If you feel uncertain about how to chart your health center’s path forward in the wake of new policy developments, you’re not alone.
The “One Big Beautiful Bill Act” (BBB) cut Medicaid by nearly $1 trillion dollars and includes many other provisions that restrict access to care. It will leave millions uninsured, and puts hospitals, health centers, and other essential care providers in danger of closing.
Amid all the numerous provisions, the various timelines for rollouts, and the different policies at the state-level, health centers are left scrambling to understand how exactly this will affect them — and how best to prepare.
We recently hosted a webinar with Joe Dunn, Chief Policy Officer at NACHC and Yuvo CEO Cesar Herrera to discuss what we know and what health centers can do. We’ve put together this page based on the questions from our community. You can jump to a certain question, or you can watch the full video here:
If you have other questions, feel free to get in touch. We’re here to be a resource for you.
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The BBB’s timing, policies, and rollout
- What exactly is in the One Big Beautiful Bill and where does it stand now?
- What are the expected timelines for the rollouts of the various regulations?
- Is it detrimental for health centers to take a “wait and see” mentality?
- How communicative has HRSA or other federal agencies been with CHCs that are having trouble accessing their grants funding or funding?
Working with at-risk populations
- Does NACHC or Yuvo Health have a position or stance on health centers that are providing gender-affirming care for trans and non-binary minors as well as adults?
- Are health centers seeing a drop in utilization or increase in no-show rates among patients who are foreign-born or undocumented immigrants? How can health centers support patients who are immigrants?
- How do we reconcile the executive order not to use federal dollars for undocumented immigrants, versus the prior law that mandated that we cannot ask for proof of immigration status?
Charting a path to sustainability
- What are the actions that community health centers can be doing right now to prioritize?
- How can health centers embrace value-based contracts for payment for service to Medicaid patients?
- With funding set to expire on September 30th, 2025, what concrete advocacy steps should health centers be prioritizing now to ensure sustainability beyond that point?
- How can health centers engage their state governments? What can they expect from state responses?
The BBB’s timing, policies, and rollout
What exactly is in the One Big Beautiful Bill and where does it stand now?
As Joe Dunn explains, the “One Big Beautiful Bill Act” (as the bill itself is called) is “a pretty fundamental rewrite” of the Medicaid program. It includes some big changes, including:
- Community engagement or work requirements
- New eligibility checks that will be required around the Medicaid expansion population every six months
- Changes to healthcare for immigrants
- Changes around state financing such as provider taxes and state directed payments
“We want to make sure that through that program, rural health centers are getting the funding that they need, along with other health centers in the states. Because it's not just rural health centers that are named in the law, it's actually health centers and look-alikes across the board.”
- Joe Dunn, Chief Policy Officer, NACHC
Another change that health centers should be aware of? “There's a new $50 billion fund over a five-year period for rural health transformation, and health centers are eligible for that,” explains Dunn. “We want to make sure that through that program, rural health centers are getting the funding that they need, along with other health centers in the states. Because it's not just rural health centers that are named in the law, it's actually health centers and look-alikes across the board.”
What are the expected timelines for the rollouts of the various regulations?
The provisions will be rolled out on different timelines. “We’ll start to see guidance from HHS on some of the changes — for example, around eligibility determinations — starting this year,” Dunn explains. For the new rural health transformation fund, there’s a “planning process where states will have to develop their plans and then CMS will have to approve those plans by the end of this year and then have the funding available.”
Other things, such as Medicaid work requirements, will go into effect a bit later. “It could be as early as the end of 2026,” says Dunn. “That's the original start date for the federal side.” He explains that some states may implement it earlier. “If they have an 1115 waiver, the law actually says you can start that earlier,” he says. “Some of those applications are already pending from or within CMS. But then there's also a two-year potential delay that the HHS secretary can grant the states if they're acting in a good faith. That’s just an example of how it may play out differently in one state versus another.”
He emphasizes the importance of staying informed. “Stay connected through our webinars and our calls that we have [at NACHC],” he says. “And connect with your primary care association, your external partners like Yuvo, and others who are going to be monitoring this.”
There are other changes that are further out in 2028 and 2029, which are around “cost sharing requirements for expansion individuals,” Dunn says. “We were able to make sure that health center services were excluded from that, so we were able to work on language to improve the bill. So FQHC services are not going to be subject to cost sharing, but otherwise that's an example that would start in 2028.”
Is it detrimental for health centers to take a “wait and see” mentality?
As Joe Dunn emphasizes, “The fact that this law takes $1 trillion out of Medicaid is really concerning.” Health centers will have to operate in this new reality — and it’s going to be about mitigating the impact as much as possible.
“I would encourage people to start to think about this,” he says. That means asking:
- How many patients do you have at your health center, and how many are within traditional Medicaid versus Medicaid expansion?
- What could you do to have a relationship with your primary care association or directly with your state Medicaid agency?
- Where do you have the connection with your members of Congress? If you start to run into problems, how can you then go to them and ask for changes or be aware of what's happening?
