Community health centers provide comprehensive primary care and preventive services to some of the most vulnerable and underserved Americans, reducing the need for more costly forms of care, such as hospitalizations and emergency department visits, down the line. Their presence in underserved rural and urban communities also serves as a stimulus to local economies. For these reasons, health centers have enjoyed bipartisan support for decades.
The Affordable Care Act (ACA) greatly altered the landscape for community health centers. The law not only increased their federal funding, but it expanded the share of health center patients with insurance coverage and invested in programs to grow the health center workforce. To track how health centers across the United States are changing in light of these shifts in the policy landscape, we compared results from the 2013 Commonwealth Fund Survey of Federally Qualified Health Centers — conducted two years after increased federal funding began and one year prior to the ACA’s insurance expansions — with results from the most recent survey in 2018. (To see the impact of the ACA’s expansion of Medicaid eligibility on community health centers, see our earlier brief, The Role of Medicaid Expansion in Care Delivery at Community Health Centers.)
In 2018, community health centers reported changes compared to 2013 in:
- Access to care: Significantly more reported offering same- or next-day appointments (89% vs. 83% in 2013) and telephone advice outside regular hours (92% vs. 80%). More health centers also made bilingual staff available to patients (67% vs. 62%) or provided access to telephone-based interpreters (91% vs. 70%).
- Technology: Nearly all health centers now use an electronic health record (99% vs. 93% in 2013), and the percentage of health centers leveraging technology to improve care increased. For example, the percentage of health centers allowing patients to request refills for prescriptions online almost doubled (64% vs. 34%).
- Innovation: More health centers are engaged in innovative models of care. In particular, the proportion of health centers recognized as a patient-centered medical home rose substantially (84% vs. 35% in 2013).
However, health centers continue to face several challenges, particularly in staffing. Compared to 2013, greater percentages of health centers in 2018 reported budgeted but unfilled positions for primary care physicians, registered nurses or licensed practical nurses, and licensed mental health providers.
Federally funded community health centers deliver comprehensive primary care to more than 25 million Americans, providing a safety net to people who would otherwise be unable to access or afford care, including those living in poverty, rural residents, children, and veterans.1 To be designated as a community health center and receive federal funding, a provider must:
- be a not-for-profit or public organization
- offer sliding-scale fees to patients
- provide care to patients regardless of ability to pay
- have a board with a majority of community members or patients
- serve medically underserved areas (like rural communities) or populations (like low-income)
- provide comprehensive health services
- engage in quality improvement activities.
With the timely treatment and preventive services they provide, community health centers help their patients avoid developing more serious and costlier health problems later on. Health centers also are important to the health of local economies.2
Over the past decade, health centers have undergone significant changes, in large part because of the Affordable Care Act. First, the ACA’s insurance expansions, including the option for states to expand Medicaid eligibility, contributed to an increase in the share of insured patients, and a decrease in the share of uninsured patients, that health centers see. This shift boosted health centers’ revenue from Medicaid while increasing patient access to care and the affordability of care. The overall number of patients served by health centers also rose following the ACA coverage expansions, from 21.7 million in 2013 to 27.2 million in 2017.3
Second, the ACA’s Community Health Center Fund has doubled federal funding and improved the financial stability of health centers.4 The fund was authorized for five years, from 2011 to 2015, and has been renewed incrementally ever since. This fund is set to expire in September 2019 if Congress fails to renew it.
Third, ACA incentives, such as training opportunities and tuition reimbursement, have encouraged providers to practice in health centers.5
This data brief examines how health centers have responded to these shifts in their patient population, funding, and workforce and identifies areas where health centers might need further support. We compare results from our 2013 survey, fielded one year before the ACA’s insurance expansions took effect, with those from our 2018 survey to assess changes in measures of access, technology, care delivery, and challenges.
Health centers reported they have expanded access to timely care, which has been shown to reduce emergency department visits, increase patient satisfaction, and reduce unmet medical need.6 Between 2013 and 2018, there was a significant increase in health centers reporting that they offer same- or next-day appointments and allow patients to receive clinical advice over the phone on weekends. Slightly more health centers in 2018 (94%) reported offering regular or well visits outside of traditional office hours (either mornings, evenings, or weekends), though the change was not statistically significant.
