Community Health Centers’ Response to the COVID-19 Pandemic

As the single largest source of comprehensive primary health care for medically underserved communities, community health centers have played a vital role during the COVID-19 pandemic. The Health Resources and Services Administration (HRSA), which administers the Health Center Program, launched a Health Center COVID-19 Survey in April 2020. From April 2020 until July 2021, health centers reported information on a weekly basis; starting in July 2021, reporting became bi-weekly. HRSA’s survey tool has been revised over time to capture the evolving nature of the COVID-19 pandemic and the health center response as the federal government ramped up emergency funding and states made important changes to Medicaid coverage (in particular, payment for virtual healthcare visits). The survey was designed to capture evidence of health centers’ role in testing, preventing, and treating COVID-19 as the science of prevention, detection and treatment evolved.

The earliest reports in 2020 focused on health centers’ ability to test for the COVID-19 virus, the number of patients tested, and the number of staff members and patients who tested positive. The early surveys also were designed to assess the pandemic’s impacts on health centers’ operational capacity—including the share of staff members who were unable to work, the number of sites that had to be temporarily closed, and changes in weekly visit volume compared to pre-pandemic visit rates. The survey also measured the availability of worker protections, such as the share of health centers with adequate supplies of personal protective equipment needed to protect their staff members and patients from infection. Over time, HRSA modified the survey, dropping certain original measures (e.g., temporary site closures, staff unable to work, and changes in weekly visit volume—the last reported data on these measures is included in this report) and adding new measures to reflect the shift from testing to receipt of COVID-19 vaccines, provision of therapies such as monoclonal antibody therapy and oral antiviral medications, and community prophylactic measures such as distribution of at-home testing kits and N95 masks.

Given the disproportionate effects of the pandemic on racial/ethnic minority populations, the significant role played by health centers in serving low-income communities and patients of color, and the emphasis placed on health equity for underserved communities by the Biden administration, HRSA has consistently emphasized the collection of patient race/ethnicity data as part of its COVID-19 surveys. In order to document health centers’ ongoing role in advancing health equity, HRSA initially included race/ethnicity data collection on both patients tested and the percentage of people who tested positive for the novel coronavirus. Later reports included the race/ethnicity of patients who received COVID-19 antibody tests, flu vaccinations, COVID-19 vaccine doses, and COVID-19 oral antiviral medication. While initially focused on services provided to existing health center patients, over time, the survey expanded to document additional activity offered by the health centers including the provision of COVID-19 test kits, testing supplies, and N95 masks to the broader communities in which health centers are located along with historically medically underserved populations, including public housing residents or patients who are homeless, migratory or agricultural workers, and patients with limited English proficiency (LEP). The survey also measures the provision of COVID-19 oral antiviral medication to patients who are members of medically underserved populations.

The Geiger Gibson/RCHN Community Health Foundation Research Collaborative has published an ongoing series of reports over the past two years that present key findings from the Health Center COVID-19 Survey data. This brief presents findings from 88 of HRSA’s national survey reports covering two full years of data, from April 3, 2020 to April 8, 2022. The HRSA reports seek to provide information on all community health centers that receive federal funding under §330 of the Public Health Service Act and that collectively served 28.6 million patients in 2020. An additional 87 “look-alike” community health centers that meet all federal requirements but do not receive §330 grant funding served 679,010 patients that year. The survey response rate has generally exceeded 70 percent for the majority of survey reports, particularly since 2021 because health centers that participate in the Health Center COVID-19 Vaccine Program are required to respond to the survey.

Where possible we present findings on trend data over time, as well as cumulative totals such as the number of patients tested and who received vaccine doses. We also present a snapshot of the current status of community health centers’ COVID-19 response, the challenges they are continuing to face, and new challenges on the horizon.

Community health centers have tested more than 18.5 million patients for the novel coronavirus.

Since April 2020, HRSA has reported the number of patients who received diagnostic tests (PCR, antigen) for the COVID-19 virus and the number who tested positive. As illustrated by Figure 1, which shows these numbers on an approximately monthly basis, the number of patients tested rose in line with the surges in U.S. COVID-19 cases in the summer 2020 and winter of 2020-2021, and again during the summer and fall of 2021 as the Delta variant arrived. Testing reached its peak in mid-January 2022 during the Omicron variant surge. Over this two-year period from April 2020 to April 2022, health centers tested more than 18.5 million patients, and more than 2.5 million tested positive.

 

Figure 1 

While earlier months of testing data showed that health center patients testing positive for the novel coronavirus were disproportionally racial/ethnic minorities, this no longer holds true. For the two-week period ending April 8, 2022, racial/ethnic minority patients accounted for 65 percent of patients tested and 66 percent of those who tested positive, more closely reflecting the proportion of all health center patients who are members of racial/ethnic minority populations (62 percent in 2020).

