They Held a Closed-Door Session at CHI Called "Protecting the CEO"
By Jill Steeley, former FQHC CEO and host of the Community Health Collective podcast
I didn't make it to NACHC's Community Health Institute this year. So I did the next best thing - I asked Steve Weinman to come on the podcast and tell me what the room actually felt like.
Steve has been inside community health centers for 42 years. He's a principal at FQHC Associates, my co-lead on the CEO Connect Bootcamp, and the person I call when I want the technical, jurisdiction-aware answer instead of the comfortable one.
He brought back a lot. But one detail reframed everything else.
In this article:
The closed-door CEO session at CHI, and what it tells you about how leaders actually feel right now
The 375,000-touchpoint problem hiding inside a 25,000-patient Medicaid panel
The panel math formula, so you can calculate your own exposure instead of borrowing a national average
Why procedural coverage loss costs you more than actual ineligibility
Five problems this creates in your health center, and five things you can do about them starting this week
Why 42 years of experience says this is a business model problem, not a funding problem
What happened at NACHC CHI this year?
Three conversations dominated, according to Steve.
The first was HR 1. He said he didn't run into a single leadership-level person at a health center who didn't bring it up at some point. Not as a policy abstraction - as a specific, personal question about their own Medicaid panel.
The second was mergers and acquisitions. There was a governance workshop on it, and the hallway conversations were everywhere. I want to be careful here, because M&A isn't inherently a distress signal. But I've been the CEO who got approached, and I've had clients on both sides of these deals. In my experience, that conversation usually starts when a health center is struggling enough that leadership is looking at the possibility of closing the doors. When it's the talk of a national conference, that tells you something about the room.
The third was the one I can't stop thinking about.
NACHC held a closed-door session called "Protecting the CEO." You had to prove you were a health center CEO before they would let you into it.
They don't build a room like that unless they've read the room. And what they read is that a lot of CEOs are worried - not just about their health centers, but about their own jobs. Because when something goes wrong, the instinct is to blame the person in the chair, even when what went wrong was federal legislation nobody in that building voted on.
Here's the thing though. A CEO's job is to keep the doors open and keep the organization able to serve its community. If your business model only works when Medicaid, the PPS rate, and federal grants all behave, then you don't have a business model. You have a hope. And your board is going to hold you accountable for the difference.
What is actually changing with Medicaid on January 1st?
A closed loop is any part of your organization where thThe headline change is that redeterminations move from once a year to every six months for expansion adults, ages 19 to 64, for renewals scheduled on or after January 1, 2027. Work and community-engagement requirements come online at the same time, verified at both application and renewal.
Every renewal obligation effectively doubles. And that's before you add monthly work-requirement verification on top.
Steve put a number on what that creates. On a 25,000-member Medicaid panel, you get roughly 15 different renewal and work-requirement decision points running at once for every member, all year long.
That's 375,000 touchpoints a year.
You cannot hand-manage 375,000 touchpoints with an enrollment team. And every touchpoint that gets missed is a lapsed record, which is money walking out the door.
Here's the part people miss: the danger isn't that your patients become ineligible. Most of them won't. The danger is that they don't make it through the paperwork. Steve's framing was that they've thrown so many barriers in front of the patient that a lot of people simply won't make it to the finish line. And these are patients whose lives already aren't a cakewalk - they have to take time off work, find childcare, arrange transportation, and produce documentation, twice a year, forever.
One more wrinkle. States were largely left to implement this their own way, which means 50 states doing it 50 ways, and many of them still haven't published how it's going to work. It's already September.
How do I calculate my health center's Medicaid exposure?
Don't use the national statistics. Steve had the best line on this that I've heard: if you put one hand in the oven and one hand in the ice box, the average temperature is a comfortable 70 degrees, but one hand is frozen and the other one is on fire.
National averages blend 50 states, urban and rural, tiny centers and enormous ones. Your number is the only one that matters.
Here's the formula:
Panel size × procedural loss rate × per member per year reimbursement = revenue at risk
Using the numbers from CHI:
1. Start with your Medicaid panel size. CHI used 25,000 members as the example. Yours may be a fraction of that or several times larger.
2. Apply a 30% procedural loss rate. That's the share of a panel that typically drops at renewal for procedural reasons alone. On 25,000 members, that's 7,500 people who are still eligible but got lost in the paperwork.
3. Multiply by $650 per member per year. That's the reimbursement assumption CHI used.
25,000 × 30% × $650 = $4.9 million a year in revenue at risk.
Run yours. Then run it again with your actual per-member reimbursement, because your PPS rate and your payer mix are yours.
Why does a three-day coverage lapse matter so much?
This is the piece I didn't fully understand until I recorded episode #36 with Howard Archer, whose company does retroactive Medicaid recovery.
When coverage lapses - even for three days - and then comes back, the patient doesn't necessarily come back the same way. Most states run most of their Medicaid through managed care. When someone re-enrolls, they may land in a different plan than they were in before. Different plan means different benefits, which can mean different reimbursement to your health center for the same patient getting the same care.
Steve told me about a mother with three children at his health center who didn't elect a plan, and all three kids got auto-assigned to three different Medicaid plans. That was the old system, with one redetermination a year. Now multiply that friction by two cycles a year and a whole lot more churn.
