ABOUT COMMUNITY HEALTH CENTERS

ABOUT COMMUNITY HEALTH CENTERS The National Association of Community Health Centers (NACHC) is pleased to present Community Health Center Chartbook, an overview of the Health Center Program and the communities they serve. Health centers began over fifty years ago as part of President Lyndon B. Johnson s declared War on Poverty. Their aim then, as it is now, is to provide affordable, high quality, comprehensive primary care to medically underserved populations, regardless of their insurance status or ability to pay for services. A growing number of health centers also provide dental, behavioral health, pharmacy, and other important services. No two health centers are alike, but they all share one common purpose: to provide primary and preventive health care services that are coordinated, culturally and linguistically competent, and community-directed. Health centers play a critical role in the U.S. health care system, delivering care to over 25 million* people today. Across the country, health centers produce positive results for their patients and for the communities they serve. They stand as evidence that communities can improve health, reduce health disparities, and deal with a multitude of costly and significant public health and social problems including substance abuse, HIV/AIDS, mental illness, and homelessness if they have the resources to do so. Federal and state support, along with adequate third party reimbursement, are critically important to keep pace with escalating health care needs and rising costs among populations served by health centers. Who health centers serve, what they do, and their impressive record of accomplishment in keeping communities healthy are represented in the following charts. *Includes patients of federally-funded health centers, non-federally funded health centers (health center look-alikes ), and expected patient growth for 2016. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

ABOUT THIS CHARTBOOK This Chartbook highlights data from and research findings on Community, Migrant, Homeless and Public Housing Health Centers, as well as other Federally-Qualified Health Centers (FQHCs). In this document, unless otherwise noted, the term health center is generally used to refer to organizations that receive grants under the Health Center Program as authorized under section 330 of the Public Health Service Act, as amended (referred to as grantees ). Data and research sources can be found at the bottom of each figure. Most slides draw from the Uniform Data System (UDS) maintained by the Bureau of Primary Health Care, HRSA, DHHS. UDS data included in this Chartbook are limited to health centers that meet the federal grant requirements and receive federal funding from the Bureau of Primary Health Care. For more information about UDS data, visit https://bphc.hrsa.gov/uds/datacenter.aspx.

About Community Health Centers About this Chartbook Table of Contents Section I: Who Health Centers Serve Figure 1.1: Health Centers Serve Figure 1.2: Health Center Patients Are Predominately Low Income Figure 1.3: Most Health Center Patients are Members of Racial and Ethnic Minority Groups Figure 1.4: Health Center Patients are Disproportionately Members of Racial/Ethnic Minority Groups Figure 1.5: Health Centers Serve Patients Throughout the Life Cycle Figure 1.6: Most Health Center Patients are Publicly Insured or Uninsured Figure 1.7: Health Center Patient Mix is Unique Among Ambulatory Care Providers Figure 1.8: Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured Figure 1.9: Many Health Center Patients Suffer from Chronic Conditions Figure 1.10: Health Centers Serve Many Special Populations Figure 1.11: Health Centers Serve Disproportionate Amounts of Special Populations Figure 1.12: Health Centers Insurance Revenue Sources Do Not Resemble Those of Private Physicians Section II: Expanding Access to Care Figure 2.1: Health Center Grantee Organizations and Sites, 2006-2015 Figure 2.2: The Number of Health Center Patients and Visits Continues to Increase Figure 2.3: Health Center Patients by Insurance Status, 2006-2015 Figure 2.4: Even as More Patients Receive Insurance, Health Centers are Serving Increasingly More of the Nation s Uninsured Figure 2.5: The Number of Health Center Patients in Poverty is Growing Faster than the Number in Poverty Nationally, 2006-2015 Figure 2.6: The Number of Health Center Medicaid Patients Grew Faster than the Number of Medicaid Beneficiaries Nationally, 2006-2015 Figure 2.7: Health Centers Have Expanded the Breadth of Services Offered to Both New and Existing Patients Figure 2.8: Health Centers Have Expanded Their Capacity to Provide More Services by Employing a Wider Variety of Staff Types and Integrating Care Figure 2.9: Health Centers Have Higher Rates of Accepting New Patients Regardless of Insurance Coverage Compared to Other Primary Care Providers