More health centers in 2018 offered translation and interpretation for patients who needed it compared to 2013. These services have been linked to improved access to primary care and better quality.7 There was a modest, though not statistically significant, increase in the share of health centers that reported their patients who don’t speak English usually or often have access to bilingual staff and a significant increase in access to phone-based interpretation. The percentage of health centers that said more than a quarter of their patients were served in a language other than English increased significantly between 2013 and 2018, indicating a shift in patient populations as well.
Health centers have expanded their use of technologies to improve care. First, significantly more health centers now report they can use their patient medical record system to easily generate lists of patients who are due or overdue for tests or preventive care, allowing them to identify and reach out to these patients. There was also a significant increase between 2013 and 2018 in the rate at which health centers usually or often send patients reminder notices for check-ups and a doubling of the percentage of centers that allow patients to request refills for prescriptions online.
The proportion of health centers using an electronic health record (EHR) also grew, and 99 percent now use one. This growth has likely been driven by incentives included in the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. However, health centers continue to report challenges in using their EHR system, most notably a decrease in staff productivity and the annual cost of maintaining or updating their EHR system (data not shown).
Health centers have increasingly worked to adapt or adopt innovative models of care that link payment to performance, with the goal of improving health care quality and cutting costs. Health centers in 2018 were significantly more likely than in 2013 to report being able to receive financial incentives for achieving high patient satisfaction ratings or for meeting clinical care targets. Health centers also significantly increased their affiliation with accountable care organizations over time.
There has also been a significant increase in health centers that are patient-centered medical homes, with the large majority achieving recognition for providing coordinated, comprehensive, and evidence-based primary care.8 The Bureau of Primary Health Care, the federal agency that oversees health centers, made medical home transformation a priority starting in 2011, providing grants to support and monitor health centers’ medical home recognition.
Health centers, like all primary care practices, continue to face staffing challenges.9 Between 2013 and 2018, the number of budgeted but unfilled positions at health centers grew by at least 10 percent for every type of provider except nurse practitioners and physician assistants. Growing staff shortages may reflect the struggle health centers face to meet the growing demand for services, particularly as patient populations nearly doubled in the past 10 years.
In our 2013 survey, we asked health centers what challenges they anticipated over the next year, particularly in anticipation of Medicaid expansion, which was expected to take effect in 2014. At that time, respondents indicated that the most significant problems they anticipated were physician shortages, decreased Medicaid reimbursement rates, and shortages of nurse practitioners and physician assistants (data not shown). While the survey did not ask an identical question in 2018, it did ask about expected challenges over the next two years. Health centers’ top concerns were increased competition with retail clinics and providing more uncompensated care. Like in 2013, health centers in 2018 anticipated issues related to staffing — including shortages in primary care physicians and greater staff turnover — as well as finances, with nearly a third anticipating decreased Medicaid funding. But unlike in 2013, these concerns did not top the list.
Conclusion and Policy Implications
Community health centers made many improvements to patient care between 2013 and 2018. Compared to five years prior, more health centers reported they are taking steps to improve access to appointments; leveraging technology to ensure patients receive timely, needed medical care; and entering arrangements with insurers where they have the opportunity to be paid based on quality of care. Although these findings don’t tell us how health centers have managed to make these improvements, the ACA’s changes to the health care system, like insurance expansion and increased federal funding, could have played a role.
However, health centers continue to face challenges. Despite substantial federal investment in the health center workforce, centers reported many unfilled positions and anticipated that staffing shortages and turnover will only increase over the next couple of years. The shortage of primary care and mental health providers is a nationwide issue, but it may be felt more acutely by health centers that need to compete with private practices and retail clinics.
Many health centers also anticipate an increase in uncompensated care and a decrease in Medicaid funding over the next two years, perhaps because of new policies that roll back Medicaid coverage, such as work requirements. These predicted shifts are particularly concerning, since health centers face other financial uncertainties. Federal funding, which represents 18 percent of total health center revenue, could be eliminated if Congress fails to renew it by September 2019.10 This financial uncertainty could exacerbate current problems, like recruitment and retention, if health care professionals are leery of joining a center that might lose one-fifth of its funding and cut costs through layoffs. Similarly, ongoing financial instability could halt or even reverse health center improvements and stifle innovation. While bills in Congress to extend health center funding have been introduced, none have passed.11
On the whole, health centers have taken steps to improve health care access and quality over the past five years. Our survey findings suggest that stabilizing health center funding and maintaining workforce investments would add to the positive steps these providers have already taken to improve health care for millions of Americans.
