Federally qualified health centers (FQHCs)

There is strong evidence that federally qualified health centers (FQHCs) increase access to primary care (Urban-Saloner 2014, Shi 2013, Lo Sasso 2010, Siegel 2004, Gresenz 2006, Bodenheimer 2010, Hicks 2006, O'Malley 2005, Lee 2023, Cunningham 2004, Shi 2007, Shi 2007a) and improve health outcomes for their patients (NBER-Kose 2022, Meredith 2016, Wright 2015, Ross 2012, Lee 2023, Goldman 2012, Bodenheimer 2010, Hicks 2006).

FQHCs have been shown to perform as well as or better than non-safety net providers on measures of quality and access to care, such as continuity of care and delivery of preventive services (Shi 2013, Shi 2012, Goldman 2012, Hicks 2006, O'Malley 2005), particularly for children (Gresenz 2006) and Medicare patients (Lavelle 2018, Ross 2012). FQHCs may improve access to oral health care (Jones 2013) and appear to provide effective care for PTSD (Meredith 2016). They may increase prenatal care and smoking cessation in pregnant women, and reduce low birthweight births (NBER-Kose 2022).

Centers with medical training programs may improve some patient outcomes, including hypertension, cancer screenings and immunizations (Choi 2023), and FQHCs with community health worker and patient navigator programs increase cancer screenings in medically underserved populations (Roland 2017). FQHCs that become advanced primary care practices (APCPs) or that adopt principles of the patient centered medical home may further improve health and health care (RAND-Kahn 2015, Calman 2013).

FQHCs in states that expanded Medicaid under the Affordable Care Act (ACA) increased patient volumes, increased Medicaid coverage among patients, and reduced numbers of patients without insurance (Cole 2018, Cole 2017, Han 2017). Expanded Medicaid funding was associated with more clinic visits, including preventative and mental health visits (Han 2017) and, in rural FQHCs, improved quality of care and increased service provision (Cole 2018). States that expanded dental benefits increased the number of dental visits (Lyu 2023). Additionally, states that expanded Medicaid were more likely to have new FQHCs open in medically underserved areas with higher rates of poverty, uninsurance, and residents of color (Behr 2022).

Patients who receive most of their ambulatory care at community health centers such as FQHCs have lower overall medical expenditures than those who receive care elsewhere (Richard 2012), and many patients continue to use FQHCs even after obtaining insurance (Ku 2011). FQHCs may be more likely than other providers to offer appointments outside standard business hours (i.e. early or late appointments, on weekends), behavioral health services including providing medication-assisted treatment for opioid use, and screen patients for social and financial needs (Lewis 2021a).

Investments in community health centers have been shown to reduce costs for local health care systems and provide economic benefits for surrounding communities (Rothkopf 2011, Dor 2009, Shi 2007a, NACHC-Primary care 2007).

There is some evidence that federally qualified health centers (FQHCs) have the potential to decrease disparities in access to primary care health services for people with low incomes, people of color, and people without health insurance (Urban-Saloner 2014, O'Malley 2005, Hicks 2006, Lee 2023, Shi 2013,Gresenz 2006, Shi 2007, Shi 2007a, Cunningham 2004, Bodenheimer 2010), as well as improve health outcomes (NBER-Kose 2022, Wright 2015, Hicks 2006, Lee 2023, Goldman 2012, Bodenheimer 2010). By serving uninsured, underinsured, and other vulnerable patients, FQHCs provide care to those who may previously have had little or no opportunity to receive regular, non-emergency care (Bodenheimer 2010, Starfield 2005, Siegel 2004). Additional research is needed to confirm effects.

Patients living near a FQHC or similar safety net provider may be more likely to seek health services (Lee 2023), including uninsured children (Gresenz 2006). FQHCs may be more likely to provide appointments to Medicaid patients than non-FQHCS (Urban-Saloner 2014). FQHCs may reduce low birth weight births among populations with low incomes, populations of color, and in rural areas (NBER-Kose 2022, Starfield 2005, Siegel 2004). FQHCs appear to decrease hospitalizations due to ambulatory care-sensitive conditions among patients who are Black and Hispanic (Wright 2015), and for Medicaid and Medicare eligible Black patients (Wright 2017b). FQHCs decrease disparities in the quality of care for chronic diseases, such as hypertension and asthma, among populations with low incomes and populations of color (Hicks 2006, Goldman 2012). For mental health care, expanding the intensity of services available, versus increasing the number of patients that can be served, may be more effective at reducing emergency department use for psychiatric care among Black youth (Bruckner 2020).

