Editor’s note: This commentary is by Jennifer Wallace, of Groton, who has worked as a practice manager at a Federally Qualified Health Center and as a project manager for the Vermont Blueprint for Health. She is currently finishing her master’s of public health degree at the University of Vermont and is on the board of Capstone Community Action.
[W]hen people ask me what it is like to work in health care during this era of great change and uncertainty, I often describe it by saying, “We are fixing the plane as we are flying it.”
With the impending repeal of the Affordable Care Act (ACA) from the Trump administration there is serious concern for community health centers. In the last three years I have had the privilege of working for two different Federally Qualified Health Centers (FQHC) in Vermont. Health centers are unique in that we are able to offer comprehensive primary care services to all people regardless of their ability to pay or health insurance status. Health centers provide primary care for over 24 million Americans. Many to whom we serve are Medicaid beneficiaries and uninsured people, and 75 percent have income below the federal poverty level.
The health center program has grown significantly over time and has a history of strong bipartisan support. Under the ACA, Medicaid eligibility was expanded and substantial increases in federal grant funding was made through a special trust fund for health centers. The expansion has strengthened health center finances and capacity. The increase in funding is partially from higher reimbursement rates that the ACA authorizes but also from increased number of patients who come to the clinic who now have health insurance.
Reducing the number of patients served will leave the most medically underserved population with reduced access to comprehensive primary health care.
The ACA has been successful at providing new pathways for access but has not adequately addressed the issues of cost. The rural health centers here in Vermont are continually experiencing many insured people who are unable to pay deductibles or participate in cost sharing. There has been an increase of insured patients who pay according to a sliding fee schedule. Without federal grant funding it is unlikely that health centers will be able to continue efforts in reducing barriers to access for health services.
Health centers have always taken pride in the quality of services provided. Health centers were designed to be integrated and responsive to the needs of each individual community. The ACA supports the quality of health services by providing funding for FQHCs to have additional operating funds for preventative programing and additional staff to support the overall health of the population. The ACA requires insurance companies to provide essential health benefits that are now reimbursable such as prevention and wellness. The ACA helps build a foundation for a payment reform model that is being piloted right here in Vermont. The Vermont all payer accountable care organization model puts incentives towards health care quality with a focus on health outcomes of each individual community. The ACA plays an important role in laying the foundation for the transformation of the health care system.
If the ACA were repealed, ending Medicaid expansion and the health center trust fund, health centers would have a very hard time to sustain operations at the current capacity. Reducing the number of patients served will leave the most medically underserved population with reduced access to comprehensive primary health care. A full repeal of the ACA without a replacement will limit future growth and put a strain on the current new staffing and resources that have been added. The greatest challenge policy makers face is not having enough time and adequate data to know whether or not the overall objectives of the ACA are being met to reduce cost, increase quality, and increase access. The new administration needs to take pause and give the ACA more time to see the long-term effects of the systemic changes that have been made. If we are fixing the plane as it is flying it might be wise to coast for a while with the new repairs.
