While community health centers accept all patients regardless of their insurance, the same is not true of specialists outside health centers. The majority of CHCs reported difficulty getting timely specialist appointments for their Medicaid patients or those without insurance, more so than for Medicare or privately insured patients. This aligns with other research showing fewer specialists accept Medicaid compared to Medicare or private insurance.26
eConsults, a coordination tool where providers receive advice to inform patient care from specialists without the specialist having to see the patient, may be a solution. However, only 20 percent of CHCs in 2024 reported that they usually or often use eConsults to connect with specialists (data not shown), indicating gaps in access to specialty services.
Discussion
Our findings demonstrate that amid several major public health challenges — from COVID-19 to the behavioral health crisis — community health centers are continuing to provide millions of patients with accessible, comprehensive, and coordinated health care.27 Since 2018, CHCs have maintained timely access to care for their patients, with nearly all consistently offering expanded hours and same- or next-day appointments, accompanied by a substantial rise in telehealth services. They also have made strides in making care more comprehensive for their patients by offering behavioral health services, particularly treatment for substance use disorders, and screening patients for social needs.
We found some differences between urban and rural community health centers. Urban CHCs were more likely to offer direct social services and translation assistance, while rural CHCs reported higher rates of same- or next-day appointments, behavioral health screening, and complex care management — although overall health centers reported high rates of offering these services regardless of geography. These differences could reflect CHCs adapting to the needs of their unique patient populations or differing financial and staffing capacities in rural and urban settings.
Despite their progress, community health centers are facing challenges that threaten their ability to continue offering high-quality care. They are increasingly reporting shortages across their workforce, and they struggle to coordinate with off-site specialists, behavioral health care, and community-based organizations.
These challenges could be exacerbated in the future, as community health centers already operate on thin financial margins due to their reliance on low Medicaid reimbursem*nts and federal funds that have not kept up with inflation or the increased number of health centers.28 Impacts of the COVID-19 pandemic and Medicaid eligibility redeterminations will likely continue to stress their finances.29
Policymakers can take several steps to maintain improvements among community health centers and address remaining challenges:
- Reauthorize and expand the Community Health Center Fund. The Community Health Center Fund, a key source of federal funding, is periodically reauthorized by Congress and is currently slated to expire at the end of 2024. Congress can alleviate the funding uncertainty that CHCs are facing by reauthorizing multiyear funding for the program and increasing the amount of funding to keep up with inflation.30 A recent report by the Congressional Budget Office found that increases in CHC funding, which Congress is considering, would yield savings by lowering Medicare and Medicaid expenditures through reductions in high-cost utilization like hospitalizations.31
- Grow the community health center workforce. To address the growing workforce shortages experienced by CHCs, Congress can expand recruitment, retention, and training programs that encourage providers to practice in medically underserved or rural areas, such as the National Health Service Corps and the Teaching Health Center Graduate Medical Education Program.32
- Support the provision of telehealth. Given the reported benefits of telehealth for patients’ access to care and CHC finances, Congress can take steps to ensure CHCs have sufficient resources to continue offering telehealth, including by aligning telehealth reimbursem*nt more closely with reimbursem*nt for in-person care. Financial assistance could be targeted to rural community health centers, which reported financial challenges to offering telehealth at higher rates, and where telehealth could be critical for ensuring access to care. Congress also could extend federal flexibilities that enabled CHCs to implement and expand telehealth use during the pandemic, such as increased payment rates, which are set to expire at the end of 2024.
- Engage community health centers in payment reform. Beyond grant funding, policymakers can support CHCs’ engagement in value-based payment models, which offer more predictable, flexible funding and reward the provision of high-quality, comprehensive care.33 Models could be designed to intentionally encourage and enable coordination between CHCs and specialists or other providers outside the CHC, which we found was a key gap. To ensure that CHCs engaging in value-based payment are successful, policymakers can offer upfront funding and technical assistance to support their transition.34
HOW WE CONDUCTED THIS STUDY
2024 Survey
The Commonwealth Fund 2024 National Survey of Federally Qualified Health Centers was conducted by SSRS from October 17, 2023, through April 2, 2024, among a nationally representative sample of executive directors, clinical directors, or project directors at federally qualified health centers (FQHCs). The survey sample was drawn from the Uniformed Data System (UDS) list of all FQHCs in 2022 that have at least one site that is a community-based primary care clinic. The National Association of Community Health Centers provided the list.
