SURVEY BRIEF APRIL 2019 The Role of Community health centers provide comprehensive primary care to medically underserved communities, regardless of patients’ insurance status or ability to pay. Health centers have enjoyed bipartisan support for decades, because they provide affordable, cost-effective Medicaid care for millions of Americans while saving the overall health care system money.1 When people gained insurance coverage under the Affordable Care Act (ACA), it was expected Expansion in that reliance on health centers would increase. As a result, Congress doubled federal grant funding for centers and created incentives for clinicians to practice in them. Care Delivery Previous research has shown that health centers in states that expanded Medicaid have particularly benefitted from the ACA.2 But less is known about how the delivery of health care in centers has changed. This brief uses data from the Commonwealth Fund 2018 at Community National Survey of Federally Qualified Health Centers to compare the experiences of health centers in states that have and have not expanded Medicaid. Health Centers HIGHLIGHTS ealth centers in Medicaid expansion states, compared to those in nonexpansion H states, were significantly more likely to report improvements in their financial stability (69% vs. 41%) and in their ability to provide affordable care to patients (76% vs. 52%) since the ACA took effect. They have also been somewhat more likely to operate under a value-based payment model, like the patient-centered medical home. Corinne Lewis Research Associate ealth centers in Medicaid expansion states were more likely to offer medication- H The Commonwealth Fund assisted treatment for opioid addiction (44% vs. 25%), provide counseling and other behavioral health services, and coordinate patient care with social service providers Akeiisa Coleman Associate Program Officer in the community (58% v. 48%) than health centers in nonexpansion states. The Commonwealth Fund owever, health centers in states that expanded Medicaid were more likely than H those in nonexpansion states to report unfilled job openings for mental health Melinda K. Abrams Vice President and Director professionals (73% vs. 64%) and social service providers (45% vs. 36%), perhaps The Commonwealth Fund indicating higher demand for these professionals and insufficient supply. Michelle M. Doty Vice President The Commonwealth Fund The Role of Medicaid Expansion in Care Delivery at Community Health Centers 2 hile many factors account for the observed differences between W Anticipating this increased demand, the ACA created the Community expansion and nonexpansion states, community health centers Health Center Fund, which appropriated $11 billion over five years appear to benefit from Medicaid expansion. If Congress does not to support health center expansion — a doubling of federal funding renew federal funding for health centers this year, there could be to these providers.6 To ensure the increased demand could be met, a reversal in these gains, jeopardizing the health care safety net in the ACA also enhanced incentives for care providers to work in communities throughout the United States. health centers, through loan forgiveness programs, new training opportunities, and more.7 BACKGROUND However, the ACA did not affect health centers uniformly. Previous More than 1,300 Federally Qualified Health Center organizations research has indicated that health centers in states that expanded (FQHCs) operate in more than 11,000 sites across the U.S. They Medicaid have fared better, particularly because of the fewer number provide high-quality, comprehensive primary care to one of every of uninsured patients, compared to centers in states not expanding 12 Americans.3 Health centers serve as a safety net for low-income Medicaid.8 Since health centers serve a disproportionate number and uninsured people, providing free or low-cost care regardless of of low-income, medically complex patients, it is important to insurance status or ability to pay. They also provide health services in understand if, and how, care delivery itself differs between health areas of the U.S. where primary care providers are lacking. centers in expansion and nonexpansion states.9 For decades, health centers have enjoyed bipartisan support. That’s In this brief, we examine findings from the recent Commonwealth because they benefit all Americans, by:4 Fund 2018 National Survey of Federally Qualified Health Centers to compare the experiences of health centers in the 31 states and the • reducing the need for more expensive care, like emergency District of Columbia that had expanded Medicaid as of September department visits 2018 to those in the 19 states that had not (Appendix A). We look at • lowering overall health care costs financial stability; participation in payment arrangements, in which • employing thousands of people reimbursement is tied to performance; availability of behavioral health care and social services; and other characteristics (see “How We • generating billions of dollars in economic activity through job Conducted This Study” for more detail). Readers should note, however, creation and the purchase of goods and services. that the differences observed may be influenced by factors other than The ACA shifted the landscape for health centers significantly. As Medicaid expansion, such as whether health centers are located in millions of previously uninsured people gained health insurance an urban area or in a particular region of the country (Appendix B), coverage through the marketplaces and the expansion of Medicaid what kind of Medicaid policies a state has in place, or differences in the eligibility in many states, demand for health center services increased.5 populations of Medicaid expansion and nonexpansion states. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 3 Health Centers in Medicaid Expansion States Were More Likely to Report Improvements in Capacity and Financial Stability Since the ACA Health Centers in Medicaid Expansion States Were More Likely to Report Improvements in Capacity and Financial Stability Since the ACA The survey found significant On the whole, since the Affordable Care Act was passed in 2010, the following differences between health have much improved or improved at your health center organization . . . centers in Medicaid expansion states and nonexpansion states related to finances and capacity to serve patients 76%* (Appendix C). Health centers 69%* in expansion states were 62%* significantly more likely 52% to believe their financial 46% stability and funding had 41% improved since the ACA took hold, with nearly 70 percent reporting increased financial stability compared Financial stability Funding for service or Ability to provide affordable care to 41 percent in nonexpansion site expansions and upgrades to more patients in the states. Three of four health for facilities community you serve centers in expansion states felt they were better able to FQHCs in expansion states FQHCs in nonexpansion states provide affordable care to their community, while only * Statistically significantly difference compared to nonexpansion states (p≤.05). Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. half did in health centers in nonexpansion states. Source: Corinne Lewis et al., The Role of Medicaid Expansion in Care Delivery at Community Health Centers (Commonwealth Fund, Apr. 2019). * Statistically significant difference compared to nonexpansion states (p≤.05). Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 4 Health Centers in Medicaid Expansion States Were More Likely to Report Participation in Value-Based Payment Arrangements Health Centers in Medicaid Expansion States Were More Likely to Report Participation in Value-Based Payment Arrangements Paying health care providers Health center currently . . . based on the value of care they deliver to patients has the potential to lower the costs of 86%* care while improving health.10 79%* 80% We found that health centers in expansion states were 69% significantly more likely to participate in models in which 53%* they or their clinicians could 45% receive financial incentives for achieving quality-of-care targets. They were also more likely to be recognized as patient- centered medical homes and Could receive incentives for Recognized as PCMH Awarded financial incentives for receive financial incentives for achieving certain clinical care participation in PCMH participating in such programs. targets like HEDIS measures Patient-centered medical homes have been shown to improve FQHCs in expansion states FQHCs in nonexpansion states health outcomes and reduce health disparities for low- * Statistically significantly difference compared to nonexpansion states (p≤.05). Notes: HEDIS = Healthcare Effectiveness Data and Information Set. PCMH = patient-centered medical home. Respondents were asked to think of their largest site if their health center organization income populations.11 However, operated more than one health center site. for some models of value- Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. based payment, there were no * Statistically significant difference compared to nonexpansion states (p≤.05). significant differences between Source: Corinne Lewis et al., The Role of Medicaid Expansion in Care Delivery at Community Health Centers (Commonwealth Fund, Apr. 2019). Notes: HEDIS = Healthcare Effectiveness Data and Information Set. PCMH = patient-centered medical home. Respondents were asked to health centers in expansion think of their largest site if their health center organization operated more than one health center site. and nonexpansion states Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. (Appendix D). commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 5 Health Centers in Medicaid Expansion States Were More Likely to Address Behavioral Health Needs of Patients Health Centers in Medicaid Expansion States Were More Likely to Address Behavioral Health Needs of Patients Behavioral health issues, including substance use and Health center usually or often offers the following for patients with emotional or behavioral health needs . . . mental health disorders, disproportionately affect low- income people, but accessing 89%* behavioral health services 82% is difficult for many.12 As the safety-net provider for millions of low-income people in the 57%* U.S., health centers play a key 48% role in addressing patients’ 44%* behavioral health problems. A large majority of health centers 25% surveyed offered onsite, short- term