72. Uncertain Times for Community Health Centers with Feygele Jacobs, DrPH, MS, MPH and Joe Dunn
Hello one and all and welcome back to The Rural Impact. I'm Michelle Rathman, and as you know, by now we are the podcast that does work hard to connect the dots between policy and rural everything, or as we like to say, often rural quality of life. We are so glad that you have joined us today. It is our last episode of the year 2025 and oh, what a year we have had together,
I believe by count, we've probably done 25 episodes or so covering a wide range of issues and as we always do, our guests on every episode, our thought leaders who have a deep understanding of policies that all too often paint rural out of the picture. We aim to change that. So, before we started recording today, I went back to refresh myself on where we started off this year, and low and behold, we kicked off 2025 talking about a subject that we will end the year with, and that is health policy.
And I know we've been talking about that a lot lately because if you've been paying attention to any of the headlines, you know that the world of healthcare is in a world of uncertainty, as we are recording this today on December 8th. And of course you're hearing this on December 18th, and we still don't quite know what's going to happen with the ACA tax credits expiring and a plan from the Republicans on healthcare.
I have no crystal ball based on the headlines I'm reading, we are going to be doing some nail biting the next few weeks, so we shall see what happens. Of course, news happens fast. This might change by the time you hear it, but nonetheless, we have some challenges before us.
So, I wanna just tell you the very first episode that we did in, in January of this year. I did sit down with Larry Levitt, Vice President for Health Policy at KFF. And I also was joined by Edwin Park, and if you recall, Edwin is a Research Professor at the Georgetown University Center for Children and Families. Now, I do encourage you to go back and listen to that one because the entire conversation, well, we might as well have had a crystal ball because it focused on the what ifs with respect to the ACA Medicaid cuts, which as it turns out, of course was quite foretelling given where we are at this point. Okay?
So again, things might have changed, but we can be sure that 2026 is gonna have far more health challenges ahead, just by the way things are going right now. So, all these unprecedented policy shifts, we're gonna have one more conversation about rural health, and I do hope that you will stay with us and listen to this conversation because I am joined by two guests today, both of them offering outstanding information.
And very unique perspectives about policy shifts and their impact on rural serving community health centers. Now, you may also know them as federally qualified health clinics or FQHCs. So, first you're gonna hear my conversation with the very engaging Dr. Feygele Jacobs. Great to have her here. And Feygele Jacobs is the director of the Geiger Gibson Program and Community Health and Professor of Health Policy and Management at Milken Institute of Public Health.
And from there you're gonna hear my conversation with Mr. Joe Dunn, and Joe is the Chief Policy Officer at the National Association of Community Health Centers. And when you listen to the very end, you're going to hear something from Joe that is an insightful, it's really as insightful as it gets because he talks about effective strategies for successful advocacy efforts with your member of Congress and those serving you at the state level.
I'm not gonna give this one away. I really want you to listen to his very sage advice about how we can be effective advocates for equitable healthcare and rural America. Again, I am so excited that you've made the choice to join us. I know you are ready to get going. So, you're gonna say it with me? Are you ready. I am. So, let's just go.
Michelle Rathman: Dr. Feygele Jacobs, welcome to the Rural Impact. We are so pleased, and I, I mean it sincerely to have you here for this critically important conversation. Welcome.
Feygele Jacobs, DrPH, MS, MPH: Hi. Very nice to be here. Thanks for inviting me.
Michelle Rathman: It is my pleasure. Okay. Well, everyone who listens to this podcast knows that we are working to connect the dots between policy and rural quality of life, and Dr. Jacobs, especially after the signing of HR 1. Of course we all knew it before, is the One Big Beautiful Bill. We've been having many conversations on this podcast about the implications and the impact that this legislation is having on rural health systems.
And the bulk of those conversations have really been focused on the plight of rural hospitals, which is important, but they are not the only health safety net as they are called in need of a lifeline as I see it. Because we also know that community health centers, also known as federally qualified health centers, arebracing for an impact that I can just say in all the years I've been doing this, I don't think anyone saw coming.
So, and maybe you all didn't either because in early of November of this year, you were one of several authors of a policy brief that I found titled, "Widening Holes in the Safety Net Communities Health Centers are at Risk."
So, before we dive into your findings, 'cause I wanna hear all about it, let's not assume our listeners understand what these health centers do and who they serve. So, let's start there.
Feygele Jacobs, DrPH, MS, MPH: Great. So, thank you so much for that great introduction, Michelle. Community health centers. Community health centers occupy a really unique place in the American healthcare landscape, and the very first community health centers in the country were actually launched as a small demonstration program.
They were part of President Lyndon Bain's Johnson's Office of Economic Opportunity, and their roots really go back both to Civil Rights Movement and the War on Poverty, and since their earliest days back in the sixties, health centers have been critical access points for primary care.
They operate as nonprofit organizations. They're governed by their communities, and they're really designed specifically to serve entire communities and to think of community health issues from a broader perspective. So, by mission and law they address the healthcare needs of people who are low income, of people who live in medically underserved communities and often especially vulnerable populations, people who may be experiencing homelessness or people who are agricultural workers or seasonal workers, or people who live in public housing.
So, this all started with just two health centers. One rural, one urban in 1965, and so, you know, two, two small locations and there's really a, you know, fantastic story and history behind that. But what I'd really like to, you know, convey for our listeners here today is what's happened in the intervening years is that those two health centers have resulted in a movement, and health centers have really flourished in a way that few people would imagine. So, today there are about 1400 health center organizations, and they're operating more than 10 times as many service sites or locations. So, there are more than 16,000 access points where people can get care through a health center.
And throughout that history, health centers have stayed true to their core mission, and that is to provide a healthcare home to everyone, irrespective of whether they have insurance, regardless of their ability to pay, and to work in communities that otherwise would have limited access to care.
So, when you look at who's served today. It's about 33 million people, nearly 90% of whom live in households whose incomes are under 200% of the federal poverty level. That's pretty low income. Nearly 50% of those people are covered by Medicaid program. More than 18% have no insurance. And so, you know, sort to put it a different way when you think about it from a population perspective.
It's one in 10 people in the United States, one in eight children, more than one in 15 people who are age 65 or older. One in five people who live in rural communities, about half a million veterans. So really, you know, a diverse group of people all across the country. In urban areas, frontier areas, rural areas.
