Community health centers had been at the front lines of health care in the nation's poorest neighborhoods even before the spread of the coronavirus. But in the midst of the pandemic, patients who fear deportation or infection are forcing many centers to close.
Public health officials worry that the populations that these centers serve — mostly people with low incomes and immigrants — aren't getting proper health care and testing, may be unable to quarantine themselves and could contribute to spreading the coronavirus to the wider population.
"People are worried about COVID-19," says Joslyn Pettway, acting CEO of Covenant Community Care in Detroit, a nonprofit health center. "If patients don't come in for a visit, we lose money."
Covenant serves more than 20,000 patients each year through five locations with a staff of about 200. Pettway was forced to furlough about 50 staff members and shut down two full-service dental centers, because dental care is not essential, even though 1,400 patients are on a waiting list.
The lack of patients seeking health care is a direct result of Michigan's tough battle against the coronavirus. As of May 18, the state had more than 51,000 confirmed cases, with Detroit registering more than 10,000 confirmed cases and 1,255 deaths, according to Michigan state health data.
"Our patient population has been hard hit, no doubt about it," Pettway says. "Those health disparities that we've seen due to COVID, they existed long before COVID. COVID just brought it to light."
There's no better time to argue for affordable access to care for everyone, she adds. The coronavirus pandemic shows why we need to keep pushing to expand access to medical care for everybody, regardless of the person's status, Pettway says.
"Nobody is excluded from the impact of COVID. And so people who are unable to access care for a variety of reasons, they increase the spread of the virus," ultimately impacting all of us, she says.
Community health centers, like Covenant Community Care, were launched in 1965 as part of President Lyndon B. Johnson's Office of Economic Opportunity, propelled by the civil rights movement and the War on Poverty. Their aim then, as it is now, is to provide comprehensive and affordable primary care to medically underserved populations, regardless of their insurance or immigration status and their ability to pay for services.
Pettway says it's not atypical for Covenant patients to delay care, especially preventive care. To many low-income residents, preventive health care is a luxury. They either can't take the time away from work or lack transportation or child care.
"They were already struggling before the pandemic," she says.
Covenant has been hit hard by the pandemic. Only one site is open for in-person urgent visits, such as testing for the coronavirus, newborn checkups or an abscess that needs to be drained. The other four locations are currently serving patients virtually.
Using $997,490 from the federal CARES Act, Pettway invested in telehealth software in March to keep the Covenant centers running.
"We are working very hard not to shut down locations," she says. "The need is massive in Detroit."
Before the coronavirus, Sage Davis, a family nurse practitioner at Covenant, relied heavily on the full panel of a patient's vital signs, lab work and physical exam. Now she doesn't have that information to make decisions about a patient's treatment.
Davis is making different calculations, along with her patients.
"What's the risk of possible exposure going to medical facilities? And then, what's the risk if we don't get lab work right now or we don't get this imaging right now?" she asks. "It takes a lot of clinical judgment to determine if this is something that we really do need to get right now or if it's something that can wait. We really are looking at the patient in front of us and just treating our patient."
Davis, who is managing the center's transition to telehealth, says she constantly reminds her patients to call back if things get worse or change. A decision made today gets reviewed and assessed, she says.
"I do have options for sending people to an in-person visit if they need it," and that gives Davis peace of mind.
One of the silver linings of telehealth, Davis says, is that before COVID-19, patients stepped out of their environment to come into the center for care.
"Now we're in their environment in a way," which Davis says is helpful.
For example, let's say a patient with diabetes and joint problems walks up the stairs slowly and unsteadily to get a thermometer.
"I can see in the video the amount of time and effort it takes her to climb that set of stairs," she says. "Whereas in my office, I'm cognizant of her joint problem, but I don't see her climbing stairs."
Around the U.S., 1,400 health center organizations across 14,000 locations in rural and urban areas serve more than 29 million people, most of whom are low income, are uninsured or on Medicaid and Medicare, or are immigrants, according to the National Association of Community Health Centers. Almost 2,000 sites have shut down since the pandemic hit.
"Financially, these centers are getting a blow in this pandemic," says Dr. Ron Yee, chief medical officer for the National Association of Community Health Centers.
"When you cut your visits by half, that's going to change your revenue, even though you may make up for it a little bit with virtual visits," Yee says.
Virtual visits don't get reimbursed at the same rate as regular in-person visits. For example, he says, an online visit is currently being reimbursed at between $13 and $93, while community health centers receive between $100 and $150 in reimbursement for an in-person appointment.
But it's not only the coronavirus crisis that concerns Yee. Community health centers operate on short-term funding, and it expires on Nov. 30, unless Congress acts.
"I'm very worried about the future of our centers," Yee says.
And doctors and nurses are struggling in this crisis.
"Right now health centers are projected to lose about $7.6 billion between April and September to get through this, to stay whole so that we can be up and running when we get through this pandemic," he says, adding that this projection is based on a 60% decline in visits systemwide.
Community health centers are playing a vital role in this pandemic. As of May 1, more than 300,000 patients had been tested for the coronavirus.
In California, a large number of patients at community health centers are recent immigrants, says Dr. Edgar Chavez, who serves as medical director at Universal Community Health Center, a cluster of three centers in South Los Angeles.
Chavez says patients fear that being tested for the coronavirus will land them on a list to be deported. This mistrust of the government and reluctance to seek medical care stem from the Trump administration's public charge rule, Chavez says.
Chaves is working virtually, and his staff is calling patients and checking in on them for depression and anxiety as well as to see if they need to be tested for anything.
"Telehealth can only go so far with chronic care. You still need that lab data point," he says with a sigh. "We are going to have a lot of people that go without Pap smears, go without mammograms, go without all these different things that we use to improve and maintain their health."
Chavez says he worries about the health of his patients.
"People aren't eating well. They are not exercising, and they are anxious," he says. "I fear that we are going to be hit with a huge wave of uncontrolled patients with chronic care-related conditions, especially diabetes, hypertension and heart disease."
Chavez's voice trails off.
"It is very tough," he says. "We're doing the best that we can, but we're going to be facing a pretty, pretty tough situation."
The need was already massive before this public health crisis hit and it will get worse after the pandemic is over, health care providers say.