New FQHCs and FQHC sites that opened after the passage of the Affordable Care Act (ACA) were more likely to be in Medically Underserved Areas (MUAs) with higher rates of poverty, uninsurance, and residents of color (Behr 2022), but not in rural areas (Behr 2022, Chang 2019). However, these expanded locations did not improve access for individuals who may experience cultural or language barriers (Evans 2022). Experts recommend expanding FQHCs in MUAs and Health Professional Shortage Areas (HPSAs) in small towns, metro areas, and formerly redlined sections of urban cities to increase to access of care (Lee 2023, Xue 2018).

FQHCs may increase availability of providers in underserved areas, such as HPSAs (Xue 2018). States with higher rates of explicit and implicit racial bias appear to have fewer FQHCs and fewer qualifying areas acknowledged as HPSAs. These findings suggest there are fewer opportunities of care for those served by FQHCs, and more barriers to identifying treatment needs of Black patients and patients with low incomes (Snowden 2023).

The Federal Housing Administration’s redlining practices entrenched racial residential segregation in the U.S. and resulted in fewer health care facilities, resources, and funding in urban areas with largely Black populations (Lee 2023, Lee 2022c). Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods that are primarily Black and low income (Lee 2023). Formerly redlined neighborhoods are more likely to be near man-made environmental hazards producing pollution or toxins, and have older homes in poor condition containing health hazards such as lead paint and mold (Braveman 2022). Residents of redlined neighborhoods continue to experience worse health outcomes, such as increased likelihood of preterm birth and a higher prevalence of asthma, heat-related conditions, and chronic diseases like diabetes (Lee 2022c).

Community Health Centers (CHCs), forerunners of federally qualified health centers (FQHCs), were established in 1965 as part of the War on Poverty to provide primary preventive care to medically underserved communities, including families with low incomes, people without health insurance, migrants, and those experiencing homelessness (NBER-Kose 2022). The CHC program was formalized by Congress in 1975; Section 330 of the Public Health Service Act required them to serve medically underserved areas (MUAs) (NBER-Kose 2022). In 1989, in response to low Medicaid reimbursement rates in some states, the Omnibus Budget Reconciliation Act created FQHCs and changed financing and reimbursement options (NBER-Kose 2022). Ongoing federal support, including initiatives in the 2009 American Recovery and Reinvestment Act, the 2010 Affordable Care Act (ACA), and financial incentives for services provided to Medicare and Medicaid patients, has supported expansion (Chang 2019). The ACA expanded Medicaid eligibility and increased federal funding of section 330 of the Public Health Service Act, the two largest sources of funding for FQHCs (Lyu 2023, Han 2017).

• How can your community advocate to increase state-level and health system-level commitments to provide care to underserved populations, including through FQHCs?
• Are there areas in your community that are not designated as a Health Provider Shortage Areas (HPSA) or Medically Underserved Areas (MUA) that meet the criteria? What organizations could you partner with to open an FQHC and support their application for the MUA and/or HPSA designation(s)?
• What organizations could you collaborate with to improve access to services provided at FQHCs?

In 2022, there were 1,373 federally qualified health centers (FQHCs) operating more than 15,000 service sites in the United States and its territories. These FQHCs served 30.5 million patients through over 126 million patient visits (HRSA-FQHC Trends 2022). As of 2019, more than 91% of FQHC patients reported incomes below 200% of the federal poverty level. Furthermore, 48% of patients were enrolled in Medicaid, 23% were uninsured, and 63% of patients receiving care at FQHCs were from racial/ethnic minority groups. Yet, there are still many medically underserved areas (MUAs) that do not have any FQHCs.

FQHCs are primarily funded through the federal Community Health Center Fund and Medicaid reimbursements (CWF-Horstman 2023). However, federal funding does not appear to have kept up with market forces and inflation (NACHC-Community Health Center Funding 2023).

‡ Resources with a focus on equity.

CiMH-Jarvis 2011 - Jarvis D, Freeman J. Toolkit of promising practices for financing integrated care in the California safety net. Sacramento: California institute for Mental Health (CiMH); 2011.

HRSA-Health centers - Health Resources and Services Administration (HRSA). What is a health center?

NCIOM - North Carolina Institute of Medicine (NCIOM). Health care services for the uninsured and other underserved populations: A technical assistance manual to help communities create or expand health care safety net services. Durham: North Carolina Institute of Medicine (NCIOM); 2008.

RHIhub-FQHCs^‡ - Rural Health Information Hub (RHIhub). Federally Qualified Health Centers (FQHCs) and the Health Center Program.

* Journal subscription may be required for access.

Behr 2022 - Behr CL, Hull P, Hsu J, Newhouse JP, Fung V. Geographic access to federally qualified health centers before and after the affordable care act. BMC Health Services Research. 2022;22:385.

