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Although the House of Representative Republicans’ effort to repeal and replace the Affordable Care Act failed to make it to a vote, the ACA’s future remains uncertain. President Donald Trump reacted to the defeat by saying that “the best thing we can do, politically speaking, is let Obamacare explode.” There are any number of ways the program could be inflicted a slow death.
Likewise uncertain is the future of Medicaid, the federal-state program that – with millions more now insured under the ACA’s Medicaid expansion provision – provides health care coverage for about 75 million low-income children and adults and people with disabilities. Tom Price, the secretary of the Department of Health and Human Services, and Seema Verma, administrator of the Centers for Medicare and Medicaid Services, sent a letter to governors last month encouraging restrictions on Medicaid benefits.
A recent report from George Washington University’s Geiger Gibson Program in Community Health Policy and the RCHN Community Health Foundation Research Collaborative focuses on what Medicaid expansion, for which the federal government has been paying 90 percent of the cost, has meant to one particular traditionally underserved population: people who receive care at migrant health centers.
The study, titled “How are Migrant Health Centers and their Patients Faring Under the Affordable Care Act?”, found that from 2013 to 2014 the number of patients who arrive at migrant health centers with no insurance in states that have expanded Medicaid dropped much more (from 34 percent to 24 percent) than in states that have not expanded Medicaid (45 percent to 42 percent).
The study, said RCHN president and CEO Feygele Jacobs, underscores the importance of Medicaid expansion for a population that plays an integral role in our nation’s economy.
As the authors of the migrant health center report write, “Migrant and seasonal agricultural workers are essential to America’s agriculture and agriculture-related industries, which in 2014 contributed $835 billion to the national GDP.
“Between 2.4 million and 3 million agricultural workers plant, cultivate, harvest, handle, package, and process crops, as well as feed and care for farm animals.”
If the Affordable Care Act were to tumble, a great many of these farmworkers and their family members will once again be uninsured.
Community health centers are the go-to source of primary care for medically underserved communities.
According to the Kaiser Family Foundation, 1,375 health centers provided care to 24.3 million patients in 2015, including one in 12 U.S. residents and about one in six Medicaid enrollees.
Almost three-quarters of health center patients live below the federal poverty level.
Increased patient revenues as a result of the ACA have led to an increase in the number of health centers and their capacity to provide services.
“State Medicaid expansion decisions made a large difference in coverage,” the report states. “Over half of health center patients in expansion states had Medicaid, compared to one-third in non-expansion states.”
About 20% of health center patients in Medicaid expansion states remained uninsured, compared to about 30% in non-expansion states.
“Health centers in Medicaid expansion states reported higher total operating revenues than those in non-expansion states,” the authors write, “and Medicaid provided a larger share of their revenues.”
The community health center model is built on integrated primary and preventive care. The centers serve as a medical home for underserved populations. They rely on a toolkit of quality-improvement practices that leverages health information technology. Care teams include specialists in primary, behavioral and dental care; nutritionists; and financial and resource advocates.
Community health centers provide translation and transportation and often extend hours to accommodate work schedules. Services of this nature tend to reduce emergency department visits and in-patient bed stays.
“I think that we need to see primary and preventive care – which is what heath centers really excel at – as not only important in the short term but very, very important in the long term,” Jacobs said.
‘What Really Works’
Finger Lakes Community Health, headquartered in Geneva, New York, is a federally qualified health center and one of three migrant health center programs in New York.
“If you want to provide better health outcomes, you provide care management,” said Finger Lakes CEO Mary Zelazny of the medical home model. “That’s what really works.”
Zelazny said that she and her staff tell those in the area who hire farmworkers, “‘If we can do our thing, we can produce a healthier workforce for you.’”
They ask permission to go onto farms to offer onsite care and health education. “That’s good for all of us,” she said.
In its first year of operation, 1989, Zelazny said, Finger Lakes served some 400 farmworkers; this year it’ll serve more than 9,000, with 26,000 patients on its registry. The center has a staff of 210.
Finger Lakes hires as many bilingual and bicultural staff members as it can – better yet: those who’ve lived and worked in farmworker communities.