One in six health center visits remain virtual, down from a peak of over half of visits in April 2020.

At the start of the pandemic, community health centers rapidly pivoted to telehealth visits to provide continuity for their patients. As cases have decreased, in-person visits have resumed, although telehealth visits continue. An analysis of national Uniform Data System data found that clinic visits dropped by 30 percent from 2019 to 2020, while virtual visits increased by nearly 6,000 percent and accounted for a quarter of all health center visits in 2020. Based on HRSA’s survey data, the average share of visits provided via telehealth declined from its peak of 54 percent in April 2020 to 16 percent as of the April 8, 2022 report (Figure 2).

 

Figure 2

Health center patients have received more than 20 million COVID-19 vaccine doses.

Beginning in January 2021, HRSA has tracked the number of patients who received COVID-19 vaccine doses in any setting (i.e., at the health center or elsewhere) and reported the number of patients who initiated (received one dose of a two-dose vaccine) and completed their vaccine series (received their second dose of a two-dose vaccine or one dose of the Johnson & Johnson vaccine). HRSA also started reporting the number of patients who received additional vaccine doses, also known as boosters, in September 2021. Figure 3 shows the trend lines at approximately monthly intervals for the number of patients receiving initial, completed, and additional vaccine doses on a weekly or bi-weekly basis. The number of patients who received their initial vaccine dose peaked at more than 551,000 the week of April 9th, 2021, around the time when all U.S. adults became eligible for COVID-19 vaccination, and has been trending downward ever since. Since November 2021, the number of patients receiving booster vaccine doses has exceeded the number of patients initiating or completing their COVID-19 vaccine series.

 

Figure 3

Since January 2021, community health centers have reported that nearly 9 million patients initiated vaccination, almost 8.5 million completed their vaccine series, and more than 2.8 million patients received additional vaccine doses (Figure 4). HRSA reports that of the more than 20.2 million vaccine doses received by health center patients, nearly seven in ten (69 percent) were administered to racial/ethnic minority patients, a figure that exceeds the share of health center patients who are members of racial/ethnic minority groups (62 percent in 2020). Since February 2021, the federal government has provided direct supplies of COVID-19 vaccines to community health centers through the Health Center COVID-19 Vaccine Program, and HRSA also reports the share of health center patient vaccinations supplied through the Program. In sum, federally-allocated vaccine doses accounted for nearly 8.6 million (42 percent) of the total of 20.2 vaccine doses received by health center patients, and more than three in four (76 percent) federally-allocated doses were received by racial/ethnic minority patients.

 

Figure 4

With the availability of the Health Center COVID-19 Vaccine Program and the general increase of vaccine supplies, the share of community health centers reporting vaccine supply as a challenge to deploying COVID-19 vaccines fell from 65 percent as of January 2021 to 2 percent as of April 2022 (Figure 5). Still, vaccine deployment challenges persist. Figure 5 shows that while more than four in ten (42 percent) health centers are currently reporting no challenges in deploying COVID-19 vaccines, one in three (33 percent) report vaccine confidence as a challenge, nearly double the 17 percent rate reported in January 2021.

 

Figure 5

In order to increase access to COVID-19 vaccination, community health centers have used mobile vans and hosted pop-up, school-based, and family vaccination clinics. HRSA started reporting health centers’ use of mobile vans and pop-up vaccination clinics the week of April 9th, 2021 but modified the measure in May 2021 to report the share of health centers hosting mobile vans, pop-up, and/or school-based vaccination clinics. As shown in Figure 6, which displays both the original and modified versions of the data, approximately a quarter of health centers hosted pop-up clinics in April and May 2021 and 7-8 percent used mobile vans for vaccination. The share of health centers hosting mobile vans, pop-up, and/or school-based vaccination clinics fell from 42 percent in May 2021 to 28 percent as of the April 8, 2022 reporting period. In December 2021, HRSA also began reporting the number of family vaccination clinics, including both on-site and off-site family vaccination events hosted by health centers; since December 17, 2021, the number reported decreased from 1,666 for that survey period to 1,083 as of the April 8, 2022 survey period.

 

Figure 6

Six in ten community health centers provide access to monoclonal antibody therapy. One in eight is providing oral antiviral medication.

HRSA has reported on health centers’ provision of monoclonal antibody therapy for patients with COVID-19 since August 2021. As Figure 7 shows, the share of responding health centers that report providing access to monoclonal antibody therapies, whether through direct provision and/or referrals to another organization, grew from 44 percent in August 2021 to 62 percent as of April 2022, although the share that directly provide monoclonal therapy grew modestly over that time period from five to nine percent. In September 2021, HRSA also started reporting the number of monoclonal antibody doses administered by health centers that directly provide monoclonal antibody therapy. Health centers administered a cumulative total of 24,708 doses from September 2021 to April 2022, with the number of administered doses peaking in mid-January 2022 amid the Omicron variant case surge, and then falling to 240 doses as of the April 8, 2022 report (Figure 8).

