Analyses of repeal of the Affordable Care Act (ACA) have tended to focus on coverage. This study, which gauges the potential effects of repealing certain ACA provisions, looks at the question of primary health care access itself, with a focus on medically underserved communities. A survey developed and fielded in early 2017 asked community health centers to estimate the impact of ending the Health Centers Fund established under the ACA as well as ending expanded Medicaid coverage and subsidies designed to make private insurance affordable for lower income patients. Forty-one percent of health centers responded; 69 percent were located in Medicaid expansion states and 31 percent in non-expansion states. Responses were weighted to ensure representativeness.

• Nearly half of all respondents estimated catastrophic funding losses, in excess of 40 percent of total revenue, flowing from the combined loss of Medicaid, subsidized health insurance, and federal grant funding.
• Nearly 60 percent indicated they would need to close one or more service sites in response to revenue losses under a repeal scenario.
• Respondents estimated staffing reductions averaging 34 staff members, including medical, behavioral health, dental, and administrative staff, as well as staff who work with patients to break down barriers to coverage and care.
• Over 90 percent responded that they would eliminate or reduce services. The most common services targeted for elimination were nutrition and health education, care management for persons with chronic health conditions, and patient enabling services.
• Respondents estimated that revenue losses under a repeal scenario would result in fewer patients served. Among respondents, three-quarters estimated that their health center would serve at least 1,000 fewer patients, while nearly one in four estimated that their health centers would serve at least 5,000 fewer patients.

A decline in primary care access on this scale – flowing from a combined revenue loss – would be unprecedented. Paradoxically, this type of reduction would coincide with a surge in need for affordable care in lower-cost settings as the number of uninsured patients surges, thereby placing a growing burden on state and local governments and hospitals, particularly for emergency care.