Community health centers provide essential healthcare to people who are uninsured or underinsured. Increasingly, these health centers are offering additional critical services like dental and mental health care, and the question of how we support and enhance these resources is becoming more pressing. In this podcast, Abt's Ann Loeffler speaks to Annette Kowal, president and CEO for the Colorado Community Health Network, about the state of the health center movement, how health centers have evolved, and how they might move forward.
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Eric Tischler: More and more people are turning to health centers to provide more and more vital services, including social services. In this podcast, Abt's Ann Loeffler speaks to Annette Kowal, president and chief executive officer for the Colorado Community Health Network about how we got here. And, more importantly, what the future hold of these increasingly critical health resources.
Ann Loeffler: Hi, I'm Ann Loeffler. I'm a principal associate scientist with Abt Associates and I'm here with Annette Kowal, long time and beloved health center CEO of Primary Care Association. Annette has been an advocate and friend to the health center movement for well over 25 years, 27? Annette, is that right?
Annette Kowal: Yeah!
Ann: So I feel really lucky to have this conversation with you. We've had a long go together and I know you have a lot of wisdom to share with us. So, looking forward to getting your insights on some of these questions.
Annette: Yea, thanks. It was so fun thinking about our long-term friendship, because we came together in the health center movement.
Ann: Well, and we'll get into some of that of what you've been seeing in terms of trends. I really am curious what your thoughts are, because there's been so much change, because health centers really are charged with doing “all the things.” And I think, when we first started in health centers back in the day, it was really focused on primary medical care. And now it's a lot of public health things, disease prevention, behavioral health, oral health, vision, pharmacy, housing sometimes. All kinds of areas that health centers are being asked to help address and certainly they can always rise to the occasion. Most recently with COVID, health centers are being asked to do what we often hear in the field called “more and more and more.” So with that, what do you think are the biggest threats to health center sustainability and what do you think needs to change?
Annette: And as I was thinking about this a little bit, I don't know that my response would've been the same pre-COVID. We've just maybe, knock on wood ... we're coming through this tunnel that we've been in for three years, not really knowing how it was going to play out or anything. But as I think about it, right now inflation is a huge, a huge threat to health center sustainability. Health centers receive some federal funding and that's called a base grant in our world here, and those base grants have not been adjusted in five, six, seven years. And yet inflation is skyrocketing as is the cost of everything. And so there's, of course, payers, such as Medicaid, commercial insurance companies, they're not increasing their rates to pay the health centers to keep up with inflation.
So just the literal cost of doing care, getting their PPE, getting vaccines and syringes and all of that stuff, you need to run a primary physical health, oral health, and behavioral health center. That's all going up. I think the other big threat, and I know other industries are feeling this, but workforce. The pandemic had people of all different career types rethink, "Why am I doing this and is this how I want to spend the rest of my life?" And so the health centers have seen providers leaving, frontline staff leaving, administrative staff leaving to go find something else to do that's not so stressful. As well as the hospitals. In Colorado, the amount of new buildings they've built in the last decade, just between where you live and I live, Ann, the other day going up to Boulder, there's like 25 new hospitals, connected to existing hospital systems, but it's crazy.
And they obviously have way more money and way more capital to spend than health centers. And they can offer a signing bonus of $20,000 and they can offer to pay a frontline medical assistant $10 more an hour than a health center. So there's both of those workforce just really impacting health centers.
Ann: It's tricky. You hear about health centers hiring and training up MAs only to lose them to the hospital down the street that can pay more. So it's this pipeline that was not intended at all.
Annette: Right, right. Yeah.
Ann: I'm curious about what they're calling the “unwinding” of people who were eligible for Medicaid under the public health emergency, and how people's eligibility for Medicaid is going to change or health centers are going to need to do extra things—when they're already doing lots of other extra things—to make sure that people have access to health insurance through Medicaid. I'm curious what your thoughts are about that. What needs to change there?
Annette: So, boy, the public health emergency, I never thought it would be going on this long and yet thank goodness for the people that COVID has impacted and the economy has impacted and their ability to continue to be enrolled in Medicaid, a health insurance program, and get the care they need. And whenever the public health emergency ends, that is going to be this huge unwinding.