Bodenheimer 2010* - Bodenheimer T, Pham HH. Primary care: Current problems and proposed solutions. Health Affairs. 2010;29(5):799-805.

Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.

Bruckner 2020 - Bruckner TA, Singh P, Yoon J, Chakravarthy B, Snowden LR. African American/white disparities in psychiatric emergencies among youth following rapid expansion of Federally Qualified Health Centers. Health Services Research. 2020;55:26-34.

Calman 2013 - Calman NS, Hauser D, Weiss L, et al. Becoming a patient-centered medical home: A 9-year transition for a network of federally qualified health centers. Annals of Family Medicine. 2013;11(Suppl 1):S68-S73.

Chang 2019* - Chang CH, Bynum JPW, Lurie JD. Geographic expansion of federally qualified health centers 2007–2014. Journal of Rural Health. 2019;35(3):385-394.

Choi 2023* - Choi S, Davlyatov G, Cendoma P, Borkowski N. The association between federally qualified health centers’ medical training programs and clinical outcomes. Journal of Ambulatory Care Management. 2023;46(3):183-193.

Cole 2017 - Cole MB, Galárraga O, Wilson IB, Wright B, Trivedi AN. At federally funded health centers, Medicaid expansion was associated with improved quality of care. Health Affairs. 2017;36(1):40-48.

Cole 2018 - Cole MB, Wright B, Wilson IB, Galárraga O, Trivedi AN. Medicaid expansion and community health centers: Care quality and service use increased for rural patients. Health Affairs. 2018;37(6):900-907.

Cunningham 2004 - Cunningham P, Hadley J. Expanding care versus expanding coverage: How to improve access to care. Health Affairs. 2004;23(4):234-44.

CWF-Horstman 2023 - Horstman C, Lewis C, Ayo-Vaughan M, Fernandez H. Community health centers need increased and sustained federal funding. New York: The Commonwealth Fund (CWF); 2023.

Dor 2009 - Dor A, Richard P, Tan E, et al. Community health centers in Indiana: State investments and returns. New York: Geiger Gibson/RCHN Community Health Foundation Research Collaborative (RCHN CHF); 2009.

Evans 2022 - Evans L, Fabian MP, Charns MP, et al. Medicaid expansion and change in federally qualified health center accessibility from 2008 to 2016. Medical Care. 2022;60(10):743-749.

Goldman 2012* - Goldman LE, Chu PW, Tran H, Romano MJ, Stafford RS. Federally qualified health centers and private practice performance on ambulatory care measures. American Journal of Preventive Medicine. 2012;43(2):142-9.

Gresenz 2006 - Gresenz CR, Rogowski J, Escarce JJ. Dimensions of the local health care environment and use of care by uninsured children in rural and urban areas. Pediatrics. 2006;117(3):e509-17.

Han 2017 - Han X, Luo Q, Ku L. Medicaid expansion and grant funding increases helped improve community health center capacity. Health Affairs. 2017;36(1):49-56.

Hicks 2006 - Hicks LS, O’Malley AJ, Lieu TA, et al. The quality of chronic disease care in U.S. community health centers. Health Affairs. 2006;25(6):1712-1723.

HRSA-FQHC Trends 2022 - Health Resources and Services Administration (HRSA). National Health Center Data System (UDS) Awardee Data. 2022.

HRSA-Health centers - Health Resources and Services Administration (HRSA). What is a health center?

Jones 2013* - Jones E, Shi L, Hayashi AS, et al. Access to oral health care: The role of federally qualified health centers in addressing disparities and expanding access. American Journal of Public Health. 2013;103(3):488-493.

KFF-CHCs - KFF. Community health center delivery sites and patient visits (CHCs).

Ku 2011 - Ku L, Jones E, Shin P, Rothenberg F, Long SK. Safety-net providers after health care reform: Lessons from Massachusetts. Archives of Internal Medicine. 2011;171(15):1379-1384.

Lavelle 2018 - Lavelle TA, Rose AJ, Timbie JW, et al. Utilization of health care services among Medicare beneficiaries who visit federally qualified health centers. BMC Health Services Research. 2018;18:41.

Lee 2022c* - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.

Lee 2023* - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.

Lewis 2021a - Lewis VA, Spivack S, Murray GF, Rodriguez HP. FQHC designation and safety net patient revenue associated with primary care practice capabilities for access and quality. Journal of General Internal Medicine. 2021;36(10):2922-2928.

Lo Sasso 2010* - Lo Sasso AT, Byck GR. Funding growth drives community health center services. Health Affairs. 2010;29(2):289-296.