I used to joke with my kids when they were young adults driving across the country from one part of the country to the other. I live in New York City. My younger son at the time was living in Oregon, in his state on the west coast. And I used to say, if your car breaks down, find the health center.
They may not know me. But they'll know that you're part of the community, that you sought out a health center and someone will find a way to help you. And it was sort of a joke, but sort of not, right?.
Michelle Rathman: It's not, it's not because I, as I think about this in my mind, I'm thinking, okay, you talk about all the locations, access points for care, how many patients are served, it also makes up a very large portion of our health workforce.
Feygele Jacobs, DrPH, MS, MPH: Absolutely, and I think that one of the things that health centers are known for going back to the very earliest days, is providing really good work and job opportunities and career development opportunities for people who live in those local communities. So, they're not just providing healthcare services, they're really an economic development engine as well.
My colleague Layton Coup, you know, who's an expert in that area, has done a lot of work in the area, not only of how the healthcare workforce, you know, supports the economy. But what some of the changes under HR 1 are going to mean for the economy, not only at the federal level, but at the state and local level, and in terms of job loss, not only health centers, but the broader healthcare system.
And it's really stunning. It's really quite
Michelle Rathman: and it, it's been very challenging for many folks that I talked to, you know, not on this podcast, just in general. I think because it feels so intangible right now that people are like, well, you know, things always tend to work out well in this particular case. I mean, we are on, we are like teetering on the edge.
I wanna kind of go here because we are recording this conversation on December 4th. And as of today, it seems all but certain, maybe to others, maybe not, that the Affordable Care Act enhanced premium tax credits will expire at the end of this month, and as a result, this is not, you know, hyperbole here, millions of patients will likely lose their health insurance marketplace coverage. We know that premiums are gonna skyrocket, health centers, you know, they're going to have major losses in 2026, which is just a month away.
What does that look like, like in terms of some hard numbers, if you can, for what will FQHCs do based on the findings of your report?
Maybe, maybe tee up your report a little bit so that folks can have some context.
Feygele Jacobs, DrPH, MS, MPH: Sure. And I really appreciate that question. And then if there's time, Michelle, I'd love to come back to premium tax credits. But, let me, you know, try to address specifically this issue. And you're absolutely right. You know, every day we wake up and we sort of hold our breaths, you know, to look at the healthcare news aggregators, right?
And of course, today more articles saying, well, three weeks to go. Not clear what's gonna happen. So, just to sort of frame where health centers were before we got to this year. Since the introduction of the Affordable Care Act, we've seen enormous growth in health centers. They've grown over time, as I mentioned, since 1965, but really a huge share of that growth has happened just in the past 10 or 12 years. In 2013, just before the ACA really took effect, health centers were serving about 21 million people. And as I mentioned earlier today or in 2024, so let me just say that the latest data that are available that are universal data for the Health Center program are for 2024.
So, in 2024, they were serving more than 33 million people. So, that's a growth of more than 30% in just that short period of time. And what we discuss in that report that you mentioned is that growth continued, and it continued even through the pandemic. But now health centers are really under pressure. And while the volume has increased financially, they haven't done nearly as well.
So, it's important to understand that health centers, you know, receive their funding from multiple sources. There are insurance payments. There are grants. Grants from the Bureau of Primary Healthcare, part of HRSA provide core funding for infrastructure and help support care for the under for the uninsured.
And they are extremely important and part of the bigger funding bill issue. But Medicaid is really the largest source of health center revenue. And so, what we've seen is that even just between 2023 and 2024, health center revenue increased, but it increased at a lower rate than in prior years. And meanwhile, costs and expenses continued to climb.
So, when you look at what we call operating margins, which basically you know your revenue less your cost, we saw that operating margins have dropped in 2020, there was a positive margin. It wasn't a huge margin. It was $ 1.4 billion, but that was about 4%. But by 2024, health centers were operating in the red, and the situation had almost totally reversed with total losses of about $1.1 billion, which is a margin of negative.
2%, right? And so, as these policy changes in HR 1 take effect, the conditions are likely to worsen, making it even more difficult for health centers to, you know, remain, sustainable. And of course, 2025, some of this has already begun, so we don't yet have that 2025 data, but you know, this could have already occurred, so, so why is this happening?
Michelle Rathman: It was my, that's a great question because I'm gonna. Like, why, what? Why this, and now this.
Feygele Jacobs, DrPH, MS, MPH: Yeah, yeah. So, let me see if I can help sort of shed some light on that. So, one thing is that during the pandemic, we had what was called continuous Medicaid eligibility. People did not have to re-certify to continue to get their Medicaid coverage, and that would've been the normal practice.
But when the public health emergency ended, that provision went back to its prior status, meaning people had to demonstrate that they remained eligible. And what you need to keep in mind here is that often people remain eligible from an income point of view or from a health status point of view, but because of the huge administrative challenge of, you know, getting your documents together, submitting them, figuring out how to use the systems.
Many people lose coverage just for those administrative reasons. And you know, for anyone who's ever had to navigate any type of healthcare coverage, whether it's public or private, you know, that is something that I think will really, you know resonate for you. So, Medicaid began to, to unwind, as we call it, and Medicaid became a smaller share of patient revenue.
By 2024, average Medicaid enrollment had declined. But one of the things that we know is, you know, you continue to meet healthcare whether you have coverage or not. Right? Now, some people choose to forego their care. But often people will continue their care, and they seek care when they need it, where they can get it, even if they have no coverage.
And because health centers serve everybody irrespective of their ability to pay, they will care for uninsured people on a sliding fee scale basis. Well, that brings in a lot less revenue than than regular Medicaid payments, right? So that was one issue. Second issue was that during COVID, there were supplemental grants that were provided to healthcare providers, including health centers.
But those ran out. The fund balances were depleted, that again, that pandemic period ended, and those supplemental monies ended. And then finally those core grants that come through HRSA, essentially flat, even though demand for care was increasing, the grant amounts really have been relatively flat and they haven't kept up with inflation, so, so what you see is that by 2024 in the majority of states, health centers had some net losses in, I think it was, seven states.
I have to stop, but now try to remember them. Um, those losses exceeded, 10%. And many of those, you know, many, you, you, I know this is the Rural Impact Podcast. Many of those were, were states with, you know, large rural populations.
