Community Health Centers and Primary Care Workforce: A Rural Safety Net

Rural healthcare is under siege from the current language in the looming American Health Care Act (AHCA), which is raising its own issues along with the vulnerability of Medicaid and the ongoing insurance exchange crises under the Patient Protection and Affordable Care Act (PPACA).

That said, U.S. Sen. Bernie Sanders (I-Vt.) and U.S. Rep. Jim Clyburn (R-S.C.) this week introduced a bill titled  the Community Health Center and Primary Care Workforce Expansion Act.

Created by a mandated funding stream that was part of the PPACA, the Community Health Center Fund provides financial resources for Federally Qualified Health Centers (FQHCs) and the National Health Service Corps (NHSC). Additionally, it created the Teaching Health Center Graduate Medical Education program (THCGME). The PPACA also appropriated funds for these three programs for the 2011 through 2015 fiscal years. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended funding for 2016-2017, but the funding expires Sept. 30, 2017 – and its absence will create a domino effect of healthcare devastation for rural providers.

Additionally, the PPACA included a three-year Nurse Practitioner Residency Training demonstration for FQHCs and Nurse Managed Health Centers (NMHCs) that expired in 2015.

Expansion Act: Possible Hope for Rural Health

The FHQC model currently serves nearly 25 million people across the nation, representing a group of important safety net providers in rural America, where about a third of all residents live in underserved areas. The FQHC model provides enhanced reimbursement from Medicare and Medicaid, as well as other benefits, via a sliding fee scale and comprehensive services (either on-site or by arrangement with another provider), including preventive health, dental, mental health and substance abuse, transportation necessary for adequate patient care, access to hospitals and specialty care, and an ongoing quality assurance program.

Robust Fund Allocation for an Increased Number of Patients

The bill Senator Sanders and Congressman Clyburn introduced would achieve a win-win for urban and rural access to care via the goal of doubling the number of patients served by community health centers/FQHCs, as well as doubling the NHSC budget. This would allow such entities to train more nurse practitioners while adequately funding teaching health centers, all of which are much-needed steps in addressing the primary healthcare workforce crisis. Today there is a predicted shortage of 30,000 primary care physicians and nearly a million nurses over the coming 15 years, nationwide.

Additionally, the Community Health Center and Primary Care Workforce Expansion Act would dramatically expand (and make permanent after 10 years) these four programs and provide robust funding for physical capacity and infrastructure building of community health centers to meet the needs of a growing and medically underserved population.

Legislation Needs and Increased Funding

The proposed bill would provide the following:

• $5.1 billion in FQHC in 2018, rising to a 2027 total of $12.5 billion, allowing capacity building for CHCs/FQHCs to meet the healthcare needs of twice as many people by 2028.
• Increased funding for the NHSC, with its budget projected to rise from $850 million in 2018 to $1.5 billion in 2028. This is especially important since 59 million Americans live in designated primary care shortage areas, 47 million live in dental health care shortage areas, and 97 million live in mental and behavioral healthcare designated shortage areas.
• An increase in funding of THCGME, from $176 million in 2018 to $260 million in 2027. This is critical since teaching health centers are located in 27 states, and 75 percent are FQHCs. Additionally, studies find that, unfortunately, nearly four in 10 THC graduates (compared with 2 percent of traditional medical residents) become primary care providers in nonprofit, community health centers in underserved communities.
• The authorization and appropriation of over $18 billion for capital projects to invest in the infrastructure and expand the physical capacity of the over 1,400 FQHCs in the United States.
• Increased funding for nurse practitioner residency training programs, going from $35 million in 2018 to $80 million by 2027. This is much needed since such programs are in desperate need, from scope of practice  to training, recruitment, succession planning, and expansion into community-based settings.
• A mechanism for a sustained increase of funding for every year after 2027, taking into account the expansive needs of the aforementioned programs so that they never face budget threats in the future.

Get on Board

For those who have FQHC questions, please reach out to Senator Sanders’s Subcommittee on Primary Health and Retirement Security staff at 202-224-5480 – or, if your FQHC would like to be added to the list of support organizations, contact Britt Weinstock (britt weinstock@help.senate.gov), staff director of the HELP Committee.

Endorsers & Legislative Supporters

Organizations endorsing this legislation include the National Association of Community Health Centers, National Association of Social Workers, the National Healthy Start Association, API, Morehouse School of Medicine, Association of Clinicians for the Underserved, NAACP, Public Citizen, National Center for Lesbian Rights, National Minority Quality Forum, Remote Area Medical, Prescription Justice, Racial and Ethnic Health Disparities Coalition, Los Angeles LGBT Center, Lana’i Community Health Center, African American Health Alliance, Bi-State Primary Care Association, Waimanalo Health Center, and STEM4Us.

Sen. Elizabeth Warren (D-Mass.) and Reps. Sanford Bishop (D-Ga.), Yvette Clarke (D-N.Y.), Lacy Clay (D-Mo.), Bonnie Watson Coleman (D-N.J.), Elijah Cummings (D-Md.), Dwight Evans (D-Penn.), Raul Grijalva (D-Ariz.). Colleen Hanabusa (D-Hawaii), Ro Khanna (D-Calif.), Barbara Lee (D-Calif.), Gwen Moore (D-Wisc.), Eleanor Holmes Norton (D-D.C.), Gregorio Sablan (D-M.I.), Jan Schakowsky (D-Ill.), José Serrano (D-N.Y.), Bennie Thompson (D-Miss.), Nydia Velazquez (D-N.Y.), and Frederica Wilson (D-Fla.) are original co-sponsors of the legislation.

Closing

Rural America is at an impasse. On top of the aforementioned additional disparities of care, federal healthcare reform must protect access to care, including enhanced reimbursements for rural providers.