Spending fights, supply chain delays slow mobile health boom

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Dec 29

Lauren Clason | CQ-Roll Call (TNS)

Nan's Donuts, located in the central Pennsylvania region of Sugar Valley, is only open Wednesdays and Saturdays. That's why Don Lynch parks Evangelical Community Hospital's mobile health clinic in the parking lot of the adjoining Amish grocery on the first Wednesday of each month.

Nan's Amish bakery offers more than 40 types of donuts, including rotating seasonal flavors — like pumpkin streusel — that tempt the sweet tooth of valley residents from well beyond the town borders of Loganton.

Loganton is home to only 463 people. But Nan's has around 1,600 followers on Facebook.

Lynch, a paramedic and the hospital's mobile coordinator, piggybacks on Nan's foot traffic to draw in rural residents for free preventive blood screenings. The hospital itself is located 30 miles east — a tough trip for the elderly and those traveling by horse and buggy.

The use of mobile health clinics exploded during the COVID-19 pandemic, driven by the need to reach patients in outdoor, decentralized locations and also by the trillions of dollars in federal aid that Congress poured into the economy. In rural areas, mobile clinics often replace the dwindling preventive care network that helps keep patients healthy and out of the emergency room.

Next year, a 2022 law will also authorize the further expansion of mobile clinics. But Congress would have to fund it first.

Pennsylvania is home to the country's largest Amish population, with nearly 90,000 living in 61 settlements across the state, according to Elizabethtown College's Young Center for Anabaptist and Pietist Studies.

Evangelical's established community presence is important to reach the area's sizable Amish community, which generally avoids using modern technology and can be skeptical of modern medicine. Amish people also often lack health insurance, which can make health care too pricey to afford.

The hospital set up its mobile clinic before the pandemic. This month, Lynch saw 24 clients in Loganton — nearly three times the usual turnout in spite of snow. He estimated about seven were Amish.

The hospital's community-based approach is apparent in the number of Amish patients it serves, Lynch said.

"But there's always some hesitancy there," he added.

Mobile clinic boom

Evangelical purchased its mobile clinic in 2018 using a mix of philanthropic grants and money from local businesses and the Amish and Mennonite community. When the pandemic hit, the rush on mobile units led to waiting periods of up to two years, administrators and industry representatives told CQ Roll Call.

The scramble was concentrated among the country's 1,377 federally qualified health centers, which received $6.1 billion in funds from the March 2021 COVID-19 aid law. The centers had to spend the money by March 31, 2023, though many received an extension. Dropping half a million dollars on a new mobile clinic was a good way to use the money, said Steve Messinger, policy director at the Nevada Primary Care Association.

That, combined with newer, looser restrictions on funding for mobile clinics set to take effect in January, is pushing mobile health into a new era. Messinger worked with Nevada Democrats Jacky Rosen in the Senate and Susie Lee in the House to write the 2022 law.

"The innovations are about to explode," he said.

In January, health centers will be able to request federal funding for new mobile units without establishing additional brick-and-mortar clinics — a change from previous law. But the Health Resources and Services Administration's "new access point" grants haven't been awarded since 2019. And while the agency previously forecast that new funding was expected this month, Congress is still fighting over fiscal 2024 appropriations.

HRSA asked for more than $5 billion in President Joe Biden's fiscal 2024 budget request for the health center program, including $150 million for new access point grants, noting that it was only able to fund 75 out of 550 applications in 2019.

Despite that, COVID-19 money helped fuel a boom. The Mobile Healthcare Association saw a 30 percent increase in 2023, according to Executive Director Elizabeth Wallace, following a 21 percent increase in 2022.

Mobile health's advantages became increasingly clear during the pandemic. Wallace pointed to a study done in Loma Linda, Calif., demonstrating the success of mobile clinics versus mass vaccination events in delivering COVID-19 vaccines to Black communities.

"Mobile health has a proven track record of reaching the vulnerable," she said. "Reaching the hard-to-reach who don't want to access or can't access traditional health care."

Jana Eubank, executive director of the Texas Association of Community Health Centers, said interest in mobile clinics surged during the pandemic, but the wait time for a unit stretched up to a year.

In Texas, growth is concentrated in rural areas where hospitals are increasingly closing. Maternal mortality is a big concern, with some women driving hours just to reach an emergency room — not even a hospital with a maternity ward.

Health centers, rural clinics and emergency rooms are "pretty much the safety net," she said. Health centers often partner with hospitals to reduce unnecessary ER visits and fill care gaps too, Eubank said, and mobile clinics help extend their reach.

"We're all in this together," she said. "And we have to figure out how to maintain that infrastructure in these really needy communities."

Parts backlogs

Mobile clinics typically range in size from vans to recreational vehicles, and are usually made by adapting American-made automobile or RV shells. The recent delays are partly caused by back orders of the shells, though Wisconsin-based CGS Premier avoided the worst of the disruption by maintaining its own in-house stock

The company makes "drop trailers" that lower to the ground for easier patient access, and has seen growing interest in elevating curb appeal and other cosmetic touches to improve the patient experience.

President and CEO Greg Peterson said orders have tripled since March 2020, with a focus on reaching underserved areas, including tribal lands. Clients like Eli Lilly and Co. are also using them to run decentralized clinical trials in order to reach a more diverse patient pool, and Molina Healthcare used them to respond to the 2023 tornadoes in Mississippi.

"The governor called and said, 'hey we need your clinics,'" Peterson said. "'We need a base. People need to get their prescriptions filled.'"

Downsides

Mobile clinics are not a cure to the country's myriad health care woes. They still need to be staffed, maintained and driven from place to place, which requires money and people. Both are often lacking in rural areas.

Placing a clinician in a mobile unit usually means one less clinician at the main hospital or health center. And in many rural areas, there's often only one practitioner of each specialty available, if any at all.

The presence of a mobile clinic doesn't automatically win over the skeptical, either. Lynch sometimes ventures outside the RV to try and recruit smokers lingering around the clinic's locations in Pennsylvania, but usually receives the brush-off.

"The ones that just sort of say, 'you got to die of something' and don't care — they're not even going to come and look at it," he said.

But progress is often measured in modest increments. Lynch said he's seeing more and more repeat customers, with turnout continuing to improve.

Dawn Jeffries, the community liaison for the Sugar Valley Rural Charter School, helped coordinate Evangelical's monthly visits to Nan's. The school district's recent decision to shutter a local school was a blow to the town, so the need to strengthen the community's foundations was especially acute.

"Our community was fractured at that time," she said. "It's getting better, but it still hasn't quite felt the same."

Jeffries also brainstormed a winter festival last year that brought together local businesses and community groups to give away free food, cocoa and sleigh rides for valley residents.

Word of mouth drove a larger turnout this year, and it's doing the same for the mobile health clinic.

"The fact that they're talking," she said, "and it's out there, the knowledge is out there, is a good thing."

(This reporting is supported by a fellowship through the Association of Health Care Journalists and funding by the Commonwealth Fund.)