Luckily, Colorado has decided to do it in, whenever it happens, a thoughtful way. However, at the end of the day, we expect about 500,000 people in Colorado who currently are able to receive healthcare, because they're insurance coverage is Medicaid, to become uninsured and then have to decide, if they have the resources, to buy an exchange product, which of course, there's some subsidies and they're based on your ability to pay kind of. But in this economy, will they have the money to be able to do that and continue to pay their rent, or their mortgage, or get the shoes for the kids and put food on the table? Who knows?
So as health centers in Colorado, and I'm sure nationwide, we are really embracing, first, too, when that public health emergency ends, to begin working with patients we think will fall off of Medicaid as part of that, just try to get them enrolled in the exchange product. And if that's not successful, they will remain uninsured. And there's hardly any other provider type in the state of Colorado or in the nation who will be your primary healthcare home if you're uninsured, because that means that they're not getting any reimbursement except what I, as the uninsured person, can afford to pay. So we really do think that has the potential of really impacting health centers' ability to keep all of their doors open, continue to see as many patients as they are, et cetera.
Ann: I love this way of thinking about health centers, that this is a national problem, the lack of access that people have, and health centers are these local solutions to national problems. I love it when I hear people say that, because I think it's so true.
Annette: Health centers were started in the early 1960s as part of the war on poverty, under the Johnson administration, by two courageous, very young men, Jack Geiger and Count Gibson. And because they had seen health centers in South Africa, they came back and they said, "We need these in the United States." Access to affordable, high-quality healthcare, regardless of your income, regardless of the color of your skin, regardless of who you loved, it was a privilege and Jack Geiger and Count Gibson thought that it is a basic human right. Access to affordable, high-quality healthcare for everyone.
Fast forward to today, I would argue that we, as a nation, still have not decided if healthcare is a basic human right or if it continues to be a privilege. And so thank goodness for the health centers, because they'll see you regardless of your ability to pay.
Ann: Given all of this change and uncertainty right now, what do you think health centers need now more than ever from HRSA and contractors like Abt?
Annette: Well, that's a good question and I just want to make sure that the people listening to this understand that consultants like Abt and then the national association, the primary care associations, like the one I work for, the Health Center Network, and even the folks at the Bureau of Primary Health Care, we all have a role in helping ensure that this incredible health center system that's been developed over the last 55, 60 years is sustained and high functioning. And so, Ann, I just want the audience to know, over the years you have helped CCHN and all the health centers in Colorado think differently and get outside of our box and try to do things differently. And so I just want to make sure people know that there's a huge role for Abt and other consultants to help with that.
Like you were saying, I think there are some good things that have come with this spotlight on health centers, and let's get our houses in order, let's make sure we're complying with all the laws and regulations. And yet it's become so compliance-based and taking up, using dollars that could be going to direct patient care, getting more people having access to care. So what flexibilities could we open up now, now that we've seen we can comply, da, da, da. Without getting rid of that, but is there some flexibility HRSA could think about?
And then also, Ann, my goodness with the value-based payment movement. And like in Colorado, Medicaid is in that now. And the Medicare shared savings program that Colorado health centers participate in through our clinically integrated network. Other payers are talking about value-based care and yet every single one of those, they're measuring different metrics or even maybe the same thing, but they're doing the calculation differently across.
So again, this administrative nightmare within the health centers and I would argue not a good use of taxpayer dollars across the payer systems. How can we align what payers are looking at? And that's where Abt comes in, helping HRSA think about that differently, helping NAC think about that differently. And then together we can help build the momentum for change. And what do you think about that?
