Thousands of health clinics serving the nation’s poorest residents face closure and cutbacks amid the sweeping coronavirus pandemic, a trend that could imperil hard-hit communities long after the disease is contained.
One in 11 Americans — about 31 million people — depend on safety-net health clinics for care not otherwise available because they have no health insurance, live in isolated areas, speak no English, or experience homelessness. These clinics include some 12,000 community health centers funded by federal tax dollars and 1,300 charitable clinics run with donations and volunteers.
But a drop in donations, uncertain federal funding, staff and volunteer shortages, and an overall lack of pandemic preparedness has forced some to scale back services or shut their doors.
As a result, America’s most vulnerable residents are at risk — not just from the COVID-19 pandemic, but because they’re now losing access to care for other pressing medical needs.
“The gaps that pre-existed, they still exist. And they're getting bigger as this emergency unfolds because we’re having to redirect the resources we have at this new threat,” said Thomas Tighe, CEO of the medical nonprofit Direct Relief.
In Orlando, Florida, the nonprofit Grace Medical Home closed about half its specialty care clinics because its volunteer doctors all fit the high-risk profile — elderly, with preexisting conditions — for severe COVID-19. On top of that, the group had to cancel its annual fundraiser.
In Hollywood, California, the federally funded QueensCare Health Centers has protective gear on their shelves but can’t find a supplier to guarantee they will get more.
And in Washington state, the Olympia Free Clinic cut its entire staff one day down to the sole volunteer not considered to be in a high-risk category for coronavirus.
“We’re flying by the seat of our pants,” said Dr. Mike Matlock, the free clinic’s medical director.
The challenges are exacerbated by where safety-net health providers work and because so few were prepared for a pandemic.
Most are located in counties that federal officials have deemed ill prepared for a disaster or as having a shortage of healthcare services, according to a USA TODAY analysis of federal data and clinic locations. About two-thirds of those extremely vulnerable communities already have confirmed cases of COVID-19.
Just half of those clinics had plans for handling an infectious disease epidemic, according to a survey conducted in early March by Direct Relief. Many are now rushing to adapt.
The emergency coronavirus bill Congress passed last week provided $2 billion for community health centers. Experts said that’s less than half of what they need to handle both normal services and coronavirus response through November.
Meanwhile, the doctors, nurses and volunteers that staff these clinics are scrambling to address the influx of potentially infected residents while trying to manage their regular caseload of broken bones, pregnancy check-ups and diabetes-related infections.
But many safety-net providers have canceled in-person appointments to comply with public health orders to limit the virus’ spread. Some are instead switching to video chats and phone calls. Others simply must wait for care until after the pandemic.
Many federally funded programs report difficulty hiring and maintaining staff because Congress has only approved funding for a few months. Other providers report that office visits have sharply declined, in part due to shelter-in-place orders, causing them to lose revenue and lay off staff, according to the National Association of Community Health Centers.
Donations to charitable clinics also have dropped as nervous Americans tighten their belts. And major fundraisers have been scuttled because of the national ban on large gatherings.
Some of the clinics in hard-hit areas have closed, perhaps permanently. Others have dramatically scaled back services. About a third of the safety-net providers surveyed by Direct Relief said they expect to reduce or stop services because of the novel coronavirus.
When safety-net clinics close or have to cut services, experts say it could have significant consequences on community health long after the coronavirus pandemic ends.
“People will just get increasingly ill,” Washington Healthcare Access Alliance Executive Director Christine Lindquist said. “And some people will die.”
Vulnerable to start
Safety-net clinics often are the sole source of health care for those living below the poverty line and those who cannot afford hospital care, even with insurance.
“They work in construction; they’re housekeepers, they’re truck drivers, they’re service industry employees; they’re caretakers and home health workers; they’re restaurant employees,” said Stephanie Garris, CEO of the charitable Grace Medical Home in Orlando, Florida. “If they’re offered health insurance, they can’t afford it.”
The novel coronavirus and the broader economic fallout add new challenges for people already vulnerable because of their health or socioeconomic situation: Those who previously struggled to afford medicines and treatments could lose them entirely, worsening their health conditions and landing them in an emergency room already overwhelmed by coronavirus cases.
