Shenandoah County clinic braces for surge as insurance losses mount

A year ago, Leigh Sicina warned that federal changes to health care funding could overwhelm the Shenandoah Community Health Clinic and leave thousands of the region's most vulnerable residents without care.

That scenario is now unfolding.

"Even in December, we started seeing an increase — a shift from insured to uninsured," said Sicina, executive director of the clinic at 124 Valley Vista Drive. "We've got more people coming in looking for financial assistance. They can't afford their medications anymore, or they don't have insurance anymore."

Across Virginia, free and charitable clinics are confronting a wave of newly uninsured patients driven by the expiration of enhanced Affordable Care Act premium subsidies at the end of 2025 and looming changes to Medicaid that could strip coverage from hundreds of thousands more.

The clinics, already stretched thin by years of rising costs and declining volunteerism, are turning to state lawmakers for emergency funding even as the General Assembly grapples with a $3.2 billion Medicaid shortfall of its own.

Virginia's Bureau of Insurance approved a 20% average premium increase on ACA marketplace plans for 2026, and the enhanced federal tax credits that had kept those plans affordable for more than 300,000 Virginians expired Dec. 31. Preliminary data from the Virginia Health Benefit Exchange shows enrollment has already dropped by roughly 20,000 households compared to the same period last year.

Sicina said several patients have told the clinic directly that they dropped their marketplace coverage.

"We've had several come in and say, 'I don't have insurance anymore. I couldn't afford it,'" she said. "Their premiums were doubled or tripled depending on their ages and their health conditions."

A June analysis by the Joint Economic Committee estimates that approximately 302,600 Virginians could lose health insurance by 2034 due to the combined effect of the subsidy expiration and Medicaid changes included in H.R. 1, the One Big Beautiful Bill Act, which imposes new work requirements and shifts eligibility redeterminations to every six months beginning in January 2027.

Virginia's 70 free and charitable clinics currently serve 113,000 patients — roughly 72,500 of them uninsured — on $8.8 million in annual state funding, which is leveraged into more than $211 million in care largely through volunteer providers. But the per-patient cost of care has surged 178% over the past decade to roughly $1,000 per year, driven primarily by staffing costs as clinics have hired paid providers to replace volunteers who left during the pandemic and never returned.

Between 2022 and 2024, clinics saw a 43% increase in uninsured, underinsured and Medicaid patients, according to the Virginia Association of Free and Charitable Clinics.

"It's a little bit like putting your finger in the dike," said Rufus Phillips, CEO of the association. "There is an overwhelming situation with so much need."

A clinic stretched thin

In Woodstock, the clinic has nearly doubled its patient load over the past year after hiring a full-time paid provider it didn't have before. But the growth has come at a cost — paid staff are expensive, and the clinic has only one volunteer dentist, who comes in one day a week, and one medical volunteer.

Sicina said recruiting providers to a rural community where the area can't match private-sector salaries or the lures of urban life remains one of her biggest challenges.

The clinic now has capacity on the medical side, but mental health and dental services remain severely constrained. The wait for a dental appointment is at least eight months.

"I could hire 10 providers for each of those business lines and still have limited capacity," Sicina said.

The patients walking through the door are making difficult tradeoffs. Food and utilities are often what give way first, Sicina said. Some arrive carrying hospital bills for thousands of dollars asking for assistance after waiting too long and ending up in the emergency room.

"Sometimes we can't," Sicina said.

The clinic helps patients work through hospital financial assistance paperwork, but the damage is often already done.

Transportation remains a persistent barrier in the rural county. The clinic offers telehealth, but Sicina said it only works for patients who are compliant with their medications and lab work. She described a diabetic patient who hadn't been seen in eight months and had gone six months without medication, the kind of case that can't be managed through a screen.

"These are also the patients that work at (a businesses like) George's," Sicina said, referring to the poultry processing plant. "And if they miss a shift, they get in trouble. So it's a forever cycle."

Budget amendments before the General Assembly would increase annual state funding for free clinics by $10 million to $15 million — sponsored by Sen. Mamie Locke, D-Hampton, and Del. Rodney Willett, D-Henrico, respectively. At roughly $1,000 per patient per year, the higher figure would allow clinics statewide to serve approximately 15,000 more patients according to Phillips— significant, but a fraction of those projected to lose coverage.

The alternative, Phillips said, is that uninsured patients end up in emergency rooms for non-emergency care. The average ER visit costs $2,453, according to the Peterson-KFF Health System Tracker.

"If those 15,000 patients can't find care elsewhere at a primary care level, it's almost $100 million during the course of the year in ER visits," Phillips said. "This is a very effective use of state money."

It remains unclear whether the funding will survive a budget year in which a November Medicaid forecast revealed a $3.2 billion shortfall driven by rising costs among sicker enrollees and losses among managed care organizations.

Sicina said the math is simple. Without additional funding, "we will for sure have to reduce services," she said. "And that's saying that we can keep the doors open."

She said for a county where a large share of residents are already living at or near the poverty line, the consequences of further coverage losses will be severe.

"For some families, this will not be survivable," Sicina said. "They're really going to have to make hard choices if somebody gets sick."

"It's like an avalanche sitting on the edge of a mountain right now," she added, "and we're just hoping the snow doesn't fall."