 

Figure 7

 

Figure 8

In December 2021, HRSA’s Health Center COVID-19 Therapeutics Program was launched under the Biden Administration’s Test to Treat Initiative to provide direct supplies of COVID-19 oral antiviral medication to health centers for the outpatient treatment of their patients with mild to moderate COVID-19. The program began with a group of 200 health centers with pharmacy capacity and extensive experience serving underserved populations or those disproportionally affected by COVID-19, and/or significant COVID-19 testing capacity. By late March 2022, the program expanded to all health centers with pharmacy capacity.

As Figure 9 shows, the share of surveyed health centers reporting provision of COVID-19 oral antiviral medication grew from five percent in January 2022 to 12 percent in April 2022. The share of patients who received COVID-19 oral antiviral medication through the HRSA Health Center COVID-19 Therapeutics Program and who identify as racial/ethnic minority ranged from 25 percent to 63 percent, and most recently stood at just under half (47 percent). As of the April 8, 2022 survey period, patients experiencing homelessness accounted for 15 percent of those who received a course of COVID-19 oral antiviral medication through the HRSA Health Center COVID-19 Therapeutics Program, patients with LEP accounted for 11 percent, and public housing residents for five percent (Figure 10).

 

Figure 9

 

Figure 10

Community health centers are distributing COVID-19 test kits and N95 masks to prevent COVID-19.

Beginning in January 2022, community health centers were able to start ordering and distributing high-quality N95 masks at no cost to their patients and communities through the HRSA Health Center COVID-19 N95 Mask Program. The program started with a group of 500 health centers with large patient populations and was then expanded to all community health centers, look-alike health centers, and Medicare-certified rural health clinics that wanted to participate. Similarly, the HRSA COVID-19 Testing Supply Program began in December 2021 under the Biden Administration's "Path Out of the Pandemic" COVID-19 Action Plan to enable community health centers, look-alike health centers, and Medicare-certified rural health clinics to provide at-home COVID-19 self-testing kits and point-of-care testing supplies[1] at no cost for their patients and community members. From the inception of these programs to the April 8, 2022 survey report, HRSA-funded community health centers have distributed nearly 5.4 million testing kits and more than 3.6 million N95 masks to their patients and community members (Figure 11). Figure 12 shows how health centers distributed these supplies for the April 8, 2022 survey period. More than three quarters of  responding health centers reported that they distributed testing kits and N95 masks to existing health center patients (85 percent and 87 percent, respectively)  while well over half (59 percent and 62 percent, respectively) provided supplies to members of the general public or broader community who went to the health center. Approximately a third (31/34 percent) of health centers distributed testing kits and N95 masks at other community events and nearly one quarter (22/24 percent) through special vaccination events such as mobile vans, pop-up clinics, school-based clinics, and family vaccination clinics.

 

Figure 11 

 

Figure 12

Two years into the pandemic, community health centers are facing significant challenges.

Although the federal government may declare an end to the public health emergency (PHE) in the coming months, the COVID-19 pandemic and its aftermath will continue to be a significant presence, particularly in underserved communities whose populations disproportionately experience the burdens of low family income and elevated health risks. Furthermore, even as community health centers must maintain a sustained COVID testing, treatment, and vaccination presence, they also must restore normal operations and continue transitioning back to greater levels of in-person care. In doing so, however, health centers likely will feel the effects of increased patient care costs, since they will need to maintain various types of COVID-19 safety precautions. Finally, once the public health emergency declaration ends, state Medicaid programs will begin to unwind Medicaid’s special continuous enrollment guarantee that, since March 2020, has elevated the proportion of insured health center patients. Patients’ insurance coverage may end at this point, but of course their need for care will not.  In sum, community health centers face the confluence of several key challenges–costs associated with the resumption of normal operations; costs associated with a continued need to provide COVID-19 treatment and to protect workers and patients safely from infection; and the potential for widespread loss of Medicaid revenue.

