Texas refuses to expand Medicaid. Community health centers and uninsured people suffer
Community health centers are a safety net for people who are uninsured. But in Texas, the work is more challenging because the state hasn’t expanded Medicaid.
Federally qualified health centers, also known as community health centers, act as a safety net for uninsured and under-insured patients.
But in Texas, the clinics face more challenges because the state hasn’t expanded Medicaid. That leaves almost 800,000 people with limited options for health care, according to the Kaiser Family Foundation.
What would it mean for these clinics and the communities they support if Texas increased health care eligibility?
What are FQHCs?
Federally qualified health centers, or FQHCs, are nonprofit primary and preventative care clinics that take all patients, regardless of their ability to pay. There are close to 1,400 across the United States, and 73 in Texas with more than 650 locations in both rural and urban communities.
“We are the family doctor,” said Leonor Márquez, CEO of the LBU Community Clinic in Dallas. “That's probably the easiest way to describe it.”
LBU Community Clinic opened in 1971, and now has five locations around the city.
“We started very humbly,” Márquez said. “We started in two portable trailers, and we have grown to where we’re almost 100,000 square feet of clinics throughout Dallas.”
Jana Eubank, the executive director of the Texas Association of Community Health Centers, said FQHCs adapt to the communities around them.
“We've learned that a person's zip code and income level often is a bigger predictor of their health outcomes than even their genetics,” she said. “And so, our model of care also includes connecting our patients to other needs that they have in the community.”
Eubank said clinics screen people for the social determinants of health — non-medical experiences and systems that impact people’s health outcomes. Those could include food insecurity, housing insecurity, unemployment, transportation access and income. Clinics then connect people with community partners to address these issues.
“We really try to connect everyone [to] all the services that they can get in the community,” Eubank said, “because you're really at a disadvantage if you're uninsured in the state.”
What kinds of patients do community health centers serve?
A majority of FQHC patients in Texas are uninsured, or have Medicaid or Medicare coverage, according to the Texas Association of Community Health Centers.
Joleen Bagwell, the chief development officer for LBU Community Clinic, said they see about 27,000 patients a year. More than half of their patients are uninsured, about 3% of patients have private insurance, and the rest have Medicaid or the Children’s Health Insurance Program (CHIP).
The latest census data show that 18% of Texans are uninsured. That is as if everyone in Dallas, Houston and San Antonio didn’t have health insurance. One reason many Texans are uninsured is the state has yet to expand Medicaid to low-income working adults.
About 800,000 people fall into the insurance coverage gap, where they make too much to qualify for Medicaid, but not enough to afford other kinds of insurance.
Márquez said not having insurance puts a strain on a patient’s ability to access care.
“The number one and two killers in this community here in West Dallas are heart disease and cancer,” Márquez said. “The difference is people are dying 10 and 20 years earlier [here]. That speaks volumes for health insurance, access to a doctor, safe communities.”
Both adults and kids without insurance have worse health outcomes. Older adults with cardiovascular disease and diabetes got sicker, and kids without insurance were more likely to be hospitalized and not receive medical treatment for chronic illnesses like asthma or diabetes.
What challenges do community health centers face?
Terri Sabella is the CEO of HealthPoint, an FQHC with clinics all over the greater Brazos Valley. She said about a third of their patients — primarily pediatric patients — have Medicaid coverage, and a little less than a quarter are uninsured.
When uninsured patients come to the clinic for care, it’s often after an emergency room visit or a serious health complication, Sabella said.
“Sometimes there's already organ damage by the time we're caring for them,” she said. “Some of them may even have known that they had a chronic disease like diabetes or heart disease, but they weren't able to consistently take their medication because of the cost of the medication.”
She said it makes treating patients more challenging, because people may need more intensive care than the clinic offers. A quarter of patients that visit FQHCs need referrals to specialists, but “fewer specialists are participating in the care of vulnerable populations, and there is no clear system for patients or primary care physicians to access those who do provide care,” according to a study from the Journal of Health Services Research.
Specialty care doctors often don’t take Medicaid patients because of low pay rates in comparison to private insurance patients. Before 2023, Texas had not increased Medicaid payments in more than a decade, but this year increased reimbursement rates for labor, delivery, and pediatric visits.
