Hospitals aren’t the only part of the health care system hemorrhaging money  during the coronavirus pandemic. Community health clinics, which serve many uninsured and low-income families, are facing financial setbacks that leaders fear may have lasting impacts.
In recent weeks, community health clinics have cut back on services like dental and other non-emergent services. Nearly all have had to furlough staff and some clinics have had to close locations.
At the same time, clinic leaders worry that as unemployment numbers rise, more people will be dropped from their current health insurance plans. That could cause demand for the community clinic services to spike in the future, but those clinics may not be financially equipped to handle it.
“It’s a general truth for all of us that we have been impacted financially, operationally, and in regards to capacity,” said Sonia Tucker, the chief quality improvement officer at La Maestra Community Health Centers, which has clinics in City Heights, El Cajon, Lemon Grove and National City.
Michelle Gonzalez, president and CEO of North County Health Services, said normally the organization operates 12 health centers throughout Riverside and San Diego counties, but since the pandemic, they have had to close eight centers and reduce hours to preserve personal protective equipment.
Gonzalez estimates they lost close to a $1 million in April due to a decrease in patients and have had to furlough roughly 300 employees. They’ve pretty much had to halt dentistry and chiropractic services.
Kevin Mattson, president and CEO of San Ysidro Health Center, said his organization has lost roughly 400 patients a day in dental visits.
San Ysidro Health Center initially furloughed 300 full-time employees, but has been able to maintain employee health insurance. It then had to partially furlough another 300, cutting hours by 50 to 80 percent. It asked all clinical staff to take at least one day off, reducing them by 20 percent. Nearly all dental staff was furloughed.
“We went from having 25 dentists on staff to two overnight just for emergencies,” Mattson said.
San Ysidro Health Center has shut down a total of 13 clinic sites, but the physicians from those sites are still available for telehealth.
Family Health Centers of San Diego, meanwhile, has furloughed or laid off roughly 120 people, said Anthony White, the director of community and government relations for the organization. Prior to making some changes, including layoffs and dramatically cutting back hours, the organization was losing about $1 million a week in revenue after the stay-at-home and other public health orders restricting elective procedures and visits went into place.
The organizations have received some funding from the federal CARES Act, but they say the aid doesn’t come close to covering their losses. For example, Gonzalez said North County Health Services have received federal relief funds that amount to roughly 17 days of operating costs.
At the end of April, Health Center Partners of Southern California, a member organization that advocates for community health centers, sent a letter  to Gov. Gavin Newsom, requesting additional state assistance.
The average community health center in the state has just 128 days of cash on hand, Health Center Partners President and CEO Henry Tuttle wrote. Given that lack of cash and lost revenue from diminished activity, he estimated that 77 health centers will default on payroll and be forced to close in the next three months, taking 18,000 jobs with them.
“While our federal advocacy efforts are not over, I anticipate a shortfall,” Tuttle wrote. “Therefore, I respectfully request CHCs be included to receive direct state financial support in recognition of their financial hardship and to reinforce the need for a robust primary care delivery system — the backbone of California’s statewide Medi-Cal program — now and into the future.”
A Safety Net for Patients
Community clinic providers are especially concerned about how these changes will impact the people they serve, who already face barriers in accessing health care.
“They don’t have transportation,” Tucker said. “They don’t understand how to navigate a complex system. We need to bring down barriers.”
Community health centers often serve as preventative measures, operating in communities to fill gaps in the continuum of care to keep low-income families and those who don’t have access to health insurance out of hospital ERs.
“We are the safety net,” Gonzalez said. “We won’t turn anyone away.”
North County Health Services, Vista Community Clinic and Neighborhood Healthcare serve more than 120,000 people in North County, according to Health Center Partners of Southern California. In 2018, 72 percent of patients served by these North County centers had household incomes of less than $25,750 for a family of four. Nearly 60 percent of their patients are Latino.
Some things, like vaccines for children, can’t be provided by telehealth. Yet Dr. Kelly Motadel, the chief medical officer at Vista Community Clinic, said they’ve seen a drop in pediatric patients.
“Just the other night, I spent 10 minutes explaining to a mom that it was important enough for her to take her 24-month-old and two-month-old in for immunizations,” Motadel said.
Providers also said they’ve been seeing higher numbers of behavioral health needs in the community, far more than some of the organizations budgeted for this year. People are experiencing increased isolation and stress.
“We fully anticipate the demand being more than what we can handle,” Gonzalez said.
Gonzalez said North County Health Clinic employees have had to get creative to ensure patients get what they need. For example, they noticed a huge spike in medication that wasn’t being picked up at the beginning of the stay-at-home orders. They began an outreach and education campaign, and started bringing medications out to people’s cars.
There is also the concern that centers will see a surge of people requiring their services because they have been putting off care. They are worried they’ll see an even higher demand after COVID than they saw before because of all the job or wage losses people are experiencing during the pandemic.
“There will be a lot more demand,” Tucker said. “As it was, prior to this, it was hard. We were trying to increase access to care. What we’re foreseeing is, as we open, those people who have been putting off services that were vital, like those who have diabetes or high blood pressure, will come in and we don’t know what that will look like.”
A Need for Telehealth to Continue
The saving grace for many clinics has been a law that allows them to get reimbursements from the government for telehealth visits during an emergency, but clinic leaders say they are worried that could change.
Medicare changed the rules of what is billable during an emergency, meaning providers can bill for video and audio visits, so patients can even talk to their doctors by phone if they don’t have internet access.
Today, 82 percent of visits are being done via telehealth at San Ysidro Health Center, Mattson said. If the emergency order is lifted and the center can’t keep seeing people via telehealth, he expects things will get more difficult. Telemedicine has allowed the medical side of San Ysidro Health Center to maintain relatively stable.
“We’ve heard that we’re going to go backwards once we go back to regular operations, and telephone and video visits will no longer be reimbursable,” Tucker said.
White said one of Family Health Center’s biggest advocacy pushes has been towards continuing telehealth.
“It decreases so many barriers to health,” White said. “We’ve been trying to get the government to allow telehealth for a long time and it’s been difficult. The population we serve often doesn’t have cars or can’t take time off work to go see a doctor.”