Community Health Centers, COVID‐19, and Potential Vulnerability to Lapses in Federal Funding

RESEARCH OBJECTIVE: The Community Health Center Fund (CHCF) was created by the Affordable Care Act in 2011 to increase access to federally qualified health centers (FQHCs), and now comprises the majority of federal Section 330 funds that support FQHCs. The CHCF, however, has faced numerous expirations and short‐term extensions since 2015, which could pose challenges to long‐term planning, especially for FQHCs that rely more on federal funds. To examine the potential implications of changes or lapses in federal funding, we identified FQHCs that likely receive a larger share of revenue from federal funds and compared their local area traits with other FQHCs. STUDY DESIGN: We used publicly available data for 2010–2018 from the Uniform Data System, which contains information on FQHC traits, patient volume, and non‐patient revenue. Because total and patient revenue were unavailable, we classified FQHCs as receiving a high share of total revenue from Section 330 funding if >75% of their non‐patient revenue was from Section 330 funding and > 25% of their patients were uninsured (as a proxy for patient revenue). We assessed the association between annual changes in Section 330 funding and FQHC patient volume for FQHCs meeting this classification vs. not, using multivariate linear regression with FQHC‐level random effects. We then compared FQHCs with vs. without a high share of revenue from Section 330 funding in 2018 using multivariate logistic regression. Lastly, we compared county‐level COVID‐19 mortality data for these FQHCs. POPULATION STUDIED: FQHCs, excluding those in US territories, that received Section 330 funding 2010–2018 (N = 1258 in 2018). PRINCIPAL FINDINGS: Although the mean proportion of uninsured FQHC patients decreased from 38.2% to 23.9% from 2010–2018, more FQHCs were classified as having a high Section 330 revenue share: 7.9% in 2010 (N = 80) versus 16.2% in 2018 (N = 203). The positive association between annual changes in Section 330 funding and patient volume was greater for FQHCs classified as having high Section 330 revenue share vs. not (+0.05 percentage point greater increase in patient volume [95% CI: 0.03–0.07] for a 1‐ppt increase in funding). In 2018, compared to other FQHCs, those with a high Section 330 revenue share were smaller, more often located in the South (68.5% vs. 27.7%; aOR = 2.94, 95% CI: 1.27–6.81 vs. Northeast) and primary care shortage areas (57.6% vs. 30.1%; aOR = 1.92, 95% CI: 1.23–3.00), and less likely in Medicaid expansion states (35.5% vs. 77.7%, aOR = 0.33, 95% CI: 0.21–0.52). In bivariate analyses, FQHCs with high Section 330 revenue share were located in counties with higher mean COVID‐19 mortality rates (e.g., 102.2 vs. 84.8 deaths/100,000 for May–December 2020, p < 0.001). CONCLUSIONS: Patient volume was more responsive to changes in Section 330 funding for FQHCs with high proportions of uninsured patients and non‐patient revenue from Section 330 funds. FQHCs that could be more vulnerable to lapses in federal funding are more frequently located in the South, primary care shortage areas, states without Medicaid expansion, and counties with higher COVID‐19 mortality rates. IMPLICATIONS FOR POLICY OR PRACTICE: These findings underscore the importance of longer‐term reauthorization of the CHCF to maintain consistent access to safety net care for underserved populations, including those disproportionately impacted by COVID‐19. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.