Paula Arellano was born in California. Her parents came to this country from the Mexican state of Michoacán. She was a migrant farmworker from childhood and has been around farmworkers all her life. She missed her first day of high school to provide translation during a farmworker’s surgery.
Arellano’s family moved every couple of years – her father working as a laborer and manager, her mom as a cook for the workers.
“They always made us look at it as an adventure,” she said of this peripatetic life, “like there was always something else to look at.”
Arellano is today employed by Finger Lakes as a patient navigator. She stresses to her clients the importance of preventive health care and helps schedule appointments. She finds specialty care as necessary and provides transportation and translation when needed.
“I like to call myself a bridge,” she said, a bridge to better health.
Leaving in Tears
New York is one of 31 states that have elected to expand Medicaid. That decision, Zelazny said, has been a godsend to the state’s community health center network.
“Providers say to me, ‘I’m getting so many patients that have never been to the doctor,’” Zelazny said.
Finger Lakes staff assist patients with Medicaid enrollment, “and they leave in tears, because they’re blown away that they can finally get health care.” They’re no longer ashamed, Zelazny said, because they don’t have to ask for help they need but can’t afford. “It keeps people out of the emergency room, and it cuts down the costs.”
Finger Lakes has experienced about a 15 percent increase since 2014 in patients covered by Medicaid.
But beyond the numbers of people who are newly enrolled in Medicaid or who can now afford private insurance, Feygele Jacobs speaks of the Affordable Care Act’s domino effect – of benefits even for those who remain uninsured.
When community health centers are seeing more patients with insurance, for example, it allows them to hire more health care professionals, to extend hours, to launch a new program.
“And because the health center model provides care to everybody irrespective of whether they can pay or not,” Jacobs said, “you’re going to benefit from all of those things.”
Geiger Gibson researchers followed up their earlier study on the benefits of Medicaid expansion for community health centers with a report on findings from interviews in January and February with administrators at almost 600 centers across the country. They asked what the anticipated hit would be of a “reversal of the coverage gains and increased funding made possible by the ACA.”
Almost one in four estimated that their center would have to drop at 5,000 participants, and three-quarters estimated they would have to stop serving at least 1,000. Services at greatest risk of being eliminated would include mental health and substance abuse treatment, nutritional and health education, care management for chronic health conditions and efforts to promote access.
The authors write that community health centers “would be forced to lay off mission-critical staff, including doctors, nurses and others who provide care to high-risk, vulnerable people” in already underserved communities.
“I love it,” Paula Arellano attests. “I love working with our farmworkers because I can really relate to them.”
She sometimes sees patients she knew years ago in New Jersey. “It’s like a circle; it just keeps going. I get very excited. It’s a small world.”
The trend now though is for farmworkers to be less migratory; to become permanent residents of a community.
“That trend has been rising in the past 10 years or so,” said Bobbi Ryder, director of the National Center for Farmworker Health. That’s due, to an extent, to a more stable economy. “There are other sectors that these people can go to work in.
“But it also has to do with the fact that the borders under Obama have been relatively closed.”
Ryder bristles at the demonization of this population.
“We enjoy the lowest cost per capita of food in any industrialized nation,” she said, and it’s because “farmers aren’t making a lot of money, and farmworkers aren’t making a lot of money.”
“Look at the return on investment,” she urges, “in terms of the planting of a crop and the harvesting of a crop, and all of the dollars that it creates. The pennies that farmworkers are making – a portion of which, yes, they may send home – are such a small portion of what that whole investment does, that whole crop does, to stimulate the economy of a large community, that it’s very shortsighted of us to be that stingy about our attitudes.”
Providing fundamental health care, Ryder believes, is a small price to pay for that return.
Arellano says that she still sometimes cries when someone she’s assisted with their health care needs tells her, “‘You’re treating me like a human being. You see me; I exist.’” That, she said, “is why I’m here.”
“To the extent that we isolate ourselves, and hold ourselves separate from, as opposed to embracing people who are helping to populate and fuel our country,” Ryder said, “we create problems, we create walls, we create barriers.”
“There are people I see who are in really bad shape,” Arellano said, “and then they go to a health center where they’re treated well – they go to a place where they’re treated like humans – and it’s kind of like a shock to them.”
“How sad is that?” Zelazny asks. “It shouldn’t be that way in this country.”