper, L. A. (2014). Race, discrimination and cardiovascular disease. American Medical Association Journal of Ethics16(6), 455-460. 10.1001/virtualmentor.2014.16.6.stas2-1406
  10. Substance Abuse and Mental Health Services Administration. (2020, May 26). Behavioral Health Equity. Retrieved July 15, 2020, from https://www.samhsa.gov/behavioral-health-equity/black-african-american
  11. Gordon, D. D. (2020, March 23). What to do if you lose your health insurance during the COVID-19 crisis. MSN Money. Retrieved July 15, 2020, from https://www.msn.com/en-us/money/other/what-to-do-if-you-lose-your-health-insurance-during-the-covid-19-crisis/ar-BB11zREf
  12. Center for Disease Control and Prevention. (2019, October 25). Adults with disabilities: Ethnicity and race. Retrieved July 15, 2020, from https://www.cdc.gov/ncbddd/disabilityandhealth/materials/infographic-disabilities-ethnicity-race.html
  13. Ollove, M. (2017, December 18). Congress won’t act; now community health centers weigh closures. The Pew Charitable Trusts: Stateline.  Retrieved July 15, 2020, from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/12/18/congress-wont-act-now-community-health-centers-weigh-closures

Acknowledgements
The authors thank Megan Ray and Shannon Monnat for edits on an earlier version of this brief.

About the Author
Ashley Van Slyke is an undergraduate student studying Nursing at the University of Pittsburgh and a Research Assistant at the Lerner Center for Public Health Promotion at Syracuse University (ajvansly@syr.edu).

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