Since Ohio's expansion of Medicaid, community health centers have been able to add locations, expand services, grow their staff and treat more patients.

Federally qualified health centers (FQHCs) provide care regardless of one's ability to pay. Uninsured patients are charged a nominal fee on a sliding scale. But now, as those patients gain coverage and the centers are able to bill for services, patient revenue is climbing. And FQHCs are reinvesting that money in growth and expansion.

Ohio has 55 FQHC and FQHC lookalikes, comprising about 330 health care delivery sites. (Lookalikes do not receive Health Center Program funding but are eligible to apply to the Centers for Medicare and Medicaid Services (CMS) for reimbursement under FQHC Medicare and Medicaid payment methodologies.) Between 2013, before expansion, and 2016, the state's centers increased that number of sites by 35%, grew staff by 47% and saw 25% more patients, said Julie DiRossi-King, chief operating officer of the Ohio Association of Community Health Centers.

"Community health centers are certainly able to provide greater access to care because of Medicaid expansion," DiRossi-King said.

Neighborhood Family Practice, for instance, went from between 23% and 25% of its patients being uninsured to just 7%.

"Thousands of additional people have coverage now, and they were no longer uninsured," said Jean Polster, president and CEO of Neighborhood Family Practice. "Our sliding-scale fee begins at only $5. So you would go from paying somewhere between $5 to $25 for visit to us receiving for that same visit about $130. So when you compound that over thousands of visits, that gives us a better ability to expand our sites of service and our services within."

Since expansion, Neighborhood Family Practice has opened new sites and added dental and pharmacy services. Between 2012 and 2018, revenue and staff more than doubled at the health center. Polster said that growth is due to the confidence Medicaid expansion gave NFP that it had a sustainable business model.

A recent report from the Commonwealth Fund found that health centers in Medicaid expansion states, compared to those in nonexpansion states, were more likely to report improvements in their financial stability and ability to provide affordable care to patients. They were more likely to offer medication-assisted treatment for opioid addition, provide counseling and other behavior health services and coordinate patient care with social service providers in the community.

"Essentially, when people have health insurance, it makes it easier for the provider because there's increased revenues," said Melinda Abrams, vice president and director of delivery system reform at The Commonwealth Fund, a nonprofit private foundation supporting independent health care research. "There's also fewer deficits from nonpaying patients. So community health centers, they take all comers. They provide care to the insured and uninsured. So when they have more people who have health insurance, it makes it easier for them to innovate, to invest in technology, to hire new staff, train existing staff and adopt new models and approaches to care, such as integration with behavioral health."

Care Alliance Health Center saw its uninsured rate drop from 90% to 34%. As a result of expansion, the center has been able to hire more people, increase its revenue, see more patients, expand its behavioral health offerings and add wraparound services, such as care coordinators, said Eleace Sawyers, president and CEO of Care Alliance.

At Akron-based AxessPointe Community Health Centers, before the expansion, patients paying on a sliding fee scale accounted for 70% to 80% of the center's payer mix. Today, it's down to 17%-18%.

"What Medicaid expansion has done is allow us to add more Medicaid people, and the way that our funding works, the more Medicaid we have, it gives us more overall resources that will help us then take care of the uninsured," said Dr. Jay Williamson, board president for AxessPointe. "Through the federal program at our main sites, we get an enhanced Medicaid reimbursement for seeing Medicaid patients. … Then, what we do is we spread that out to take care of everyone in our system."

Asian Services in Action has been able to add staff to help take care of the growing number of mental health and substance-use disorder patients it's been seeing. Elaine Tso, interim CEO at Asian Services in Action, doing business as the International Community Health Center, said the organization has been able to become more sustainable and financially stable in recent years.

The Medicaid expansion has afforded Circle Health the opportunity to provide wraparound services that are not typically reimbursed, such as transportation, care coordination, connection to counseling and case management.

Medicaid expansion has "absolutely" been beneficial, said Elizabeth Newman, president and CEO of Circle Health (formerly known as The Free Clinic of Greater Cleveland). "But it hasn't been a silver bullet, either," she added. "It hasn't solved every challenge that we face."

For instance, centers in expansion states are more likely those in than nonexpansion states to report unfilled job openings for mental health professionals and social service providers.

Nationwide, more than 1,300 FQHCs operate in more than 11,000 sites and provide comprehensive primary care to one out of every 12 Americans, according to the report. They've long enjoyed bipartisan support.

The Commonwealth Fund report concludes that "Any further weakening of the (Affordable Care Act), like the enactment of Medicaid work requirements and other policies that restrict health insurance coverage, could increase the number of uninsured, thereby reducing health centers' revenue from insurance and increasing costs."

Federal funding for health centers is set to expire in September. FQHC leaders stress that it's critical for Congress to renew these funds, which DiRossi-King said provide 15%-20% of health centers' overall operating budget.

The various potential threats to FQHCs' well-being — from loss of federal funding to loss of Medicaid expansion — are top of mind for centers' leaders.

"I think if expansion were to go away, it certainly would send health centers into a financial shock, if you will, and you would certainly see, without a doubt, a halt in all the growth that the community health center program and the health centers themselves have been able to make," DiRossi-King said. "But I think in reality we would also see a clawback. They would be taking steps backwards and having these services either scaled back or end altogether or, worst-case scenario, some sites would have to close. It's absolutely been instrumental in our ability to grow primary care capacity, and that includes helping our patients that are on the path to recovery."