Figure 2.10: Percent of Uninsured Served by Health Centers, 2014 Figure 2.11: Percent of Medicaid Beneficiaries Served by Health Centers, 2014 Figure 2.12: Federal Health Center Appropriation History, FY2004-2016 Health Centers Provide a Broad Array of Services Section III: High Quality Care and Reducing Health Disparities Figure 3.1: Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians Figure 3.2: Health Centers Exceed Medicaid Managed Care Organization High Performance Benchmark Scores Figure 3.3: Health Center Patients Have Higher Rates of Blood Pressure and Diabetes Control than the National Average Figure 3.4: Health Center Patients Have Lower Rates of Low Birth Weight than the U.S. Average Figure 3.5: Health Centers Provide More Preventive Services than Other Primary Care Providers Figure 3.6: Many Health Centers Exceed Healthy People 2020 Goals by Key Health Outcomes Figure 3.7: Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally Figure 3.8: Health Center Women Needing Mammograms are More Likely to Receive Them than Their Counterparts Nationally Figure 3.9: Health Center Women Needing Pap Smears are More Likely to Receive Them than Their Counterparts Nationally Figure 3.10: Health Center Patients Needing Colorectal Cancer Screenings Are More Likely to Receive Them than Their Counterparts Nationally Figure 3.11: Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts Figure 3.12: Health Centers Reduce Disparities in Medicaid Patients Receipt of New Medications for Uncontrolled Hypertension Compared to Privately Insured Patients Section IV: Cost-Effective Care Figure 4.1: Health Centers Average Daily Cost Per Patient is Lower Compared to All Physician Settings Figure 4.2: Health Centers Save 24% Per Medicaid Patient Compared to Other Providers Figure 4.3: Health Centers Have Lower Total Spending Per Medicaid Patient Compared to Other Providers Figure 4.4: Health Centers Save 35% Per Child, Compared to Other Providers Figure 4.5: Areas with High Health Center Penetration Spend $926 Less per Medicare Beneficiary than Areas with Low Health Center Penetration Figure 4.6: Health Centers are Associated with Lower Total Costs of Care for Medicare Patients Compared to Other Providers Figure 4.7: Health Centers Save $1,263 Per Patient Per Year

Section V: Health Center Services and Staffing Figure 5.1: Health Center Care Team Staff Provide a Broad Array of Services Figure 5.2: Health Centers Medical Services Staff, 2015 Figure 5.3: Health Centers Dental Services Staff, 2015 Figure 5.4: Health Centers Behavioral Health Services Staff, 2015 Figure 5.5: Health Centers Enabling Services Staff, 2015 Figure 5.6: Growth in Health Center Medical Providers, 2006-2015 Figure 5.7: Health Centers are Hiring Non-Physician Providers at Higher Rates than Physicians Section VI: Challenges in Meeting Demand for Care Figure 6.1: Health Center Funding Per Uninsured Patient is Well Below Total Per Patient Cost Figure 6.2: Payments From Third Party Payers are Less Than Cost, 2015 Figure 6.3: Health Center Operating Margins are Less Than Hospital Operating Margins Figure 6.4: 26 States Will Provide Funding to Health Centers in State Fiscal Year 2017 Figure 6.5: Estimated Percent of County Residents Experiencing Shortages of Primary Care Physicians, 2013 Figure 6.6: Health Center Capital Project Plans and Funding Needs

Section I Who Health Centers Serve

Figure 1.1 Note: Includes patients of federally-funded health centers and non-federally funded health centers, and expected patient growth for 2016. Sources: NACHC, 2017. Analysis based on 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. US Census Bureau. Health Insurance Coverage in the United States: 2015. September 2016. Kaiser Family Foundation. Total Monthly Medicaid and CHIP Enrollment: December 2015. US Census Bureau. Income and Poverty in the United States: 2015. September 2016. Kaiser Family Foundation. Population Distribution by Metropolitan Status: 2015.

Figure 1.2 Health Center Patients are Predominately Low Income 151-200% FPL 7% Over 200% FPL 8% 101-150% FPL 15% 100% FPL and Below 71% Note: Federal Poverty Level (FPL) for a family of three in 2015 was $20,090. (See https://aspe.hhs.gov/2015-poverty-guidelines). Based on percent known. Percents may not total 100% due to rounding. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 1.3 Most Health Center Patients are Members of Racial and Ethnic Minority Groups Hispanic/Latino 35% More than one race 4% Asian/Hawaiian/Pacific Islander 5% Black/African American 23% Non-Hispanic/ Latino 65% White 67% 62% of health center patients are members of racial and ethnic minority groups American Indian/Alaska Native 1% Note: Based on percent known. Percents may not total 100% due to rounding. The 62% of health center patients that are members of racial and ethnic minorities is not shown in this figure. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 1.4 Health Center Patients are Disproportionately Members of Racial/Ethnic Minority Groups 40% 35% 30% 25% 20% 15% 10% 5% 0% 35% 18% 23% 13% Hispanic/Latino African American/Black Asian/Hawaiian/Pacific Islander Health Centers 5% United States 6% 1% 1% American Indian/Alaska Native Sources: Based on 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. U.S. Census Bureau, Population Division: Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States, States, and Counties: April 1, 2010 to July 1, 2015 Released June 2015.

