The United States does not have a National Health Service – certainly nothing that we could display with a choreographed song and dance routine – but the federal government does support an extensive network of safety net health clinics. According to recent figures, 19.5 million individuals receive treatment every year at 1,124 Federally Qualified Health Centers (FQHC). Millions of others receive treatment at “look alike” community clinics that are also eligible to receive federal dollars.
FQHCs are an improbable triumph of American health policy – conceived of by liberal policymakers in the 1960s, rapidly scaled-up under George W. Bush in the last decade, and expanded again under the health reform legislation – they represent one of the few inclusive, community-based health strategies embraced in U.S. policymaking. How well do they work?
FQHC skeptics might argue that community clinics perpetuate an already socioeconomically segregated health care system. Although FQHCs have attempted to broaden their client base to serve people with private insurance, they still mainly cater to low-income uninsured and people with public health insurance. FQHC supporters might counter that community clinics fill an essential void in underserved communities, providing ongoing medical attention to people who would otherwise be lining up in the emergency room.
Ultimately, evaluating FQHCs requires an answer to the “in comparison to what?” question. Putting money into community health centers represents a modest strategy to increasing access to care for medically underserved populations. The evidence I present below strongly suggests that FQHCs produce favorable results under the status quo viable, but to my knowledge there is little rigorous evidence from a demonstration project to quantify their effectiveness compared to alternative interventions.
Access to care should be the clearest success of FQHCs to quantify. By putting more providers in communities, there are more appointments available for underserved populations. That said, we do not know where the patients that go to FQHCs would go if they did not exist, and also what their providers would do (presumably some would not work in underserved areas, but some might still elect to provide care in those settings).
One challenge to measuring the success of FQHCs is that, by design, FQHCs go to the communities where the need for treatment is greatest. This typically confounds the relationship between proximity to an FQHC and access to treatment. In a 2004 paper, two researchers attempted to skirt this challenge by using political variables (like the “liberalness” of a small area) to identify the placement of FQHCs in areas with more generous social safety nets. Using these political variables as an instrument for proximity to an FQHC, and controlling for many other sociodemographic variables, they find that being close to an FQHC significantly reduces the likelihood of individuals having poor access to care (unmet need, delaying care, hospitalizations). This is compelling, but not ironclad, evidence.
In a 2007 study, Shi and colleagues compared samples of Medicaid and uninsured from community health centers to patients with the same insurance coverage receiving care in other settings, and examined the likelihood that each group would receive routine screenings and behavioral counseling. Across a broad spectrum of different measures, the community health center patients were more likely to affirm that they had received the preventive health services. However, there are two caveats. First, there were still large fractions in the CHC population that did not receive the preventive health screens. Second, the two populations were quite different on a range of different basic demographic categories, which may not have been successfully addressed in multivariate regression analysis.
To the extent that community health centers provide higher quality care, it is probably a result of their practice model: they tailor strategies that are relevant to their catchment areas (such as culturally appropriate care), they are more likely to use physician extenders and nurses who can provide behavioral counseling, and they have the infrastructure and practice design to adopt useful innovations like electronic medical records.
Health Reform and the Unfinished Task
The Affordable Care Act increases funding to expand the number of FQHCs and to broaden the array of services provided. This is a daunting task, especially since the ACA will undoubtedly increase the volume of people seeking medical care by increasing insurance enrollment. Some providers are in good shape to expand, but others are not.
An in-depth study of FQHCs in 12 communities by the Center for Studying Health System Change found that the performance of FQHCs varied widely across sites – and that they are much better set-up to become medical homes in cities like Boston and Miami where they are already integral to the social safety net than in places like Lansing, Michigan where they receive little political or health system support.
A major problem is attracting enough providers to serve in FQHCs, which are perceived by medical trainees to provide “low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities.” This is a broader problem in primary care for the medically underserved, and the real solution to the problem is much broader than reforming FQHCs. To improve community health centers, a comprehensive solution needs to improve the prestige and pay of providing medical care for the neediest populations, and offering providers the training to be competent providers in those settings.