Can a Clinic Comply with Trump’s Executive Orders Without Leaving Patients Behind?‌

Tell me about Fair Haven Community Health Care and who it serves.‌

Fair Haven Community Health Clinic, as it was called then, was founded in 1971 by a group of women activists. This has long been an immigrant community—go back 70 or 80 years, and it was largely Irish and Italian. By the early ’70s it was becoming more Hispanic. A group of women got a $5,000 grant from the New Haven Foundation, which was the precursor to what is now the Community Foundation for Greater New Haven. We saw our first patient in August of 1971, in the gymnasium of a local school. We would see people in the evening hours. ‌

We became recognized as a Federally Qualified Health Center in 1980. Last year, we served over 36,000 unique individuals in over 160,000 visits. We provide a full spectrum of care—from cradle to grave, I like to say. We have a very active nurse midwifery program, which was one of the first services we provided. We continue to provide nurse midwifery all the way through to a very robust geriatric program, and everything in the middle. ‌

We also now have a dental program with two full-time dentists. We do a lot around substance abuse disorders. We serve an area that includes a large pediatric population, so over 60% of our 36,000 patients are 18 or under. We provide the full spectrum of care, and we provide care to anyone who seeks our care, regardless of their ability to pay.‌

What does it mean to be a Federally Qualified Health Center? What is the role of federal funding in your budget?‌

There are just shy of 1,400 Federally Qualified Health Centers nationwide. Collectively, we are truly the safety net of this country—last year, collectively, we served over 32 million unique individuals. ‌

And federal funding is critical. For Fair Haven, that federal funding, what we call our base grant, is approximately $5 million a year. My annual budget is about $54 million a year, so there’s still a lot of other revenue that has to get generated to keep this place running. But that $5 million a year is essential.‌

As a Federally Qualified Health Center, there are certain grants that I’m eligible for that not every other entity is eligible for. Right now we have a few of those—one around behavioral health service expansion, one around expanding our hours. In total, my federal funding today, with that $5 million base grant and then additional dollars from what they call supplemental grants, is about $6.5 to $6.6 million.‌

What are the executive orders and other actions taken by the federal administration that are affecting Fair Haven Health the most?‌

Right now there are three buckets of executive orders that have a direct impact on entities like ours: those that impact DEI, those that impact gender-affirming care, and those that impact immigrants. And let me just take them one by one.‌

The first one, DEI, those came out the day of President Trump’s inauguration. There are grants out there that specifically have equity or DEI in their titles—that is their goal—but we didn’t have any of those. It was advised to us that we make sure that our public-facing documents, like our website, our social media sites, our patient brochures, did not use certain words. So we did that. It has not changed in any way whatsoever what we do. Our priorities remain the same. It doesn’t impact my hiring practices. We had nobody with DEI in their titles, so we didn’t have to address that. So I don’t think we were ever in violation of any of the executive orders related to DEI.‌

Of the two gender-affirming-care orders, there’s one that specifically addresses the delivery of gender-affirming care to children, and they define that as anyone under the age of 19. It’s not through any act of volition, but we don’t currently care for anybody under the age of 19 who carries a diagnosis of gender dysphoria. So that one really does not apply to us.‌

The other one talks more about “gender ideology.” We looked to see, how many people over the age of 19 do we have who carry the diagnosis of gender dysphoria? The answer is roughly 120. Of that 120, roughly 70 receive hormonal treatment through our clinicians. That population is definitely a source of concern to me.‌

But as soon as that executive order on gender-affirming care was published, a large national organization called PFLAG, together with several other groups such as the ACLU, filed a suit against the Trump administration claiming that these executive orders violated the Constitution. A temporary restraining order was placed against these executive orders, and on March 4, it was replaced with a preliminary injunction, which will be in place until the lawsuit is litigated. ‌

The third bucket of executive orders has to do with immigration. Basically, it says no federal funds should in any way, directly or indirectly, support people who are in the country illegally. But it also acknowledges that currently there is no system in place to verify a person’s immigration status. For instance, at our health center, we do not ask a person’s immigration status. We have no record of it. My guess is that of those 36,000 individuals we saw in the past year, somewhere between 5,000 and 6,000 are undocumented. But it’s a guess and I certainly can’t provide a list of names. ‌

Thus far, the executive order on immigration does not have any threat of withholding federal funding, but it is signaling that this is very likely coming down the pike, because it required the agencies to establish a system for verification of citizenship status. ‌

What are the principles that you’re keeping in mind as you respond to these executive orders?‌

I keep telling my staff two things. We’re not going to break any laws. We can’t put our federal funding at risk. But on the other hand, we are not going to abandon any patients, and we are firmly committed to that.‌