All 1,368 FQHCs were sent the questionnaire and 766 responded, yielding a response rate of 56 percent. We were unable to determine the geography of 29 centers and their responses are excluded from this analysis. The survey consisted of a 12-page questionnaire, informed by the Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers and qualitative research conducted by the African American Research Collaborative.35 The questionnaire could be completed by mail or web. Data were weighted by the number of patients, number of sites, geographic region, and urban/rural location to reflect the universe of FQHCs as accurately as possible. We used chi-square tests to assess differences between health centers in rural and urban areas, as well as between 2018 and 2024 responses.
2018 Survey
The Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers was conducted by SSRS from May 16, 2018, through September 30, 2018, among a nationally representative sample of 694 executive directors or clinical directors at FQHCs. The survey sample was drawn from the Uniformed Data System (UDS) list of all FQHCs in 2016 that have at least one site that is a community-based primary care clinic. The National Association of Community Health Centers provided the list.
All 1,367 FQHCs were sent the questionnaire and 694 responded, yielding a response rate of 51 percent. The survey consisted of a 12-page questionnaire that took approximately 20 to 25 minutes to complete. Data 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. Expansion status was determined using the FQHC-reported largest site address. If the largest site address was not provided, and the FQHC had only one site, we used UDS data to determine the health center's geography. We used chi-square tests to assess differences between health centers in rural and urban areas.
ACKNOWLEDGMENTS
The authors thank the National Association of Community Health Centers (NACHC) and experts including Hope Glassberg, Peter Shin, Robert Nocon, Rob Saunders, Tony Shih, Nathaniel Counts, Sandra Wilkness, Rocco Perla, and Rebecca Onie for providing input on our survey instrument and this brief. We also thank Robyn Rapoport, Elizabeth Sciupac, Molly Fisch-Friedman, and Hope Wilson of SSRS for assistance in designing and administering the survey.
NOTES
- Health Resources and Services Administration, “National Health Center Program Uniform Data System (UDS) Awardee Data,” n.d. ↩
- National Association of Community Health Centers, “Community Health Centers: Providers, Partners and Employers of Choice — 2024 Chartbook,” Mar. 2023. ↩
- National Association of Community Health Centers, “Community Health Centers: Providers, Partners and Employers of Choice — 2024 Chartbook,” Mar. 2023; and Bureau of Primary Health Care, “By the Numbers: Health Care Use and Spending,” Health Resources and Services Administration, n.d. ↩
- National Association of Community Health Centers, “Community Health Centers: Providers, Partners and Employers of Choice — 2024 Chartbook,” Mar. 2023; and Nathaniel Bell et al., Distances to Federally Qualified Health Centers and Rural Health Clinics Following Rural Hospital Closures, 2006–2018 (Rural and Minority Health Research Center, University of South Carolina, Oct. 2022). ↩
- Celli Horstman et al., “Community Health Centers Need Increased and Sustained Federal Funding,” To the Point (blog), Commonwealth Fund, Sept. 25, 2023. ↩
- Celli Horstman, “Underfunded and Overburdened: The Toll of the COVID-19 Pandemic on Community Health Centers,” To the Point (blog), Commonwealth Fund, June 5, 2023; Peter Shin et al., “One Year After Medicaid Unwinding Began, Community Health Centers, Their Patients, and Their Communities Are Feeling the Impact,” Milken Institute School of Public Health (Data Note), Apr. 2024; and National Association of Community Health Centers, Current State of the Health Center Workforce: Pandemic Challenges and Policy Solutions to Strengthen the Workforce of the Future (NACHC, Mar. 2022). ↩
- “2018 National Survey of Federally Qualified Health Centers,” Commonwealth Fund, Apr. 3, 2019. ↩
- 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. ↩
- Agency for Healthcare Research and Quality, Chartbook on Access to Health Care (AHRQ, May 2016). ↩
- Celli Horstman, “Underfunded and Overburdened: The Toll of the COVID-19 Pandemic on Community Health Centers,” To the Point (blog), Commonwealth Fund, June 5, 2023. ↩