Vermont, Texas, Wyoming, Minnesota, Arizona, Right? So, you know, what you're seeing is losses. And again, the situation may have, you know, deteriorated even further. You know, we are in this period where there's health center funding now, has been temporarily extended through the funding bill through July, but what the longer term funding prospects are for fiscal 26 hasn't yet been determined.
And so, when you have uncertainty about your funding, that also creates pressures, right? And that's the situation that we really find ourselves in today.
Michelle Rathman: Yeah. You know, I read something this morning. I like, you know, I wake up and like I start reading all sorts of, that's just my major health policy things, but rural policy in particular. And I read a piece today and I don't remember the author, but the analogy was that we treat healthcare like day trading instead of longtime long-term investing.
And so, you know, at the end of the day, you said it, folks still need healthcare, and what I really see happening here, something that's the trend is, is that we we're gonna have more people who are sicker and because they are foregoing their care, they'll seek care on more expensive venues like an emergency department and so forth. It's just a mess is all I can say.
Let's transition over to something here, because in the paper you talk about some of the immediate and future risks, and you would have to be, I'm sorry folks, you may be mad at me for saying that living under a rock not to understand the next thing I'm going to say, which is the restrictions on care for immigrants, whether they are here, I mean, legal, I people who have come here, they've gone through the process.
They are here for, you know, they've got their papers as they say. But regardless of whether or not you have that status, we know that community health centers are, you know, they care a great deal for immigrant populations. Now we've got these restrictions. Talk a little bit about that.
Feygele Jacobs, DrPH, MS, MPH: Sure. So first,let me say, um, two things. One is I love your day trader analogy. And the second is, I am the US born citizen child of parents who were refugees. So for me, this whole question about immigration and how we treat immigrants, I can't say enough how important that feels to me. You know, e even being, even being born here and even at my age and even, and even with the work I do.
So, because health centers serve poorer communities, whether they're urban or rural, they're more likely to serve immigrant families. And that includes people like myself, US citizen children who were born in the US to parents who were immigrants. Now, in keeping with both their mission and their statutory obligations, health centers don't collect information on immigration or citizen or citizenship status.
Excuse me, I stammered over that. But, we know, you know, given the communities that health centers are in, that a large number of people getting their care at health centers are immigrants. But recent policy changes, as you said, have hindered immigrants access to care. So, there are a couple of things.
One is that in the O-B-B-B-A, there were changes in immigrant eligibility for both Medicaid and marketplace health plans. So, people who were, so certain categories of immigrants, only certain categories of immigrants remain eligible. But other categories, like people who were refugees or asylees, lose their Medicaid coverage. So, that's one of the things that's happening now.
In July, several federal agencies including, HHS issued a notice that reinterpreted a longstanding policy called PRWORA, which which stands for the Personal Responsibility and Work Opportunity Reconciliation Act. That's a mouthful, and that's US law that governs eligibility for benefit.
And what they did with this notice is they significantly expanded the definition of what's a federal and public benefit. And they declared that community health centers and many other types of programs, including things like Head Start, which by the way got their, got their start in 1965 in the very same set of Office of Economic Opportunity Programs as a health center program.
But what that notice ruled was that these programs could no longer serve people who were undocumented or what are called other non-qualified immigrants. Now, that's contrary to the statute that governs community health centers, but the policy was meant to be effective immediately upon publication.
It was challenged in the courts and in response to lawsuits there was an injunction, so enforcement was temporarily paused. So, the ultimate legal outcome is unresolved, but that's sort of the backdrop to all of this. Now, more recently, there was a separate but related notice of a proposed rule on something called public charge, which is an immigration policy that's intended to determine whether an immigrant is likely to depend on the government for their subsistence.
And if it's determined that that's the case, they would be inadmissible to the US. So, putting aside the, you know, the fact that there's been an injunction on PRWORA, you can imagine that this creates a widespread fear in communities. Including among people who are here legally, right? Or people who have what we call mixed-status families.
Maybe, you know, maybe the children are US foreign citizens, but mom or grandma is not. So as a result, they avoid seeking healthcare. They avoid going to care. That's what we call the chilling effect. And so, you know, these kinds of policies and proposed policies are especially harmful, for programs like health centers, they're especially harmful for health centers that may serve, for example, agricultural workers.
You know, I mentioned that there's, you know, there's a group of health centers that specifically serve agricultural workers. And so, you know, these policies don't change the funding levels for health centers directly, but what they do is they affect, the access for people who historically have been able to get care.
So, this whole immigration issue, as you said, you know, you, you, you would have to be living under a rock, to not be aware of it. And huge, huge implications, you know, for our communities.
Michelle Rathman: Yeah, we, the punitive nature, you know, and I think about these are, these are organizations whose whole charge is to provide essential and vital health services. And now they face punishment, fines and whatnot for doing that, or withholding. Let's talk about another one. There's a few more. Before we, kind of close out here.
I wanna talk a little bit about the Medicaid coverage for family planning. This one, you know, I just don't understand how these are not like screaming headlines for folks because now we've got restrictions on how folks can access just things as simple as family planning. Let's talk about the provisions, in this law where this is concerned.
Feygele Jacobs, DrPH, MS, MPH: Okay. Wow. So, this is another one where you just gotta go. What is happening here? Right? You know, and again, full disclosure, decades ago I started my career working in Planned Parenthood. So, HR1 you know, I, I, I think I used the acronym O-B-B-B-A without saying, you know, one big beautiful Bill Act, which HR 1.
Yeah. It's a horrible acronym. Doesn't really roll off the tongue. So, what HR 1 did with respect to family planning is it banned Medicaid funding from any organization that provided reproductive health and abortion services. That earned, um, you know, more than a threshold amount, per year from Medicaid.
You know, it's important to understand that Planned Parenthood already could not accept Medicaid for abortion services because of the high amendment that prohibits federal funding from being used for abortion. But what does is it really is a direct attack on all other services that Planned Parenthood provides.
And many young people will know that Planned Parenthood does way more than just abortion. You know, they provide well woman care and contraception, cancer screenings and screening for, you know, sexually transmitted infections and so on. Now this week a federal judge has again blocked a provision that's stripped federal Medicaid funding from Planned Parenthood affiliates.
So, there's again, you know, sort of a temporary lull, but we know that already a number of Planned Parenthood centers have closed. We've been reading that in the media. You know, and, and this goes back to, the summer, you know, when an appeals court had let the rule take effect.
