Among those along the front lines in confronting COVID-19 are the nation's federally supported community health centers. In West Virginia, 32 CHCs in some 400 locations throughout the state provide care for one in four residents.
Sherri Ferrell, CEO of the West Virginia Primary Care Association, which represents the state's community health system, said that CHCs have been strategizing with their local health departments and hospitals to put coordinated community responses to the virus into action.
"Health centers are being creative," Ferrell said. "They're reaching patients by phone before they come to the health center to see if their conditions can be managed remotely or require additional precautions." They're opening alternative testing sites and advising on recommended quarantine procedures.
Former Gov. Earl Ray Tomblin's decision in 2014 to expand the state's Medicaid program, as allowed for under the Affordable Care Act, provides West Virginia's CHCs with a firmer foundation from which to prepare than that of many of its neighboring states.
Thirty-six states and the District of Columbia have elected to expand Medicaid. Of the 14 that have not, six are in the Appalachian region: Alabama, Georgia, Mississippi, North Carolina, South Carolina and Tennessee.
Advocates argue that Medicaid expansion has bolstered the nation's front-line health care defenses– foremost, community health centers and hospitals serving underserved areas– and that the COVID-19 pandemic has heightened the urgency of enrolling more people in the program.
A brief released last week by the Kaiser Family Foundation points out that Medicaid covers nearly half of all children with special health needs, 45 percent of nonelderly adults with disabilities and more than six in 10 nursing home residents. The authors emphasize that people can enroll in Medicaid as soon as they become eligible– critical in crises such as COVID-19.
Craig Robinson is executive director of Cabin Creek Health Systems, which has clinics in Charleston, West Virginia, and neighboring rural communities, including school-based clinics. He said that his state government's decision to expand Medicaid has allowed those clinics to provide a broader range of urgently needed services.
For example, Robinson said, "There's no way for us to have been able to provide addiction treatment without the expanded Medicaid." So many of those that Cabin Creek treats in its medication-assisted treatment program would otherwise be uninsured.
With the onset of COVID-19, Robinson said, that coverage is yet more critical.
Cabin Creek is a federally qualified health center. FQHCs receive federal assistance to provide primary care to underserved communities, regardless of the patient's ability to pay. With massive job losses as a result of the pandemic, those Cabin Creek serves who now have little or no income will be Medicaid eligible, enhancing the clinics' ability to provide them with care.
'Undiagnosed and Untreated'
Recognizing the potential health and economic implications of the virus, two motions were recently filed by Democrats in Alabama's House of Representatives to expand the state's Medicaid program.
Not expanding Medicaid, the drafters of one of those motions wrote, "ensures that many Alabamians that may become infected will go undiagnosed and untreated." People "for whom going to the doctor would result in financial calamity tend not to do so before their health circumstances become dire."
"I get they want Medicaid expansion, but this isn't about Medicaid expansion," Senate President Pro Tem Del Marsh was quoted in the Montgomery Advertiser as saying. "It's about making sure the people of Alabama understand Alabama is ready to deal with this issue, regardless of how big it is not or may be."
But the CEO of an Alabama community health center believes that expansion and preparation are synonymous. And he argues that further investment in those front-line defenses saves not only lives but money.
Cahaba Medical Care, a CHC based in Centreville, Alabama, operates 26 clinics in largely underserved communities, both rural and urban. John Waits, its CEO and a family physician, is a strong advocate for Medicaid expansion. Like Cabin Creek, his clinics see patients regardless of whether they can pay. But there are limits on what CHCs' budgets permit them to provide, and the burden of treating the uninsured reverberates through the health care system.
The evidence is clear in the states that have expanded Medicaid, Waits said, that if people have "a viable way to present to community health centers and doctor's offices … they get preventive care, they get chronic-disease care and we avoid many, many unnecessary hospital admissions and ER visits."
This is particularly important today, he stressed. "We don't want the ER to be overrun with people who just need screening. The ER is a terrible place to cost-effectively screen people for COVID-19."
With the limited resources at their disposal, Waits and his colleagues braced for what lay ahead. They began testing those who exhibited symptoms of COVID-19, but, he said, "We have not been issued any type of testing from the federal government or state or local health departments." All of Cahaba's supplies have been provided by two commercial laboratory testing facilities.
Cahaba has consolidated its COVID-19 testing into two "fever and cough" clinics, one in rural Centreville, the other in the Birmingham neighborhood of West End. Waits said this allows them to properly train concentrated teams of staff in the technical procedures involved in testing, including proper wear of the personal protective equipment. It also lends reassurance that evidence-based safeguards are in place to protect the health of everyone involved.
Craig Robinson is mystified by the fact that 18 state attorneys general – including his state's, Patrick Morrisey – continue to press forward with a lawsuit challenging the constitutionality of the Affordable Care Act.
"I can't imagine attempting to deal with this pandemic," Robinson said, "and continuing to deal with the epidemic of addiction, not to mention all the other chronic and acute diseases that people have as a matter of course," without having expanded Medicaid.
Robinson described an "underlying anxiety" regarding the lawsuit, and the "paradox that West Virginia is devoting resources to fighting against" expansion, a program "that's providing coverage for a couple of hundred thousand West Virginians and is so particularly critical right now with what we're facing– absolutely critical right now."
Six hundred miles to the south, John Waits makes the case for his own state's expansion: "I think Medicaid expansion would be a fantastic stimulus for these overrun hospitals and doctor's offices, and it would give financial security to what is undoubtedly about to be a growing number of patients who have no health insurance."
Editorial Note: This story was updated April 27 at 1:45 p.m. to include additional information about how the COVID-19 pandemic is impacting Appalachian health care providers.