Over the past month, we provided additional details on the structure, funding, and evaluation of the Maternal, Infant, Early Childhood, Home Visiting (MIECHV) program and Medicare Therapy Caps. In this post we will go into detail on the structure, funding, and outlook of the “primary care cliff,” and specifically the three programs relating to community health centers. This is part of an ongoing series we are doing on the potential riders of a health care minibus. The “minibus” refers to a handful of policy provisions tied together in one piece of legislation. This minibus will carry a number of provisions into law, although the number of riders onboard the minibus, and when the minibus leaves the station, remains to be seen.

Future posts will review additional details of other potential riders on the minibus.

Overview

Funding for community health centers that is up for extension includes: community health center funding provided through section 330 of the Public Health Service Act, the National Health Service Corps (NHSC), and the Teaching Health Center Graduate Medical Education (THCGME) program. Funding for each of these programs was most recently extended through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These programs need to be reauthorized by September 30, 2017, in order to continue.

Community Health Centers

Funding for community health centers has been bipartisan for decades. Congress enacted the health center program in the 1960s to address a lack of primary health care services and a growing number of medically underserved areas. In 1975, the community health center program was authorized under section 330 of the Public Health Service Act, and has been reauthorized and expanded to focus on underserved communities and vulnerable populations. In 1996, the Health Center Consolidation Act brought together various health center programs under the same umbrella to support the continued development of community-based health centers. In 2002, the Health Care Safety Net Amendments reauthorized the health center program, requiring health centers to participate in the Children’s Health Insurance Program, in addition to authorizing various grant programs. In 2010, the Affordable Care Act (ACA) established the Community Health Center Fund (CHCF), which provides a mandatory funding stream for community health centers.

Funding for community health centers through the Public Health Service Act is designed to be used for various health care activities, including expanding and improving the services provided at existing health centers, as well as building new health centers and various grant programs. Additionally, the fund can be used to address public health emergencies. In 2015, according to the National Association of Community Health Centers, federally funded health centers served over 24 million patients while employing over 180,000 individuals.

National Health Service Corps

The NHSC is a program designed to place clinicians in health professional shortage areas by making loan repayment and scholarships available to clinicians in exchange for at least two years of their service. The program was created in response to a primary care shortage in the 1950s and 1960s. The Emergency Health Personnel Act Amendments established the NHSC Scholarship Program in 1972, and within six months of its enactment placed nearly 180 clinicians in over 100 communities. Currently, an estimated 10,400 NHSC clinicians provide care to over 11 million people in rural and urban health shortage areas. The ACA permanently reauthorized the NHSC and provided mandatory funding through fiscal year 2015. Prior to the ACA, the NHSC relied solely on annual discretionary appropriations that were established during its inception in the early 1970s. The NHSC was last authorized by MACRA through September 30, 2017.

As of FY2015, according to the Congressional Research Service, behavioral and mental health clinicians make up the majority of the NHSC field staff, followed by allopathic/osteopathic physicians, nurse practitioners, and dentists. Among the changes in the ACA, NHSC clinicians can count time spent teaching at teaching health centers towards their NHSC service commitments.

The Teaching Health Center Graduate Medical Education Program

The THCGME program was established by the ACA in 2010 and aims to increase the number of primary care residents and dentists trained in community-based settings, address the primary care workforce shortage (specifically in rural and underserved areas), and provide health care services in underserved communities. Through the THCGME program, primary care physician interns and residents are trained in a community-based setting, instead of the traditional hospital-based setting. The THCGME program trains residents in a number of specialties, including family medicine, pediatrics, psychiatry, obstetrics, gynecology, dentistry, pediatrics, internal medicine, and geriatrics.

The program has grown from 11 programs in its first year of funding to 59 programs in this current academic year. During the last academic year (2016-2017), the THCGME program supported the training of over 700 residents across 24 states. The program was extended through MACRA. However, per resident payment was reduced from $150,000 to $95,000 for teaching health centers, placing increased financial strain on the programs. There is an ongoing evaluation of the THCGME program.

Funding Cliff

The Community Health Center Funds have been awarded annually since 2011 to all 50 states and the District of Columbia, as well as the U.S. territories. For FY2016 and FY2017, MACRA provided $3.6 billion for health centers, $310 million for the NHSC, and $60 million for teaching health centers. These programs need to be reauthorized by September 30, 2017.

Outlook

In President Trump’s FY2018 budget, the Administration calls for continued funding of CHCs, the NHSC, and THCGME. CHC’s would receive an $89 million increase, NHSC funding would see an increase of $21 million, and THCGME would be increased by $4 million (based off the recently passed FY2017 budget). Funding for CHC’s was also included in a number of the proposed repeal bills, suggesting that there is support for these programs to continue on both sides of the aisle.

Congress will have to produce a package that extends these programs by September 30th. However, there are a number of competing issues (e.g., the debt limit) that Congress must address upon returning from recess, which could extend the health care minibus discussions beyond this deadline.

As for the minibus, it’s not really a question of policy – but of politics. Community health center funding, and other riders on the minibus, will need 60 votes to pass. So Republicans and Democrats will need to work together and comprise to move community health center and other minibus riders along. Following the health care repeal debate, it’s still unclear whether there is an appetite for bipartisan collaboration.

We will listen for signs of progress in early September.