So what does this mean for health centers? Well, first of all, health centers don't offer abortion services, but they do provide women and their families with well woman care. With prenatal and perinatal care, with family planning, and in some states, more than 30% of all women of reproductive health of reproductive age may receive their healthcare at a health center.
Last year, more than 8 million women in their childbearing years relied on health centers for care. So that's about one in eight women in America, you know, between the teenage years and let's say 45. Right? And in 2024 alone, those women made about 6 million visits to health centers for reproductive healthcare services.
So, when Planned Parenthood is attacked, when Planned Parenthood can no longer provide these vital services, there are a few places that women can turn and that families can turn. They turn to health centers, which on the one hand, it's great that the health centers are there, but it means that there's more demand for care and that demand is coming at a time when health centers are already being stressed by all of these other things that we've talked about that are really affecting their bottom line.
Michelle Rathman: Yeah, absolutely. And I'm gonna say I, I've never shared this with our audience, but Planned Parenthood, that's where I received all my prenatal care when I had my first child, who's now is 40, you know? And so back then, it was the only place I could go to be able to afford because I was working but uninsured and they received me.
So, yes, a shout out, because, you know, ignorance is bliss as they say. And there's a narrative out there that just is, you know, it's just frankly not true, about what it is that they do.
Okay, so let's talk about one other major roadblock to care, which are the Medicaid work requirements. I know that there are a lot of health organizations out there that have had to literally hire a person, so expend more dollars on hiring a person to help patients navigate work requirements. I see this as being just another pile on strain for community health centers. What kind of share with us what youth foresee the landscape being when all of these things start kicking in and the clock is ticking. It's happening soon.
Feygele Jacobs, DrPH, MS, MPH: The clock is really ticking. So, what HR 1 did is it made substantial changes to Medicaid law. It shortened renewal periods, it added a lot of administrative barriers. It, you know, shifts the burden to the states, and it restricts how states finance their share of costs and how they pay providers. But finally, it has imposed these mandatory new work requirements.
And beginning in January 2027, states must require that Medicaid enrollees, adult Medicaid enrollees between the ages of 19 and 64, meet what are called work or community engagement requirements. They must demonstrate that they are engaged in that work or community engagement for at least 20 hours a week, 80 hours a month, unless they're exempt.
Now, I mentioned earlier that a lot of this is about administrative burden. We've done a number of other studies with different colleagues that show that, you know, this myth that the people who are on Medicaid who aren't working are, you know, young men sitting around playing video games and nothing could be further than the truth.
I'm sure there's, you know, maybe someone knows one example of that, but, that's really not who are not working. You know, and what some of our colleagues have found is that who's not working are largely women, women who are somewhat older in their fifties and sixties, they've left the workforce to care for family members.
Maybe it's a grandchild, maybe it's an unwell spouse. Right? But it's, it's not, you know, young and, and they may not yet have a particular, health condition, but they're aging, right? So, they have all of the normal issues related with aging. And of course, these documentation requirements are, are really prohibitive.
So, I worked, our team, worked with colleagues at an organization called Capital Link to analyze what this will mean for health center patients. What we've estimated is that about 5.6 million community health center patients could lose coverage because of mandatory Medicaid work requirements. And I'm sure people have seen many estimates of, you know, sort of the broader workforce loss and what that looks like.
We think that it's going to disproportionately hit community health center patients because of who they are, right? Because of their income levels, because of where they live, because of their extreme poverty. And so that loss of about five point of coverage for by about 5.6 million people could lead to losses of about $32 billion in health center revenue.
And by the way, you know, we talked for a second about, enhanced premium tax credits. You know, similarly we have looked at what's the impact on health center patients of those tax credits disappearing? And we've estimated very conservatively that about 2 million patients could lose their marketplace coverage. And here the losses are going to be particularly serious in states that didn't expand Medicaid, where more people get their coverage from the marketplace.
And we've estimated that it could be a shortfall of nearly $10 billion for health centers. So, you've got on the one hand, Medicaid, on the other hand, marketplace plans, which have filled an extremely important role, especially in those states that did not expand Medicaid for working age people. So it's like a double whammy.
Michelle Rathman: Right. And I have so many other questions. I wish we had so much time because I'm thinking about the Medicaid work requirements and we've talked about on this show. For rural, it's different. There are challenges that are inherent to rural. So, we talk about, I just thought about this over the weekend, folks, Tyson announced the closure of a gigantic food, pro meat processing plant in Lexington, Nebraska. I've been there. There's a critical access hospital there. Think about how many employees now have found, will find themselves come January thousand, over a thousand, unemployed and you know, when we talk about transportation barriers and so forth, so it's not an unwillingness to work.
It is truly the circumstances that prohibit folks from being gainfully employed. And sometimes you are employed with three jobs and you still don't have a place to go. Oh my gosh. All right, so I'm gonna go, here's my closer for you.
Your policy brief, and I'm going to put the links of the policy brief on our website, the ruralimpact.com, but it concludes that the Congressional Budget office CBO has confirmed that health centers are cost effective and increasing mandatory CHT funding levels could lower overall federal Medicaid and Medicare costs. Isn't that what we're supposed to be doing? Right? Isn't that the whole ruse here that we're supposed to be saving ourselves? That said, how do you foresee community health centers surviving given the circumstances they are in today? What do our listeners need to understand about that?
Feygele Jacobs, DrPH, MS, MPH: Well, I wish we had another hour, Michelle, because you know, you've raised so many really interesting points and of course, you know, hearing about this, the plant that's closing, we're hearing that again and again and again, especially in rural communities.
Michelle Rathman: That's where they are.
Feygele Jacobs, DrPH, MS, MPH: Et cetera. It's quite horrible. And you're right.
You know, there's, there's all this evidence that shows that high quality primary care at health centers helps reduce the need for more expensive care. There was a recent study by some of our colleagues that showed that, even though Medicaid patients who live in really isolated neighborhoods are less likely to have a primary care visit if they get care.
It's at a community health center. Right? But as you've just laid out healthcare policies at an inflection point, there's enormous pressure. You've got these, you know, headwinds shifting.