- Michael Butzner and Yendelela Cuffee, “Telehealth Interventions and Outcomes Across Rural Communities in the United States: Narrative Review,” Journal of Medical Internet Research 23, no. 8 (Aug. 26, 2021): e29575. ↩
- June-Ho Kim et al., “How the Rapid Shift to Telehealth Leaves Many Community Health Centers Behind During the COVID-19 Pandemic,” Health Affairs Forefront (blog), June 2, 2020; and Celli Horstman, “Underfunded and Overburdened: The Toll of the COVID-19 Pandemic on Community Health Centers,” To the Point (blog), Commonwealth Fund, June 5, 2023. ↩
- Abbye E. Alexander, Christopher J. Tellner, and Talya Van Embden, “End of a Pandemic Era: What Now for Federally Qualified Health Centers?,” Reuters (commentary), May 2, 2023. ↩
- Celli Horstman, “Underfunded and Overburdened: The Toll of the COVID-19 Pandemic on Community Health Centers,” To the Point (blog), Commonwealth Fund, June 5, 2023. ↩
- Health Resources and Services Administration, “National Health Center Program Uniform Data System (UDS) Awardee Data,” n.d. ↩
- Health Resources and Services Administration, “National Health Center Program Uniform Data System (UDS) Awardee Data,” n.d. ↩
- Sadiq Y. Patel et al., “Provision of Evaluation and Management Visits by Nurse Practitioners and Physician Assistants in the U.S.A. from 2013 to 2019: Cross-Sectional Time Series Study,” BMJ 382 (Sept. 14, 2023): e073933. ↩
- National Association of Community Health Centers, Current State of the Health Center Workforce: Pandemic Challenges and Policy Solutions to Strengthen the Workforce of the Future (NACHC, Mar. 2022). ↩
- Celli Horstman, “How Community Health Centers Can Meet the Rising Demand for Behavioral Health Care,” To the Point (blog), Commonwealth Fund, Mar. 7, 2024. ↩
- Dawn A. Morales, Crystal L. Barksdale, and Andrea C. Beckel-Mitchener, “A Call to Action to Address Rural Mental Health Disparities,” Journal of Clinical and Translational Science 4, no. 5 (May 4, 2020): 463–67. ↩
- Bradley Corallo et al., Community Health Centers and Medication-Assisted Treatment for Opioid Use Disorder (KFF, Aug. 2020). ↩
- National Association of Community Health Centers, “America’s Health Centers: By the Numbers,” Aug. 7, 2023. ↩
- Celli Horstman, How U.S. Health Care Providers Are Addressing the Drivers of Health (Commonwealth Fund, May 2024). ↩
- Celli Horstman, Alexandra Bryan, and Corinne Lewis, How the CMS Innovation Center’s Payment and Delivery Reform Models Seek to Address the Drivers of Health (Commonwealth Fund, Aug. 2022). ↩
- Neal O’Hara et al., “Effective Care Management by Next Generation Accountable Care Organizations,” American Journal of Managed Care 26, no. 7 (July 2020): 296–302. ↩
- Kayla Holgash and Martha Heberlein, “Physician Acceptance of New Medicaid Patients: What Matters and What Doesn’t,” Health Affairs Forefront (blog), Apr. 10, 2019. ↩
- Celli Horstman, “Underfunded and Overburdened: The Toll of the COVID-19 Pandemic on Community Health Centers,” To the Point (blog), Commonwealth Fund, June 5, 2023; and Celli Horstman, “How Community Health Centers Can Meet the Rising Demand for Behavioral Health Care,” To the Point (blog), Commonwealth Fund, Mar. 7, 2024. ↩
- Alex Brill, The Overlooked Decline in Community Health Center Funding (National Association of Community Health Centers, Mar, 2023). ↩
- Katheryn Houghton, “Safety-Net Health Clinics Cut Services and Staff Amid Medicaid ‘Unwinding,’” KFF Health News, May 30, 2024. ↩
- Celli Horstman et al., “Community Health Centers Need Increased and Sustained Federal Funding,” To the Point (blog), Commonwealth Fund, Sept. 25, 2023. ↩
- Congressional Budget Office, “S. 2840, Bipartisan Primary Care and Health Workforce Act: As reported by the Senate Committee on Health, Education, Labor, and Pensions,” Nov. 8, 2023. ↩
- Health Resources and Services Administration, “Health Workforce: Biden-Harris Administration — 2021 HRSA Highlights,” n.d. ↩
- Corinne Lewis et al., “Value-Based Care: What It Is, and Why It’s Needed” (explainer), Commonwealth Fund, Feb. 7, 2023. ↩
- Corinne Lewis, Alexandra Bryan, and Celli Horstman, “Federally Qualified Health Centers Can Make the Switch to Value-Based Payment, But Need Assistance,” To the Point (blog), Commonwealth Fund, Feb. 26, 2024. ↩
- Celli Horstman et al., “Community Health Centers Need Increased and Sustained Federal Funding,” To the Point (blog), Commonwealth Fund, Sept. 25, 2023. ↩
