Are Health Centers the Future?

by Leigh Page | Jan 12, 2014 | Magazine

As millions of uninsured people get coverage under the Affordable Care Act (ACA), job opportunities for registered nurses could open up in the nation’s community health centers because many of the newly insured are expected to go there for care. These facilities, also known as federally qualified health centers (FQHCs), provide primary care in medically underserved areas, regardless of patients’ ability to pay. Teams of physicians, nurse practitioners, registered nurses, and other health care workers treat mostly Medicaid patients and the uninsured.

FQHCs, the mainstay of the nation’s health care safety net, have been growing by leaps and bounds in the past decade, posting an 80% increase in new jobs. Now a new wave of patients is expected, fueled by the Medicaid expansion and the new health insurance exchanges, where premiums for low-income people are subsidized.

No one knows, however, how many new patients will come, and the centers, operating under tight budgets, have been holding off on hiring until they get a better idea.

Also, while FQHCs employ a significant number of RNs, these facilities may not appeal to everyone. Salary levels vary widely, with some facilities paying less than hospitals, and many FQHCs are more interested in health care workers with less training, like licensed practical nurses.

What FQHCs Want

Community health centers are looking for nurses who are committed to serving low-income people, usually minorities, says Gary Wiltz, MD, chair of the National Association of Community Health Centers.

“The work should be viewed as a calling,” he says. When Wiltz interviews job applicants for his own FQHC, the Teche Action Clinic in southern Louisiana, he says he wants to see compassion. “The patients are disenfranchised, but many of them have jobs and are working very hard,” he notes. “As a provider, you have to be aware of what they are going through.”

Jennifer Fabre, RN, a nurse practitioner at Teche Action, says nurses are paid less than those who work in hospitals or nursing homes. But Community Health Services, an FQHC in Hartford, Connecticut, pays them comparable rates, according to Valerie Tyson, RN, a nurse at the Connecticut facility.

Tyson says working in a FQHC is very different from the hospital med-surg unit where she used to work. “The hospital has people who are very sick, but here the patients have an acute illness or need follow-up care for a chronic illness,” she says. “This is their primary care stop.”

A big part of the job, she explains, is teaching patients to manage chronic conditions. The RNs also take patients’ calls, routing some of them to doctors or nurse practitioners but taking care of most of them, she adds.

The Connecticut FQHC serves inner-city patients who are mostly Hispanic and black, some sharing Tyson’s roots in Jamaica. Unlike in the hospital, “you get to know these patients over time,” she says. “You develop a relationship with them.”

Fabre added that nurses have to understand their patients’ needs. “You do whatever you need to do to help the patient,” she says. “It doesn’t do patients any good if you prescribe a medication for them and they can’t pay for it.”

Roots in the Civil Rights Era 

FQHCs have a rich history of community service, going back to the Civil Rights era. The oldest rural FQHC, the Delta Health Center, was founded in 1967 in Mound Bayou, Mississippi—the oldest predominantly black settlement in America.

This little village is in the heart of the Mississippi Delta, a land of cotton fields that gave birth to the blues. The health center sits on land once owned by the brother of Confederate president Jefferson Davis, Joseph E. Davis, who encouraged “self-leadership” among his slaves, letting them build a “model community.”

After emancipation, Joseph E. Davis’ former slaves spent two decades earning enough money to purchase the land, founding the village in 1887. Today, Mound Bayou has 687 households and is still almost entirely black. The town came into prominence again in the Civil Rights era of the 1960s, when it caught the eye of H. Jack Geiger, MD, an idealistic Massachusetts physician who wanted to create a new type of health care facility for the poor.

In the 1964 Economic Opportunity Act, the cornerstone of President Lyndon Johnson’s “War on Poverty,” Geiger persuaded President Johnson to include $1.2 million for test sites at Mound Bayou and Boston. Envisioning a self-sustaining community, Geiger and his followers not only built a clinic in Mound Bayou but also dug wells and helped residents improve farming methods.

FQHCs have enjoyed a renaissance in the new century, starting with a wave of new federal funding under President George W. Bush. Patient volume grew by 50%, reaching the 15 million mark in 2006. Under President Obama, the Recovery Act set aside $2 billion in extra funding for FQHCs in 2009, and patient volume then reached 20 million.

The ACA set aside $11 billion for the centers, mostly for construction, to help them build capacity to meet the coverage expansion. The Delta Health Center received $5 million of this funding, allowing for its first significant expansion since it opened 47 years ago.

The new building will open in February. “We’re going to have brand-new rooms and new equipment,” says Neuaviska Stidhum, RN, the chief operating officer at Delta. “It means we’ll be able to see more patients.”

Centers Holding off on Hiring 

But even as Delta and many other FQHCs expand, they are holding off on hiring more staff and even, in some cases, opening some of their new projects. Facilities have to be careful about hiring because the new federal funding does not cover operational expenses. Teche Action Clinic, Wiltz’s FQHC in Louisiana, renovated two new sites using federal money, but it doesn’t have the funds to open them.

Moreover, there are signs that the anticipated onrush of new patients may not be as large as expected. Half of the states, including Mississippi and Louisiana, aren’t participating in the Medicaid expansion. Technical problems with exchange websites are dissuading some people from signing up, and the fine for not obtaining coverage may initially be too low to force some people to buy insurance.

Stidhum adds that many doctors’ offices in the Delta region still have a lot of capacity, so there would be less reason for the newly insured patients to use her FQHC. “We don’t know what we’ll do yet, “said Stidhum when asked about hiring. “Maybe we’ll need more staff, or maybe we’ll just need to shift their duties around.”

The story is different in Connecticut, which has joined the Medicaid expansion and has a very active insurance exchange. Tyson says her Hartford FQHC has put off hiring, but she is optimistic about hiring in the future. “The center is really busy,” she says. “If there are more patients, we would have to hire more nurses.”