How We Conducted This Study
The Commonwealth Fund 2013 and 2018 National Surveys of Federally Qualified Health Centers were conducted by SSRS. The 2013 survey was conducted from June 19, 2013, through October 24, 2013, and the 2018 survey from May 16, 2018, through September 30, 2018, among nationally representative samples of executive directors or clinical directors at federally qualified health centers (FQHCs). The 2013 survey was sent to 1,128 FQHCs and 679 responded, yielding a response rate of 60 percent. The 2018 survey was sent to 1,367 FQHCs and 694 responded, yielding a response rate of 51 percent. Both survey samples were drawn from the Uniformed Data System (UDS) list of all FQHCs that have at least one site that is a community-based primary care clinic. In 2013 the list was provided by the federal Bureau of Primary Health Care and in 2018 by the National Association of Community Health Centers (NACHC). Surveys in both years consisted of a 12-page questionnaire that took approximately 20 to 25 minutes to complete.
Data in each year were weighted by number of patients, number of sites, geographic region, and urban/rural location to reflect the universe of primary care community centers as accurately as possible. We used chi-square tests to assess differences between 2013 and 2018.
The authors thank Michelle Proser of the National Association of Community Health Centers (NACHC) for providing input on our survey instrument; Robyn Rapoport, Erin Czyzewicz, and James Noack of SSRS for assistance with designing and administering the survey; and Munira Gunja, Arnav Shah, and Mekdes Tsega of the Commonwealth Fund for assistance with verifying data.
2. Christopher S. Evans et al., “The Effect of Community Health Center (CHC) Density on Preventable Hospital Admissions in Medicaid and Uninsured Patients,” Journal of Health Care for the Poor and Underserved 26, no. 3 (Aug. 2015): 839–51; George Rust et al., “Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties,” Journal of Rural Health 25, no. 1 (Winter 2009): 8–16; and Sara Rosenbaum and Peter Shin, Community Health Centers and the Economy: Assessing Centers’ Role in Immediate Job Creation Efforts (Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University Milken Institute School of Public Health, Sept. 2011).
3. Jessica Sharac et al., Community Health Centers Continued to Expand Patient and Service Capacity in 2017 (Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University Milken Institute School of Public Health, Sept. 2018); Sara Rosenbaum et al., Community Health Centers: Growing Importance in a Changing Health Care System (Henry J. Kaiser Family Foundation, Mar. 2019); and Julia Paradise et al., Community Health Centers: Recent Growth and the Role of the ACA (Henry J. Kaiser Family Foundation, Jan. 2017).
4. Sara Rosenbaum et al., Community Health Center Financing: The Role of Medicaid and Section 330 Grant Funding Explained (Henry J. Kaiser Family Foundation, Mar. 2019).
5. Melinda K. Abrams et al., Realizing Health Reform’s Potential: How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers (Commonwealth Fund, Jan. 2011).
6. Ann S. O’Malley, “After-Hours Access to Primary Care Practices Linked with Lower Emergency Department Use and Less Unmet Medical Need,” Health Affairs 32, no. 1 (Jan. 2013): 175–83; and Mark Murray and Donald M. Berwick, “Advanced Access: Reducing Waiting and Delays in Primary Care,” Journal of the American Medical Association 289, no. 8 (Feb. 26, 2003): 1035–40.
7. Elizabeth A. Jacobs et al., “Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services,” American Journal of Public Health 94, no. 5 (May 2004): 866–69.
8. National Committee for Quality Assurance, Benefits of NCQA Patient-Centered Medical Home Recognition (NCQA, Oct. 2017).
9. Stephen M. Petterson et al., “Projecting U.S. Primary Care Physician Workforce Needs: 2010–2025,” Annals of Family Medicine 10, no. 6 (Nov./Dec. 2012): 503–9; and Stephen P. Juraschek et al., “United States Registered Nurse Workforce Report Card and Shortage Forecast,” American Journal of Medical Quality 27, no. 3 (May 2012): 241–49.
10. Rosenbaum et al., Community Health Center Financing, 2019.
11. Steven Ross Johnson, “Congress May Not Push Community Health Center Funding off the Cliff,” Modern Healthcare, July 20, 2019.