Safety-net hospitals, which primarily care for poor patients, already struggle financially and are worried about their situation getting worse during the coronavirus pandemic.

The Trump administration has paid out $30 billion to doctors and hospitals from the coronavirus stimulus, known as the CARES Act. Additional funding is on the way.

Calls are mounting for Congress to pass another relief package that would increase the amount of funding hospitals and other healthcare providers get to make up for their losses.

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Saint Anthony Hospital in Chicago was already losing money before it got slammed with the coronavirus pandemic.

The small community hospital, located on the city's Southwest side, cares for exactly the types of patients who've been hit hardest by the coronavirus — people of color and patients who have underlying health problems related to living in poverty.

Most of Saint Anthony's patients are covered by Medicaid or another government program for low income people, which reimburse hospitals at lower rates than private insurance. Some of Saint Anthony's financial problems stem from delayed payments from the state of Illinois and from private health insurers that cover people with low incomes.

"Any time that you're working in a marginalized community you're always struggling for resources because these are the people that are often forgotten unfortunately, and yet these are the people we are here to serve and that we commit to serve," said James Sifuentes, senior vice president for mission and community development at the hospital.

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Now that coronavirus cases are surging in Chicago, Saint Anthony's financial woes are getting worse. Since March, the hospital estimates it has lost $10 million — in part from canceling surgeries that aren't considered emergencies — and increased spending by another $2.5 million to pay for resources and overtime.

$30 billion went out to help healthcare providers. Saint Anthony got just $792,000.

The hospital is losing staff, because it can't afford to compete with hospitals in other parts of the city that are offering healthcare workers higher pay to help with the coronavirus surge. Others are going to work at a temporary medical facility opening soon at Chicago's McCormick Place, a lakefront convention center that'll be housing 3,000 patients with mild symptoms from the coronavirus.

In Illinois, 20% of people getting tested for the coronavirus have been positive. But at Saint Anthony, half of the 150 patients tested have been positive. In all, Chicago has reported more than 17,000 cases.

The $2 trillion coronavirus stimulus bill that President Donald Trump signed in late March, called the CARES Act, included $100 billion for healthcare providers, money members of Congress billed as a relief package for the neediest, most overwhelmed hospitals.

Read more: A leaked document from Senate Democrats provides clues on how the federal government will allocate $100 billion from the coronavirus stimulus to hospitals

Around $30 billion has been distributed so far, and Saint Anthony has received just $792,000. Sifuentes said the situation will become untenable if the hospital doesn't get financial relief.

"Does that mean closing? I don't know," he said, stressing the hospital would do everything it could to care for patients by innovating its services and alerting elected officials of its struggle.

Coronavirus takes a financial toll on the healthcare system

Hospitals in the hardest-hit parts of the US have been struggling to treat a surge in patients with COVID-19, as the disease caused by the coronavirus is known. Healthcare workers are reckoning with a virus that doesn't yet have a vaccine or cure, and one that patients can carry and pass on to others without showing any symptoms.

Read more: Here are the 15 leading coronavirus treatments already being tested in COVID-19 patients, and the major trials now underway to see if they work

They're dealing with financial strains, too. Because of a shortage of protective equipment, hospitals are paying higher prices than they normally would for gloves, masks, and other supplies. On top of that, state officials have told hospitals to cancel medical procedures that aren't emergencies, cutting off a main source of revenue.

For safety-net hospitals like Saint Anthony, the financial toll is particularly dire. Hospitals that operate to serve the poorest patients have much smaller financial reserves than large hospitals systems. When the first round of federal government stimulus money for healthcare providers went out Friday to hospitals and medical offices all over the US, they were at a disadvantage.

Dr. Eden Takhsh, chief quality officer for Saint Anthony Hospital. Courtesy of Saint Anthony Hospital.

The Trump administration direct deposited $30 billion in funding to all medical providers who had billed Medicare during the past year.

The formula was based on how much money they'd gotten from the government health program. On average, hospitals get about 41% of their funding from Medicare, but at Saint Anthony, Medicare covers only about 17% of the patients they see, putting the facility at a disadvantage.

There's still $70 billion more in stimulus funding that's set to go out as part of the CARES Act, but it's not clear when that's happening and whether that'll be enough to keep hospitals afloat. The Trump administration has said funding will go to rural hospitals and those with higher shares of patients covered by Medicaid or who are uninsured.

"As other systems can wait for the money to arrive from the stimulus, maybe they can wait a month, two months, three months, we need that money today in order to keep providing the care that we need to," said Dr. Eden Takhsh, Saint Anthony's chief quality officer.