Almost 22 million people live in counties considered by the CDC to be extremely vulnerable to disasters, according to the agency’s Social Vulnerability Index. Some places have an even higher risk: On top of being vulnerable, about 300 counties also are deemed medically underserved by the federal Health Resources and Services Administration.
Most are in the Southeast: from coastal Virginia to Louisiana to Southern Texas. About 11% of clinics and health centers — more than 1,700 of them — operate in those communities.
Medically underserved areas often report higher rates of health conditions, such as diabetes or hypertension, that make people more likely to develop severe COVID-19 symptoms.
Other health conditions treated by safety-net clinics might worsen if closures and service reductions caused by the novel coronavirus effectively end people’s ability to get care.
“They have nowhere else to turn,” said Nicole Lamoureux, executive director at the National Association of Free and Charitable Clinics.
In addition to asking whether clinics had a general plan to respond to an epidemic, Direct Relief asked whether clinics were developing a specific plan for COVID-19. A quarter said they weren't.
Federally funded health centers are required by the U.S. Centers for Medicare & Medicaid Services to have emergency plans but are not required to include an infectious disease outbreak. Instead, they might focus on hurricanes, tornadoes or chemical exposures from a prominent industry.
“Some health centers may have a pandemic low on their hazards list,” said Dr. Ron Yee, the chief medical officer for the National Association of Community Health Centers.
Still, Yee said, any familiarity with an incident command structure and emergency response would be a helpful foundation for adapting to an unexpected threat like the novel coronavirus.
Unlike health centers, charitable clinics are not required to have emergency plans because they are not supported by federal funding and do not bill federal programs like Medicaid or Medicare.
Some clinic leaders say they were prepared, at least to some degree, by previous, smaller outbreaks in their community, such as the H1N1 flu or the Zika virus.
Still, about a third of the safety-net providers surveyed said they expect to reduce or stop services because of the novel coronavirus.
In Washington, one of the first states to see a local outbreak, several charitable clinics already have closed, uncertain if they will be able to reopen, according to the Washington Healthcare Access Alliance and the National Association of Free and Charitable Clinics.
Others have had to radically rethink how they provide care.
“There’s very little, if anything that is unchanged in the last couple of weeks,” Olympia Free Clinic Director Katie Madinger said.
The Olympia Free Clinic was one of a dozen programs offered in a one-stop-shop for social services in Washington’s capital city. On a typical day, it would draw some 200 people — a crowd size that is dangerous during an infectious disease outbreak.
The center is now closed to walk-ins but still offering telemedicine and in-person visits by appointment. Half the clinic’s patients are homeless and most do not have cell phones.
“That’s the group I’m most worried about,” Madinger said. “What I’m looking for is some leadership from the county health department…. I haven’t heard from them yet about their strategy.”
For now, the clinic has asked other social service agencies to allow their patients, or anyone in need, to call the clinic for coronavirus screening or to talk with a doctor about other medical concerns. When absolutely necessary, in-person appointments can be arranged.
“We’re not quite sure how it’s going to work,” Madinger said.
USA Today looked at two key federal measures to understand which communities have the most vulnerable residents and least access to health care. The Centers for Disease Control and Prevention calculates its Social Vulnerability Index using 15 metrics from U.S. Census data, such as unemployment, income, disability, age, language, and housing, to understand the resiliency of communities facing disasters. We focused on “extremely vulnerable” communities that had SVI scores of 0.9 or higher on a scale of 0 to 1. The bigger the score is, the more vulnerable the area is. The federal Health Resources & Services Administration tracks characteristics of communities served by community health centers. It also considers data on access to health care and the number of providers per person, among other metrics, to identify places that are “medically underserved.” We focused on areas with a score of 62 or less on the federal Index of Medical Underservice. This excludes some places with higher (better) scores that still have health care service gaps among particular groups of people. We also relied on survey data from the nonprofit Direct Relief and COVID-19 case counts compiled daily by USA Today from official reports.