But doctors still aren’t required to take patients without insurance or even with Medicaid. That leaves clinics like LBU and HealthPoint having to cobble together “an informal network of specialty providers that are willing to see someone,” said Jana Eubank with the Texas Association of Community Health Centers.
“Let's say we have a patient that we screen, and she has breast cancer,” she said. “We don't provide oncology services; those are specialty care services. So, we try to use our friends and call-in favors from other providers to be able to see our patients. But we can’t always swing that or there's often not providers that are willing to do that.”
Without access to specialty services, “uninsured adults with cancer are diagnosed at more advanced stages of disease, have poorer outcomes, and die sooner, even after adjusting for stage of disease,” according to research by the National Academy of Sciences. This is also true across other chronic illnesses like diabetes, heart disease and hypertension.
Funding and recruitment
Because such a large percentage of patients coming to FQHCs are uninsured, clinics work on “razor-thin financial margins,” Sabella said.
While she said clinics are grateful for federal funding from the Health Resources and Services Administration (HRSA) and some state grants, it often doesn’t cover the total cost of operations.
Leonor Márquez from LBU Community Clinic in Dallas said the more uninsured patients there are in the state, the greater the financial strain is on clinics helping them.
“Imagine the uninsured adult that comes in, we might collect $30, $40, when the care will cost $350,” she said. “What it means is that's uncompensated care. We're happy to see them, but paying for the doctors, paying for the facility, paying for overhead, paying for the support staff, it just makes it all the more difficult.”
The clinic has close to 300 employees who are committed to their work, but “they're also just folks trying to pay their bills and struggle with inflation and gas prices, just like everyone else in this community,” she said.
At HealthPoint, Sabella also said the state’s lack of Medicaid expansion has impacted staffing.
“We recruit on a nationwide basis, and [providers] might be reluctant to join organizations that are running super thin margins, or in states where Medicaid has not been expanded because they might have fear of financial instability,” she said.
Challenges in staffing and finances means clinics often can’t expand services or locations to keep up with demand, Sabella said. It puts a strain on organizations like HealthPoint, where some locations are the only primary care providers in the community.
Rural communities also may lack access to hospital care and emergency departments because Texas has the highest number of rural hospital closures in the country — 21 over the past ten years, according to a report by the U.S. Government Accountability Office.
How would Medicaid expansion impact their work and the communities they help?
Overall, said Jana Eubank with the Texas Association of Community Health Centers, Medicaid expansion would improve the financial stability of safety-net clinics, improve access to care services, and expand programs to address social determinants of health, like housing, childcare and transportation.
Leonor Márquez in Dallas said many times, clients are making choices between addressing health issues and putting food on the table.
“I would like to take that out of the equation, that it's not either/or, it's both/and,” she said. “If Texas expanded Medicaid, what it would mean is there's thousands and thousands and thousands of adults who will have access to health insurance. It takes away the fear of, ‘I hope I don't get sick, I hope I don't get injured on the job, I hope I don't get in a car accident.’
"All of those things are very scary things when you don't have health insurance.”
It would also help the clinic meet growing community needs, she said.
“For the organization, it means stronger financial health,” she said. “It means that we don't have to sweat bullets over the increasing number of patients coming in, and how are we going to pay?”
Terri Sabella with HealthPoint said Medicaid expansion would encourage health professionals to take jobs in the state.
“Medicaid expansion might send a message that there's a commitment to care for the working poor in our communities,” she said. "It might alleviate some of that [financial] concern and draw more of those graduates into our communities.”
Eubank said community health centers are in 137 of the 254 counties in Texas, and Medicaid expansion would help them expand to communities that don’t yet have care access.
“It would be a game changer,” she said. “The most important thing is, it's the right thing to do for people. I mean, just that peace of mind that you have when you have insurance is huge.”
While Texas lawmakers have yet to significantly advance Medicaid expansion bills, Eubank is hopeful people will understand the urgency of this issue and act.
“I know a lot of policymakers are interested in this and are looking at this, but we've been a little bit slow to adopt compared to some other states,” she said. “We need our legislature, our governor, and our state Medicaid agency to really think more creatively on how to address some of the health care needs that we have in this state.”
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