Nearly 1.34 Million Uninsured Community Health Center Patients Would Gain Coverage in 2022 under Build Back Better

 Community health centers (CHCs) provide comprehensive primary health care in the nation’s most seriously medically underserved urban and rural communities. In 2020, CHCs served nearly 29 million patients, 22 percent of whom were uninsured. Uninsured rates are significantly greater among patients served by CHCs located in states that have not adopted the Affordable Care Act’s Medicaid expansion (33 percent compared to 18 percent in Medicaid expansion states in 2020). Health insurance plays a vital role for health centers and their patients in two respects. Because insurance is so determinative of health care access, community health centers have a significantly easier time securing the specialized clinical care their patients need when they are insured. Furthermore, health insurance provides CHCs with much-needed revenue that can be invested in sites, services, and staffing. CHCs in Medicaid expansion states on average serve more patients, have larger and more robust staff, and operate a greater number of sites, and are more likely to offer a wider range of services.The draft Build Back Better (BBB) Act, now pending in the House of Representatives, would make permanent the more generous enhanced Marketplace premium subsidies established in the American Rescue Plan Act. BBB would also address the coverage gap in Medicaid non-expansion states by extending Marketplace subsidies for individuals with incomes below 100 percent of the federal poverty level ($12,880 for one person in 2021) who today remain completely uninsured. These two reforms are expected to increase insurance coverage by: 1) expanding access to affordable Marketplace coverage for previously ineligible uninsured people in non-expansion states for three years, from 2022 to 2025; 2) providing more generous subsidies for low-income people that would encourage greater enrollment among those who were previously eligible but not enrolled in Marketplace plans; and 3) slightly increasing Medicaid or Children’s Health Insurance Plan (CHIP) enrollment by identifying family members of Marketplace applicants who are eligible for Medicaid/CHIP. Urban Institute researchers have estimated that together, these reforms will reduce the number of uninsured individuals in the U.S. by nearly seven million people in 2022. They also developed state-by state impact estimates showing how these changes overall would affect uninsured individuals in the 50 states and the District of Columbia (DC). To estimate the impact of these reforms on community health center patients, we applied the Urban Institute’s state-specific estimated declines in uninsured rates to the number of uninsured health center patients in the 50 states and DC, as reported by CHCs in the 2020 Uniform Data System. Although the share of uninsured health center patients has declined over the past decade, from 38 percent in 2010 to 22 percent in 2020, some 6.2 million CHC patients remained uninsured in 2020 and, as noted, the uninsured rate remained far higher in Medicaid non-expansion states. Table 1 shows the estimated increase in insured health center patients by state and the sum totals by expansion status and for all states and DC. The total number of health center patients nationally who can be expected to gain insurance coverage is just under 1.34 million, or approximately 22 percent of the 6.2 million patients who were uninsured in 2020. We project that more than half (55 percent) of all community health center patients expected to gain insurance coverage under BBB reside in the 12 non-expansion states. Table 1: Estimated insurance gains at community health centers based on BBB reforms, 2022StateEstimated reduction in the uninsured populationUninsured community health center patients (2020)Estimated CHC patients who would gain coverageShare of total CHC patients who would gain coverageAlabama-43.8%115,18950,4534%Florida-18.7%502,350148,19311%Georgia-21.0%194,34675,9896%Kansas-23.1%74,28422,8052%Mississippi-11.4%110,02147,0894%North Carolina-18.1%267,27487,9337%South Carolina-12.7%116,97045,6183%South Dakota-9.4%17,0055,9180.4%Tennessee-12.0%127,45450,3444%Texas-29.5%634,939197,46615%Wisconsin-39.1%46,8134,9620.4%Wyoming-15.8%8,9791,6880.1%Non-expansion states 2,215,624738,45955%Alaska-10.7%18,9693,5470.3%Arizona-12.7%118,06724,7942%Arkansas-21.3%52,80612,1981%California-20.0%1,001,376114,1579%Colorado-30.7%140,20825,3782%Connecticut-20.8%66,3288,4241%Delaware-22.9%12,6921,1930.1%District of Columbia-11.6%29,4193,5300.3%Hawaii-8.0%17,7602,8060.2%Idaho-7.8%45,8404,9050.4%Illinois-17.3%322,22740,9233%Indiana-13.3%81,65517,3931%Iowa-42.8%45,6559,1311%Kentucky-23.7%67,02313,9411%Louisiana-19.9%67,05715,3561%Maine-13.4%23,4572,7210.2%Maryland-17.8%53,3624,2690.3%Massachusetts-25.0%102,7448,0141%Michigan-12.0%74,51312,8911%Minnesota-19.3%44,0495,8590.4%Missouri-14.7%149,25735,3743%Montana-32.9%20,4384,0670.3%Nebraska-18.6%48,1976,4580.5%Nevada-26.2%30,1145,3600.4%New Hampshire-17.2%11,6942,9240.2%New Jersey-18.5%149,50217,9401%New Mexico-17.6%59,70211,5221%New York-9.7%263,94738,8003%North Dakota-39.0%8,3791,5580.1%Ohio-34.8%112,60129,5012%Oklahoma-39.5%75,44712,9771%Oregon-31.1%70,10512,9691%Pennsylvania-5.6%115,63820,3522%Rhode Island-10.0%19,7351,9140.1%Utah-12.5%74,1824,1540.3%Vermont-18.1%12,7161,2720.1%Virginia-28.3%90,15111,2691%Washington-10.6%193,58835,0393%West Virginia-18.8%44,42112,5711%Medicaid expansion states 3,935,021597,45345%Sum total for 50 states DC  6,150,6451,335,912  Sources: GW analysis of 2020 UDS data, Health Resources and Services Administration; Banthin, Simpson, Green, 2021.Limitations The state estimates on which this analysis were based did not distinguish between insurance gains from Marketplace coverage and incidental Medicaid/CHIP coverage. Therefore, while the vast majority of insurance gains from BBB reforms are expected to be through Marketplace coverage, it is not possible to differentiate the number of health center patients who will gain Marketplace or Medicaid/CHIP coverage. The coverage gains are expected to increase health center revenue, which ought to lead to some additional increase in patient care capacity across the board from 2022 to 2025. However, Marketplace insurance does not have the enhanced payment rates associated with Medicaid and could require co-payments, although the BBB expansions have strict cost-sharing limits, particularly for those with incomes below 150 percent of poverty.Conclusion The insurance reforms expected to be included in the BBB legislation could provide substantial gains in insurance coverage for community health center patients, most of whom are low-income and more than 1 in 5 of whom are uninsured. The potential health insurance reforms are especially important for poor, uninsured health center patients who live in non-expansion states, who fall into the coverage gap and who remain completely uninsured.