Figure 1.5 Health Centers Serve Patients Throughout the Life Cycle Ages 65+ 8% Under 5 10% Ages 45-64 24% Ages 5-12 14% Ages 13-19 10% Ages 25-44 27% Ages 20-24 7% Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Note: Percents may not total 100% due to rounding.

Figure 1.6 Most Health Center Patients are Publicly Insured or Uninsured Other Public Insurance 1% Medicare 9% Private 17% Uninsured 24% Medicaid 49% Notes: Percents may not total 100% due to rounding. Other public insurance may include non-medicaid CHIP and state-funded insurance programs. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 1.7 Health Center Patient Mix is Unique Among Ambulatory Care Providers 100% 90% 17% 1% 10% 11% 80% 70% 60% 50% 40% 30% 20% 10% 0% 24% 36% 60% Other/Unknown 9% Private 15% Uninsured 4% 20% Medicare Medicaid 49% 27% 30% 13% Health Center Private Physician Emergency Department Note: Private Physician and Emergency Department numbers may not add up to 100% because of rounding and more than one category could be indicated. Sources: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. National Ambulatory Medical Care Survey, 2013. Table 7. Expected Sources of Payment at Office Visits: United States, 2013. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2013. Table 6. Expected Sources of Payment at Emergency Department Visits: United States, 2013.

Figure 1.8 Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 24% 9% 49% 20% 71% 14% Uninsured Medicaid At or below 100% of Poverty Health Centers United States 92% 32% Under 200% of Poverty Poverty levels based on percent known. Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation, State Health Facts Online, www.statehealthfacts.org. US Census Bureau. March 2015 Current Population Survey (CPS: Annual Social and Economic Supplements).

Figure 1.9 Many Health Center Patients Suffer From Chronic Conditions Percent of patients who report ever being told they have: Percent of patients reporting: 45% 40% 35% 30% 42% 33% 32% 25% 20% 15% 10% 5% 22% 15% 22% 0% High cholesterol Hypertension Asthma Diabetes* Health is fair or poor * Other than during pregnancy. Source: 2014 Health Center Patient Survey. Bureau of Primary Health Care, HRSA, DHHS. Needed mental health care in the past year

Figure 1.10 Health Centers Serve Many Special Populations 910,172 Agricultural Worker Patients 1,191,772 Homeless Patients 649,132 School-Based Health Center Patients 305,520 Veteran Patients 1,510,842 Public Housing Patients Source: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

Figure 1.11 Health Centers Serve Disproportionate Amounts of Special Populations 6% 5% 3% 0.95% 0.18% 0.68% Migratory/Seasonal Farmworkers Homeless Persons Residents of Public Housing Percent of HC Population Percent of US Population Sources: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. National Center for Farmworker Health, Inc. Farmworker Factsheet. August 2012. National Alliance to End Homelessness. The State of Homelessness in America, 2015. Center on Budget and Policy Priorities. Policy Basics: Public Housing. May 31, 2016. US Census Bureau. March 2015 Current Population Survey (CPS: Annual Social and Economic Supplements).

Figure 1.12 Health Centers Insurance Revenue Sources Do Not Resemble Those of Private Physicians 100% 7% 4% 80% 60% 13% 10% 2% 60% Self-Pay/Uninsured Private Insurance Other Public Insurance 40% 20% 68% 27% Medicare Medicaid/SCHIP 0% Health Center 13% Private Physicians Note: Health Centers includes third party revenue only. Private Physicians does not equal 100% because more than one category could be indicated. Numbers also may not add to 100% because of rounding. Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. National Ambulatory Medical Care Survey, 2013. Table 7. Expected Sources of Payment at Office Visits: United States, 2013.

Section II Expanding Access to Care

Number of Grantee Organizations Number of Sites Figure 2.1 Health Center Grantee Organizations and Sites, 2006-2015 1,600 12,000 1,400 1,200 1,000 800 1,002 6,139 1,131 1,124 1,128 1,067 1,080 7,621 8,320 6,612 7,257 6,949 1,375 1,198 1,202 1,278 10,000 9,754 8,912 9,170 8,801 8,000 6,000 600 4,000 400 200 2,000-2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 - Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Total Patients (in millions) Figure 2.2 The Number of Health Center Patients and Visits Continues to Increase 30 25 20 15 10 5 62% growth in patients and 64% growth in visits since 2006 15.0 59.2 16.1 63.0 17.1 66.9 18.8 73.8 19.5 77.1 20.2 80.0 21.1 83.8 21.7 85.6 22.9 90.4 24.3 97.0 120 100 80 60 40 20 Total Patient Visits (in millions) 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Number of Patients (in millions) Figure 2.3 Health Center Patients by Insurance Status, 2006-2015 12 11 10 9 8 7 6 5 4 3 2 1 0 0.4 6.0 6.2 5.3 6.6 5.7 6.1 7.2 6.9 7.5 8.0 7.3 7.4 8.4 8.8 7.6 7.6 2.3 2.5 2.7 2.7 2.7 2.9 3.0 3.1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 2.0 2.2 0.4 0.5 0.5 10.7 6.4 3.6 5.9 4.1 0.5 0.5 0.5 0.4 0.3 0.2 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 11.9 Medicaid Uninsured Private Medicare Other Public Insurance Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 2.4 Even as More Patients Receive Insurance, Health Centers are Serving Increasingly More of the Nation s Uninsured Note: Proportion of all US residents does not account for health centers located in U.S. territories. Sources: 2012 and 2015 Uniform Data System. Bureau of Primary Health Care. HRSA, DHHS. U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2012. Current Population Reports, P60-245. and Health Insurance Coverage in the United States: 2015. Current Population Reports, P60-257.