You know, and what's happening is that the entire system is really contracting. So, you know, I don't wanna be a Pollyanna, but I guess I wanna say that health centers are known to be highly innovative. They're known to be highly agile and they've faced a lot of change before. None perhaps so extreme as now, you know? But for anyone who lived through the Reagan administration block grants, you know, we know, health centers have come through hard times. And I think that over those times they have demonstrated that, you know, there are a lot of things they can do, but given these policy changes, you know, they can't indefinitely sustain losses with, you know, funding uncertainty and policy changes. So, I think that the coming months will, you know, really be telling about how health centers can strategically uphold their mission. I think they will be at the forefront of new approaches to thinking about. How do you preserve care?
You mentioned navigators. Navigators have been part of health center programs forever. One of the things that health centers do under law is they provide what are called enabling services like transportation and navigation and translation to help people get access. So that kind of thing is embedded, but I think that there's, you know, really the need for more of that.
And I think health centers are going to have to really look on the one hand to how do they help their patients keep their coverage, right? First and foremost. And that's something that part of our team is working on right now.
On the one hand, so we wanna make sure people keep their coverage. And on the other hand. We need to look at how do we really stretch limited resources. Maybe that's through partnerships or technology. So, one thing to know about health centers is that they have strong membership organizations at the national level, but also at the state level. These are called primary care associations or health center-controlled networks.
And that network model I think becomes really important here because it gives some infrastructure basis for health centers to think about how can they maybe adopt more efficiencies? Are there places where they could consolidate or operate more effectively? And I think that that's gonna be the name of the game.
You know, but, but first and foremost, I think health centers are here to stay. They, they, this is our lifeblood, right? This is what we do. We care for people who are under-resourced. We care for entire communities. We provide much more than just medical care in health centers. I think that's gonna continue.
And I think, you know, we are looking for, you know, ways that health centers can be more resourceful and, you know, in my role, you know, which has now moved into an academic and a research and a support role rather than where I spent most of my career. You know, more out, directly consumer facing organizations or working with more directly with those organizations.
What I can say is I think health centers are, you know, they're in it to win it on behalf of their patients. That's what they're there for on behalf of their communities.
Michelle Rathman: Yeah, that's wonderful. Oh my gosh. Well, you actually gave me a great segue because we are gonna, after a quick break, we are gonna hear from Joe Dunn, and Joe is the Chief Policy Officer at the National Association of Community Health Centers. So we're gonna talk a lot about policy on the other side of this.
But for now, Feygele Jacobs, I cannot tell you what a pleasure it was to meet you. You are welcome back anytime. Listen, any research that you've got that affects rural, you know who to call you now you've got a phone. I've got a phone in front of you and you've got one in me.
Feygele Jacobs, DrPH, MS, MPH: Great. I hope to come back and I really appreciate, the invitation and the opportunity to talk with you. Michelle, thank you so much.
Michelle Rathman: Thank you. So thank you to you. Everyone stick around, as I said, we've got another guest coming up on this episode of The Rural Impact. We'll see you in just a few minutes.
Interview with Joe Dunn
Michelle Rathman: Well, as promised we are back because we have a second part of this conversation that we're talking about today, community health centers and really the plight of, you know, where they are today and what we're foreseeing might be the case in 2026. And to help us with this conversation, I am very happy to welcome Joe Dunn, Chief Policy Officer at the National Association of Community Health Centers.
Joe, it's really good to have you here. Welcome to the Rural Impact.
Joe Dunn: Thank you so much for the opportunity, Michelle. Really, looking forward to the conversation.
Michelle Rathman: I thank you so much. You know, Joe, my listeners know and they heard, someone that you know, Dr. Feygele Jacobs we had on earlier. We know that this is just, we're talking about it because it cannot be saidenough. And quite frankly, I don't think there's just enough headlines. Mainstream media certainly isn't talking about it.
I know they've got their plates full with other distractions. But at the end of the day, you know, as we heard from Dr. Feygele Jacobs, she covered a policy brief focus on the widening holes in safety net, with a focus on the finances. And I know we're gonna talk about that as well with you. But first, you all published your own report that was brought to my attention.
That goes really deep into the many ways in which community health centers are lifelines. I mean, really, truly lifelines for rural populations. So, your piece was, the report is called, "Community Health Centers and Rural Health Essential Access Enduring Challenges." And I think enduring challenges is a very generous understatement. Our listeners, are hearing this conversation at the end of 2025. It's our last episode of the year, and it also marks the 60th anniversary of Community Health Centers. So, let's start there from your perspective, Joe, what do our listeners need to know, understand about the contributions of community health centers in the rural space for the past six decades?
Joe Dunn: Yeah, so I really appreciate the opportunity to come and talk to you about this. This is so critical, and as you mentioned, you know, for generations, health centers have been meeting the needs of their communities. And this is one of the models that really works well in rural communities, right? Providing that comprehensive primary care that includes medical, dental, behavioral health, pharmacy, enabling services like transportation.
All under one roof are very integral to the success of a community. And the way I always think about this is if you're in a rural or small town, area of the country, you know, having, primary care is essential. To attracting that economic development, right? That factory, the processing plant, the local provider, you know, base.
So, it is just central. So, as we think of, you know, this, environment where unfortunately too many rural hospitals have closed, really, rural health centers have stepped up. Health centers are in 40% of health centers are in rural communities, and they are facing really significant challenges, either through the funding instability, the workforce challenges, aging facilities, you know, some of those things that, you are out there.
But really what's central to us is we try to work every day to help the health center patients and the organizations meet the needs of the community. And they, we've had such success over the last 60 years.
Michelle Rathman: Yeah, don't, I know it. As we were talking with Dr. Jacobs, I mean just the, the, the totality, the impact that community health centers make and some of the things that you mentioned she did as well. And of course, we know that there has been a great deal of focus this year on MAHA, Make America Healthy Again.
And I say, kind of on the side of my mouth, I wonder what the before time was. But community health centers have consistently shown, even though the budget office says it as well, that you've got a commitment to clinical quality excellence, you guys are working on chronic disease management, prenatal care, and so much more.
So, talk to us a little bit more about what data can you share about how community health centers really have always been focused on healthy outcomes for patients they serve. The goal isn't to just treat sick people, really I see community health centers as at the forefront of that preventative care that is so underrated, I think because it's not as tangible as dollars for treating somebody who might have an illness.
