Federally Qualified Health Center Users Continue to Have Limited Options for Health Care under Health Reform and Give Federally Qualified Health Centers Mixed Reviews
Christal Ramos, Terri Coughlin, Adam Weiss, and Sharon K. Long
August 26, 2016
The Affordable Care Act (ACA) has brought about a major shift in health insurance coverage, especially for low-income individuals. The act has also fundamentally changed how health care is delivered in the United States. Important to implementing health reform are federally qualified health centers (FQHCs), the foundation of the health care safety net. Although FQHCs have long enjoyed considerable financial assistance from the federal government, including under the ACA, health reform poses challenges for them. Most notably, many traditional FQHC patients have gained insurance coverage under the ACA either through Medicaid or the Marketplace, potentially bringing a substantial amount of new revenue to FQHCs. This infusion of new revenue, however, only benefits FQHCs if they are able to keep their patients. Now that the newly insured have more options among health care providers, some FQHCs may find themselves in the unfamiliar position of competing with private providers for patients who previously had nowhere else to go. To be successful in the post-ACA environment, FQHCs need to deliver quality health care efficiently and in a manner that builds their patient base of insured individuals.
What We Did
We used data from the September and December 2014 waves of the Urban Institute’s Health Reform Monitoring Survey (HRMS), as well as follow-up interviews with survey respondents from the December wave, to examine FQHC use in 2014. In the follow-up interviews, which were conducted between March and April 2015, we explored respondents’ reasons for going to FQHCs for care, their perceptions about the quality of care they have received at FQHCs, and their assessment of the options they have (or do not have) in where to obtain health care. In this brief we summarize the responses from the follow-up interviews.
The follow-up interviews were conducted with a subset of 48 HRMS respondents who reported using an FQHC in the past year. A stratified sample was used to identify interviewees representing a range of ages, family income levels, insurance and health statuses, languages (English and Spanish), locations (urban and rural), and states (that had and had not as of September 2014 expanded Medicaid under the ACA). For the interviews, we developed a semistructured interview guide with questions asking interviewees about their reasons for using an FQHC, whether they felt they have a choice in where they get their health care, and their experiences with the care they receive at the FQHC. Interviews were conducted by phone, recorded, summarized, and coded using NVivo 10 qualitative analysis software to identify themes.
What We Found
Many interviewees who had used an FQHC in the past year gave a pragmatic reason for relying on FQHCs: the center took their health insurance coverage.
Although most FQHC users felt they had a choice of where they could go for health care, many felt the choice was limited. This was particularly true for those with Medicaid and the uninsured. Medicaid enrollees reported that not many places would take Medicaid, and the uninsured reported that few places took patients without insurance, leaving the hospital or emergency room as the only other option in some cases. Interviewees often mentioned that their other options were other FQHCs. One interviewee with Medicaid said, “I suppose I’m a statistic because I’m poor and I have to use this type of facility because I can’t afford to go anywhere else.”
Some adults with employer-sponsored insurance also reported limited care options as a reason for relying on an FQHC, although those interviewees were often living in small towns or rural areas with few private providers.
Several interviewees mentioned that they were assigned or referred to the FQHC by their insurance company or that they chose a primary care doctor who practiced at the FQHC from a list given to them by their insurance company.
Gains in health insurance coverage sometimes led to a change in providers, but many interviewees remain loyal to their FQHC.
Although a few interviewees reported that they stopped going to FQHC when they gained health insurance, many longtime users of FQHCs chose to stay even though they gained insurance or changed coverage type. Others who were newly insured through Medicaid had just started using FQHCs in the past year. Several newly insured interviewees mentioned they had not been previously receiving care anywhere else. One newly insured person said, “[I] wish there was more info for people like me who are new to the health care system.”
Proximity and accessibility were important for many of the interviewees who rely on an FQHC.
The FQHC users interviewed highlighted the location and convenience of the FQHC as an important factor in relying on the center for care, a finding echoed in the HRMS survey data (figure 1). Interviewees also reported liking their FQHC because getting an appointment there is easy and it offers multiple services in one place. Many respondents (mostly those with Medicaid and the uninsured) also mentioned that the staff is friendly; several respondents described FQHC staff as “less judgmental” than staff at other places. One interviewee liked that FQHC staff did not treat him with suspicion when dispensing narcotic prescriptions.
FQHC users are not always happy with the care they receive, frequently describing their experience as impersonal.
Interviewees reported mixed experiences with the care they received at FQHCs. A common complaint was that the experience is impersonal. This sentiment was frequently expressed by those with employer-sponsored insurance; one interviewee with ESI mentioned that “you are just a number there,” and another described an FQHC as “an assembly line.” Indeed, some interviewees reported that they switched from one FQHC to another because they felt they were treated poorly. Interviewees also frequently mentioned that they disliked the high staff turnover at their FQHC and that they see a different doctor every time, forcing those respondents to re-explain their health needs.
