All graphs trace trends in the percent of the US population served by an FQHC, defined by the number of FQHC patients in the 50 US states in the demographic group specified, divided by the number of total US residents in that same demographic group. Counts of FQHC patients were determined using the Uniform Data System from the Health Resources and Services administration5 (HRSA) and included all patients seen at HRSA grantee FQHC organizations in the 50 US states. Corresponding population data were gathered yearly from the US Census’s American Community Survey.6 All groups had significant differences in trends when analyzed using ordinary least squares regression with interaction between demographic group and year (P ≤ .001). AI/AN indicates American Indian and Alaska native; FPL, federal poverty line.
Numbers in parentheses indicate a decrease; all others, an increase. CT indicates Connecticut; DC, District of Columbia; DE, Delaware; MA, Massachusetts; MD, Maryland; NH, New Hampshire; NJ, New Jersey; RI, Rhode Island; VT, Vermont; and WV, West Virginia.
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Nath JB, Costigan S, Hsia RY. Changes in Demographics of Patients Seen at Federally Qualified Health Centers, 2005-2014. JAMA Intern Med. 2016;176(5):712–714. doi:10.1001/jamainternmed.2016.0705
Over the past decade, federal support for Federally Qualified Health Centers (FQHCs) has expanded under both the American Recovery and Reinvestment Act and the Affordable Care Act. The 2 expansions paralleled 2 demographic shifts in demand for FQHCs’ safety net health care and social services. The first such shift occurred with the loss of employer-sponsored insurance during the economic recession of 2008-2009; and the second with the expansion of health care coverage under the Affordable Care Act, including 6.5 million persons insured through Medicaid.1 Despite the increasingly important role of FQHCs in primary care in the United States, published analyses examining the trajectory of the FQHC network’s patients predate those expansions, lack population adjustments, or focus on a single demographic variable.2-4 We conducted a study to overcome these shortcomings by describing the changes in the demographics of patients seen by FQHCs over the past decade.
We retrospectively analyzed data on patients seen at FQHCs in all 50 US states from 2005 to 2014, using the Uniform Data System, a publicly available data set of health center operational information from the US Health Resources and Services Administration. We examined the demographic characteristics of FQHC patients including race, ethnicity, income as a percentage of the federal poverty line (FPL), insurance status, and state of residence. Because of changes in race reporting in the Uniform Data System, analyses of trends in race and ethnicity were limited to 2007-2014, and our health insurance analysis was limited to 2008-2014 because of changes in reporting practices by the US Census Bureau. The University of California–San Francisco Committee on Human Research approved this study.
To account for changes in the national population over time, we divided the number of patients in each demographic category by the total population of the United States in the corresponding demographic group in the US Census Bureau’s American Community Survey. To determine the significance of FQHC population trends, we conducted ordinary least squares regressions for each demographic, using an interaction between year and demographic to determine the significance of differential trends by specific demographic strata.
From 2005 to 2014, the proportion of Americans served at FQHCs increased from 5% to 7%, with more than 8.7 million additional Americans seeking care. Medicaid and uninsured populations were served at the highest rates (rate change from 2008 to 2014 for the Medicaid population, 13.5%-17.3% [P < .001 for the regression]; uninsured population, 14.7%-17.2% [P = .001 for the regression]), and the rate of FQHC use grew significantly faster than either Medicare or privately insured populations (rate change for the Medicare population, 3.0%-3.8% [P < .001 for the regression]; privately insured population, 1.2%-1.7% [P < .001 for the regression]) (Figure 1A).
In 2014, more than 1 in 4 persons living in poverty were seen by FQHCs compared with 0.6% of persons who had incomes greater than 200% of the FPL. The proportion of lower-income populations served by FQHCs grew significantly more rapidly over the study period than that of higher income groups (rate change from 2005 to 2014 for those at <100% FPL, 20.7%-25.3%; 100%-150% FPL, 6.0%-8.3%; >150%-200% FPL, 2.6%-3.7%; and >200% FPL, 0.5%-0.6% [for all, P < .001 for the regression]) (Figure 1B).
The rate of FQHC use was consistently highest in the youngest populations. The proportion of 0- to 19-year-olds seen by FQHCs grew at the fastest rate during the study period (from 6.3% to 9.2%; P < .001 for the regression; Figure 1C). There was also significant heterogeneity in the proportion of the population cared for at FQHCs by state (Figure 2).
A higher proportion of patients in minority racial groups, specifically black and American Indian populations, were seen by FQHCs and had service rates with significantly higher growth between 2007 and 2014 compared with the service rates for white or Asian American populations (rate of change for the white population, 3.5%-5.5%; black population, 9.5%-11.3%; American Indian and Alaska native population, 7.8%-10.0%; and Asian American population, 3.0%-4.4% [for all, P < .001 for the regression]) (Figure 1D). The proportion of Hispanic Americans served by FQHCs grew from 11.2% in 2007 to 13.4% in 2014, which was a significantly more rapid rate of growth than that of non-Hispanic Americans (4.1% to 5.7%; P < .001 for the regression).
In contrast to previous work showing a largely stable demographic profile of patients seen at FQHCs in earlier periods,2,3 we found that the proportion of young, low-income, uninsured or Medicaid-insured, and racial and ethnic minority Americans served by FQHCs between 2005 and 2014 increased slightly more rapidly than that of other demographic groups. These underserved groups represent the core populations that FQHCs are meant to serve. In addition, more than 17% of Medicaid and uninsured patients in the United States received care at FQHCs in 2014, which emphasizes the importance of an FQHC partnership in health policy changes aimed at those populations.
Corresponding Author: Renee Y. Hsia, MD, MSc, Department of Emergency Medicine, Philip R. Lee Institute for Health Policy Studies, University of California–San Francisco, 1001 Potrero Ave, Room 1E21, San Francisco, CA 94110 (firstname.lastname@example.org).
Published Online: April 11, 2016. doi:10.1001/jamainternmed.2016.0705.
Author Contributions: Ms Nath had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Nath, Costigan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Nath.
Administrative, technical, or material support: All authors.
Study supervision: Nath, Hsia.
Conflict of Interest Disclosures: None reported.