Percent Growth Figure 2.5 The Number of Health Center Patients in Poverty is Growing Faster than the Number in Poverty Nationally, 2006-2015 60% 50% 54% 40% 30% 20% 18% 10% 0% Health Center Low Income Low Income Nationally Note: Represents patients/people under 100% of the federal poverty level. Source: 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. US Census Bureau, Historical Poverty Data, Table 2: Poverty Status of People By Family Relationship, Race, and Hispanic Origin.

Percent Growth Figure 2.6 The Number of Health Center Medicaid Patients is Growing Faster than the Number of Medicaid Beneficiaries Nationally, 2006-2015 140% 120% 125% 100% 80% 72% 60% 40% 20% 0% Health Center Medicaid Medicaid Nationally Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation. Medicaid Enrollment Snapshot: December 2013. Table A-2: Total Medicaid Enrollment by State, December 2006 2013.

Figure 2.7 Health Centers Have Expanded the Breadth of Services Offered to Both New and Existing Patients Note: Behavioral health refers to mental health and substance abuse. Sources: 2015 and 2010 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 2.8 Health Centers Have Expanded Their Capacity to Provide More Services by Employing a Wider Variety of Staff Types and Integrating Care Note: Behavioral health refers to mental health and substance abuse. Sources: 2015 and 2010 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 2.9 Health Centers Have Higher Rates of Accepting New Patients Compared to Other Primary Care Providers 120% 100% 98% 97% 93% 96% 80% 66% 76% 81% 60% 40% 39% 20% 0% New Patients New Medicaid Patients New Medicare Patients New Uninsured Health Center Other Primary Care Providers Source: Hing E, Hooker RS, Ashman JJ. Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 June; 36(3): 406-13.

Figure 2.10 Percent of Uninsured Served by Health Centers, 2015 31% 24% 36% 39% 8% 32% 10% 25% 40% 30% 12% 25% 31% 30% 12% Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation. Distribution of the Nonelderly Uninsured. U.S. Census American Fact Finder. Health Insurance Coverage Status, 2015 American Community Survey 1-year Estimates, Puerto Rico. 17% 25% 23% 12% 28% 12% 15% 27% 26% 15% 23% 13% 31% 25% 22% 18% 16% 18% 21% 14% 18% 30% 12% 18% 20% 18% 25% 51% CT 26% DC 44% DE 20% MA 41% MD 14% NH 18% NJ 18% RI 37% VT 32% % of Uninsured Served by Health Centers < 15.2% 15.2 21.8% 21.8 27.6% 27.6 36.8% >36.8%

Figure 2.11 Percent of Medicaid Beneficiaries Served By Health 21% 32% Centers, 2015 11% 12% 21% 8% 14% 18% 13% 16% 5% 15% 14% 13% 6% 10% 24% 16% 12% 8% 21% 24% 27% 14% 24% 8% 16% 6% 8% 17% 14% 8% 8% 14% 11% 6% 14% 7% 25% Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Monthly Medicaid and CHIP Enrollment, December 2015, Kaiser Commission on Medicaid and the Uninsured. Medicaid.gov. Puerto Rico. Monthly Medicaid and CHIP Enrollment Data. 14% 16% 16% CT 30% DC 35% DE 8% MA 21% MD 13% NH 15% NJ 17% RI 31% VT 26% % Medicaid Patients Served by Health Centers < 8.04% 8.04 13.34% 13.34 15.84% 15.84 22.26% >22.62%

Appropriations (in billions) $6.0 $5.0 Figure 2.12 Federal Health Center Appropriation History, FY2004-FY2016 $5.1 $5.1 $5.1 $4.0 $3.69 $3.0 $2.0 $1.78 $1.99 $2.07 $2.19 $2.19 $2.60 $2.78 $2.99 $1.0 $- FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 Note: Federal appropriations are for consolidated health centers under PHSA Section 330. Federally funded health centers only.

