Lincoln Community Health Center in Durham always seems to be bustling. The patients drifting in and out of the clinic’s main location on Fayetteville Street offer a snapshot of the city’s lower-income population: a mix of Black, white, and Latino residents who are there for low-cost medical, dental, mental health, or pharmacy services.
Heidi Flores is just leaving the facility. With her T-shirt, cutoffs, and shy smile, she looks like the young woman on the precipice of adulthood that she is. She was here for a checkup.
“It was my first checkup, actually,” says Flores, who just turned 20. She doesn’t have health insurance and had been worried about how much a visit to a primary care provider might cost. She’s seen her aunt receive bill after bill following medical visits. In response, Flores, like several of her friends, has simply stayed away.
But the health center charges on a sliding scale, and the appointment only cost her $20. Happily, everything looked fine on this visit, though she had some blood work done and is waiting on the results. Flores says she’d definitely come more often if she had health insurance.
Flores—and roughly 600,000 other low-income North Carolinians—may be in luck. Early this month, the North Carolina Senate overwhelmingly approved a bill that would expand Medicaid for people earning up to 138 percent of the federal poverty level, or about $18,000 for an individual. After almost a decade of resisting Medicaid expansion, the senate’s vote was historic. But it wasn’t decisive: to become law, the bill must still pass the state house of representatives, where the reception is likely to be much chillier.
No group arguably stands to gain as much from Medicaid expansion as community health centers and their patients. Located across the state, these mission-driven nonprofit clinics, also known as federally qualified health centers (FQHCs), are legally obligated to accept everyone regardless of ability to pay. They see roughly 560,000 North Carolinians; the vast majority are poor, and 40 percent lack health insurance.
In the Triangle, four community health organizations run a total of about 27 clinics, reaching from Louisburg, located just east of Wake County, to Siler City in western Chatham County. Each one is a little different, but generally they all offer primary care to adults and kids, dental care, and some mental health services.
The clinics and their patients—more than 100,000 Triangle residents—would vastly benefit if Medicaid were expanded.
“We see a very sick population,” says Claretta Foye, Lincoln’s CEO. “Diabetes, hypertension, COPD, asthma—a lot of our patients have all of those.” Those chronic conditions are best managed through preventive care and regular checkups, but over half of the center’s patients lack health insurance or are “under-insured,” paying for lab tests or specialists out of pocket. And with inflation spiking, even $20 to see a provider can be prohibitive.
The result is patients who wind up much sicker, often needlessly so. Problems that could’ve been prevented early on may blossom into full-blown crises—and patients, with little recourse, may wind up at the emergency room.
“I had a patient with a large diabetic foot ulcer who was sent to the emergency department due to concerns of osteomyelitis, an infection in the bone,” Dr. Raleigh Rumley, a primary care provider with Advance Community Health in Wake County, wrote in an email. “Because of their lack of insurance, the emergency department just made sure they were stable and discharged them, not obtaining the expensive tests needed to check the severity of the ulcer.” Thanks to an assistance program that helped with costs, the patient saw an orthopedist the next week. But in the end, part of their foot had to be amputated.
There’s no shortage of similar stories among FQHC providers: patients who urgently needed surgery but had to wait because they didn’t have insurance. People diagnosed with cancer who postponed care because they didn’t want their family to be burdened with high medical bills after they died. Medicaid coverage would end those life-or-death dilemmas, and it would allow beneficiaries to receive preventive care to keep them healthier in the first place.
But there would be a secondary benefit for the health centers. Not only would their patients get better treatment under Medicaid; the clinics themselves would receive reimbursements for care that could be used to strengthen their service provision. Just about all FQHCs in states that have expanded Medicaid have seen a significant increase in revenues.
“Part of the community health center model is doing a lot with very little,” says Brendan Riley, vice president for government relations and external affairs at the NC Community Health Center Association. “By our mission and requirements, health centers reinvest all reimbursements into expanding access to care. So [the absence of Medicaid expansion] is really capping our potential to care for more patients and expand to a broader array of comprehensive services.”
First of all, the centers could see more patients. “The need is much larger than there are community health centers,” says Daniel Lipparelli, CEO of NeighborHealth Center, an FQHC in central Raleigh. Providers at some clinics report being asked to see increasing numbers of patients every day, because demand for their low-cost services is so great.
And with more revenues coming in, the centers could broaden their range of offerings to wraparound services like chronic disease management and nutrition. In particular, just about every FQHC leader mentions a major uptick in the need for behavioral health services—among adults with PTSD in the wake of the pandemic, young people struggling with anxiety, and those with substance abuse issues seeking medically assisted treatment. It’s becoming an urgent priority among all of the area’s FQHCs. But they can’t meet the need without the funding to hire more providers.
Brian Toomey, CEO of Piedmont Health Services—the largest FQHC in the Triangle, with clinics in Orange, Chatham, and Alamance Counties—thinks Medicaid expansion itself could reduce some of that demand.
“You take someone who’s uninsured, has chronic conditions, is working, needs to take care of their health, and is worried about their existence. To take that burden of anxiety off their plate? That’d be tremendous for them,” he says. “Our depression screenings will improve because of it, we think.”
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