Bracing for a surge

Truman Medical Centers, a safety-net hospital system in Kansas City, Missouri. Courtesy of Truman Medical Centers Over in Kansas City, Missouri, another safety-net provider called Truman Medical Centers received $5 million from the CARES Act, an amount that covers all their workers' pay for a week.

Truman CEO Charlie Shields said that running its two hospitals over a two-week period costs $25 million when factoring in supplies, equipment, and other expenses. But the needed funding could go much higher if Kansas City gets the surge of patients with coronavirus expected in late April.

"If you had a surge and filled the hospital up, the finances would change dramatically," Shields said.

As of Tuesday, Truman had tested 1,700 people, finding 117 positive cases. Ten people were checked into the hospital and another 19 had been discharged. Four died.

Shields said he was hopeful that state stay-at-home orders implemented early would help keep the number of cases at bay. Still, there's no telling when the surge will end and when Truman will be able to resume typical operations.

Right now, Truman is limiting visitors and deploying staff to other jobs. It set up drive-thru testing centers, upped cleaning operations, and boosted call centers so nurses could answer questions from patients who worry about getting infected by the coronavirus.

"We have to be ready should the surge happen, and that's obviously a financial challenge for all hospitals but it's a particular challenge for safety-net hospitals who tend to operate on much lower, narrow margins than what you would describe as a typical suburban hospital," Shields said.

In Houston, Harris Health System is bracing for a surge expected in the next two to three weeks, even though it feels it's in good shape financially. Its leaders are keeping an eye on the county jail, concerned there might be an outbreak there compounding a surge in Houston that would cause them to run out of beds and supplies. Harris Health System in Houston. Courtesy of Harris Health System.

"I'm concerned about having adequate supplies, having access to more testing. That's what really keeps my CEO up at night," said King Hillier, vice president of public policy and government relations. King Hillier, vice president of public policy and government relations at Harris Health System. Courtesy of Harris Health System

Harris received $9.2 million on Friday as part of the CARES Act, but had to put some workers on paid time off and have them accrue a negative paid time off balance when they run out. Staff will have to work those hours later, and a larger influx of cash would help alleviate these changes, Hillier said.

"Financing is going to get tricky. We need to have these types of dollars flowing in. But the more immediate need is that if the surge hits, will we be able to respond?" King said.

Harris and Truman are both in states that didn't expand Medicaid, meaning that they have a larger percentage of patients who are uninsured than most states do.

Under the Affordable Care Act, states can expand Medicaid so that it covers low-income people, but 14 states haven't done this due to Republican opposition to the law and concerns about whether states would be able to afford their share of costs in the long run.

A push for more funding

On Monday, America's Essential Hospitals, which represents safety-net hospitals, sent a letter to congressional leaders asking for more funding and for the remaining funding to go out to hospitals that face dire need.

"The positive is that it got out really quick," Shields of Truman in Kansas City said of the first round of funding. "To be able to turn money around two weeks after a bill is passed is pretty remarkable. They did it with a formula that was incredibly easy to understand. Give credit where credit is due, I think everybody is appreciative of that. The challenge for safety-net hospitals is that typically Medicare is not a big part of our patient base."

Charlie Shields, CEO of Truman Medical Centers. Courtesy of Truman Medical Centers

For the first round of funding, roughly 500,000 providers across the US got money regardless of whether their businesses were in danger of closing or whether they were directly fighting the coronavirus pandemic. There's still $70 billion to distribute, but the list of places it's likely to go next is growing, meaning there might not be enough to go around.

For instance, children's hospitals didn't get as much funding with the first round of payments because Medicare mostly covers seniors. Nursing homes, which have been hard-hit by the coronavirus, are also primarily funded by Medicaid, and Medicare generally doesn't pay for their services. The Trump administration has said some of the money would also go directly to paying for the testing and care given to people with COVID-19 who are uninsured.

Congressional Democrats are pushing Republicans to attach $100 billion more to an interim stimulus package the Senate is negotiating. Senate Democratic leaders on Monday sent a letter to Health and Human Services Secretary Alex Azar asking that the next round of funding be more targeted.

Democrats attached a release to their letter that said a more targeted approach was "as Congress intended," but the language of the CARES Act is far more broad. It encompasses not only front line workers and the money that providers spend to treat people with coronavirus, but also foregone revenues. Many healthcare providers have seen their revenues shrink due to stay-at-home orders and state officials forcing providers to halt non-essential care.

An FAQ about the stimulus package that Democrats wrote also supports distributing the stimulus funds to a wide range of providers, even though Democratic leaders billed the $100 billion relief as a lifeline to struggling hospitals.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, told reporters Wednesday that more announcements about the next wave of funding would come at the end of this week. The agency would target spots that were hard hit and providers who were left out of the first round, she said.

"We want the second piece to be a broader swath so that it's impacting all providers based on their relative revenue," Verma said.