Section III High Quality Care and Reducing Health Disparities

Figure 3.1 Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians No electroardiogram screening in low-risk patients 99% 93% No use of benzodiazepines in depression 91% 84% Blood pressure screening 90% 86% β-blocker use in coronary artery disease 47% 59% Health Centers Aspirin use in coronary artery disease Ace inhibitor use in congestive heart failure 57% 44% 51% 37% Private Practice Physicians Prescription of new antihypertensive medication for uncontrolled hypertension* 18% 16% 0% 20% 40% 60% 80% 100% 120% Percentage of Patients Sources: Goldman, LE et al. Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures. American Journal of Preventive Medicine. 2012. 43(2):142-149. *Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians Offices. Health Services Research. April 2017. 52:2.

Share of Patients Meeting Quality Benchmark Figure 3.2 Health Centers Exceed Medicaid Managed Care Organization High Performance Benchmark Scores 90% 80% 70% 60% 79% 71% 73% 63% 62% 62% 81% 54% 72% 50% 40% 30% 20% 10% 0% Diabetes Control Blood Pressure Control Pap Test Average Rate in High-Performing Health Centers Average Rate in All Health Centers Medicaid MCO High Performance Benchmark (75 th percentile) Note: Quality Measures include control of diabetes: share of patients with diabetes with HbA1c between 7% and 9%; Control of hypertension: share of patients with hypertension with blood pressure < 140/90 mm Hg; Pap Tests: share of female patients age 24 64 who received Pap test within past three years. Source: Shin P, Sharac J, Rosenbaum S, Paradise J. Quality of care in community health centers and factors associated with performance. Kaiser Commission on Medicaid and the Uninsured Report #8447 (June 2013).

Figure 3.3 Health Center Patients Have Higher Rates of Diabetes and Blood Pressure Control than the National Average 80% 70% 70% 64% 60% 50% 54% 52% 40% 30% Health Centers National 20% 10% 0% Diabetes* Blood Pressure * Estimated percentage of patients with Hba1c < 9% Estimated percentage of patients with blood pressure < 140/90 Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. NCHS Data Brief. No. 220. November 2015. Hypertension Prevalence and Control Among Adults: United States, 2011 2014. National Committee for Quality Assurance. Comprehensive Diabetes Care, The State of Health Care Quality (2016).

Figure 3.4 Health Center Patients Have Fewer Low Birth Weight Babies than the US Average 8.2% 8.0% 8.1% 7.9% 8.0% 8.0% 8.0% 8.1% 7.8% 7.6% 7.4% 7.4% 7.4% 7.3% 7.3% 7.6% 7.2% 7.1% 7.0% 6.8% 6.6% 2010 2011 2012 2013 2014 2015 United States Health Centers Sources: 2010-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics (NCHS).

Figure 3.5 Health Centers Provide More Preventive Services than Other Primary Care Providers Health Education 37% 51% Immunizations for 65 years and older 70% 65% Pap Smears in the last 3 years 85% 81% Tobacco Cessation Education for Smoking Patients 19% 33% Asthma Education for Asthmatic Patients 15% 24% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Health Center Patients Visits Patient Visits to Other Providers Source: Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients. J Ambul Care Manage 32(4): 342 50. Shi L, Leburn L, Tsai J and Zhu J. (2010). Characteristics of Ambulatory Care Patients and Services: A Comparison of Community Health Centers and Physicians' Offices J Health Care for Poor and Underserved 21 (4): 1169-83. Hing E, Hooker RS, Ashman JJ. (2010). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 Jun; 36(3): 406 13.

Figure 3.6 Many Health Centers Exceed Healthy People 2020 Goals by Key Health Outcomes 100% 90% 80% 70% 60% 50% 40% % Meeting or Exceeding Healthy People 2020 Goal 37% 60% 93% 30% 20% 15% 10% 0% Hypertension Control Diabetes Control Low Birth Weight Meet or Exceed at Least One Goal Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Office of Disease Prevention and Health Promotion. Healthy People 2020. 2020 Topics and Objectives.

Figure 3.7 Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally 100% 96% 98% 90% 87% 80% 70% 60% 50% 40% 37% 30% 20% 10% 0% Satisfied with Hours of Operation Health Center Patients Satisfied with Overall Care Received Low Income Patients Nationally 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.

Figure 3.8 Health Center Women Needing Mammograms are More Likely to Receive Them than Their Counterparts Nationally 90% 80% 70% 60% 50% 40% 30% 20% 10% 82% 76% 67% 69% 61% 63% 50% 37% 0% Hispanic Black In Poverty* Uninsured Health Centers Nationally *Includes women below 100% FPL or at 100% FPL and below Source: Health Resources and Services Administration, 2014 Health Center Patient Survey. Female Health Center Patients Aged 40+ Who Had a Mammogram in the Past 2 Years. US Census Bureau. Health, United States, 2015. Table 70. Use of Mammography Among Women Aged 40 and Over, by Selected Characteristics: United States, Selected Years 1987 2013.

