Geographic access to federally qualified health centers before and after the affordable care act

(2022) 22:385 Behr et al. BMC Health Services Research https://doi.org/10.1186/s12913-022-07685-0 Open Access RESEARCH Geographic access to federally qualified health centers before and after the affordable care act Caroline L Behr1,2, Peter Hull3,4, John Hsu1,2, Joseph P Newhouse1,4,5,6 and Vicki Fung1,2* Abstract Background: The Affordable Care Act (ACA) increased funding for Federally Qualified Health Centers (FQHCs). We defined FQHC service areas based on patient use and examined the characteristics of areas that gained FQHC access post-ACA. Methods: We defined FQHC service areas using total patient counts by ZIP code from the Uniform Data System (UDS) and compared this approach with existing methods. We then compared the characteristics of ZIP codes included in Medically Underserved Areas/Populations (MUA/Ps) that gained access vs. MUA/P ZIP codes that did not gain access to FQHCs between 2011–15. Results: FQHC service areas based on UDS data vs. Primary Care Service Areas or counties included a higher percentage of each FQHC’s patients (86% vs. 49% and 71%) and ZIP codes with greater use of FQHCs among low-income residents (29% vs. 22% and 22%), on average. MUA/Ps that gained FQHC access 2011–2015 included more poor, uninsured, publicly insured, and foreign-born residents than underserved areas that did not gain access, but were less likely to be rural (p < .05). Conclusions: Measures of actual patient use provide a promising method of assessing FQHC service areas and access. Post-ACA funding, the FQHC program expanded access into areas that were more likely to have higher rates of poverty and uninsurance, which could help address disparities in access to care. Rural areas were less likely to gain access to FQHCs, underscoring the persistent challenges of providing care in these areas. Keywords: Access to care, Underserved populations, Primary care safety net, Rural health, Health disparities Background Federally Qualified Health Centers (FQHCs) are a critical component of the US primary care safety net [1]. The Affordable Care Act established the Community Health Center Fund (CHCF) to support the expansion of FQHCs between 2011–2015, allocating $11 billion over five years. The creation of the CHCF, along with the ACA’s Medicaid expansion, led to a dramatic increase in both the *Correspondence: 1 Harvard Medical School, Boston, USA Full list of author information is available at the end of the article funding and growth of FQHCs [2]. FQHC delivery sites are owned by FQHC Grantee organizations (Grantees), which may operate multiple FQHC sites. During the initial CHCF authorization period from 2010 to 2015, the number of Grantees grew from 1,124 to 1,375, the number of FQHC delivery sites increased from 6,949 to 9,754, and the total number of patients served grew 25%, from 19.5 million to 24.3 million [3]. Despite the new funding and growth in sites and patients, there remains no standard by which to assess this growth – in part because of uncertainty on how to best define the area served by an FQHC. In this paper we seek to assess how the post-ACA © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Behr et al. BMC Health Services Research (2022) 22:385 expansion of FQHC sites expanded geographic access to care and for which populations using data on the locations of FQHC patients. Expansion of FQHC sites to underserved areas could help reduce geographic health disparities. FQHCs are required to include Medically Underserved Areas (MUAs) or Populations (MUPs), which are designated by the Health Resources and Services Administration (HRSA) or specially designated on the state level. They are also required to provide care to patients regardless of ability to pay, making them a critical source of care for the uninsured. Geographic proximity to FQHCs has been associated with a greater probability of having a usual source of care and having physician visits in the past year [4–6]. Moreover, some studies have demonstrated that low-income patients receiving care from FQHC- vs. nonFQHC providers have better care quality, such as receipt of cancer screening, better access to dental care, better diabetes outcomes, and fewer preventable hospitalizations and emergency room visits [6–14]. The post-ACA expansion of the FQHC program has been shown to improve primary care access in shortage areas; provider availability has improved and more patients have a usual source of care [13, 15]. Findings are limited and mixed, however, on which types of underserved areas were more likely to benefit from recent expansions of the FQHC program [16, 17]. A contributing factor to these varied findings is the challenge of defining an FQHC’s service area. Data on FQHCs are collected on the Grantee level, but organizations might have up to hundreds of FQHC delivery sites. Depending on the number of FQHCs and the range of locations operated by a Grantee, these service areas vary considerably in size and can encompass noncontiguous geographic areas. In addition, patients’ use of FQHCs could vary as a function of both FQHC capacity and the local availability of non-FQHC providers. Thus, access is likely predicated on patient need and behavior given available options and might not map cleanly to administrative geographic boundaries. Previous studies have used pre-existing geographic boundaries, such as counties [18] or Primary Care Services Areas (PCSAs) as defined by the Dartmouth Atlas [17], while others have sought to define service areas based on commuting time from FQHC delivery sites [16]. These approaches could be poor reflections of actual access, as reflected in patient use. They may underestimate the care provided by centers, and hinder evaluations that seek to characterize the populations gaining access to FQHCs. In this analysis we evaluated the performance of an approach adapted from hospital market share definitions to empirically define the service areas of FQHC (...truncated)