counseling to patients, Short-term counseling Treatment for substance use Medication-assisted treatment with centers in expansion disorder for opioid addiction states significantly more likely to provide this critical service. FQHCs in expansion states FQHCs in nonexpansion states Health centers in Medicaid expansion states were more * Statistically significantly difference compared to nonexpansion states (p≤.05). likely to offer treatment for Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. substance use disorder as Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. well as medication-assisted treatment for opioid addiction Source: Corinne Lewis et al., The Role of Medicaid Expansion in Care Delivery at Community Health Centers (Commonwealth Fund, Apr. 2019). * Statistically significant difference compared to nonexpansion states (p≤.05). at a rate almost twice as high Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. as in centers in nonexpansion Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. states (Appendix E). commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 6 Health Centers in Medicaid Expansion States Were More Likely to Address Social Needs of Patients Health Centers in Medicaid Expansion States Were More Likely to Address Social Needs of Patients Patients served by Health center usually or often . . . health centers are disproportionately living in poverty and therefore are at greater risk for hardships like homelessness, transportation barriers, or food insecurity than are 58%* other patients.13 Because 48% 48%* unmet social needs can 39% have a negative impact on physical health and access to health care, the majority of health centers offered some services to identify and Coordinates patient care with social service Offers transportation to and from providers in community medical appointments address them. Health centers in expansion states were more likely to address the FQHCs in expansion states FQHCs in nonexpansion states social needs of their patients, typically by coordinating * Statistically significantly difference compared to nonexpansion states (p≤.05). patient care with social Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. service providers in the community and offering Source: Corinne Lewis et al., The Role of Medicaid Expansion in Care Delivery at Community Health Centers (Commonwealth Fund, Apr. 2019). transportation to and from * Statistically significant difference compared to nonexpansion states (p≤.05). medical appointments Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. (Appendix F). Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 7 Health Centers in Medicaid Expansion States Were More Likely to Report Behavioral Health and Social Service Staffing Needs Health Centers in Medicaid Expansion States Were More Likely to Report Behavioral Health and Social Service Staffing Needs While health centers in Health center currently has budgeted, unfilled positions for . . . expansion states were more likely to offer behavioral health and social services to their patients, they were still struggling to hire more 73%* mental health and social 64% service providers. Health centers in expansion states were more likely to report 45%* having budgeted but unfilled 36% positions for mental health providers, social workers, and staff to help patients obtain social services. As Licensed mental health providers, including Social workers or others to help obtain psychiatrists and substance use disorder counselors social services health centers in expansion and nonexpansion states alike look to expand FQHCs in expansion states FQHCs in nonexpansion states provision of these services, such shortfalls in workforce * Statistically significantly difference compared to nonexpansion states (p≤.05). capacity could present a Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. barrier to care (Appendix G). Source: Corinne Lewis et al., The Role of Medicaid Expansion in Care Delivery at Community Health Centers (Commonwealth Fund, Apr. 2019). * Statistically significant difference compared to nonexpansion states (p≤.05). Note: Respondents were asked to think of their largest site if their health center organization operated more than one health center site. Data: Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 8 CONCLUSION AND POLICY IMPLICATIONS Compared to community health centers in nonexpansion states, centers in expansion HOW WE CONDUCTED THIS STUDY states reported greater financial stability, engagement in value-based payment The Commonwealth Fund 2018 National Survey of arrangements, and availability of behavioral health care and social services. While Federally Qualified Health Centers was conducted many factors other than Medicaid expansion likely influence these differences, the by SSRS from May 16, 2018, through September increased Medicaid revenue that health centers in expansion states receive may help 30, 2018, among a nationally representative sample them improve the way they deliver care. Medicaid expansion also may incentivize of 694 executive directors or clinical directors at health centers to offer the behavioral health care and nonmedical services that a Federally Qualified Health Centers (FQHCs). The survey sample was drawn from the Uniformed Data growing share of