With National Health Center Week just wrapping up a couple of weeks ago (August 3-9, 2025), I think it is timely to highlight the work and obstacles that our community health centers across the country are facing, especially in light of increased regulation and decreased funding.
What Are Community Health Centers?
First off, for those of you who aren’t aware, Community Health
Centers (CHCs) or Federally Qualified Health Centers (FQHCs) as they are also
known are community-based health clinics that provide primary care and, in many
cases, also provide other comprehensive services such as mental health, dental, pharmacy,
and other key services designed to strengthen the health of the communities that
they serve. These health centers are patient-governed with at least 51% of
their board members being comprised of patients of the health center and the board
composition matching the demographics of the community in which they operate.
These FQHCs typically operate in underserved areas ensuring essential access to
health care services for those who might have barriers to access elsewhere such
as cost, no insurance, or language differences. FQHCs offer sliding fee
schedules to accommodate those who don’t have insurance and might not be able
to fully pay for their health care treatment. These health care centers provide
a health care “safety net” for the populations that they serve ensuring that
they always have access to essential health care services to improve the health
of the communities they serve.
How Are FQHCs Funded?
Now that we all know what FQHCs are and the essential services that they provide, let’s talk a little bit about how they are funded. Like all health care providers, FQHCs have a mix of payors that fund or reimburse them for the services that they provide. These payors can include Medicaid programs, Medicare, federal grants, and to a lesser extent, commercial insurance payors. Additional sources of funding may also include private grants and donations. Federal grants for FQHCs are administered by the Health Resources and Services Administration (HRSA) which is part of the Department of Health and Human Services (HHS). These are competitive grants where potential grantees have to demonstrate need in their community and ability to serve that need. HRSA then looks at all grant applications and determines which communities have the most demonstrated need based on socioeconomic, demographic, and available health care resources to determine which areas qualify for the limited new grant funding available each year. Once a grant is awarded, a grantee has to continue to demonstrate performance through the annual submission of Uniform Data Systems (UDS) reports to HRSA which provide information on patient demographics, services, and outcomes which HRSA then uses to assess program performance and recommend quality improvement programs. Additionally, FQHCs are subject to intensive weeklong site visits either annually for newer or lesser performing FHQCs to every three years for more mature, higher performing grantees.
To be clear, FQHCs probably
have some of the most rigorous reporting and review requirements of any federal
grantees and taxpayers can be assured that money spent on this program is not
only put to the use that it was intended, but that those dollars are achieving
measurable outcomes in the communities in which they are invested. The word "invested" in the last sentence is critical here as these programs aren’t
entitlements as some politicians would like to frame them, but rather they are
investments in the health of communities all around our country. Without healthy
communities, we truly cannot have a healthy country, and these programs are
quietly contributing to overall health and well-being of our country one
community at a time.
Another service that many FQHCs provide is pharmacy services
through a program administered by HRSA known as the 340B program. This program
allows eligible entities such as FQHCs to access drugs from pharmaceutical manufacturers
at deeply discounted rates. The FQHCs in turn use these savings to provide free
or reduced-cost prescriptions to patients. In many cases, these pharmacies
operated by FQHCs are the only pharmacy available in the community.
So, now that we have discussed what FQHCs are and their importance to the overall health and wellbeing of our communities, let’s talk about the challenges that FQHCs face. I am going to break these down into the following categories:
- Funding
- Workforce Shortages
- Administrative Burdens and Regulation
Funding
We have talked a little bit about the sources of funding
that FQHCs face. Unfortunately, most of those sources are under continuous political
attack. The recently passed “One Big Beautiful Bill” is anticipated to result
in the loss of Medicaid coverage for over 10 million people according to the
Congressional Budget Office (CBO). Many of these recipients are currently
patients of FQHCs and will probably remain patients in some respect even after
they lose their Medicaid coverage. This means that in these cases, instead of
receiving reimbursement from Medicaid for the essential services provided to
these patients, these FQHCs will be providing care on a greatly reduced sliding
fee scale which doesn’t even come close to covering the cost of those services.
