Because of its value and cost-effectiveness, primary care has long been a focus of federal health policies aimed at improving care for low-income, medically vulnerable communities. Strong primary care — the foundation of health care — requires a commitment to sustained, targeted investment in access enhancement and quality improvement. Short-term funding extensions such as the one included in February’s Bipartisan Budget Act, although essential, create a situation in which the potential for instability looms. Instead, ongoing investments in personnel, training, health information technology, and new access points must be made to maintain the infrastructure essential to bringing high-value health care to communities that otherwise would go without it.
How Is the Supply of Primary Care in Low-Income Communities Supported Today?
Since the 1970s, the federal government has pursued two complementary strategies for developing and sustaining primary care in medically underserved communities: community health centers that by law are located in and serve populations designated as medically underserved, and the National Health Service Corps, which deploys primary care medical, nursing, dental, and other health professionals into primary health care shortage areas. Both have steadily expanded since then. The Affordable Care Act (ACA) created a guaranteed source of funding, and also invested in teaching health centers, which train primary care professionals in the communities that need them to increase the chances that they will settle there over the long-term.
These three programs now anchor the supply of primary care in medically underserved communities. In 2016, health centers operating in more than 10,000 locations served nearly 26 million people, including one in six Medicaid beneficiaries. Nearly 10,000 National Health Service Corps professionals, over half of whom work at community health centers, cared for over 10 million people in 5,000 care delivery sites. And the teaching health center program now trains approximately 700 training professionals spanning a wide range of primary care specialties. Teaching health centers’ importance to community health centers is underscored by the fact that, among staff hired by health centers in the preceding two years, 58 percent had trained at the health center at which they were hired, while 30 percent had trained at another health center.
A Need for Stable Funding
The guaranteed funding model established under the ACA assures sustainable operating grant funding over a multiyear time period, without need for year-to-year appropriations. Today the fund represents 70 percent of all health center grant funding and virtually all funding available to the National Health Service Corps and teaching health centers. Their mission to serve the poor means that these programs depend on federal grants for core funding; 23 percent of all health center patients — more than 2.5 times the national average — are uninsured.
To be effective, primary care needs ongoing, stable grant funding to care for uninsured populations, provide necessary but uncovered services (such as adult dental care), and meet other uncovered costs such as high deductibles. The 2018 Bipartisan Budget Act established a 10-year funding window for the Children’s Health Insurance Program (CHIP); this keeps CHIP reliable and stable over time. Programs that are designed to assure a stable supply of primary care in the poorest communities need a similar assurance. Although the Medicaid expansion has had an enormous impact on the amount of revenue available for primary care in poor communities, even in expansion states such a high proportion of patients remains uninsured, an indicator of the difficulties the poorest communities experience in attracting adequate health care resources on their own.
Investing in Strengthened Care
Beyond basic long-term funding, targeted investment is needed to strengthen key aspects of care, such as integration of primary physical and mental health care, and funds to enable care delivery innovations such as team-based care, telehealth, and improvements in health information exchange. The 2018 budget legislation authorizes the U.S. Department of Health and Human Services (HHS) Secretary to spend some of its funding on such improvements: care delivery for people with multiple, chronic conditions; reconfiguring the health center workforce; reforms aimed at increasing efficiency and lowering costs; quality improvement; expanded care coordination and use of technology; integration of primary and behavioral health care; and improving responses to public health emergencies. Additional discretionary funding, beyond the guaranteed funding extension, was separately provided in order to boost health centers’ capacity to respond to the opioid crisis, disproportionately centered in low-income, isolated communities.
Changes such as these require investment that can come in the form of grants or — in strategic cases — loan guarantees, which are made through a Health Resources and Services Administration program that guarantees bank loans to health centers for capital funding. Over the years, the health center loan guarantee fund has been well managed, with virtually no defaults. It also has been cost-effective: $15 million set aside for loan guarantees has translated into $160 million in capital expansion funding. The Trump administration could repurpose a small portion of its new funding for loan guarantees, a strategy consistent with the administration’s emphasis on public-private partnerships.
While the new law authorizes expenditures for these improvements, it does not mandate that HHS strengthen the quality and scope of care. Given the gap that exists between the need for care and existing capacity — virtually every health center reports significant waits for care, especially for new patients — there is always the risk that funding will be used only to increase patient care numbers through additional sites, more staff, and extended hours — rather than improving performance.
Working with health centers, teaching programs, the National Health Service Corps, and state Medicaid agencies — whose ability to improve access to high-value health care turns on the strength of states’ underlying primary care systems for low-income populations — HHS could embark on a collaborative access and quality improvement strategy as a core element of its primary care strategy. Such a strategy would focus not simply on seeing more patients but on strengthening the primary care experience by improving health centers’ ability to integrate primary physical and behavioral health care, develop health care teams, extend their hours of operation and their locations, and expand their health information technology capabilities. The success of health care transformation depends on it, as do millions of residents of medically underserved communities.