Lyu 2023* - Lyu W, Wehby GL. The effects of Medicaid expansions on dental services at federally qualified health centers. Journal of the American Dental Association. 2023;154(3):215-224.e10.

Meredith 2016* - Meredith LS, Eisenman DP, Han B, et al. Impact of collaborative care for underserved patients with PTSD in primary care: A randomized controlled trial. Journal of General Internal Medicine. 2016;31(5):509-517.

NACHC-Community Health Center Funding 2023 - National Association of Community Health Centers (NACHC). The overlooked decline in community health center funding. 2023.

NACHC-Primary care 2007 - National Association of Community Health Centers (NACHC). Access granted: The primary care payoff. Washington, D.C.: National Association of Community Health Centers (NACHC), Robert Graham Center, Capital Link; 2007.

NBER-Kose 2022 - Kose E, O’Keefe SM, Rosales-Rueda M. Does the delivery of primary health care improve birth outcomes? Evidence from the rollout of community health centers. National Bureau of Economic Research (NBER). 2022: Working Paper 30047.

O'Malley 2005 - O’Malley AS, Forrest CB, Politzer RM, Wulu JT, Shi L. Health center trends, 1994-2001: What do they portend for the federal growth initiative? Health Affairs. 2005;24(2):465-472.

RAND-Kahn 2015 - Kahn KL, Timbie JW, Friedberg MW, et al. Evaluation of CMS's federally qualified health center (FQHC) advanced primary care practice (APCP) demonstration: Final second annual report. Santa Monica: RAND Corporation; 2015.

Richard 2012* - Richard P, Ku L, Dor A, et al. Cost savings associated with the use of community health centers. Journal of Ambulatory Care Management. 2012;35(1):50-59.

Roland 2017 - Roland KB, Milliken EL, Rohan EA, et al. Use of community health workers and patient navigators to improve cancer outcomes among patients served by federally qualified health centers: A systematic literature review. Health Equity. 2017;1(1):61-76.

Ross 2012* - Ross JS, Bernheim SM, Lin Z, et al. Based on key measures, care quality for medicare enrollees at safety-net and non-safety-net hospitals was almost equal. Health Affairs. 2012;31(8):1739-1748.

Rothkopf 2011* - Rothkopf J, Brookler K, Wadhwa S, Sajovetz M. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers. Health Affairs. 2011;30(7):1335-1342.

Shi 2007* - Shi L, Stevens GD, Politzer RM. Access to care for U.S. health center patients and patients nationally: How do the most vulnerable populations fare? Medical Care. 2007;45(3):206-213.

Shi 2007a* - Shi L, Stevens GD. The role of community health centers in delivering primary care to the underserved: Experiences of the uninsured and Medicaid insured. Journal of Ambulatory Care Management. 2007;30(2):159-170.

Shi 2012* - Shi L, Lebrun LA, Zhu J, et al. Clinical quality performance in U.S. health centers. Health Services Research. 2012;47(6):2225-2249.

Shi 2013* - Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing disparities in access to primary care and patient satisfaction with care: The role of health centers. Journal of Health Care for the Poor and Underserved. 2013;24(1):56-66.

Siegel 2004* - Siegel B, Regenstein M, Shin P. Health reform and the safety net: Big opportunities; major risks. Journal of Law, Medicine & Ethics. 2004;32(3):426-432.

Snowden 2023 - Snowden LR, Michaels E. Racial bias correlates with states having fewer Health Professional Shortage Areas and fewer Federally Qualified Community Health Center sites. Journal of Racial and Ethnic Health Disparities. 2023;10:325-333.

Starfield 2005 - Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly 2005;83(3):457-502.

Urban-Saloner 2014 - Saloner B, Kenney GM, Polsky D, et al. The availability of new patient appointments for primary care at federally qualified health centers: Findings from an audit study. Washington, D.C.: The Urban Institute; 2014.

WI DHS-FQHC Funding 2022 - Wisconsin Department of Health Services (WI DHS). Public Notice: Funding for a Federally Qualified Health Center (FQHC) 2022.

Wright 2015* - Wright B, Potter AJ, Trivedi A. Federally qualified health center use among dual eligibles: Rates of hospitalizations and emergency department visits. Health Affairs. 2015;34(7):1147-1155.

Wright 2017b - Wright B, Potter AJ, Trivedi AN. Use of federally qualified health centers and potentially preventable hospital utilization among older Medicare-Medicaid enrollees. Journal of Ambulatory Care Management. 2017;40(2):139-149.

Xue 2018* - Xue Y, Greener E, Kannan V, et al. Federally qualified health centers reduce the primary care provider gap in health professional shortage counties. Nursing Outlook. 2018;66(3):263-272.