Holes in the safety net of healthcare

June 8, 2020, by Katherine Hymel Downs, RN, MPH


Many of us were forced to delay routine healthcare in one way or another due to COVID-19, whether a dental cleaning or counseling session. In fact, according to researchers at Harvard University, visits at ambulatory health clinics dropped by 60% by late April and were finally seeing a rebound as of mid-May. Now, we are left to investigate the continuing impact. Tangible metrics include the effects of economic loss incurred by the facilities themselves, including staffing furloughs and office closures. But how do we quantify losses in health of patients—losses from delay of care? What about those patients that now find themselves on the outskirts of our healthcare system due to unemployment and loss of benefits? For patients who rely on safety net clinics (rural health clinics, federally qualified health centers, free and charitable clinics), where can they turn when those already strained facilities are forced to close?

In early April, the Health Management Association predicted that Medicaid enrollment could increase from 71 million to the upwards of 94 million due to COVID-19 and related legislation. The process of Medicaid enrollment can be done by phone, without need of internet access. However, patients often require assistance selecting a plan accepted by their healthcare provider or gathering the necessary documentation. In the wake of social distancing measures where many public libraries and even social services buildings are closed to the public, where are people to turn? How many patients even realize they are now eligible to enroll, unless they were advised by a care coordination team at the end of a hospital stay? States are no longer held to the same timeliness standards amidst the pandemic, with limited staff and modified workflows.

Part of the Families First Coronavirus Response Act (FFCRA) did address this prediction of increased enrollment from a financial standpoint. States could benefit from a 6.2% increase in federal match rate (FMAP) (an estimated $36 billion) if they met certain criteria, including the assumption of cost for testing and treatment of the virus. But how exactly does this money reach an individual clinic that serves Medicaid patients—many of whom may not be coming in the door due to COVID-19? Clinics were forced to quickly adopt telehealth services, defined by Medicaid as including both a video and audio component for reimbursement. This presents the following barriers to patients: adequate technology, internet service, and digital literacy. Hybrid clinics that serve a variety of patients—Medicare, Medicaid and uninsured—rely on reimbursements to reserve other funding sources for uninsured patients and general overhead (payroll and benefits, PPE for staff, translation services). Now they are dependent on other relief measures such as the Paycheck Protection Program and outside grants to keep doors open and meet a growing need for care.

As a healthcare provider at a rural health clinic, I admit I do not have all the answers to policy changes. However, the following action items are worth investigating:

  • Medicaid expansion for states who have not already done so
  • Modify regulations to remove barriers from the Medicaid application process
  • Consistent and clear guidelines on reimbursement for telemedicine
  • Provision of cell phones with video technology by managed care organizations (MCOs) to ensure patients have access to telemedicine