‘It’s insanity’: Providers end Covid care for uninsured in the wake of congressional inaction

The cuts at the not-for-profit clinic, which serves about 11,000 patients, are just one example of how Covid-19 programs around the country have shrunk over the last month, a consequence of Congress’ failure to provide fresh funding to combat the pandemic.

Curative, a large private testing company, no longer offers its services to uninsured people at more than 10,000 testing sites across the country. In New York, a pharmacist who was administering thousands of vaccine doses a week to underinsured communities has stopped his outreach work. In Maine, a community health center that serves one of the state’s poorest areas is putting plans on hold to expand its dental and mental health services to pay for Covid care.

The dried-up dollars are making it harder for the low-income people who rely on these providers for testing and vaccines to get them, threatening to widen health disparities across the country. Less access could also prolong the pandemic, allowing the virus to circulate and perhaps provide a haven for new, more dangerous variants.

“From my perspective, it’s insanity,” says Neal Smoller, the pharmacist in Woodstock, New York, who was running the outreach operation. From September until March, he drove out to neighboring areas to administer a few thousand shots a week. When the federal reimbursements that covered the administrative costs of those shots ended, he had to stop, though he continues to give vaccines free of cost to people who come into his pharmacy.

“The moment that we get a little bit ahead of this problem, they rip back any protections we have,” Smoller said. “I know people are fatigued, but this virus is more patient than we are.”

The cuts come amid a fresh increase in both infections and hospitalizations. The 7-day average of cases was 44,416 as of April 25, up more than 20 percent over the previous week, according to the Centers for Disease Control and Prevention. Hospitalizations were up 6.6 percent percent over the previous week.

In March, the White House requested $22.5 billion from Congress in Covid aid, including $1.5 billion that would have kept money flowing to providers who offer testing, treatment and vaccines to uninsured and underinsured Americans. But Republicans balked at the price tag, and that tranche of money got carved out of the deal lawmakers are now considering.

A bipartisan deal for $10 billion fell apart earlier this month when Republicans demanded a vote on an amendment that would keep in place a Trump-era policy limiting immigration because of the pandemic.

But even if Congress approves that smaller package, more money to reimburse providers for their services to uninsured Americans won’t likely be in it.

“Making sure uninsured people have access is absolutely critical,” White House Covid-19 response coordinator Ashish Jha said during the Tuesday press briefing. “If Congress continues to not fund these urgent priorities, it’s going to get harder and harder for people to access care.”

The lack of federal funding could upend significant progress on mitigating racial disparities in Covid-19 outcomes and take the country back to the pandemic’s early days, where people of color fell ill and died at higher rates from the virus than their white counterparts. In 2021, uninsured rates were highest among Hispanic and Black American adults, according to CDC data.

Reimbursing providers for uninsured Americans’ Covid care to reach those groups has been a key plank of the federal government’s pandemic response since April 2020, when the Health Resources and Services Administration started to pay providers for testing and treatment.

Since then, the agency has paid over $20 billion in claims to more than 50,000 providers for testing, treatment and vaccination administration through HRSA’s Covid-19 Uninsured Program. Through a separate fund, more than 3,800 providers have been reimbursed for another $13 million in claims for vaccine administration to the underinsured. The funding for those programs ended on March 22 and April 5.

“It’s truly irresponsible of the government to take away funding for Covid when Covid is far from over and health care systems are already strained,” said Coleen Elias, CEO of Community Clinical Services in Lewiston, Maine. “We have to pay a living wage to our staff that works extremely hard.”

The clinic, which started submitting claims to HRSA for Covid-19 testing in May 2020, was already operating at a loss. Now that it will have to foot the bill for Covid care for its uninsured patients, Elias said the clinic is holding off on new hiring and putting off plans to expand its dental, primary care and mental health services this year.

Both federally funded health centers, known as FQHCs, and vaccine providers that receive doses from the CDC are required to treat patients regardless of their insured status, leaving the groups grappling with how to provide care without getting reimbursed for any overhead costs, including provider time and paperwork.

The CDC warned vaccine providers last week that it might stop giving free vaccines if the agency discovered that providers are charging patients for vaccination, turning people away for being uninsured, or billing patients for an office visit to get the shot, according to an email obtained by POLITICO. The CDC did not respond to a request for comment.

Curative, the testing company, was reimbursed nearly $600 million for testing and was the largest beneficiary of the HRSA uninsured program, said it is now looking for other ways to continue to provide testing to all patients. The company did not say how many tests it was reimbursed for but noted that “less than a quarter” of tests were submitted to HRSA when the program was still accepting claims. The company says it has given more than 31 million tests in 40 states.

“We are deeply concerned about this recent development and the impact it will have on uninsured patients,” the company said in a statement. “Our real-time data shows the pandemic is not over and points to a potential surge of cases on the horizon.”

For now, many of the health centers, which function as a safety net for uninsured Americans, are trying to find room in their budgets to cover the costs of continuing to provide Covid care. Some are cutting back on community immunization events. Others are scaling back their workforce development efforts.

“We’re really the last game in town in many, many communities. The county has pulled out. Hospitals have decided, ‘OK, we need to just focus on our operations,’” said Jana Eubank, executive director of the Texas Association of Community Health Centers. “If the centers aren’t able to do this work, I am really concerned about what’s going to happen to a lot of our marginalized populations and individuals on the frontlines that are most vulnerable to getting Covid.”

For many health centers still able to provide services, it is only because the demand for testing and vaccination remains relatively low. A wave like Delta or Omicron could see health centers again stretched to their limits, with insufficient time to ramp up their Covid response.

“We’re good for right now, but if there’s another wave two months from here, we can’t guarantee if they’ll have enough dollars for that,” said Vacheria Keys, director of regulatory affairs at the National Association of Community Health Centers. “I don’t know if we have the resources to continue to ramp up again and again and again.”

Not all health centers are in dire straits. Those that serve a majority Medicaid population say they are in a better financial position than their sister organizations that serve primarily uninsured patients because a larger chunk of their revenue is stable.

Laura Owens, CEO of Carolina Family Health Centers in North Carolina, said the federal uninsured dollars made it easier for the health centers to serve their community because they didn’t even have to think about someone’s insurance status when providing care.

“The underlying benefit to this program, outside of budgets and plans and workflows, is that it definitely reduced barriers to care for individuals,” Owens said. “People didn’t have to make decisions around vaccination or testing when they don’t have an insurance card in their wallet.”

Free testing is also still available for uninsured individuals at other venues, including pharmacies such as CVS and Walgreens and some public health departments, though the latter appears to have slowed or stopped in some parts of the country.

But the dwindling access threatens to reopen a gap in care many have been trying to close since the pandemic began. Health care advocates who work with migrant workers in rural areas say their patients struggle to get to in-town facilities and to make appointments for testing or vaccines, lacking either the documentation or the language skills to navigate the health system.

“The farmworkers that we serve don’t have the transportation, the means, the documentation that is required to present at [government-run] testing sites,” said Isabel Garcia, executive director of RCMA, a migrant advocacy group in Florida. “Before the (HRSA) program ended, it was still hard — a lot of the clinics and testing are in town or in the city — but it was more accessible.” Now, she says, people are just not getting tested.

When working with a vulnerable population, obtaining care has to be as easy as possible, Marilyn Sumerford, executive director at Access Family Health Services in northeastern Mississippi, said.

“Any barrier, it doesn’t matter how big, that keeps people from getting the services they need,” Sumerford said, “our health care system is going to be paying for it for years to come.”