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Six Appalachian States Did Not Expand Medicaid. Their Free Clinics Are Bearing the Burden of COVID-19.

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Members of the Army and Air National Guard from across several states have been activated under Operation COVID-19 to support federal, state and local efforts. Photo: Sgt. Amouris Cos/U.S. Army National Guard

West Virginia was the final state to confirm a case of COVID-19, but at that point, over a week ago, only 39 West Virginians had been tested. In a news conference at the time, Gov. Jim Justice said, “I mean, let’s be real. It has to be here. We just haven’t found it yet.” 

“Where we are is just plain simply this,” the governor said, “we’ve got a monster that’s looming.”

On the front lines of this impending battle are the nation’s federally supported community health centers. In West Virginia, 32 CHCs in some 400 locations throughout the state provide care for one in four residents, regardless of the ability to pay. 

Sherri Ferrell, CEO of the West Virginia Primary Care Association, which represents the state’s community health system, said that in preparation for the onslaught of COVID-19 cases, CHCs are huddling with their local health departments and hospitals to put coordinated community responses into action.

Health Right in Charleston, West Virginia, is just one of the state’s community health centers that provide care regardless of a person’s ability to pay. Photo: West Virginia Public Broadcasting

“Health centers are being creative,” Ferrell said. “They’re reaching patients by phone before they come to the health center to see if their conditions can be managed remotely or require additional precautions.” They’re opening alternative testing sites and advising on recommended quarantine procedures

In 2014, West Virginia expanded its Medicaid program, as allowed for under the Affordable Care Act, and Medicaid enrollment in the state is up nearly 50 percent from 2013. Thirty-six states and the District of Columbia have elected to expand Medicaid. Of the 14 that have not, six are in the Appalachian region: Alabama, Georgia, Mississippi, North Carolina, South Carolina and Tennessee. 

Advocates argue that Medicaid expansion has bolstered the nation’s front-line health care defenses– foremost, hospitals and community health centers serving underserved areas– and that the COVID-19 pandemic heightens the urgency of enrolling more people in the program. 

‘Undiagnosed and Untreated’

A brief released last week by the Kaiser Family Foundation points out that Medicaid covers nearly half of all children with special health needs, 45 percent of nonelderly adults with disabilities and more than six in 10 nursing home residents. The authors emphasize that people can enroll in Medicaid as soon as they become eligible– critical in crises such as COVID-19.

Recognizing the potential health and economic implications of the virus, two motions were recently filed by Democrats in Alabama’s House of Representatives to expand the state’s Medicaid program. 

Not expanding Medicaid, the drafters of one of those motions wrote, “ensures that many Alabamians that may become infected will go undiagnosed and untreated.” People “for whom going to the doctor would result in financial calamity tend not to do so before their health circumstances become dire.”  

“I get they want Medicaid expansion, but this isn’t about Medicaid expansion,” Senate President Pro Tem Del Marsh was quoted in the Montgomery Advertiser as saying. “It’s about making sure the people of Alabama understand Alabama is ready to deal with this issue, regardless of how big it is not or may be.”

But the CEO of an Alabama community health center believes that expansion and preparation are synonymous. And he argues that further investment in those front-line defenses saves not only lives but money.

Amping Up 

Cahaba Medical Care, a CHC based in Centreville, Alabama, operates 26 clinics in largely underserved communities, both rural and urban. John Waits, its CEO and a family physician, is a strong advocate for Medicaid expansion. His clinics see patients regardless of whether they can pay. But there are limits on what CHCs’ budgets permit them to provide, and the burden of treating the uninsured reverberates through the health care system. 

The evidence is clear in the states that have expanded Medicaid, Waits said, that if people have “a viable way to present to community health centers and doctor’s offices … they get preventive care, they get chronic-disease care and we avoid many, many unnecessary hospital admissions and ER visits.”

Dr. John Waits. Photo: Taylor Sisk/100 Days in Appalachia

This is particularly important today, he stressed. “We don’t want the ER to be overrun with people who just need screening. The ER is a terrible place to cost-effectively screen people for COVID-19.”

With the limited resources at their disposal, Waits and his colleagues are bracing for the weeks ahead. They’ve begun testing those who exhibit symptoms of COVID-19, but, he said, “We have not been issued any type of testing from the federal government or state or local health departments.” 

All of Cahaba’s supplies have been provided by two commercial laboratory testing facilities.

“I’m responding to questions five or 10 times a day,” Waits said, “‘Why can’t you test everybody?’ Wednesday night, March 11, we heard the president say that everybody who wants to be tested can be tested, and so we have people coming in and calling saying, ‘I want to be tested.’” 

Cahaba has consolidated its COVID-19 testing into two “fever and cough” clinics, one in rural Centreville, the other in the Birmingham neighborhood of West End. Waits said this allows them to properly train concentrated teams of staff in the technical procedures involved in testing, including proper wear of the personal protective equipment. It also lends reassurance that evidence-based safeguards are in place to protect the health of everyone involved. 

‘Fantastic Stimulus’

“I think Medicaid expansion would be a fantastic stimulus for these overrun hospitals and doctor’s offices,” Waits said, “and it would give financial security to what is undoubtedly about to be a growing number of patients who have no health insurance.” 

Meanwhile, Waits has additional cause for concern about what lies ahead for community health centers. The stimulus package Congress has not yet reached agreement on is the legislative vehicle for all community health center renewals, as well as for the National Health Service Corps, which provides scholarships and loan repayments to health care professionals working in undeserved communities. 

In this “challenging environment,” Waits said, community health centers are a critical investment.