When an FQHC receives full Medicaid payment for a patient visit, that payment
may only cover about 82% of the cost of providing the service. If that service
has to be provided for only a nominal fee or even free under a sliding fee
scale, that problem is greatly amplified. At the same time, grant funding is
stagnate and has not kept up with inflation. Grant funding is what FQHCs depend
on to bridge the gap between what they receive on fee-for-service basis to
provide services and what those services actually cost. So, with inflation raising
the cost of those services, fewer patients being eligible for Medicaid, and
stagnate or even decreasing HRSA grant funding available to bridge the cost gap
of those services, you can see how our system of FQHCs is becoming increasingly
vulnerable to funding challenges. Without changes to how we prioritize and fund
this valuable work, many of these essential health care centers providing safety
net services are going to be forced close their doors in the coming years.
Workforce Shortages
While staffing and workforce shortages are rampant across
our entire health care system, especially after COVID, the impact on FQHCs is
even more dramatic. With limited funding, FQHCs struggle to compete with
larger, private sector health care entities that can offer higher benefits and
salaries. On top of that, many FQHCs are in rural areas which just adds to the
difficulty in recruiting and retaining talent. Add to that the ever-increasing
demand for FQHC services resulting in heavy workloads and high patient volumes and
you have a recipe for staff burnout and dramatic staff turnover.
Administrative Burdens and Regulation
The administrative burdens and associated costs of running an
FQHC are great. We already discussed the fact that FQHCs are under strict
oversight by HRSA requiring submission of detailed UDS reports every year and
intensive site visits, not to mention whatever regulatory burden that is imposed
by state or local agencies. But in addition to that, FQHCs are increasingly
being required to adopt frameworks around and address the complex needs of Social
Determinants of Health (SDOH) which requires the FQHC not only to consider the
patient’s physical health needs, but also things like housing or food
insecurity which many traditional reimbursement models do not adequately
address. SDOH requires complex coordination of services across various needs
and specialties with ever shrinking resources.
Additionally, FQHCs are responsible for ensuring access to
care for the populations that they serve. This means providing non-traditional
care mechanisms such as telehealth services. Telehealth services require
increased technology capacity and capabilities and, in some cases, even
providing technology devices to their patients to ensure their ability to
access services.
All health care entities are highly regulated under HIPAA which requires strict controls to protect the privacy of patient data. Compliance with these regulations require extensive and expensive compliance and cybersecurity programs. With all of the breaches of health care organizations that are occurring, the requirements under HIPAA are going to become even more extensive over the next year. These additional controls will just add to the expense and complexity of managing cybersecurity operations for FQHCs. Unfortunately, while acute (inpatient) organizations have access to funds from large technology companies like Microsoft and the federal government for cybersecurity, these funds are not made available to FQHCs. While inpatient health care is a key component of our health care system in this country, we need to keep in mind that the whole point of a healthy primary care system is to help keep our patients out of inpatient settings as much as possible. Many hospital admissions can be prevented by providing access to adequate primary care services, a fact that seems lost on our technology communities and government.
Conclusion
In this article, we have discussed what an FQHC is, how they
are funded, and some of the challenges that they face to their continued survival.
Through this article, I hope I have explained the urgent necessity behind our
FQHC system and why they are vital to the continued health and well-being of
our communities. The threats that our FQHCs currently face really threaten our
entire health care system. When FQHCs are not available to provide services in
their communities, that need will eventually need to be met, usually by
emergency departments and urgent care centers. This additional load on our
emergency departments and urgent care centers means that those services are
less available to everyone else. FQHCs providing preventive and primary care
services to these patients prevent that escalation in the need of care that
results in emergency department or urgent care visits and relieves overall
pressure on our entire health care system.
In future articles, I will address some of the challenges
faced by FQHCs from my perspective as an executive responsible for the technology
portfolio of an FQHC and integrated health system.