Ann: Well, it felt like value-based payment talk was put on the back burner during COVID. I think our health center's got a little bit of a breather, not a lot, but actually I think the pandemic really amplified the need for value-based payment. Even just trying to get telehealth services paid for. Don't nickel and dime for the modality. Is the patient getting the care that they need and are we going to have this debate again when it's not telehealth, when it's virtual reality or some other means of delivering care? Can we just get over that part? Just ask, “Was it high quality? Did they get access?” And I know it's not that simple, but at the same time, health centers have had to live in both worlds where it's fee for service and then maybe a little bit of value-based payment. We're going to dabble with that and experiment 20 different ways depending on the payer. And it just creates a lot of uncertainty in terms of how health centers can shape their strategies, because is it population based or is it volume driven? And so it really does change how they deliver care, how they design their staffing models, how they plan for sustainability. I think that value-based payment for health centers is a huge issue.
And I can definitely see a role that Abt and other organizations like us can play as states consider, "Well, how can we do this in a way that actually adds the most value for the patient and puts those resources where they belong?"
Annette: Well, I wonder Ann, based on what you said, because that was really good. The Bureau of Primary Health Care, where the health center federal grant comes from, part of HRSA and part the HHS, they're thinking about what value-based payment might look like for health centers. So for the last 55 years, you get a base grant if Congress funds it and, thank goodness, every year Congress funds the program, so health centers are able to maintain that 17 percent of their revenue.
But to move to something maybe a little different that had some value component or something. On the one hand, I think health centers who've been around and really understand it, they're excited about that, helping the bureau think through that. But for newer, smaller health center, it's like, "Oh my gosh, no, don't change the way we're funded." So, I don't know. I do see Abt, that would be an incredible thing to help the bureau think through "What." It's not going to happen overnight, but this is going to have to be done in a very thoughtful way.
Ann: And in a coordinated way too. At the bureau level with CMS, making sure that those collaborations are happening, so those quality measures can be aligned. I think that's key. And then thinking about health centers in rural communities and places where they have a really small sample. They have small numbers and so their quality measures can wildly swing, depending on one person sometimes. And so making sure that is being accounted for, in addition to health centers that are in places where their patients have a lot more socially complex issues that also need to be addressed in order for those quality measures to move the needle. So incentivizing that would be really important.
And I think we've seen the bureau dabble with these more value based with the quality awards. Does this seem like a good pilot into that? What are your thoughts on how that has played out and whether that's beginning of a good path for the bureau to be thinking about?
Annette: I thought the quality awards, I remember when they announced they were going to do that the next year. And we're all sitting at a NAC conference in Orlando. And in Colorado, we usually sit around the same table together. And I was kind of excited, but I looked at some of the health center CEOs and medical directors and then I'm like, "Oh my goodness, no, no, no." But after five or six years of it, I really do think it incentivized health centers to look at things internally and make changes, because even though it's one-time funding, at the end of the day, medical directors, I have found over my last 27 years, are hyper-competitive. And so when they see their colleague in Colorado Springs did better than them, they want to really up the ante and make the system changes needed to better their quality. The bureau has moved, and I can't think of the technical term they're calling it, but they moved all of that funding to another way of funding big grants, but to very few health centers. And so this last round is for maternal health.
And I can't remember if the awards have been made yet. I don't think they have. But they're going to be $2 million awards for 10 to 20 health centers. And there was a big... “Grief” is too strong a word, but health centers in Colorado were bummed when the quality awards got changed to that. But I think what the bureau is doing, which is good, is experimenting, again, this is a second experiment around value-based pay, the second baby step. And so this is another way of them looking at what might this look like in a decade.
Ann: And I love how it was framed to the health centers. It's “not everybody gets a sweater.”
Annette: Right. Yes, yes. Yeah.
Ann: We're going to be strategic about where we're investing and when we have priorities, we want to see "Show us what you can do." And I think health centers have really stepped up to get to that call. And I think we've seen some really interesting work come out of those initiatives so far. In terms of the ability for health centers, the ones less resourced and have lower capacity, how do you see the investments being made for those health centers that maybe need to be become more mature in the advancing health center excellence framework?