And you probably won't find out until the claim denies. The patient usually doesn't know their coverage lapsed either.
The five problems this creates
1. Volume that breaks the process. 375,000 touchpoints on a 25,000-member panel is not a staffing problem you can solve by hiring one more enrollment specialist.
2. Revenue loss that has nothing to do with eligibility. Roughly $4.9 million a year on that panel size, from paperwork alone.
3. Reimbursement changes you didn't authorize. Coverage lapses, patient re-enrolls in a different plan, your payment changes.
4. Denials you find out about too late. No one tells you the coverage lapsed. The claim tells you, weeks later.
5. Fifty states, fifty implementations, and no published playbook with four months on the clock.
The five things to do about it
1. Run your panel math and take it to your board. Steve's first instruction: get with your CFO and calculate your exposure. He said most of the leaders he asked at CHI had no idea what their number was. Then brief your board early, so that when you propose changes they've already absorbed the reason. Surprised boards say no.
2. Turn your enrollment team into a retention team. The job used to be getting people enrolled. The job now is keeping people covered. Same people, same building, different mission - and that's where your return on investment lives. Train your staff to check eligibility ahead of the appointment so you can have the conversation with the patient while they're standing in front of you.
3. Use technology to manage it at scale. Deadlines, reminders, and documentation across a whole panel is not a manual process anymore. Steve and I have both talked with Vital Interaction about exactly this, and they've presented to our Bootcamp cohort on managing redetermination outreach without burning out your staff. Schedule a call with Vital Interaction and get a 33% discount on their software.
4. Go find the fast money. Three places, in order of speed. Retroactive Medicaid recovery - one of our Bootcamp participants found $15,000 immediately, and I have health centers I referred who are still pulling in $15,000 a month. It's contingency-based, so if you don't get paid, they don't get paid. Second, 340B. Most health centers leave real money on the table, and there are whole lines of business that generate significantly more 340B revenue than what you're capturing now. And yes, people have been predicting 340B's demise for 15 years and it's still here - keep advocating for it, and take full advantage of it while it exists. Third, your commercial payer contracts. A lot of health centers haven't renegotiated in years, and some leaders don't realize renegotiating is even an option. You are not the smaller party in that conversation. The health plan is selling a product; you're the one delivering the service.
5. Change the business model, not just the workflow. Attract commercially insured patients. Build a Medicare strategy. Reduce costs. Increase provider productivity. These are the levers you actually control.
Is this a funding problem or a business model problem?
I asked Steve directly, because 42 years earns you the right to a verdict.
He said it's definitely not a funding problem. It's a business model problem.
The health center program started out almost entirely grant-supported - his own center was about 90% grant-dependent when he started in the 1980s. As the program grew, it grew more dependent on outside funding, not less. That's how it was designed. He compared it to the Voyager spacecraft: built to stop working decades ago, and we keep finding clever ways to keep it beeping.
You cannot depend on a single payer. Especially when political considerations can turn that payer into a problem overnight.
And I want to be honest about why this lands so hard for me. When I took over my health center, we had a 42% uninsured rate. 62.5% of our budget was federal funding and grants. We were almost a million dollars in the red, and my board gave me 12 months to figure it out or we were closing the doors.
I couldn't cut services. I couldn't cut sites. There was nothing left to cut - they'd already done it.
So I did the only thing left. I found four levers I could actually pull:
1. Increase and diversify revenue - beyond grants, beyond federal funding, beyond Medicaid.
2. Decrease costs and increase productivity.
3. Build a real market presence - and I don't mean your front desk person running the social media accounts. I mean getting out into your community.
4. Retain the patients you already have through exceptional patient care.
Pull hard on one, and the other three start coming along with it. We took federal dependency from 62.5% to 17%.
I tell that whole story in Episode #43, the one right before this one.
What to do next
If you have four months and a number you haven't calculated yet, start there. Get with your CFO this week.
Then join us. Steve and I are hosting a free live webinar on Friday, September 11th at 10:00 AM Pacific, 1:00 PM Eastern: "I've Already Run a Health Center at 42% Uninsured: Here's Why the Medicaid Cliff Doesn't Scare Me." Sixty minutes on those four levers and how they took federal dependency from 62.5% to 17%.
If you want the full build - the frameworks, the 340B revenue strategies, the payer contract negotiation templates, the implementation toolkits - that's the FQHC CEO Connect Bootcamp. Our fifth cohort starts on October 9th: www.fqhc-ceo.com
If retroactive Medicaid recovery is the fastest thing you can do this month, you can schedule a call with the CEO of RetroCAID from my partners page: www.jillsteeley.com/partners
And if you're not sure what applies to you, just schedule a call with me. Let's talk it through.
This work is hard. But you're capable of more than you think, and you're not doing this alone.
About the Author
Jill Steeley is the host of the Community Health Collective Podcast and an executive coach to leaders across community health centers, FQHCs, and mission-driven healthcare organizations. After two decades inside the healthcare leadership world and close to 250 healthcare leaders coached and mentored, she helps healthcare executives build the leadership skills they were never formally taught - and helps full leadership teams shift culture together rather than one leader at a time.
Learn more at jillsteeley.com.