Figure 3.9 Health Center Women Needing Pap Smears are More Likely to Receive Them than Their Counterparts Nationally 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 92% 71% 89% 75% Hispanic Black In Poverty* Uninsured Health Centers 82% Nationally *Includes women below 100% FPL or at 100% FPL and below Source: Health Resources and Services Administration, 2014 Health Center Patient Survey. Female Health Center Patients Aged 18+ Who Had a Pap Smear in the Past 3 Years. US Census Bureau. Health, United States, 2015. Table 71. Use of Pap Smears Among Women Aged 18 and Over, by Selected Characteristics: United States, Selected Years 1987 2013. 61% 76% 58%

Figure 3.10 Health Center Patients Needing Colorectal Cancer Screenings Are More Likely to Receive Them than Their Counterparts Nationally 60% 50% 40% 30% 20% 10% 55% 55% 57% 54% 38% 41% 0% Hispanic Black In Poverty* Health Centers Nationally *Includes individuals below 100% FPL or at 100% FPL and below Source: Health Resources and Services Administration, 2014 Health Center Patient Survey. Health Center Patients Aged 50+ Who Ever Had a Colonoscopy. US Census Bureau. Health, United States, 2015. Table 72. Use of Colorectal Tests or Procedures Among Adults Aged 50-75, by Selected Characteristics: United States, Selected Years 2000 2013.

Figure 3.11 Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts 16.0% 14.0% 12.0% 13.0% 14.9% 10.7% If the black-white low birth weight disparity seen at health centers could be achieved nationally, there would be 17,100 fewer black low birth weight infants annually. 10.0% 8.0% 6.0% 8.2% 7.7% 7.5% 7.5% 7.5% 6.6% 6.5% 6.8% 6.0% 5.6% 9.1% 7.4% 4.0% 2.0% 0.0% Total Asian Black Hispanic White US US Low Income Health Center Source: Shi, L., et al. America s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes. 2004. Health Services Research, 39(6), Part I, 1881-1901.

Figure 3.12 Health Centers Reduce Disparities in Medicaid Patients Receipt of New Medications for Uncontrolled Hypertension Compared to Privately Insured Patients 25% 20% 15% % of Medicaid Patients Receiving New Medication for Uncontrolled Hypertension 21% Health Centers Private Practice Physicians 10% 9% 5% 0% Source: Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians Offices. Health Services Research. April 2017. 52:2.

Section IV Cost Effective Care

Average Daily Cost Per Patient Figure 4.1 Health Centers Average Daily Cost Per Patient is Lower Compared to All Physician Settings $3.50 $3.00 $3.06 $2.50 $2.00 $2.09 $1.50 $1.00 $0.50 $0.00 All Physician Settings Health Centers Source: 2014 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS., Agency for Healthcare Research and Quality. Medical Expenditure Survey. Table 8.1a: Office-based Medical Provider Services-Mean and Median Expenses per Person with Expense and Distribution of Expenses by Source of Payment: United States, 2014. Visits to physicians only.

Figure 4.2 Health Centers Save 24% Per Medicaid Patient Compared to Other Providers $12,000 $10,000 $8,000 24% lower spending $7,518 $9,889 $6,000 $4,000 $2,000 $0 23% lower spending $1,845 $1,430 Primary Care 33% lower spending $2,948 $2,704 $2,324 $1,964 Other Outpatient Care 14% lower spending $216 $244 $2,047 $1,496 Rx Drug Spending Emergency Room Inpatient Care Total Spending Health Centers 11% lower spending Non-Health Centers 27% lower spending Note: Non-health centers include private physician offices and outpatient clinics. Source: Nocon et al. Health care use and spending for Medicaid enrollees in federally qualified health centers versus other primary care settings. AJPH. November 2016. 106(11): 1981-1989.

Percent Lower Spending in State Studied 70% 60% 63% lower Fig. 4.3 Health Centers Have Lower Total Spending per Medicaid Patient Compared to Other Providers 50% 40% 30% 20% 22% lower 26% lower 19% lower 32% lower 27% 27% lower lower 19% lower 29% lower 22% lower 15% lower 18% lower 10% 0% AL CA CO CT FL IA IL MS NC TX VT WV Notes: Non-health centers include private physician offices and outpatient clinics. MT was included in the national-level analyses, but did not have a large enough sample size to be included in the adjusted state-level analyses Source: Nocon et al. Health care use and spending for Medicaid enrollees in federally qualified health centers versus other primary care settings. AJPH. November 2016. 106(11): 1981-1989.

