Visits down by as much as 70%. Millions of dollars of revenue per month gone. Staff laid off or furloughed.
But customers — perhaps more than ever — are ready to come back.
These statistics aren’t from just any business hit hard by COVID-19: They’re from community health centers, the biggest provider of health care to New Yorkers on public insurance plans. And the system could grow larger, with millions of newly unemployed workers seeking coverage in the state.
“Whenever this ends, there will be a huge pent-up demand and it’ll be hard to ramp back up,” said Rose Duhan, who heads the Community Health Care Association of New York State, which represents the centers.
Before the pandemic, the centers provided one in eight New York City residents with medical care, from wellness visits to cardiology services. As essential businesses, they stayed open, but saw few patients in person for weeks, according to center operators.
The mandate to stay home has exacted multiple costs, Duhan says: The centers couldn’t manage patients’ in-person care, meaning a loss of revenue.
That put them behind in serving the hundreds of thousands of new patients who have signed up for public health plans since March — and in preparing for the hundreds of thousands more who likely will.
Health ‘Slip’ Concerns
Meanwhile, current patients are avoiding appointments for everything from treatment for chronic illnesses to checkups aimed at preventing sickness. And new customers are unsure how to navigate the system.
“If people are afraid of the virus, there’s a pause in accessing care and a slip in how they manage their own health and wellness,” said Dr. Isaac Dapkins, chief medical officer of the Family Health Centers at NYU Langone in Sunset Park.
The Affordable Care Act’s Medicaid expansion led to a surge of signups as the percentage of uninsured New York residents dropped from 12% in 2010 to 5% in 2018.
But that only goes so far if insured patients can’t see a doctor.
Now, health centers are devising strategies to bring in new patients, convince existing ones they’re safe from the virus, and bill enough for telehealth care to break even.
Against this backdrop, total tax revenue in the city is expected to plummet by an estimated $9.7 billion over two years, according to the Independent Budget Office. In addition, Medicaid appears likely to get squeezed, economists say.
Federally Qualified Health Centers are a specific designation for the groups of clinics that manage care for patients — many, but not all, on public health plans. By meeting certain quality metrics, the centers receive federal grant funding annually.
The rest of their revenue comes from billing. In the case of Medicaid patients, who make up about 60% of the centers’ clientele, that money is a 50-50 split between the state and the federal government.
At the city’s health centers, 90% of patients are at 200% of the federal poverty level or below. The centers in the five boroughs see many more uninsured patients than most — while the statewide uninsured rate was about 5%, about 15% of centers’ patients don’t have any insurance.
If unemployment surges to 20% in the city, as the most dire estimates predict, some of those who’ve lost their employer health care may end up turning to the centers.
That means the providers not only need to come back — but come back strong.
Slow Wave of Sign-Ups
Since the pandemic began, Renata Marinaro, the national director of health services at The Actors Fund, a nonprofit that supports performing artists, has been running weekly webinars about getting or keeping health insurance for artists and freelancers.
The week of May 4, 20 RSVPs came in, she said, as the initial panic about layoffs seemed to ease with the arrival of unemployment insurance benefits, pandemic unemployed assistance and stimulus checks.
The following week, though, 80 signed up for the seminar as new apprehension hit about what would happen to health coverage in the long haul.
‘It’ll be very intense in the fall and the winter as people lose coverage.’
“There is going to be an increase over the summer, and then in the fall I think we are going to see a lot of people looking for coverage,” Marinaro said. “It’s a bit of a delayed response. I think it’ll be very intense in the fall and the winter as people lose coverage.”
After losing her job on March 17, Jessica Capone, 36, who worked in business development at Tribeca Rooftop, an event space, saw the $1,200 price tag to continue her employer health coverage through COBRA and froze.
“I wasn’t sure what to do,” she said.
The company kept her coverage until the end of March. Capone, who had to reschedule a planned minor, non-urgent surgery, looked for a replacement immediately.
She tried to sign up through the exchange on her own.
But because of her salary for the first two and a half months of the year, she couldn’t find an affordable plan. That makes her the type of patient that experts and health navigators worry about, since she might not have known how to make her way to a health center.
Capone ended up qualifying for a Medicaid plan through United Healthcare, which her current doctors accepted. A health navigator at a nonprofit called Public Health Solutions helped get her set.
“It’s a huge relief,” Capone said. “With no income and huge medical bills I didn’t know how I would afford anything.”
Uncertain Where to Turn
Capone is one of 200,000 New York State residents who have signed up for new coverage through the exchanges since the beginning of March as 2.4 million have lost jobs statewide, according to the Department of Labor, with 136,000 of them now on Medicaid.
But coverage is one thing, and care is another.
