For decades, community health clinics designated as Federally Qualified Health Centers (FQHCs) have been providing critical services to citizens regardless of their ability to pay, making them an integral part of the health-care safety net.
The Louisville Family Health Centers network, which celebrates its 40th anniversary this year, is one of three FQHCs in the Derby City. It expects to serve about 40,000 people this year, but the Louisville organization and the rest of Kentucky’s Federally Qualified Health Centers could face an uncertain future if an overhaul of the state’s Medicaid program is enacted.
On the season premiere of Kentucky Health, host Dr. Wayne Tuckson speaks with the Louisville Family Health Centers’ executive director about the organization’s history, its services, and its goals going forward.
Bill Wagner has worked for Louisville Family Health Centers for more than 35 years, the past 18 as executive director. In 2006, Wagner was named the U of L Alumni Fellow from the Kent School of Social Work.
Wagner says that Louisville Family Health Centers is most often associated with its hub at the Portland Clinic in Louisville’s West End but has a total of seven facilities in the city. It is joined as a FQHC by three clinics operated by Park DuValle Community Health Center, and by a new clinic operated by Shawnee Christian Health Center.
Kentucky has 23 FQHCs across the state, part of a national network that numbers some 1,300 organizations and originated over 50 years ago as part of President Lyndon Johnson’s War on Poverty.
“I think there was a recognition during the 1960s that in order to alleviate poverty, first we had to create jobs, and community health centers created jobs in the communities where they existed, but also that we needed to address the health of the workforce and of the communities…as a way of fighting the War on Poverty,” he says. “And so, the FQHC concept really grew out of that, with the recognition that the health care delivery system at the time wasn’t delivering, and wasn’t improving the health of the populations the way it should have been.”
A Variety of Services for Anyone in Need
Louisville Family Health Centers offer primarily outpatient facilities, and select inpatient services such as childbirth in conjunction with area hospitals. They provide primary care services organized around four medical specialties: family medicine, internal medicine, pediatrics, and obstetrics/gynecology.
In addition, Wagner says Louisville Family Health Centers operate dental clinics at two locations, have diagnostic lab and radiology services, and, perhaps most importantly in light of the opioid epidemic ravaging Louisville, offer mental health services and substance abuse treatment. The centers also conduct health education classes, and even have an attorney on staff to help patients with legal problems that might create barriers to health care.
“For a long time, we’ve had this philosophy of community-oriented primary care, that it’s really the community we’re taking care of, not just those people who came through the door who were sick,” Wagner says. “We wanted to make sure that the community had preventive health screenings, and that we detected disease early and began treatment early, and keep people out of the hospital. … It’s really part of trying to provide more affordable care, and really give better value to the taxpayer as well.”
While Louisville Family Health Centers are located in medically under-served neighborhoods, anyone can use their services. The centers are participating providers in all commercial health insurance plans in Kentucky, participate in Medicaid and Medicare, and have a sliding fee scale for those without insurance. They historically have been funded via federal programs such as the Community Health Center Program or the Health Care for the Homeless Program, but also receive funding from Louisville Metro Government (they receive no state funding).
Wagner says that since the implementation of the Affordable Care Act on Jan. 1, 2014, and former Gov. Steve Beshear’s establishment of the Kynect insurance exchange and expansion of Medicaid, the number of uninsured patients accessing Louisville Family Health Centers has dropped from approximately 51 percent to 18 percent.
He adds that the overwhelming majority of those patients who secured insurance were able to do so because they were newly eligible for Medicaid. “Those uninsured patients who received insurance, many of them did so for the first time,” he notes. “And over 90 percent of our homeless patients ended up getting health insurance for the first time under the expansion. A single adult with low income could get Medicaid for the first time.”
The Impact of Proposed Medicaid Changes
Wagner says that, due to the expansion of medical insurance in Kentucky, health outcomes have improved for patients at Louisville Family Health Centers. He explains that more patients are getting annual exams and preventive screenings, establishing permanent relationships with doctors, and making one of the centers’ seven clinics their medical home.
“Whether it’s helping case manage a high-risk diabetic patient, a patient with multiple chronic diseases, a homeless patient who might have severe mental illness or a substance abuse problem, the expansion allows us to address some of these social determinants which we know are really important to address if we are going to move the needle on some of the quality measures,” he says.
Earlier this year, Gov. Matt Bevin announced that he will close the Kynect exchange, which is used by middle-income Kentuckians who don’t have employer-provided health insurance and earn too much money to qualify for expanded Medicaid. The state exchange is due to end this fall, forcing its members to apply to the federal exchange for health insurance, and transferring to a new computer system the state’s 1.3 million Medicaid enrollees who previously used the Kynect portal to access benefits.
In addition, Bevin also recently submitted a waiver proposal to the federal Department for Health and Human Services that would substantially transform the Medicaid expansion program enacted by his predecessor, Gov. Beshear. Bevin’s proposed waiver, currently under consideration, would place work requirements on Medicaid recipients and remove certain services as covered benefits.
Wagner believes that, if approved, the Bevin administration’s changes to Medicaid expansion in Kentucky would negatively effect Louisville Family Health Centers’ patients, and patients who access Kentucky’s other 22 FQHC systems in general.
First, Wagner says that the changes would reduce the reimbursement rates that Medicaid managed-care organizations receive, which he believes would trickle down and also reduce payments for providers such as the Louisville Family Health Centers and other FQHCs. Second, he is concerned that closing Kynect’s enrollment portal will cause mass confusion and, possibly, the unintentional elimination of benefits as people “fall through the cracks.”
Lastly, Wagner strongly believes that the new administration’s contention that Kentucky cannot afford the additional costs of Medicaid expansion is untrue. He contends that the federal government will, at the least, pay for 90 percent of the expansion in the years to come, which he says is a good deal for a state that historically has been one of the unhealthiest in the nation.
Wagner says in order to have healthy students, employees, and moms and dads, we need to invest in the population’s long-term health, and not be thinking “short term.”
Further, Wagner cites a recent study conducted by the Harvard School of Public Health that surveyed patients in states that expanded Medicaid, including Kentucky and Arkansas, as well as those that did not. That study indicated that patients in expanded Medicaid states are already reporting better health measures.
“People are saying that they have a regular medical home, that they no longer have problems affording medication, that they don’t go to the ER as often, that they get more preventive health screenings — just a variety of measures,” he says. “This is the most recent study that shows that there really is an immediate benefit.”