patients requires. System (UDS) list of all FQHCs in 2016 that have at However, health centers in expansion states were more likely than their counterparts least one site that is a community-based primary to report unfilled positions for mental health and social service staff, a potential care clinic. The list was provided by the National barrier to meeting needs for behavioral health and social care. It’s also important Association of Community Health Centers (NACHC). to note that differences in care and capacity in Medicaid expansion states versus All 1,367 FQHCs were sent the questionnaire nonexpansion states were sometimes modest. In addition, although not demonstrated and 694 responded, yielding a response rate of by our analysis, other changes since the ACA took effect, such as the national, 51 percent. The survey consisted of a 12-page enhanced federal funding for health centers and the increase in private, subsidized questionnaire that took approximately 20 to 25 minutes to complete. Data were weighted by health insurance coverage, likely impacted health centers in all states as well. number of patients, number of sites, geographic Any further weakening of the ACA, like the enactment of Medicaid work requirements region, and urban/rural location to reflect the and other policies that restrict health insurance coverage, could increase the number universe of primary care community centers of uninsured, thereby reducing health centers’ revenue from insurance and increasing as accurately as possible. Expansion status was costs. This ultimately could have a negative impact on the financial stability of determined using the FQHC-reported largest site health centers. Moreover, if Congress fails to renew federal funding — set to expire address. If the largest site address was not provided, in September 2019 — health centers may be forced to halt their efforts to innovate, and the FQHC had only one site, we used UDS expand, and improve care. Such outcomes could affect the entire U.S. health care data to determine the site’s state. We excluded 21 responses because we were unable to determine system, whose success and efficiency depends on a high-performing safety net. their largest site through one of these methods, yielding a total sample of 673 responses. We used chi-square tests to assess differences between health centers in expansion states and those in nonexpansion states. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 9 NOTES 1. National Association of Community Health Centers, Health Centers Provide 11. National Committee for Quality Assurance, Latest Evidence: Benefits of Cost Effective Care (NACHC, July 2015). NCQA Patient-Centered Medical Home Recognition (NCQA, Oct. 2017). 2. Julia Paradise et al., Community Health Centers: Recent Growth and the Role 12. Judith Weissman et al., Serious Psychological Distress Among Adults: United of the ACA (Henry J. Kaiser Family Foundation, Jan. 2017). States, 2009–2013 (Centers for Disease Control and Prevention, May 2015); and Stacy Hodgkinson et al., “Improving Mental Health Access for Low-Income 3. National Association of Community Health Centers, Community Health Children and Families in the Primary Care Setting,” Pediatrics 139, no. 1 (Jan. Center Chartbook (NACHC, Jan. 2019). 2017): 1–9. 4. NACHC, Health Centers Provide, 2015. 13. Nath, Costigan, and Hsia, “Changes in Demographics,” 2016. 5. Sara Rosenbaum et al., Community Health Centers: Growing Importance in a Changing Health Care System (Henry J. Kaiser Family Foundation, Mar. 2018). 6. Health Resources and Services Administration, The Affordable Care Act and Health Centers (U.S. Department of Health and Human Services, 2012). 7. Melinda K. Abrams et al., Realizing Health Reform’s Potential: How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers (Commonwealth Fund, Jan. 2011). 8. Paradise et al., Community Health Centers, 2017. 9. Julia B. Nath, Shaughnessy Costigan, and Renee Y. Hsia, “Changes in Demographics of Patients Seen at Federally Qualified Health Centers, 2005–2014,” JAMA Internal Medicine 176, no. 5 (May 2016): 712–14; and Leiyu Shi, “The Impact of Primary Care: A Focused Review,” Scientifica (May 2012): 1–22. 10. Rachel Donlon, Hannah Dorr, and Kitty Purington, State Strategies to Develop Value-Based Payment Methodologies for Federally Qualified Health Centers (National Academy for State Health Policy, May 2018). commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 10 APPENDIX A. Medicaid Expansion Status of States Included in the Analysis Expansion states Nonexpansion states Alaska Alabama Arizona Florida Arkansas Georgia California Idaho Colorado Kansas Connecticut Maine Delaware Mississippi Hawaii Missouri District of Columbia Nebraska Illinois North Carolina Indiana Oklahoma Iowa South Carolina Kentucky South Dakota Louisiana Tennessee Maryland Texas Massachusetts Utah Michigan Virginia Minnesota Wisconsin Montana Wyoming Nevada New Hampshire New Jersey New Mexico NOTE Maine and Virginia were New York included as nonexpansion North Dakota states because, although expansion had passed at the Ohio time of the survey in both Oregon states, expansion coverage did not become effective Pennsylvania until January 2019. Idaho, Rhode Island Nebraska, and Utah, which passed Medicaid expansion by Vermont ballot measure In November Washington 2018, after our survey was conducted, were counted as West Virginia nonexpansion states. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 11 APPENDIX B. Characteristics of Health Centers Surveyed Total FQHCs in expansion states FQHCs in nonexpansion states (unweighted n=673) (unweighted n=435) (unweighted n=238) % % % Insurance status of patients 25% or more of patients are insured by . . . Medicaid/CHIP 77 87* 58 Medicare 14 13 16 Other public insurance 2 3 1 Private insurance 25 22* 30 Self-pay 32 17* 61 Geography of largest site Large city 33 37* 26 Suburb or small city 38 37 39 Rural area 27 24* 34 Percent of Medicaid patients covered by managed care plans Less than one-third 21 16* 32 * Statistically significant difference compared to More than one-third 72 78* 61 nonexpansion states (p≤.05). Race and ethnicity of patient population 25% or more of patients are . . . NOTES Respondents were asked African American or Black 31 27* 37 to think of their largest site if their health center Hispanic or Latino 42 43 41 organization operated more than one health center site. Served in a language other than English 36 38* 30 Percentages do not always sum to 100 percent because of blank or “not sure” responses. DATA Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 12 APPENDIX C. Improvements Since Affordable Care Act Passage Total FQHCs in expansion states FQHCs in nonexpansion states (unweighted n=673) (unweighted n=435) (unweighted n=238) On the whole, since the Affordable Much Much Much Care Act was improved or About the Much worse improved or About the Much worse improved or About the Much worse passed in 2010, improved same or worse improved same or worse improved same or worse the following are . . . % % % % % % % % % Financial stability 59 27 7 69* 20 6 41 40 10 Funding for service or site expansions and 56 31 6 62* 28 4 46 35 9 upgrades in facilities Patient satisfaction and experiences 48 42 3 52* 38 2 40 49 3 with care Ability to provide affordable care to 68 23 4 76* 17 3 52 34 8 more patients in the community Staff retention 23 59 11 24 58 11 20 60 13 Staff shortages 15 58 20 17 56 20 12 60 20 Provider and 26 52 14 28 51 12 22 54 17 staff satisfaction Ability to provide after-hours care outside normal working * Statistically significant 32 58 4 34 57 3 30 59 5 hours, including difference compared to evening nonexpansion states (p≤.05). and weekends NOTE Ability to provide Percentages do not always treatment for mental sum to 100 percent because 59 28 7 64* 25 5 50 33 10 health and substance of blank or “not sure” use disorder responses. Ability to connect DATA patients to social 36 50 7 43* 46 6 24 58 8 Commonwealth Fund 2018 service providers National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 13 APPENDIX D. Participation in Value-Based Payment Arrangements Total FQHCs in expansion states FQHCs in nonexpansion states (unweighted n=673) (unweighted n=435) (unweighted n=238) Largest site of your health center organization currently . . . % % % Participates in program where provider or center could receive financial incentives for 37 38 36 high patient satisfaction ratings Participates in program where provider or center could receive financial incentives for 75 79* 69 achieving certain clinical care targets (e.g., performance on HEDIS-like measures) Participates in patient-centered 84 86* 80 medical home Participates in an accountable care organization 39 36* 44 Participates in bundled payments 23 21 25 Participates in any other alternative 22 25* 16 payment models Receives enhanced payment for patient- * Statistically significant 50 53* 45 difference compared to centered medical home recognition nonexpansion states (p≤.05). Receives enhanced payment for accountable NOTES 23 23 23 care organization participation HEDIS = Healthcare Effectiveness Data and Receives enhanced payment for Information Set. Respondents 12 12 13 were asked to think of their bundled payments largest site if their health center organization operated Receives enhanced payment for any more than one health center 16 18 13 other alternative payment models site. DATA Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 14 APPENDIX E. Availability of Onsite Behavioral Health Care Total FQHCs in expansion states FQHCs in nonexpansion states (unweighted n=673) (unweighted n=435) (unweighted n=238) Largest site of your health center organization offers the following for patients Usually Sometimes, Usually Sometimes, Usually Sometimes, with emotional or behavioral or often rarely, or never or often rarely, or never or often rarely, or never health needs . . . % % % % % % Short-term counseling for 87 13 89* 11 82 18 mental health problems Long-term counseling for mental 68 32 69 31 67 33 health problems Treatment for substance use 54 46 57* 43 48 52 disorders Medication-assisted treatment 37 63 44* 56 25 75 for opioid addiction APPENDIX F. Identifying and Addressing Social Needs of Patients Total FQHCs in expansion states FQHCs in nonexpansion states * Statistically significant (unweighted n=673) (unweighted n=435) (unweighted n=238) difference compared to nonexpansion states (p≤.05). Largest site of your Usually Sometimes, Usually Sometimes, Usually Sometimes, health center organization NOTES or often rarely, or never