Average Annual Cost per Child Figure 4.4 Health Centers Save 35% Per Child, Compared to Other Providers $2,000 35% lower spending $1,800 $1,751 $1,600 $1,400 Health Centers Non-Health Centers $1,200 $1,000 $1,133 40% lower spending $800 $600 $400 $418 $697 49% lower spending $320 $200 $163 $0 Total Ambulatory Prescription Drugs Source: Bruen B, Ku L. Community health centers reduce the costs of children s health care. Geiger Gibson/RCHN Community Health Foundation Research Collaborative. Policy Research Brief #48. June 20, 2017.

Total Medicare Cost per Beneficiary Figure 4.5 Areas with High Health Center Penetration Spend $926 Less per Medicare Beneficiary than Areas with Low Health Center Penetration $9,900 $9,600 $9,300 10% Lower Medicare Spending in Areas with High Health Center Penetration $9,542 $9,222 $9,000 $8,700 $8,616 $8,400 $8,100 High Health Center Penetration Area Low Health Center Penetration Area All Areas Notes: High health center penetration corresponds to 54% health center penetration rate among low-income residents; Low health center penetration corresponds to 3% health center penetration rate among low-income residents; Average health center penetration rate among low-income residents was 21%. Source: Sharma R, Lebrun-Harris L, Ngo-Metzger Q. Costs and Clinical Quality Among Medicare Beneficiaries: Associations with Health Center Penetration of Low-Income Residents. Medicare & Medicaid Research Review. 2014; 4(3):E1-E17.

Figure 4.6 Health Centers Are Associated with Lower Total Costs of Care for Medicare Patients Compared to Other Providers $4,000 $3,500 $3,000 10% lower than physician office patients and 30% lower than outpatient clinic patients $2,667 $3,580 $2,500 $2,370 $2,000 $1,500 $1,000 $500 $0 Health Centers Physician Offices Outpatient Clinics Source: Mukamel DB, White LM, Nocon RS, et al. Comparing the cost of caring for Medicare beneficiaries in federally funded health centers to other care settings. Health Serv Res. April 2016. 51(2): 625-644.

Fig. 4.7 Health Centers Save $1,263 Per Patient Per Year $6,000 $5,306 $5,000 $4,000 $3,000 $2,000 $4,043 Hospital Emergency Department Hospital Inpatient Ambulatory Other Services $1,000 $0 Health Center Users Non - Health Center Users Source: NACHC analysis based on Ku et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.

Section V Health Center Services and Staffing

Figure 5.1 Health Center Care Team Staff Provide a Broad Array of Services 21% Other Medical Personnel 2% Laboratory 1% X-Ray 10% Physicians 9% NPs/Pas/CNMs 1% Other Professional Services 13% Nurses 20% Enabling and Other Programs and Services 3% Pharmacy 7% Behavioral Health 12% Dental 104,531.7 Total Full Time Equivalent Care Team Staff Notes: Percents may not total 100% due to rounding. NPs/Pas/CNMs represents Nurse Practitioners/Physicians Assistants/Certified Nurse Midwives. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 5.2 Health Center Medical Services Staff, 2015 Other Medical Personnel 44% Total Physicians 18% Nurses 23% Total NPs, PAs, CNMs 15% Total Medical Personnel = 67,627.62 Full Time Equivalents Obstetrician/ Gynecologists 10% Pediatricians 22% Internists 16% General Practitioners 3% Other Specialty Physicians 3% Total Physicians = 11,867.21 Full Time Equivalents Family Physicians 46% Note: Total Physicians excludes Psychiatrists and Optometrists. NP, PA, CNM stands for Nurse Practitioners, Physician Assistants, Certified Nurse Midwives. Other Medical Personnel includes Laboratory personnel and X-Ray personnel. Percents may not total 100% due to rounding. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 5.3 Health Center Dental Services Staff, 2015 Total Dental Personnel = 14,557.84 Full Time Equivalents Dentists 28% Dental Assistants, Aides, Techs 59% Dental Hygienists 13% Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Percents may not total 100% due to rounding.

Figure 5.4 Health Center Behavioral Health Services Staff, 2015 Other Mental Health Staff 23% Substance Abuse Services 11% Psychiatrists 7% Licensed Clinical Psychologists 8% Total = 8,740.39 Full Time Equivalents Other Licensed Mental Health Providers 22% Licensed Clinical Social Workers 30% Note: Percents may not total 100% due to rounding. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 5.5 Health Center Enabling Services Staff, 2015 Other Enabling Services Interpretation Staff 3% 5% Total = 18,859.49 Full Time Equivalents Eligibility Assistance Workers 25% Case Managers 36% Transportation Staff 3% Outreach Workers 15% Note: Percents may not total 100% due to rounding. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Patients/Community Education Specialists 14%

