Community health centers expect to sign up millions of newly insured patients under President Barack Obama's health reform law, but U.S. budget cuts just as they need to beef up services may make it hard to keep the newcomers.
The federally funded centers have been a safety net in the nation's poorest areas since 1965, offering primary care and mental health services to 22 million people, more than a third of them without insurance.
When the Affordable Care Act, popularly known as Obamacare, takes full effect on Jan. 1, the 1,200 clinics plan to help enroll many of the newly insured. That campaign is expected to bring 10 million new patients within a year.
But with scant funding to improve their services and level of care, the centers are scrambling to ensure they can keep the new patients. The fear is that, over time, many of the insured patients will look for better service at private practices and hospitals, diverting a fresh source of much-needed income for the centers.
"There's a big competitive reality coming for us," said Don Blanchon, executive director of Whitman-Walker Health, a community health center in Washington. "We're finally getting to the point where this is really about how good we provide care, and it's about outcomes."
That is precisely what worries Raymond Martins, chief medical officer at Whitman-Walker.
"If patients have to wait too long or can't get an appointment, they'll go somewhere else," Martins said. "The care model that the health centers operate sure as hell needs to be able to compete with private practice and hospital-based doctors."
The wait time for an appointment at Whitman-Walker is typically between three weeks to six weeks, but at many other centers it can take months. To prepare for the health reform influx, Whitman-Walker hopes to rent more space, doubling its exam room capacity and tripling the number of dental chairs.
Health center directors said they want to become a preferred provider for patients with options, rather than a last resort.
A provision of the healthcare law provides incentives for them to become registered Patient Centered Medical Homes. A PCMH is a healthcare model in which a team, led by a primary care physician, provides comprehensive care throughout a patient's lifetime.
Along those lines, Whitman-Walker plans to give each patient access to a care team. There are also plans to hire two more medical practitioners and at least one more dentist and dental hygienist. Martins believes the efforts will help build a loyal following.
Many patients at the community health centers value the convenience of their neighborhood locations and their services for health issues affecting low-income areas, including nutrition counseling and crime victims' support groups.
"I guess I could switch but won't because of the cost and accessibility of coming here," said Adam, a Blue Cross Blue Shield insurance patient who received an HIV test at Whitman-Walker in June. He requested only his first name be used.
Community health centers never turn away patients for lack of insurance. Those who earn up to two times the federal poverty level - amounting to $11,490 for one person and $23,550 for a family of four - pay on a sliding scale or have fees waived.
But the centers are struggling with a more than 5 percent chop to their base funding in March under across-the-board U.S. government budget cuts. That means the centers will be able to serve 900,000 fewer patients and accommodate 3 million fewer visits this year, according to the Kaiser Family Foundation.
There were 400 applications from around the country this year for new health centers under the healthcare law but the budget cuts meant only 25 could be accepted.
The Patient Protection and Affordable Care Act in 2010 earmarked $11 billion over five years to bolster community health centers, but only $3 billion has made it through Congress so far.
That means the centers are counting on enrolling patients having some insurance from Obamacare, whether through government subsidies to individuals who will buy coverage or an expansion of the Medicaid program for the poor.
Aurelia Jones-Taylor, chief executive of Aaron E. Henry Community Health Center in Clarksdale, Mississippi, said the clinic is anticipating a 25 percent increase in patients at the beginning of the calendar year.
It is hiring two more employees to help people understand their options in a community where nearly 95 percent live below the federal poverty line, Jones-Taylor said.
The clinic also needs two nurse practitioners and two physicians. It can hire the practitioners but doesn't have the money for new doctors.
Beatrice Bostick, chief executive of Alliance Medical Center in Healdsburg, California, faces a similar situation. The clinic currently sees 12,000 patients a year, and expects that figure to reach at least 14,000 next year.
Bostick said she needs three more doctors, but for now hopes to hire one by September and a second by January.
Her center has ambitious goals for drawing in eligible members. It has two staff members helping people sign up for health insurance and plans to hire two more.
The Department of Health and Human Services has provided a $150 million grant to help the centers explain the new law to patients and sign them up for insurance benefits.
The clinic hopes to enroll half of its community's eligible population by December, three months after people can begin signing up for the government insurance exchanges under Obamacare. It wants to enroll another 60 percent of the remaining uninsured by April 2014.
Many of those who are eligible need help in enrolling, says Dan Hawkins, the National Association for Community Health Center's senior vice president of public policy and research.
"You get folks that work like heck to keep a roof over their heads and put food on the table for their families and don't have a lot of time to go through this stuff," he said.