Given Medicaid’s importance for health centers—46 percent of health center patients were covered by Medicaid and Medicaid accounted for 40 percent of health center revenue in 2020—the most concerning implication of the end of the PHE is the end of enhanced Medicaid funding and the requirement for continuous coverage of Medicaid enrollees that spurred a 21 percent growth nationwide in Medicaid enrollment from February 2020 to November 2021. Once the PHE ends, states can begin redetermination processes for Medicaid enrollees; although some enrollees may lose eligibility because they no longer meet income eligibility criteria, others who remain eligible for Medicaid will lose coverage if they are unaware of the need to or unable to renew their coverage. Based on estimates from 20 states, one in eight Medicaid enrollees (13 percent) is expected to lose coverage at the end of the PHE, although loss estimates varied by state from eight percent to 30 percent. Further estimates from the Urban Institute predict that, if the PHE ends after the second quarter of 2022, 14.4 million enrollees will lose coverage in the 14 months after the PHE ends. Based on findings from a survey of health centers in late 2021 on the actions they had taken or planned to take in response to the end of the PHE, nearly half (49 percent) planned to identify all patients at risk of losing Medicaid coverage and to flag their chart for reminders and 46 percent planned to send reminders to Medicaid patients regarding the need to renew their coverage (forthcoming, Kaiser Family Foundation [KFF]).

Health centers are facing other sources of financial pressure. In 2020, health centers received nearly $1.3 billion in supplemental COVID-19 grant funding, nearly $838 million from the Provider Relief Fund, and nearly $50 million from the COVID-19 Uninsured Program, and COVID-19 related funding accounted for six percent of health center revenue that year. This funding and enhanced Medicaid reimbursement contributed to an increase of more than $3 billion in total health center revenue, from $31.4 billion in 2019 to $34.5 billion in 2020, which offset the $2 billion in increased costs health centers faced, from $31.8 billion in 2019 to $33.8 billion in 2020. The Consolidated Appropriations Act, 2021 authorized $4 billion in mandatory funding each year for community health centers for FY2021 to FY2023, $1.7 billion in discretionary funding for FY2021, and flexibility in calculating lost revenue under the Provider Relief Fund. The American Rescue Plan devoted $7.6 billion in emergency COVID-19 funding for community health centers and more than $1.3 billion for the National Health Service Corps, Nurse Corps, and Teaching Health Center Graduate Medical Education programs, which help health centers to recruit and retain health care providers. The Department of Health and Human Services recently announced that $90 million in American Rescue Plan funding would be available to health centers to collect and report data to reduce health inequities.

However, some funding sources have run out while other health center funding supports are losing revenue. The COVID-19 Uninsured Program recently stopped accepting reimbursement claims for testing for, treating, and vaccinating against COVID-19, which will have dire consequences for health centers and their uninsured patients. The current $10 billion COVID-19 funding deal, which is now stalled in the Senate, does not include funding for the Uninsured Program. The White House has warned that the lack of a new funding package compromises the federal government’s ability to purchase antiviral medications and monoclonal antibody therapies, to fund additional vaccine doses including variant-specific vaccines, and to maintain their COVID-19 testing capacity and surveillance for new variants.

Another threat comes from changes to the 340B Drug Pricing Program, which allows health centers to offer discounted prescription medications to their patients and to invest those savings back into their health centers to expand their scope of services and patient capacity. According to health centers surveyed in late 2021, nearly seven in ten (69 percent) indicated that pharmaceutical manufacturers’ restrictions on 340B drugs dispensed through outside (contract) pharmacies has had a negative effect on their health center’s revenue (forthcoming, KFF).

As noted earlier, telehealth’s importance for providing access to health center services has decreased since the earliest months of the pandemic but still accounts for one in six health center visits. The end of the PHE has implications for health centers’ use of telehealth services since states and the federal government can allow flexible PHE telehealth policies to expire; these policies expanded the range of covered telehealth services and allowable providers, and permitted reimbursement for virtual visits at parity with in-person visits. While some states may choose to keep those flexible telehealth policies in place, nearly four in five (79 percent) health centers surveyed in late 2021 reported that they would decrease telehealth services use from existing levels if those temporary telehealth rules are not maintained (forthcoming, KFF).

Finally, community health centers have long struggled to maintain an adequate workforce. The COVID-19 pandemic saw an overall decline in the number of employees in the health care sector and health care and social assistance workforce quit rates that exceeded those among the entire workforce. Health centers nationally reported a modest one percent growth in the number of full-time equivalent employees from 2019 to 2020, even as the number of visits fell by seven percent and the number of patients dropped by four percent during that time frame. It remains to be seen if health centers were able to maintain or increase their staffing levels in 2021 and 2022, but a recent survey from the National Association of Community Health Centers reported high rates of health center employees leaving their jobs in the past six months among surveyed health centers, with the most commonly cited reasons for staff departures being higher salaries offered by competing health care providers and stress from the ongoing pandemic. Consistent with national health center survey findings from 2016, 2018, and 2019, a nationwide survey of community health centers conducted in late 2021 found that workforce recruitment and retention were the top challenges currently facing health centers (forthcoming, KFF). That same survey also found that staffing shortages were the most commonly reported barriers to providing mental health, substance use disorder, and social and supportive services, the demand for which has grown exponentially throughout the pandemic.