By Douglas J. Guth, Crain’s Cleveland Business  | January 30, 2017

It wasn’t long before President Donald Trump took office that he and Congressional Republicans began plotting how to repeal Barack Obama’s hallmark health care initiative. Replacing the Affordable Care Act would have an untold impact on the American public, while the region’s federally qualified health centers face similar questions about the future of their critical services.

Community health center leaders interviewed by Crain’s said repealing the act without a clear replacement plan would jeopardize coverage of patients who rely on neighborhood facilities as their primary care source. Also, because the ACA boosted the number of Americans with insurance, a swift repeal could cut off critical revenue streams that have allowed these centers to expand services in their communities.

“The word I’d use about the situation is uncertainty,” said Jean Polster, president and CEO of Neighborhood Family Practice, a community health provider for 12 communities across Cleveland’s West Side.

NFP, with five full-time and two part-time locations, gives residents access to primary medical care along with dental and behavioral services. In 2016, the provider saw 18,500 unique patients, an uptick of 1,000 from the year before. Like its other federally funded brethren, NFP tailors its offerings based on the needs of the surrounding region.

“We know who lives in our neighborhoods and understand what they need,” Polster said.

She added, “Having all of those services under one roof provides a strong foundation for keeping people healthy.”

The ACA, known informally as Obamacare, expanded access to both insurance and sites of care, with a ripple effect of reducing exorbitant health care costs for federal and state governments, Polster said. More than 900,000 additional Ohioans currently have health coverage due to ACA provisions, according to a Jan. 11 study from nonprofit research group Policy Matters Ohio. The expansions were made possible by broadening eligibility of the Medicaid program and offering subsidies to reduce the cost of purchasing commercial insurance.

NFP’s poorest patients would be those most hurt by a repeal, Polster noted, as ACA’s Medicaid expansion covered people earning up to 138% of the federal poverty level, or a yearly income of about $16,400 for an individual and $27,800 for a single parent with two children. Individuals already struggling to pay for basic expenses such as food and rent would land back on uninsured rolls should they lose Medicaid as well.

“We had 23% uninsured before ACA, now that number is at 10%,” Polster said. “(A repeal) may roll coverage back to pre-ACA levels.”

Going without

With Congressional Republicans moving ahead on legislation aimed at dismantling the controversial health reform law, officials at Care Alliance Health Center foresee a “significant impact” in how they would treat their patients, many of them homeless or living in public housing.

Care Alliance, which treats about 13,500 patients annually, employs 80 clinicians on a budget of $10 million. Already relying on government grants, local foundations and individual donations, the nonprofit would seek further funding from the foundation level should Congress continue on its path, said center president and CEO Francis Afram-Gyening. The nonprofit’s primary and preventative care services would remain under a repeal, but specialty offerings including pediatrics, dental and women’s health would likely undergo cuts.

“Maintaining that level of service would be a stretch,” Afram-Gyening said. “If there’s no mechanism to pay for these services, people are going to go without them.”

Out-of-house providers like the Cleveland Clinic are potential partners for specialty services, although that possibility presents its own set of challenges, Afram-Gyening said.

“Those big health systems are struggling themselves because of payment reforms,” he said. “To overload them with additional patients would be difficult.”

Non-native English speakers formerly on ACA’s rolls may be left behind two-fold, noted Michael Byun, CEO of Asia Services in Action Inc. (ASIA), a nonprofit providing medical services to the area’s Asian-American population.

Not only will these patients be kicked from Medicaid and the Healthcare.gov marketplace following a repeal, a lag on language access previously provided by ACA may keep them out of whatever health care model comes next.

“All that infrastructure set up for them may be completely dismantled by getting rid of ACA,” Byun said. “That’s something we’re very concerned about.”

Preparing for change

Without a plan similar to Obamacare, working-age adults age 20-65, who don’t normally qualify for Medicaid due to income restrictions, are most at risk of losing their coverage entirely, said Polster of Neighborhood Family Practice.

NFP’s patients are taking a wait-and-see attitude, but that hasn’t stopped queries regarding the inevitable changes on the horizon.

“There’s talk of ‘repeal and replace’ in the press, but we’re hearing about ‘repeal and wait’ from our national advocacy organization,” Polster said. “People are nervous.”

Leadership at the Ohio Association of Community Health Centers (OACHC), a Columbus trade group overseeing 49 facilities throughout the state, have no worries about patients’ voices being heard. Community health centers are designated as 501(c)(3) nonprofits, meaning there’s a 51% patient majority on each individual center’s board of directors, said Julie DiRossi-King, OACHC’s chief operations officer.

Meanwhile, DiRossi-King and her fellow association officials are pushing policymakers for equal or improved health care coverage post-ACA.

“We’ve been talking to everyone at the state and federal level, including Gov. Kasich, who’s been a staunch ally in making sure Ohio’s most vulnerable populations have access to coverage,” DiRossi-King said. “We’re talking about the need to be thoughtful and not repeal (the ACA) without an adequate and sustainable replacement.”

Any potential change portends a cloudy future for health care, but area care facility leaders promise to continue to provide services regardless of a patient’s ability to pay.

“We’re assuring people that we’ll be open to help them get on Medicaid until the plan changes,” Polster said. “We’re here and we’ll keep doing the good work we’ve been doing.”