“The person who gets sick for the first time after not having insurance, and who is not known regularly to a provider, that’s who I’m worried about,” said Larry McReynolds executive director of the Family Health Centers at NYU Langone. “Now they’re on Medicaid, they don’t know where to go. They think, ‘Who is going to take it?’”
McReynolds and other health center officials say they have not seen a rise in patients. But they are expecting them — and preparing.
‘We’ve been through the AIDS epidemic, the Great Recession of 2008. We never turned away a patient.’
Brian McIndoe, the head of Ryan Health, which has six freestanding clinics and others in schools, says the centers will resume Saturday hours when needed, stay open late some weekdays, and bring back the medical residents who had been reassigned to hospitals.
“We’ve been through the AIDS epidemic, the Great Recession of 2008 when there was no money,” McIndoe said. “We never turned away a patient.”
Spread around the more than 800 centers in the state, even a million new patients is not an overwhelming onslaught, he said: “I don’t think additional volume will be all at once.”
Getting Patients Back
When the 72 NYU Langone health center sites slowed non-essential visits in March, patients listened, Dapkins said.
That was important for everyone’s health then.
Now, however, Dapkins wants his patients back and has set up various safety precautions to protect workers and clients.
Colon cancer screenings are down, as are pediatric vaccine rates, he said, adding that he expects to see a resurgence of preventable hospitalizations once people’s chronic illnesses catch up with them.
“This is a honeymoon period while people are home focusing on avoiding going anywhere,” he said. “But at some point their congestive heart failure or diabetes comes back.”
So far, Dapkins said, pregnant patients are beginning to return for prenatal exams, and some parents are bringing in kids for vaccinations.
People with sore teeth are happy to be able to be attended to by dentists who dress in full protective equipment and operate on a limited schedule in mostly empty offices.
Some patients with chronic illnesses have been coming in all along, and social workers call them frequently to make sure they continue.
Through various state and federal initiatives, New York has spent a decade trying to get people to go to their primary care visits to cut down on preventable and repeat hospitalizations.
Because of the pandemic, the state extended renewal dates by four months so that current patients didn’t have to worry about reapplying for Medicaid or Essential plans.
Still, Dapkins worries that being unable to deliver quality care to those with chronic illness will land patients managing their health back in the emergency room, which is ultimately more expensive and has worse outcomes.
‘People should reach out for care, even if they’re afraid of the emergency room.’
“We have had patients not deal with symptoms when they should have,” he said. “People should reach out for care, even if they’re afraid of the emergency room.”
Of course, getting patients back in is the key to staying solvent. With billings down from existing patients, they might not have the staff around to serve new folks.
There’s also a key uncertainty in the way health centers get funding that’s always made it hard to plan, but now more than ever. Every two years, the centers have to reapply for federal funding, which makes up a large percentage of their budgets.
Since September, the federal funding hasn’t been officially renewed, instead getting extended temporarily again and again.
“That leaves health centers not knowing what will come next,” said McIndoe. “We lose the ability to plan.”
Ryan Health currently gets $9 million in federal grants, or almost 15% of its budget.
Telemedicine Questions
For the last two months, hundreds of thousands of patients have seen their doctors via their phones and computers instead of in person. At NYU Langone, the centers eventually were seeing about 70% of their in-person volume of patients virtually.
“They have really quickly pivoted to a care model for patients,” said Duhan. “But it’ll have to be revisited.”
Some specialty services just don’t work remotely. “We can’t do telehealth dental checkups,” said McIndoe.
And, Dapkins noted, seeing doctors remotely can be “challenging for people living in poverty,” because of connectivity and bandwidth problems. “Seeing them in person is so important,” he said.
Providers’ fee-for-service payments from Medicaid are the same as for face-to-face visits, according to a state spokesperson.
A Bill Looms
The payer is now the state, not an employer, says McReynolds, which could seem worrisome to New Yorkers and providers wondering how the state and city’s finances will bear the cost.
The good news is most people new to Medicaid won’t be particularly costly to care for, since they are generally young and healthy, said Dave Friedfel of the Citizens Budget Commission.
So far, cuts from Gov. Andrew Cuomo have focused on not growing certain pricey programs. But Cuomo also pushed a $1.7 billion Medicaid bill to next year, since the state was still paying last year’s bill.
That financial crutch, along with the possibility that revenues fall more dramatically than expected, could mean that a worst-case scenario sees drastic Medicaid cuts.
“One of the biggest problems we have is that healthcare is driven by the finances of healthcare,” said Dapkins.
“If all of a sudden people are afraid to see the doctor, you don’t have your revenue anymore. And you have to make hard decisions about that.”
This story was funded in part by the Ravitch Fiscal Reporting Program at the Craig Newmark Graduate School of Journalism at CUNY and is part of a national effort to assess state net safety systems during the pandemic.