With Community Health Centers' funding facing challenges from pharmacy benefit managers, some state lawmakers are getting involved.

The centers are a nonprofit safety net created by Congress in 1965 to provide health care services to medically underserved communities both urban and rural. They are the medical home for 600,000 Missourians.

They are funded by private insurance and Medicaid, federal government grants, and the 340b drug-pricing program. Under 340b, drug manufacturers agree to discount drugs to safety-net providers in exchange for their drugs being covered by Medicare and Medicaid.

Until recently, insurance companies and pharmacy benefit managers reimbursed the retail price, and the health centers were able to pocket the difference with the mandate they use the money to reach more eligible patients and provide more comprehensive services.

Colleen Meiman, a national policy adviser for state associations of Community Health Centers, said in recent years, the benefit managers have changed their approach.

"What has happened in the past five to 10 years or so is that the PBMs have figured out, 'Wait a second, you're a health center. You're eligible for 340b, we know you're paying less for drugs than everybody else, so we're going to reimburse you less for drugs,' " Meiman explained.

Meiman pointed out 22 states have passed laws against 340b workarounds. A bill to make these practices illegal died in committee in the Missouri Legislature last term.

Meiman noted for decades, the financial stability of Community Health Centers has relied in part on 340b savings, and pharmacy benefit managers are exploiting a loophole.

"Just because you just recently figured out that there's this loophole in the law, and you can get your hands on our savings, does not negate the fact that those savings are critical to keeping the primary-care infrastructure safety net in this country running," Meiman contended.

She added over time, the benefit managers' tactics have evolved to avoid providing 340b drug access in the first place.

"You'll see 'Oh you dispense 340b drugs, pharmacy? We're not going to let you into our preferred network,' is a favorite approach," Meiman stressed. "'We're not going to cover 340b drugs anymore', so there's many different ways of instead of just paying them less, just keep the patients from getting the 340b drug in the first place."

Community health centers serve as the medical home for more than 30 million Americans of all ages.

Nurses are concerned about the closure of a Portland-area birth center set to go through today.

The Family Birth Center at Legacy Mount Hood Medical Center is closing because the hospital says "it maintains a low volume of births with an unusually high-cost care model."

Nurses in the facility were in the process of unionizing. Labor and Delivery Registered Nurse Alejandrina Felipe works in the center and said it provided a valuable 24-hour service to an underserved area east of Portland.

"Any emergencies, or if a patient has a headache, they're worried for high blood pressure, they don't feel the baby move," said Felipe, "the first thing their OB provider tells them is go to the nearest emergency department. And they come to Mount Hood because we're here."

Felipe said nurses were offered the chance for a job in another part of the hospital, but she is taking severance. The center delivered more than 750 babies a year.

The Oregon Health Authority hasn't yet approved the closure and said in a statement this week that the hospital could be subject to regulatory action if the center closes its doors.

Felipe said the birth center's closure leaves a gap for a diverse group of patients.

"More than 50% of our patients are Latinos, Russian, Middle Eastern or a lot of the Asian Pacific Islander, API," said Felipe.

Felipe said nurses wanted to unionize because they felt management at Legacy was making decisions without input from them.

"We're working towards becoming a union," said Felipe. "If we were union, we would not be going through this."


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President Joe Biden's proposal to increase taxes on Americans earning more than $400,000 a year from 3.8% to 5% in order to shore up Medicare is being welcomed by an unlikely constituency, the ultrarich.

Morris Pearl, chair of the group Patriotic Millionaires and a former managing director at BlackRock, said there is more than enough money to fund Medicare. He argued the wealthiest Americans, especially those living off of their investments, can and should be paying more.

"Our country can go two different directions," Pearl asserted. "We can ask the financially challenged people who need Medicare to sacrifice more by having less medical care, or we can ask the ultrarich to sacrifice more, by being a little bit less ultrarich."

Biden's proposal would keep Medicare solvent for at least the next 25 years, according to estimates by the Medicare Office of the Chief Actuary. Sen. Mitch McConnell, R-Ky., the Minority Leader, has dismissed the proposal and promised it will not advance in Congress. Critics said raising taxes would hurt the economy, which depends on consumer activity. They argued people would spend less if their earnings drop.

Pearl agreed the economy depends on consumer spending, and stressed working Americans who spend most of what they bring home should be allowed to keep more of their money.

"The very rich people are not going to spend more money; they'll just become a little bit richer," Pearl contended. "Somebody like me, if my tax rates are cut, I'm not going to live any differently. I'll just see the balances in my portfolio be a little bit higher than they would otherwise."

More than 65 million people in Colorado and across the U.S. depend on Medicare coverage, but the fund's trustees warn cuts to benefits will be necessary by 2028 without increased revenues. Pearl noted the nation's economy was strong under the Republican Eisenhower administration, when the wealthiest Americans paid tax rates up to 90% on their second, third and fourth millions.

"And there's no reason why people who make a lot of money now should be paying -- not the same tax rate as people who work for a living -- but actually lower tax rates than people that work," Pearl emphasized. "We need to change the system."


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Billboards have gone up across California warning about the negative effects of unchecked mergers in the health-care system. The Protect California Patients campaign is a coalition of more than 30 organizations that support Assembly Bill 1091, which would give the attorney general more oversight on mergers worth more than $15-million.

Rachel Linn Gish is director of communications for Health Access California, which is helping lead the campaign.

"For 30 years, the Attorney General has successfully overseen many health-care mergers. That makes sure that patients are protected, that vital services are continued, and that prices don't spike. And we want to extend that oversight to other entities in the market, like for-profit hospitals" she said.

The billboards are visible on roadways in Northern California, the Central Valley and in Los Angeles. Find out more about the campaign on the website at ProtectCAPatients.

In a statement, the California Hospital Association said the bill is unnecessary because the state already has an Office of Healthcare Affordability. The CHA also asserted AB 1091 would prohibit many arrangements between health-care providers and payers, making it more expensive and unpredictable to partner.

Gish said after a merger, however, companies often eliminate services they see as duplicative - which can force patients to travel farther to find a quality hospital.

"Health care is a business," she said. "So, the bottom line is often to make money, and in order to do so, a lot of times that means increasing costs for patients or cutting vital access to services for patients, if they're deemed not profitable. This could be things like labor and delivery rooms, emergency-room departments, and things like that."

The new oversight would also cover future mergers of religiously affiliated health systems, which currently provide one in six hospital beds in California but often restrict reproductive services, including contraception, abortion, miscarriage management, tubal ligation and gender-affirming care.