Annette: And that's a great question. Before the pandemic, and I think these conversations will start it up again, the Bureau was also thinking about what if some of the funding went to the health centers that are a little more vulnerable. Again, it would be one time maybe over two or three years to get a specific system figured out, operating well, make the changes needed to help hopefully enhance patient outcomes, revenue generation, et cetera. So I think those conversations will start up again next month at the NAC CHI, because I do think that's a another... You can fund innovation at high end, well-operated health centers, but I love what Jim McCray, the head of the bureau, has said over the years. We're only as strong as our weakest link. And so then how do we move some of this funding to those health centers that are more vulnerable and help them figure out how to become more sustainable?
Ann: No, that's great. I hope so too. I hope that there's more movement on that as well. The health center movement, as you described, was one of the positive things that came out of the war on poverty and civil rights movement. And when you think about health centers, often I see people say, "Well, we've been doing social determinants of health and addressing health equity from the beginning. That's the root of the health center movement right there." And also, I see health centers struggling with addressing equity, because it's a journey and it needs to be tended to along the way. And you can't just assume that you're practicing equity, maybe just because that's where you started. And so I'm curious to hear your thoughts on where the health center is struggling with advancing health equity, and what do you think they need to bolster their efforts?
Annette: Yeah, that's the million-dollar question out there right now, it really is. Maybe I'll just share a little background. Health equity, which as you mentioned, health centers, that's their bailiwick. And over the decades, I've been doing this, whenever that was, 20 years ago, 15 years ago, I saw the dismantling in Colorado as well as across the nation of the public health infrastructure, under various administrations. And before that unraveling, I would go to health centers in Colorado and they'd have social services in there. A lot of the health centers had those housed internally and partnered. And then with the unwinding and unraveling of that, I think health centers are trying to figure out “How do we bring some of that in house? We don't have the funding, but is there a way to partner?" Da, da, da.
So it is a sad state, I think, when something was working well and yet elected officials decided to unravel it, and now we're saying, "Oh my God, COVID taught us. We need to put these back together," but where does the money come to do that? How do you do that in this day and age versus back in the '90s? So I think there's that.
At CCHN, and I want to say the CCHN nation, so that means the Colorado health centers, as well as the Primary Care Association, we've really started talking about equity with two frames right now, just to try to get our head wrapped around it. So there's health equity. And now we're talking about racial equity too. And what does that mean? Where do those two intersect? When do they intersect? What does that mean internally for our policies and procedures on how we hire people, on where we purchase things, on where we bank, where do we put our money?
And those are huge questions, but we're starting down this journey we're calling the racial equity roadmap. We think our racial equity roadmap are going to have various entrances and exits that health centers, regardless of where you are on this journey, can come on and off that roadmap to start trying new and different things, approaches both to health equity as well as racial equity. And so going back to the roots that you mentioned of the community health center, it's community. It's community, and that means the people in that community need to be running, not just governing the board of directors of the health center, but running the health center. And when you look around the table at the, at the CCHN board meeting or a NAC, yes, there are some of the community people in there, but it is not the majority. It's mainly white people like me doing that. And so how do we change that over the next decade? And that is not an easy question to answer.
Ann: It's really almost the ultimate capacity-building mindset. I would just love to hear your thoughts as you reflect on your long career and work in the health center movement, what do you think have been the most difficult challenges and, or surprising lessons that you've gleaned?
Annette: So let me see. I'll share an example. I started, before the pandemic, looking at my association board agendas from 20 years ago, because we were getting so many new people and we have what we call tri-annual events, where we, before COVID, were would bring all the health center leaders, about 200 across the state of Colorado, to one place to do peer learning one day. And then the next day was the board meeting. And so really trying to help them ground them in the health center movement, but also say, "Here's what we were working on 20 years ago. How does that compare to today?" Oh my gosh. Our agendas, what we're dealing with is the same darn thing. The state government and federal government call them different things now. But it's still the same thing. I got a little depressed, I’ve got to tell you, because I feel like we're successful. We make change. We're making impacts, we're bettering the lives of people and yet we're still working. And I think it comes down to how you started this. The national issue and health centers are the local solution. And then what I laid on top of that is because we have not, as a country, decided that healthcare is a basic human right.
Ann: Well, I just want to say thank you not just because you did this podcast with us, but because you are such a leader in the movement.
Annette: Well, thank you, Ann!