However, several respondents mentioned that although their experience with FQHCs was impersonal, they did not want to complain and felt happy to have somewhere to go for health care. One person with Medicaid said he did not expect too much because, “I have a poor person’s insurance.”
Other common complaints about the care received at FQHCs were long wait times, poor waiting room conditions, and unsatisfactory access to or coordination with specialty care. Some interviewees felt that their FQHC is understaffed and said the doctor spent very little time with them and that wait times were long even with an appointment. Long wait times were the most common dislike among interviewees (particularly those with Medicaid and the uninsured). Many interviewees also complained about the number of sick people in the waiting room; as one interviewee said, “it’s gross.” A handful of interviewees mentioned they have noticed that their health center has been more crowded lately or that the wait has been longer. In one case the interviewee mentioned such changes were specifically “since health reform.”
Although FQHCs’ mission is to provide primary and preventive care services, one of the most common complaints voiced by interviewees is the lack of access to specialty care or other services, such as pharmacy or dental care. When asked what she likes least about health centers, one interviewee said, “They don’t do everything—you have to go other places for specialists.” A few interviewees also noted a lack of care coordination when they were referred elsewhere for specialty care, as one uninsured interviewee shared, “They [the FQHC] don’t know what you don’t tell them” in terms of what happened at the specialist appointment.
What It Means
Previous work on health care safety-net providers concluded that patients do not view FQHCs as providers of last resort but rather prefer FQHCs’ care and services for their convenience and affordability (Ku et al. 2011). Although our results are consistent with these findings, more practical reasons drive some individuals to use FQHCs. Insured individuals report that the main reasons they go to a FQHC is because FQHCs take their insurance; the uninsured go because they cannot afford to go elsewhere.
Interviews also revealed both opportunities and challenges ahead for FQHCs. Many interviewees, for example, reported having largely positive experiences at FQHCs, noting their friendly environment, convenience, and location—important features that FQHCs can build on to expand and to thrive in the post-ACA environment. Findings also suggest that FQHCs have forged relationships with insurance companies, both for employer-sponsored and non–employer sponsored coverage; such relationships could be expanded to draw in more insured patients. In particular, FQHCs have actively pursued contracts with health plans offered through the Marketplaces (Mead et al. 2016). Such contracts provide particular opportunity for safety-net clinics because the ACA requires that qualified health plans available through the Marketplace include a sufficient number and geographic distribution of essential community providers (which include FQHCs).1
On the other hand, interviewees voiced several common complaints, such as long wait times, sick people in the waiting rooms, impersonal treatment, inconsistent providers, and lack of care coordination. Although fragmentation in the US health care system has been widespread and is not unique to FQHCs (Corrigan 2005), the ACA has led to several efforts to improve the way care is organized through delivery system reform (Blumenthal, Abrams, and Nuzum 2015). For FQHCs to thrive, they need to address these issues or risk losing patients. Most but not all FQHC users see themselves as having options, including other FQHCs, for where to receive health care, highlighting that FQHCs are in competition not only with other types of providers but also with each other.
Given both the growing importance of FQHCs to the country’s health care system and the significant investment being made in them, it will be important to track the experience of FQHC patients as the ACA evolves and matures.
Blumenthal, David, Melinda Abrams, and Rachel Nuzum. “The Affordable Care Act at 5 Years.” New England Journal of Medicine 372 (25): 2451–58.
Corrigan, Janet M. 2005. “Crossing the Quality Chasm.” In Building a Better Delivery System: A New Engineering/Health Care Partnership, edited by Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang. Washington, DC: National Academies Press.
Ku, Leighton, Emily Jones, Peter Shin, Fraser Rothenberg Byrne, and Sharon K. Long. “Safety-Net Providers after Health Care Reform: Lessons from Massachusetts.” Archives of Internal Medicine 171 (15): 1379–83.
Mead, Katherine H., Erin Brantley, Julia Zur, and Debora Goetz Goldberg. 2016. “Collaboration across the Safety Net in the Era of Health Reform: Opportunities or Obstacles?” Medical Care Research and Review.
About the Series
This brief is part of a series drawing on the HRMS, a survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.
For more information on the HRMS and for other briefs in this series, visit www.urban.org/hrms.
About the Authors
Christal Ramos is a research associate, Terri Coughlin is a senior fellow, Adam Weiss is a research associate, and Sharon K. Long is a senior fellow with the Urban Institute's Health Policy Center.