Last fall, Kim Wagenaar started to plan how she would close the health clinic she runs in rural North Carolina — when Congress let funding lapse for thousands of centers like hers 127 days ago and counting.

The Cabarrus Rowan Community Health Center offers primary care services to patients, largely uninsured and unable to afford visits elsewhere. Its four buildings, scattered across suburban Charlotte and more rural areas to the north, do not suffer from low demand. They saw more than 8,000 patients last year alone.

“I’m usually a very optimistic person,” Wagenaar says. “I always feel like the community health centers have great support. But I’ll be honest, this is the first time I’m not 100 percent sure this will get fixed.”

Nationally, millions of Americans visit community health centers each year. An estimate from 2016 found the 2,000 centers provided care to 26.5 million people. They rely heavily on federal funds that have passed with bipartisan support in recent decades. George W. Bush expanded the program, and the Affordable Care Act made another big investment in them.

But this fall, the $3.6 billion budget lapsed at the same time as the Children’s Health Insurance Program. CHIP, which provides coverage to millions of poor children, just got its funding back in late January. But community health centers were not included in the deal.

Legislators from both parties have said they want to extend the health centers’ budget. But so far, they haven’t. If they don’t do it very soon, health care access will decline for potentially millions of vulnerable Americans.

George W. Bush and Barack Obama were both ardent community health center advocates

Community health centers began as a tiny experiment in Mississippi and Massachusetts in the 1960s, a small element of President Lyndon B. Johnson’s war on poverty.

An enterprising young doctor named H. Jack Geiger had done work in South Africa and saw the difference that access to primary care could make for underserved communities.

Four decades later, it was George W. Bush who pushed for a major expansion of the program. As the New York Times reported in 2008, the president “came to admire the missionary zeal and cost-efficiency of the not-for-profit community health centers” and “proposed to open or expand 1,200 clinics over five years (mission accomplished) and to double the number of patients served (the increase has ended up closer to 60 percent).”

President Obama followed up on the Bush-era expansion with increased community health center funding through the Affordable Care Act. With the law expanding coverage to millions, the Obama administration wanted to ensure that the newly insured would have adequate access to medical services.

Community health centers experienced another growth spurt. The number of patient visits grew from 19.5 million in 2010 to 26.5 million in 2016. An additional 200 community health centers opened and increasingly expanded their work into dental and mental health services.

When Obamacare funding lapsed in 2015, Congress passed a bill funding both community health centers and CHIP for an additional two years — until September 30, 2017, when both initiatives saw their budgets lapse.

“There was a fairly widespread assumption that this would become the norm, that these two programs would travel together,” says Sara Rosenbaum, a health policy professor at George Washington University who has written on community health centers. “One program would address coverage and the other access, but this year has upended that assumption. Now the program is standing on its own.”

Community health center advocates preferred having the two travel as a unit, a pair of programs that both make it easier for underserved communities to get health care. They worry about now having to fight the battle for funding on their own, without the CHIP program as part of the package.

“I’ve always had this philosophy that it’s better to be the ornament than the tree,” says Dan Hawkins, senior vice president at the National Association of Community Health Centers. “They [CHIP] were the tree — but I guess we’re the tree now. While I am thrilled for them that their crisis is averted, we now stand alone. We’re the biggest program out there that remains uncertain of its funding.”

If Congress doesn’t fund community health centers, thousands are expected to close

Rosenbaum recently led an analysis of what would happen if Congress let funding lapse.

Community health centers would still have other income streams, including other grants, as well as reimbursements from the insurance plans (often Medicaid) that cover 77 percent of their patients. But the loss of the federal dollars currently at stake — $3.6 billion in annual funding — would be a significant hit.

Some places, like North Carolina, would be hit harder than others. North Carolina, for example, is among the 18 states that have not expanded Medicaid. This means that it still has high uninsured rates among its patients and is relies more on federal funding.

Wagenaar estimates that losing federal funding would reduce their budget by 52 percent — and that would force the clinic to make some tough decisions.

“I’ve had these contingency plans in place and ready since October [when funding lapsed],” she says. “We’re working with our lawyer to start crafting a reduction in workforce plan so that I can make sure employees get an appropriate amount of notice.”

She’s applying for other grants too, as a safeguard, but that wouldn’t be enough to keep the clinic afloat.

“We’ll probably at minimum have to close two sites, one in each county we serve,” she says. “We’re still waiting on other grants we applied for. Worst case, we’d close three of our four sites and leave Rowan County entirely.”

Congress is dallying: ”It’s all about the pay-fors”

Congressional aides on both sides of the aisle say they expect community health center funding to be attached to the next must-pass piece of legislation. That is likely a bill to fund the government that’ll need to pass when the current short-term patch runs out on February 8.

“It is my belief that providing this critical, long-term funding needs to be a top priority when the House returns next week,” Rep. Greg Walden (R-OR), who chairs the Energy and Commerce Committee, wrote in an op-ed last Friday.

But so far, there is no firm proposal. The biggest obstacle is figuring out how to pay for it, according to Hawkins. Congress use the euphemism “pay-for” when describing the process of cutting one program to fund another.

“It’s all about the pay-fors,” Hawkins says of his conversations with congressional staff. “It wasn’t in the tax bill, it wasn’t in the continuing resolution a few weeks ago, and it’s all about where are you going to get the money? They’re working through that. We hear they’re closer than ever.”

Community health centers are asking for Congress to keep their funding relatively stable, at $3.6 billion each year, which would work out to $36 billion over a decade (although it’s not clear whether Congress would extend its budget for that long — its last extension, for example, was only for two years).

This is a tiny amount of money compared to the $1.5 trillion price tag of the recent Republican tax cuts. Funding it for two years, as Congress did in 2015, would work out to $7.4 billion — less than half the estimated $18 billion cost of the first phase of the border wall that President Trump has proposed.

And that frustrates the supporters of these centers, who point to how effective they are given their relatively small costs.

Wagenaar hopes the funding will come through but also emphasizes that some damage has already been done. She has frozen hiring on seven positions at her clinics. That includes an open position for a doctor, who could be seeing patients and expanding the clinics’ capacity if it weren’t for the lapsed budget.

“Our staff have had to cover for the providers [who] were missing, so they are not only seeing their patients but seeing some additional patients,” she says. “In the last three years we’ve seen 30 percent growth in our patients, so I really need more space. But I can’t open another site if I don’t know I have the funding to keep it open.”

Join the conversation

Are you interested in more discussions around health care policy? Join our Facebook community for conversation and updates.