Figure 5.6 Growth in Health Center Medical Providers, 2006-2015 18,000 16,000 14,000 12,000 10,000 56% Increase 11,867 141% Increase 10,332 81% Increase 15,857 190% Increase 133% Increase 14,558 8,000 6,000 7,595 8,776 8,740 6,250 4,000 2,000 4,292 3,018 - Physicans NPs, PAs, CNMs Nurses Behavioral Health Staff Dental Staff 2006 2015 Note: NP, PA, CNM stand for Nurse Practitioners, Physician Assistants, Certified Nurse Midwives, respectively. Behavioral Health Staff includes Substance Abuse staff. Sources: 2006 and 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 5.7 Health Centers are Hiring Non-Physician Providers at Higher Rates than Physicians Ratio of PA, NP, and CNM FTEs to Physician FTEs 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.54 0.55 0.54 0.55 0.56 0.57 0.59 0.61 0.63 0.66 0.70 0.72 0.76 0.81 0.87 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Notes: PA, NP, and CNM stand for Physician Assistant, Nurse Practitioner, Certified Nurse Midwife, respectively. FTE stands for Full-Time Equivalent. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Section VI Challenges in Meeting Demand for Care

Figure 6.1 Health Center Funding Per Uninsured Patient Is Well Below Total Per Patient Cost 900 800 700 600 500 $538 $562 $588 $600 $630 $654 $687 $721 $504 $763 $624 $827 400 300 $267 $270 $281 $271 $273 $312 $344 $374 200 100 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Annual Health Center Funding per Uninsured Patient Annual Health Center Total Cost per Total Patient Note: Not adjusted for inflation. Federal appropriations are for consolidated health centers under PHSA Section 330. Source: 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.

Figure 6.2 Payments from Third Party Payers Are Less Than Cost, 2015 Percent of Charges Collected From Third Party Payers 90% 80% 82% 70% 60% 56% 60% 57% 50% 40% 30% 20% 10% 0% Note: Health centers are non-profits, and thus charges are a proxy for costs. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Medicaid Medicare Other Public Insurance Private Insurance

Figure 6.3 Health Center Operating Margins are Less than Hospital Operating Margins 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% -1.0% -2.0% -3.0% 3.3% Hospital Health Centers with American Recovery and Reinvestment ACT (ARRA) Funds Health Centers without American Recovery and Reinvestment ACT (ARRA) Funds 3.6% 3.7% 0.5% 0.9% 1.0% 4.0% 0.2% 4.3% 0.8% 3.3% -0.1% -1.1% 4.4% 1.8% 5.5% 5.5% 3.4% -2.4% 4.7% -0.2% Thanks to ARRA funding between 2009 and 2014, health center operating margins nationally were higher, but were still below those of hospitals. 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 6.5% 3.4% 1.6% 5.7% 1.6% 1.1% 6.4% 3.02% 2.63% 4.3% Note: Operating margin data for Hospitals in 2015 is unavailable. Sources: 2003 2015 Uniform Data System. Bureau of Primary Health Care, HRSA. DHHS. American Hospital Association. Trendwatch Chartbook 2016: Trends Affecting Hospitals and Health Systems. Supplementary Data Tables. Table 4.1: Aggregate Total Hospital Margins and Operating Margins; Percentage of Hospitals with Negative Total Margins; and Aggregate Non-operating Gains as a Percentage of Total Net Revenue, 1994 2014.

Figure 6.4 26 States Will Provide Funding to Health Centers in State Fiscal Year 2017 WA NH MT ND VT ME CA OR NV AK ID AZ UT WY CO NM HI SD NE KS OK TX MN IA MO AR LA WI IL MS MI PA OH IN WV VA KY NC TN SC GA AL FL NY DC NJ DE MD MA RI CT None Less than $2 million $2 million to $5 million $5 million to $10 million $10 million to $50 million $50 million to $80 million No data available PR Source: NACHC 2016. 2016 Annual Primary Care Association (PCA) Assessment.

Figure 6.5 Estimated Percent of County Residents Experiencing Shortages of Primary Care Physicians, 2013 62 million people experience inadequate or no access to primary care because of shortages of physicians in their communities Source: Created by The Robert Graham Center (2014). US Census 2010; HRSA Data Warehouse 2014 HPSA and MUA/P shapefiles; AMA Masterfile 2013; UDS Mapper 2014. The Medically Disenfranchised and the Shortage of Primary Care: The Role of Health Centers in Improving Access to Care. NACHC. March 2014.

Figure 6.6 Health Center Capital Project Plans and Funding Needs, 2015 79% of health centers have plans to initiate capital projects within the next several years. These plans represent 2,300 capital projects These planned projects are estimated to cost $4.6 billion: which will result in 12 million square feet of new space, accommodating 6,100 new providers who will serve 5.4 million new patients annually However 75% of health centers report funding gaps for these planned projects Source: CapLink. Health Center Capital Project Plans and Funding Needs. 2015.