Joe Dunn: Yeah, and you know, we completely agree with the focus around reducing the chronic disease burden and, treating and preventing that. And health centers are, you know, gonna be central and vital to that. So, you know, chronic diseases are a leading cause of poor health outcomes and higher healthcare costs and, you know, really leads to people going to seek care at an emergency department rather than, you know, at the front end, getting that care at a primary care setting, like a health center.
And you know, it's really one of these things where, you know, especially in rural communities where there's a higher and heavier chronic disease burden. Particularly in cardiovascular and behavioral health but you know, the good news is that health centers report higher rates of hypertension and heart disease, mental health conditions, but often will exceed the national averages on these conditions and the outcomes that they have through the comprehensiveness of the care that is provided.
And so, you know, the good news is we know that's a model that works, and we would love to have that expanded into other communities. You know, you mentioned one of the reports that we did a few years ago, we did another one, that really highlighted that a hundred million Americans across the country lack access to primary care. And most of those, as we looked at the map, were in rural and small-town America, right? And so, so we think of, you know, policy solutions.
Here's a real proof of concept of something that works. There's data behind it. As you mentioned, the Congressional Budget Office has recognized this as investments in health centers will lead to better health outcomes and lower costs downstream, through reduced utilization of emergency departments and hospitals and, and so this is something that we are really committed to working with the current administration, with the Congress, health centers have always been nonpartisan, but have enjoyed bipartisan support.
And especially in rural communities where they are often the only. Healthcare provider in town. They are just, they, we need them to be supported. And luckily, we've had that tremendous support from the Congress, across the board.
Michelle Rathman: Well that, that is good to hear. 'cause the next topic I wanna talk to you about is the Rural Health Transformation Fund. I mean, we know. Well, we know what it is for our listeners. They've been tuning in. They understand what it is. How have community health centers participated with their states? What are some of the asks? Because it's a $50 billion in taxpayer investment and, it was a, I know many people who were involved with devising their own state applications and plans. It was an exhaustive body of work in a very short period of time. So again, how have community health centers participated?
What have your, has your input been, what are some of the asks? And from there, what are some of the expectations you have once the money starts flowing? The first half of that 25, the 50 billion is the 25 billion that we can expect to start to see. I don't know the date. Maybe you do.
Joe Dunn: Yeah, so it's the applications were due a little while ago, earlier, or actually last month now. But you know, decisions will be made by the end of this year and money would be available starting next year. So maybe to zoom out, we were really, pushing and advocating for health centers to be included as part of this.
A lot of the media attention and, you know, the focus had been about rural hospitals, and while rural hospitals are critical parts of the rural healthcare system, you can't forget about health centers. As I mentioned, you know, a lot of them are the only provider in their communities. And so we wanted to make sure that that was an option and we were successful in getting the legislation adjusted and to make sure that it was happening.
So as the states were really in this compressed timeframe from July to November, as they were developing their applications, a lot of them looked to community health centers, the state associations, which we call primary care associations, to try to harness what, is out there and what the capability could be to really prop up and support the rural healthcare system.
So, you know, examples around this, a lot around technology. You know, a number of states are looking at, technology advancements. So, things like remote patient monitoring or other kind of things, that often are outta reach for health centers, right? They are very high touch in terms of high and trusted, providers, but maybe not always high tech because of some of the challenges, financially that I know, many of 'em are facing.
And so something like, ambient AI or artificial intelligence, so a scribe that is, you know, rather than a person, but, you know, kind of a technology platform that could be useful in helping the physician or clinician, you know categorize notes or make, suggestions or, you know, help with clinical decision making.
Those are all things that some are thinking about along with, you know, a number of them are looking at workforce and other kinds of approaches. So it varies from one state to the next, but I think what we've been really encouraged by is so many of the states look to health centers as key partners throughout this.
To really make sure that the money is spent in the most efficient and impactful way, you know, given the, the core issues facing rural America, but also, you know, the value of federal investments. And we don't wanna have anything squandered.
Michelle Rathman: Absolutely. And you, and you don't, I mean, it's like, the most lean, nimble organizations you will find operating on razor thin margins. You know, it's not about profit. Let's talk a little bit about some of the policy challenges, because we do work to connect the dots between policy and rural quality of life.
I mean. Great. We've got this fund, we can look forward to seeing innovation and whatnot. But at the same time, we've got headwinds in other areas, including severe workforce shortages. And Joe, I've been thinking about the news that came out last week about, professional degrees and how it is really targeting like nursing degrees and so forth.
Community health centers rely heavily on nurses and not just physicians of course, but there's a whole nother world out there of those who are providing care. What is the policy stance? You know, what are some of the things that you all are doing to help alleviate the ever-growing challenges of severe workforce shortages?
I mean, we are not Chicken Little like the sky is falling. This is a real thing happening.
Joe Dunn: Yeah, and it's, it's so critical. You know, we as all health centers, they, employ about 330,000 full-time employees about a third of those are 93,000 healthcare professionals in rural communities. And you're exactly right. That that includes physicians, nurse practitioners, dentists, behavioral health providers, case managers, frontline staff, you know, so it's, it really is a whole team effort.
And that, I think is a differentiating factor compared to maybe a private practice physician, right? That may just have the physician and one, you know, or two support staff, right? This is a whole team. And so, when you go to a health center, you're going for a number of different things. And that one stop shop, and especially, you know, I think it's important, around behavioral health, right?
We think of the stigma associated with behavioral health, and especially in a rural community where you may know all of your neighbors. You know, seeing that red truck at the health center versus seeing it at a mental health provider only. Right. That's gonna be different because that person may be there for any number of things.
Right. So, you know, we support a number of different workforce initiatives. One of them that has been so critically important is the National Service Corps. So this is a program that's been around for, I think it's 50 something years, where it really has been impactful in placing individuals in rural and underserved communities, you know, through a loan repayment or a scholarship approach where they are able to, reduce some of their, you know, educational costs, because of the commitment that they give to rural and underserved communities.
And it has been so successful. It's really kind of the backbone of, you know, the workforce initiatives that the country has around, this, especially in rural. And so, we are supporting increased funding for that. There's another one called the Teaching Health Center Graduate Medical Education Program, which is really flipping, the education of physicians on its head.
So, providing residencies that are more community-based at a health center or another community provider, rather than just having it at a hospital. And the difference there is that if you expose people, especially in a rural community to this type of setting. A lot of them want to stay there. But the challenge in rural in particular is if you don't necessarily grow up in that area, you may be unfamiliar or you know, skeptical about, oh, can I fit in?