“That education piece is really critical,” says Dunn. “And it's going to have to be iterative. Because these things are going to be changing as HHS releases guidance or CMS releases a rule.”
It’s going to be about “having that mindset of being forward-leaning,” he says, and “understanding that there will be changes, and then asking, ‘How can we really position health centers in a way that we're a solution to some of these things and not necessarily having the complete downside to this?’”
How communicative has HRSA or other federal agencies been with CHCs that are having trouble accessing their grants funding or funding?
Earlier in the year some health centers had challenges due to the funding freeze, but those were resolved. Joe Dunn emphasizes that if any health centers are having trouble accessing their funding, they should contact his office.
“If it's other grants outside of HRSA, I'd also love to know so we can try to scale the potential issues,” he says. In terms of staying up-to-date, “HRSA certainly is trying to provide updates through their update calls.”
Working with at-risk populations
Does NACHC or Yuvo Health have a position or stance on health centers that are providing gender-affirming care for trans and non-binary minors as well as adults?
“There's certainly a lot of attention around this issue,” says Joe Dunn. “Earlier this year there was an executive order around this issue. There's other attention in Congress, so multiple bills have been introduced around this topic.” For Dunn, it’s an issue that needs to be watched closely.
“We understand that healthcare is at the local level and health centers are going to make determinations based on their patient population,” he says. “NACHC wants to ensure compliance with state and federal laws, and so this is an area that I think we're going to need to continue to watch and monitor to see how this may begin to change over time.”
Cesar Herrera agrees. “Here on the Yuvo Health side, we are not a political organization. We don't dictate the set of services that are provided by any of our FQHC partners,” he says. “But as a result of that, we deeply support and are very proud of how our FQHC partners have deployed the services to meet the needs of the communities that they serve. We have several FQHC partners that serve a predominantly LGBTQIA+ community and will continue to support them in the work that they do, as we will with any FQHC because we simply deeply care about their respective missions.”
Are health centers seeing a drop in utilization or increase in no-show rates among patients who are foreign-born or undocumented immigrants? How can health centers support patients who are immigrants?
While neither Joe Dunn nor Cesar Herrera have heard of a drop in utilization rates or no-show rates, they both acknowledge that there’s a lot of fear right now.
As Herrera says, it’s important for health centers to “really lean into their mission and speak to their centers as a safe place for anyone to seek care regardless of their immigration status.”
For Dunn, it’s an issue that NACHC is watching closely, hosting calls about, and hearing from attorneys who have “suggested everybody take a breath not to change policy right now because more information is needed to understand the environment.” He explains that there is a comment period. “NACHC will be providing a comment but also a template for health centers,” he says. “If you choose to, you can express an opinion to the government around these changes through this template letter or a different letter if you want.”
How do we reconcile the executive order not to use federal dollars for undocumented immigrants, versus the prior law that mandated that we cannot ask for proof of immigration status?
Previous federal law says that non-profit charitable organizations do not have to verify status, and these policy changes are something that NACHC has been watching closely. “Our attorneys have talked about it and I encourage you to look that up through our Docebo platform,” Joe Dunn says.
The real crux of it, he explains, is understanding “what HRSA is going to do moving forward” to operationalize these changes. Right now, that’s a little unclear. Another complication, Dunn explains, is that “Section 330 right now says that you're required to provide care for all residents within your service area.”
Between the underlying federal law, the new federal law around verification of status for nonprofits, and this stipulation about providing care, Dunn says that it falls on HRSA to provide more information and understanding.
To understand more about NACHC’s position and questions, Dunn recommends reading the organization’s comment letter.
Charting a path to sustainability
What are the actions that community health centers can be doing right now to prioritize?
As Cesar Herrera emphasizes, there’s no one strategy that health centers should prioritize right now. Navigating this moment requires taking on a combination of strategies in addition to staying informed and consistently advocating for the health center community.
Joe Dunn agrees, and outlines the areas where health centers can focus their efforts, including:
- Looking back at how your health center approached the Medicaid unwinding process for guidance on how to move forward
- Building and strengthening relationships with health plans, state Medicaid agencies, and other community organizations who serve similar patient populations
- Keeping track of the developments happening with the Rural Health Transformation Program
- Getting involved with your Primary Care Association at the state level
- Understanding the opportunities with the PACE program and the 340B program
- Maintaining connections with your members of Congress
For Dunn, it comes down to three things:
- Staying aware and involved
- Understanding what’s happening at your health center
- Continuing to build relationships.
He also recommends joining NACHC’s monthly Policy Pulse calls to stay informed.
Health centers can also explore opportunities with technology partners. As Herrera notes, “Many of the regulations that are coming out of OB3 are relying on administrative barriers creating the cuts in Medicaid enrollment.”
He gave an example of two technology companies working in this area. The first is Fortuna Health, which “offers a seamless consumer-based application for Medicaid enrollment and re-enrollment, and are already diving in to prepare for work requirements in the various states.” In addition, an organization called Mindset helps Medicaid beneficiaries apply for SSI and SSDI benefits.