So how do you do those two things? We are preparing to be able to flip the switch on creating what is called an OLB, which stands for Other Line of Business. It’s basically Fair Haven saying, we’re going to take a small portion of what we do out from under the umbrella of the feds. We’re going to set up our own private practice. ‌

We meet weekly, and we’ve done a lot of homework. We’ve already defined a separate location, because we can’t provide those services in any building that touches the federal government. We have to have a completely separate book of business. We have to pay providers separately. Right now, the government pays for my providers to have malpractice insurance; I have to go out and get malpractice insurance. I have to set up a billing system. It’s no different from setting up any private practice.‌

Our best guess is that for one year of operations, it would cost us about $1.5 million to run this Other Line of Business. If this comes to pass, between a limited amount of reserves and hopefully some generous philanthropy, we could probably do this at least for a few years as we see how this all plays out.‌

But we are working very aggressively. My mantra is, we’re not going to break any laws and we’re not going to abandon any patients. That’s critical. And the only way we can do that is being ready to provide services under an umbrella without any dependency on federal funding. Now, we can all hope and pray that this never becomes necessary. But I think our experience is telling us is that the odds are pretty good we’ll need to flip the switch at some point.‌

There’s also the possibility of major cuts to Medicaid. ‌

Right. In the House bill that was passed, House Energy & Commerce budget is cut by $880 billion over a 10-year period. Surprisingly, Energy & Commerce oversees Medicaid. Despite the fact that President Trump and Speaker of the House Johnson and a lot of other influential Republicans have said that they don’t want to touch Medicaid, everybody who has looked at the budget of Energy & Commerce said there is absolutely no way they can cut $880 billion in 10 years without significantly cutting the Medicaid budget. And there are all kinds of scenarios as to what that looks like. Cuts could be huge, and that potentially becomes an existential threat. ‌

The Tobin Center for Economic Policy at Yale has been doing some scenario planning with DSS here in the state of Connecticut. There are just shy of one million Connecticut residents who currently get Medicaid. And for us it’s about 22,000 of our 36,000 patients.‌

What’s likely going to happen is the federal budget will pass in July or August and at that point in time, if the impact to Medicaid is huge, the Connecticut General Assembly will call an emergency session, and then Connecticut legislators will have to make a decision. Does the state just take those hits and not do anything about it? That would mean that they would have to eliminate Medicaid eligibility for literally hundreds of thousands of patients. The odds are the state will never be able to fully fill the gap created by federal cuts, because the gap will probably be too large. But will the state do something to fill some of the gap? ‌

The bottom line is we are expecting major impacts to Medicaid. We’re expecting major impacts to us and to our patients. ‌

What are the potential effects of all of this on vulnerable populations when you multiply it out across the whole country?‌

Huge. ‌

We have 22,000 patients with Medicaid. Let’s say 5,000 of them lose coverage because of Medicaid cuts. We will continue to see these patients. Again, we will not abandon any patients, including in the scenario where Medicaid reimbursement is massively cut. There could easily come a point where federal cuts threaten our existence. There is a fiscal reality: when does this whole house of cards start crumbling down? But I am fully committed that we’re not going to break any laws and we’re not going to abandon any patients.‌

I have some reasons for optimism. I’ll give you an example. Last night I was asked to come and speak to a group of neighbors in Hamden who are just feeling frustrated. They see a lot of things going on that frighten them. They see the threats. They need to feel like they could make a difference. I don’t know how they could make a difference quite yet, but I’m encouraged by the fact that there’s a real visceral desire to help and not to let this happen. So I have to believe that no matter what comes out of DC, that somehow or other, between some state support and other people’s support, we can continue to care for our patients.‌

But there’s a huge impact. Right now, if somebody comes to me who has Medicaid, my clinicians can order a CT scan, they can order some blood work and not worry about it because it’s going to get done. If they come to me and now have no insurance, we will still see them. But will I be able to get that CT scan? Does that mean a lot more people going to emergency rooms, with the hospitals are already struggling? What’s the impact of all of this on the whole system?‌

I think the next few years are going to be rough, but I have to believe that they’re survivable.‌

What are the demands on you as a leader at this time? What kinds of skills and abilities and strengths you are needing to draw on right now?‌

Here’s what I perceive as the challenge and what I’m trying to address—whether I’m succeeding is another question. ‌

I need to ensure that my staff, which today number over 330, are kept informed. I had a discussion with them in February, I had one last week, and I’ll continue to have them, so that they don’t have to worry about the whole spectrum of possibilities. They ask: Is their job at risk? Is the whole system going to collapse? ‌

So it’s communicating in a way that’s transparent and realistic but hopefully somewhat uplifting and supportive. That’s a fine line to walk. The last two months have been somewhat quiet. We are working really hard to set up the OLB, because when the need comes, we anticipate it will come suddenly. We’re not going to have time to plan for it then. We’re going to have to be ready to hit the ground running.‌