Can maybe a spouse, you know, find a job? Is there something for me to do? Is it gonna be enough? You know, educational for, you know, maybe a family. That's where through this program, the Teaching Health Center program, they're able to expose people early on in their career. And that really leads to better outcomes, better care, and actually a much more, focus around primary care, which the nation as a whole needs desperately.
Michelle Rathman: Yeah, and sensitive to the culture, the communities, because it's not, you know, you go to the west coast, to the east coast, south, north, I mean, it all looks different and having individuals within your community interested in staying. Isn't that what we want? You know, and plus they're trusted and, and communities trust people they know.
Let's talk a little bit about the, funding instability. And with that, the aging facilities and infrastructure, because the Rural Health Transformation Fund, as I understand it, does not, there's no money in that for facilities, capital improvements, and that nature. And I think about aging facilities really from a hospital's perspective.
'Cause I've been working on them for so many hospital replacements and so forth for many years. What are some of the challenges that there's an intersection to policy where funding in stability, of course, reimbursements, and aging facilities and infrastructure. Infrastructure is something that we could all maybe not understand completely.
But you know when infrastructure is not invested in, you'll know it.
Joe Dunn: Yeah. Yeah. No, it's such a great point because, you know, many of these, areas or facilities are, you know, older. You know, one of the things in rural in particular is, we've been very supportive of mobile healthcare, right? And so in.
Not necessarily that you need a brick and mortar facility in every community, but maybe through a mobile van or a, you know, some other type of arrangement where, you know, you can provide care to a community in a number of different ways.
But I think what you're really, driving at is, you know, some of the challenges that we see in Washington right now, so the bulk of health center funding comes through an account and a pathway that was originally started in 2010. It's now about 70% of the funding. The idea behind this initially was it was gonna be multi-year funding that you could count on, that they, the health centers could plan around. That they knew there was gonna be a growth and investment strategies that they can bank on. The difficulty that we've seen over the last couple years is that that has not been the case. It's been much more piecemeal. So right now you may like with the government shutdown that just occurred. We actually had a lapse in funding.
Luckily, they were still able to draw down the money, but that was only for a temporary period of time. But the issue is we are on the seventh now, short-term extension of this funding, now it goes through the end of January. We are constantly trying to educate members of Congress about the challenges that presents, right?
That the difficulty to plan ahead and to know, can I make investments? Can I look at retrofitting, a facility with other dollars because there are some other limitations within the, that pot of money for facilities. And so, you know, this is just something that we always are kind of thinking of.
You know, we believe that, when you go into, any health center that the, it should reflect, the best care. We want health centers to be the employer, provider and partner of choice in their communities. And so, part of that is the look and the feel of the organization. And sometimes, you know, need, changes need to be made. It's just, difficult given the financial challenges.
Michelle Rathman: And it's not, it's not about aesthetics, folks. It really is about ensuring that there is an environment that is the highest, provides the best opportunity to provide high-quality clinical care.
You know, I wanna talk a little bit about geographic isolation and transportation barriers. Unlike critical access hospitals, community health centers do look to find transportation solutions and mobility solutions.
I've, our listeners know that we just did a, a podcast, a, a live stream about my time in rural Massachusetts and driving the entire state with somebody in two days and really getting a firsthand look at how challenging it is to get from point A to point B, because it could be 75 miles apart. So, talk about where policies can help to close the barriers of transportation that are born just strictly outta geographic isolation.
Joe Dunn: So, this has been something, I think especially post-pandemic, where around telehealth policy, there's really been a broad bipartisan support and that's that's one mechanism that I think, could solve some of these challenges. Certainly, you know, you need to be seen in person for, a lot of things, but especially maybe around mental health.
We've seen a lot of tele-mental health or tele-behavioral health that has been very impactful. That's one another issue though that has been kinda had this short term extension and actually lapsed, also during the government shutdown. But, you know, we really think that technology plays a significant role for care.
But you know, we also know that many rural areas lack reliable high-speed internet or cell coverage. And that makes it a challenge. But, you know, I reflect back on one of the health centers I've had the fortune of to visit was, in Alaska. It was a community in Bethel, Alaska, off the road system.
You know, internet was the number one issue that they faced. And it was so interesting. You know, this is a, this was a health center again, off the road system. They pointed outside to me. They had two mobile approaches. One was a boat, for the summer when the river was open and there were two snow machines, and those were to really get towards remote, native communities that needed care.
And you know, it provided them year-round access to these communities. But that's an example of some of the challenges that these rural health centers face, but also the ingenuity that they have to really think about, okay, how do we meet the needs of our patients and how do we get there?
So, it's something that, is always, awe-inspiring as to how they figure it out. You know, I'm also thinking back now, a health center that we work with really closely in South Dakota, they have, facilities and towns of like three or 400 people. You know, that's, if that health center wasn't there. There's not gonna be anybody else, right?
And there's no one coming in. So that's why the policies need to be supportive of them, provide the funding, and then, you know, other things like telehealth, to provide that full wraparound service.
Michelle Rathman: Yeah. I love that. I love that Alaska, I mean, I, I worked at Wrangle, Alaska. So I mean, it is as remote as it gets, although there's a lot of remote places here as well. And to your point, I mean, it's one thing to say we're gonna have policy that says we have to, you know, have provisions to help make our communities healthy.
But then when you put up roadblocks in other places, it's like that game of whack-a-mole, that the vision I have. Alright, Joe, before I let you go, I always like to ask our guests who are in your position, advocacy works. Advocacy and, volume. More voices, the, the better. So what is an advocacy tool or idea that you can share with our listeners that they can take away today and potentially put into action tomorrow? That is going to help to make sure that policy shifts 'cause we got a lot of shift happening. Policy shifts are in favor to ensure that community health centers not only survive 'cause that's not the point. For communities to thrive, community health centers, rural health providers have to thrive as well.
So, what are some of the advocacy tools that you all are recommending to your, I don't know how many members you have, but I know it's a lot. I've been to your conference. It's a sea of really committed people. What can we be doing right now? I know people are busy for the holidays when this drops. It's just before Christmas, but this work can't stop.
