Unprecedented financial losses at health care organizations pose risk to primary care access in NH

Federally qualified health centers, or FQHCs, are required to serve medically underserved geographic areas with a shortage of primary care services. (Getty Images)

As the president and chief executive officer of Amoskeag Health, a nonprofit federally qualified health center (FQHC) that has served Manchester since 1993, I am writing today to urgently address the collective financial crisis New Hampshire’s community health centers are facing.

Driven by a perfect storm of financial pressures, including an erosion of support from some funding sources and reimbursement rates not keeping pace with the rising costs of providing care in a “post-emergency” world, New Hampshire’s FQHCs are in significant need of a strategic investment of emergency stabilization funding to preserve access to care for the 1 in 14 Granite Staters we serve.

There is an expression, “Once you’ve been to one FQHC, you’ve been to one FQHC,” because our services and programs are unique and tailored to our community’s needs.

Beyond delivering primary care, New Hampshire’s FQHC programs meet the basic human needs of patients who have an immeasurable impact on their overall health and wellness, like access to healthy foods, transportation, housing, and child care. We deliver health care and social services outside our clinic walls, at dental clinics, pediatric centers, schools, recovery community organizations, community mental health centers, child care centers, soup kitchens, churches, and mobile unit sites across the state. We care for approximately 20,000 children, 16,000 adults aged 65 and older, 5,500 individuals experiencing homelessness, and 2,600 veterans.

FQHCs are required to serve medically underserved geographic areas with a shortage of primary care services. In some rural Granite State communities, where patients would otherwise have to drive hours to see a doctor, FQHCs are the only source of primary care.

While health centers save lives, they also save the health care system money, which has a ripple effect throughout the state. New Hampshire’s health centers were responsible for generating $336 million in total economic activity and creating over 2,000 high-quality jobs in 2021. A study by Capital Link showed that for every dollar of federal funding invested in health centers $11 is generated in total economic activity through increased spending on related health service expenses, food services, transportation, construction, and more. We currently employ over 1,070 Granite Staters.

FQHCs have enjoyed over 50 years of bipartisan support and success; but over the past few years – particularly since the pandemic – our health centers have been met with new circumstances so daunting, we are forced to face the fragility of our future.

There are several factors contributing to these unprecedented financial challenges.

Workforce shortages

The foundation of community health center quality care is our dedicated workforce; in fact, community health centers serve as the training sites for much of our nation’s primary care workforce.

But the competition for nurses, medical assistants, providers, and other health care staff in a very highly competitive market puts our nonprofit organizations at an incredible disadvantage.

FQHC employees are working at rates that are not competitive with for-profit hospitals and private practices, causing many staff to have to choose between not making ends meet and leaving nonprofit work so they can care for themselves and their family.

Medicaid unwinding

Thousands of Granite Staters who were covered by Medicaid during the public health emergency have now lost that coverage, including approximately 3,000 FQHC patients (comparing the 2022 and 2023 FQHC payer mix).

The visits for these patients who lost Medicaid coverage, instead of being reimbursed at our state’s newly increased Medicaid rates, are in most cases shifted to “self-pay” and “sliding fee discount,” driving up uncompensated care costs that are borne by our federal grants and other revenue.

Mission-driven, we will continue to care for those in need, regardless of their insurance status, as well as help these patients maintain or find insurance coverage.

Erosion of 340B savings

To make a difficult situation worse, the 340B program, which has served as a consistent revenue stream for our FQHCs since 1992, is under heightened attack. This program – not funded by taxpayer dollars and accounting for less than 3 percent of all drug purchases in the U.S. – provides discounts from the pharmaceutical industry that help vulnerable or underserved patients purchase drugs at lower costs.

We see many patients at Amoskeag Health who, although they are employed, are low-income and do not have health insurance, and they are able to buy their medications for chronic illnesses like HIV, diabetes, heart disease, and thyroid conditions at a fraction of the cost through the 340B program.

Unfortunately, the program is in jeopardy for several reasons, including the refusals of some pharmaceutical companies to honor 340B discounts, which has led to a dramatic reduction in our 340B savings. And, heartbreakingly, the loss of 340B savings puts many of our patients in danger of losing access to the affordable medications they need.

Response to the pandemic

Pandemic-related expense increases (across labor, drugs, and supplies) have created an unsustainable situation for FQHCs. Further compounding our financial challenges is the expiration of federal supplemental pandemic funding, which made up 7 percent of community health center revenues in 2021. Once again, we are faced with flat budgets against this new unrelenting landscape of stubbornly increasing inflationary and operational challenges.

With millions of dollars in operating losses this fiscal year, New Hampshire’s community health centers are working tirelessly on spearheading advocacy efforts and discussions with state and federal agencies, building partnerships to address systemic workforce and uncompensated care challenges, and developing operational strategies to reduce expenses and gain efficiencies.

But we need help to ensure we can keep our doors open and our programs running: The impact of FQHCs’ financial strain risks leaving communities throughout the state without access to preventive and primary care services including maternal and child health, dental, pharmacy services, pediatric care, behavioral health, medication assisted treatment, and substance use disorder treatment.

Despite dire circumstances, we remain vigilant and hopeful that a significant opportunity lies before us to strengthen the primary care infrastructure in the Granite State and develop a plan for long-term sustainability.

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