Josie Gutierrez's 4-year-old son sits on his lap in an exam room lined with Curious George wallpaper, wailing after the last in a series of shots that will vaccinate him against measles and polio.
Gutierrez, 31, has relied on this place, Neighborhood Health, a community health clinic in Alexandria, Virginia, for years. He works two jobs to support his three sons — ages 2, 4 and 6 — and their mother, and says the discounted services at the clinic help keep his health care costs down.
"I hope they don't cancel the program," he said as he slid on his toddler's navy coat. "It's very helpful for our kids," he added, saying he wasn't sure how he'd access health care without it.
Basim Khan, a physician who oversees a community health center network that serves 18,000 patients across four clinics in Northern Virginia, including Neighborhood Health, says facilities like this give adults without health insurance "some sense of security around their medical care."
"We provide a really critical role in their lives," Khan said. What the clinics provide ranges from routine checkups to discount asthma inhalers and intrauterine devices for birth control, which cost $18 for patients of Neighborhood Health but could be $1,000 or more elsewhere for patients without insurance.
"Even though they may not have the means to affordable health care, we can help them to get access to medications for very low costs or for free," Khan said.
Six miles north, in Washington, D.C., Congress has been unable to agree on how to fund Neighborhood Health and the more than 10,400 other community clinics across the country. Combined, they provide health care services for more than 25 million people — one out of every 12 Americans — who have little to no insurance. It's a population that since 2001 has risen 151 percent.
The first two community health clinics, authorized as part of President Lyndon B. Johnson's War on Poverty, first opened in the 1960s in Mound Bayou, Mississippi, and Boston, Massachusetts. Since then, clinics have opened in thousands of low-income and medically underserved areas across the country. Overseen by the U.S. Health Resources and Services Administration (HRSA), they're open to anyone, and offer a range of medical, dental, mental health and substance abuse services. Often, they also offer case management, health education and transportation to and from appointments. HRSA has said nearly all sites improve the quality of health care for the community, and most boost health outcomes for patients with diabetes and hypertension, compared to the national average.
The messy months-long debate over funding that shut down the government in January now entangles community health clinics. Congress must vote on a spending deal by Thursday to avoid another government shutdown. Federal grant funds expired for these clinics on Sept. 30, the same day that funding expired for the Children's Health Insurance Program (CHIP), which provides insurance for nearly 9 million children whose families often earn too much to qualify for Medicaid but too little to afford their own health insurance.
While Congress ultimately reauthorized the popular children's insurance program for six years as part of a deal to end the government shutdown last month, a long-term funding solution for community health centers has been stalled, pieced together through a series of short-term legislation. The House passed a bill Tuesday that would fund the government through March 23 — and community health centers for the next two years. But Senate leaders announced their own two-year budget deal, and it's unclear whether the House will back it. Unless Congress can agree on the health center funding this week, federal dollars for community health centers, which account for 19 percent of their funding, will dry up by March 31.
Sen. Patty Murray, the ranking Democrat on the Senate Health, Education, Labor and Pensions Committee, said in a written statement Tuesday that any further delay on community health center funding "is inexcusable."
"This shouldn't be a partisan issue, and I'm very hopeful that Republicans will act responsibly and work with Democrats to get this done quickly—and without slashing other critical investments in public health— so that communities don't have to go without health providers they need and trust," she said.
There was no response for a request for comment from Sen. Lamar Alexander, a Tennessee Republican and the committee's chairman.
Community health centers have long enjoyed bipartisan support, says Avik Roy, president of the Foundation for Research on Equal Opportunity, and "the natural thing to expect is that funding will continue this way. But after the Affordable Care Act changed the way these centers are funded, Roy said partisanship may lead to different funding for these clinics.
"There will always be support for community health centers and what they do," he said. "How they are supported may change to the degree that Republicans may want to support community health centers with mechanisms that they don't associate with the Affordable Care Act."
Community health centers do get a majority of funding from Medicare, Medicaid, patient fees and private insurance, according to HRSA. But facing uncertainty from Congress over federal funding, two-thirds of these centers said they may freeze hiring staff or halt plans to expand or renovate, according to preliminary findings from the 2018 Survey of Community Health Centers from George Washington University. More than half of community health centers said they have considered firing staff, and more than a third said they are contemplating the closure of at least one health center site.
During a historic flu season and the opioid public health crisis, community health centers have filled a crucial role by providing flu vaccinations and offering things like behavioral health specialists, said Dan Hawkins, the senior vice president for public policy and research at the National Association for Community Health Centers in Bethesda, Maryland. He said the centers are already showing signs of strain due to Congress' indecision. Nationwide, some centers reported losing physicians and dentists because "they can't commit to a long-term employment agreement," Hawkins said. And if these clinics cut services or close, rural and urban patients will lose access to affordable health care.
"Every day that this thing goes on — with the uncertainty that goes with it — causes more unnecessary havoc and pain in 10,000 communities across the country," he said.
At 11 a.m. last Thursday, a dozen people sat in the waiting room at Neighborhood Health, which shares a parking lot with a dry cleaner and a restaurant that fires up burgers and barbecue ribs. A toddler squirmed in a beige chair next to his mother. An uninsured couple worked with a clinic employee to figure out how they could pay for a doctor's visit. On a typical day, about 80 people pass through this clinic, most of them adults who work but have no health insurance.
Brenda Berdick, a nurse practitioner at Neighborhood Health, has worked in women's health in Northern Virginia for 15 years, serving patients in low-income, underserved and immigrant communities. In January alone, she identified 64 women with unusual PAP smear results. She followed up by offering a $15 colposcopy (which normally cost $200, Berdick said), to further screen for cancer and other illnesses.
When Berdick examines women for a family planning visit, other issues often emerge — depression, hypertension, domestic violence and more. When she learned her clinic in Alexandria could lose as much as 30 percent of funding if the federal government balks at its own deadline, Berdick threw her head back in frustration.
"A decrease in funding would kill us," she said.
Nuvia Gomez Arevalo, 42, cleans offices in Arlington, Virginia, part-time and has gone to the clinic for four years because that is the only way she can afford to pay for health care. She has no insurance. Recently, she slipped and fell in her bathtub. Her right knee grew inflamed and she started to worry she may have broken a bone.
A clinic employee helped Arevalo fill out financial aid paperwork that completely covered the costs of X-rays at a nearby hospital. If the clinic loses funding and has to cut back on services, lose staff or close, Arevalo said through an interpreter that she, and others, will no longer be able to pay for medical visits: "And people will become sicker," she said, "because they cannot access medical care."