Of course, technology isn’t a silver bullet for everything. Herrera notes that organizations like NACHC are doing “a lot of great work to vet these partners to make sure that they are of like-minded mission, because the last thing that we want as well is for health centers to be exploited by tech.”
How can health centers embrace value-based contracts for payment for service to Medicaid patients?
“[Around] two to three percent of the Medicaid premium is actually going to primary care costs that are served by FQHCs. That’s not truly representative of the value that health centers are creating in the system to keep patients healthy, keep them engaged in their care, and bring down total cost of care within Medicaid and Medicare.”
- Cesar Herrera, CEO, Yuvo Health
As Cesar Herrera notes, his answer might be skewed given the work that Yuvo does in value-based care, but, “the BBB has really been a catalyst to force different ways of thinking and strategic initiatives around value-based care as a means to extract more value that they're creating in the system and bring it back to health centers.”
Currently, according to NACHC data, around “two to three percent of the Medicaid premium is actually going to primary care costs that are served by FQHCs,” says Herrera. “That’s not truly representative of the value that health centers are creating in the system to keep patients healthy, keep them engaged in their care, and bring down total cost of care within Medicaid and Medicare.”
For Herrera, it’s about helping health centers stay sustainable. “Sometimes I hear it as this do-or-die moment for health centers to do something and get ahead of this, especially knowing that in a fee-for-service world with less Medicaid beneficiaries will come less revenue. There’s a need to preserve that revenue, increase that revenue, and diversify those revenue streams.”
Dunn anticipates that there’s “going to be a lot of attention around value,” including “demonstrating and being reimbursed around value.” It may also be a way to get more investment in primary care. “Only five percent of federal healthcare spending goes towards primary care,” he explains. “In other countries, it's triple that. We need more money going into primary care.”
Demonstrating the value that health centers can provide may help increase that funding, and it’s an area to watch with the new law. “We certainly want to work with partners like you all and the health centers to really guide that discussion and the conversation,” he says.
With funding set to expire on September 30th, 2025, what concrete advocacy steps should health centers be prioritizing now to ensure sustainability beyond that point?
Pushing for increased, longer-term funding is essential, and it’s something health centers will need to continue to advocate for. Dunn recommends making sure you’re signed up as an advocate through NACHC’s Washington Update newsletter. Any time there’s an action alert, you’ll get an email along with an easy way to contact your representatives.
NACHC is also planning two fly-ins. “That’s where you can come into DC and you can push your message on the Hill directly,” he explains. There’s one scheduled from September 16th and 17th. And, because of the likelihood of there being another extension, there’s another one on December 9th and 10th.
If you can’t make it to DC, Dunn recommends inviting a member of Congress to your health center. “Have that connection with those members of Congress and their staff,” he says, and “really emphasize, ‘This is mission-critical stuff. If we want to reduce chronic disease in America, there's no better way to do it than investing in health centers.’”
How can health centers engage their state governments? What can they expect from state responses?
For health centers, it’s key to present a unified message and strategy. Dunn recommends connecting with your primary care association to present a group response or strategy for your state agency officials, including your public health department or state Medicaid agency.
Cesar Herrera agrees. “I never say that there's any one strategy that one should do,” he says. “There are always going to be a mixture of strategies that we should be thinking about to support this work because it is so varied and interdependent.”
But, Herrera explains, “the state is always going to be the one that will then dictate how Medicaid is provisioned within that particular state. They're the ones that are going to be setting the requirements for the health plans. And based on HR1, they're also the ones that could stand to be the most impacted from a funding standpoint associated with it.”
He finds, in the states where Yuvo works with FQHCs, that the state health department and state Medicaid agencies are “really open and engaging partners in this work. So I definitely encourage anyone to continue to leverage the state in that way.”
Conclusion
The impact of the BBB is devastating. But things are still subject to change. For health centers, that means continuing to advocate, build relationships, and understand the opportunities that are out there.
As Cesar Herrera puts it, “We’re only just barely scratching the surface on what these implications are and what we can do about it.” As we learn more, his message to health centers is to “continue talking to each other, and know that there are resources and partners available to support you as you think through strategies to stay resilient in light of the BBB.”
Yuvo Health can help
Read more about how community health centers can take action in a time of uncertainty and survive Medicaid cuts.
FQHCs that recognize this transitional moment and adapt to it will be better positioned to achieve their goals and continue to support their communities with exceptional and sustainable care.
As both an MSO and an IPA, Yuvo Health has experience leading other community health centers through these changes.
As Dr. Rita Bilello, CEO of at Metro Community Health Centers, put it:
“With Yuvo taking this challenge on and eliminating the barriers, it gives FQHCs a voice in the conversation but also allows us, to some degree, to prove what we’re capable of doing.”
In particular, we can help your team:
- Enter into higher quality VBC contracts with extensive bargaining power
- Gain access to revenue where Yuvo Health assumes the downside risk
- Overcome common hurdles with technology, including data collection, processing, and analytics
- Organize care coordination, patient outreach, planning, and engagement
- Make data-driven decisions that result in increased quality of care and revenue
You can learn more about us here or schedule a meeting today.
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