or often rarely, or never or often rarely, or never Respondents were asked currently . . . % % % % % % to think of their largest site if their health center Coordinates patient care with organization operated more community social service 55 45 58* 41 48 51 than one health center site. providers Percentages do not always sum to 100 percent because Offers transportation to and from of blank or “not sure” 45 54 48* 51 39 60 responses. medical appointments Receives a report back from the DATA social service organization about 23 76 25 74 20 79 Commonwealth Fund 2018 services received National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 15 APPENDIX G. Ongoing Staffing Needs Total FQHCs in expansion states FQHCs in nonexpansion states Largest site of your health center (unweighted n=673) (unweighted n=435) (unweighted n=238) organization has budgeted positions that are currently unfilled for . . . % % % Primary care physicians 65 67 62 Nurse practitioners (including certified 39 46* 25 nurse midwives/physician assistants) Complex care managers 42 45 38 Medical assistants 49 51 45 Nurses (including RNs and LPNs) 54 56 50 Dentists 42 40 45 Benefit and insurance eligibility 18 18 17 counselors Licensed mental health providers, including psychiatrists and substance 70 73* 64 use disorder counselors Social workers or others to help obtain 42 45* 36 social services Community health workers or other 29 30 28 community-based patient advocates * Statistically significant difference compared to nonexpansion states (p≤.05). NOTES Respondents were asked to think of their largest site if their health center organization operated more than one health center site. DATA Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers. commonwealthfund.org Survey Brief, April 2019 The Role of Medicaid Expansion in Care Delivery at Community Health Centers 16 ABOUT THE AUTHORS Melinda K. Abrams, M.S., vice president at the Commonwealth Fund, Corinne Lewis, L.M.S.W., is the research associate in the Commonwealth leads the foundation’s Health Care Delivery System Reform program. Fund’s Delivery System Reform Program, where she performs a variety Since coming to the Fund in 1997, Ms. Abrams has worked on the of duties including writing, editing, and research, as well as general Fund’s Task Force on Academic Health Centers, the Child Development program-wide coordination and management. Before joining the Fund, and Preventive Care program, and most recently, she led the Patient- she was a health research analyst with Mathematica Policy Research, Centered Primary Care Program. Ms. Abrams has served on many Inc., where she gained extensive experience in mixed methods research national committees and boards for private organizations and federal on federal demonstrations of innovative models of care. Before joining agencies, and is a peer-reviewer for several journals. Ms. Abrams holds a Mathematica, she was a project coordinator at the Laboratory for Youth B.A. in history from Cornell University and an M.S. in health policy and Mental Health at Harvard University and had internships with the management from the Harvard T.H. Chan School of Public Health. Centers for Medicare and Medicaid Services and NYU Augustana Center Michelle McEvoy Doty, Ph.D., is vice president of survey research at NYU Lutheran Medical Center. Ms. Lewis holds a B.A. in psychology and evaluation for the Commonwealth Fund. She has authored from Boston University and a master of science in social policy from numerous publications on cross-national comparisons of health Columbia University’s School of Social Work. system performance, access to quality health care among vulnerable Akeiisa Coleman, M.S.W., is an associate program officer in the Federal populations, and the extent to which lack of health insurance contributes and State Health Policy (FSHP) initiative at the Commonwealth Fund and to inequities in quality of care. Dr. Doty holds an M.P.H. and a Ph.D. in is responsible for the Medicaid and state-facing grants and coordinating public health from the University of California, Los Angeles. the cross-program Medicaid initiative. As part of the FSHP team, she advises on strategy around federal and state policy, contributing to Fund ACKNOWLEDGMENTS research and publications and helping to execute projects and events The authors thank Michelle Proser of the National Association of to inform and educate policymakers at the state and federal level. Prior Community Health Centers (NACHC) for providing input on our to joining the Fund in August 2018, Ms. Coleman was a senior policy survey instrument; Robyn Rapoport, Erin Czyzewicz, and James Noack analyst with the National Governors Association, where she managed of SSRS for assistance designing and administering the survey; and multiple projects related to social determinants of health, Medicaid, and Yaphet Getachew and Mekdes Tsega of the Commonwealth Fund for behavioral health. Before that, she was a health policy associate with the assistance with verifying data. Missouri Foundation for Health. Ms. Coleman earned her Master of Social Work from Washington University in St. Louis and her B.A. in sociology from the University of Southern California. commonwealthfund.org Survey Brief, April 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.