Joe Dunn: The advocacy is so critical, and the reason why health centers have grown to serve at least 34 million patients annually and, up to 52 million over a three year period and be that comprehensive home is because of the work of others over the decades, right? That advocacy that they had. So, this is the lifeblood.
We really believe that grassroots power, grasstops power that people have in their communities. So, in terms of specific steps, we always recommend, you know, go in and meet with your member of Congress or their congressional staff. I'm a former Hill staffer myself. I worked there for 11 years. I know the power of when somebody takes time out of their day or invites somebody to, you know, the facility or you know, to, to talk about an issue.
I know how powerful that can be and to change the minds, right? And so that's one part of it. How you can do that. We have tools on our website. We also have, you know, so like a toolkit as to how you could go about that. How do you invite a member of Congress, either to a health center or another place? We have what we call the Washington Update, which is our weekly, advocacy alert that, you know, provides that information, you know, the key things.
Where is that Bill going? What is that bill doing? All of that is right there as once you sign up for that, then you'd be able to get the activities that we have more on an urgent basis when we send in an action art where we need somebody to contact the member of Congress that's populated with a specific letter or email.
So those are certain things that I have, but I think, you know, just generally having an approach or a mindset that we all have a vested interest in the sake of our communities. And by taking time outta your day to do something, to have that commitment, that either I'm gonna engage in, it could be at the local level to get that stop sign in at the, the corner of the street or at the federal level when you're talking about billions of dollars that would support the rural healthcare system.
Just that mindset is so important as a foundation. And then there's a number of different tools, like I said, that we have or others, to really engage in the political process.
Michelle Rathman: You know, Joe, gosh, if I could be a fly on the wall when you were a staffer. I've been on the Hill. I've, I've met with my representatives because I put my money where my mouth is. I go to the Our Policy Institute every year in, in February. One thing that we have not touched on, if you don't mind is, you know, community health centers, your boards are made up there are by mandate of people who live in the community. What is the value of board members and those who work within the clinic making their faces known and their stories known.
What, what would that look like in sitting in front of a person like you who in the mindset of a staffer, when board members who say, I'm a part of the community, I'm not a lobbyist or anything like that, here's our story.
Are those, do those work?
Joe Dunn: Oh, it's so incredibly impactful because, you know, you really see, as a, as a staffer, I met with every type of provider group, every clinician type, you know, all the guilds and the patient advocacy, and I loved all those meetings and those connections. However, when somebody comes in, either from a business or an organization says, you know, “Hey, I'm gonna lose money, or I need a higher reimbursement or something,” you know, that's important.
But when somebody is coming in and being, "Hey, I really need this care for me and my family and I am dictating," or” I'm, I'm providing direction to this organization as to what they should invest in or how we can meet a community that's totally different, right?” That patient board member requirement is a central thing that is just so foundational to the health center movement.
You know, some of the other things like we have to, health centers have to see everybody, regardless of their ability to pay, health centers, have to have a sliding fee scale discount, right? So, there's skin in the game for everybody. You know, those are, you know, kind of some three differentiating features.
But the patient board voice is so important in the policymaking sense, in the, like, again, at the practice level where, you know. If a board member were to say, we don't have enough dental capacity, I, you know, I know that this is an issue, or we need to start opening up more pediatric care in, school-based health centers.
Right? That is so important. 'Cause they're representing their community, right? They're, they're really the voice. And so I think it's such a differentiating feature that health centers have that other organizations, don't, and I really think that's part of the secret sauce that has made health centers successful. So advocacy is is really critical.
Michelle Rathman: It's critical. And I'm gonna say that before we, before we have to sign off, I wanna say, build your bench. And what I mean by that is community health centers out there, make sure that other community influencers, key stakeholders, your insurance guy, local insurance broker, your Chamber of Commerce, your faith-based organizations.
We, I don't believe that rural healthcare organizations do enough and not 'cause their place are full to make sure that other people and the community, it's not about helping you know, shoulder the burden or feel the pain bring along with you. What would it look like in our community if this community health center was gone tomorrow for our employers, for our schools, so forth and so on.
So don't go alone. Get a choir to go with you. And it's not just about those who are working in the healthcare space.
Joe Dunn: Yeah, I couldn't agree more. Those partnerships at the local level are so important and that, you know, again, back as a former staffer, when I heard about something about health centers from the local food pantry or the community-based organization and they said, “Hey, this is important,” that that echo chamber is, you know, impactful as well.
It breaks through in a different way. Um, so totally agree with you
Michelle Rathman: Absolutely. Oh my gosh, Joe, it's been so great to have you here with us today. I mean it when I say, be sure to let us know any new policy updates where rural is concerned and community health centers, we'd love to have you back and, and let's talk about this. You know, let's check our watch and see where we are in six months and we'll see if we're in a better spot than, than we are right now.
So again, Joe, thank you. It's great to have you here.
Joe Dunn: Sounds great. Thank you again for the opportunity.
Michelle Rathman: It is my pleasure. Okay. Although we had to say goodbye to Joe, stay with us. We'll be right back with some closing thoughts on this last episode of The Rural Impact in 2025. I'll be right back.
My thanks to Dr. Jacobs and to Joe Dunn, and to all of you for helping to make the Rural Impact Podcast a leading podcast in this very unique space. What a year we have had. We are so grateful to our subscribers, to our partners in 2025, and they include the American Heart Association, the National Association of Rural Health Clinics, and the New England Rural Health Association.
Again, we're so grateful for your partnership and collaboration and the investment that you have made in our content. Now, if your organization has an interest in expanding its rural reach, or if you would like to bring the podcast on the road recording from one of your 2026 rural-focused events, be it on education, workforce, economic development, you name it, we are interested in those topics.
Reach out to us and see how we might be able to make an impact together. All you have to do is email us at partners, that's [email protected]. Pretty easy to find us. And while you're there, make sure you that you subscribe, leave notes, comments. We love when you do that.
My thanks to Brea Corsaro and to Sarah Garvin for all another great year. A lot of hard work behind the scenes couldn't do without you. And to all of you, I'm gonna say this from my heart. I am sincerely wishing you peace, rest and all the best in the coming year. We know these are not light subjects and we know that millions of people living in rural America are struggling at this time.
And so, with that, I'd like to also remind you to take really good care of yourself and to the best of your ability, all those around you. We will see you again on a new season and a new year of the Rural Impact.
